Surgical management of necrotizing pneumonia with advanced empyema in a 3-year-old child: A case report

Rajamma1*, Shalini H S2, Vijaya kumari. D3

1Nursing Incharge, Kauvery Hospital, Electronic city.

2CNO, Kauvery Hospital, Electronic City.

3Nurse Educator, Kauvery Hospital, Electronic City

*Correspondence

Abstract

Necrotizing pneumonia is an uncommon but severe complication of bacterial pneumonia, associated with high morbidity and mortality. Necrotizing pneumonia is a rare and severe complication of bacterial community-acquired pneumonia (CAP). Lying on a spectrum between lung abscess and pulmonary gangrene, necrotizing pneumonia is characterized by pulmonary inflammation with consolidation, peripheral necrosis and multiple small cavities. Compromise of the bronchial and pulmonary vascular supply has the potential for devitalization of lung parenchyma. The lack of blood supply to the under perfused areas impedes delivery of antibiotics, allowing for uncontrolled infection and further destruction of lung tissue. Pulmonary gangrene is the “final stage in a continuum of progressive devitalization of pulmonary parenchyma “and is characterized by “sloughing of a pulmonary segment or lobe. Managing patients with necrotizing pneumonia is challenging because there are no firm guidelines outlining when to proceed from medical to surgical management. The mainstay of treatment is supportive with appropriate antibiotics; however, if patients fail to improve, surgery may be a life-saving option.

Key words: Necrotizing pneumonia; Pulmonary gangrene; Streptococcus pneumoniae

Introduction

Pneumonia remains one of the leading infectious causes of death in children worldwide, with the greatest burden seen in South Asia and sub-Saharan Africa. Streptococcus pneumoniae remains the most common bacterial cause of pneumonia in children globally. Necrotizing pneumonia is an uncommon but severe complication of community-acquired pneumonia and is characterized by liquefaction, cavitation, and destruction of lung parenchyma. It is frequently associated with pleural complications, including parapneumonic effusion and empyema, and may require prolonged antimicrobial therapy, respiratory support, and surgical intervention in selected cases. We report the successful multidisciplinary management of a 3-year-old child with invasive pneumococcal disease complicated by severe necrotizing pneumonia and advanced empyema, who required video-assisted thoracoscopic surgery (VATS) with decortication.

Case presentation

A 3-year-old girl weighing 12.3 kg (10th–25th centile) and measuring 89 cm in height (3rd–10th centile) presented with a 5-day history of high-grade fever and reduced activity. This was preceded by a 2-week history of cold and cough, along with a 2-day history of left-sided chest pain. Her recent medical history was notable for a urinary tract infection 3 weeks earlier, which had been treated with oral antibiotics. She also had a history of nebulization since June 2025 without controller therapy.

On arrival, she was markedly unwell, with tachycardia (heart rate 190/min), tachypnoea (respiratory rate 68/min), and hypoxia (SpO2 89% on room air). Clinical examination revealed subcostal retractions, shallow breathing, restricted chest movement, and decreased air entry on the left side. She appeared drowsy, although no focal neurological deficits were present. She was immediately started on high-flow nasal cannula (HFNC) oxygen support and transferred to the Paediatric Intensive Care Unit (PICU) for further management.

Investigations

Initial laboratory evaluation showed a total leukocyte count of 30,030/mm3 with 74% neutrophils, an elevated C-reactive protein (CRP) of 44.8 mg/dL, and a procalcitonin level of 28.87 ng/mL. Pleural fluid analysis was consistent with an exudative pleural infection, with a cell count of 1600/mm3 (90% neutrophils), protein 4.61 g/dL, glucose 11 mg/dL, and LDH 72,511 U/L.

Respiratory polymerase chain reaction (PCR) testing was positive for Streptococcus pneumoniae. Blood and pleural fluid cultures showed no growth.

Chest radiography demonstrated extensive left-sided consolidation with pleural effusion. Ultrasound of the chest performed on 11/11/2025 showed consolidation in the left lower lobe with air bronchograms and mild pleural effusion. Contrast-enhanced computed tomography (CECT) of the thorax revealed a large area of consolidation with air bronchograms involving the left upper and lower lobes, along with areas of non-enhancement and architectural distortion in the left apico-posterior segment, consistent with necrotizing pneumonia. Mild left pleural effusion and patchy atelectatic changes in the right upper lobe were also noted.

A 2D echocardiogram was normal. Evaluation for primary immunodeficiency, including immunoglobulin levels, Dihydrorhodamine (DHR) testing, and lymphocyte subset analysis, was also normal.

Initial management and pre-operative Care

The patient was managed in the PICU with continuous monitoring of heart rate, respiratory rate, oxygen saturation, and work of breathing. She remained on HFNC oxygen support and received intravenous fluid therapy.

Empirical antimicrobial treatment was initiated with intravenous Ceftriaxone and oral Azithromycin. Once the surgical plan was finalized, she was kept Nil per Oral (NPO). A right femoral central venous line was placed to ensure secure vascular access.

Surgical management

On 13/11/2025, corresponding to day 3 of admission, the patient underwent left video-assisted thoracoscopic surgery with decortication under general anaesthesia, performed by Dr. Shounak C.

Intra-operatively, thick pleural fluid and advanced empyema, described during surgery as Stage IV empyema, were identified. There was near-complete necrotization of the left lower lobe, and a major air leak was noted arising from the left lower lobe. Thoracoscopic ports were inserted at the 5 mm scapular angle, 5 mm anterior axillary line, and 5 mm paraspinal area. Following decortication, thorough pleural lavage was performed.

