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
Pathophysiology
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
Complications
Fibrothorax
Respiratory distress
Diagnosis
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
Management
Antibiotics active against Staphylococcus:
Cloxacillin
Vancomycin
Drainage of fluid/pus (collected in the pleural cavity):
