Empyema: An Uncommon

Complication of Common Pneumonia

Heather Hsu, HMS III
Gillian Lieberman, MD
March 2011
Heather Hsu, HMS III
Gillian Lieberman, MD
1
Overview
Heather Hsu, HMS III
Gillian Lieberman, MD
Patient presentation
History of present illness and other relevant information
Menu of appropriate radiologic tests and their indications
Review of lung anatomy on chest x-ray
Overview of our patients radiographic findings
Differential diagnosis
A complication of the diagnosis
Definition and epidemiology
Appearance on imaging
Companion patient images
Management overview
Update on our patients clinical course
Summary
2
Our Patient: History of Present
Illness at First Presentation
CC: left-sided chest/shoulder pain and
dyspnea
HPI: 70-year-old woman presents with 2 days
of increasing, constant, non-radiating left-
sided chest and shoulder pain and 1 day of
increasing dyspnea and productive cough.
PMH: type 2 DM, HTN, hypothyroid, chronic
pain, hyperlipidemia, breast CA (1989, s/p
mastectomy), thyroid CA (2005, s/p
thyroidectomy and I-125)
Heather Hsu, HMS III
Gillian Lieberman, MD
3
Our Patient: First Presentation
Vital Signs, Physical Exam, and Labs
Vitals: T 99.6, HR 127, BP 134/70, RR 16,
O
2
sat 98% RA
Physical Exam: crackles in left lung base,
pain with movement of left shoulder
Labs: WBC 13 (90% PMNs)
Heather Hsu, HMS III
Gillian Lieberman, MD
4
At this point, acute respiratory illness is a likely
etiology for our patients presentation.
However, the differential diagnosis remains broad.
We will now consider the use of imaging
to narrow this differential.
Heather Hsu, HMS III
Gillian Lieberman, MD
5
Menu of Radiologic Tests for Adults
with Acute Respiratory Illness
Chest X-ray (CXR)
CT chest
Heather Hsu, HMS III
Gillian Lieberman, MD
www.acr.org; Mandell, et al., Clin Infect Dis 2007
6
Indications for Imaging in Adults with
Acute Respiratory Illness: Chest X-Ray
Chest X-ray
Indicated for evaluation of acute respiratory illness
in patients with the following characteristics:
Age >40 years
Hemoptysis
Dementia
Comorbidities (e.g., CAD, CHF, etc.)
Associated abnormalities (e.g., hypoxia, leukocytosis)
Clinical suspicion of pneumonia
Chest CT
Heather Hsu, HMS III
Gillian Lieberman, MD
www.acr.org; Mandell, et al., Clin Infect Dis 2007
7
Indications for Imaging in Adults with
Acute Respiratory Illness: Chest CT
Chest X-ray
Chest CT
Indicated for evaluation of:
Abnormalities seen on plain x-ray
Recurrent or persistent pneumonia
Suspected pleural abnormality
Suspected lung abscess
Pulmonary embolism
Airway patency
Guidance for thoracentesis when u/s is not sufficient
Depending on the goal of the study, it may be
performed with and/or without contrast
Heather Hsu, HMS III
Gillian Lieberman, MD
www.acr.org; Mandell, et al., Clin Infect Dis 2007
8
Given this menu of potential tests, their
indications, and our patients clinical
presentation, a chest x-ray was obtained.
Before we examine our patients current chest
x-ray, we will review some basic anatomy
using prior films.
