EMPYEMA

Empyema is a collection of pus in the space between the lung and the inside of the chest wall (pleural space).

Causes, incidence, and risk factors

Empyema is caused by an infection that spreads from the lung. It leads to a buildup of pus in the pleural space.

There can be a pint or more of infected fluid. This fluid puts pressure on the lungs.

Risk factors include:

 Bacterial pneumonia

 Lung abscess

 Thoracic surgery

 Trauma or injury to the chest

In rare cases, empyema can occur when a needle is inserted through the chest wall to draw off fluid in the pleural

space (thoracentesis)

Symptoms

 Chest pain, which worsens when you breathe in deeply (inspiration)

 Dry cough

 Excessive sweating, especially night sweats

 Fever and chills

 General discomfort, uneasiness, or ill feeling (malaise)

 Shortness of breath

 Unintentional weight loss

Signs and tests

The health care provider may note decreased breath sounds or a friction rub when listening to the chest with a

stethoscope (auscultation).

Tests may include the following:

 Chest x-ray
  CT scan of chest

 Pleural fluid gram stain and culture

 Thoracentesis

Treatment

The goal of treatment is to cure the infection and remove the collection of pus from the lung. Antibiotics are

prescribed to control the infection.

The health care provider will place a chest tube to completely drain the pus. A surgeon may need to perform a

procedure to peel away the lining of the lung (decortication) if the lung does not expand properly.

Expectations (prognosis)

When empyema complicates pneumonia, the risk of permanent lung damage and death goes up. Patients will

need long-term treatment with antibiotics and drainage. However, most people fully recover from empyema.

Complications

 Pleural thickening

 Reduced lung function

Calling your health care provider

Call your health care provider if you develop symptoms of empyema.

Prevention

Prompt and effective treatment of lung infections may prevent some cases of empyema.

Definition
Empyema is a condition in which pus and fluid from infected tissue collects in a body cavity. The
name comes from the Greek word empyein meaning pus-producing (suppurate). Empyema is most
often used to refer to collections of pus in the space around the lungs (pleural cavity), but sometimes
refers to similar collections in the gall bladder or the pelvic cavity. Empyema in the pleural cavity is
sometimes called empyema thoracis, or empyema of the chest, to distinguish it from empyema
elsewhere in the body.
Description
Empyema may have a number of causes but is most frequently a complication of pneumonia. Its
development can be divided into three phases: an acute phase in which the body cavity fills with a thin
fluid containing some pus; a second stage in which the fluid thickens and a fibrous, coagulation
protein (fibrin) begins to accumulate within the cavity; and a third or chronic stage in which the lung or
other organ is encased within a thick covering of fibrous material.

Causes and symptoms

Empyema thoracis can be caused by a number of different organisms, including bacteria, fungi, and
amebas, in connection with pneumonia, chest wounds, chest surgery, lung abscesses, or a ruptured
esophagus. The infective organism can get into the pleural cavity either through the bloodstream or
other circulatory system, in secretions from lung tissue, or on the surfaces of surgical instruments or
objects that cause open chest wounds. The most common organisms that cause empyema are the
following bacteria: Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus.
S. aureus is the most common cause in all age groups, accounting for 90% of cases of empyema in
infants and children. Pelvic empyema in women is most often caused by Bacteroides strains or
Pseudomonas aeruginosa. In elderly, chronically ill, or alcoholic patients, empyema is often caused by
Klebsiella pneumoniae species of bacteria.
When the disease organisms arrive in the cavity surrounding the lungs, they infect the tissues that
cover the lungs and line the chest wall. As the body attempts to fight off the infection, the cavity fills up
with tissue fluid, pus, and dead tissue cells. Empyema of the gall bladder or pelvis results from similar
reactions to infection in those parts of the body.
The signs and symptoms of empyema vary somewhat according to the location of the infection and its
severity. In empyema thoracis, patients usually exhibit symptoms of pneumonia, including fever,
cough, fatigue, shortness of breath, and chest pain. They may prefer to lie on the side of the body
affected by the empyema. Family members may notice bad breath. In severe cases, the patient may
become dehydrated, cough up blood or greenish-brown sputum, run a fever as high as 105°F
(40.6°C), or fall into a coma.
Patients with thoracic empyema may develop potentially life-threatening complications if the condition
is not treated. The infected tissues may develop large collections of pus (abscesses) that can rupture
into the patient's airway, or the infection may spread to the tissues surrounding the heart. In extreme
cases the empyema may spread to the brain by means of bacteria carried in the bloodstream.
In pelvic empyema, the infection produces large amounts of thick, foul-smelling pus that is rapidly
replaced even after drainage. Empyema of the gallbladder is marked by intense pain on the upper
right side of the abdomen, high fever, and rigidity of the muscles over the infected area.

