3/31/2017 ParapneumonicPleuralEffusionsandEmpyemaThoracis:Background,Pathophysiology,Epidemiology

ParapneumonicPleuralEffusionsand
EmpyemaThoracis
Updated:Sep15,2016
Author:AtikunLimsukon,MDChiefEditor:NaderKamangar,MD,FACP,FCCP,FCCMmore...

OVERVIEW

Background
Pleuraleffusionsareacommonfindinginpatientswithpneumonia.Morethan40%ofpatientswith
bacterialpneumoniaand60%ofpatientswithpneumococcalpneumoniadevelopparapneumonic
effusions.Whiletreatmentwithantibioticsleadstoresolutioninmostpatients,somepatients
developamorefibrinousreaction,withthepresenceoffrankpusinthemostseverecases.The
latterisreferredtoasanempyemaorempyemathoracis.

Parapneumonicpleuraleffusionsareclassifiedintothreebroadgroupsbasedonfluid
characteristics,which,inturn,providesareflectiononboththeseverityandnaturalhistoryofthe
pleuraleffusion.

Uncomplicatedparapneumoniceffusions:Theseareexudative,predominantlyneutrophilic
effusionsreflectingincreasingpassageofinterstitialfluidasaresultofinflammation
associatedwithpneumonia.Thefluidmaybeslightlycloudyorevenclear,withoutany
organismsnotedonGramstainorculture.Theyresolvewithappropriateantibiotictreatment
ofthepneumonia.
Complicatedparapneumoniceffusions:Theseoccurasaresultofbacterialinvasionintothe
pleuralspacethatleadstoanincreasednumberofneutrophils,decreasedglucoselevels,
pleuralfluidacidosis,andanelevatedlacticdehydrogenase(LDH)concentration.These
effusionsoftenaresterilebecausebacteriaareusuallyclearedrapidlyfromthepleural
space.Thefluidistypicallycloudyandisclassifiedascomplicatedbecauseitrequires
drainageforresolution.
Empyemathoracis:Thisdevelopsasfrankpusaccumulatesinthepleuralspace.Laboratory
studiesindicatethatpreexistingpleuralfluidisrequiredforthedevelopmentofanempyema
becauseempyemaisnotseenafterdirectinoculationintoa"dry"pleuralspace.Thepusis
seenafterthoracentesisoranydrainageprocedureofthepleuralspaceandisgenerally
characterizedasthick,viscous,andopaque.

Empyemathoracishasbeenrecognizedasaseriousproblemforcenturies.Inapproximately500
BCE,Hippocratesrecommendedtreatingempyemawithopendrainage.Thetreatmentof
empyemaremainedessentiallyunchangeduntilthemiddleofthe19thcentury.In1876,Hewitt
describedamethodofcloseddrainageofthechestinwhicharubbertubewasplacedintothe
empyemacavitytodrainviaawatersealdrainagemethod.Intheearly20thcentury,surgical
therapiesforempyema(eg,thoracoplasty,decortication)wereintroduced.Morerecently,video
assistedthoracoscopicsurgery(VATS)hasplayedamajorroleinthetreatmentofpatientswith
empyemathoracis.

Etiology
Virtuallyanytypeofpneumonia(eg,bacterial,viral,atypical)canbeassociatedwitha
parapneumonicpleuraleffusion.However,therelativeincidenceofparapneumonicpleural
effusionsvarieswiththeorganism.ViralpneumoniaandMycoplasmapneumoniacausesmall
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pleuraleffusionsin20%ofpatients.Forthoracicempyema,bacterialpneumoniaisthecausein
70%.[1]Increasingly,empyemathoracisisacomplicationofprevioussurgery,whichaccountsfor
30%ofcases.Traumamayalsobecomplicatedbyinfectionofthepleuralspace.Intheabsence
oftraumaorsurgery,theinfectingorganismmayspreadfrombloodorotherorgansintothepleural
space.Thesecandevelopintosubdiaphragmaticabscesses,arupturedesophagus,mediastinitis,
osteomyelitis,pericarditis,cholangitis,anddiverticulitis,amongothers.