Heather Hsu, HMS III
Gillian Lieberman, MD
9
Review of Lung Anatomy on CXR
Heather Hsu, HMS III
Gillian Lieberman, MD
Our patient: Prior PA CXR Prior lateral CXR
BIDMC, PACS
10
Anatomy Review: Right Lung Fissures
Heather Hsu, HMS III
Gillian Lieberman, MD
Prior PA CXR Prior lateral CXR
Right
major
fissure
Minor fissure
Minor fissure
BIDMC, PACS
11
Anatomy Review: Right Upper Lobe
Heather Hsu, HMS III
Gillian Lieberman, MD
Prior PA CXR Prior lateral CXR
RUL
RUL
BIDMC, PACS
12
Anatomy Review: Right Middle Lobe
Heather Hsu, HMS III
Gillian Lieberman, MD
Prior PA CXR Prior lateral CXR
RML RML
Silhouette sign: On the PA film, an opacity in the right middle lobe may
obscure the right heart border ( )
BIDMC, PACS
13
Anatomy Review: Right Lower Lobe
Heather Hsu, HMS III
Gillian Lieberman, MD
Prior PA CXR Prior lateral CXR
RLL
RLL
Silhouette sign: On a PA film, an
opacity in the RLL may obscure the
right hemidiaphragm ( )
Spine sign: On lateral, a RLL opacity
may interrupt the normal progressive
increase in lucency of the thoracic
vertebral bodies ( )
BIDMC, PACS
14
Anatomy Review: Left Major Fissure
Heather Hsu, HMS III
Gillian Lieberman, MD
Prior PA CXR Prior lateral CXR
Left major
fissure
Left major
fissure
BIDMC, PACS
15
Anatomy Review: Left Upper Lobe
Heather Hsu, HMS III
Gillian Lieberman, MD
Prior PA CXR Prior lateral CXR
LUL LUL
Silhouette sign: On the PA film, an opacity in the lingular portion of the left
upper lobe may obscure the left heart border ( )
BIDMC, PACS
16
Anatomy Review: Left Lower Lobe
Heather Hsu, HMS III
Gillian Lieberman, MD
Prior PA CXR Prior lateral CXR
LLL
LLL
Silhouette sign: On the PA film, an
opacity in the left lower lobe may obscure
the left hemidiaphragm ( )
Spine sign: On lateral, a LLL opacity
may interrupt the normal progressive
increase in lucency of the thoracic
vertebral bodies ( )
BIDMC, PACS
17
Our Patient: Prior PA and Lateral CXR
Heather Hsu, HMS III
Gillian Lieberman, MD
Prior PA CXR Prior lateral CXR
Please pause to review our patients prior films
and give your general impression.
BIDMC, PACS
18
Our Patient: Prior CXR Findings
Heather Hsu, HMS III
Gillian Lieberman, MD
Prior PA CXR Prior lateral CXR
General impression: Normal chest X-ray, note the absence
of the left breast shadow ( ) s/p mastectomy
BIDMC, PACS
19
Now back to our patients current presentation with
left-sided chest pain and dyspnea
ECG is unchanged from prior.
A portable AP chest X-ray is obtained.
Heather Hsu, HMS III
Gillian Lieberman, MD
20
Our Patient: Current AP CXR
Heather Hsu, HMS III
Gillian Lieberman, MD
BIDMC, PACS; Liebermans E-Radiology
First admission AP CXR Prior PA CXR
Please pause to compare our patients new
CXR with the prior film.
Reminder - Systematic
Approach to CXR:
-Acknowledge major
abnormalities
-Quality control
-Lines + hardware
-Heart + mediastinum
-Lungs + diaphragm
-Pleura
-Bones
-Soft tissues
-Checkpoints
-Apices
-Aortic knob
-Hila
-Retrocardiac regions
21
Our Patient: Current AP CXR Findings
Heather Hsu, HMS III
Gillian Lieberman, MD
BIDMC, PACS
First admission AP CXR
Absence of left breast
shadow ( ) s/p
mastectomy
Small left pleural
effusion ( ) obscuring
costophrenic angle
Opacity in left mid + lower
lung fields with air
bronchograms, partially
obscuring L hemidiaphragm
Given these findings, what is the differential diagnosis?
Note that we are comparing
a current AP CXR with a
prior PA film, so changes in
heart size cannot be
adequately assessed.
Prior PA CXR
22
Our Patient:
Differential Diagnosis at First Presentation
Pneumonia
Malignancy
Primary
Metastasis
Pleural effusion
Parapneumonic
Malignant
Atelectasis
Heather Hsu, HMS III
Gillian Lieberman, MD
23
Given our patients clinical presentation and CXR
findings, she is diagnosed with a left lower lobe
community-acquired pneumonia, admitted to the
hospital, and started on levofloxacin.
Over the next two days, her white blood cell count,
dyspnea, cough, and chest pain improve
and she is discharged.
Heather Hsu, HMS III
Gillian Lieberman, MD
24
Our Patient: Second Presentation
After discharge, our patient returns home.
The next morning, she presents again with
severe, pleuritic, left-sided chest pain.
She is afebrile, tachycardic, and tachypneic.
