Infections of the Chest Wall

A. SKIN AND SOFT TISSUE INFECTION A-1 Abscess 1. It is rarely associated with an abnormal chest radiograph. 2. Potentially serious infections of the chest wall are subpectoral and subscapular abscesses.

A-1 Abscess 3. Local pain with or without swelling, fever and leukocytosis may be present. 4. Chest CT scan can identify the problem. 5. Prompt drainage and antibiotics therapy can be successful.

A-2 Gangrene 1. These necrotizing infections are usually at the chest tube or thoracotomy site. 2. Infections of the head and neck as well as dental manipulation are the source of necrotizing infections of chest wall.

A-2 Gangrene 3. Radical debridement, antibiotics therapy, ventilatory support and delayed closure of the wound are choice of treatment. 4. Antibiotics includes penicillin or ampicillin, an aminoglycocide, and clindamycin or metronidazole.

B. INFECTIOUS CHEST WALL INVASION 1. Drug resistance or superinfection on antibiotics therapy can cause pneumonia progressing to infectious chest wall invasion. 2. Acinetobacter calcoaceticus, Actinomyces species infections are ever reported. Penicillin therapy is helpful and surgical intervention may not be necessary.

C. EMPYEMA NECESSITATIS 1. It refers soft tissue infection because of undrained underlying pleural infection. 2. It is infrequent today. 3. The soft tissue component may require separate drainage and resolve if empyema is drained promptly.

D. MONDOR’S DISEASE 1. It is a benign disease with localized thrombophlebitis of the anterior chest wall, axilla and breast. 2. Its true incidence is unknown. 3. Most cases are female and radical mastectomy will induce the disease. 4. The disease presents as cordlike structure. 5. No specific therapy is necessary.

E. MISCELLANEOUS INFECTIONS 1. Golladay reported 3 benign diseases presented as chest wall masses. 2. These diseases are trichinosis, nodular fasciitis and myositis ossificans. 3. The latter 2 were secondary to trauma.

E-1 Tietze’s syndrome 1. It refers painful, nonsuppurative swelling of the costal cartilages without abnormal histologic change. 2. Its true incidence is unknown. 3. Emotional tension is frequently associated with the symptom complex. 4. Treatment with compounds containing ibuprofen, hydrocortisone infiltration and surgical removal of the involved area may be helpful.

E-2 Costochondritis 1. Before 1940, most chondritis was caused by tuberculosis. 2. Today, it was followed by surgery, most cases are sternotomy for cardiac disease.

E-2 Costochondritis 3. The 5th to 9th costal cartilages are fused, so infections involve any these segments may dictate a major resection for cure. 4. The xiphoid is partially a cartilage structure, so it can promote bilateral spread of the infection.

E-2 Costochondritis 5. The primary organisms are. E. coli, S. Pneumo- niae, P. aeruginosa, M.tuberculosis, staphy- lococci, streptococci, and Norcardia. 6. Radical resection is the preferred treatment. 7. If lower ribs are involved then all fused segments must be removed. 8. No bare cartilage is left in the infected wound.

E-3 Osteomyelitis E-3-1 Sternal osteomyelitis 1. It was uncommon today. 2. Primary sternal osteomyelitis usually occurs in heroin addicts. 3. Secondary sternal osteomyelitis usually occurs after cardiac surgical procedure.

E-3-1 Sternal osteomyelitis 4. The risk factors includes DM, low cardiac output, use of bilateral internal thoracic artery graft and re-operation for postoperative bleeding. 5. The first sign of postoperative sternal osteomyelitis are unstable sternum and discharge

E-3-1 Sternal osteomyelitis 6. In chronic sternal osteomyelitis, extensive sternal and chondral removal with myocutaneous reconstruction can be performed. 7. Bilateral pectoralis major( PM ) flap is the most common used flap.

E-3-1 Sternal osteomyelitis 8. A modified H incision is used to mobilize the PM muscle with the thoracoacromial artery. 9. If possible, the upper manubrium and clavicular attachment is left intact. 10. The humeral head of PM muscle is transected.

E-3 Osteomyelitis E-3-2 Rib osteomyelitis 1. It is diagnosed by local inflammatory signs and symptoms or persistent draining sinus. 2. Confirmation is made by CXR, and CT scan is not usually necessary. 3. Excision of all diseased bones is helpful.

E-3 Osteomyelitis E-3-3 Sternoclavicular osteomyelitis 1. It usually occurs in addicts and patients with subclavian catheters. 2. Routine CXR is not helpful, even CT scan has little help. 3. MRI is more sensitive than CT scan.

E-3-3 Sternoclavicular osteomyelitis 4. Radical debridement with removal of the sternoclavicular joint, including sternum, clavicle and the 1st rib. 5. It was reported to remove a portion of the 2nd rib. 6. A flap is made including PM muscle. 7. A foreign material or mesh should be avoided.

E-3 Osteomyelitis E-3-4 osteoradionecrosis 1. It is usually caused by radiation for breast cancer. 2. Wide excision with primary coverage of the defect is the choice of treatment. 3. Flaps can used, including PM, rectus abdominis and latissimus dorsi flaps. 4. A foreign material or mesh should be avoided if infection is present.

F. IMMUNOCOMPROMISED PATIENTS 1. Patients are immunocompromised because of malignancy, malnutrition and HIV infection. 2. Chest wall infection of these patients may be subtle. 3. Aggressive debridement and antibiotics therapy may lead to good results.