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Empyema Microchapters

Patient Information



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]


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 occurs 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 including the following: 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 most frequently caused by bacteria. Causes may be tuberculous or nontuberculous. Tuberculous empyema is the most common cause of empyema necessitans with majority of affected patients 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]

Empyema classification

Classification by Organ System or Location of Empyema

Pleural empyema

Pleural empyema is also called empyema thoracis. Thoracic empyema arises from an infection within the lung. It must be differentiated from an abscess, which is a collection of necrotic and suppurated tissue located in the parenchyma of an organ.[22] Empyema is most commonly used to refer to pus collection in the pleural cavity although several other organs can be affected including the brain, gallbladder, joints, and urinary bladder. Thoracic empyema arises from an infection within the lung, often associated with parapneumonic effusions. Parapneumonic effusions may be uncomplicated or complicated effusions. Complicated parapneumonic effusion results when bacteria invade the pleural space with a resultant formation of an empyema.

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] Gallbladder empyema 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 a life-threatening infection, consisting of a localized collection of purulent material, typically unilateral, between the dura mater and the arachnoid mater. Subdural empyema may be classified according to location of the infection into 2 groups: intracranial and spinal, with intracranial being the more common of the two groups, accounting for 95% of subdural empyema patients.[23][24] Subdural empyema accounts for approximately 15-25% of focal central nervous system infections. In 2014, the incidence of subdural empyema was estimated to be less than 1 case per 100,000 individuals, with a male predominance.[25] The most common pathogens of intracranial subdural empyema are anaerobic and microaerophilic Streptococci, compared to spinal subdural epmyema, which may be caused by either Streptococci or Staphylococcus aureus.[24] If left untreated, subdural empyema frequently evolves into severe fever, headache, nausea, vomiting, seizures, coma, and subsequent death. Complications to subdural empyema include status epilepticus, neurological deficits, and thrombosis. Prognosis is generally good with antimicrobial therapy. Physical examination of patients with subdural empyema is usually remarkable for fever, facial pain, and altered mental status.[26][27][28] MRI is the primary imaging study of epidural abscess, with CT scan as a secondary alternative. Treatment of subdural empyema requires a combined medical and surgical approach. In order to evacuate the pus, burr hole placement or craniotomy may be used to treat the subdural empyema. The preferred surgical mainstay of treatment for subdural empyema is craniotomy.

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 (e.g. 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[29] urinary bladder. Empyema cystis may be treated by intermittent self-catherterization[30] or vaginal vesicostomy for empyema of dysfunctional bladder.[31]

Differential Diagnosis

Causes of

lung cavities

Differentiating Features Differentiating radiological findings Diagnosis


  • CXR and CT demonstrates cavities in the upper lobe of the lung
  • Sputum smear positive for acid-fast bacilli and nucleic acid amplification tests (NAAT) is used on sputum or any sterile fluid for rapid diagnosis and is positive for mycobacteria.
  • Any age group
  • Acute, fulminant life threating complication of prior infection
  • >100.4 °F fever, with hemodynamic instability
  • Worsening pneumonia-like symptoms
  • CBC is positive for causative organism
  • Children and elderly are at risk
  • Empyema appears lenticular in shape and has a thin wall with smooth luminal margins
  • Pulmonary nodules with cavities and infiltrates are a frequent manifestation on CXR
  • Elderly females of 40-50 age group
  • Manifestation of rheumatoid arthritis
  • Presents with other systemic symptoms including symmetric arthritis of the small joints of the hands and feet with morning stiffness are common manifestations
  • Pulmonary nodules with cavitation are located in the upper lobe (Caplan syndrome) on X-ray
  • On CXR bilateral adenopathy and coarse reticular opacities are seen
  • CT of the chest demonstrates extensive hilar and mediastinal adenopathy
  • Additional findings on CT include fibrosis (honeycomb, linear, or associated with bronchial distortion), pleural thickening, and ground-glass opacities.[38]
  • Common appearance on CT is patchy consolidation,often accompanied by ground-glass opacities and nodules.[42]
  • Exclusively afflicts smokers, with a peak age of onset of between 20 and 40 years
  • Clinical presentation varies, but symptoms generally include months of dry cough, fever, night sweats, and weight loss
  • Skin is involved in 80% of the cases, scaly erythematous rash is typical
  • Thin-walled cystic cavities are the usual radiographic manifestation, observed in over 50% of patients by either CXR or CT scans.[44]
  • Biopsy of the lung


