Medscape is available in 5 Language Editions – Choose your Edition here.


Pediatric Empyema Differential Diagnoses

  • Author: Peter H Michelson, MD; Chief Editor: Michael R Bye, MD  more...
Updated: Dec 03, 2014
Contributor Information and Disclosures

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: International Society for Heart and Lung Transplantation, American Academy of Pediatrics, American Thoracic Society

Disclosure: Nothing to disclose.

Specialty Editor Board

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, Chief, Department of Pediatrics and Pediatric Pulmonology, Tripler 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, Christian Medical and Dental Associations

Disclosure: Nothing to disclose.

Chief Editor

Michael R Bye, MD Professor of Clinical Pediatrics, State University of New York at Buffalo School of Medicine; Attending Physician, Pediatric Pulmonary Division, Women's and Children's Hospital of Buffalo

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

Disclosure: Nothing to disclose.

Additional Contributors

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

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

Disclosure: Nothing to disclose.

  1. Osler W. The Principles and Practice of Medicine. 4th ed. New York, NY: D Appleton; 1901. 108.

  2. Buckingham SC, King MD, Miller ML. Incidence and etiologies of complicated parapneumonic effusions in children, 1996 to 2001. Pediatr Infect Dis J. June 2003. 22(6):499-504.

  3. Menon P, Rao KL, Singh M, Venkatesh MA, Kanojia RP, Samujh R, et al. Surgical management and outcome analysis of stage III pediatric empyema thoracis. J Indian Assoc Pediatr Surg. 2010 Jan. 15(1):9-14. [Medline]. [Full Text].

  4. Nyambat B, Kilgore PE, Yong DE, et al. Survey of childhood empyema in Asia: implications for detecting the unmeasured burden of culture-negative bacterial disease. BMC Infect Dis. 2008 Jul 11. 8:90. [Medline].

  5. Ramnath RR, Heller RM, Ben-Ami T, et al. Implications of early sonographic evaluation of parapneumonic effusions in children with pneumonia. Pediatrics. 1998 Jan. 101(1 Pt 1):68-71. [Medline].

  6. Paludo C, Zhang L, Lincho CS, Lemos DV, Real GG, Bergamin JA. Chest physical therapy for children hospitalised with acute pneumonia: a randomised controlled trial. Thorax. 2008 Sep. 63(9):791-4. [Medline].

  7. Ray TL, Berkenbosch JW, Russo P, Tobias JD. Tissue plasminogen activator as an adjuvant therapy for pleural empyema in pediatric patients. J Intensive Care Med. 2004 Jan-Feb. 19(1):44-50. [Medline].

  8. Stefanutti G, Ghirardo V, Barbato A, Gamba P. Evaluation of a pediatric protocol of intrapleural urokinase for pleural empyema: a prospective study. Surgery. 2010 Sep. 148(3):589-94. [Medline].

  9. Bishay M, Short M, Shah K, et al. Efficacy of video-assisted thoracoscopic surgery in managing childhood empyema: a large single-centre study. J Pediatr Surg. 2009 Feb. 44(2):337-42. [Medline].

  10. Schneider CR, Gauderer MW, Blackhurst D, Chandler JC, Abrams RS. Video-assisted thoracoscopic surgery as a primary intervention in pediatric parapneumonic effusion and empyema. Am Surg. 2010 Sep. 76(9):957-61. [Medline].

  11. Avansino JR, Goldman B, Sawin RS, Flum DR. Primary operative versus nonoperative therapy for pediatric empyema: a meta-analysis. Pediatrics. 2005 Jun. 115(6):1652-9. [Medline].

  12. Marhuenda C, Barceló C, Fuentes I, Guillén G, Cano I, López M, et al. Urokinase Versus VATS for Treatment of Empyema: A Randomized Multicenter Clinical Trial. Pediatrics. 2014 Nov. 134(5):e1301-7. [Medline].

  13. Proesmans M, Gijsens B, Van de Wijdeven P, De Caluwe H, Verhaegen J, Lagrou K, et al. Clinical outcome of parapneumonic empyema in children treated according to a standardized medical treatment. Eur J Pediatr. 2014 Oct. 173(10):1339-45. [Medline].

  14. Alkrinawi S, Chernick V. Pleural infection in children. Semin Respir Infect. 1996 Sep. 11(3):148-54. [Medline].

  15. Antony VB, Mohammed KA. Pathophysiology of pleural space infections. Semin Respir Infect. 1999 Mar. 14(1):9-17. [Medline].

  16. Bouros D, Schiza S, Siafakas N. Fibrinolytics in the treatment of parapneumonic effusions. Monaldi Arch Chest Dis. 1999 Jun. 54(3):258-63. [Medline].

