eMedicine Specialties > Radiology > Chest

Empyema

Marc Tobler, MD, Staff Physician, Department of Diagnostic Radiology, Scott and White Memorial Hospital and Clinic
John M Holbert, MD, Professor, Department of Radiology, Scott and White Memorial Hospital and Clinic

Updated: Feb 27, 2010

Introduction

Background

Empyema is inflammatory fluid and debris in the pleural space. It results from an untreated pleural-space infection that progresses from free-flowing pleural fluid to a complex collection in the pleural space.

Empyema, as shown below, most commonly occurs in the setting of bacterial pneumonia. About 20-60% of all cases of pneumonia are associated with parapneumonic effusion. With appropriate antibiotic therapy, parapneumonic effusions most often resolve without complications, and they are of little clinical significance. However, some effusions do not resolve; these are called complicated effusions. The resulting infection and inflammatory response can proceed until adhesive bands form. The infected fluid becomes loculated pus in the pleural space.

Posteroanterior (PA) chest radiograph in a 52-year-old man who had severe pneumonia in his early 20s shows a large right pleural-based mass. He was treated with antibiotics for 3 days but had a high temperature and chest pain for several weeks. When this image was obtained, the patient was asymptomatic. Courtesy of Judith Amorosa, MD.

Computed tomography (CT) scan (mediastinal window; same patient as in the above image) shows a mass with a thick, calcified wall arising from the pleura with an air-fluid level. This finding represents an organized, walled-off, old empyema. Courtesy of Judith Amorosa, MD.

• Thoracic trauma (About 1-5% of cases of thoracic trauma lead to an empyema.)
• Rupture of a lung abscess into the pleural space
• Extension of a non–pleural-based infection (eg, mediastinitis, abdominal infection)
• Esophageal tear
• Iatrogenic introduction at the time of thoracic surgery
• An indwelling catheter that is a nidus for infection

Mortality related to empyema is associated with respiratory failure and systemic sepsis, which occurs when the immune response and antibiotics are inadequate to control the infection.

Drainage is performed to remove the collection and to improve outcomes. The proper intervention depends on the severity of the disease and ranges from minimally invasive catheter drainage to open surgical decortication. Early intervention decreases the mortality rate associated with empyema. Prompt diagnosis, treatment, and proper management of empyema are crucial.

Recent reports

Grijalva et al compared the frequency of childhood pneumonia hospitalizations complicated by empyema before (1996-1999) and after (2001-2007) the introduction of the 7-valent pneumococcal conjugate vaccine (PCV7). The study found that all-cause pneumonia hospitalization rates decreased post-PCV7 for children under age 2 years and remained stable in children aged 2-4 years, while pneumococcal pneumonia hospitalization rates decreased in both age groups. However, from 2005-2007, in both groups, rates of pneumonia hospitalizations complicated by empyema increased significantly over the pre-PCV7 period, for pneumococcal, streptococcal, staphylococcal, and other or unspecified empyema (with the exception of pneumococcal and streptococcal empyema in patients <2 y, in whom these conditions remained stable).^{[1 ]}

Meier et al investigated which factors might predict treatment failure or complication development in patients undergoing video-assisted thoracoscopic debridement (VATD) for pediatric empyema. Utilizing data from 152 procedures in 151 patients, the authors found that complications, although infrequent (13.8% of the study's patients) and primarily minor, tended to occur more often with older age and with a lower hematocrit on admission. The average hospital stay in the study was 10.1 days, although the length of stay was significantly longer if VATD was performed after another procedure or if the patient suffered a complication.^{[2 ]}

Pathophysiology

The secretion of fluid into the pleural space is normally in equilibrium with drainage by the subpleural lymphatics. The pleural lymphatic system can drain almost 500 mL/d. When the volume of pleural fluid exceeds the ability of the lymphatics to drain it, an effusion begins to form.

Parapneumonic effusions are the most common causes of empyema. Pneumonia triggers an inflammatory response. Inflammation near the pleura increases permeability of the mesothelial cells, the outermost monolayer of cells on the pleura. Mesothelial cells thus affected have increased permeability to albumin and other proteins. This is why pleural effusions due to infection are rich in protein.

Chemical mediators of the inflammatory process stimulate the mesothelial cells to release chemokines, which recruit other inflammatory cells to the area. Mesothelial cells play an important role in attracting neutrophils to the pleural space. Under normal conditions, neutrophils are not found in pleural fluid. They are found only in the pleural space when they are recruited as part of the inflammatory process. Neutrophils, mononuclear phagocytes, and lymphocytes amplify the inflammatory response and release mediators to attract additional inflammatory cells to the pleural space.

