Pyopneumothorax could arise as a progression of either underlying hydropneumothorax or empyema. Therefore, etiological agents that cause these conditions could also play a role in the evolution of pyopneumothorax [1].

Symptoms of pyopneumothorax overlap with the symptoms seen in any severe lung infection and correlate with the degree of lung collapse on the ipsilateral side. Patients may present with pleuritic chest pain, severe cough and dyspnea, whilst also manifesting certain nonspecific symptoms such as fever, loss of appetite, loss of weight, and night sweats.

A recent history of pneumonia, pleural drainage, or penetrating injury may also be suggestive of the diagnosis [2] [3].

A variety of risk factors predisposing to pleural effusion or empyema that may progress to pyopneumothorax have been identified. Some of these predisposing factors are chronic lung disease, gastrointestinal reflux, and immunosuppression. Laboratory findings such as platelets >400 X 10*9, albumin < 30 g/L, sodium < 130 mmol/L and C-reactive protein >100 mg/L, and a history of either alcohol or drug abuse, suggests an increased risk of purulent pleural complications in patients admitted for community-acquired pneumonia [4].

Physical examination may reveal tachypnea, egophony, a dull note on percussion, decreased or absent breath sounds, rales, and rhonchi [5].

• Fever

  The presence of fever may mandate a blood culture. Chest radiography is of prime importance for the differential diagnosis of pneumonia, pulmonary abscess, and empyema. [symptoma.com]

  We report an unusual complication of chronic foreign body aspiration--pyopneumothorax--in a 52-year-old patient presenting with productive cough and intermittent fever for more than 3 months. [ncbi.nlm.nih.gov]

  On physical examination fever (39.2 C), exudative pharyngitis, tenderness and swelling in the left anterior cervical area were noted. [tandfonline.com]

  Presentation Fever, chest pain and cough. Patient Data Age: 45 years Gender: Male Thick lined, loculated radio-opacity in right hemithorax, with an air-fluid level, loss of silhouette with the right dome of diaphragm. [radiopaedia.org]

• Fishing

  A case of massive pyopneumothorax as a rare sequelae of retropharyngeal abscess following fish bone ingestion is reported. [ncbi.nlm.nih.gov]

  CrossRef Google Scholar Volume 107, Issue 5 May 1993, pp. 460-462 Abstract A case of massive pyopneumothorax as a rare sequelae of retropharyngeal abscess following fish bone ingestion is reported. [cambridge.org]

• Intermittent Fever

  We report an unusual complication of chronic foreign body aspiration--pyopneumothorax--in a 52-year-old patient presenting with productive cough and intermittent fever for more than 3 months. [ncbi.nlm.nih.gov]

• Splenectomy

  A 68-year-old man who had undergone total gastrectomy with splenectomy for gastric cancer and was receiving chemotherapy for esophageal cancer was presented to our hospital with dyspnea. [ncbi.nlm.nih.gov]

• Pleural Disorder

  Pleural effusions are the most common pleural disorders arising from a wide spectrum of pathologies. [apamedcentral.org]

• Abdominal Pain

  This underscores that pleural effusion associated with acute abdominal pain may reveal the existence of a communication of this type, and requires surgical management. The full text of this article is available in PDF format. [em-consulte.com]

• Pyorrhea

  […] pyometra, pyomyositis, pyonephrosis, pyong, pyongyang, pyorrhea, pyorrhea alveolaris, pyorrhoea, pyot, pyotr alexeyevich kropotkin ... or search for pyopneumothorax inside other dictionary definitions. Search inside [synonyms.com]

• Eruptions

  […] troop, thorp, aport, parto, porta, aroph, pharo, phora, penup, prepn, nappe, upper, pupae, appet, paper, rappe, appmt, pneum, perun, prune, enapt, paten, penta, tapen, phren, phane, arpen, paren, prunt, punta, unapt, untap, unhap, petum, erump, pumex, erupt [myanagram.com]

• Ulcer

  The object of this report is to present a hitherto unreported association of concomitant pleural effusion and acute infectious abdominal disease, due to perforated duodenal ulcer. [em-consulte.com]

• Irritability

  Kerosene vapours may be mildly irritating to the respiratory system and spray applications of kerosene may provoke signs of pulmonary irritation such as coughing and dyspnoea. Kerosene aspiration leads to inflammation and loss of surfactant. [ncbi.nlm.nih.gov]

  The patient sought treatment at the emergency room due to right-sided pleuritic chest pain for one month and, 15 days later, developed an irritating cough and dyspnea that worsened progressively, without any other accompanying symptoms. [scielo.br]

  Agents that irritate the respiratory tract, such as isoflurane or desflurane, should be avoided during the induction of anaesthesia. [ijaweb.org]

Laboratory and imaging techniques can be used to confirm the diagnosis. Leucocytosis is seen on a complete blood count, with the differential count suggestive of a left shift. Sputum should be collected in order to identify the etiological agent and to exclude tuberculosis. Antibiotic sensitivity testing should further be done on these samples. The presence of fever may mandate a blood culture.

Chest radiography is of prime importance for the differential diagnosis of pneumonia, pulmonary abscess, and empyema. An accurate diagnosis decides the course of future therapy, with pneumonia and lung abscess being treated with antibiotics, while empyema requires surgical evacuation of the pleural cavity [6] [7]. On a chest X-ray, lung abscess usually appears as a single round density with an air-fluid level. The empyema is characterized by the presence of an air-fluid level that extends to the chest wall. This is accompanied by the blunting of the costophrenic angle. Radiography in the lateral decubitus position may help determine whether the pleural collection is mobile or localized.

Chest CT should be performed when the clinical signs are characteristic for lung/pleural infection but the chest radiography is negative. Such a situation may be encountered in patients with immunosuppression. However, a CT-scan should be avoided in children due to the potential risks associated with excessive radiation exposure at a young age [8].

A Doppler ultrasonography may help distinguish a peripheral abscess from empyema by the presence of blood vessels in the tissue surrounding the abscess [9]. An ultrasonography control is needed during needle aspiration and drainage of the pleural cavity to avoid potential complications [10].

Pleural fluid obtained through diagnostic thoracentesis may reveal findings suggestive of an empyema. These pleural fluid characteristics include a purulent character of the fluid, elevated neutrophils, pleural fluid glucose levels < 60 mg/dl, lactate dehydrogenase >1000 IU/ml and the presence of microorganisms on pleural culture.

• Clostridium Perfringens

  Five patients developed pleural empyema due to Clostridium perfringens in the absence of penetration of the thorax; two of the patients presented with pyopneumothorax. Thirteen additional cases from the literature are reviewed. [ncbi.nlm.nih.gov]

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3. Burgos J, Falco V, Pahissa A. The increasing incidence of empyema. Curr Opin Pulm Med. 2013;19(4):350-356.
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6. Khwaja S, Rosenbaum DH, Paul MC et al. Surgical treatment of thoracic empyema in HIV-infected patients: severity and treatment modality is associated with CD4 count status. Chest. 2005;128 (1): 246-249.
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10. Chen HJ, Yu YH, Tu CY, Chen CH, Hsia TC, Tsai KD. Ultrasound in peripheral pulmonary air-fluid lesions. Color Doppler imaging as an aid in differentiating empyema and abscess. Chest. 2009;135(6):1426-1432.