An empyema should be suspected in patients with pulmonary infection if there is persisting or recurrent pyrexia despite treatment with a suitable antibiotic. Patients with empyema due to aerobic bacterial infection usually have high and remittent pyrexia, rigors, sweating, malaise and weight loss. Blood counts show polymorphonuclear leukocytosis and high C-reactive protein. Locally, there is pleural pain, breathlessness, cough and sputum. Empyema with anaerobic bacterial infections involving the pleural space presents with a subacute illness with symptoms for more than 7 days.

Low grade fever, weight loss and anemia is commonly seen. Clinical signs of pleural effusion are present such as decreased or absent breath sounds, dull notes on percussion, a decreased tactile fremitus. Large pleural effusions may show an evidence of tension and contralateral tracheal shift [6].

• Fever

  The patients have fever, cough, shortness of breath, and chest pain that increases on breathing or movement of chest. They may have a low grade fever, loss of appetite and weight loss in some infections. [symptoma.com]

  She had presented with fever after being treated for presumed pneumonia and parapneumonic effusion 2 months prior. CT scan showed splenic abscesses eroding through the diaphragm causing a left pleural empyema. [ncbi.nlm.nih.gov]

  Symptoms of epidural abscess include fever, headache, vomiting, and sometimes lethargy, focal neurologic deficits, seizures, and/or coma. [msdmanuals.com]

  On the contrary, fever enhances immune defences and reduces virus and bacteria replication and many serotypes of Streptococcus pneumoniae are thermolabile and do not survive at 40-41°C. [pharmaco-vigilance.eu]

• Malaise

  Visit for more related articles at Journal of Pulmonary & Respiratory Medicine A 50-year-old man presented with two months of malaise, weight loss, and back pain after an accidental aspiration. Labs showed a neutrophilic leukocytosis of 23,000/uL. [omicsonline.org]

  Symptoms Dry cough Fever and chills Excessive sweating, especially night sweats General discomfort, uneasiness or ill feeling (malaise) Unintentional weight loss Chest pain, which worsens on deep inhalation (inspiration) Diagnosis The health care provider [hopkinsmedicine.org]

  Malaise, fever, and declining mental status can occur rapidly. Complications can include dural venous thrombosis, parenchymal abscess, epidural abscess, and meningitis. Mass effect or secondary venous infarction can cause focal neurologic deficits. [epilepsy.com]

  Symptoms Symptoms of empyema may include any of the following: Chest pain, which worsens when you breathe in deeply (pleurisy) Dry cough Excessive sweating, especially night sweats Fever and chills General discomfort, uneasiness, or ill feeling ( malaise [mountsinai.org]

  Symptoms include dyspnea, coughing, chest pain on one side, malaise, and fever. thoracentesis may be done to confirm the diagnosis and determine the specific causative organism. [medical-dictionary.thefreedictionary.com]

• Fatigue

  Symptoms Most patients with empyema experience fatigue, fever, chills, sweating and loss of appetite, but elderly patients and those with diabetes may not have specific symptoms. Other symptoms depend on the site of the infection. [cirse.org]

  Signs and symptoms of empyema and lung infections include: Chest pain Dry cough Excessive sweating Fever and chills Shortness of breath Sharp or stabbing chest pain Headache Confusion Loss of appetite, low energy, fatigue Weight loss How is empyema and [brighamandwomens.org]

   Easy fatiguability.  Loss of weight.  Night sweating. 12. [slideshare.net]

  Extreme exhaustion (fatigue). Unexplained weight loss. What causes empyema? Empyema typically develops when an infection spreads from your lungs to the pleural space. The most common cause of empyema is pneumonia. Other causes include: Tuberculosis. [my.clevelandclinic.org]

  Common signs and symptoms include: Fever and chills Night sweats Chest pain, often sharp and worsening with inspiration Shortness of breath A dry cough A productive cough if there's associated pneumonia Decreased appetite Fatigue A general sense of not [verywellhealth.com]

• Streptococcal Infection

  THE importance of Staphylococcus aureus as the etiologic agent in pneumonia complicated by empyema has been emphasized in many recent reviews. 1, 2 The problem of pneumonia and empyema secondary to streptococcal infection has been ignored since the advent [nejm.org]

  Group A streptococcal infections should be treated for at least 21 days. [clinicaladvisor.com]