The formation of an empyema has 3 stages:

1. Exudative stage: Protein-rich pleural fluid remains free flowing. The number of neutrophils is rapidly increasing. Glucose and pH levels are normal. Drainage of the effusion and appropriate antimicrobial therapy are normally sufficient for treatment.
2. Fibrinolytic stage: Viscosity of the pleural fluid increases. Coagulation factors are activated, and fibroblastic activity begins coating the pleural membrane with an adhesive meshwork. Glucose and pH levels are lower than normal.
3. Organizing stage: Loculations form. Fibroblastic activity causes adherence to the visceral and parietal pleura. This activity may progress with the formation of pleural peels in which the pleural layers are indistinguishable. Pus, which is a protein-rich fluid with inflammatory cells and debris, is present in the pleural space. Surgical intervention is often required at this stage.

Simple parapneumonic effusions^{[3 ]}resolve with treatment of the underlying disease. The lymphatics drain the effusion, and the mesothelial layer returns to normal. A parapneumonic effusion is considered complicated if the effusion does not resolve with antibiotic therapy. Complicated effusions progress to empyema if they are not drained.

Frequency

United States

One million pleural-space infections occur each year in the United States.

In a review of several published case series, Strange and Sahn analyzed the causes of pleural infections. They identified parapneumonic effusions as the origins of 70% of pleural infections.^{[5 ]}

About 5-10% of simple parapneumonic effusions become complicated effusions.

As many as 5% of patients with thoracic trauma develop an empyema.

International

Overall, the international incidence of pleural-space infection or empyema is not known. However, 4000 pleural-space infections occur each year in the United Kingdom.

Mortality/Morbidity

• The table below shows radiographic predictors of mortality and rates in a series of patients with clinical pneumonia.^{[6 ]}
• 
  

  Effusion	Mortality Rate, %
  	7 Day	30 Day
  None	1.3	4
  Unilateral	2.5	5.9
  Bilateral*	10	28

  ^* Bilateral effusions due to congestive heart failure were not excluded from this analysis.

• In the United Kingdom, the mortality rate due to frank empyema is 20%.
• Comorbid conditions increase mortality due to pleural-space infection. In elderly and chronically debilitated patients, reported mortality rates are 25-75%.

Race

Race statistics for pleural-space infection or empyema are not known.

Sex

The male-to-female ratio is 1.8:1. No definite cause for the increased rate in men has been described. Men with pneumonia may seek treatment at a late stage of infection, when antibiotics are insufficient.

Age

Age statistics for pleural-space infection are not known.

Anatomy

The thoracic cavity encompasses 2 pleural cavities and the mediastinum. The mediastinum contains the heart, the esophagus, the trachea, the great vessels, and other structures. The left and right pleural cavities are lateral to the mediastinum and contain the lungs and their associated structures. A pleural sac surrounds each lung. The pleura is a continuous layer of mesothelial cells and submesothelial matrix that covers the chest wall and lungs.

The parietal pleura lines the wall of the pleural cavity. Connective tissue attaches it to the internal thoracic wall and the superior surface of the diaphragm. During respiration, the parietal pleura moves with diaphragmatic contraction and with expansion of the chest wall. The parietal pleura is continuous with the visceral pleura at the hilum, where structures enter and leave the lung.

The visceral pleura envelops the lung and is attached to the lung by connective tissue. Reflections of the visceral pleura line the lobes of the lungs and are visualized as pulmonary fissures on chest radiographs. The visceral pleural is normally near the parietal pleura as the lung expands to fill the potential pleural space.

Presentation

As many as 70% of all empyemas are due to complications of pneumonia. In the setting of pneumonia, empyema may be associated with several symptoms. Patients may report having chills, high-grade fever, sweating, poor appetite, malaise, and cough. Pleurisy and dyspnea may be symptoms in some patients. Pleurisy and dyspnea do not depend on the size of the effusion. If an effusion of sufficient size is present, physical findings may include dullness to percussion and absent breath sounds.

Before the modern era of antibiotics, most effusions and empyemas were related to Streptococcus pneumoniae pneumonia. Pneumococcal infections normally respond to antibiotic therapy. These are less frequently associated with pleural-space infections today than they were before. Staphylococcal species and anaerobic pathogens are now the most common microorganisms associated with empyema. Because half of staphylococcal effusions progress to empyema, early drainage may be indicated if this organism is isolated. The reemergence of tuberculosis may increase the association of Mycobacterium infection with empyema.

