History

Clinical manifestations of parapneumonic effusions and empyema largely depend on whether the patient has an aerobic or anaerobic infection. Aerobic infections are more acute in onset with acute febrile symptoms, while anaerobic infections can be indolent in their time course and symptoms may be nonspecific with low-grade fevers. If fever persists for more than 48 hours after the initiation of antibiotic treatment, a complicating parapneumonic effusion or empyema likely exists.

Aerobic bacterial infection

The clinical presentation in patients with aerobic bacterial pleural space infection is similar to that of patients with bacterial pneumonia. Patients present with an acute febrile illness with chest pain, sputum production, and leukocytosis. A complicated parapneumonic effusion is suggested by the presence of a fever lasting more than 48 hours after the initiation of antibiotic therapy.

Anaerobic bacterial infection

Patients with anaerobic bacterial infections involving the pleural space usually present with a subacute illness. Most of these patients have symptoms persisting for more than 7 days. Approximately 60% of patients have weight loss. Anemia is also common. Most of these patients have poor oral hygiene, many have alcoholism, or other factors that predispose them to recurrent aspiration.

Physical Examination

Most patients are febrile with tachypnea and tachycardia, often appearing toxic and fulfilling criteria for the systemic inflammatory response syndrome (SIRS). Signs of pleural effusion upon physical examination include the following:

Decreased or absent breath sounds
Dullness to percussion
Decreased tactile fremitus
Evidence of tension and contralateral tracheal shift possible with large effusions

In areas in which pneumonia and lung consolidation are adjacent and more extensive than pleural fluid, findings include (1) rales or crackles and/or (2) bronchial breath sounds or egophony.

Differential Diagnoses

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Media Gallery

Left pleural effusion developed 4 days after antibiotic treatment for pneumococcal pneumonia. Patient developed fever, left-sided chest pain, and increasing dyspnea. During thoracentesis, purulent pleural fluid was removed, and the Gram stain showed gram-positive diplococci. The culture confirmed this to be Streptococcus pneumoniae.
Left lateral chest radiograph shows a large, left pleural effusion.
A right lateral decubitus chest radiograph shows a free-flowing pleural effusion, which should be sampled with thoracentesis for pH determination, Gram stain, and culture.
CT scan of thorax shows loculated pleural effusion on left and contrast enhancement of visceral pleura, indicating the etiology is likely an empyema.
Chest CT scan with intravenous contrast in a patient with mixed Streptococcus milleri and anaerobic empyema following aspiration pneumonia, showing a thickened contrast-enhanced pleural rind, high-density pleural effusion, loculation, and septation. Thoracentesis yielded foul-smelling pus.
Chest CT scan with intravenous contrast in a patient with mixed Streptococcus milleri and anaerobic empyema following aspiration pneumonia, 3 days following thoracostomy and intrapleural fibrinolysis (Reteplase).
Chest CT scan with intravenous contrast (axial, coronal, and sagittal views) of an alcoholic male patient with an anaerobic empyema demonstrating the split pleura sign.

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Author

Atikun Limsukon, MD Assistant Professor, Department of Pulmonary, Allergy and Critical Care Medicine, Department of Internal Medicine, Faculty of Medicine, Chiang Mai University, Thailand

Disclosure: Nothing to disclose.

Coauthor(s)

Guy W Soo Hoo, MD, MPH Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Director, Medical Intensive Care Unit, Chief, Pulmonary, Critical Care and Sleep Section, West Los Angeles VA Healthcare Center, Veteran Affairs Greater Los Angeles Healthcare System

Guy W Soo Hoo, MD, MPH is a member of the following medical societies: American Association for Respiratory Care, American College of Chest Physicians, American College of Physicians, American Thoracic Society, California Thoracic Society, Society of Critical Care Medicine

Disclosure: Nothing to disclose.

Specialty Editor Board

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

Disclosure: Received salary from Medscape for employment. for: Medscape.

Chief Editor

Nader Kamangar, MD, FACP, FCCP, FCCM Professor of Clinical Medicine, University of California, Los Angeles, David Geffen School of Medicine; Chief, Division of Pulmonary and Critical Care Medicine, Vice-Chair, Department of Medicine, Olive View-UCLA Medical Center

Nader Kamangar, MD, FACP, FCCP, FCCM is a member of the following medical societies: Academy of Persian Physicians, American Academy of Sleep Medicine, American Association for Bronchology and Interventional Pulmonology, American College of Chest Physicians, American College of Critical Care Medicine, American College of Physicians, American Lung Association, American Medical Association, American Thoracic Society, Association of Pulmonary and Critical Care Medicine Program Directors, Association of Specialty Professors, California Sleep Society, California Thoracic Society, Clerkship Directors in Internal Medicine, Society of Critical Care Medicine, Trudeau Society of Los Angeles, World Association for Bronchology and Interventional Pulmonology

Disclosure: Nothing to disclose.

Additional Contributors

Michael Peterson, MD Chief of Medicine, Vice-Chair of Medicine, University of California, San Francisco, School of Medicine; Endowed Professor of Medicine, University of California, San Francisco-Fresno, School of Medicine

Michael Peterson, MD is a member of the following medical societies: American College of Chest Physicians, American College of Physicians, American Thoracic Society

Disclosure: Nothing to disclose.

Acknowledgements

The authors and editors of Medscape Reference gratefully acknowledge the contributions of previous author, Sat Sharma, MD, FRCPC, to the development and writing of this article.

Sections Parapneumonic Pleural Effusions and Empyema Thoracis
Overview
Presentation
DDx
Workup
Treatment
Medication
Questions & Answers
Media Gallery
References

Parapneumonic Pleural Effusions and Empyema Thoracis Clinical Presentation

History

Aerobic bacterial infection

Anaerobic bacterial infection

Physical Examination

References

Tables

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