Empyema is defined as accumulation of pus or fluid
with demonstrable bacteria in pleural space.
Clinical Picture
- Patients present with fever,
chills, pleuritic chest pain and cough
- It can be acute , subacute
or chronic.
- Leukocytosis with shift
to left and Doehle bodies can be noted on CBC.
- Besides findings of effusion
, clubbing, chest wall erythema and edema, increased
warmth may be noted on physical exam.
- CXR will show effusion and cannot be
distinguished from other types. Loculated effusions should raise
suspicion for empyema.
- Lack of fever or
leukocytosis does not rule out empyema.
Etiology and Pathophysiology
- Empyema most often is due
to extension of infection from pneumonia. Staphylococcal, gram
negative and anaerobic infections are common infections presenting in this
mode.
- Anaerobic infections can
seed pleura and start as the primary site of infection
without a preceding pneumonitis.
- It could also follow contamination of
pleural space from non-sterile pleural taps.
Diagnosis
- Pleural tap should be done immediately
once empyema is a consideration. If the fluid is grossly purulentdiagnosis is established.
- Gram stain of the pleural fluid
and cultures for aerobes and anaerobes should be
obtained.
- If the fluid is not purulent
then obtain Ph, glucose and LDH. This will help categorize
parapneumonic effusions as simple and complicated effusions.
- CBC and cultures of sputum
and blood are routine.
Treatment
- Empyema should be drained
immediately with chest tube insertion..
- Appropriate Antibiotics should
be started immediately, empiric to start with followed by specific drug
based on culture.
- Streptokinase is useful to break up
adhesions if there are loculations.
- Some patients not responding
to this regimen may require thoracotomy to lyse adhesions .
This can be accomplished by thoracoscope. Some would require decortication,
if a thick pyemic peel has formed and prevent lung expansion.