32 Necrotising breast fasciitis due to empyema necessitatis

Abstract The patient, a 73-year-old woman with multiple medical history, consulted the emergency department (ED) of a second-level hospital due to severe left rib pain radiating to the abdomen. Initially, it was diagnosed as postherpetic neuralgia. However, during the examination in the ED, absence of breath sounds were found in the left lung base and severe pain in the left hemithorax, leading to a chest X-ray which revealed a massive left pleural effusion. A thoracentesis was performed which confirmed the presence of empyema. The patient was admitted, treatment was started with empirical Ceftriaxone and a pleural drain was placed. Urokinase was administered for 5 days and the drain was removed. She presented a torpid evolution with persistent fever and elevation of acute phase reactants despite treatment. During admission, the patient developed inflammation of the left lower chest wall, which was diagnosed as cellulitis. Antibiotic coverage was extended to Linezolid and Imipenem. However, the patient worsened clinically, presenting hypotension and tachycardia, leading to suspicion of necrotizing fasciitis. An urgent thoracic CT scan revealed a bilateral acute pneumonic infectious process with pulmonary necrosis and signs of pleural-extraspleural fistula, which was classified as necrotizing pneumonia complicated by empyema necessitatis. Clindamycin was added to the treatment. The patient was referred to a tertiary hospital in order to be evaluated by thoracic surgeons for urgent surgical debridement. Significant fibrous pleuropulmonary adhesions were found requiring costal resection. Malodorous fluid was aspirated and pleural and thoracic drains were placed. During surgery, the patient presented poor hemodynamic and ventilatory tolerance, requiring bipulmonary ventilation and the impossibility of extubation after surgery, therefore she was admitted to the ICU. Due to a poor hemodynamic evolution, the patient required a second septic control surgery one week later. A left thoracotomy was performed and multiple fibrous pleuropulmonary adhesions were again observed. Abundant purulent material was evacuated and cultures were positive for Parvimona and mixed aero-anaerobic flora. The patient required vasoactive support during the first 72 hours, but this was subsequently withdrawn without incident. A follow-up CT scan 5 days after the second surgery showed worsening of the necrotizing pneumonia. A third urgent surgery was performed in which pleuropulmonary fibropurulent tissue was observed and removed, abundant lavage was performed and drains were placed in muscular and costal planes. Negative pressure therapy (VAC system) was performed. After a prolonged admission to the ICU presented favorable evolution and she was discharged to the ward.