Diagnosis
A physician may consider the possibility of empyema thoracis in patients with pneumonia or other
symptoms of lung infection. When listening to sounds within the patient's chest with a stethoscope,
the sounds of breathing will be partly muffled and harder to hear in the patients with empyema. The
area of the chest over the infection will sound dull when tapped or thumped (percussed). On an x ray,
empyema thoracis will appear as a cloudy or opaque area. The amount of fluid present in the pleural
cavity can be estimated using an ultrasound imaging procedure. The diagnosis of empyema,
however, has to be confirmed with laboratory tests because its symptoms can be caused by other
disease conditions.
The diagnosis of empyema is usually confirmed by analyzing a sample of fluid taken from the pleural
cavity. The sample is obtained by a procedure called thoracentesis. In this procedure, the patient is
given a local anesthetic, a needle is inserted into the pleural cavity through the back between the ribs
on the infected side, and a sample of fluid is withdrawn. If the patient has empyema, there will be a
very high level of one particular kind of immune cell (white blood cells), a high level of protein, and a
very low level of blood sugar. The fluid can also be tested for the specific disease organism by
staining or tissue cultures. In some cases, the color, smell, or consistency of the tissue fluid also helps
to confirm the diagnosis.
Treatment
Empyema is treated using a combination of medications and surgical techniques. Treatment with
medication involves intravenously administering a two-week course of antibiotics. It is important to
give antibiotics as soon as possible to prevent first-stage empyema from progressing to its later
stages. The antibiotics most commonly used are penicillin and vancomycin. Patients experiencing
difficulty breathing are also given oxygen therapy.
Surgical treatment of empyema has two goals: drainage of the infected fluid and closing up of the
space left in the pleural cavity. If the infection is still in its early stages, the fluid can be drained by
thoracentesis. In second-stage empyema, the surgeon will insert a chest tube in the patient's rib cage
or remove part of a rib (rib resection) in order to drain the fluid. In third-stage empyema, the surgeon
may cut or peel away the thick fibrous layer coating the lung. This procedure is called decortication.
When the fibrous covering is removed, the lung will expand to fill the space in the chest cavity. The
doctor can use video-assisted thoracic surgery (VATS) techniques to position the chest tube or to
perform a limited decortication. The VATS technique allows a physician to see within the body during
certain surgical procedures. Empyema of the gallbladder is a serious condition that is treated with
intravenous antibiotics and surgical removal of the gallbladder.

Prognosis
The prognosis for recovery is generally good, except in those cases with complications, such as a
brain abscess or blood poisoning, or cases caused by certain types of streptococci.

Key terms
Empyema — The collection of pus in a body cavity, particularly the lung or pleural cavity.

Empyema

Definition

Empyema is a condition in which pus and fluid from infected tissue collects in a body cavity. The name comes
from the Greek word empyein meaning pus-producing (suppurate). Empyema is most often used to refer to
collections of pus in the space around the lungs (pleural cavity), but sometimes refers to similar collections in the
gall bladder or the pelvic cavity. Empyema in the pleural cavity is sometimes called empyema thoracis, or
empyema of the chest, to distinguish it from empyema elsewhere in the body.

Description

Empyema may have a number of causes but is most frequently a complication of pneumonia. Its development
can be divided into three phases: an acute phase in which the body cavity fills with a thin fluid containing some
pus; a second stage in which the fluid thickens and a fibrous, coagulation protein (fibrin) begins to accumulate
within the cavity; and