Empyema Thoracis after Blunt Traumatic Esophageal Perforation

Abstract

A43-year-old male was admitted recently to our emergency department with thoracic back pain and shortness of breath after colliding with a car and falling off his motorcycle. Computed tomography (CT) scan revealed multiple rib fractures, total left pneumothorax with right mediastinal shift, and bilateral pneumomediastinum with an air–fluid level at the esophageal hiatus. A chest tube was inserted and abundant foul-smelling serosanguineous fluid was drained: a blunt traumatic esophageal perforation was suspected. At exploratory laparotomy, a centimetric longitudinal laceration was identified on the anterior wall of the suprahiatal esophagus and was sutured manually. The patient did well after the intervention but despite antibiotic therapy with teicoplanin and piperacillin-tazobactam, the chest drain started putting out traces of purulent discharge. Thoracic imaging showed bilateral pleural effusion, of which the left-sided component appeared organized, hence, a pigtail intercostal catheter was placed to drain the empyema better and retrieve the material for analysis (Fig. 1 and Fig. 2). Pleural fluid culture yielded Bacillus lentus. A 2-wk course of meropenem (2 g three times daily) and linezolid (600 mg twice daily) effected a complete cure and the patient was dismissed without any drain.

FIG. 1.

Computed tomography scan of the chest documenting a left-sided organized pyothorax.

FIG. 2.

Fluoroscopic imaging and drainage of the pleural empyema.

Blunt traumatic esophageal perforation is a rare event: approximately only 100 cases have been described as of 2013 [1]. The pathogenetic mechanism underlying this type of injury is still unclear: sudden increase of intra-esophageal pressure against a closed glottis, excessive traction secondary to uncoordinated hyperextension of the neck, compression exerted by associated cervical fractures, and blast effect combined with a tracheal injury represent the most accredited determinants [2]. This is a life-threatening condition in which morbidity and mortality remain high because of the spread of gastrointestinal content (fluid and bacteria) to the para-esophageal spaces and delays in diagnosis and treatment [2,3]. On the one hand, if pleura is intact, the discharge collects within the mediastinum where it triggers chemical inflammation along with bacterial infection (mediastinitis); on the other hand, when there is a concomitant pleural injury, it can flow into the pleural space and result in empyema thoracis, as found prior to our case [3]. The correlation between esophageal perforation and subsequent pleural empyema fed by strains of the genus Bacillus is exceptional, as only one description is present in the current literature dealing with Bacillus licheniformis and Bacillus subtilis [4]. Such a rarity is mostly because, except for Bacillus anthracis and Bacillus cereus, the other species of these aerobic gram-positive bacteria are normally non-pathogenic for the gut and skin of human beings [4]. Bacillus lentus also belongs to this group: to date, the only confirmed human infection caused by this germ is keratitis [5].

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