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INTRODUCTION

Primary infections of the chest wall, although uncommon, are an important problem for thoracic surgeons. The severity of these infections can range from relatively minor and inconvenient to life-threatening situations that require urgent and aggressive care. Since most surgeons will see only a small number of cases in their careers, an organized approach to management is essential. In this chapter, we present our preferred methods of classification and review the various aspects of management.

CLASSIFICATION

A review of the literature suggests that there is no standard or ideal way to categorize all primary chest wall infections. In our experience, classification according to type of organism, anatomic location, and the presence or absence of necrosis are the most important variables for organizing the majority of clinical presentations of chest wall infections.

TYPE OF ORGANISM

Bacterial

Bacterial infection is among the most common type of chest wall infection. Although diagnosis may be straightforward on culture, this may not be the case with certain fastidious organisms or if the patient has already received antibiotic therapy. Infections may be mono- or polymicrobial. Staphylococcus sp. is a common organism that produces typical features of infection and can vary in appearance from small abscesses to destructive chest wall masses. Although Staphylococcus sp. infections may develop without any warning or history, they most commonly arise as a complication of surgical procedures or trauma. Streptococcus spp., such as pneumoniae and milleri, also are common culprits and can be related to underlying empyema. Anaerobic infections (e.g., Bacteroides spp.) can be life-threatening and often arise from the oral cavity as a result of poor dentition with extension into the head and neck, mediastinum, and chest wall. Invasion of the chest wall from an underlying lung infection is not unusual and can be difficult to distinguish from a primary pulmonary malignancy with chest wall invasion. These infections are more common in immunocompromised patients such as those with diabetes.

Unusual organisms, such as Actinomyces spp., can arise in the oropharynx and affect the chest wall and underlying thoracic structures. The most common of these organisms is Actinomyces israelii. Aspiration is the most common cause, with lower lobes being the predominant area affected. Pulmonary infection from Actinomyces spp. may also result in an empyema, which in turn may extend into the chest wall.1 Sulfur granules are pathognomonic of Actinomyces infection and are composed of colonies of organisms surrounded by neutrophils.2

Fungal

Fungal infections of the chest wall are quite uncommon and typically arise in immunocompromised individuals either as a primary infection or as part of a disseminated infection. Occasionally, these types of infections occur after surgical procedures. Fungal organisms that may cause infection include Aspergillus, Candida, Rhizopus, Mucor, Absidia, and Phycomyces spp.3 Fungal infections can be extremely difficult to eradicate and may ...

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