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Empyema: Causes, Symptoms and Treatment

An empyema is a collection of pus within a pre-formed body cavity, most commonly the pleural space. It typically develops as a complication of a bacterial infection such as pneumonia.

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Things worth knowing about "Empyema"

An empyema is a collection of pus within a pre-formed body cavity, most commonly the pleural space. It typically develops as a complication of a bacterial infection such as pneumonia.

What Is an Empyema?

An empyema refers to the accumulation of pus within a naturally occurring body cavity. The most common form is the pleural empyema (also called empyema thoracis), in which infected fluid collects in the pleural space -- the area between the lungs and the chest wall. Other sites that can be affected include joints (leading to septic arthritis), the gallbladder, the sinuses, and the epidural space surrounding the spinal cord.

Causes

Empyema typically arises as a complication of an existing infection or medical procedure. The most common causes include:

Bacterial pneumonia: the leading cause of pleural empyema
Thoracic or abdominal surgery
Chest trauma
Rupture of a lung abscess into the pleural space
Bloodstream infection (bacteremia) spreading to a body cavity
Esophageal perforation

Common causative bacteria include Streptococcus pneumoniae, Staphylococcus aureus (including MRSA), gram-negative organisms, and anaerobes.

Symptoms

Symptoms vary depending on the location and severity of the infection. Typical symptoms of pleural empyema include:

Fever and chills
Chest pain, often worsening with breathing
Cough, sometimes with sputum production
Shortness of breath (dyspnea)
General malaise, fatigue, and weight loss
Reduced appetite

In chronic cases, a thickened fibrous layer called a pleural peel (fibrothorax) may develop, permanently restricting lung expansion.

Diagnosis

Diagnosis of empyema involves a combination of clinical evaluation and diagnostic testing:

Imaging: chest X-ray, pleural ultrasound, and CT scan to assess the size, location, and characteristics of the fluid collection
Thoracentesis (pleural tap): removal of fluid from the pleural space for biochemical, cytological, and microbiological analysis. Turbid or frankly purulent fluid with low pH, low glucose, and elevated LDH is characteristic of empyema.
Laboratory tests: full blood count (elevated white cell count), CRP, procalcitonin, and blood cultures to identify the causative organism

Treatment

The goals of treatment are to drain the infected fluid, eradicate the infection, and allow full re-expansion of the lung.

Antibiotic Therapy

Intravenous antibiotics are always required. The choice of antibiotic is guided by culture results; broad-spectrum agents are used initially when the causative organism is not yet known.

Drainage

Drainage of the pus is the cornerstone of treatment. Options include:

Thoracentesis: simple needle aspiration for uncomplicated effusions
Chest tube drainage: insertion of a drainage tube for continuous evacuation of infected fluid
Intrapleural fibrinolytic therapy: instillation of agents such as tPA and DNase through the drain to break down loculations and improve drainage
Video-assisted thoracoscopic surgery (VATS): minimally invasive surgical procedure to debride and drain multiloculated empyemas
Open thoracotomy and decortication: surgical removal of the fibrous pleural peel in chronic, organized empyema

Supportive Care

Breathing exercises and physiotherapy are important adjuncts to promote full lung re-expansion and restore respiratory function.

Prognosis

With prompt diagnosis and appropriate management, the prognosis is generally favorable. Delayed treatment can lead to chronic empyema, fibrothorax, sepsis, or life-threatening complications. Elderly patients, immunocompromised individuals, and those with significant comorbidities are at highest risk of poor outcomes.

References

Davies H.E., Davies R.J., Davies C.W. - Management of pleural infection in adults: British Thoracic Society Pleural Disease Guideline 2010. Thorax, 65(Suppl 2):ii41-53.
Light R.W. - Parapneumonic effusions and empyema. Proceedings of the American Thoracic Society, 2006; 3(1):75-80.
Maskell N.A. et al. - U.K. Controlled trial of intrapleural streptokinase for pleural infection. New England Journal of Medicine, 2005; 352(9):865-874.

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