Fever, chest pain, malaise, cough, dyspnea and purulent sputum are clinical signs of pneumonia and pleuritic chest pain, a more specific sign of pleural involvement, may be reported as well, but its absence does not exclude the presence of a parapneumonic effusion [1] [2]. Apart from weakness, elderly patients may not report any additional symptoms [2], which is why a meticulous assessment must be performed to exclude life-threatening pulmonary infection.

• Fever

  […] or duration of fever after admission. [ncbi.nlm.nih.gov]

  The main clinical symptoms are pleuritic chest pain, fever, cough, expectoration of purulent sputum and dyspnea. [symptoma.com]

  Chest tube drainage Continued respiratorydistress and fever Chest drain inserted Not suggestive ofempyema – Noleukocytes / growth No significant drainage Continued to have lowgrade fever Repeat ultrasoundshowed fluid collectionand tube to be in [slideshare.net]

• Inflammation

  Other factors such as the extent of the patient's pneumonia, severity of systemic signs of inflammation, radiographic features of the effusion, and pleural fluid chemical profile assist clinical decision making. [ncbi.nlm.nih.gov]

  This can result from lung injury and inflammation, which is seen in pneumonia. It can also arise following increased pressure in blood vessels, which sometimes occurs in heart failure. [wisegeek.com]

  Keywords Pneumonia Empyema Pleural effusion Inflammation Severity Mortality This is a preview of subscription content, log in to check access. [link.springer.com]

  […] pneumonia despite 48 hours of antibiotics Chest pain or pleuritic pain and refusal to lie on one side Features on examination: Localised decreased air entry Dullness to percussion Decreased chest expansion Appearance of spinal scoliosis due to underlying inflammation [rch.org.au]

  Pleurisy parapneumonica uncomplicated: the exudative form, reflecting the predominantly neutrophilic interstitial fluid passage increased as a result of inflammation associated with pneumonia. [medicaldb.blogspot.com]

• Asymptomatic

  Asymptomatic effusions and effusions causing dyspnea unrelieved by thoracentesis do not require additional procedures. [merckmanuals.com]

  […] nephrotic syndrome peritoneal dialysis atelectasis exudative effusion bacterial pneumonia malignancy viral infection pulmonary embolism tuberculosis collagen vascular disorder Prognosis depends on the cause of the pleural effusion Presentation Symptoms asymptomatic [medbullets.com]

  These included fever after talc pleurodesis, asymptomatic pneumothorax after chest tube removal, and minor would infection in a patient with empyema. [researchgate.net]

• Pneumonia

  Streptococcus pneumoniae was the leading pathogen in this series (20% of cases). None of the S. pneumoniae isolates were susceptible to penicillin. Mycoplasma pneumoniae accounted for 19% of cases based on immunoglobulin M assay. [ncbi.nlm.nih.gov]

  pneumoniae, pseudomonas aeruginosa) have also been described as underlying pathogens. [symptoma.com]

• Pleural Effusion

  Univariate analysis showed that pleural effusion leukocyte count, effusion amount, and loculation of pleural effusion were significantly related to the outcome of chest tube drainage. [ncbi.nlm.nih.gov]

  Infected pleural effusion with pus in pleural space or mention of empyema is coded to 510.9 if no fistula is documented. 0 Votes - Sign in to vote or reply. [codapedia.com]

• Dyspnea

  The main clinical symptoms are pleuritic chest pain, fever, cough, expectoration of purulent sputum and dyspnea. [symptoma.com]

  A 60-year-old man having prolonged productive cough and dyspnea with fever was initially diagnosed as pneumonia with parapneumonic effusion. [ncbi.nlm.nih.gov]

  If dyspnea caused by malignant pleural effusion is relieved by thoracentesis but fluid and dyspnea redevelop, chronic (intermittent) drainage or pleurodesis is indicated. [merckmanuals.com]

  Review Topic QID: 109320 2 Decreased tactile fremitus 4 Increased tympanic percussion M2 Select Answer to see Preferred Response PREFERRED RESPONSE 2 (M2.PL.4799) A 67-year-old male comes into the ED complaining of dyspnea and a heavy feeling in his chest [medbullets.com]

  Patient developed fever, left-sided chest pain, and increasing dyspnea. During thoracentesis, purulent pleural fluid was removed, and the Gram stain showed gram-positive diplococci. The culture confirmed this to be Streptococcus pneumoniae. [emedicine.medscape.com]

