Pediatric Empyema Clinical Presentation

Updated: Sep 30, 2016
  • Author: Peter H Michelson, MD; Chief Editor: Girish D Sharma, MD, FCCP, FAAP  more...
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Presentation

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

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  • 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.

  • Mycoplasma pneumoniae, viruses, and atypical pneumonias can also present with exudative pleural effusions, although mononuclear cells primarily characterize them.

  • A study investigated the risk factors of empyema after acute viral infection and the association between empyema and the use of nonsteroidal anti-inflammatory drugs (NSAIDs). The study found that NSAIDs use during acute viral infection is associated with an increased risk of empyema in children. [6]

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