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Chest
Diagnosis
Pleural Diseases
Effusion
Empyema
Empyema
Julia Alegría, MD; Jonathan Hero Chung, MD
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KEY FACTS

  • Terminology

    • Imaging

      • Top Differential Diagnoses

        • Pathology

          • Clinical Issues

            • Diagnostic Checklist

              TERMINOLOGY

              • Definitions

                • Pleural space infection; abscess
                  • Typically infected parapneumonic pleural effusion
                  • May result from hematogenous seeding of bacteria
                  • Rare but dangerous complication of chest surgery, trauma, mediastinitis, esophageal perforation
                  • Complication of other disease process, e.g., sub-diaphragmatic abscess
                • Empyema necessitatis
                  • Empyema that drains spontaneously to chest wall; pleurocutaneous fistula
                  • Typically: Tuberculosis, fungal infection, actinomycosis
                  • May involve breast; mastitis
                • Tension empyema
                  • Large or rapidly expanding pleural infection with lung compression and mediastinal shift
                  • Rarely complicated by cardiac arrest

              IMAGING

              • General Features

                • Radiographic Findings

                  • CT Findings

                    • MR Findings

                      • Ultrasonographic Findings

                        • Imaging Recommendations

                          DIFFERENTIAL DIAGNOSIS

                            PATHOLOGY

                            • General Features

                              • Staging, Grading, & Classification

                                • Gross Pathologic & Surgical Features

                                  • Microscopic Features

                                    CLINICAL ISSUES

                                    • Presentation

                                      • Demographics

                                        • Natural History & Prognosis

                                          • Treatment

                                            DIAGNOSTIC CHECKLIST

                                            • Consider

                                              Selected References

                                              1. Garvia V et al: Empyema 2020
                                              2. Godfrey MS et al: Medical and surgical management of empyema. Semin Respir Crit Care Med. 40(3):361-74, 2019
                                              3. Shaw JA et al: Pleural tuberculosis: a concise clinical review. Clin Respir J. 12(5):1779-86, 2018
                                              4. Santamarina MG et al: Multidetector CT for evaluation of the extrapleural space. Radiographics. 37(5):1352-70, 2017
                                              5. Shen KR et al: The American Association for Thoracic Surgery consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg. 153(6):e129-46, 2017
                                              6. Wongwaisayawan S et al: Emergency thoracic US: the essentials. Radiographics. 36(3):640-59, 2016
                                              7. Helm EJ et al: Imaging of the pleura. J Magn Reson Imaging. 32(6):1275-86, 2010
                                              8. Kraus GJ: The split pleura sign. Radiology. 243(1):297-8, 2007
                                              9. Chae EJ et al: Radiographic and CT findings of thoracic complications after pneumonectomy. Radiographics. 26(5):1449-68, 2006
                                              10. Qureshi NR et al: Imaging of pleural disease. Clin Chest Med. 27(2):193-213, 2006
                                              11. Wurnig PN et al: Video-assisted thoracic surgery for pleural empyema. Ann Thorac Surg. 81(1):309-13, 2006
                                              12. Bramley D et al: Tension empyema as a reversible cause for cardiac arrest. Emerg Med J. 22(12):919-20, 2005
                                              13. Cheng G et al: A retrospective analysis of the management of parapneumonic empyemas in a county teaching facility from 1992 to 2004. Chest. 128(5):3284-90, 2005
                                              14. Falguera M et al: Etiology and outcome of community-acquired pneumonia in patients with diabetes mellitus. Chest. 128(5):3233-9, 2005
                                              15. Misthos P et al: Early use of intrapleural fibrinolytics in the management of postpneumonic empyema. A prospective study. Eur J Cardiothorac Surg. 28(4):599-603, 2005
                                              16. Tsai TH et al: Community-acquired thoracic empyema in older people. J Am Geriatr Soc. 53(7):1203-9, 2005
                                              17. Evans AL et al: Radiology in pleural disease: state of the art. Respirology. 9(3):300-12, 2004
                                              Related Anatomy
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                                              Related Differential Diagnoses
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                                              References
                                              Tables

