Clinical features

One should suspect an empyema in a patient with pneumonia who fails to respond to antibiotics or who develops a fever after initial response to antibiotics.

The clinical features of empyemata include:

• high, swinging fever
• night sweats
• chest pain
• clinical examination reveals signs of a pleural effusion

If the condition becomes chronic then the patient may develop:

• clubbing
• weight loss
• anaemia
• clinical signs of extensive pleural thickening
  • in the later stage of empyema, the pleura thickens and an inelastic membrane known as a pleural 'cortex' (also called a 'peel' or 'rind') develops over about 8 weeks. This cortex adheres to the lung and may restrict lung expansion and chest wall movement

Such clinical signs are not invariably present. In the elderly the systemic signs of infection may be absent.

Notes (1):

• in rare cases, infected pleural fluid can spontaneously discharge through the chest wall
• patients may have symptoms suggesting an underlying cause of empyema (e.g. a history of atypical chest pain and vomiting may indicate oesophageal rupture)

Reference:

1. Drug and Therapeutics Bulletin 2006;44 (3): 17-20.