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Heather Hsu, HMS III Gillian Lieberman, MD March 2011 Empyema: An Uncommon Complication of Common Pneumonia Heather Hsu, HMS III Gillian Lieberman, MD Heather Hsu, HMS III Gillian Lieberman, MD Overview • Patient presentation – – – – – History of present illness and other relevant information Menu of appropriate radiologic tests and their indications Review of lung anatomy on chest x-ray Overview of our patient’s radiographic findings Differential diagnosis • A complication of the diagnosis – – – – Definition and epidemiology Appearance on imaging Companion patient images Management overview • Update on our patient’s clinical course • Summary 1 Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: History of Present Illness at First Presentation • CC: left-sided chest/shoulder pain and dyspnea • HPI: 70-year-old woman presents with 2 days of increasing, constant, non-radiating leftsided chest and shoulder pain and 1 day of increasing dyspnea and productive cough. • PMH: type 2 DM, HTN, hypothyroid, chronic pain, hyperlipidemia, breast CA (1989, s/p mastectomy), thyroid CA (2005, s/p thyroidectomy and I-125) 2 Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: First Presentation Vital Signs, Physical Exam, and Labs • Vitals: T 99.6, HR 127, BP 134/70, RR 16, O2sat 98% RA • Physical Exam: crackles in left lung base, pain with movement of left shoulder • Labs: WBC 13 (90% PMNs) 3 Heather Hsu, HMS III Gillian Lieberman, MD At this point, acute respiratory illness is a likely etiology for our patient’s presentation. However, the differential diagnosis remains broad. We will now consider the use of imaging to narrow this differential. 4 Heather Hsu, HMS III Gillian Lieberman, MD Menu of Radiologic Tests for Adults with Acute Respiratory Illness • Chest X-ray (CXR) • CT chest 5 www.acr.org; Mandell, et al., Clin Infect Dis 2007 Heather Hsu, HMS III Gillian Lieberman, MD Indications for Imaging in Adults with Acute Respiratory Illness: Chest X-Ray • Chest X-ray – Indicated for evaluation of acute respiratory illness in patients with the following characteristics: • • • • • • Age >40 years Hemoptysis Dementia Comorbidities (e.g., CAD, CHF, etc.) Associated abnormalities (e.g., hypoxia, leukocytosis) Clinical suspicion of pneumonia • Chest CT 6 www.acr.org; Mandell, et al., Clin Infect Dis 2007 Heather Hsu, HMS III Gillian Lieberman, MD Indications for Imaging in Adults with Acute Respiratory Illness: Chest CT • Chest X-ray • Chest CT – Indicated for evaluation of: • • • • • • • Abnormalities seen on plain x-ray Recurrent or persistent pneumonia Suspected pleural abnormality Suspected lung abscess Pulmonary embolism Airway patency Guidance for thoracentesis when u/s is not sufficient – Depending on the goal of the study, it may be performed with and/or without contrast www.acr.org; Mandell, et al., Clin Infect Dis 2007 7 Heather Hsu, HMS III Gillian Lieberman, MD Given this menu of potential tests, their indications, and our patient’s clinical presentation, a chest x-ray was obtained. Before we examine our patient’s current chest x-ray, we will review some basic anatomy using prior films. 8 Heather Hsu, HMS III Gillian Lieberman, MD Review of Lung Anatomy on CXR Our patient: Prior PA CXR Prior lateral CXR 9 BIDMC, PACS Heather Hsu, HMS III Gillian Lieberman, MD Anatomy Review: Right Lung Fissures Minor fissure Minor fissure Right major fissure Prior PA CXR Prior lateral CXR 10 BIDMC, PACS Heather Hsu, HMS III Gillian Lieberman, MD Anatomy Review: Right Upper Lobe RUL Prior PA CXR RUL Prior lateral CXR 11 BIDMC, PACS Heather Hsu, HMS III Gillian Lieberman, MD Anatomy Review: Right Middle Lobe RML Prior PA CXR RML Prior lateral CXR “Silhouette sign”: On the PA film, an opacity in the right middle lobe may obscure the right heart border ( ) BIDMC, PACS 12 Heather Hsu, HMS III Gillian Lieberman, MD Anatomy Review: Right Lower Lobe RLL RLL BIDMC, PACS Prior PA CXR Prior lateral CXR “Silhouette sign”: On a PA film, an opacity in the RLL may obscure the right hemidiaphragm ( ) “Spine sign”: On lateral, a RLL opacity may interrupt the normal progressive increase in lucency of the thoracic vertebral bodies ( ) 13 Heather Hsu, HMS III Gillian Lieberman, MD Anatomy Review: Left Major Fissure Left major fissure Left major fissure Prior PA CXR Prior lateral CXR 14 BIDMC, PACS Heather Hsu, HMS III Gillian Lieberman, MD Anatomy Review: Left Upper Lobe LUL Prior PA CXR LUL Prior lateral CXR “Silhouette sign”: On the PA film, an opacity in the lingular portion of the left upper lobe may obscure the left heart border ( ) 15 BIDMC, PACS Heather Hsu, HMS III Gillian Lieberman, MD Anatomy Review: Left Lower Lobe LLL LLL BIDMC, PACS Prior PA CXR Prior lateral CXR “Silhouette sign”: On the PA film, an opacity in the left lower lobe may obscure the left hemidiaphragm ( ) “Spine sign”: On lateral, a LLL opacity may interrupt the normal progressive increase in lucency of the thoracic vertebral bodies ( ) 16 Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: Prior PA and Lateral CXR Prior PA CXR Prior lateral CXR Please pause to review our patient’s prior films and give your general impression. BIDMC, PACS 17 Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: Prior CXR Findings Prior PA CXR BIDMC, PACS Prior lateral CXR General impression: Normal chest X-ray, note the absence of the left breast shadow ( ) s/p mastectomy 18 Heather Hsu, HMS III Gillian Lieberman, MD Now back to our patient’s current presentation with left-sided chest pain and dyspnea… ECG is unchanged from prior. A portable AP chest X-ray is obtained. 