Pediatric Empyema Workup

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

Laboratory Studies

The following studies are indicated in empyema:

  • CBC count
  • Blood culture: Blood culture is obtained to assist in the identification of the offending organism. In pediatric patients, in whom sputum production is uncommon, identifying the cause of the pulmonary symptoms early in the course of a pulmonary infection is difficult. However, with parapneumonic effusions, the patient may become bacteremic as the organism invades into the pleural space, and a blood culture may reveal the organism.
  • Serum lactate dehydrogenase (LDH) level
  • Total protein level
  • Glucose concentration
  • Bacterial, mycobacterial, and fungal cultures
  • Serologic studies of the aspirated pleural fluid
  • pH level
  • Amylase concentration
  • Lipid stain or triglyceride level
  • Cell count and differential: Although the pleural fluid obtained at thoracentesis is typically purulent, with an elevated WBC count and a predominance of polymorphonuclear cells (PMNs), an effusion evaluated early in the infectious process may well be more transudative, with a less cellular WBC count and a differential that is less PMN predominant. Regardless of the cell count and differential, the treatment should be based on clinical course, pending the culture results. Cytokine analyses of pleural fluid have been performed in experimental settings and may prove to add prognostic value on the degree of inflammation present and may be beneficial in determining treatment course in the near future.
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Imaging Studies

  • Radiologic evaluation is the primary tool for the diagnosis of a parapneumonic effusion. Standard chest radiography is the first step to assess for pleural fluid. See the image below. Radiographic imaging of a parapneumonic effusion mRadiographic 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.
  • Examination should include upright views of the chest to examine the diaphragmatic margins, which are obliterated with pleural fluid collections. Because as much as 400 mL may be required before these costophrenic angles are obscured in older children and adolescents, further diagnostic imaging may be needed.
  • In cases in which the effusion is moderate, radiography may reveal displacement of the mediastinum to the contralateral hemithorax, as well as scoliosis.
  • Indistinct diaphragmatic contours merit lateral decubitus views of the chest.
  • Free-flowing pleural effusions suggest less complicated parapneumonic processes, which may not require extensive diagnostic and therapeutic interventions. Ultrasonography that reveals the absence of loculations suggests that effective treatment can be achieved without surgical intervention. The absence of free layering fluid on the decubitus films does not exclude the possibility of a loculated pleural effusion.[5]
  • Consider ultrasonography or CT imaging to identify the presence of consolidated lung or fibrinous septations. In patients with complex fluid collections, chest CT imaging has emerged as the study of choice. Chest CT imaging can be used to detect and define pleural fluid and image the airways, guide interventional procedures, and discriminate between pleural fluid and chest consolidation.
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Other Tests

  • Pleural fluid latex agglutination (or counter immunoelectrophoresis [CIE] for specific bacteria) may be helpful if the cause of the infection cannot be ascertained from culture results.
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Procedures

  • Thoracentesis can provide both significant diagnostic information and therapeutic relief for parapneumonic effusions.
  • The presence of pus establishes the presence of an empyema, and the determination of the Gram stain, cell differential, and chemistries helps to guide therapy.
  • Performing thoracentesis before the initiation of antibiotics increases the diagnostic yield of the fluid cultures and allows for more specific antimicrobial therapy.
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Proceed to Treatment & Management
 
 
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.

References

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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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