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    "textoCompleto" => "<span class="elsevierStyleSections"><p id="par0005" class="elsevierStylePara elsevierViewall">Pleural infection often complicates pneumonia&#44; with a mortality rate of approximately 20&#37;&#46;<a class="elsevierStyleCrossRefs" href="#bib0040"><span class="elsevierStyleSup">1&#8211;3</span></a> It can also occur as a complication of pleural management &#40;e&#46;g&#46;&#44; surgical procedures&#41; or spontaneously&#46; Surgery is often required in cases that are not resolved by medical therapy and the risks and costs are not negligible&#46; Recent data indicate the effectiveness of intrapleural combined therapy&#44; in which deoxyribonuclease is used in conjunction with a fibrinolytic&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> The authors report two cases of patients with pleural infection who received this treatment&#44; with excellent results&#46;</p><span id="sec0005" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0005">Case 1</span><p id="par0010" class="elsevierStylePara elsevierViewall">A 54-year-old man with a history of cervical spinal cord injury 28 years ago&#44; with tetraparesis and chronic hypercapnic respiratory failure under nocturnal non-invasive ventilation &#40;NIV&#41;&#44; was hospitalized for sympathectomy due hyperhidrosis&#46; The procedure was complicated by a left pneumothorax&#44; and a chest tube was placed&#46; Approximately 24<span class="elsevierStyleHsp" style=""></span>h after chest tube removal&#44; systemic inflammation was documented&#44; and the chest radiograph showed a left pleural effusion&#44; which thoracic ultrasound proved to be multiloculated &#40;pleural fluid characteristics after thoracentesis were indicative of pleural infection&#41;&#46; Despite antibiotics and the insertion of a new chest tube &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#44; the patient continued to present with fever&#44; and pleural fluid drainage was very limited during subsequent days&#46; Given the high patient surgical risks inherent to his comorbidities&#44; combined intrapleural therapy &#40;CIT&#41; was started using a protocol similar to that explained by Rahman et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> with 5<span class="elsevierStyleHsp" style=""></span>mg dornase alfa &#40;DNase&#41; diluted in 45<span class="elsevierStyleHsp" style=""></span>ml NaCl 0&#46;9&#37; and 10<span class="elsevierStyleHsp" style=""></span>mg alteplase &#40;fibrinolytic&#41;&#44; diluted in 40<span class="elsevierStyleHsp" style=""></span>ml NaCl 0&#46;9&#37; &#40;both administered sequentially twice a day&#44; for 3 consecutive days&#41;&#44; clamping the drain for 1<span class="elsevierStyleHsp" style=""></span>h following administration of each drug&#44; allowing them to act&#46; This resulted in a significant increase in pleural fluid drainage&#44; and rapid clinical and radiological improvement &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; There were no complications associated with this treatment&#44; and the patient was discharged 10 days after beginning CIT&#44; without the need for any additional interventions&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 41-year-old woman with no relevant past medical history&#44; presented with right pleuritic pain&#44; systemic inflammatory syndrome and evidence of loculated right pleural effusion in thoracic ultrasound&#46; Thoracentesis was indicative of pleural infection&#44; so she was given antibiotics&#44; and a chest tube was placed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; On subsequent days&#44; pleural fluid drainage remained vestigial&#44; and analytic inflammatory markers remained elevated&#46; Thoracic surgery was not found to be emergent&#59; consequently&#44; CIT was undertaken&#44; following a similar protocol as in Case 1&#44; with comparable results &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; The patient was discharged 12 days after beginning intrapleural treatment&#44; and no further drainage was needed&#46; As a complication&#44; she reported intense local pain during the instillation of the drugs&#44; which was suitably controlled with systemic analgesia administered before subsequent procedures&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The efficacy of fibrinolytic therapy in the pleural infection is controversial&#44; as the results obtained in several studies are not consistent&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Case reports and small observational studies suggest its effectiveness&#44; but it has not been confirmed in larger studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4&#44;6</span></a> In the largest randomized&#44; controlled and double-blind trial&#44; Markell et al&#46; concluded that streptokinase was not superior to placebo in reducing mortality or the need for surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> In a Cochrane meta-analysis&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> which included the previous study&#44; Cameron and Davies concluded that there is a potential benefit of fibrinolytics&#44; although this result should be interpreted with caution&#46; More recently&#44; in another randomized&#44; controlled and double-blind trial&#44; Rahman et al&#46; found that only the combination of alteplase and dornase alfa was effective in increasing drainage&#44; and reducing the length of stay and the need for surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> In a more recent meta-analysis&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Janda and Swiston concluded that fibrinolytics are potentially beneficial in pleural infection in adults&#44; and that they should be considered in loculated pleural effusion&#44; as they may reduce the need for surgery&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the cases discussed above&#44; CIT using dornase alfa and alteplase contributed to the resolution of the pleural infection and prevented surgery&#44; which presented a very high risk in Case 1&#44; even if the considered approach was a less invasive option than video-assisted thoracoscopic surgery&#44; which would involve perioperative lung collapse&#46; Although the formal criteria for intra-pleural therapy or the most effective protocol has not yet been defined&#44; the therapy should be considered in patients with contraindication or high risk for surgery&#44; as it appears to have advantages related to costs and associated risks&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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Letter to the Editor
Combined intrapleural therapy in infectious pleural effusion
H. Dabó
Corresponding author
hansdabo@yahoo.com.br

Corresponding author.