Bacteriology
Bacteriologicfeaturesofculturepositiveparapneumonicpleuraleffusionshavechangedovertime.
Priortotheantibioticera,Streptococcuspneumoniaewasthemostcommon.Spneumoniaeand
Staphylococcusaureusnowaccountforapproximately70%ofaerobicGrampositivecultures.
Presently,aerobicorganismsareisolatedslightlymorefrequentlythananaerobicorganisms.
Streptococcusmillerihasalsobecomemorecommon.[2,3,4]Klebsiella,Pseudomonas,and
HaemophilusspeciesarethethreemostcommonlyisolatedaerobicGramnegativeorganisms.
BacteroidesandPeptostreptococcusspeciesarethe2mostcommonlyisolatedanaerobic
organisms.Currently,empyemathoracisismostoftenassociatedwithaspirationpneumoniawith
mixedbacterialfloraecontainingaerobicandanaerobicbacteria.[5]Theusualorganismisolatedin
empyemathoraciscomplicatingprevioussurgeryisSaureus.

Pathophysiology
Theevolutionofaparapneumonicpleuraleffusion,asshownintheimagebelow,canbedivided
into3stages,includingexudative,fibrinopurulent,andorganizationstages.[1]

Leftpleuraleffusiondeveloped4daysafterantibiotictreatmentforpneumococcalpneumonia.Patient
developedfever,leftsidedchestpain,andincreasingdyspnea.Duringthoracentesis,purulentpleuralfluidwas
removed,andtheGramstainshowedgrampositivediplococci.ThecultureconfirmedthistobeStreptococcus
pneumoniae.
ViewMediaGallery

Duringtheexudativestage,sterilepleuralfluidrapidlyaccumulatesinthepleuralspace.The
pleuralfluidoriginatesintheinterstitialspacesofthelungandinthecapillariesofthevisceral
pleurabecauseofincreasedpermeability.Thepleuralfluidhasalowwhitebloodcell(WBC)count
andarelativelylowLDHlevel.ThepleuralfluidglucoseandpHlevelsarewithinthereference
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range.Theseeffusionsresolvewithantibiotictherapy,andchesttubeinsertionisnotrequired.This
stagetakesapproximately25daysfromtheonsetofpneumonia.

Inthesecondstage,orfibrinopurulentstage,bacterialinvasionofthepleuralspaceoccurs,with
accumulationofpolymorphonuclearleukocytes,bacteria,andcellulardebris.Atendencytoward
loculationandseptationexists,pleuralfluidpH(<7.20)andglucoselevelsarelower(<60mg/dL),
andtheLDHlevelsincrease.Atthisstage,bacteriologicalstainsand/orculturesofthepleuralfluid
canbepositiveformicroorganisms.Thisstagetakesapproximately510daysafterpneumonia
onset.

Inthelast,ororganizationstage,fibroblastsgrowintotheexudatesfromboththevisceraland
parietalpleuralsurfaces,andtheyproduceaninelasticmembranecalledapleuralpeel.Pleural
fluidisthick.Inanuntreatedpatient,pleuralfluidmaydrainspontaneouslythroughthechestwall
(ie,empyemathoracisnecessitatis).Empyemathoracismayarisewithoutanassociated
pneumonicprocess,suchasfromesophagealperforation,trauma,asurgicalprocedureinthe
pleuralspace,orsepticemia.Thislaststagemaytake23weekstodevelop.

Epidemiology
Frequency
UnitedStates

Basedonhospitaldischargedata,approximately1.3millionpatientsarehospitalizedeachyear
withpneumoniaintheUnitedStates.Theprevalenceofparapneumoniceffusionsisdependent,in
part,ontheorganisminvolved.Overall,pleuraleffusionsareseeninapproximately3540%of
patientswithbacterialpneumoniaoranaerobicpneumonia,withaprevalenceinpneumococcal
pneumoniaapproaching60%.Complicatedpleuraleffusionsaremorecommonlyseenwith
anaerobicpleuropulmonaryinfections.Thisresultsinanestimated500,000750,000patientswith
parapneumoniceffusionsannually.Nogoodestimatesareavailableregardingthefractionofthese
patientsthatproceedtocomplicatedeffusionsorempyema,butinsmallseries,approximately5
10%requireadrainageorasurgicalprocedure.