Most parapneumonic effusions resolve with appropriate and timely antibiotic therapy. However, other effusions can progress to an empyema if drainage is not promptly performed. Interventions are uncomfortable, and complications can occur.

See Intervention for more information about treatments.

Preferred Examination

Standard 2-view chest radiography remains the first study for evaluating effusion or empyema. If an effusion is present, bilateral decubitus imaging is indicated for further characterization. These examinations are informative and cost-effective.

Ultrasonography may show small volumes of pleural fluid, and it may provide information about viscosity. Ultrasonography may also quickly demonstrate septa in the pleural fluid collection.

Chest CT provides the most information. CT imaging depicts fluid, loculation, and thickening of the pleural membranes. CT and ultrasonography are also used in the placement of drainage catheters.

Limitations of Techniques

Two-view chest radiographs and decubitus views are not always obtainable in the intensive care unit. Radiographs are often limited to bedside supine or semierect anteroposterior views in very ill patients. A small fluid collection in the subpulmonic recess may be present but not detected on radiographs. Ultrasonography may demonstrate septa in the pleural fluid, but it poorly demonstrates the thickness of the pleura.

Patient Education: For excellent patient education resources, visit eMedicine's Pneumonia Center. Also, see eMedicine's patient education article Bacterial Pneumonia.

Differential Diagnoses

Effusion, Pleural
Mesothelioma, Malignant

Radiography

Findings

Free-flowing pleural fluid collects in the dependent portion of the pleural space. On 2-view chest radiographs, pleural fluid obscures the costophrenic angle (as in the image below). Approximately 75 mL of fluid is required to blunt the posterior costophrenic angle on a lateral chest radiograph. Almost 200 mL of fluid is required to blunt the lateral costophrenic angles on frontal radiographs. If loculations have formed, fluid opacity may be seen in a nondependent area. The D configuration of loculated fluid bulging out from the chest wall is a classically described but infrequently observed finding.

Posteroanterior (PA) chest radiograph of a man in his 50s who had a 2-week history of partially treated pneumonia. He presented with persistent fever and chest pain. The patchy bilateral lung parenchymal opacities indicate pneumonia. The obliterated left costophrenic angle suggests a left pleural effusion.

If a pleural effusion is suspected, bilateral decubitus views are recommended. When an effusion is identified, the width of the layering fluid may be measured. If the width of the fluid is <10 mm, the effusion may be managed medically and followed up with serial radiographs. However, if the effusion is wider than 10 mm, thoracentesis or catheter drainage should be performed, if clinically indicated. CT or ultrasonographic guidance is best for placing a pleural catheter for drainage.

Degree of Confidence

When 2-view chest radiographs are used to detect pleural fluid, the sensitivity is 67% and the specificity is 70%. Decubitus views increase the degree of confidence. However, decubitus views are often skipped, and instead, the patient undergoes a CT examination.

False Positives/Negatives

Empyema is not diagnosed strictly on the basis of traditional radiographic findings. Further imaging with CT and confirmation of pleural infection with thoracentesis are usually required to diagnose empyema.

Computed Tomography

Findings

CT is the imaging study of choice for evaluating possible empyema. Depending on the expected clinical management, patients can undergo imaging with or without intravenously administered contrast material. If tapping of a clinically significant pleural effusion is clinically indicated, no intravenous contrast medium is necessary to evaluate for the presence and location of pleural fluid.

The typical empyema is lenticular. Nonenhanced CT scans can demonstrate atypical pleural effusions along the mediastinum, thickened pleurae, loculations in the fissures, septa, or gas bubbles in the pleural space (indicated in the first image below). Gas bubbles in the pleural space strongly suggest an empyema in the proper clinical context (ie, in the absence of recent thoracentesis). Lung windows can demonstrate pneumonia adjacent to the abnormal pleural collection. Soft-tissue windows can demonstrate a cause for the empyema, such as esophageal rupture or mediastinal surgery.

With most empyemas, enhanced chest CT scans demonstrate the split-pleura sign (demonstrated in the second and third images below). This sign can also be seen in chronic pleural effusions. Enhanced CT scans also depict parietal pleural thickening in most cases of empyema.

