INTRODUCTION:

Pleural empyema (PE) is the term for pus in the pleural space, which is frequently brought on by nearby pneumonia, damage to the chest wall, or a post-thoracic surgical problem. It can be managed with a variety of treatment approaches, such as thoracotomy drainage, video-assisted thoracoscopic surgery (VATS), intercostal drainage, and percutaneous aspiration¹. In terms of treatment success, surgical debridement or decortication—possibly through video-assisted thoracoscopic surgery (VATS)—has been shown to be superior to tube thoracostomy alone². About 65 percent of infections are caused by streptococcal species, such as S. aureus and SMG³. It seems that a subset of pleural empyema is caused by a group of bacteria that are not typically thought to be involved in pneumonia⁴. The presence of bacteria in pleural fluid as determined by Gram stain, culture, or 16S rRNA gene PCR was characterized as PE⁵. On rare occasions, fluid may accumulate in the spaces between the pleural layers or in the fissures when pleuritis is present (visceral and parietal). The most common things to culture are blood, pus, and exudative fluid⁶. Histoplasmosis is a primary fungal disease and a granulomatous disease caused by Histoplasma capsulatum. Although distributed worldwide, it is most prevalent in South, Central, and North America.⁷

Most Histoplasma infections are asymptomatic in normal immune hosts and do not result in long-term adverse sequelae. The remaining infected individuals develop one of several different clinical syndromes. A classification scheme subdivides symptomatic disease into acute pulmonary histoplasmosis, disseminated histoplasmosis, chronic pulmonary histoplasmosis, and complications from an excessive fibrotic response to the body⁸ Disseminated histoplasmosis occurs primarily in immunocompromised persons, elderly individuals, and patients with underlying chronic diseases.⁹

Few reports have investigated pleural effusion with Histoplasma, and a small number of acute histoplasmosis cases lead to pleural effusion¹⁰. Herein, we report for the first time, to our best knowledge, a case of empyema due to Histoplasma and bacterial infections in a diabetic patient after gastric cancer surgery treated with oral anticancer agents. We also review the literature to highlight the clinical features of this uncommon manifestation of histoplasmosis¹¹. Because of the fluid's plasma protein content, the pleural layers converge and may become adherent, organizing fibrin. Fibrous tissue restricts lung mobility, which ultimately results in a change in the patient's breathing pattern¹². The goals of physical therapy are to prevent the development of incapacitating adhesions between two pleural layers, restore lung expansion in its entirety, enhance lung ventilation, increase exercise tolerance, and preserve joint mobility¹³. In this case, the patient was receiving treatment and rehabilitation in hopes of improving his pleural empyema diagnosis, which was made a few months previously. He was referred to the physical therapy department, where the patient was given a proper, carefully planned treatment plan.

CASE PRESENTATION:

Patient Information:

The patient is a 44-year-old guy with a dominant right hand who initially complained of dyspnoea, a persistent cough with white sputum, and chest pain that lasted for one month. These sensations have gotten worse over time, making it harder to carry out regular tasks and decreasing your range of motion. First, the patient went to a Yavatmal private hospital and was given medicine. Later, Acharya Vinobha Bhave Rural Hospital was recommended to him, where X-rays and other diagnostic tests were performed, leading to a diagnosis of pleural empyema. Following this, he was referred for cardiopulmonary physiotherapy. Written and verbal consent from the patient was taken. On examination, the patient was found lying supine with the head end 30 degrees up. The patient suffered tachypnoea while being observed. He knew the time, where it was, and who all these people were. With a respiratory rate of 26 breaths per minute and an oxygen saturation of 95% on room air, the patient was mesomorphic and afebrile. A chest auscultation demonstrated bilaterally reduced air entry, and lower zones had intentional heard crackles. Chest radiograph revealed a uniform, greyish-white area that obscures the costophrenic angle, and the pleural membranes appear thickened and irregular.

Diagnostic Assessment:

To inspect the condition and severity, radiographic scans were carried out after and before the treatment. The chest X-ray, which reveals pleural empyema pre-treatment (Figure 1) and the chest x-ray of post treatment show positive recovery (Figure 2).

Therapeutic Intervention:

After the patient was made aware of his condition and approval was obtained, the procedure went as planned. A multidisciplinary approach facilitated the patient's faster recovery by increasing air entry throughout treatment. For three weeks, nebulization and aerosol therapy were applied three times a day to improve air circulation. The treatment was effective, based on the outcome measures that were obtained during the evaluation. As a result, the patient received interventions is given in (Table 1).

