A70-24 Integrated Medical and Surgical Management of Tuberculous Empyema: Challenges and Outcomes

Abstract Introduction Tuberculous empyema is a rare manifestation of pleural tuberculosis and accounts for 15-25 % of cases. Complications of tuberculosis empyema often lead to respiratory compromise and reduced quality of life. Case Presentation A 42-year-old male presented with a three month history of cough productive of yellow sputum, hemoptysis, dyspnea on exertion, right-sided pleuritic chest pain, weight loss, and anorexia. He had no fever or night sweats. Computed Tomography (CT) Chest imaging revealed a large right hydropneumothorax, right upper lobe thick-walled cavities, diffuse “tree-in-bud” opacities, and bronchiectasis. His sputum sample was Acid Fast Bacilli smear positive, with Mycobacterium tuberculosis detected. Microbiological analysis of pleural fluid revealed superimposed Proteus and Pseudomonas infection. He was diagnosed as: Tuberculous Empyema with persistent air leak and was treated with anti-tuberculous therapy and Ceftazidime. Due to failure of medical management, the patient underwent Right Thoracotomy and Decortication. Intraoperative findings included necrotic upper lobe cavities, thickened pleura, and a bronchopleural fistula, which was repaired. Postoperatively, he required ventilatory support and was extubated successfully. However he later developed septic shock and died on postoperative day 22. Discussion Tuberculous empyema is a chronic active infection caused by Mycobacterium Tuberculosis, that invades the pleural cavity. It is often characterised with pleural thickening, loculated purulent collections and bronchopleural fistula. The primary goals of management are infection control, lung re-expansion and prevention of fibrothorax. Anti-tuberculosis medication using Rifampicin , Isoniazid , Pyrazinamide and Ethambutol (R.I.P.E) remains the cornerstone of treatment with addition of antimicrobial agents, if suspected. Surgical intervention is indicated when medical therapy fails or in cases of a chronic empyema. Minimally invasive procedures such as Video Assisted Thoracoscopic Surgery Techniques (VATS) are preferred but in advance or chronic cases open thoracotomy with decortication is done. In this case, despite appropriate anti-tuberculosis therapy, drainage, surgical intervention and supportive care, the patient’s condition continued to deteriorate, and unfortunately he succumbed to complications of advanced disease. This highlights the severe nature of tuberculous empyema, which has a mortality rate of 10- 20 % globally and emphasizes the importance of early recognition, multidisciplinary management, and close monitoring to improve survival and patient outcome. This abstract is funded by: n/a