Contrast-enhanced axial computed tomography (CT) scan at the level of the inferior pulmonary veins; the patient was a man in his 50s who had a 2-week history of partially treated pneumonia. The image demonstrates loculated fluid in the left major fissure, a pseudotumor (arrow). Gas bubbles are present in the dependent collection of pleural fluid (arrowheads).

Enhanced axial computed tomography (CT) scan a few centimeters inferior to the level in the above image. Enhancing pleural membranes (arrows) anterior and posterior to the fluid collection indicate the split-pleura sign. The patient had pus in the pleural space; this indicated empyema. Courtesy of Judith Amorosa, MD.

Image obtained in a patient with an empyema shows the split-pleura sign in the setting of right lower lobe (RLL) consolidation and atelectasis.

Enhanced axial computed tomography (CT) scan obtained at the level of the aortic valve in a septic, alcoholic patient who was brought to the emergency department from a homeless shelter several days after becoming ill. Image shows several gas bubbles in a large right pleural fluid collection. An enhancing pleural membrane (arrow) defines the empyema extending into the chest wall. These are the findings of empyema necessitatis.

Degree of Confidence

If no interventional procedure has been performed, gas bubbles in a pleural fluid collection are virtually diagnostic of an empyema. Enhancing pleura and thickened parietal pleura are also strongly associated with empyema. In a study of empyema, pleural enhancement was seen in every case, and pleural thickening was seen in 92%.^{[7 ]}

False Positives/Negatives

An enhancing pleura sign can be present in chronic pleural effusion and metastatic disease.

Magnetic Resonance Imaging

Findings

MRI is rarely used to image pleural effusion and empyema. It may be useful for evaluating thickening of the pleural membrane when the administration of contrast material is contraindicated.

Degree of Confidence

The degree of confidence in the diagnosis of empyema is moderate.

False Positives/Negatives

MRI is not routinely used to diagnose empyema.

Ultrasonography

Findings

Ultrasonography is an important adjunct in defining the characteristics of a pleural effusion. It may be used to detect small effusions. Ultrasonography also provides information about fluid viscosity, the presence of septa, and the free-flowing or loculated nature of the effusion.

Degree of Confidence

Loculated effusions suggest empyema in the proper clinical context, but the diagnosis must be confirmed with thoracentesis.

False Positives/Negatives

The diagnosis of empyema is not based solely on ultrasonographic results.

Nuclear Imaging

Findings

Nuclear medicine scans are not used in the routine workup for effusion and empyema. Effusions may be seen on ventilation and perfusion scans. Diffusely decreased unilateral intensity on both ventilation and perfusion studies may suggest a layering effusion.

Degree of Confidence

Nuclear medicine tests are not used as diagnostic studies for empyema.

Angiography

Findings

Angiography does not have a role in the management of empyema. The interventional radiologist may need to perform thoracentesis with imaging guidance, and an indwelling catheter may be needed.

Intervention

The main clinical decision is determining the appropriate time to drain the empyema. Appropriate imaging may help the clinician in choosing and timing intervention. Choosing the appropriate time to perform drainage is a difficult clinical decision.^{[8 ]}

In 2000, the American College of Chest Physicians reviewed the literature and issued a consensus statement on the medical and surgical treatment of parapneumonic effusions. In the setting of a parapneumonic effusion, the following findings suggest a moderate or high risk for a poor outcome: large, free-flowing effusion (at least half of a hemithorax); loculated effusion or effusion with thickened parietal pleura; positive cultures or Gram stains; pleural pus; and pH < 7.20. When these findings are present, drainage is recommended.

Light's criteria define transudative and exudative effusions. Other investigators have tried to clarify when an exudative effusion should be drained. Laboratory indications for consideration of drainage are the following:

• pH < 7.20
• Glucose level < 60 mg/dL
• Lactate dehydrogenase (LDH) level > 600 IU/L
• Bacteria on Gram staining

Thoracentesis

Ultrasonography or CT guidance is often used to improve the success of a thoracentesis. Single thoracentesis and a course of antibiotics may be effective at the earliest stages of empyema formation. If the effusion recurs, placement of a chest tube or small-bore catheter for continuous drainage is the next step. The placement of a small-bore catheter (thin-walled, 8-16F catheter) is also often accomplished under ultrasonographic or CT guidance. The small-bore catheter is often more comfortable for the patient than the traditional thoracostomy tube.

Surgical interventions

In the past, a few loculations in an empyema often indicated the need for surgical intervention because the loculations did not drain well. Fibrinolytics increase the success rate of catheter drainage by decreasing the viscosity of the effusion and by dissolving some adhesions. Fibrinolytic therapy has reduced the need for surgery.

