Pleural empyema caused by incarceration and perforation of the stomach wall discovered several years later after thoracic trauma

Address for correspondence: Szymon Smoliński MD, Department of Thoracic Surgery, Wielkopolskie Centrum Pulmonologii i Torakochirurgii, 62 Szamarzewskiego St, 60-569 Poznan, Poland, phone: +48 606 667 422, fax: +48 606 667 422, e-mail: [email protected] Received: 21.07.2016, accepted: 16.08.2016. Pleural empyema occurs most often as a complication of pneumonitis, a complication of diagnostic or surgical procedures within the chest, or a consequence of chest trauma [1]. Performing imaging examinations (chest X-ray, pleural ultrasound, and chest computed tomography (CT)) and thoracocentesis enables quick diagnosis and implementation of proper therapy. During the early stage of empyema development (exudative phase), the treatment is conservative and consists in draining the pleural cavity and administering antibiotics. When diagnosis is delayed (and achieved during the fibrinopurulent phase or the organizing phase), surgical treatment often becomes a necessity. In chest trauma patients, empyema usually develops due to the infection of a pleural hematoma. However, it should be remembered that, in post-traumatic patients, diaphragmatic injury must be excluded before the start of treatment. Differentiating pleural empyema and post-traumatic diaphragmatic injury is difficult, especially if the diagnostic process is delayed; at the same time, a hasty decision to drain the pleural cavity may result in tragic complications [2]. One should also keep in mind the possibility of abdominal organ incarceration in the defect of the injured diaphragm, which usually manifests with tumultuous symptoms occurring shortly after the injury. This article presents a rare case of pleural empyema resulting from the rupture of the diaphragmatic dome with stomach incarceration and perforation, diagnosed several years after the injury. The 35-year-old male patient was admitted to the Department of Thoracic Surgery in January 2012 with suspicion of left pleural empyema. Months earlier, after vomiting, he started to experience moderate pain in the left side of the chest and epigastrium. He received analgesics and muscle relaxants. Approximately 8 days before admission, the patient’s condition deteriorated, and he started to experience dyspnea, fever (38.5°C), fatigue, and loss of appetite. Four years earlier, the patient had suffered a blunt trauma to the chest during a motorcycle accident, but was not hospitalized at the time. Laboratory investigation revealed anemization (Hb: 8.1 g/dl; Hct: 29%), leukocytosis (WBC: 16.4 G/l), and a high level of C-reactive protein (CRP) (246 g/dl). Chest X-ray revealed only left-sided pneumothorax by demonstrating an air-fluid level in the left pleural cavity. Left pleurocentesis was performed, obtaining purulent content. Left pleural empyema was diagnosed; a drain was introduced through the 5th intercostal space in the midaxillary line, obtaining 2200 ml of purulent content; empirical and later targeted antibiotic treatment was introduced, resulting in evident clinical improvement. The Enterobacter cloacae (ESBL) strain was cultured from samples of the pleural fluid. Over the next 3 days, the daily volume of drained fluid remained at the level of 600 ml. On the 5th day of drainage, the volume increased to 1000 ml, and its appearance was observed to change after meals. After the oral administration of methylene blue, its presence was confirmed in the pleural drain. Chest CT with oral Uropoline contrast demonstrated that the contrast agent leaked into the left pleural cavity from the stomach, which had been displaced into the chest (Fig. 1). The patient was diagnosed with a gas-