History

The patient's history may reveal the following findings:

Recent diagnosis and treatment of pneumonia
Recent history of penetrating chest trauma or diaphragmatic injury (should raise clinical suspicion for empyema)^[16]
Cough productive of bloody sputum that frequently has a fetid odor or offensive appearance
Fever
Shortness of breath
Anorexia, weight loss
Night sweats
Pleuritic chest pain

At the onset, the cough is non-productive, but a productive cough is the typical sign, sometimes followed by hemoptysis. Clubbing fingers may be present in patients with chronic abscess.^[4]

Chalmers et al in a prospective observational study identified six risk factors that were associated with patients admitted with community-acquired pneumonia who subsequently developed a complicated parapneumonic effusion or empyema. These factors include albumin < 30 g/L, sodium < 130 mmol/L, platelet count >400 X 10⁹, C-reactive protein >100 mg/L, and a history of alcohol abuse or intravenous drug use.^[13]Other predispositions to development of a parapneumonic effusion and empyema include immunosuppression (eg, HIV, diabetes mellitus, malnutrition), gastrointestinal reflux, poor dental hygiene, bronchial aspiration, and chronic lung disease.

Physical Examination

The physical examination may reveal the following findings:

Temperature frequently elevated but usually not greater than 102°F
Tachypnea
Rales
Rhonchi
Egophony
Tubular breath sounds
Decreased breath sounds
Dullness to percussion

