Internal Medicine

Empyema thoracis

Collection of pus in the pleural cavity.


Parapneumonic effusion (70%):

  • Streptococcus pneumoniae and Staphylococcus aureus

Traumatic cause (30%):

  • Trauma, post-thoracic surgery, oesophagal ruptures, or cervical infectionsknown as

Primary empyema (30%):  not related to previous pneumonia/intervention


Schema shows mechanism of pleural effusion development in pneumonia. Initial bacterial infection causes local inflammatory reaction resulting in increased capillary microvascular permeability and a rapid outpouring of fluid containing inflammatory cells into the pleural space. Comorbidities such as heart failure also further contribute to interstitial edema. IL-8, interleukin 8; TNF-α, tumor necrosis factor α; VEGF, vascular endothelial growth factor. | McCauley, L., & Dean, N. (2015). Pneumonia and empyema: causal, casual or unknown. Journal of thoracic disease, 7(6), 992–998. doi:10.3978/j.issn.2072-1439.2015.04.36

Clinical features

  • Fever
  • Breathing difficulty
  • Toxic appearance of child
  • ↓ movement of respiration (decreased air entry)
  • Vocal resonance
  • Dull percussion note
  • Empyema necessitans: Pulsatile swelling over chest


  • Fibrothorax
  • Respiratory distress


Pleural tap:

  • Purulent fluid with pus cells, high protein and low sugar
  • ↑ LDH, proteins, neutrophils, and dead cells

X-ray (chest):

  • Shift in mediastinum
  • Obliteration of costophrenic angle
  • Opacification (varying degree)
A: This patient presented with a pneumococcal pneumonia which was complicated by pleural infection. A small bore tube was inserted but drainage was limited by extensive septations within the effusion. The patient remained febrile with elevated inflammatory markers; B: Intrapleural tPA and DNase was administered twice daily for three days with dramatic clearance of the loculated effusion. Her fever and inflammatory markers settled and was discharged on antibiotics; C: CXR at 3 months after discharge, with marked improvement of pleural opacities. | Rosenstengel A. (2012). Pleural infection-current diagnosis and management. Journal of thoracic disease, 4(2), 186–193. doi:10.3978/j.issn.2072-1439.2012.01.12

Differential diagnosis

Other causes of pleural effusion:

  • Tuberculosis
  • Neoplasia


Antibiotics active against Staphylococcus:

  • Cloxacillin
  • Vancomycin

Drainage of fluid/pus (collected in the pleural cavity):

  • Intercostal drainage tube
  • Drainage of fluid under thoracoscopy

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