Abstract Introduction Empyema is an infection of the pleura where there is a collection of pus. This case report highlights the utility of the Clagett procedure in managing prelobectomy empyema in a 56-year-old male with immunosuppression who had failed chest tube drainage and appropriate antibiotic therapy. Case Presentation A 56-year-old male with a history of orthotopic heart transplant presented 4 months after his surgery with pulmonary mucormycosis in the right lower lobe and required robotic debridement and decortication. Anatomic root section was not possible due to concern for bronchial stump breakdown and bronchopleural fistula. Postoperatively, the patient was managed with chest tube drainage and broad-spectrum antibiotics. The postoperative course was complicated by persistent empyema which grew vancomycin-resistant Enterococcus (VRE). The patient did not respond to a combination of intravenous linezolid and amphotericin. However, he initially had a good response to a short course of intrapleural daptomycin via the chest tube. The intrapleural daptomycin was discontinued when the patient experienced a treatment-associated adverse reaction. The patient was monitored by serial pleural cultures that showed no recurrent VRE. When both intrapleural and blood cultures were subsequently positive for Klebsiella Pneumoniae, the patient underwent right lower lobe lobectomy, followed by nine weeks of chest tube drainage and intravenous antibiotics. After this, the patient was taken back to the operating room for a second procedure with antibiotic irrigation of intrapleural space. Synthetic, non-absorbable, monofilament suture was used to attach the skin to the periosteum, and the empyema cavity was packed with wet and dry sterile gauze. Postoperatively, the patient was managed by negative pressure wound therapy and daily dressing changes. He was discharged at postoperative week 4. At postoperative month 9 outpatient follow-up, the patient had made significant recovery and there were no signs of intrapleural empyema recurrence. Discussion The Clagett procedure has demonstrated great success as a surgical option for managing persistent empyema. In the majority of cases where the Clagett procedure is indicated, empyema typically arises after pneumonectomy or lobectomy. In contrast, this patient developed persistent empyema before lobectomy. He had necrotizing pneumonia which was complicated by persistent empyema after a robotic debridement and decortication. Long-term immunosuppression was likely a significant risk factor. This case report suggests that the Clagett procedure can be a viable surgical option for managing necrotizing pneumonia in patients with prolonged immunosuppression. More prospective studies are warranted to further substantiate this speculation. This abstract is funded by: None
Bui et al. (Fri,) studied this question.