19 Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: Current AP CXR Reminder - Systematic Approach to CXR: -Acknowledge major abnormalities First admission AP CXR Prior PA CXR Please pause to compare our patient’s new CXR with the prior film. BIDMC, PACS; Lieberman’s E-Radiology -Quality control -Lines + hardware -Heart + mediastinum -Lungs + diaphragm -Pleura -Bones -Soft tissues -Checkpoints -Apices -Aortic knob -Hila -Retrocardiac regions 20 Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: Current AP CXR Findings Note that we are comparing a current AP CXR with a prior PA film, so changes in heart size cannot be adequately assessed. Opacity in left mid + lower lung fields with air bronchograms, partially obscuring L hemidiaphragm Prior PA CXR Small left pleural effusion ( ) obscuring costophrenic angle Absence of left breast shadow ( ) s/p mastectomy First admission AP CXR Given these findings, what is the differential diagnosis? BIDMC, PACS 21 Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: Differential Diagnosis at First Presentation • Pneumonia • Malignancy – Primary – Metastasis • Pleural effusion – Parapneumonic – Malignant • Atelectasis 22 Heather Hsu, HMS III Gillian Lieberman, MD Given our patient’s clinical presentation and CXR findings, she is diagnosed with a left lower lobe community-acquired pneumonia, admitted to the hospital, and started on levofloxacin. Over the next two days, her white blood cell count, dyspnea, cough, and chest pain improve and she is discharged. 23 Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: Second Presentation After discharge, our patient returns home. The next morning, she presents again with severe, pleuritic, left-sided chest pain. She is afebrile, tachycardic, and tachypneic. Another chest X-ray is obtained. 24 Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: CXR at Second Presentation Current AP and lateral CXR Please pause to compare our patient’s current CXR with the film from her prior admission. BIDMC, PACS First admission AP CXR 25 Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: Findings from CXR at Second Presentation New Findings: More prominent opacity in left mid and lower lung fields, silhouetting out the left heart border and hemidiaphragm. The left costophrenic angle ( ) is obscured. Spine sign ( ) Second admission AP and lateral CXR Quality control: Mediastinum appears wide ( ) due to the patient’s rotated position. Poor arm positioning ( ) obscures upper lung fields. 26 BIDMC, PACS Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: Differential Diagnosis at Second Presentation • Inadequately treated pneumonia • Complicated pneumonia – – – – • • • • • Simple parapneumonic effusion Complicated parapneumonic effusion Empyema Necrotizing pneumonia Lung collapse/atelectasis Mucus plug Lung malignancy Malignant effusion Pulmonary embolism Given this differential diagnosis, what should the next step be? Do we need further imaging? 27 Heather Hsu, HMS III Gillian Lieberman, MD Based on the findings from the chest X-ray and the patient’s worsening clinical condition, the decision is made to order a CTA to rule out pulmonary embolus and further characterize the abnormalities seen on CXR. 28 Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: Chest CTA from Second Presentation Cross-sectional views, C+ Chest CT, soft tissue window Not depicted: Contrast opacification of pulmonary arteries is complete to segmental level and the central airways are patent. Please pause to evaluate the images. 29 BIDMC, PACS Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: Chest CTA Findings Left lower lobe collapse with worsening consolidation ( ) Non-hemorrhagic pleural effusion ( ), with pleural fluid measuring ~27 Hounsfield units Septation within pleural effusion ( ) and nondependent layering ( ) indicating loculation Cross-sectional view, C+ Chest CT, soft tissue window Reminder re: Hounsfield units (HU): Air: -1000 HU Fat: -30 HU Water: 0 HU Soft tissue: +30 HU Blood: +40 HU Bone: +1000 HU 30 BIDMC, PACS Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: Revised Differential Diagnosis Following Chest CTA • Complicated pneumonia – Simple parapneumonic effusion – Complicated parapneumonic effusion – Empyema • Lung collapse/atelectasis • Lung malignancy • Malignant effusion 31 Heather Hsu, HMS III Gillian Lieberman, MD Based on the findings from the chest CTA and the patient’s clinical presentation, she is diagnosed with a probable empyema and transferred to the ICU for further management. 