  17. Bouros D, Schiza S, Tzanakis N, et al. Intrapleural urokinase versus normal saline in the treatment of complicated parapneumonic effusions and empyema. A randomized, double-blind study. Am J Respir Crit Care Med. 1999 Jan. 159(1):37-42. [Medline].

  18. Brook I. Lung abscesses and pleural empyema in children. Adv Pediatr Infect Dis. 1993. 8:159-76. [Medline].

  19. Bryant RE, Salmon CJ. Pleural empyema. Clin Infect Dis. 1996 May. 22(5):747-62; quiz 763-4. [Medline].

  20. Gates RL, Caniano DA, Hayes JR, Arca MJ. Does VATS provide optimal treatment of empyema in children? A systematic review. J Pediatr Surg. 2004 Mar. 39(3):381-6. [Medline].

  21. Givan DC, Eigen H. Common pleural effusions in children. Clin Chest Med. 1998 Jun. 19(2):363-71. [Medline].

  22. Grewal H, Jackson RJ, Wagner CW, Smith SD. Early video-assisted thoracic surgery in the management of empyema. Pediatrics. 1999 May. 103(5):e63. [Medline].

  23. Hardie WD, Roberts NE, Reising SF, Christie CD. Complicated parapneumonic effusions in children caused by penicillin-nonsusceptible Streptococcus pneumoniae. Pediatrics. 1998 Mar. 101(3 Pt 1):388-92. [Medline].

  24. Heffner JE. Indications for draining a parapneumonic effusion: an evidence-based approach. Semin Respir Infect. 1999 Mar. 14(1):48-58. [Medline].

  25. Heffner JE. Infection of the pleural space. Clin Chest Med. 1999 Sep. 20(3):607-22. [Medline].

  26. Heffner JE, McDonald J, Barbieri C, Klein J. Management of parapneumonic effusions. An analysis of physician practice patterns. Arch Surg. 1995 Apr. 130(4):433-8. [Medline].

  27. Hoff SJ, Neblett WW 3rd, Heller RM, et al. Postpneumonic empyema in childhood: selecting appropriate therapy. J Pediatr Surg. 1989 Jul. 24(7):659-63; discussion 663-4. [Medline].

  28. Hoff SJ, Neblett WW, Edwards KM, et al. Parapneumonic empyema in children: decortication hastens recovery in patients with severe pleural infections. Pediatr Infect Dis J. 1991 Mar. 10(3):194-9. [Medline].

  29. Kennedy AS, Agness M, Bailey L, White JJ. Decortication for childhood empyema. The primary provider's peccadillo. Arch Surg. 1991 Oct. 126(10):1287-91. [Medline].

  30. Kern JA, Rodgers BM. Thoracoscopy in the management of empyema in children. J Pediatr Surg. 1993 Sep. 28(9):1128-32. [Medline].

  31. Kosloske AM, Cartwright KC. The controversial role of decortication in the management of pediatric empyema. J Thorac Cardiovasc Surg. 1988 Jul. 96(1):166-70. [Medline].

  32. LeMense GP, Strange C, Sahn SA. Empyema thoracis. Therapeutic management and outcome. Chest. 1995 Jun. 107(6):1532-7. [Medline].

  33. Light RW. Pleural effusion. Nadel JA, ed. Textbook of Respiratory Medicine. 2nd ed. Philadelphia, PA: WB Saunders; 1994. 1719-30.

  34. McLaughlin FJ, Goldmann DA, Rosenbaum DM, et al. Empyema in children: clinical course and long-term follow-up. Pediatrics. 1984 May. 73(5):587-93. [Medline].

  35. Moulton JS, Benkert RE, Weisiger KH, Chambers JA. Treatment of complicated pleural fluid collections with image-guided drainage and intracavitary urokinase. Chest. 1995 Nov. 108(5):1252-9. [Medline].

  36. Pollak JS, Passik CS. Intrapleural urokinase in the treatment of loculated pleural effusions. Chest. 1994 Mar. 105(3):868-73. [Medline].

  37. Redding GJ, Walund L, Walund D, et al. Lung function in children following empyema. Am J Dis Child. 1990 Dec. 144(12):1337-42. [Medline].

  38. Sahn SA. Management of complicated parapneumonic effusions. Am Rev Respir Dis. 1993 Sep. 148(3):813-17. [Medline].

  39. Stovroff M, Teague G, Heiss KF, et al. Thoracoscopy in the management of pediatric empyema. J Pediatr Surg. 1995 Aug. 30(8):1211-5. [Medline].

  40. Stringel G, Hartman AR. Intrapleural instillation of urokinase in the treatment of loculated pleural effusions in children. J Pediatr Surg. 1994 Dec. 29(12):1539-40. [Medline].

  41. Wells RG, Havens PL. Intrapleural fibrinolysis for parapneumonic effusion and empyema in children. Radiology. 2003 Aug. 228(2):370-8. [Medline].

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.
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.