EMPYEMA

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.

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