Empyema is a condition in which pus and fluid from infected tissue collects in a body cavity. The name comes from the Greek word empyein meaning pus-producing (suppurate). Empyema is most often used to refer to collections of pus in the space around the lungs (pleural cavity), but sometimes refers to similar collections in the gall bladder or the pelvic cavity. Empyema in the pleural cavity is sometimes called empyema thoracis, or empyema of the chest, to distinguish it from empyema elsewhere in the body.
Description
Empyema may have a number of causes but is most frequently a complication of pneumonia. Its development can be divided into three phases: an acute phase in which the body cavity fills with a thin fluid containing some pus; a second stage in which the fluid thickens and a fibrous, coagulation protein (fibrin) begins to accumulate within the cavity; and a third or chronic stage in which the lung or other organ is encased within a thick covering of fibrous material.
Causes and symptoms
Empyema thoracis can be caused by a number of different organisms, including bacteria, fungi, and amebas, in connection with pneumonia, chest wounds, chest surgery, lung abscesses, or a ruptured esophagus. The infective organism can get into the pleural cavity either through the bloodstream or other circulatory system, in secretions from lung tissue, or on the surfaces of surgical instruments or objects that cause open chest wounds. The most common organisms that cause empyema are the following bacteria: Streptococcus pneumoniae, Haemophilus influenzae, and Staphylococcus aureus. S. aureus is the most common cause in all age groups, accounting for 90% of cases of empyema in infants and children. Pelvic empyema in women is most often caused by Bacteroidesstrains or Pseudomonas aeruginosa. In elderly, chronically ill, or alcoholic patients, empyema is often caused by Klebsiella pneumoniae species of bacteria.
When the disease organisms arrive in the cavity surrounding the lungs, they infect the tissues that cover the lungs and line the chest wall. As the body attempts to fight off the infection, the cavity fills up with tissue fluid, pus, and dead tissue cells. Empyema of the gall bladder or pelvis results from similar reactions to infection in those parts of the body.
The signs and symptoms of empyema vary somewhat according to the location of the infection and its severity. In empyema thoracis, patients usually exhibit symptoms of pneumonia, including fever, cough, fatigue, shortness of breath, and chest pain. They may prefer to lie on the side of the body affected by the empyema. Family members may notice bad breath. In severe cases, the patient may become dehydrated, cough up blood or greenish-brown sputum, run a fever as high as 105°F (40.6°C), or fall into a coma.
Patients with thoracic empyema may develop potentially life-threatening complications if the condition is not treated. The infected tissues may develop large collections of pus (abscesses) that can rupture into the patient's airway, or the infection may spread to the tissues surrounding the heart. In extreme cases the empyema may spread to the brain by means of bacteria carried in the bloodstream.
In pelvic empyema, the infection produces large amounts of thick, foul-smelling pus that is rapidly replaced even after drainage. Empyema of the gallbladder is marked by intense pain on the upper right side of the abdomen, high fever, and rigidity of the muscles over the infected area.
Diagnosis
A physician may consider the possibility of empyema thoracis in patients with pneumonia or other symptoms of lung infection. When listening to sounds within the patient's chest with a stethoscope, the sounds of breathing will be partly muffled and harder to hear in the patients with empyema. The area of the chest over the infection will sound dull when tapped or thumped (percussed). On an x ray, empyema thoracis will appear as a cloudy or opaque area. The amount of fluid present in the pleural cavity can be estimated using an ultrasound imaging procedure. The diagnosis of empyema, however, has to be confirmed with laboratory tests because its symptoms can be caused by other disease conditions.
The diagnosis of empyema is usually confirmed by analyzing a sample of fluid taken from the pleural cavity. The sample is obtained by a procedure called thoracentesis. In this procedure, the patient is given a local anesthetic, a needle is inserted into the pleural cavity through the back between the ribs on the infected side, and a sample of fluid is withdrawn. If the patient has empyema, there will be a very high level of one particular kind of immune cell (white blood cells), a high level of protein, and a very low level of blood sugar. The fluid can also be tested for the specific disease organism by staining or tissue cultures. In some cases, the color, smell, or consistency of the tissue fluid also helps to confirm the diagnosis.
