Rare Infections of the Pleural Space

João Marcelo Lopes Toscano de Brito, MD, Alessandro Wasum Mariani, MD, PhD, Ismael A. Conti Díaz

Key Points

  • The pleural space can be the primary or secondary site for many infections;
  • Some of these rare infections can be suspected on the radiological exam, like hydatidosis; others, like nontuberculous mycobacteriosis, can be unspecific;
  • The diagnostic approach to rare infections of the pleural space can require the analysis of the gross material, direct examination, culture, pathological, and even molecular exams;
  • Independently of the etiology, if there is no direct contamination of the pleural space, thoracic drainage may be only necessary to alleviate symptoms; on the other hand, if there is direct pleural contamination, the evacuation of the gross infected material from the pleural space and adequate drug therapy will be the basis of treatment;
  • Pleural hydatidosis can rarely happen by direct dissemination but is most commonly secondary to the rupture of hydatid cysts adjacent to the pleura;
  • Pleuropulmonary amoebic disease is predominantly caused by complications of the extraintestinal parasitic infection, mainly direct extension from the amoebic liver abscess;
  • Fungal infections of the pleural space are rare but can be very serious. There are descriptions for aspergillosis, actinomycosis, histoplasmosis, coccidioidomycosis, blastomycosis, mucormycosis, cryptococcosis, and candida albicans on the pleural space;
  • In contrast to tuberculosis, the nontuberculous mycobacteria rarely affects the pleural space; however, high mortality is expected whenever it happens;
  • Nocardia pleural involvement is due to the contiguous spread of a necrotizing pneumonitis, and the diagnosis is essential to guarantee adequate drug treatment (usually sulfonamides) and appropriate pleural intervention;
  • Metagenomic next-generation sequencing and targeret molecular testing are promising tools in the diagnosis of atypical pathogens.

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