Early pleural decortication for thoracic empyema in immunosuppressed patients

Patients with empyema and impaired immune response often remain in a toxic condition after tube thoracostomy because the infection is not localized and walled off satisfactorily. Consequently, the reported mortality rate is extremely high. Despite the expectation of a high mortality rate from thoracotomy and débridement in this category of critically ill patients, we were forced to perform pleural decortication in eight patients after lesser procedures had failed. They were immunodeficient because of (1) high-dose steroids (HDS) for sagittal sinus thrombosis, (2) HDS for systemic lupus erythematosus, (3) HDS for chronic myelogenous leukemia and myelofibrosis, (4) HDS for multiple myeloma, (5) hemolytic anemia with pulmonary infiltrates, (6) chemotherapy for Hodgkin's disease, (7) diabetes mellitus with Kimmelstiel-Wilson disease, and (8) diabetes mellitus with chronic glomerulonephritis. Six of the eight patients survived and were discharged with completely healed incisions 3 to 6 weeks after operation. This compares well with the survival rates reported by others. Although risky, the over-all survival rate may be better with thoracotomy and decortication than with prolonged tube drainage and open drainage in immunodeficient patients with empyema, and the period of morbidity is shortened considerably.