• Pleuritic Pain

  Five independent baseline characteristics could predict the development of empyema/complicated parapneumonic effusion: age < 60 yrs (p = 0.012), alcoholism (p = 0.002), pleuritic pain (p = 0.002), tachycardia >100 beats·min⁻¹ (p = 0.006) and leukocytosis [ncbi.nlm.nih.gov]

  How to assess Red flag features in Red Features on history: As for pneumonia: Fever Anorexia Lethargy/malaise Breathlessness Persistent fever in the setting of pneumonia despite 48 hours of antibiotics Chest pain or pleuritic pain and refusal to lie on [rch.org.au]

  Many cause dyspnea, pleuritic chest pain, or both. Pleuritic chest pain, a vague discomfort or sharp pain that worsens during inspiration, indicates inflammation of the parietal pleura. [merckmanuals.com]

  Patients may also present with fever, chest pain, cough, purulent sputum and dyspnoea. The absence of pleuritic pain does not exclude pleural infection ( 1 ). [jtd.amegroups.com]

• Withdrawn

  The needle can then be withdrawn and another syringe can be attached to the catheter, allowing fluid to be withdrawn. Placing a three-way stopcock in line can allow large amounts of fluid to be removed if desired. [clinicaladvisor.com]

• Lethargy

  How to assess Red flag features in Red Features on history: As for pneumonia: Fever Anorexia Lethargy/malaise Breathlessness Persistent fever in the setting of pneumonia despite 48 hours of antibiotics Chest pain or pleuritic pain and refusal to lie on [rch.org.au]

A thorough physical examination is the first step, followed by imaging studies that will identify fluid in the pleural space. Radiography, ultrasonography, or CT can be used for visualization of the effusion, but the mainstay of diagnosis is thoracentesis - the sampling of pleural fluid through the thorax [2]. Subsequent analysis of the aspirate for its acidity, presence of leukocytes, CRP, LDH and bacteria is performed and should be mandatory for every patient in whom pleural effusions develop due to pneumonia [2] [5].

• Pulmonary Infiltrate

  Seite 643 - Short-course empiric antibiotic therapy for patients with pulmonary infiltrates in the intensive care unit. A proposed solution for indiscriminate antibiotic prescription. Am J Respir Crit Care Med. ‎ [books.google.de]

  Other possibilities for pulmonary infiltrates and pleural effusions need to be considered and may include pulmonary embolism, acute pancreatitis, Dressler's syndrome, and other diseases. [enotes.tripod.com]

  If the diagnosis remains unclear after pleural fluid analysis, CT angiography is indicated to look for pulmonary emboli, pulmonary infiltrates, or mediastinal lesions.. [merckmanuals.com]

• Pleural Effusion on Chest X-Ray

  Chest X-ray is the mainstay of identification of pleural effusions in the setting of infection, but pleural ultrasound plays a critical role in the assessment of and guidance of drainage in pleural infection. [jtd.amegroups.com]

• Pleural Effusion

  Univariate analysis showed that pleural effusion leukocyte count, effusion amount, and loculation of pleural effusion were significantly related to the outcome of chest tube drainage. [ncbi.nlm.nih.gov]

  Infected pleural effusion with pus in pleural space or mention of empyema is coded to 510.9 if no fistula is documented. 0 Votes - Sign in to vote or reply. [codapedia.com]

Intravenous antibiotic therapy may be recommended for uncomplicated PPE, but in many patients, the therapeutic effects of thoracentesis have been well-documented and the procedure is often used for both diagnostic and therapeutic purposes [1] [2]. For severe PPE, chest tube drainage is favored, while the role of fibrinolytic in treatment of PPE was evaluated across many studies and their administration seems to facilitate drainage of excess pleural fluid due to resolution of thrombi in the local circulation [2] [6]. For empyemas and severe effusions, surgical procedures such as thoracoscopy, standard thoracotomy and video-assisted thoracic surgery are favored [1] [4].

A parapneumonic effusion significantly increases mortality rates of pneumonia, as its occurrence potentiates a more severe form of pulmonary infection. Empyema carries a mortality rate of 5-30% depending on the presence of comorbidities, while in immunocompromised hosts, a mortality rate of 40% was established [1]. For this reason, an early diagnosis is detrimental in preventing disease progression and to ensure proper treatment in its initial stages.