, L. Meira, I. Neves, A. Marinho, I. Gomes
Serviço de Pneumologia, Centro Hospitalar do São João, EPE, Porto, Portugal
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with tetraparesis and chronic hypercapnic respiratory failure under nocturnal non-invasive ventilation &#40;NIV&#41;&#44; was hospitalized for sympathectomy due hyperhidrosis&#46; The procedure was complicated by a left pneumothorax&#44; and a chest tube was placed&#46; Approximately 24<span class="elsevierStyleHsp" style=""></span>h after chest tube removal&#44; systemic inflammation was documented&#44; and the chest radiograph showed a left pleural effusion&#44; which thoracic ultrasound proved to be multiloculated &#40;pleural fluid characteristics after thoracentesis were indicative of pleural infection&#41;&#46; Despite antibiotics and the insertion of a new chest tube &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>A&#41;&#44; the patient continued to present with fever&#44; and pleural fluid drainage was very limited during subsequent days&#46; Given the high patient surgical risks inherent to his comorbidities&#44; combined intrapleural therapy &#40;CIT&#41; was started using a protocol similar to that explained by Rahman et al&#46;&#44;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> with 5<span class="elsevierStyleHsp" style=""></span>mg dornase alfa &#40;DNase&#41; diluted in 45<span class="elsevierStyleHsp" style=""></span>ml NaCl 0&#46;9&#37; and 10<span class="elsevierStyleHsp" style=""></span>mg alteplase &#40;fibrinolytic&#41;&#44; diluted in 40<span class="elsevierStyleHsp" style=""></span>ml NaCl 0&#46;9&#37; &#40;both administered sequentially twice a day&#44; for 3 consecutive days&#41;&#44; clamping the drain for 1<span class="elsevierStyleHsp" style=""></span>h following administration of each drug&#44; allowing them to act&#46; This resulted in a significant increase in pleural fluid drainage&#44; and rapid clinical and radiological improvement &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>B&#41;&#46; There were no complications associated with this treatment&#44; and the patient was discharged 10 days after beginning CIT&#44; without the need for any additional interventions&#46;</p><elsevierMultimedia ident="fig0005"></elsevierMultimedia></span><span id="sec0010" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0010">Case 2</span><p id="par0015" class="elsevierStylePara elsevierViewall">A 41-year-old woman with no relevant past medical history&#44; presented with right pleuritic pain&#44; systemic inflammatory syndrome and evidence of loculated right pleural effusion in thoracic ultrasound&#46; Thoracentesis was indicative of pleural infection&#44; so she was given antibiotics&#44; and a chest tube was placed &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>C&#41;&#46; On subsequent days&#44; pleural fluid drainage remained vestigial&#44; and analytic inflammatory markers remained elevated&#46; Thoracic surgery was not found to be emergent&#59; consequently&#44; CIT was undertaken&#44; following a similar protocol as in Case 1&#44; with comparable results &#40;<a class="elsevierStyleCrossRef" href="#fig0005">Fig&#46; 1</a>D&#41;&#46; The patient was discharged 12 days after beginning intrapleural treatment&#44; and no further drainage was needed&#46; As a complication&#44; she reported intense local pain during the instillation of the drugs&#44; which was suitably controlled with systemic analgesia administered before subsequent procedures&#46;</p><p id="par0020" class="elsevierStylePara elsevierViewall">The efficacy of fibrinolytic therapy in the pleural infection is controversial&#44; as the results obtained in several studies are not consistent&#46;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Case reports and small observational studies suggest its effectiveness&#44; but it has not been confirmed in larger studies&#46;<a class="elsevierStyleCrossRefs" href="#bib0055"><span class="elsevierStyleSup">4&#44;6</span></a> In the largest randomized&#44; controlled and double-blind trial&#44; Markell et al&#46; concluded that streptokinase was not superior to placebo in reducing mortality or the need for surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0065"><span class="elsevierStyleSup">6</span></a> In a Cochrane meta-analysis&#44;<a class="elsevierStyleCrossRef" href="#bib0070"><span class="elsevierStyleSup">7</span></a> which included the previous study&#44; Cameron and Davies concluded that there is a potential benefit of fibrinolytics&#44; although this result should be interpreted with caution&#46; More recently&#44; in another randomized&#44; controlled and double-blind trial&#44; Rahman et al&#46; found that only the combination of alteplase and dornase alfa was effective in increasing drainage&#44; and reducing the length of stay and the need for surgery&#46;<a class="elsevierStyleCrossRef" href="#bib0055"><span class="elsevierStyleSup">4</span></a> In a more recent meta-analysis&#44;<a class="elsevierStyleCrossRef" href="#bib0060"><span class="elsevierStyleSup">5</span></a> Janda and Swiston concluded that fibrinolytics are potentially beneficial in pleural infection in adults&#44; and that they should be considered in loculated pleural effusion&#44; as they may reduce the need for surgery&#46;</p><p id="par0025" class="elsevierStylePara elsevierViewall">In the cases discussed above&#44; CIT using dornase alfa and alteplase contributed to the resolution of the pleural infection and prevented surgery&#44; which presented a very high risk in Case 1&#44; even if the considered approach was a less invasive option than video-assisted thoracoscopic surgery&#44; which would involve perioperative lung collapse&#46; Although the formal criteria for intra-pleural therapy or the most effective protocol has not yet been defined&#44; the therapy should be considered in patients with contraindication or high risk for surgery&#44; as it appears to have advantages related to costs and associated risks&#46;</p></span><span id="sec0015" class="elsevierStyleSection elsevierViewall"><span class="elsevierStyleSectionTitle" id="sect0015">Conflict of interest</span><p id="par0030" class="elsevierStylePara elsevierViewall">The authors declare no conflict of interest&#46;</p></span></span>"
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ISSN: 21735115
Original language: English
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