Empyema and Abscess Pneumonia in Emergency Medicine 

  • Author: Mark Zwanger, MD, MBA; Chief Editor: Robert E O'Connor, MD, MPH   more...
 
Updated: Jan 24, 2011
 

Background

A lung abscess is a subacute infection in which an area of necrosis forms in the lung parenchyma. It usually is in a dependent section of the lung, more often involves the right lung than the left, and is most commonly seen after aspiration of oropharyngeal secretions. Lung abscesses have a slow, insidious presentation and usually develop 1-2 weeks after the initial aspiration event. A lung abscess is shown in the image below.

A thick-walled lung abscess. A thick-walled lung abscess.

Empyema is defined as pus in the pleural space. It typically is a complication of pneumonia. However, it can also arise from penetrating chest trauma, esophageal rupture, complication from lung surgery, or inoculation of the pleural cavity after thoracentesis or chest tube placement. An empyema can also occur from extension of a subdiaphragmatic or paravertebral abscess.

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Pathophysiology

A lung abscess involves the lung parenchyma, whereas an empyema involves the pleural space. In many patients with pneumonia, a sterile simple parapneumonic effusion develops in the pleural space. If this pleural effusion becomes infected, it is labeled a complicated parapneumonic effusion, whereas the presence of frank pus in the pleural space defines an empyema.

The development stages of an effusion can be divided into 3 phases: exudative, fibropurulent, and organizational. The initial effusion develops from increased pulmonary interstitial fluid along with progressive capillary vascular permeability. A simple effusion is frequently sterile and resolves with antibiotic treatment of the underlying pulmonary infection.

In 5-10% of the patients with a pleural effusion, the effusion becomes infected and neutrophils buildup. This inflammatory response, shown in the images below, also causes the production of chemokines, cytokines, oxidants, and protease mediators.

Histology of a lung abscess shows dense inflammatoHistology of a lung abscess shows dense inflammatory reaction (low power). Histology of a lung abscess shows dense inflammatoHistology of a lung abscess shows dense inflammatory reaction (high power).

This more complicated parapneumonic effusion needs both antibiotics and some form of surgical drainage or alternative treatment modality to remove the purulent effusion. In these more complicated effusions, fibrinolysis and activation of the coagulation cascade leads to the production of fibrin with subsequent adhesions and loculated fluid collections. This process ultimately can cause pleural fibrosis and impairment of lung expansion.

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Epidemiology

Frequency

United States

An estimated 60,000 pleural infections are diagnosed annually in the United States.

Mortality/Morbidity

The mortality rate for lung abscesses is approximately 4-7% but varies with the type of material aspirated. Aspiration of fluids with mixed gram-negative flora has a mortality rate approaching 20%, while aspiration of acidic materials has an even higher rate. The fatality rate for complicated parapneumonic effusions is estimated to be as high as 15%.

Age

Complicated effusions and empyema are more common in elderly persons and during childhood. An increase has occurred in the incidence of empyema in the pediatric population. Lung abscess is more common in elderly persons.

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Proceed to Clinical Presentation
 
 
Contributor Information and Disclosures
Author

Mark Zwanger, MD, MBA  Assistant Professor, Department of Emergency Medicine, Jefferson Medical College of Thomas Jefferson University

Mark Zwanger, MD, MBA is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, and American Medical Association

Disclosure: Nothing to disclose.

Specialty Editor Board

Mark S Slabinski, MD, FACEP, FAAEM  Vice President, EMP Medical Group

Mark S Slabinski, MD, FACEP, FAAEM is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, American Medical Association, and Ohio State Medical Association

Disclosure: Nothing to disclose.

Francisco Talavera, PharmD, PhD  Adjunct Assistant Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Medscape Salary Employment

Paul Blackburn, DO, FACOEP, FACEP  Attending Physician, Department of Emergency Medicine, Maricopa Medical Center

Paul Blackburn, DO, FACOEP, FACEP is a member of the following medical societies: American College of Emergency Physicians, American College of Osteopathic Emergency Physicians, American Medical Association, and Arizona Medical Association

Disclosure: Nothing to disclose.

John D Halamka, MD, MS  Associate Professor of Medicine, Harvard Medical School, Beth Israel Deaconess Medical Center; Chief Information Officer, CareGroup Healthcare System and Harvard Medical School; Attending Physician, Division of Emergency Medicine, Beth Israel Deaconess Medical Center

John D Halamka, MD, MS is a member of the following medical societies: American College of Emergency Physicians, American Medical Informatics Association, Phi Beta Kappa, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Chief Editor

Robert E O'Connor, MD, MPH  Professor and Chair, Department of Emergency Medicine, University of Virginia Health System

Robert E O'Connor, MD, MPH is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, American College of Physician Executives, American Heart Association, American Medical Association, Medical Society of Delaware, National Association of EMS Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

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Histology of a lung abscess shows dense inflammatory reaction (low power).
A thick-walled lung abscess.
Pneumococcal pneumonia complicated by lung necrosis and abscess formation.
A lateral chest radiograph shows air-fluid level characteristic of lung abscess.
A 54-year-old patient developed cough with foul-smelling sputum production. A chest radiograph shows lung abscess in the left lower lobe, superior segment.
A 42-year-old man developed fever and production of foul-smelling sputum. He had a history of heavy alcohol use, and poor dentition was obvious on physical examination. Chest radiograph shows lung abscess in the posterior segment of the right upper lobe.
A 42-year-old man developed fever and production of foul-smelling sputum. He had a history of heavy alcohol use, and poor dentition was obvious on physical examination. Lung abscess in the posterior segment of the right upper lobe was demonstrated on chest radiograph. CT scan shows a thin-walled cavity with surrounding consolidation.
Chest radiograph of a patient who had foul-smelling and bad-tasting sputum, an almost diagnostic feature of anaerobic lung abscess.
Histology of a lung abscess shows dense inflammatory reaction (high power).
 
 
 
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