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Pleural empyema
Classification and external resources
ICD-10 J86.
ICD-9 510
DiseasesDB 4200
MedlinePlus 000123
eMedicine med/659
MeSH D016724

Pleural empyema (also known as a pyothorax[1] or purulent pleuritis) is an accumulation of pus in the pleural cavity. Most pleural empyemas arise from an infection within the lung (pneumonia), often associated with parapneumonic effusions. There are three stages: exudative, fibrinopurulent and organizing. In the exudative stage, the pus accumulates. This is followed by the fibrinopurulent stage in which there is loculation of the pleural fluid (the creation of grapelike pus pockets). In the final organizing stage, scarring of the pleural space may lead to lung entrapment.



CT chest showing large right sided hydro-pneumothorax from pleural empyema. Arrows A: air, B: fluid

Symptoms of pleural empyema may vary in severity. Typical symptoms include: cough, fever, chest pain, sweating and shortness of breath.

Clubbing of the fingernails may be present cases of a chronic nature. There is a dull percussion note and reduced breath sounds on the affected side of the chest. Other diagnostic tools include a blood white cell count, chest x-ray, CT scan, and ultrasonography.


Diagnosis is confirmed by thoracentesis; frank pus or merely cloudy fluid may be aspirated from the pleural space. The pleural fluid typically has a leukocytosis, low pH (<7.20), low glucose (<60 mg/dL), a high LDH (lactic dehydrogenase), elevated protein and may contain infectious organisms.


Definitive treatment for pleural empyema entails drainage of the infected pleural fluid. A chest tube may be inserted, often using ultrasound guidance. Intravenous antibiotics are given. If this is insufficient, surgical debridement of the pleural space may be required. This is frequently done using thoracoscopic techniques but if the the disease is chronic, a limited thoracotomy may be necessary to fully drain the empyema and remove the filbrinopurulent excudate from the lung and from the chest wall. Occasionally, a full thoracotomy, formal decortication and pleurectomy are required. Rarely, portions of the lung have to be resected. Chest tubes in the setting of empyema have a tendency to become clogged. To combat this problem, surgeons will often place large bore chest tubes, or more than one chest tube. Chest tube clogging in the setting of an empyema can lead to re accumulation of pus and infected material, a worsening clinical picture, organ failure and even death. Thus managing chest tube clogging is particularly important after the treatment of an empyema.


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