Pleural empyema is a known complication of bacterial pneumonia in childhood; however, it has been reported very rarely in neonatal population. The management of empyema in neonates has been either conservative with intravenous antibiotic therapy or conventional with tube thoracostomy [1]. Here, we report use of video-assisted thoracoscopic surgery (VATS) in a 20-day old neonate with staphylococcal pneumonia.

A 20-day-old male newborn was admitted to our hospital with a two-day history of fever, irritability and vomiting. The infant was born at term gestation via cesarean section with unremarkable antenatal history. Except for tachypnea, his clinical examination was normal. Chest X-ray done at admission was normal, and he was managed with intravenous fluids and antibiotics. Investigations revealed normal white cell counts but C-reactive protein (CRP) was significantly elevated (287.8 mg/L). Over next 24 hours, the infant developed respiratory distress with reducing oxygen saturation, and chest X-ray revealed dense homogenous opacification of left hemithorax. Ultrasonography of chest was suggestive of left lower lobe consolidation with no pleural collection. Infant was commenced on continuous positive airway pressure (CPAP) support. The blood culture grew methicillin-resistant Staphylococcus aureus (MRSA) and antibiotics were changed to intravenous vancomycin as per antibiotic sensitivity pattern. Chest X-ray on day 4 showed opacification of left hemithorax with heart and mediastinum pushed towards right. High resolution computed tomography (HRCT) of chest revealed gross mediastinal shift to the right with collapse of the lung medially and multiple septation running radially outwards dividing significant empyema collection in multiple loculi.

The infant underwent video-assisted thoracoscopic surgery (VATS); where evacuation of empyema fluid, debridement with breaking of multiple loculi and decortication of thickened parietal and visceral pleura was performed. Pus culture showed growth of MRSA with similar antibiotic sensitivity as in blood culture. Intercostal drain was removed on third post-operative day and infant was weaned from CPAP to room air. Infant had significantly improved left sided chest air entry and serial postoperative chest X-rays suggested well expanded lungs. Antibiotics were stopped after a total duration of 14 days. Investigations for primary immunodeficiency for the infant were normal. Both the infant’s and parents’ nasal swabs were negative for MRSA colonization. On follow-up, the infant was asymptomatic and chest radiograph after a month was normal.

Thoracoscopic decortication by early VATS as a first-line treatment for pediatric empyema has shown to reduce the mean length of hospital stay by around 6-8 days, compared to tube thoracostomy [2]. Even though VATS has been established as one of the standard modalities for the treatment of pleural empyema in pediatric population, its usage has not been reported for the same in neonates. The youngest child reported to undergo VATS for post-pneumonic empyema was older than one month, and it was used as a rescue measure for empyema that was refractory to medical response [3]. Non-availability of small sized instruments, technical limitations in suturing very small thoracic cavities and injury to surrounding tissues have been reported as an impediment for using VATS routinely in neonates [4,5]. However, we did not have any of above complications in our case. The conventional duration of antibiotic therapy in cases of empyema has been three to four weeks. In this case, we administered antibiotics for two weeks only as thoracoscopic debridement was performed early and there was clinical as well as biochemical recovery.

Staphylococcal empyema has become much more common after the introduction of pneumococcal conjugate vaccine for infants [6]. Considering the widespread prevalence of MRSA in children and adult population, more cases from neonatal population are likely to be reported as pneumococcal vaccination increases as well. We, herein suggest that while intravenous antibiotics and catheter drainage remain the mainstays of treatment of neonatal empyema, VATS can be safely considered as a primary treatment modality to promote earlier recovery and shorten antibiotic therapy.

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2. Kercher KW, Attorri RJ, Hoover JD, Morton D Jr. Thoracoscopic decortication as first-line therapy for pediatric parapneumonic empyema. A case series. Chest. 2000;118: 24-27.

3. Leung C, Chang YC. Video-assisted thoracoscopic surgery in a 1-month-old infant with pleural empyema. J Formosan Med Assoc. 2006;105:936-40.

4. Koga H, Suzuki K, Nishimura K, et al. Traction sutures allow endoscopic staples to be used safely during thoracoscopic pulmonary lobectomy in children weighing less than 15 kg. J Laparoendosc Adv Surg Tech A. 2013;23:81-3.

5. Rothenberg SS, Kuenzler KA, Middlesworth W, et al. Thoracoscopic lobectomy in infants less than 10 kg with prenatally diagnosed cystic lung disease. J Laparoendosc Adv Surg Tech A. 2011;21:181-84.

6. Schultz KD, Fan LL, Pinsky J, et al. The changing face of pleural empyemas in children: Epidemiology and management. Pediatrics. 2004;113:1735-40.