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 purulent diagnosis 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.