Empyema differential diagnosis: Difference between revisions
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|Lung mass whose cavity is rregular with undulated lumen, irregular-poorly defined boundary and shape does not change with change in patient's position.<ref name="pmid73844672">{{cite journal| author=Baber CE, Hedlund LW, Oddson TA, Putman CE| title=Differentiating empyemas and peripheral pulmonary abscesses: the value of computed tomography. | journal=Radiology | year= 1980 | volume= 135 | issue= 3 | pages= 755-8 | pmid=7384467 | doi=10.1148/radiology.135.3.7384467 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7384467 }}</ref> Mass may resolve on antibiotics | |Lung mass whose cavity is rregular with undulated lumen, irregular-poorly defined boundary and shape does not change with change in patient's position.<ref name="pmid73844672">{{cite journal| author=Baber CE, Hedlund LW, Oddson TA, Putman CE| title=Differentiating empyemas and peripheral pulmonary abscesses: the value of computed tomography. | journal=Radiology | year= 1980 | volume= 135 | issue= 3 | pages= 755-8 | pmid=7384467 | doi=10.1148/radiology.135.3.7384467 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=7384467 }}</ref> Mass may resolve on antibiotics | ||
| | |In most cases CT imaging may not provide additional information that would influence the clinical decision-making process.<ref name="pmid26545413">{{cite journal| author=Corcoran JP, Acton L, Ahmed A, Hallifax RJ, Psallidas I, Wrightson JM et al.| title=Diagnostic value of radiological imaging pre- and post-drainage of pleural effusions. | journal=Respirology | year= 2016 | volume= 21 | issue= 2 | pages= 392-5 | pmid=26545413 | doi=10.1111/resp.12675 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=26545413 }}</ref><ref name="pmid3485341">{{cite journal| author=Federle MP, Mark AS, Guillaumin ES| title=CT of subpulmonic pleural effusions and atelectasis: criteria for differentiation from subphrenic fluid. | journal=AJR Am J Roentgenol | year= 1986 | volume= 146 | issue= 4 | pages= 685-9 | pmid=3485341 | doi=10.2214/ajr.146.4.685 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3485341 }}</ref> <ref name="pmid35363062">{{cite journal| author=Halvorsen RA, Thompson WM| title=Ascites or pleural effusion? CT and ultrasound differentiation. | journal=Crit Rev Diagn Imaging | year= 1986 | volume= 26 | issue= 3 | pages= 201-40 | pmid=3536306 | doi= | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=3536306 }}</ref> CT scan shows heterogeneous opacification of the affected side and cardiomediastinal shift to the opposite site in unilateral effusion.<ref name="pmid6878700">{{cite journal| author=Wolverson MK, Crepps LF, Sundaram M, Heiberg E, Vas WG, Shields JB| title=Hyperdensity of recent hemorrhage at body computed tomography: incidence and morphologic variation. | journal=Radiology | year= 1983 | volume= 148 | issue= 3 | pages= 779-84 | pmid=6878700 | doi=10.1148/radiology.148.3.6878700 | pmc= | url=https://www.ncbi.nlm.nih.gov/entrez/eutils/elink.fcgi?dbfrom=pubmed&tool=sumsearch.org/cite&retmode=ref&cmd=prlinks&id=6878700 }}</ref> | ||
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* CT findings in pneumonia include:<sup>[[Pneumonia CT|[1]]]</sup> | * CT findings in pneumonia include:<sup>[[Pneumonia CT|[1]]]</sup> |
Revision as of 20:34, 6 January 2017
Empyema Microchapters |
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]
Overview
Differential diagnosis
Empyema must be diffrentiated from pneumonia, lung abscess, lung cancer and parapneumonic effusions as shown below:
Variable | Empyema Thoracis | Lung abscess | Pleural effusion | Pneumonia | Lung cancer |
---|---|---|---|---|---|
Presentation | Variable presentation but may follow long standing pneumonia | Usually has history of aspiration pneumonia, alcoholics, drug abusers, seizure disorder, have undergone recent general anesthesia, or have a nasogastric or endotracheal tube. | Usually follows pneumonia as a complication | presents with fever, pleuritc chest pain, cough | mostly asymptomatic but may have cough productive with hemoptysis and chronic history of smoking |
Causes | In general any bacteria can cause an empyema, however different bacteria are associated with different rates of empyema formation.[1] Common causes include bacteroides, fusobacterium, haemophilus influenzae, pneumococcal infections, staphylococcus aureus, streptococcus, TB | Lung abscess is commonly caused by bacterial infections and these include bacteroides, peptostreptococcus and prevotella mostly after aspiration | Common causes of transudative pleural effusion include;[1][2][3][4][5] left ventricular failure, Nephrotic syndrome, and cirrhosis, while common causes of exudative pleural effusions[6] are bacterial pneumonia and malignancy | Pneumonia can result from a variety of causes, including infection with bacteria, viruses, fungi, parasites, and chemical injury to the lungs | Direct cause of lung cancers is DNA mutations that often result in either activation of proto-oncogenes (e.g. K-RAS) or the inactivation of tumors suppressor genes (e.g. TP53) or both. The risk of these genetic mutations may be increased following exposure to environmental components example smoking |