Another chest X-ray is obtained.
Heather Hsu, HMS III
Gillian Lieberman, MD
25
Our Patient:
CXR at Second Presentation
Heather Hsu, HMS III
Gillian Lieberman, MD
Current AP and lateral CXR First admission AP CXR
BIDMC, PACS
Please pause to compare our
patients current CXR with the film
from her prior admission.
26
Our Patient: Findings from CXR at
Second Presentation
Heather Hsu, HMS III
Gillian Lieberman, MD
Second admission AP and lateral CXR
BIDMC, PACS
Quality control:
Mediastinum appears wide ( ) due to the patients rotated position.
Poor arm positioning ( ) obscures upper lung fields.
New Findings:
More prominent opacity in left
mid and lower lung fields,
silhouetting out the left heart
border and hemidiaphragm.
The left costophrenic angle
( ) is obscured.
Spine sign ( )
27
Our Patient: Differential Diagnosis at
Second Presentation
Inadequately treated pneumonia
Complicated pneumonia
Simple parapneumonic effusion
Complicated parapneumonic effusion
Empyema
Necrotizing pneumonia
Lung collapse/atelectasis
Mucus plug
Lung malignancy
Malignant effusion
Pulmonary embolism
Heather Hsu, HMS III
Gillian Lieberman, MD
Given this differential diagnosis, what should the next step be?
Do we need further imaging?
28
Based on the findings from the chest X-ray and
the patients worsening clinical condition, the
decision is made to order a CTA to rule out
pulmonary embolus and further characterize
the abnormalities seen on CXR.
Heather Hsu, HMS III
Gillian Lieberman, MD
29
Our Patient: Chest CTA from
Second Presentation
Heather Hsu, HMS III
Gillian Lieberman, MD
Cross-sectional views, C+ Chest CT, soft tissue window
BIDMC, PACS
Not depicted: Contrast opacification of pulmonary arteries is complete to
segmental level and the central airways are patent.
Please pause to evaluate the images.
30
Our Patient: Chest CTA Findings
Heather Hsu, HMS III
Gillian Lieberman, MD
Cross-sectional view, C+ Chest CT, soft tissue window
BIDMC, PACS
Left lower lobe collapse with
worsening consolidation ( )
Non-hemorrhagic pleural
effusion ( ), with pleural
fluid measuring ~27
Hounsfield units
Septation within pleural
effusion ( ) and non-
dependent layering ( )
indicating loculation
Reminder re: Hounsfield units (HU):
Air: -1000 HU Fat: -30 HU
Water: 0 HU Soft tissue: +30 HU
Blood: +40 HU Bone: +1000 HU
31
Our Patient: Revised Differential
Diagnosis Following Chest CTA
Complicated pneumonia
Simple parapneumonic effusion
Complicated parapneumonic effusion
Empyema
Lung collapse/atelectasis
Lung malignancy
Malignant effusion
Heather Hsu, HMS III
Gillian Lieberman, MD
32
Based on the findings from the chest CTA and the
patients clinical presentation, she is diagnosed
with a probable empyema and transferred to the
ICU for further management.
