Severe Staphylococcal pneumonia complicated by pyopneumothorax; presentation and outcome in a term neonate managed in a resource-poor setting in North-Central Nigeria

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Staphylococcus aureus is an important cause of neonatal septicaemia with potential complications. Pyopneumothorax is a serious respiratory disorder associated with high morbidity and mortality. Cases of pneumothorax have been reported among ventilated neonates while some neonatal cases of emphysema thoracis have been reported in the context of healthcare-associated infection. Neonatal pyopneumothorax has, however, been rarely reported. A case of a 20-day old previously healthy term female neonate with severe Staphylococcal pneumonia complicated by pyopneumothorax is thus presented.

Keywords: Pyopneumothorax; Neonate; Staphylococcus; Pneumonia

Staphylococcus aureus is an important cause of late-onset neonatal septicaemia and a major cause of necrotizing pneumonitis.^1,2 An invasive Staphylococcal disease like pneumonia often follows haematogenous dissemination from a localized infection commonly of the skin.¹  Other risk factors for Staphylococcal infections include low socioeconomic status, neonatal age group and malnutrition.³

Empyema thoracis and pneumothorax have been reported to complicate 5.7% - 6.7% and 0.8% respectively of childhood pneumonia.^4,5  However, pyopneumothorax is rarely reported in children with only a few reported cases in the literature.^6,7 We therefore report the clinical presentation, risk factors, management and outcome of pyopneumothorax complicating Staphylococcal pneumonia in a neonate seen at the Dalhatu Araf Specialist Hospital, Lafia in North-Central Nigeria.

Case report

A previously healthy 20-day old term female neonate presented with six days history of diffuse pustular rash and four days history of continuous high fever, intermittent non-paroxysmal cough and worsening breathing difficulty. Pregnancy, labour, and delivery were uneventful. She had been duly vaccinated and had been fed predominantly with breast milk. The mother is a teenager and was unkempt at presentation. The family belongs to the low socio-economic class; both parents had no formal education, the mother is a full-time housewife while the father is a peasant farmer.

The baby weighed 2.75 kg and was in severe respiratory distress at presentation with a respiratory rate of 80 cycles per minute and peripheral oxygen saturation of 80% in room air. She had crepitations in the upper lung zones bilaterally and in the middle left lung zone. Breath sound intensity in the whole of the left hemithorax was reduced and percussion note was hyper-resonant.

A diagnosis of bronchopneumonia with pneumothorax was thus made. Her admitting haemogram revealed a packed cell volume of 29%, WBC of 6.6 x 10⁹/L (predominantly lymphocytes: 52%) and platelet count of 225 x 10⁹/L. Thoracocentesis yielded a gush of air and 5 ml of pus. The pus was inoculated within 30 minutes of collection on MacConkey agar, Chocolate agar and Blood agar and incubated at 37°C aerobically for 24 to 48 hours. Bacterial colonies on the agar plates were subsequently identified as Staphylococcus aureus. The organism was sensitive to erythromycin, gentamicin, ciprofloxacin and rifampicin but resistant to amoxicillin, cloxacillin and ceftriaxone.

She was commenced on humidified oxygen and empirical antibiotics (Ampicillin-Cloxacillin and cefotaxime) as well as twice-daily antiseptic bath and maintenance intravenous fluid. A chest radiograph made available 46 hours into admission showed a left-sided pyopneumothorax with a marked mediastinal shift (Fig. 1A). She subsequently had a thoracostomy done (Fig. 1B and Fig 2) with an improvised tube (size 10 nasogastric tube) on the third day of admission. Thereafter, there was a significant improvement in respiratory distress as tachypnea gradually resolved and oxygen saturation increased above 94% and she was weaned off oxygen therapy on the fifth day. However, fever persisted till the ninth day and the Packed Cell Volume dropped to 24%, necessitating blood transfusion. Initial antibiotics were also switched to ciprofloxacin and gentamicin based on the available culture sensitivity result. Fever subsequently resolved and she had 10 days of the latter antibiotics parenterally. She was successfully extubated (Fig 1C) after six days of thoracostomy drainage and was discharged home after 18 days of hospitalisation. The child was seen thrice on follow up over a period of five months with a satisfactory clinical condition.

Pyopneumothorax is the accumulation of air and pus in the pleural space. It is a cause of severe respiratory distress potentially leading to respiratory failure if not promptly recognized and managed. It is rare in children and it’s scarcely reported in the neonatal period with only a few cases reported in the literature.^6,7 Although Johnson⁶ had posited that cases of pyopneumothorax could have been missed as air could have escaped due to diagnostic thoracocentesis hence, the majority were diagnosed with empyema thoracis instead. This is plausible especially in resource-poor settings where the facility for radiographic evaluation is not readily available.

Staphylococcal pneumonia could be complicated by exudative parapneumonic effusion and pneumatocele which could rupture to give a concomitant pneumothorax. In the neonatal period, risk factors for pneumothorax include assisted ventilation and Continuous Positive Airway Pressure (CPAP)  while empyema thoracis has been mostly reported in the context of congenital pneumonia (mostly due to perinatally acquired pathogens e.g., Escherichia Coli, Streptococcus) or healthcare-associated infection (HAI).^8–10 None of these risk factors were present in the neonate highlighted in this report. However, non-exclusive breastfeeding and low socio-economic status are recognized risk factors for pneumonia while pustular skin eruption is a known antecedent to staphylococcal septicaemia; these were present in the highlighted case. Anaemia due to Staphylococcal infection as seen in this case is probably due to the lytic effects of haemolysin elaborated by the organism.¹¹ 

Thoracostomy drainage and parenteral antibiotics are the mainstays of care in the acute phase of the pleural fluid collection as in the highlighted case, while intra-pleural fibrinolytic agent instillation and surgical decortication are often required for the chronic stages of empyema.¹² Due to financial constraints, our patient had thoracostomy drainage with an improvised catheter and bottled water container for the underwater seal with good results. Although Video-Assisted Thoracoscopic Surgery (VATS) could have improved the safety of the thoracostomy drainage, facilities for this procedure was not available in our centre.¹² Nevertheless, our patient did not develop any complications from the procedure. A similar satisfactory result has been reported with the use of improvised thoracostomy drainage from a previous study.⁵ The isolate in the highlighted neonate was sensitive to erythromycin, gentamicin, ciprofloxacin and rifampicin but resistant to amoxicillin, cloxacillin and ceftriaxone which necessitated a switch from the empirical antibiotic regimen. There are reports of S. aureus strains resistant to penicillin, this has to be borne in mind and microbial culture must be pursued in all suspected cases to guide rational antibiotic use.^13,14

Ciprofloxacin was used for our patient because it was cheap and available in parenteral form. Despite the shorter duration of antibiotics therapy, the patient highlighted did not have re-accumulation of pleural collection, spent lesser days on admission and has satisfactory clinical findings on follow up. However, in previous studies antibiotics therapy was prolonged (21 days) and the duration of hospitalizations was longer.^9,15 But unlike the highlighted case where the patient developed pyopneumothorax following community-acquired pneumonia, the patients in these latter cases had developed empyema thoracis while on admission which would suggest HAI thus, justifying longer duration of antibiotics treatment and prolonged hospitalisation.

Staphylococcal pneumonia could be complicated by pyopneumothorax in the neonatal period especially in the context of the highlighted risk factors. Low-cost interventions could be used with good results in the resource-constraint setting.

Ethical Consideration

Informed consent was sought and obtained from the parent of the subject highlighted

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