Parapneumonic effusions are primarily caused by streptococcal (S. pneumoniae, S. pyogenes, and the S. anginosus group) and staphylococcal (S. aureus, both methicillin-sensitive and methicillin-resistant strains) species, while gram-negative bacilli (klebsiella pneumoniae, pseudomonas aeruginosa) have also been described as underlying pathogens [2].

Approximately 1 million patients are hospitalized due to pneumonia in the United States and between 20-57% develop parapneumonic effusion, while 5-10% develop empyema, considered to be the end-stage of parapneumonic effusion [1]. Immunocompromised patients have shown to be at an increased risk for PPE, whereas cigarette smoking and alcohol consumption promote aspiration of oropharyngeal microorganisms [1].

In the majority of cases, the initial pulmonary infection stems from aspiration of bacteria residing in the oropharynx and subsequent development of pneumonia [1]. After 2-5 days of microbial spread and disruption of the capillary endothelium, effusion of fluid into the pleural space may occur as a complication of the infection. If left untreated, the progressive clinical course may result in secretion of pus in the pleural space and the formation of an abscess, termed empyema [1].

Early recognition of pneumonia is by far the most important preventive strategy, as more complicated forms of PPE and empyema may substantially increase mortality rates of this infection if not recognized on time.

Effusion of fluid or formation of pus in the pleural space as a result of pneumonia is termed parapneumonic effusion (PPE) [1]. Streptococcus pneumoniae, streptococcus pyogenes, streptococcus anginosus and staphylococcus aureus are most frequent causative agents and up to 50% of patients suffering from pneumonia develop this complication, depending on the presence of comorbidities and the status of the immune system [2]. The main clinical symptoms are pleuritic chest pain, fever, cough, expectoration of purulent sputum and dyspnea [2]. The initial diagnosis can be made clinically, but imaging studies (X-ray, ultrasound or computed tomography (CT)) and laboratory workup (leukocyte count, lactate dehydrogenase (LDH) and C-reactive protein (CRP)) are necessary for confirmation [3] [4]. Thoracentesis, however, is the gold standard in the diagnosis of parapneumonic effusion [2]. Treatment strategies include drainage of accumulated fluid through either blind or image-guided catheter placement, open thoracotomy or video-assisted thoracoscopic surgery [4].

The term parapneumonic effusion describes the leakage of fluid into space between two layers of pleura (a thin membrane covering the lungs) caused by more severe forms of pneumonia. In most cases, streptococcal and staphylococcal bacteria are causative agents of pneumonia, that has shown to be responsible for over 1 million hospitalizations in the United States every year. Between 20-57% of patients develop parapneumonic effusion and this complication may substantially increase mortality rates of pneumonia if not recognized on time. For this reason, why symptoms such as fever, cough, breathing difficulties and chest pain should not be taken lightly. X-rays or ultrasound may reveal the presence of fluid in the pleural space, but to confirm the infection, a sample of fluid is aspirated during a procedure known as thoracentesis, after which it is tested for the level of acidity and the quantity of glucose, white blood cells, and bacteria. Treatment depends on the severity of effusion, ranging from antibiotics and aspiration of fluid to open surgery to remove the fluid.

1. Sahn SA. Diagnosis and management of parapneumonic effusions and empyema. Clin. Infect. Dis. 2007;45(11):1480-1486.
2. Hampson C, Lemos JA, Klein JS. Diagnosis and management of parapneumonic effusions. Semin Respir Crit Care Med. 2008;29(4):414-426.
3. Rosenstengel A, Lee YCG. Pleural infection-current diagnosis and management. Thorac Dis. 2012;4(2):186-193.
4. Hamblin SE, Furmanek DL. Intrapleural tissue plasminogen activator for the treatment of parapneumonic effusion. Pharmacotherapy. 2010;30(8):855-862.
5. Light RW. Parapneumonic effusions and empyema. Proc Am Thorac Soc. 2006;3:75–80.
6. Domej W, Wenisch C, Demel U, Tilz GP. From pneumonic infiltration to parapneumonic effusion--from effusion to pleural empyema: internal medicine aspects of parapneumonic effusion development and pleural empyema. Wien Med Wochenschr. 2003;153(15-16):349-353.