• Pleural Effusion

  Hepatic hydrothorax refers to the presence of a pleural effusion (usually >500 mL) in a patient with cirrhosis in whom other causes of pleural effusion, such as cardiopulmonary causes, pleural disease or malignancy have been excluded. [ncbi.nlm.nih.gov]

  Evidence of pleural effusion. [clinicaltrials.gov]

  […] echogenic, swirling fluid within a pleural effusion. [lifeinthefastlane.com]

• Dyspnea

  We describe a case of 42-year-old man was brought to our Emergency Department for chest pain with dyspnea and fever. The final diagnoses are empyema caused by colo-pleural fistula and colon cancer. [ncbi.nlm.nih.gov]

  The symptoms of dyspnea and chest pain improved after this procedure. [journals.lww.com]

  Symptoms include dyspnea, coughing, chest pain on one side, malaise, and fever. thoracentesis may be done to confirm the diagnosis and determine the specific causative organism. [medical-dictionary.thefreedictionary.com]

  These include fever, dyspnea, cough, increased sputum production, and pleuritic chest pain. [emdocs.net]

• Tachypnea

  Vital signs are important as we like to see stabilization of the vitals including the fever curve, tachypnea and hypoxia with the chest tube placement. [cancertherapyadvisor.com]

  The patient presented with tachypnea, decreased respiratory mobility, and vocal fremitus in the left chest. Auscultation of the left lung revealed diminished breath sounds and moist rales on the dorsal side in the supine position. [journals.lww.com]

  […] early exudative phase, an intermediate fibrinopurulent phase, and a late organizing phase. 3 Diagnosis The diagnosis of empyema thoracis is principally made in the clinical setting of febrile illness in children with pulmonary symptoms (e.g. cough, tachypnea [ipeg.org]

  At presentation, his vitals were stable except tachypnea (respiratory rate of 24/min). He was afebrile and maintaining oxygen saturation of 93% on ambient air. [bmcinfectdis.biomedcentral.com]

  Fever, tachycardia, tachypnea, hypotension, and reduced oxygen saturation are frequently seen. [pulmonologyadvisor.com]

• Pleuritic Pain

  This causes pain when you breathe in and out. The pleuritic pain lessens or stops when you hold your breath. Treatment of pleurisy involves pain control and treating the cause. [mayoclinic.org]

  Thus, diagnostic thoracocentesis should be carried out in any patient with hydrothorax who presents with fever, pleuritic pain, encephalopathy, or unexplained deterioration in renal function. 1. [atmph.org]

  Pain Pleuritic pain as well as the discomfort of a chest drain may reduce deep breathing and affect the child’s willingness to cough. Adequate analgesia is essential to promote comfort and facilitate breathing exercises and mobilisation. [pch.health.wa.gov.au]

  This causes a local pleuritic reaction, and the characteristic pleuritic chest pain described by patients (5,21). [jtd.amegroups.com]

  pain (3), Fever (1) Laisaar [30] 21 2–8 Fever, bleeding Roupie [31] 16 1–3 Chills and fever (1) Present Study 12 3–9 None Conclusions Empyema thoracis is associated with significant morbidity. [bmcinfectdis.biomedcentral.com]

• Pleural Disorder

  Merck Manual Professional Version. https://www.merckmanuals.com/professional/pulmonary-disorders/mediastinal-and-pleural-disorders/viral-pleuritis. Accessed Jan. 29, 2022. Broaddus VC, et al., eds. Pleural effusion. [mayoclinic.org]

• Abdominal Pain

  Intervention (& Technique) We report on a previously healthy 74-year-old male who was admitted at a regional hospital with severe retrosternal and abdominal pain after an episode of vigorous vomiting the morning after ingestion of large quantity of beer [ncbi.nlm.nih.gov]

  pain, fever, and constipation. [journals.lww.com]

  […] or abdominal pain Examination Appears lethargic/unwell Hypoxaemia Tachypnoea Chest wall in-drawing, splinting, retractions, grunting, nasal flaring Bronchial breath sounds and crackles (adjacent pneumonia) Localised absence of breath sounds and a dull [rch.org.au]

  The patient was admitted to our centre presenting with a one-month history of abdominal pain, which had increased during the seven days prior to the admission. [scielo.isciii.es]

  There is no specific clinical presentation of SBEM, fever and chills, abdominal pain, shortness of breath, chest pain, and consciousness disturbance are recognized presentations of SBEM; it is frequently associated with few localizing signs. [atmph.org]

