Empyema classification

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Empyema Microchapters

Patient Information

Overview

Classification

Subdural empyema
Pleural empyema

Differential Diagnosis

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]

Overview

Empyema may be classified according to the etiology, anatomical location, and pathological course of the disease.[1] Primary thoracic empyema occurs most commonly as iatrogenic empyema without associated pneumonia whereas secondary empyema happens more commonly secondary to pneumonia. Empyema necessitans is a spontaneous discharge of an empyema that has burrowed through the parietal pleura into the chest wall to form a subcutaneous abscess that may eventually rupture through the skin.[2][3] On the basis of anatomical location, empyema may be classified depending on the affected organ for example; gallbladder empyema[4][5], subdural empyema[6][7][8][9][10][11][12][13], joint empyema[14][15][16] and empyema cystitis[17][18]. Empyema is mostly caused by bacteria. It may be tuberculous or nontuberculous. Tuberculous empyema is the most common cause of empyema necessitans with majority of affected patients being immunocompromised.[19][20] There are 3 stages of empyema which are important in terms of the laboratory findings. These are exudative, fibrinopurulent and organizing.[21]

Classification

Empyema may be classified according to the etiology, anatomical location/organ, and pathological course of the disease as follows:[1]

Primary vs secondary empyema

Primary empyema occurs most commonly as iatrogenic empyema without associated pneumonia whereas secondary empyema happens more commonly secondary to pneumonia.

Empyema necessitans

Empyema necessitans is a spontaneous discharge of an empyema that has burrowed through the parietal pleura into the chest wall to form a subcutaneous abscess that may eventually rupture through the skin.[2][3]

Tuberculous vs nontuberculous empyema

Tuberculous empyema is the most common cause of empyema necessitans. This disease can be found in patients with impaired immunity or who are immunocompetent howvever majority of patients affected are immunocompromised.[19][20]

Gallbladder empyema

Gallbladder empyema is also called suppurative cholecystitis which may complicate acute/chronic cholecystitis whereby pus collects in the gall bladder lumen. It is common in people with diabetes and atherosclerotic disease.[4][5]

Normally results from an obstruction of the cystic duct hampering drainage of bile from the gall bladder which becomes secondarily infected.

Subdural empyema

Subdural empyema  is rare, however it may complicate one-third of all intracranial infections. Subdural empyema may follow pansinusitis, mastoiditis, orbital cellulitis and after surgery for lumbar lipomyelomeningocele manifesting with seizures, focal neurological deficits and altered mentatal status and possible progression to coma.[6][7][8][9][10][11][12][13]

Joint empyema

This usually occurs after superimposed infection of the sinovial fluid following some procedures example post-lumbar or sacroiliac discectomy and instrumentation or surgery.[14][15][16]

Empyema cystitis

This type of empyema may complicate a dysfunctional[17][18] or an obstructed[22] urinary bladder. Empyema cystis may be treated by intermittent self-catherterization[23] or vaginal vesicostomy for empyema of dysfunctional bladder[24]

Stages of empyema

Empyema may be classified according to the stage of the disease as follows:[25]

  • Exudative

In the exudative stage, the pus accumulates, and initial sterile fluid becomes infected with fluid characteristics of;

    • glucose>60
    • pH>7.2
    • LDH<500
  • Fibrinopurulent

During this stage, bacterial multiplies with increase in polymorphs and fibrin deposition on both pleural surfaces with fluid characteristics of;

    • glucose<40
    • pH <7.2
    • LDH>1000
  • Organizing

This stage is characterized by loculations, inelastic membranous peel, and lung entrapment as a result of scarring of the pleural space.[21]