                                              Tables

                                              KEY FACTS

                                              • Terminology

                                                • Imaging

                                                  • Top Differential Diagnoses

                                                    • Pathology

                                                      • Clinical Issues

                                                        • Diagnostic Checklist

                                                          TERMINOLOGY

                                                          • Definitions

                                                            • Pleural space infection; abscess
                                                              • Typically infected parapneumonic pleural effusion
                                                              • May result from hematogenous seeding of bacteria
                                                              • Rare but dangerous complication of chest surgery, trauma, mediastinitis, esophageal perforation
                                                              • Complication of other disease process, e.g., sub-diaphragmatic abscess
                                                            • Empyema necessitatis
                                                              • Empyema that drains spontaneously to chest wall; pleurocutaneous fistula
                                                              • Typically: Tuberculosis, fungal infection, actinomycosis
                                                              • May involve breast; mastitis
                                                            • Tension empyema
                                                              • Large or rapidly expanding pleural infection with lung compression and mediastinal shift
                                                              • Rarely complicated by cardiac arrest

                                                          IMAGING

                                                          • General Features

                                                            • Radiographic Findings

                                                              • CT Findings

                                                                • MR Findings

                                                                  • Ultrasonographic Findings

                                                                    • Imaging Recommendations

                                                                      DIFFERENTIAL DIAGNOSIS

                                                                        PATHOLOGY

                                                                        • General Features

                                                                          • Staging, Grading, & Classification

                                                                            • Gross Pathologic & Surgical Features

                                                                              • Microscopic Features

                                                                                CLINICAL ISSUES

                                                                                • Presentation

                                                                                  • Demographics

                                                                                    • Natural History & Prognosis

                                                                                      • Treatment

                                                                                        DIAGNOSTIC CHECKLIST

                                                                                        • Consider

                                                                                          Selected References

                                                                                          1. Garvia V et al: Empyema 2020
                                                                                          2. Godfrey MS et al: Medical and surgical management of empyema. Semin Respir Crit Care Med. 40(3):361-74, 2019
                                                                                          3. Shaw JA et al: Pleural tuberculosis: a concise clinical review. Clin Respir J. 12(5):1779-86, 2018
                                                                                          4. Santamarina MG et al: Multidetector CT for evaluation of the extrapleural space. Radiographics. 37(5):1352-70, 2017
                                                                                          5. Shen KR et al: The American Association for Thoracic Surgery consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg. 153(6):e129-46, 2017
                                                                                          6. Wongwaisayawan S et al: Emergency thoracic US: the essentials. Radiographics. 36(3):640-59, 2016
                                                                                          7. Helm EJ et al: Imaging of the pleura. J Magn Reson Imaging. 32(6):1275-86, 2010
                                                                                          8. Kraus GJ: The split pleura sign. Radiology. 243(1):297-8, 2007
                                                                                          9. Chae EJ et al: Radiographic and CT findings of thoracic complications after pneumonectomy. Radiographics. 26(5):1449-68, 2006
                                                                                          10. Qureshi NR et al: Imaging of pleural disease. Clin Chest Med. 27(2):193-213, 2006
                                                                                          11. Wurnig PN et al: Video-assisted thoracic surgery for pleural empyema. Ann Thorac Surg. 81(1):309-13, 2006
                                                                                          12. Bramley D et al: Tension empyema as a reversible cause for cardiac arrest. Emerg Med J. 22(12):919-20, 2005
                                                                                          13. Cheng G et al: A retrospective analysis of the management of parapneumonic empyemas in a county teaching facility from 1992 to 2004. Chest. 128(5):3284-90, 2005
                                                                                          14. Falguera M et al: Etiology and outcome of community-acquired pneumonia in patients with diabetes mellitus. Chest. 128(5):3233-9, 2005
                                                                                          15. Misthos P et al: Early use of intrapleural fibrinolytics in the management of postpneumonic empyema. A prospective study. Eur J Cardiothorac Surg. 28(4):599-603, 2005
                                                                                          16. Tsai TH et al: Community-acquired thoracic empyema in older people. J Am Geriatr Soc. 53(7):1203-9, 2005
                                                                                          17. Evans AL et al: Radiology in pleural disease: state of the art. Respirology. 9(3):300-12, 2004