Empyema and Abscess Pneumonia Clinical Presentation

Updated: Mar 18, 2015
  • Author: Michael A Ward, MD; Chief Editor: Robert E O'Connor, MD, MPH  more...
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Presentation

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) [9]
  • 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

Chalmers et al in a prospective observational study identified 6 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. [10] 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.

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Physical

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
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Causes

The most common cause of lung abscess is aspiration. Patients at the highest risk are those who have the following:

  • Poor dentition
  • Seizure disorder
  • Alcohol abuse
  • Inability to protect their airway because of an absent gag reflex (eg, patients who are comatose, have a change in mentation, or who might be undergoing general anesthesia)
  • Primary lung disorders, such as septic emboli, vasculitic disorders, cavitating lung malignancies, or pulmonary cystic disease
  • Penetrating chest trauma
  • Immunosuppression
  • Conditions associated with septic emboli, including intravenous drug use, soft tissue infections, valvular heart disease, and individuals with intravascular prosthetic material

The microbiologic organisms involved in lung abscesses typically are polymicrobial oral flora, including Bacteroides, Fusobacterium, and Peptostreptococcus species. Other organisms include Pseudomonas species, Klebsiella species, Staphylococcus aureus, Streptococcus pneumoniae, Streptococcus milleri, Nocardia species, and less commonly fungi and parasites. Immunosuppressed individuals are at increased risk for more opportunistic pathogens associated with lung abscess, including Mycobacterium tuberculosis (especially in cases of immigration from Africa or Asia), Pseudomonas, Klebsiella, Nocardia, and fungi. [11]

Klebsiella pneumoniae has been shown to have a significant preponderance for severe, necrotizing pneumonia and subsequent development for cavitary lesions and lung abscesses. [11] A recent Taiwanese study found an increasing incidence of K pneumoniae in community-acquired lung abscesses. [12] However, there is a higher incidence of K pneumoniae related infection found in Taiwan, and this trend may not translate to the US and other parts of the world. [13]

The most common cause of an empyema is from a parapneumonic effusion that becomes infected; these account for about half of all empyemas. Other causes of an empyema include the following:

  • Penetrating chest trauma
  • Undrained hemothoraces, including those secondary to blunt chest trauma
  • Contamination of a wound during procedures such as needle decompression, chest tube placement, thoracentesis, or thoracic surgery

Microbiologic organisms that can cause an empyema include Streptococcus species such as Streptococcus milleri (Streptococcus intermedius, Streptococcus constellatus, and Streptococcus anginosus), S pneumoniae,Staphylococcus aureus and methicillin-resistant Staphylococcus aureus (MRSA), and a variety of gram-negative organisms and anaerobes. [2, 14] Anaerobic involvement, either as sole organism or part of a polymicrobial infection, is common in empyemas but may be difficult to detect on cultures. [14] One should always consider enterobacteria, enterococci, and Mycobacterium tuberculosis as potential pathogens.

Bacteria from the Streptococcus milleri group have become the predominant organism cultured from adults with empyemas, especially in patients with underlying malignancy or diabetes mellitus. Recently, incidence of staphylococcal-related empyema has increased.

In the pediatric population, S pneumoniae remains the predominant organism associated with empyemas. S aureus and Pneumococcal serotypes 1, 3, and 19A, possibly secondary to the widespread use of the pneumococcal conjugate vaccine, have seen dramatic increases more recently. [3]

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