Empyema

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Empyema Microchapters

Patient Information

Overview

Classification

Subdural empyema
Pleural empyema

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]

Overview

Empyema may be classified according to the etiology, anatomical location, and pathological course of the disease.[1] Primary thoracic empyema occurs most commonly as iatrogenic empyema without associated pneumonia whereas secondary empyema occurs more commonly secondary to pneumonia. Empyema necessitans is a spontaneous discharge of an empyema that has burrowed through the parietal pleura into the chest wall to form a subcutaneous abscess that may eventually rupture through the skin.[2][3] On the basis of anatomical location, empyema may be classified depending on the affected organ including the following: gallbladder empyema,[4][5] subdural empyema,[6][7][8][9][10][11][12][13] joint empyema,[14][15][16] and empyema cystitis.[17][18] Empyema is most frequently caused by bacteria. Causes may be tuberculous or nontuberculous. Tuberculous empyema is the most common cause of empyema necessitans with majority of affected patients immunocompromised.[19][20] There are 3 stages of empyema which are important in terms of the laboratory findings. These are exudative, fibrinopurulent, and organizing.[21]

Empyema classification

Classification by Organ System or Location of Empyema

Pleural empyema

Pleural empyema is also called empyema thoracis. Thoracic empyema arises from an infection within the lung. It must be differentiated from an abscess, which is a collection of necrotic and suppurated tissue located in the parenchyma of an organ.[22] Empyema is most commonly used to refer to pus collection in the pleural cavity although several other organs can be affected including the brain, gallbladder, joints, and urinary bladder. Thoracic empyema arises from an infection within the lung, often associated with parapneumonic effusions. Parapneumonic effusions may be uncomplicated or complicated effusions. Complicated parapneumonic effusion results when bacteria invade the pleural space with a resultant formation of an empyema.

Gallbladder empyema

Gallbladder empyema is also called suppurative cholecystitis which may complicate acute/chronic cholecystitis whereby pus collects in the gall bladder lumen. It is common in people with diabetes and atherosclerotic disease.[4][5] Gallbladder empyema normally results from an obstruction of the cystic duct hampering drainage of bile from the gall bladder, which becomes secondarily infected.

Subdural empyema

Subdural empyema is a life-threatening infection, consisting of a localized collection of purulent material, typically unilateral, between the dura mater and the arachnoid mater. Subdural empyema may be classified according to location of the infection into 2 groups: intracranial and spinal, with intracranial being the more common of the two groups, accounting for 95% of subdural empyema patients.[23][24] Subdural empyema accounts for approximately 15-25% of focal central nervous system infections. In 2014, the incidence of subdural empyema was estimated to be less than 1 case per 100,000 individuals, with a male predominance.[25] The most common pathogens of intracranial subdural empyema are anaerobic and microaerophilic Streptococci, compared to spinal subdural epmyema, which may be caused by either Streptococci or Staphylococcus aureus.[24] If left untreated, subdural empyema frequently evolves into severe fever, headache, nausea, vomiting, seizures, coma, and subsequent death. Complications to subdural empyema include status epilepticus, neurological deficits, and thrombosis. Prognosis is generally good with antimicrobial therapy. Physical examination of patients with subdural empyema is usually remarkable for fever, facial pain, and altered mental status.[26][27][28] MRI is the primary imaging study of epidural abscess, with CT scan as a secondary alternative. Treatment of subdural empyema requires a combined medical and surgical approach. In order to evacuate the pus, burr hole placement or craniotomy may be used to treat the subdural empyema. The preferred surgical mainstay of treatment for subdural empyema is craniotomy.

Subdural empyema  is rare, however it may complicate one-third of all intracranial infections. Subdural empyema may follow pansinusitis, mastoiditis, orbital cellulitis, and after surgery for lumbar lipomyelomeningocele manifesting with seizures, focal neurological deficits and altered mentatal status and possible progression to coma.[6][7][8][9][10][11][12][13]

Joint empyema

This usually occurs after superimposed infection of the sinovial fluid following some procedures (e.g. post-lumbar or sacroiliac discectomy and instrumentation or surgery).[14][15][16]

Empyema cystitis

This type of empyema may complicate a dysfunctional[17][18] or an obstructed[29] urinary bladder. Empyema cystis may be treated by intermittent self-catherterization[30] or vaginal vesicostomy for empyema of dysfunctional bladder.[31]

Differential Diagnosis

Causes of

lung cavities

Differentiating Features Differentiating radiological findings Diagnosis

confirmation

  • CXR and CT demonstrates cavities in the upper lobe of the lung
  • Sputum smear positive for acid-fast bacilli and nucleic acid amplification tests (NAAT) is used on sputum or any sterile fluid for rapid diagnosis and is positive for mycobacteria.
  • Any age group
  • Acute, fulminant life threating complication of prior infection
  • >100.4 °F fever, with hemodynamic instability
  • Worsening pneumonia-like symptoms
  • CBC is positive for causative organism
  • Children and elderly are at risk
  • Empyema appears lenticular in shape and has a thin wall with smooth luminal margins
  • Pulmonary nodules with cavities and infiltrates are a frequent manifestation on CXR
  • Elderly females of 40-50 age group
  • Manifestation of rheumatoid arthritis
  • Presents with other systemic symptoms including symmetric arthritis of the small joints of the hands and feet with morning stiffness are common manifestations
  • Pulmonary nodules with cavitation are located in the upper lobe (Caplan syndrome) on X-ray
  • On CXR bilateral adenopathy and coarse reticular opacities are seen
  • CT of the chest demonstrates extensive hilar and mediastinal adenopathy
  • Additional findings on CT include fibrosis (honeycomb, linear, or associated with bronchial distortion), pleural thickening, and ground-glass opacities.[38]
  • Common appearance on CT is patchy consolidation,often accompanied by ground-glass opacities and nodules.[42]
  • Exclusively afflicts smokers, with a peak age of onset of between 20 and 40 years
  • Clinical presentation varies, but symptoms generally include months of dry cough, fever, night sweats, and weight loss
  • Skin is involved in 80% of the cases, scaly erythematous rash is typical
  • Thin-walled cystic cavities are the usual radiographic manifestation, observed in over 50% of patients by either CXR or CT scans.[44]
  • Biopsy of the lung

References

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