Surgical intervention is still required for effusions with multiple loculations that are difficult to drain and for effusions that have not responded to catheter drainage. Empyema at the organizing stage requires surgical intervention.

Surgical interventions may include the following:

• Thoracoscopic debridement
• Video-assisted thoracoscopic surgery (VATS): This relatively new intervention has reduced the frequency of open surgery.
• Open thoracotomy for debridement: This approach is effective when the deposition on the pleural surface remains gelatinous.
• Open surgical decortication: This technique is the most invasive intervention. It is required when thick pleural peels are present on the visceral pleura. The pleural peel prevents reexpansion of the lung if it is not removed.

Medicolegal Pitfalls

• Prompt diagnosis and intervention reduce patient mortality.
• Delaying diagnosis or intervention could worsen the clinical course.

Multimedia

Media file 1: Posteroanterior (PA) chest radiograph of a man in his 50s who had a 2-week history of partially treated pneumonia. He presented with persistent fever and chest pain. The patchy bilateral lung parenchymal opacities indicate pneumonia. The obliterated left costophrenic angle suggests a left pleural effusion.

Media file 2: Contrast-enhanced axial computed tomography (CT) scan at the level of the inferior pulmonary veins; the patient was a man in his 50s who had a 2-week history of partially treated pneumonia. The image demonstrates loculated fluid in the left major fissure, a pseudotumor (arrow). Gas bubbles are present in the dependent collection of pleural fluid (arrowheads).

Media file 3: Enhanced axial computed tomography (CT) scan a few centimeters inferior to the level in the above image. Enhancing pleural membranes (arrows) anterior and posterior to the fluid collection indicate the split-pleura sign. The patient had pus in the pleural space; this indicated empyema. Courtesy of Judith Amorosa, MD.

Media file 4: Image obtained in a patient with an empyema shows the split-pleura sign in the setting of right lower lobe (RLL) consolidation and atelectasis.

Media file 5: Enhanced axial computed tomography (CT) scan obtained at the level of the aortic valve in a septic, alcoholic patient who was brought to the emergency department from a homeless shelter several days after becoming ill. Image shows several gas bubbles in a large right pleural fluid collection. An enhancing pleural membrane (arrow) defines the empyema extending into the chest wall. These are the findings of empyema necessitatis.

Media file 6: Posteroanterior (PA) chest radiograph in a 52-year-old man who had severe pneumonia in his early 20s shows a large right pleural-based mass. He was treated with antibiotics for 3 days but had a high temperature and chest pain for several weeks. When this image was obtained, the patient was asymptomatic. Courtesy of Judith Amorosa, MD.

Media file 7: Computed tomography (CT) scan (mediastinal window; same patient as in the above image) shows a mass with a thick, calcified wall arising from the pleura with an air-fluid level. This finding represents an organized, walled-off, old empyema. Courtesy of Judith Amorosa, MD.

References

1. Grijalva CG, Pekka Nuorti J, Zhu Y, et al. Increasing incidence of empyema complicating childhood community-acquired pneumonia in the United States. Clin Infect Dis. Mar 15 2010;50(6):805-13. [Medline].

2. Meier AH, Hess CB, Cilley RE. Complications and treatment failures of video-assisted thoracoscopic debridement for pediatric empyema. Pediatr Surg Int. Feb 11 2010;[Medline].

3. Lujan M, Gallego M, Belmonte Y, et al. Influence of pneumococcal serotype group on outcome in adults with bacteremic pneumonia. Eur Respir J. Feb 11 2010;[Medline].

4. Llamas-Velasco M, Domínguez I, Ovejero E, Pérez-Gala S, García-Diez A. Empyema necessitatis revisited. Eur J Dermatol. Oct 12 2009;[Medline].

5. Strange C, Sahn SA. The definitions and epidemiology of pleural space infection. Semin Respir Infect. Mar 1999;14(1):3-8. [Medline].

6. Hasley PB, Albaum MN, Li YH, et al. Do pulmonary radiographic findings at presentation predict mortality in patients with community-acquired pneumonia?. Arch Intern Med. Oct 28 1996;156(19):2206-12. [Medline].

7. Kearney SE, Davies CW, Davies RJ, Gleeson FV. Computed tomography and ultrasound in parapneumonic effusions and empyema. Clin Radiol. Jul 2000;55(7):542-7. [Medline].