• Tachycardia

  However, if localized reely perforation has occurred and the patient has generalized sepsis, fevers, temperature, 103°F, chills and rigors, and confusion may be observed in association with hypotension and severe tachycardia. [laparoscopyhospital.com]

  […] sounds and a dull percussion note Assessment of severity Severity depends primarily on the clinical status of the child and may not correlate with the size or appearance of the effusion Severe respiratory distress Severe hypoxaemia or cyanosis Marked tachycardia [rch.org.au]

  An electrocardiography showed sinus tachycardia. A chest radiograph and computed tomography (CT) scan showed a large left pleural effusion with a shift of the mediastinum and trachea to the right side (Fig. 1). [journals.lww.com]

  On hospital day 6, his condition rapidly deteriorated due to sepsis (persistent fevers, tachycardia, and hypotension with rising white blood cell count), and a new 4 cm × 3 cm area of fluctuance was noticed on the left superior pectoralis region. [hindawi.com]

• Increased Sweating

  Signs and symptoms of simple empyema may include: Chest pain that worsens when breathing Confusion Decreased appetite Dry cough Fever Headache Increased sweating Shortness of breath Symptoms of complex empyema Signs and symptoms of complex empyema may [childrens.com]

• Hematuria

  Lower respiratory tract symptoms (e.g. hemoptysis, cough, dyspnea) Renal symptoms, hematuria, red cell casts Pulmonary nodules with cavities and infiltrates are a frequent manifestation on CXR Positive for P-ANCA Biopsy of the tissue involved shows necrotizing [wikidoc.org]

• Headache

  Boodman, Washington Post, 16 Dec. 2017 Other symptoms of a subdural empyema include headaches and lethargy. —Sandra G. Boodman, chicagotribune.com, 19 Dec. 2017 Other symptoms of a subdural empyema include headaches and lethargy. —Sandra G. [merriam-webster.com]

  While clinical findings indicated improvement of the sinusitis, his headache did not improve. [ncbi.nlm.nih.gov]

  Symptoms of epidural abscess include fever, headache, vomiting, and sometimes lethargy, focal neurologic deficits, seizures, and/or coma. [msdmanuals.com]

  Signs and symptoms of simple empyema may include: Chest pain that worsens when breathing Confusion Decreased appetite Dry cough Fever Headache Increased sweating Shortness of breath Symptoms of complex empyema Signs and symptoms of complex empyema may [childrens.com]

  The most consistent clinical complaint is a progressively severe headache, often related to the sinusitis. Malaise, fever, and declining mental status can occur rapidly. [epilepsy.com]

• Blood: Leukocytosis is present, and should decrease with treatment.
• Sputum culture: Gram stain may often show the causative organism.
• Chest radiographs: Evidence of pleural fluid is present. In pyopneumothorax an air-fluid level is observed.
• Ultrasonography: Shows the position of the fluid, the extent of pleural thickening and whether fluid is in a single collection or multiloculated by fibrin and debris, helps in thoracocentesis in loculated pleural effusions. 
• Computed tomography (CT) scan: CT gives information on the pleura, the underlying lung parenchyma and patency of the major bronchi. CT of the chest with contrast assists in delineating the pleural fluid loculations. 
• Aspiration of fluid: Ultrasound or CT is used to identify the optimal site to undertake aspiration, which is best performed using a wide-bore needle. If the fluid is thick and turbid pus, empyema is confirmed. Other features suggesting empyema are a fluid glucose < 40 mg/dL), LDH > 1000 U/L or a fluid pH < 7.0. Pleural fluid studies include blood cell count and differential blood cell counts. WBC counts are generally greater than 50,000 cells/µL. 
• Microbiology: Gram stain and bacterial culture may be done but antibiotic treatment may render all fluids sterile. The distinction between tuberculous and nontuberculous disease can be difficult and often requires pleural biopsy, histology and culture. 