  1. Light RW (1995). "A new classification of parapneumonic effusions and empyema". Chest. 108 (2): 299–301. PMID 7634854.
  2. 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. 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. 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. 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. 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. Monteiro R, Alfaro TM, Correia L, Simão A, Carvalho A, Costa JN (2011). "[Lung abscess and thoracic empyema: retrospective analysis in an internal medicine department]". Acta Med Port. 24 Suppl 2: 229–40. PMID 22849907.
  23. Agrawal, Amit; Timothy, Jake; Pandit, Lekha; Shetty, Lathika; Shetty, J.P. (2007). "A Review of Subdural Empyema and Its Management". Infectious Diseases in Clinical Practice. 15 (3): 149–153. doi:10.1097/01.idc.0000269905.67284.c7. ISSN 1056-9103.
  24. 24.0 24.1 Greenlee JE (2003). "Subdural Empyema". Curr Treat Options Neurol. 5 (1): 13–22. PMID 12521560.
  25. French H, Schaefer N (2014). "Intracranial Subdural Empyema: A 10-Year Case Series". Oschner J. 12 (2). doi:10.1002/bip.360240911. PMID PMC4052585 Check |pmid= value (help).
  26. Hendaus, Mohammed A. (2013). "Subdural Empyema in Children". Global Journal of Health Science. 5 (6). doi:10.5539/gjhs.v5n6p54. ISSN 1916-9744.
  27. Bruner DI, Littlejohn L, Pritchard A (2012). "Subdural empyema presenting with seizure, confusion, and focal weakness". West J Emerg Med. 13 (6): 509–11. doi:10.5811/westjem.2012.5.11727. PMC 3555596. PMID 23358438.
  28. Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett's principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0-443-06839-9.
  29. Sharon V, Kimche D, Kende L (1973). "[Empyema of the obstructed urinary bladder]". Harefuah. 84 (2): 75–7. PMID 4704614.
  30. Herwig KR (1975). "Empyema cystis treated by intermittent self-catherterization". J Urol. 113 (5): 719. PMID 1168734.
  31. Spence HM, Allen TD (1971). "Vaginal vesicostomy for empyema of the defunctionalized bladder". J Urol. 106 (6): 862–4. PMID 5116304.
  32. 32.0 32.1 Chaudhuri MR (1973). "Primary pulmonary cavitating carcinomas". Thorax. 28 (3): 354–66. PMC 470041. PMID 4353362.
  33. Mouroux J, Padovani B, Elkaïm D, Richelme H (1996). "Should cavitated bronchopulmonary cancers be considered a separate entity?". Ann. Thorac. Surg. 61 (2): 530–2. doi:10.1016/0003-4975(95)00973-6. PMID 8572761.
  34. Onn A, Choe DH, Herbst RS, Correa AM, Munden RF, Truong MT, Vaporciyan AA, Isobe T, Gilcrease MZ, Marom EM (2005). "Tumor cavitation in stage I non-small cell lung cancer: epidermal growth factor receptor expression and prediction of poor outcome". Radiology. 237 (1): 342–7. doi:10.1148/radiol.2371041650. PMID 16183941.
  35. 35.0 35.1 Langford CA, Hoffman GS (1999). "Rare diseases.3: Wegener's granulomatosis". Thorax. 54 (7): 629–37. PMC 1745525. PMID 10377211.
  36. Lee KS, Kim TS, Fujimoto K, Moriya H, Watanabe H, Tateishi U, Ashizawa K, Johkoh T, Kim EA, Kwon OJ (2003). "Thoracic manifestation of Wegener's granulomatosis: CT findings in 30 patients". Eur Radiol. 13 (1): 43–51. doi:10.1007/s00330-002-1422-2. PMID 12541109.
  37. Baughman RP, Teirstein AS, Judson MA, Rossman MD, Yeager H, Bresnitz EA, DePalo L, Hunninghake G, Iannuzzi MC, Johns CJ, McLennan G, Moller DR, Newman LS, Rabin DL, Rose C, Rybicki B, Weinberger SE, Terrin ML, Knatterud GL, Cherniak R (2001). "Clinical characteristics of patients in a case control study of sarcoidosis". Am. J. Respir. Crit. Care Med. 164 (10 Pt 1): 1885–9. doi:10.1164/ajrccm.164.10.2104046. PMID 11734441.
  38. Brauner MW, Grenier P, Mompoint D, Lenoir S, de Crémoux H (1989). "Pulmonary sarcoidosis: evaluation with high-resolution CT". Radiology. 172 (2): 467–71. doi:10.1148/radiology.172.2.2748828. PMID 2748828.
  39. Murphy J, Schnyder P, Herold C, Flower C (1998). "Bronchiolitis obliterans organising pneumonia simulating bronchial carcinoma". Eur Radiol. 8 (7): 1165–9. doi:10.1007/s003300050527. PMID 9724431.
  40. 40.0 40.1 Al-Ghanem S, Al-Jahdali H, Bamefleh H, Khan AN (2008). "Bronchiolitis obliterans organizing pneumonia: pathogenesis, clinical features, imaging and therapy review". Ann Thorac Med. 3 (2): 67–75. doi:10.4103/1817-1737.39641. PMC 2700454. PMID 19561910.
  41. Cordier JF, Loire R, Brune J (1989). "Idiopathic bronchiolitis obliterans organizing pneumonia. Definition of characteristic clinical profiles in a series of 16 patients". Chest. 96 (5): 999–1004. PMID 2805873.
  42. Lee KS, Kullnig P, Hartman TE, Müller NL (1994). "Cryptogenic organizing pneumonia: CT findings in 43 patients". AJR Am J Roentgenol. 162 (3): 543–6. doi:10.2214/ajr.162.3.8109493. PMID 8109493.
  43. Suri HS, Yi ES, Nowakowski GS, Vassallo R (2012). "Pulmonary langerhans cell histiocytosis". Orphanet J Rare Dis. 7: 16. doi:10.1186/1750-1172-7-16. PMC 3342091. PMID 22429393.
  44. Moore AD, Godwin JD, Müller NL, Naidich DP, Hammar SP, Buschman DL, Takasugi JE, de Carvalho CR (1989). "Pulmonary histiocytosis X: comparison of radiographic and CT findings". Radiology. 172 (1): 249–54. doi:10.1148/radiology.172.1.2787035. PMID 2787035.

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