8. Heffner JE, Klein JS, Hampson C. Interventional management of pleural infections. Chest. Oct 2009;136(4):1148-59. [Medline].

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

10. Aquino SL, Webb WR, Gushiken BJ. Pleural exudates and transudates: diagnosis with contrast-enhanced CT. Radiology. Sep 1994;192(3):803-8. [Medline].

11. Colice GL, Curtis A, Deslauriers J, et al. Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. Chest. Oct 2000;118(4):1158-71. [Medline].

12. Davies RJ, Gleeson FV. The diagnosis and management of pleural empyema. Curr Opin Pulm Med. May 1998;4(3):185-90. [Medline].

13. Han KT, Choi DS, Ryoo JW, Cho JM, Jeon KN, Bae KS. Diffusion-weighted MR imaging of pyogenic intraventricular empyema. Neuroradiology. Jul 24 2007;[Medline].

14. Heffner JE. Diagnosis and management of thoracic empyemas. Curr Opin Pulm Med. May 1996;2(3):198-205. [Medline].

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

16. Light RW. Clinical practice. Pleural effusion. N Engl J Med. Jun 20 2002;346(25):1971-7. [Medline].

17. Light RW. The management of parapneumonic effusions and empyema. Curr Opin Pulm Med. Jul 1998;4(4):227-9. [Medline].

18. Lim TK. Management of parapneumonic pleural effusion. Curr Opin Pulm Med. Jul 2001;7(4):193-7. [Medline].

19. Ploton C, Freydiere AM, Benito Y, Bendridi N, Mazzocchi C, Bellon G. Streptococcus pneumoniae thoracic empyema in children: rapid diagnosis by using the Binax NOW immunochromatographic membrane test in pleural fluids. Pathol Biol (Paris). Oct-Nov 2006;54(8-9):498-501. [Medline].

20. Sahn SA. Use of fibrinolytic agents in the management of complicated parapneumonic effusions and empyemas. Thorax. Aug 1998;53 Suppl 2:S65-72. [Medline].

21. Temes RT, Follis F, Kessler RM, et al. Intrapleural fibrinolytics in management of empyema thoracis. Chest. Jul 1996;110(1):102-6. [Medline].

Keywords

empyema, pleura empyema, thoracentesis, thoracoscopic, empyema surgery, empyema treatment, empyema lung, empyema pneumonia, organizing effusion, complicated effusion, loculated effusion, pleural pus, intrapleural pus, pleural-space infection

Contributor Information and Disclosures

Author

Marc Tobler, MD, Staff Physician, Department of Diagnostic Radiology, Scott and White Memorial Hospital and Clinic
Marc Tobler, MD is a member of the following medical societies: American Medical Association
Disclosure: Nothing to disclose.

Coauthor(s)

John M Holbert, MD, Professor, Department of Radiology, Scott and White Memorial Hospital and Clinic
John M Holbert, MD is a member of the following medical societies: American College of Chest Physicians, American College of Radiology, American Roentgen Ray Society, and Radiological Society of North America
Disclosure: Amirsys Royalty Independent contractor

Medical Editor

Judith K Amorosa, MD, FACR, Clinical Professor and Program Director, Department of Radiology, University of Medicine and Dentistry of New Jersey, Robert Wood Johnson Medical School; Consulting Staff, Department of Radiology, Robert Wood Johnson University Hospital
Judith K Amorosa, MD, FACR is a member of the following medical societies: American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Nothing to disclose.

Pharmacy Editor

Bernard D Coombs, MB, ChB, PhD, Consulting Staff, Department of Specialist Rehabilitation Services, Hutt Valley District Health Board, New Zealand
Disclosure: Nothing to disclose.

Managing Editor

W Richard Webb, MD, Professor, Department of Radiology, University of California at San Francisco
Disclosure: Nothing to disclose.

CME Editor

Robert M Krasny, MD, Resolution Imaging Medical Corporation
Robert M Krasny, MD is a member of the following medical societies: American Roentgen Ray Society and Radiological Society of North America
Disclosure: Nothing to disclose.

Chief Editor

Barry H Gross, MD, Professor, Department of Radiology, University of Michigan Medical School; Professor, University of Michigan Cancer Center
Barry H Gross, MD is a member of the following medical societies: American College of Chest Physicians, American College of Radiology, American Roentgen Ray Society, Association of University Radiologists, Michigan State Medical Society, Physicians for Social Responsibility, Radiological Society of North America, and Society of Thoracic Radiology
Disclosure: Nothing to disclose.

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