AstudyofUnitedStateshospitalizationdatafoundthatin1996,thenationalhospitalizationratefor
parapneumonicempyemarelateddiagnoseswas3.04per100,000by2008,ithadincreasedto
5.98per100,000,a2foldincrease.Pneumococcalempyemaratesremainedstable,but
staphylococcalempyemaratestripled.Hospitalizationratesforempyemasofotherorunknown
etiology(62.4%ofempyemahospitalizations)doubled,asdidratesfornonpneumococcal
streptococcalempyemas.[6]

International

Nogoodestimatesareavailableontheinternationalincidenceofpneumonia.TheWorldHealth
Organizationhasreportedtheburdenofdiseaserelatedtodeathsfromlowerrespiratorytract
infectionsin2004at4.2million.Onecanextrapolatetheincidenceofpleuraleffusionsand
empyemausingaUSestimate,butcautionisadvisedbecausethelackoftreatmentanddelayed
treatmentinunderdevelopedcountriesmayskewtheinternationalincidenceupward.

Riskfactors

Riskfactorsforempyemathoracisincludeage(childrenandelderlypersons),debilitation,
pneumoniarequiringhospitalization,andcomorbiddiseases,suchasbronchiectasis,rheumatoid
arthritis,alcoholism,diabetes,andgastroesophagealrefluxdisease.[1]

AlargeprospectiveobservationalstudyintheUnitedKingdom,usingmultivariateregression
analysis,identified7clinicalfactorspredictingthedevelopmentofcomplicatedparapneumonic
pleuraleffusionsorempyemathoracis.Theyidentifiedanalbuminvalueoflessthan30g/L,a
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3/31/2017 ParapneumonicPleuralEffusionsandEmpyemaThoracis:Background,Pathophysiology,Epidemiology

serumsodiumvalueoflessthan130mmol/L,aplateletcountofgreaterthan400X109/L,aC
reactiveproteinlevelofgreaterthan100mg/L,andahistoryofalcoholabuseorintravenousdrug
useasindependentlyassociatedwiththedevelopmentofcomplicatedparapneumonicpleural
effusionsorempyemathoracis,whileahistoryofchronicobstructivepulmonarydisease(COPD)
wasassociatedwithadecreasedrisk.[7]

Mortality/Morbidity
Mortalityratesfromempyemahavebeenreportedtobe1150%range.Thewidedifferenceisdue
inparttolimiteddata,withmortalityratesbeinghigher(inthe50%range)atatimewhencurrent
diagnosticimaging,antibiotics,anddrainageoptionswerenotreadilyavailable.Othercomplicating
factorsincludecardiacandrespiratorycomorbidities,immunosuppressivestatesrelatedto
medicationsorhumanimmunodeficiencyvirus(HIV)infection,andage.Deathratesrelatedto
pneumoniaarehigherinelderlypersonsandinthosewiththeoutlinedunderlyingcomorbidities.
Morerecentreportsestimatedeathsinpatientswithpneumoniaandcomplicatedpleuraleffusions
inthe710%range.

Race

Nospecificethnicpredispositionisrecognizedforempyemahowever,alargernumberofethnic
minoritieshavelimitedfinancialresources,limitedaccesstohealthcare,andmorecomorbidities,
which,inturn,mayincreasetheirriskofpneumonia,pleuraleffusions,andempyema.

Sex
Empyemahasnoknownsexualpredilection.

Age

Nospecificagepredispositionisrecognizedforempyema,althoughincreasingageandassociated
comorbiditiesincreasetheriskforpneumoniaand,subsequently,pleuraleffusionsandempyema.
Alsorecognizedisthatdifferencesexistinempyemathatoccursinchildrencomparedwithadults.
Themoststrikingdifferencesincludethedevelopmentofempyemainpreviouslyhealthychildren
(asopposedtoadultswhousuallyhavesomeunderlyingcomorbidity)andthelowerthresholdfor
treatmentwiththrombolyticsandsurgicaldrainageinchildrencomparedwithadults.See
Empyemaformoredetails.

Prognosis
Mostpatientsrecover,butthemortalityrateremainsapproximately10%.Appropriateantibiotic
therapyandearlydrainageofpleuralfluidarecrucialforrecovery.Approximately1525%of
patientsrequiresurgicalintervention,includingdecorticationand/oranopendrainageprocedure.

PatientEducation
Forpatienteducationresources,visittheLungDiseaseandRespiratoryHealthCenter.Also,
seethepatienteducationarticleBacterialPneumonia.

ClinicalPresentation

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