Differential Diagnoses

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Guo W, Gao B, Li L, et al. A community-acquired lung abscess attributable to odontogenic flora. Infect Drug Resist. 2019. 12:2467-70. [QxMD MEDLINE Link]. [Full Text].
Sabbula BR, Rammohan G, Akella J. Lung abscess. StatPearls [Internet]. 2020 Jan. [QxMD MEDLINE Link]. [Full Text].
Kuhajda I, Zarogoulidis K, Tsirgogianni K, et al. Lung abscess-etiology, diagnostic and treatment options. Ann Transl Med. 2015 Aug. 3(13):183. [QxMD MEDLINE Link]. [Full Text].
Gadkowski LB, Stout JE. Cavitary pulmonary disease. Clin Microbiol Rev. 2008 Apr. 21(2):305-33. [QxMD MEDLINE Link]. [Full Text].
Wang JL, Chen KY, Fang CT, Hsueh PR, Yang PC, Chang SC. Changing bacteriology of adult community-acquired lung abscess in Taiwan: Klebsiella pneumoniae versus anaerobes. Clin Infect Dis. 2005 Apr 1. 40(7):915-22. [QxMD MEDLINE Link].
Ko WC, Paterson DL, Sagnimeni AJ, et al. Community-acquired Klebsiella pneumoniae bacteremia: global differences in clinical patterns. Emerg Infect Dis. 2002 Feb. 8(2):160-6. [QxMD MEDLINE Link]. [Full Text].
Grijalva CG, Zhu Y, Nuorti JP, Griffin MR. Emergence of parapneumonic empyema in the USA. Thorax. 2011 Aug. 66(8):663-8. [QxMD MEDLINE Link]. [Full Text].
Maskell NA, Batt S, Hedley EL, Davies CW, Gillespie SH, Davies RJ. The bacteriology of pleural infection by genetic and standard methods and its mortality significance. Am J Respir Crit Care Med. 2006 Oct 1. 174(7):817-23. [QxMD MEDLINE Link].
Burgos J, Falco V, Pahissa A. The increasing incidence of empyema. Curr Opin Pulm Med. 2013 Jul. 19(4):350-6. [QxMD MEDLINE Link].
Li ST, Tancredi DJ. Empyema hospitalizations increased in US children despite pneumococcal conjugate vaccine. Pediatrics. 2010 Jan. 125(1):26-33. [QxMD MEDLINE Link].
Rahman NM, Davies RJO. Effusions from infections: Parapneumonic effusion and empyema. Light RW, Lee YCG, eds. Textbook of Pleural Disease. 2nd ed. London: Hodder & Stoughton; 2008. 341-66.
Chalmers JD, Singanayagam A, Murray MP, Scally C, Fawzi A, Hill AT. Risk factors for complicated parapneumonic effusion and empyema on presentation to hospital with community-acquired pneumonia. Thorax. 2009 Jul. 64(7):592-7. [QxMD MEDLINE Link].
Byington CL, Spencer LY, Johnson TA, et al. An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations. Clin Infect Dis. 2002 Feb 15. 34(4):434-40. [QxMD MEDLINE Link].
Hirshberg B, Sklair-Levi M, Nir-Paz R, Ben-Sira L, Krivoruk V, Kramer MR. Factors predicting mortality of patients with lung abscess. Chest. 1999 Mar. 115(3):746-50. [QxMD MEDLINE Link].
Barmparas G, DuBose J, Teixeira PG, et al. Risk factors for empyema after diaphragmatic injury: results of a National Trauma Databank analysis. J Trauma. 2009 Jun. 66(6):1672-6. [QxMD MEDLINE Link].
Chen HJ, Yu YH, Tu CY, et al. Ultrasound in peripheral pulmonary air-fluid lesions. Color Doppler imaging as an aid in differentiating empyema and abscess. Chest. 2009 Jun. 135(6):1426-32. [QxMD MEDLINE Link].
Jaffe A, Calder AD, Owens CM, Stanojevic S, Sonnappa S. Role of routine computed tomography in paediatric pleural empyema. Thorax. 2008 Oct. 63(10):897-902. [QxMD MEDLINE Link].
[Guideline] Balfour-Lynn IM, Abrahamson E, Cohen G, et al, for the Paediatric Pleural Diseases Subcommittee of the BTS Standards of Care Committee. BTS guidelines for the management of pleural infection in children. Thorax. 2005 Feb. 60 Suppl 1:i1-21. [QxMD MEDLINE Link]. [Full Text].
Porcel JM, Vives M, Esquerda A. Tumor necrosis factor-alpha in pleural fluid: a marker of complicated parapneumonic effusions. Chest. 2004 Jan. 125(1):160-4. [QxMD MEDLINE Link].
Odeh M, Sabo E, Srugo I, Oliven A. Correlation between levels of tumour necrosis factor-alpha and levels of pH, glucose, and lactate dehydrogenase in parapneumonic effusions. J Infect. 2005 Feb. 50(2):114-9. [QxMD MEDLINE Link].
Rezaeetalab F, Parizadeh SM, Esmaeely H, Akbari H, Akbari F, Saberi S. Tumor necrosis factor alpha and high sensitivity C-reactive protein in diagnosis of exudative pleural effusion. J Res Med Sci. 2011 Nov. 16(11):1405-9. [QxMD MEDLINE Link]. [Full Text].
Cameron R, Davies HR. Intra-pleural fibrinolytic therapy versus conservative management in the treatment of adult parapneumonic effusions and empyema. Cochrane Database Syst Rev. 2008 Apr 16. CD002312. [QxMD MEDLINE Link].
Maskell NA, Davies CW, Nunn AJ, et al, for the First Multicenter Intrapleural Sepsis Trial (MIST1) Group. U.K. Controlled trial of intrapleural streptokinase for pleural infection. N Engl J Med. 2005 Mar 3. 352(9):865-74. [QxMD MEDLINE Link]. [Full Text].
Ko Y, Tobino K, Yasuda Y, et al. A community-acquired lung abscess attributable to Streptococcus pneumoniae which extended directly into the chest wall. Intern Med. 2017. 56(1):109-13. [QxMD MEDLINE Link]. [Full Text].
Merritt RE, Shrager JB. Indications for surgery in patients with localized pulmonary infection. Thorac Surg Clin. 2012 Aug. 22(3):325-32. [QxMD MEDLINE Link].
Yu H. Management of pleural effusion, empyema, and lung abscess. Semin Intervent Radiol. 2011 Mar. 28(1):75-86. [QxMD MEDLINE Link]. [Full Text].
Wali SO. An update on the drainage of pyogenic lung abscesses. Ann Thorac Med. 2012 Jan. 7(1):3-7. [QxMD MEDLINE Link]. [Full Text].
Godfrey MS, Bramley KT, Detterbeck F. Medical and surgical management of empyema. Semin Respir Crit Care Med. 2019 Jun. 40(3):361-74. [QxMD MEDLINE Link].
Wiese AD, Griffin MR, Zhu Y, Mitchel EF Jr, Grijalva CG. Changes in empyema among U.S. children in the pneumococcal conjugate vaccine era. Vaccine. 2016 Dec 7. 34(50):6243-9. [QxMD MEDLINE Link]. [Full Text].
Saxena S, Atchison C, Cecil E, Sharland M, Koshy E, Bottle A. Additive impact of pneumococcal conjugate vaccines on pneumonia and empyema hospital admissions in England. J Infect. 2015 Oct. 71 (4):428-36. [QxMD MEDLINE Link].
Chalmers JD, Singanayagam A, Murray MP, Scally C, Fawzi A, Hill AT. Risk factors for complicated parapneumonic effusion and empyema on presentation to hospital with community-acquired pneumonia. Thorax. 2009 Jul. 64(7):592-7. [QxMD MEDLINE Link].
[Guideline] Shen KR, Bribriesco A, Crabtree T, et al. The American Association for Thoracic Surgery consensus guidelines for the management of empyema. J Thorac Cardiovasc Surg. 2017 Jun. 153(6):e129-e146. [QxMD MEDLINE Link]. [Full Text].
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Media Gallery

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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Author

Michael A Ward, MD Assistant Professor of Medicine, University of Chicago Division of the Biological Sciences, The Pritzker School of Medicine

Michael A Ward, MD is a member of the following medical societies: American College of Emergency Physicians

Disclosure: Nothing to disclose.

Coauthor(s)

David S Howes, MD Professor of Medicine and Pediatrics, Residency Program Director Emeritus, Section of Emergency Medicine, University of Chicago, University of Chicago, The Pritzker School of Medicine

David S Howes, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency 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.

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, Arizona Medical Association, American College of Osteopathic Emergency Physicians, American Medical Association

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 Heart Association, American Medical Association, National Association of EMS Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Additional Contributors

Mark S Slabinski, MD, FACEP, FAAEM Vice President, USACS Central

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, Ohio State Medical Association

Disclosure: Nothing to disclose.

Acknowledgements

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 College of Emergency Physicians

Disclosure: Nothing to disclose.