Case Report—Aspergillus Empyema Necessitans Post Double-lung Transplant

US Respiratory & Pulmonary Diseases, 2016;1(1):19–21 DOI: http://doi.org/10.17925/USRPD.2016.01.01.19

Abstract:

Empyema necessitans (also called empyema necessitatis) is a sequelae of empyema/parapneumonic effusion where infection progresses beyond the pleural space into the soft tissues of the chest wall. Typical pathogens include Mycobacterium tuberculosis, Streptococcus pneumoniae, and Staphylococcus aureus. Fungal empyema necessitans is uncommon, with the majority of cases secondary to Candida species. We report a rare and fatal case of empyema necessitans presenting in a patient with cystic fibrosis more than 10 years following double-lung transplant.
Keywords: Cystic fibrosis, Aspergillus, empyema, necessitans, necessitatis, lung transplant
Disclosure: Gannon J Yu has nothing to disclose in relation to this article.. Harvey R Rabin has been on advisory boards for Novartis and Vertex. Michael D Parkins has been on advisory boards for Gilead, Novartis, and Roche Pharmaceuticals. Harvey R Rabin and Michael D Parkins have received research support from Gilead and Cystic Fibrosis Canada. No funding was received in the publication of this article.
Received: December 10, 2015 Accepted January 06, 2016
Correspondence: Michael D Parkins, 3330 Hospital Drive NW, Calgary, AB Canada T2N 4N1. E: mdparkin@ucalgary.ca
Open Access: This article is published under the Creative Commons Attribution Noncommercial License, which permits any noncommercial use, distribution, adaptation, and reproduction provided the original author(s) and source are given appropriate credit.

Case Presentation
The patient described was diagnosed with cystic fibrosis (CF) at 2 years of age. She was pancreatic insufficient and had an F508del homozygous genotype. Her pretransplant CF-course was complicated by CF-related diabetes, chronic sino-pulmonary colonization with Pseudomonas aeruginosa (but not Aspergillus), CF-liver disease with stable cirrhosis and portal hypertension and normal synthetic function, osteoporosis, and a central line-associated venous thromboembolism. She received a lifesaving double-lung transplant in her late thirties.

Her postoperative course was initially uncomplicated, with surveillance bronchoscopies following the transplant failing to identify pathogens including fungi. No postoperative antifungal prophylaxis was received. Post-transplant medications include prednisone 5 mg orally once daily, azathioprine 100 mg orally twice daily, and tacrolimus to a target trough level of 8–10 ng/mL. Allergies include a biopsy-proven mycophenolate mofetil-induced colitis and ceftazidime rash.

The first pleural-based issues began 10 years following transplant. By this time she had progressed to have mild chronic renal failure with a glomerular filtration rate (GFR) of 52 mL/min/1.73m2. She presented with fever and dyspnea, and was diagnosed with a right lower lobe pneumonia, which included a progressive parapneumonic effusion. She recovered to baseline after a course of cefepime and metronidazole. Sputum cultures grew the same pre-transplant P. aeruginosa strain, and were negative for fungi and mycobacteria. Pleural fluid analysis revealed an exudative effusion (pleural fluid: white blood cells [WBC] 0.6 x 109/L, pH 7.42, lactate dehydrogenase [LDH] 189 U/L, total protein 36 g/L, glucose 5 mmol/L; serum LDH 125 U/L, serum total protein 74 g/L), but all cultures were negative. A small pleural collection persisted.

Over the subsequent year, the patient experienced progressive fatigue and dyspnea on exertion with no constitutional symptoms. Serial radiographs and computed tomography (CT) scans revealed no change to the small pleural collection. She received a course of intravenous iron sucrose and darbepoetin alpha for an iron deficiency anemia with no significant improvement in hemoglobin.

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Keywords: Cystic fibrosis, Aspergillus, empyema, necessitans, necessitatis, lung transplant