Hello Guiseppe, thanks for the quaestion. As noted an empyema means pus in the plueral cavity and the most common cause is a bacterial infection. Most common is Mycobacterium Tuberculosis. This is a type of Extra-pulmonary TB that can be treated using a combination of approaches.

1. Mycobacterial treatment using a combination therapy tailored to the national guidelines of the country you are in.

2. Secondly , an empyema is already a recipe for fibrotic sequale after healing and therefore a chest surgical intervention is paramount a procedure called thoracotomy (working on the chest), This needs specialist attention and therefore procedure.

Regards

The diagnosis of tuberculous empyema was established by demonstrating the tuberculosis bacilli in the pleural pus by routine staining techniques. It is most commonly a result of rupture of a subpleural caseous focus into the pleural space leading to spontaneous broncho-pleural fistulas. Rarely, it is due to hematogenous spread from involved thoracic lymph nodes or from a subdiaphragmatic focus. Tuberculous empyema accounts for only 10% of pleural empyemas.

When the diagnosis of tuberculous empyema is established there are two aims in the management: Firstly, the control of the infection using the antituberculous medication in addition to the antimicrobial agents according to cultures; Secondly, the evacuation of pus with obliteration of the created space. This should be done with the least invasive method with restoration of the function of the underlying lung. If the underlying lung was damaged, resection with or without myoplasty or thoracoplasty is added.

To read more I advise you to read the following references:

1. Sonmezoglu Y, Turna A, Cevik A, Demir A, Sayar A, Dincer Y, Bedirhan MA, Gurses A. Factors affecting morbidity in chronic tuberculous empyema. Thorac Cardiovasc Surg. 2008 Mar;56(2):99-102. doi: 10.1055/s-2007-965301.

2. Al-Kattan KM. Management of tuberculous empyema. Eur J Cardiothorac Surg. 2000 Mar;17(3):251-4.

I agree with you. When the diagnosis of tuberculous empyema is established, chest drenage in conjuntion with oral or iv anti TB drug treatment is important as first step, but intrelesional drug concentration may be sub-therapeutic. Do you believe helpfull (before invasive surgery) the use of fibrinolytic and/or disinfectants agents?

The use of fibrinolytic agents is still a debate, between early surgical intervention leading to early discharge and conservative management with prolonged hospital stay. In one study there was 25% failure rate in the streptokinase group requiring surgical decortication. In view of recent studies, early surgical intervention gives better results than conservative treatment, which should be reserved to chronically ill patients with high surgical risk.

Dear Fahami I agree with you.