References

  1. ↑ 1.0 1.1 Light RW (1995). "A new classification of parapneumonic effusions and empyema". Chest. 108 (2): 299–301. PMID 7634854.
  2. ↑ 2.0 2.1 Gomes MM, Alves M, Correia JB, Santos L (2013). "Empyema necessitans: very late complication of [[pulmonary tuberculosis]]". BMJ Case Rep. 2013. doi:10.1136/bcr-2013-202072. PMC 3863066. PMID 24326441. URL–wikilink conflict (help)
  3. ↑ 3.0 3.1 Ahmed SI, Gripaldo RE, Alao OA (2007). "Empyema necessitans in the setting of pneumonia and parapneumonic effusion". Am J Med Sci. 333 (2): 106–8. PMID 17301589.
  4. ↑ 4.0 4.1 Watanabe Y, Nagayama M, Okumura A, Amoh Y, Katsube T, Suga T; et al. (2007). "MR imaging of acute biliary disorders". Radiographics. 27 (2): 477–95. doi:10.1148/rg.272055148. PMID 17374864.
  5. ↑ 5.0 5.1 O'Connor OJ, Maher MM (2011). "Imaging of cholecystitis". AJR Am J Roentgenol. 196 (4): W367–74. doi:10.2214/AJR.10.4340. PMID 21427298.
  6. ↑ 6.0 6.1 Miller ES, Dias PS, Uttley D (1987). "Management of subdural empyema: a series of 24 cases". J Neurol Neurosurg Psychiatry. 50 (11): 1415–8. PMC 1032550. PMID 2891793.
  7. ↑ 7.0 7.1 Yüksel MO, Gürbüz MS, Karaarslan N, Caliskan T (2016). "Rapidly progressing interhemispheric subdural empyema showing a three-fold increase in size within 12 hours: Case report". Surg Neurol Int. 7 (Suppl 37): S872–S875. doi:10.4103/2152-7806.194495. PMC 5154207. PMID 27999711.
  8. ↑ 8.0 8.1 Yocum D (2016). "Fusobacterium nucleatum: An unusual cause of subdural empyema". JAAPA. 29 (12): 1–4. doi:10.1097/01.JAA.0000508216.58368.74. PMID 27898560.
  9. ↑ 9.0 9.1 Guan J, Spivak ES, Wilkerson C, Park MS (2016). "Subdural Empyema in the Setting of Multimodal Intracranial Monitoring". World Neurosurg. doi:10.1016/j.wneu.2016.10.133. PMID 27826090.
  10. ↑ 10.0 10.1 Byrne N, Plonsker JH, Tan LA, Byrne RW, Munoz LF (2016). "Orbital Cellulitis with Pansinusitis and Subdural Empyema". J Emerg Med. doi:10.1016/j.jemermed.2016.05.067. PMID 27751703.
  11. ↑ 11.0 11.1 Pallangyo P, Lyimo F, Nicholaus P, Kain U, Janabi M (2016). "Spontaneous Subdural Empyema Following a High-Parasitemia Falciparum Infection in a 58-Year-Old Female From a Malaria-Endemic Region: A Case Report". J Investig Med High Impact Case Rep. 4 (3): 2324709616666567. doi:10.1177/2324709616666567. PMC 5011302. PMID 27635411.
  12. ↑ 12.0 12.1 Doan N, Patel M, Nguyen HS, Mountoure A, Shabani S, Gelsomino M; et al. (2016). "Intracranial subdural empyema mimicking a recurrent chronic subdural hematoma". J Surg Case Rep. 2016 (9). doi:10.1093/jscr/rjw158. PMC 5029463. PMID 27651110.
  13. ↑ 13.0 13.1 Nguyen HS, Foy A, Havens P (2016). "Intracranial subdural empyema after surgery for lumbar lipomyelomeningocele: A rare complication". Surg Neurol Int. 7 (Suppl 12): S301–4. doi:10.4103/2152-7806.182388. PMC 4879841. PMID 27274400.
  14. ↑ 14.0 14.1 Bayraktutan U, Sade R, Kantarci M (2016). "Septic arthritis and empyema of the sacroiliac joint after lumbar discectomy and instrumentation". Spine J. 16 (7): e417–8. doi:10.1016/j.spinee.2015.12.033. PMID 26769350.
  15. ↑ 15.0 15.1 Schneider MM, Preiss S, Harder LP, Salzmann GM (2015). "[Destructive chondrolysis following intraarticular application of lavasorb (polihexanid) for treatment of knee empyema]". MMW Fortschr Med. 157 (8): 47–8. doi:10.1007/s15006-015-3033-2. PMID 26012684.
  16. ↑ 16.0 16.1 Oheim R, Gille J, Schoop R, Badih S, Grimme CH, Schulz AP; et al. (2014). "Surgical therapy of extensive knee joint empyema: mid-term results after two-stage versus one-stage procedures". Knee Surg Sports Traumatol Arthrosc. 22 (12): 3150–6. doi:10.1007/s00167-013-2754-y. PMID 24217715.
  17. ↑ 17.0 17.1 Min Z (2014). "A forgotten complication of a defunctionalized urinary bladder: pyocystis". Intern Emerg Med. 9 (6): 691–2. doi:10.1007/s11739-014-1060-0. PMID 24554081.
  18. ↑ 18.0 18.1 Szkodny A, Przybyla J (1975). "[Bladder empyema]". Pol Przegl Chir. 47 (2A): 301–2. PMID 1118412.
  19. ↑ 19.0 19.1 Babamahmoodi F, Davoodi L, Sheikholeslami R, Ahangarkani F (2016). "Tuberculous Empyema Necessitatis in a 40-Year-Old Immunocompetent Male". Case Rep Infect Dis. 2016: 4187108. doi:10.1155/2016/4187108. PMC 4983337. PMID 27555974.
  20. ↑ 20.0 20.1 Nishihara T, Hayama M, Okamoto N, Tanaka A, Nishida T, Shiroyama T; et al. (2016). "Endoscopic Bronchial Occlusion with Silicon Spigots for the Treatment of an Alveolar-pleural Fistula during Anti-tuberculosis Therapy for Tuberculous Empyema". Intern Med. 55 (15): 2055–9. doi:10.2169/internalmedicine.55.6672. PMID 27477414.
  21. ↑ 21.0 21.1 Strange C, Tomlinson JR, Wilson C, Harley R, Miller KS, Sahn SA (1989). "The histology of experimental pleural injury with tetracycline, empyema, and carrageenan". Exp Mol Pathol. 51 (3): 205–19. PMID 2480911.
  22. ↑ Sharon V, Kimche D, Kende L (1973). "[Empyema of the obstructed urinary bladder]". Harefuah. 84 (2): 75–7. PMID 4704614.
  23. ↑ Herwig KR (1975). "Empyema cystis treated by intermittent self-catherterization". J Urol. 113 (5): 719. PMID 1168734.
  24. ↑ Spence HM, Allen TD (1971). "Vaginal vesicostomy for empyema of the defunctionalized bladder". J Urol. 106 (6): 862–4. PMID 5116304.
  25. ↑ Reichert M, Hecker M, Witte B, Bodner J, Padberg W, Weigand MA; et al. (2016). "Stage-directed therapy of pleural empyema". Langenbecks Arch Surg. doi:10.1007/s00423-016-1498-9. PMID 27815709.
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