• Left Pleural Effusion

  (A) A chest radiograph showed a large left pleural effusion with a shift of the mediastinum and trachea to the right side. [journals.lww.com]

  Chest x-ray showed a left-sided pleural effusion. The patient was treated empirically as parapneumonic effusion with intravenous (IV) ceftriaxone plus azithromycin. [atmph.org]

  Chest drainage tubes were inserted into both sides of the pleural cavity. Bacterial culture of the right-side pleural effusion showed streptococcal species but no pathogenic species were found in the left pleural effusion. [surgicalcasereports.springeropen.com]

• Pleural Effusion

  Hepatic hydrothorax refers to the presence of a pleural effusion (usually >500 mL) in a patient with cirrhosis in whom other causes of pleural effusion, such as cardiopulmonary causes, pleural disease or malignancy have been excluded. [ncbi.nlm.nih.gov]

  Evidence of pleural effusion. [clinicaltrials.gov]

  […] echogenic, swirling fluid within a pleural effusion. [lifeinthefastlane.com]

• Pleural Adhesions

  Rabbit EMP was characterized by the development of pleural adhesions detectable by chest ultrasonography and fibrinous coating of the pleura. [ncbi.nlm.nih.gov]

  Low CO2 insuffulation pressures (e.g. 4 mm Hg) initially aids both in slow disruption of pleural adhesions and lung collapse. The pleural space is inspected and coagulum removed completely. Interlobar collections should also be sought and removed. [ipeg.org]

  […] of fibrinous pleural adhesions. [jtd.amegroups.com]

• Leukocytosis

  A pleural empyema is, in effect, an abscess: there is usually a high swinging fever and a leukocytosis the most effective treatment is surgical drainage There is a spectrum of abnormality from pure exudative parapneumonic effusions to frank pus. [gpnotebook.co.uk]

  Labs showed a neutrophilic leukocytosis of 23,000/uL. [omicsonline.org]

  Blood counts show polymorphonuclear leukocytosis and high C-reactive protein. Locally, there is pleural pain, breathlessness, cough and sputum. [symptoma.com]

  A blood test revealed leukocytosis (white blood cell count, 26 × 109 cells/L; neutrophils, 93.9%). A standing plain abdominal radiograph showed multiple intra-abdominal gas-liquid planes. [journals.lww.com]

An empyema will only heal if infection is eradicated and the empyema space is obliterated, allowing apposition of the visceral and parietal pleural layers.

Treatment of non-tuberculous empyema

• Drainage: When the patient is acutely ill and the pus is sufficiently thin, a wide-bore intercostal tube should be inserted into the most dependent part of the empyema space (using ultrasound or CT guidance in difficult cases) and connected to an underwater-seal drain system. If the initial aspirate reveals turbid fluid or frank pus, or if loculations are seen on ultrasound, the tube should be put on suction (-5 to -10 cm of water) and flushed regularly with 20 mL normal saline. 
• Fibrinolytics: Intrapleural streptokinase or urokinase is given in case of loculations [7]. 
• Surgery: Video-assisted thoracoscopic surgery (VATS) and surgery when the pus is thick or loculated. Thickened pleura in some cases might need surgical "decoration".
• Antibiotics: An antibiotic directed against the organism causing the empyema should be given for 2-4 weeks. For a patient with community-acquired pneumonia, a second or third generation cephalosporin in combination with a macrolide needs to be given. For patients hospitalized with severe community-acquired pneumonia, a macrolide plus a third-generation cephalosporin with antipseudomonal activity is required [8] [9]. 

Treatment of tuberculous empyema

Immediate initiation of antitubercular chemotherapy is essential. The pus in the pleural space is aspirated through a wide-bore needle with intercostal tube drainage if necessary until the pus ceases to reaccumulate. Surgery is occasionally required to ablate a residual empyema space.

Mortality rate from empyema is higher in the presence of cardiac and respiratory comorbidities, immunosuppressive states and old age. Surgical procedures including decortication and/or an open drainage procedure are required in 15-25% of patients. Fibrothorax with restriction and encasement of the lung in thickened, often calcified pleura, is a late complication in tuberculous empyema. Death rates are estimated to be approximately 10% [5].

70% of empyema thoracis are caused by bacterial pneumonia. 30% cases arise as complications of previous cardiothoracic surgery, in which case Staphylococcus aureus is the most common bacteria. Apart from surgery, empyema may arise with the bacterial spread locally or through blood such as from esophageal perforation or septicemia. Streptococcus pneumoniae and Staphylococcus aureus account for nearly 70% of aerobic gram-positive cultures isolated in empyema. Aerobic gram-negative organisms are mainly Klebsiella, Pseudomonas and Hemophilus species [2].