Treatment
Empyema is treated using a combination of medications and surgical techniques. Treatment with medication involves intravenously administering a two-week course of antibiotics. It is important to give antibiotics as soon as possible to prevent first-stage empyema from progressing to its later stages. The antibiotics most commonly used are penicillin and vancomycin. Patients experiencing difficulty breathing are also given oxygen therapy.
Surgical treatment of empyema has two goals: drainage of the infected fluid and closing up of the space left in the pleural cavity. If the infection is still in its early stages, the fluid can be drained by thoracentesis. In second-stage empyema, the surgeon will insert a chest tube in the patient's rib cage or remove part of a rib (rib resection) in order to drain the fluid. In third-stage empyema, the surgeon may cut or peel away the thick fibrous layer coating the lung. This procedure is called decortication. When the fibrous covering is removed, the lung will expand to fill the space in the chest cavity. The doctor can use video-assisted thoracic surgery (VATS) techniques to position the chest tube or to perform a limited decortication. The VATS technique allows a physician to see within the body during certain surgical procedures. Empyema of the gall-bladder is a serious condition that is treated with intravenous antibiotics and surgical removal of the gallbladder.
Prognosis
The prognosis for recovery is generally good, except in those cases with complications, such as a brain abscess or blood poisoning, or cases caused by certain types of streptococci.
BOOKS
"Bedside Procedures: Thoracentesis." In Surgery On Call, ed. Leonard G. Gomella and Alan T. Lefor. Stamford: Appleton & Lange, 1996.
Chambers, Henry F. "Infectious Diseases: Bacterial & Chlamydial." In Current Medical Diagnosis and Treatment, 1998. 37th ed. Ed. Stephen McPhee, et al. Stamford: Appleton & Lange, 1997.
Larsen, Gary L., et al. "Respiratory Tract & Mediastinum." In Current Pediatric Diagnosis & Treatment, ed. William W. Hay Jr., et al. Stamford: Appleton & Lange, 1997.
Nakeeb, Attila, and Keith D. Lillemoe. "Cholelithiasis and Cholecystitis." In Conn's Current Therapy, 1996, ed. Robert E. Rakel. Philadelphia: W. B. Saunders Co., 1996.
Stauffer, John L. "Lung." In Current Medical Diagnosis and Treatment, 1998. 37th ed. Ed. Stephen McPhee, et al. Stamford: Appleton & Lange, 1997.
Turley, Kevin. "Thoracic Wall, Pleura, Mediastinum, and Lung." In Current Surgical Diagnosis and Treatment. 10th ed. Ed. Lawrence W. Way. Stamford: Appleton & Lange, 1994.
Whyte, Richard I. "Pleural Effusion and Empyema Thoracis." In Conn's Current Therapy, 1996, ed. Robert E. Rakel. Philadelphia: W. B. Saunders Co., 1996.
Rebecca J. Frey
KEY TERMS
Abscess—An area of inflamed and injured body tissue that fills with pus.
Decortication—Surgical removal of the fibrous peel that covers the lungs in third-stage empyema.
Empyema—The collection of pus in a body cavity, particularly the lung or pleural cavity.
Fibrin—A fibrous blood protein vital to coagulation and blood clot formation.
Percussion—A diagnostic technique in which the back, chest, or abdomen is tapped to determine whether body cavities contain abnormal fluid.
Pleural cavity—The space surrounding the lungs, including the membranes covering the lungs and lining the inside of the chest wall.
Pneumonia—Inflammation of the lungs usually caused by a virus, bacteria, or other organism.
Resection—The surgical removal of part of an organ or body structure, as in rib resection.
Suppurate—To produce or discharge pus.
Thoracentesis—A procedure in which fluid is withdrawn from the pleural cavity through a needle inserted between the ribs. The fluid may be withdrawn either for diagnostic tests or to drain the cavity.
Video-assisted thoracic surgery (VATS)—A technique used to aid in the placement of chest tubes or when performing decortications when treating advanced empyema.
