Dermatology Online Journal

Tuberculous empyema necessitatis. A rare cause of cutaneous abscess in the XXI century
C Senent¹, I Betlloch², E Chiner¹, M Llombart¹, M Moragón³
Dermatology Online Journal 14 (3): 11

1. Servicio de Neumología. Hospital San Juan de Alicante 2. Servicio de Dermatología Hospital General Universitario de Alicante 3. Servicio de Dermatología Hospital San Juan de Alicante. betlloch_isa@gva.es

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Abstract

A 24-year-old Moroccan man was admitted to the hospital because of a tumor of the abdominal wall, fever, and purulent sputum. Imaging tests showed the presence of a pleural effusion and tumor in the right abdominal wall. The organized collection of liquid in the mass was contiguous with the thoracic collection and that of the subphrenic space. Thoracocentesis removed purulent material suggestive of empyema. Cultures and polymerase chain reaction (PCR) tests confirmed the diagnosis of tuberculous empyema. Empyema necessitatis refers to empyema that extends into the extrapleural space through a defect in the pleural surface. Various infectious etiologies may be responsible. Tuberculous empyema necessitatis is a rare complication of tuberculosis (TB); our case is even more unusual because this condition presented as an abdominal wall abcess and the patient was immunocompetent. His only predisposing factors were his country of origin, where there is a high prevalence of TB and the delay in diagnosis due to a lack of access to health care.

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Case report

A 24-year-old Moroccan man, who had moved to Spain in 2002, presented with purulent productive cough, malaise, and a painful tumor of the abdominal wall that had appeared in the previous two weeks. On physical examination his axillary temperature was 39.8ºC; hypoventilation and a decrease in breath sounds in the lower half of the right hemithorax were noted. A 12 cm diameter tumor was located in the right hypochondrium, adherent to the deeper tissues. The surface was warm and erythematous and the tumor was painful and fluctuant upon palpation (Figs. 1 & 2).

Figure 1	Figure 2

Figure 3	Figure 4

Chest radiograph showed signs of loss of volume in the right hemithorax and an organized pleural effusion (Fig. 3). On computed axial tomography (CT) an organized pleural effusion was confirmed and additional findings included atelectasis of the right inferior lobe, thickening and pleural calcifications, loss of volume of the hemithorax, and compensation hyperinsufflation of the left hemithorax. An organized liquid collection was found with trabeculations and calcifications of the right lateral and anterior abdominal wall, measuring 8 X 4 X 8 cm in continuity with the thoracic collection and that of the subphrenic space (Figs. 4 & 5).

Figure 5	Figure 6

The Mantoux test showed 22 mm of induration after 48 hours. Determination of antibodies against the human immunodeficiency virus (HIV) using the ELISA method was negative. Diagnostic thoracocentesis yielded purulent material and a drainage tube was inserted. Aspiration of the abdominal wall tumor showed pus similar to that obtained from the pleural cavity. Cultures for aerobes and anaerobes in both samples were negative. Zhiel-Nielsen's staining was negative, but the polymerase chain reaction of both the pleural liquid and the abscess was positive for Mycobacterium tuberculosis complex.

Treatment was begun with 300 mg isoniazid, 750 mg rifampicin, 800 mg ethambutol, and 2000 mg pirazinamide daily for 3 months. The first three drugs were then continued for 6 months. Clinical and radiological progress was favorable, although there was a residual right fibrothorax as a sequela (Fig. 6).

Discussion

Empyema refers to a purulent collection in the pleural space and is usually due to an active chronic infection. Various causes include progression of primary pleural effusion, extension of infection of the thoracic lymphatic ganglia or subphrenic focus, hematogenous dissemination; it may also occur after therapeutic pneumothorax, oleothorax, and post-pneumonectomy [1].

Empyema necessitatis was a rare complication of pleural empyema even in the pre-antibiotic era (10%), and Mycbacterium tuberculosis was responsible for 73 percent of the cases [2]. Other less frequent causes are pulmonary pyogenic infections (Streptococcus pneumoniae, Staphlococcus, gram negative bacilli, and polymicrobial infections), blastomycosis, actinomycosis, and neoplasias [3]. Nowadays empyema necessitatis is a very rare complication. The most common drainage site is the subcutaneous tissue of the thoracic wall [4, 5, 6] and more rarely it may involve the esophagus, spine, paravertebral soft tissue, retroperitoneum, pericardium or groin. The abdominal wall, as in our case, is a rare site for the appearance of a cutaneous abscess [2, 3, 7].

Computed axial tomography findings showing a calcified, well-defined, encapsulated pleural mass associated with an extrapleural mass may aid the diagnosis [2, 3]. However, communication between the pleural and extrapleural collections is rarely seen, probably due to their size (small and narrow) or due to their location under the lesion or tangential to the image plane [8]. Mycobacterium tuberculosis grows in only 10-47 percent of cases of tuberculous empyema and treatment by drainage and antituberculous drugs should be individually tailored [1].

Tuberculosis is a rare cause of cutaneous abscess. In addition, cutaneous TB due to skin fistulas usually originates from ganglia and bone [9, 10]. Skin abcesses originating from lung are extremely rare. Despite the frequency of TB in our setting, this form of presentation is unusual and has been seen only in patients who are HIV positive or immunosuppressed [11]. The only predisposing factor in our patient was that he was an immigrant from a country with a high prevalence of TB. He also had delayed diagnosis due to lack of easy access to health care.

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