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Complex thoracic infections frequently present in the form of complicated pneumonia, loculated pleural effusion, empyema, or pulmonary abscess. If not treated appropriately, they can become chronic infections complicated by resistant bacterial, viral, or fungal organisms. The indolent nature of these complex infections and the high rate of antibiotic resistance may end in extensive parenchymal destruction, recurrent infections, and a disseminated infectious process.
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The specialty of thoracic surgery was born in the convergence of two worldwide plagues. These were tuberculosis (TB), as old as humankind, and avian influenza, which struck during the winter of 1917 and killed more people than the bubonic plagues of the Middle Ages. Today, with TB becoming resistant to antituberculous chemotherapy, aggressive flu strains are beginning to appear around the world, with sophisticated immunosuppressive medications being added to the arsenal of what were once believed to be lethal diseases. Together with the risk of coinfection with HIV, these factors have led to a rejuvenation of surgical treatments for complex thoracic infections, and surgery may again play an important role in the management of complex infections.
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In the following chapter, we focus on the surgical treatment of TB and fungal infections. Both a historical overview and current treatment methods are reviewed. Although described for TB and/or fungal diseases, the principles of treating such infections can also be selectively used for highly complex infections that are not responsive to current treatment and that pose life-threatening or chronic debilitation for patients.
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Pulmonary Tuberculosis
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TB has been a major cause of morbidity and mortality in human society since the Stone Age. In 2016, one-fourth of the world population remained infected with TB. The annual incidence was 10.4 million, with an annual mortality rate of 1.3 million worldwide. It remains the ninth leading cause of global deaths and the leading cause of death from a single infectious agent. In addition, in 2016, an additional 374,000 deaths occurred among HIV-positive people infected with TB. TB associated with HIV and drug-resistant TB (DR-TB) are emerging as threats and continue to be treatment challenges. Of 600,000 new cases of rifampicin-resistant TB, rifampicin being the most effective first-line drug, 490,000 were multidrug-resistant TB (MDR-TB) and almost half the cases were in India, China, and Russia.1–3 Globally, the TB mortality and incidence rates are falling by 3% and 2% per year, respectively, with the goal of a 5% and 10% decrease per year by 2020, respectively, as treatment and medical care advance.3,4
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Pulmonary tuberculous diseases are contagious infections caused by bacterial organisms or bacilli of the Mycobacteriaceae family. The most common type is Mycobacterium tuberculosis, but other types produce similar pathologic changes. Pulmonary TB is the major target organ involved in 85% of the victims because the disease is transmitted by the aerolization of infected respiratory droplets (by sneezing, coughing, speaking, or spitting), and ...