Pleural fluid and lung tissue specimens were sent for microbiological assay and histopathological examination.

Post-operative course

Following the procedure, the child developed hypercarbia, repeated desaturation episodes, and a persistent major air leak. She required mechanical ventilation for 24 hours and was then extubated back to HFNC support.

Her haemoglobin dropped from 8.5 g/dL to 6.6 g/dL, necessitating transfusion of leucodepleted packed red blood cells. She also developed subcutaneous emphysema post-operatively, which gradually resolved over the following 2 weeks.

High-grade fever spikes persisted for 48 hours after surgery and subsequently decreased in frequency to approximately one febrile spike per day. Antibiotic therapy was escalated to intravenous meropenem and teicoplanin and later modified to linezolid and clindamycin based on clinical progression.

By post-operative day (POD) 10, an intercostal drainage (ICD) tube remained in situ with purulent output, following which clindamycin was initiated. On POD 14, the ICD tube was clamped. A follow-up chest X-ray showed satisfactory lung expansion with resolving consolidation. The ICD tube was removed on POD 18.

Post-operative Nursing Care

Post-operative care included close monitoring for respiratory distress, persistent air leak, and subcutaneous emphysema. The ICD site was regularly assessed, and drainage volume and characteristics were monitored, including purulent output noted on POD 10.

Pain was managed with syrup Ibugesic and intravenous analgesia. As her condition improved, chest physiotherapy, breathing exercises, and incentive spirometry were facilitated. Nutritional rehabilitation included encouragement of a protein-rich and iron-rich diet in view of iron deficiency anaemia.

Outcome and follow-up

The patient completed 4 weeks of intravenous antibiotics and remained clinically stable and afebrile for 48 hours prior to discharge. At discharge, she was haemodynamically stable, maintaining oxygen saturation above 96% on room air.

Discharge medications and advice

  • Syrup Augmentin DDS for 2 weeks (10/12/2025 to 22/12/2025)
  • Vitamin D supplementation (Calcirol sachet weekly)
  • Iron supplementation (Syp. Tonoferon P)
  • Calcimax Plus for 1 month
  • Continuation of chest physiotherapy and spirometry at home

Follow-up was scheduled with aar. Yashaswini on 16/12/2025.

 Discussion

Necrotizing pneumonia is a severe suppurative complication of paediatric community-acquired pneumonia, marked by pulmonary parenchymal destruction, cavitation, and impaired perfusion within affected lung segments. It is most associated with Streptococcus pneumoniae and Staphylococcus aureus, and often presents with persistent fever, respiratory distress, pleural involvement, and failure to improve with standard therapy. Diagnosis typically relies on a combination of chest radiography, ultrasonography, and contrast-enhanced CT, the latter being particularly helpful in identifying non-enhancing necrotic lung tissue.

This child had severe invasive pneumococcal disease with extensive unilateral consolidation, empyema, and radiological evidence of necrotizing pneumonia. Although both blood and pleural fluid cultures were sterile, respiratory PCR was positive for Streptococcus pneumoniae, which supported the diagnosis in the setting of prior antibiotic exposure and a strongly suggestive clinical-radiological picture. The intra-operative finding of near-complete necrotization of the left lower lobe with a major air leak highlighted the aggressive nature of the disease process.

The empyema in this case was advanced, with thick pleural fluid, significant pleural organization, and persistent sepsis. In children with pleural infection, medical management with antibiotics, drainage, and fibrinolytic therapy is often effective. However, surgical intervention becomes important when there is failure of clinical and radiological improvement, persistent pleural collection, bronchopleural fistula or major air leak, trapped lung, or significant pleural peel. British Thoracic Society guidance supports early surgical discussion in children who fail initial medical management and recognizes a role for decortication in organized empyema in symptomatic children.

In the present case, VATS decortication was crucial in achieving pleural clearance and allowing lung re-expansion, despite a challenging post-operative course marked by hypercarbia, persistent air leak, anaemia, and subcutaneous emphysema. The child’s eventual recovery reflects the value of timely surgery, prolonged antimicrobial therapy, intensive respiratory support, meticulous nursing care, and multidisciplinary follow-up.

This case also underscores the importance of monitoring for systemic and treatment-related complications, including anaemia, nutritional deficiencies, and prolonged drainage requirements. Reassuringly, despite the severity of necrotizing pneumonia, published reviews suggest that prognosis is often favourable when early recognition and appropriate escalation of care are achieved.

Conclusion

Necrotising pneumonia complicated by advanced empyema in young children represents a severe, life – threatening condition that often fails to respond to conservative management alone. This case highlights that timely recognition, close clinical monitoring, and stepwise escalation of care are critical for favourable outcomes. When medical management and plural drainage are inefficient, early surgical intervention such as video assisted thoracic surgery (VATS) or Open decortication plays a pivotal role in controlling infection, facilitating lung re-expansion and preventing long term pulmonary sequelae.

In this 3-year-old child, prompt surgical management resulted in complete clinical recovery with good lung function and no significant complications. This underscores the importance of multidisciplinary approach involving paediatricians, intensivist, and thoracis surgeons. Early referral for surgical evaluation in advanced empyema can significantly reduce morbidity, shorten hospital Stay and improve overall prognosis in paediatric patients.

 “Every breath regained is a victory for timely care & teamwork”.

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