In the United States, approximately 500,000 to 750,000 patients are diagnosed with parapneumonic effusions per year- of which nearly 5 to 10% require a drainage or surgical procedure. Children, elderly and debilitated persons are at a higher risk for developing empyema. Other risk factors include pneumonia requiring hospitalization and coexisting diseases like rheumatoid arthritis, bronchiectasis, diabetes mellitus, alcoholism and gastroesophageal reflux disease. Chalmers et al identified 7 clinical factors that predict the development of empyema: an albumin value of less than 30 g/L, a platelet count of greater than 400,000,000,000/L, a C-reactive protein level of greater than 100 mg/L, a serum sodium value of less than 130 mmol/L, and a history of intravenous drug or alcohol abuse. A decreased risk was found in a history of chronic obstructive pulmonary disease [3].

5 to 10 days after the onset of pneumonia, bacterial invasion of the pleural space occurs leading to the accumulation of polymorphonuclear leukocytes, bacteria, and cellular debris in the form of a thick inflammatory exudate in the pleural space. The pleural fluid may test positive for microorganisms. The pus in the pleural space is often under considerable pressure and if the condition is not adequately treated, pus may rupture into a bronchus causing a bronchopleural fistula and pyopneumothorax or track through the chest wall with the formation of a subcutaneous abscess or sinus (termed empyema necessitans). Loculation and septation may occur [4].

Early diagnosis and treatment of bacterial pneumonias can prevent many cases of empyema, especially in high risk cases. Early diagnosis and drainage may obviate the need for surgical treatment in established cases of empyema [10].

An empyema is a collection of pus within an anatomical cavity. The condition may occur for example in the uterus, the appendix or the gallbladder. Usually, the term refers to thoracic empyema which is mostly caused by bacterial invasion of the pleural space. It may present with acute symptoms of fever, chest pain and sputum in case of aerobic infections; or a more indolent subacute febrile illness with weight loss in anaerobic infections.

Clinically, empyema is characterized by decreased or absent breath sounds and dullness on percussion. Complete blood counts, microbiological analysis of sputum or pleural fluid, imaging studies of chest and ultrasound are used for diagnosis. Treatment modalities include pleural drainage, surgery, broad spectrum antibiotics and infusion of intrapleural thrombolytic agents. Mortality rates are around 10% [1].

Empyema is a collection of pus inside the thin space between the inner lining of your chest wall and the surface of the lungs. Most commonly, empyema results as a complication of pneumonia or lung abscess. Sometimes it may happen after a surgery on the chest. The patients have fever, cough, shortness of breath, and chest pain that increases on breathing or movement of chest. They may have a low grade fever, loss of appetite and weight loss in some infections. Antibiotics to treat the bacterial infection and medications for the fever are given to treat this condition. The pus is drained using chest tube to allow the lungs to expand normally. 

1. Light RW, Girard WM, Jenkinson SG, George RB. Parapneumonic effusions. Am J Med 1980; 69:507.
2. Bartlett JG, Gorbach SL, Thadepalli H, Finegold SM. Bacteriology of empyema. Lancet. Mar 2 1974; 1(7853):338-40.
3. Grijalva CG, Zhu Y, Pekka Nuorti J, Griffin MR. Emergence of parapneumonic empyema in the USA. Thorax. Aug 2011; 66(8):663-8.
4. Sahn SA. Diagnosis and management of parapneumonic effusions and empyema. Clin Infect Dis. Dec 1 2007;45(11):1480-6.
5. Wozniak CJ, Paull DE, Moezzi JE, et al. Choice of first intervention is related to outcomes in the management of empyema. Ann Thorac Surg 2009; 87:1525.
6. Chapman SJ, Davies RJ. Recent advances in parapneumonic effusion and empyema. Curr Opin Pulm Med 2004; 10:299.
7. Levinson GM, Pennington DW. Intrapleural fibrinolytics combined with image-guided chest tube drainage for pleural infection. Mayo Clin Proc. Apr 2007;82(4):407-13.
8. [Guideline] Colice GL, Curtis A, Deslauriers J, et al. Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. Chest. Oct 2000;118(4):1158-71. 
9. [Guideline] 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. Mar 1 2007;44 Suppl 2:S27-72
10. Mandal AK, Thadepalli H, Mandal AK, Chettipally U. Outcome of primary empyema thoracis: therapeutic and microbiologic aspects. Ann Thorac Surg 1998; 66:1782.