Table1: Tailored physiotherapy management which was given for one weeks

Goals	Intervention	Description of intervention	Repetition
Patient education	Guidance to patient and family members about the condition	The causes of pleural empyema are explained. The significance of pulmonary rehabilitation in conjunction with medical supervision is discussed. Patient is made aware of the importance of following an exercise program and receiving pulmonary rehabilitation.	-
To increase lung ventilation and oxygenation	Segmental breathing exercises like incentive spirometry and lateral coastal expansion deep breathing	The patient is instructed to inspire and expire while exhaling physiotherapist applies pressure laterally and downward.	10 reps x 1 set
To increase thoracic expansion	Thoracic expansion exercises	In order to promote chest expansion, the patient is told to raise their hands during inhalation and lower them during exhalation.	10 reps x 1 set
To increase flexibility	Upper limb and lower limb mobility exercises	Exercises involving active range of motion was given	10 reps x 1 set
To improve endurance	Spot marching, brisk walking and ambulation around hall.	In the presence of a physiotherapist, the patient is urged to progress their spot marching exercises to include walking up stairs and around the hall.	15 min

Table 2: Advanced pulmonary rehabilitation which was given for two weeks

Goals	Intervention	Description of intervention	Repetition
Aerobic exercise training	Arm leg ergometry	The patient receives instruction on the procedure of the static cycle. He was instructed to cycle till he was exhausted.	30 min
To enhance pulmonary function and the strength of the inspiratory muscles.	Inspiratory muscle training device	The patient is directed to breathe via the device and inhale as deeply as possible. It is carried out under the guidance of a physiotherapist.	10 reps x 2sets
Home program	Breathing techniques, such as deep breathing techniques. strengthening exercises using a one-litre water bottle for the upper and lower limbs. Inspired spirometry for endurance, walk around.	To prevent collapse, all workouts are recommended for the home program.	20 reps x 2 sets

Follow-up and outcome measure:

The patient was thoroughly assessed before patient rehabilitation, outcome measures were recorded post-rehabilitation, the home program was prescribed for two weeks, and assessment was taken at the time of follow-up (end of the seventh week) which revealed progression. Table 3 shows the outcome measures that were assessed after the completion of advanced pulmonary rehabilitation. The reliability of the six-minute walk test is 0.96 and the validity is 0.88.

Table 3:

Outcome measure	Pre-physiotherapy intervention	Post-physiotherapy intervention (5^thweek)
MMRC scale of dyspnea	Grade II	Grade I
Six-minute walk test	120 m	300m
Health-related quality of life (SF-6)	20	55

DISCUSSION:

Pus accumulation in the pleural cavity known as an empyema is most frequently brought on by underlying lung conditions such bacterial pneumonia, tuberculosis, lung abscess, or bronchiectasis. Most frequently, direct infection into the pleural space¹⁴. When fluid accumulates in the pleural cavity, pleural effusion happens. Either transudation or exudation can cause it. It could have no symptoms or be connected to pleuritic discomfort¹⁵. A secondary cause of pleural effusion may be empyema. A physiotherapist can help patients with these diseases by helping them restore mobility and function and by enhancing their quality of life¹⁶. A common component of post-thoracoscopy care has traditionally been chest physical therapy¹⁷. Thoracic expansion exercises, early mobilization, splinted coughing or huffing, the use of mechanical devices, and a carefully thought-out home exercise regimen upon discharge are all included¹⁸. Patients with pleural empyema who additionally receive physiotherapy as part of their routine care have better spirometry and radiological findings as well as shorter hospital stays, according to another study by Valenza-Demet et al.¹⁹

Intermittent positive airway pressure allows for optimal lung expansion, which accelerates the removal of pleural effusion, reduces the duration of respiratory system impairment and chest drainage in patients, shortens hospital stays, and lowers the risk of developing pulmonary complications²⁰.

We can, therefore, draw the conclusion that forced vital capacity, functional capacity, and pulmonary function can all be enhanced by using flow-metric incentive spirometry in conjunction with breathing exercises and airway clearing strategies. In order to both prevent and treat lung issues; chest physical therapy is crucial.

CONCLUSION:

This case study shows how the management of pleural empyema can be greatly improved by incorporating chest physical therapy and acting quickly. The patient's symptoms significantly improved, pleural fluid decreased, and general respiratory function improved after receiving targeted antibiotics and physiotherapeutic treatments promptly. The positive result in this instance emphasizes the need for prompt, thorough care in averting problems and avoiding more intrusive operations, which maximizes patient recovery.

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Received on 31.03.2025 Revised on 18.04.2025

Accepted on 03.05.2025 Published on 15.05.2025

Available online from May 17, 2025

Research J. Science and Tech. 2025; 17(2):115-118.

DOI: 10.52711/2349-2988.2025.00016

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