Pediatric Empyema Clinical Presentation

  • Author: Peter H Michelson, MD; Chief Editor: Michael R Bye, MD   more...
 
Updated: Mar 5, 2012
 

History

Clinical manifestations of empyema include the following:

  • Most patients with empyema present with clinical manifestations of bacterial pneumonia. Their symptoms are characterized by an acute febrile response, pleuritic chest pain, cough, dyspnea, and, possibly, cyanosis.
  • The inflammation of the pleural space may cause abdominal pain and vomiting.
  • Patients frequently exhibit characteristic splinting of the affected side.
  • Symptoms may be blunted, and fever may not be present in patients who are immunocompromised.
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Physical

Physical examination findings can vary as well.

  • Auscultation reveals crackles, decreased breath sounds, and, possibly, a pleural rub, if the process is recognized before a large amount of fluid accumulates.
  • Dullness to percussion and decreased breath sounds are likely but difficult to elicit in the younger child, who, because of discomfort, may be less cooperative with the examination.
  • Physical findings and presentation may vary depending on the organism and the duration of the illness.
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Causes

  • Increased pleural permeability associated with pneumonia or lung abscesses, as well as contiguous infections of the esophagus, mediastinum, or subdiaphragmatic region, may extend to involve the pleura.
  • Similarly, retropharyngeal, retroperitoneal, or paravertebral processes may extend to adjacent structures and involve the pleura, as well.
  • Host factors that contribute to alterations in pleural permeability, such as noninfectious inflammatory diseases, infection, trauma, or malignancy, may allow accumulation of fluid in the pleural space, which becomes secondarily infected.
  • The bacteriology of the pleural space varies with patient age. In the pediatric population, the most common implicated organisms are S pneumoniae, S aureus, and group A streptococci. H influenzae is rarely observed since the advent of the H influenzae B vaccine.
  • Because of the use of oral antibiotics before the recognition of the parapneumonic effusion, most specimens cultured are sterile; thus, the relative incidences of the aforementioned organisms are not known.
  • Anaerobic infections secondary to aspiration and fungal or mycobacterial infections in immunosuppressed patients are also reported.
  • Finally, Mycoplasma pneumoniae, viruses, and atypical pneumonias can also present with exudative pleural effusions, although mononuclear cells primarily characterize them.
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Contributor Information and Disclosures
Author

Peter H Michelson, MD  Associate Professor of Pediatrics, Division of Pulmonary and Sleep Medicine, Duke University School of Medicine

Peter H Michelson, MD is a member of the following medical societies: American Academy of Pediatrics, American Thoracic Society, and International Society for Heart and Lung Transplantation

Disclosure: Nothing to disclose.

Specialty Editor Board

Thomas Scanlin, MD  Chief, Division of Pulmonary Medicine and Cystic Fibrosis Center, Department of Pediatrics, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School

Thomas Scanlin, MD is a member of the following medical societies: American Association for the Advancement of Science, American Society for Biochemistry and Molecular Biology, American Thoracic Society, Society for Pediatric Research, and Society for Pediatric Research

Disclosure: Nothing to disclose.

Mary L Windle, PharmD  Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Charles Callahan, DO  Professor, Deputy Chief of Clinical Services, Walter Reed Army Medical Center

Charles Callahan, DO is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, American College of Osteopathic Pediatricians, American Thoracic Society, Association of Military Surgeons of the US, and Christian Medical & Dental Society

Disclosure: Nothing to disclose.

Mary E Cataletto, MD  Director of Children's Sleep Services, Winthrop Sleep Disorders Center, Mineola, NY; Professor of Clinical Pediatrics, State University of New York at Stony Brook, Stony Brook, NY

Mary E Cataletto, MD is a member of the following medical societies: American Academy of Pediatrics and American College of Chest Physicians

Disclosure: Shering Plough Pharmaceuticals Honoraria Consulting

Chief Editor

Michael R Bye, MD  Professor of Clinical Pediatrics, Division of Pulmonary Medicine, Columbia University College of Physicians and Surgeons; Attending Physician, Pediatric Pulmonary Medicine, Morgan Stanley Children's Hospital of New York Presbyterian, Columbia University Medical Center

Michael R Bye, MD is a member of the following medical societies: American Academy of Pediatrics, American College of Chest Physicians, and American Thoracic Society

Disclosure: Nothing to disclose.

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Radiographic imaging of a parapneumonic effusion may be useful in assessing the stage of the effusion and the type of drainage needed. In Figure A, the left heart border is obscured, and more than 50% of the left hemithorax is filled with an effusion, as evidenced by a fluid meniscus. In Figure B, the effusion is demonstrated to be fluid because it layers out on a decubitus film. In Figure C, the lateral radiograph again demonstrates the fluid meniscus and filling of the posterior sulcus. These findings suggest tube thoracostomy placement may be sufficient to drain this pleural process.
Most parapneumonic effusions treated with the appropriate antimicrobials of sufficient duration resolve without the development of complications or sequelae. The series of radiographs represent a patient treated with thoracentesis alone. Figure A illustrates the patient at presentation. Note the amount of fluid present. In Figure B, the radiograph demonstrates progression of the pleural fluid accumulation with further airspace disease and scoliosis noted. Despite the radiographic evidence of disease progression, the patient was clinically improving. Figure C illustrates the radiograph at follow-up, 6 months following completion of therapy. Resolution of the parapneumonic effusion with no evidence of pleural thickening or fibrosis occurred.
 
 
 
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