Heather Hsu, HMS III
Gillian Lieberman, MD
33
Empyema:
Definition, Phases, and Epidemiology
Definition: The presence of pus and/or gram
stain/culture-positive fluid in the pleural space
Three phases:
Exudative: inflammation of visceral pleura results in
exudative effusion and thickening of pleural surfaces
Fibropurulent: inflammatory cells and neutrophils invade the
pleural space, fibrin is deposited on inflamed pleural
surfaces
Organizing: recruitment of fibroblasts and capillaries results
in deposition of collagen and granulation tissue on pleural
surfaces leading to pleural fibrosis
Epidemiology: <2% of patients with community-
acquired pneumonia develop empyema
Heather Hsu, HMS III
Gillian Lieberman, MD
Ahmed, et al. Am J Med 2006; Kulman and Singha, Radiographics 1997
34
Empyema:
Appearance on Imaging
CXR: may see a pleural-based opacity that has an abnormal contour
or does not flow freely on lateral decubitus views
Ultrasonography: may see loculated effusion
C+ CT chest:
Classic appearance: oblong fluid collection with smooth inner margins
that compresses and displaces surrounding lung and airway
Important to distinguish empyema from lung abscess
CT findings favoring abscess include a thick-walled, spherical cavity that
destroys lung rather than displacing it
Split pleura sign on C+ CT:
Contrast-enhanced thickened visceral and parietal pleura separated by fluid
May be seen in the fibropurulent phase
Indicates exudative effusion (not specific to empyema)
Pleural microbubbles
Small air bubbles within fluid collection
May indicate resistance of the effusion to chest tube drainage
Heather Hsu, HMS III
Gillian Lieberman, MD
Kulman and Singha, Radiographics 1997; Smolikov, et al. Clin Radiol 2006
35
Empyema: Companion Patient Images
Heather Hsu, HMS III
Gillian Lieberman, MD
BIDMC, PACS
Cross-sectional views, C+ Chest CTA, soft tissue window
Fluid trapped in the minor fissure ( ) Loculated right pleural effusion ( )
that is layering non-dependently
Atelectasis ( ) Liver dome ( )
Middle-aged man with right-sided chest discomfort and shortness of breath
36
Empyema: Management Overview
Thoracentesis
Pleural fluid analysis, gram stain, and culture
Appropriate antibiotics
Sterilization of empyema cavity with systemic
antibiotics (minimum 4-6 weeks)
Drainage
Tube thoracostomy
Video-assisted thoracoscopic surgery (VATS)
Open decortication
Open thoracostomy
Heather Hsu, HMS III
Gillian Lieberman, MD
Colice, et al. Chest 2000
37
Our Patient:
Management of Her Clinical Course
Heather Hsu, HMS III
Gillian Lieberman, MD
Pleural fluid analysis
Culture-negative, non-malignant exudative effusion with low pH
and positive gram stain
Consistent with empyema
Antibiotics
Broad spectrum coverage with vancomycin, cefepime, and
azithromycin
Drainage
VATS and decortication procedures were attempted without
success due to difficulty ventilating the right lung during the
procedures.
Ultimately, a chest tube was placed and the effusion drained
successfully.
38
Our Patient:
ICU Course and Outcome
Heather Hsu, HMS III
Gillian Lieberman, MD
ICU course
Complicated by NSTEMI, serotonin syndrome, blood
transfusion, and benzodiazepine withdrawal
Outcome
Discharged after ~2 weeks in the ICU
Currently living at home and doing well
39
Summary
Heather Hsu, HMS III
Gillian Lieberman, MD
Patient presentation
History of present illness and other relevant information
Menu of appropriate radiologic tests and their indications
Review of lung anatomy on CXR
Overview of our patients radiographic findings
Differential diagnosis
Empyema
Definition, phases, and epidemiology
Appearance on imaging
Companion patient images
Management overview
Update on our patients clinical course
40
Bibliography
Ahmed RA, Marrie TJ , Huang J Q. Thoracic empyema in patients with community-
acquired pneumonia. Am J Med. 2006;119(10):877-83.
Colice GL, Curtis A, Deslauriers J , et al. Medical and surgical treatment of
parapneumonic effusions : an evidence-based guideline. Chest. 2000;118(4):1158-
71.
Kuhlman J E, Singha NK. Complex disease of the pleural space: radiographic and
CT evaluation. Radiographics. 1997;17:63-79.
Lieberman G. A systematic approach to evaluating chest X-rays. Liebermans E-
Radiology. http://eradiology.bidmc.harvard.edu/interactivetutorials/. Accessed
March 15, 2011.
Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of
America/American Thoracic Society consensus guidelines on the management of
community-acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2:S27-72.
Smolikov A, Smolyakov R, Riesenberg K, et al. Prevalence and clinical significance
of pleural microbubbles in computed tomography of thoracic empyema. Clin Radiol.
2006;61(6):513-9.
Washington L, Kahn A, Mohammed T. American College of Radiology
Appropriateness Criteria: Acute respiratory illness.
http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx.
Accessed March 15, 2011.
Heather Hsu, HMS III
Gillian Lieberman, MD
41
Acknowledgements
Gillian Lieberman, MD for her teaching and
guidance
Veronica Fernandes, MD for her feedback
on the presentation
Emily Hanson for technical support and
guidance
Douglas Hsu, MD for assistance in finding
companion patient images
Heather Hsu, HMS III
Gillian Lieberman, MD