Laboratory findings | Laboratory findings are non specific example leukocytosis, sputum samples for gram staining and culture. Other tests include urine antigen test, PCR, C-reactive protein and procalcitonin | The laboratory findings are non specific including: neutropenia, hyponatremia, hypokalemia, hypercalcemia, respiratory acidosis, hypercarbia, hypoxia, and tumor cells in sputum and pleural effusion cytology. | |||
Physical examination | Physical examination increased respiratory rate, low oxygen saturation, difficulty breathing, bronchial breathe sounds, crackling sounds, or increased whispered pectoriloquy. | Physical examination findings are non specific and may include decreased/absent breath sounds, pallor, low-grade fever, tachypnea and cachezia. | |||
CXR | A homogenous opacification is noted at the affected side. The costophrenic angle is obliterated with a meniscus. | CXR shows areas of diffused opacities. | CXR may show lung mass, widening of the mediastinum, atelectasis, or pleural effusion. | ||
Chest ultrasound | Ultrasound in empyema is positive for suspended microbubble sign, air fluid level, curtains sign and loss of gliding sign.[1] | Ultrasound in lung abscess is negative for suspended microbubble sign, curtains sign and loss of gliding sign but air fluid level may be seen,.[2] | Ultrasonography is helpful in making diagnosis of pleural effusion particularly in differentiating effusion from masses.[3] The extended thoracic spine sign on sonography has high sensitivity and specificity for diagnosing pleural effusion.[4] Chest or upper abdominal ultrasound may show subpulmonic effusion as shown below.[5][6][7] | Not reqiured unless complicated with empyema | |
CT scan | Seen as a lung mass whose cavity is regular with smooth and regular lumen, well-defined defined boundary and shape changes with change in patient's position.[8] Mass may resolve on antibiotics
The split pleura sign is present[9] (most reliable sign to differentiate empyema from lung abscess)[10] |
Lung mass whose cavity is rregular with undulated lumen, irregular-poorly defined boundary and shape does not change with change in patient's position.[11] Mass may resolve on antibiotics | In most cases CT imaging may not provide additional information that would influence the clinical decision-making process.[12][13] [14] CT scan shows heterogeneous opacification of the affected side and cardiomediastinal shift to the opposite site in unilateral effusion.[15] |
|
Seen as a spiculated irregular solid mass that does not resolve on antibiotics |
References
- ↑ Lin FC, Chou CW, Chang SC (2004). "Differentiating pyopneumothorax and peripheral lung abscess: chest ultrasonography". Am J Med Sci. 327 (6): 330–5. PMID 15201646.
- ↑ Lin FC, Chou CW, Chang SC (2004). "Differentiating pyopneumothorax and peripheral lung abscess: chest ultrasonography". Am J Med Sci. 327 (6): 330–5. PMID 15201646.
- ↑
- ↑ Dickman E, Terentiev V, Likourezos A, Derman A, Haines L (2015). "Extension of the Thoracic Spine Sign: A New Sonographic Marker of Pleural Effusion". J Ultrasound Med. 34 (9): 1555–61. doi:10.7863/ultra.15.14.06013. PMID 26269297.
- ↑ Almeida FA, Eiger G (2008). "Subpulmonic effusion". Intern Med J. 38 (3): 216–7. doi:10.1111/j.1445-5994.2007.01619.x. PMID 18290818.
- ↑ Connell DG, Crothers G, Cooperberg PL (1982). "The subpulmonic pleural effusion: sonographic aspects". J Can Assoc Radiol. 33 (2): 101–3. PMID 7107669.
- ↑ Halvorsen RA, Thompson WM (1986). "Ascites or pleural effusion? CT and ultrasound differentiation". Crit Rev Diagn Imaging. 26 (3): 201–40. PMID 3536306.
- ↑ Baber CE, Hedlund LW, Oddson TA, Putman CE (1980). "Differentiating empyemas and peripheral pulmonary abscesses: the value of computed tomography". Radiology. 135 (3): 755–8. doi:10.1148/radiology.135.3.7384467. PMID 7384467.
- ↑ Stark DD, Federle MP, Goodman PC, Podrasky AE, Webb WR (1983). "Differentiating lung abscess and empyema: radiography and computed tomography". AJR Am J Roentgenol. 141 (1): 163–7. doi:10.2214/ajr.141.1.163. PMID 6602513.
- ↑ Kraus GJ (2007). "The split pleura sign". Radiology. 243 (1): 297–8. doi:10.1148/radiol.2431041658. PMID 17392263.
- ↑ Baber CE, Hedlund LW, Oddson TA, Putman CE (1980). "Differentiating empyemas and peripheral pulmonary abscesses: the value of computed tomography". Radiology. 135 (3): 755–8. doi:10.1148/radiology.135.3.7384467. PMID 7384467.
- ↑ Corcoran JP, Acton L, Ahmed A, Hallifax RJ, Psallidas I, Wrightson JM; et al. (2016). "Diagnostic value of radiological imaging pre- and post-drainage of pleural effusions". Respirology. 21 (2): 392–5. doi:10.1111/resp.12675. PMID 26545413.
- ↑ Federle MP, Mark AS, Guillaumin ES (1986). "CT of subpulmonic pleural effusions and atelectasis: criteria for differentiation from subphrenic fluid". AJR Am J Roentgenol. 146 (4): 685–9. doi:10.2214/ajr.146.4.685. PMID 3485341.
- ↑ Halvorsen RA, Thompson WM (1986). "Ascites or pleural effusion? CT and ultrasound differentiation". Crit Rev Diagn Imaging. 26 (3): 201–40. PMID 3536306.
- ↑ Wolverson MK, Crepps LF, Sundaram M, Heiberg E, Vas WG, Shields JB (1983). "Hyperdensity of recent hemorrhage at body computed tomography: incidence and morphologic variation". Radiology. 148 (3): 779–84. doi:10.1148/radiology.148.3.6878700. PMID 6878700.