IMAGING COLUMN

Parapneumonic empyema diagnosed by chest

radiograph and computed tomography
Ning Jin, MD1, John Paul Brady, IV2 and David M. Widlus, MD1,3*
1
Union Memorial Hospital, Baltimore, MD, USA; 2American University of the Caribbean School of
Medicine, Coral Gables, FL; 3Department of Radiology, University of Maryland School of Medicine,
Baltimore, MD, USA

Pleural effusion is commonly seen associated with pneumonia. When this progresses to empyema, directed
therapy is frequently required. Chest radiographic and computed tomography findings can help distinguish
empyema from a transudative pleural effusion.
Keywords: chest x-ray; pneumonia; empyema; chest tube; chest CT scan

*Correspondence to: David M. Widlus, Department of Radiology, Medstar Union Memorial Hospital,
University of Maryland School of Medicine, Baltimore, MD, USA, Email: David.M.Widlus@medstar.net
Received: 25 January 2013; Revised: 26 February 2013; Accepted: 7 March 2013; Published: 17 April 2013

55-year-old African American male with a

history of HIV on antiretroviral therapy, hepatitis
C, hypertension, and uncertain tuberculosis status presented with pleuritic chest pain, gradually worsening over 2 weeks, accompanied by a productive cough
with cupful volumes of yellowish, foul-smelling sputum.
He noted dyspnea on exertion and chills, but denied fever
or headache. The patient denied alcohol usage but had a
multi-year half pack per day history of cigarette smoking.
Heroin and cocaine use 10 years earlier was noted. The
patient was afebrile with an oxygen saturation of 96% on

room air. Pertinent physical findings included decreased

bilateral breath sounds, bibasilar crackles, dullness to
percussion in the left lower lobe, and 1 edema in the
lower extremities. The patients home medications included abacavir
lamivudine 600
300 mg daily, raltegravir
400 mg BID, tenofovir 300 mg daily, and methadone
40 mg daily.
Significant laboratory findings included, WBC 10,200,
neutrophil 79.8%, Plt 39,000, PT 19 sec, and INR 1.6.
The patients initial chest x-ray showed a left pleural
effusion with an air-fluid level (Fig. 1). A computed

Fig. 1. (a) PA and (b) lateral views of the chest demonstrate a large left pleural collection with an air-fluid level (arrows).
Small right pleural effusion is also seen.
Journal of Community Hospital Internal Medicine Perspectives 2013. # 2013 Ning Jin et al. This is an Open Access article distributed under the terms of the
Creative Commons Attribution-Noncommercial 3.0 Unported License (http://creativecommons.org/licenses/by-nc/3.0/), permitting all non-commercial
use, distribution, and reproduction in any medium, provided the original work is properly cited.
Citation: Journal of Community Hospital Internal Medicine Perspectives 2013, 3: 20503 - http://dx.doi.org/10.3402/jchimp.v3i1.20503

(page number not for citation purpose)

Ning Jin et al.

Fig. 4. Coronal image of the chest demonstrates a small bore

chest tube partially surrounded by air in the left pleural
space (arrow). No remaining fluid is seen. Adjacent lung
consolidation has decreased.
Fig. 2. CT scan of the chest showing the loculated left
pleural fluid collection with air-fluid level (arrow) and the
adjacent parenchymal consolidation.

tomography (CT) scan demonstrated a loculated fluid

collection in the left pleural space with a large volume
of gas felt to indicate an empyema (Fig. 2). Sputum
Gram stain showed rare Gram-positive cocci in chains,
negative for acid fast bacilli. Peripheral blood culture
was negative.
The patient was started on vancomycin 1 g IV q12 h and
piperacillin
tazobactam 3.375 mg IV q6 h. He underwent
CT-guided chest tube placement by the interventional

Fig. 3. Small bore chest tube was placed from an anterior

approach.

radiology service (Fig. 3). The pleural fluid culture

revealed peptostreptococcus and Campylobacter gracilis.
The chest tube drained a total of 700 ml of purulent
fluid. Chest tube removal was possible after 1 week.
Vancomycin and piperacillin
tazobactam were discontinued and a 2-week course of oral clindamycin began.
The patients subsequent chest CT scan showed resolution of the left empyema with marked improvement in
consolidation in the left lower lung (Fig. 4). The patient
was discharged on his home medications and clindamycin
with a follow-up appointment at the infectious diseases
clinic.
Over one million patients in the United States are
hospitalized annually with pneumonia and in one-third
to two-third of patients, pleural effusions occur. The
majority of these are resolved by treating the underlying
pneumonia. However, 10
20% progress to an exudative
stage. Subsequent fibrinopurulent and organizing phases
can then be seen with the requirement for more aggressive
treatment. Imaging characteristics of empyema typically
include a loculated appearing fluid collection with a
thick, enhancing rim and increased central radiodensity
compared to simple fluid (higher protein content in
exudates versus transudates). A large air-fluid level, as
was seen in this case, is less common and more likely to
be seen with a bronchopleural fistula. Treatment options
include chest tube drainage, which is most successful for
thin exudative collections, fibrinolysis, which is most
successful for collections found in the fibrinopurulent
phase before the organizing phase, and decortication,
either open or using video-assisted thoracoscopy. Mortality, which occurs in up to 33% based on age and comorbidity, is substantially reduced by early treatment.

2
Citation: Journal of Community Hospital Internal Medicine Perspectives 2013, 3: 20503 - http://dx.doi.org/10.3402/jchimp.v3i1.20503
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Parapneumonic empyema diagnosed

Conflict of interest and funding

The authors have not received any funding or benefits
from industry or elsewhere to conduct this study.

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Citation: Journal of Community Hospital Internal Medicine Perspectives 2013, 3: 20503 - http://dx.doi.org/10.3402/jchimp.v3i1.20503

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