32 Heather Hsu, HMS III Gillian Lieberman, MD Empyema: Definition, Phases, and Epidemiology • Definition: The presence of pus and/or gram stain/culture-positive fluid in the pleural space • Three phases: – Exudative: inflammation of visceral pleura results in exudative effusion and thickening of pleural surfaces – Fibropurulent: inflammatory cells and neutrophils invade the pleural space, fibrin is deposited on inflamed pleural surfaces – Organizing: recruitment of fibroblasts and capillaries results in deposition of collagen and granulation tissue on pleural surfaces leading to pleural fibrosis • Epidemiology: <2% of patients with communityacquired pneumonia develop empyema 33 Ahmed, et al. Am J Med 2006; Kulman and Singha, Radiographics 1997 Heather Hsu, HMS III Gillian Lieberman, MD Empyema: Appearance on Imaging • • • CXR: may see a pleural-based opacity that has an abnormal contour or does not flow freely on lateral decubitus views Ultrasonography: may see loculated effusion C+ CT chest: – Classic appearance: oblong fluid collection with smooth inner margins that compresses and displaces surrounding lung and airway – Important to distinguish empyema from lung abscess • CT findings favoring abscess include a thick-walled, spherical cavity that destroys lung rather than displacing it – “Split pleura” sign on C+ CT: • Contrast-enhanced thickened visceral and parietal pleura separated by fluid • May be seen in the fibropurulent phase • Indicates exudative effusion (not specific to empyema) – “Pleural microbubbles” • Small air bubbles within fluid collection • May indicate resistance of the effusion to chest tube drainage 34 Kulman and Singha, Radiographics 1997; Smolikov, et al. Clin Radiol 2006 Heather Hsu, HMS III Gillian Lieberman, MD Empyema: Companion Patient Images Middle-aged man with right-sided chest discomfort and shortness of breath Cross-sectional views, C+ Chest CTA, soft tissue window Fluid trapped in the minor fissure ( ) Loculated right pleural effusion ( ) that is layering non-dependently Atelectasis ( ) Liver dome ( ) 35 BIDMC, PACS Heather Hsu, HMS III Gillian Lieberman, MD Empyema: Management Overview • Thoracentesis – Pleural fluid analysis, gram stain, and culture • Appropriate antibiotics – Sterilization of empyema cavity with systemic antibiotics (minimum 4-6 weeks) • Drainage – – – – Tube thoracostomy Video-assisted thoracoscopic surgery (VATS) Open decortication Open thoracostomy 36 Colice, et al. Chest 2000 Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: Management of Her Clinical Course • Pleural fluid analysis – Culture-negative, non-malignant exudative effusion with low pH and positive gram stain – Consistent with empyema • Antibiotics – Broad spectrum coverage with vancomycin, cefepime, and azithromycin • Drainage – VATS and decortication procedures were attempted without success due to difficulty ventilating the right lung during the procedures. – Ultimately, a chest tube was placed and the effusion drained successfully. 37 Heather Hsu, HMS III Gillian Lieberman, MD Our Patient: ICU Course and Outcome • ICU course – Complicated by NSTEMI, serotonin syndrome, blood transfusion, and benzodiazepine withdrawal • Outcome – Discharged after ~2 weeks in the ICU – Currently living at home and doing well 38 Heather Hsu, HMS III Gillian Lieberman, MD Summary • Patient presentation – – – – – History of present illness and other relevant information Menu of appropriate radiologic tests and their indications Review of lung anatomy on CXR Overview of our patient’s radiographic findings Differential diagnosis • Empyema – – – – Definition, phases, and epidemiology Appearance on imaging Companion patient images Management overview • Update on our patient’s clinical course 39 Heather Hsu, HMS III Gillian Lieberman, MD Bibliography • • • • • • • Ahmed RA, Marrie TJ, Huang JQ. Thoracic empyema in patients with communityacquired pneumonia. Am J Med. 2006;119(10):877-83. Colice GL, Curtis A, Deslauriers J, et al. Medical and surgical treatment of parapneumonic effusions : an evidence-based guideline. Chest. 2000;118(4):115871. Kuhlman JE, Singha NK. Complex disease of the pleural space: radiographic and CT evaluation. Radiographics. 1997;17:63-79. Lieberman G. A systematic approach to evaluating chest X-rays. Lieberman’s ERadiology. http://eradiology.bidmc.harvard.edu/interactivetutorials/. Accessed March 15, 2011. Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of America/American Thoracic Society consensus guidelines on the management of community-acquired pneumonia in adults. Clin Infect Dis. 2007;44 Suppl 2:S27-72. Smolikov A, Smolyakov R, Riesenberg K, et al. Prevalence and clinical significance of pleural microbubbles in computed tomography of thoracic empyema. Clin Radiol. 2006;61(6):513-9. Washington L, Kahn A, Mohammed T. American College of Radiology Appropriateness Criteria: Acute respiratory illness. http://www.acr.org/secondarymainmenucategories/quality_safety/app_criteria.aspx. Accessed March 15, 2011. 40 Heather Hsu, HMS III Gillian Lieberman, MD Acknowledgements • Gillian Lieberman, MD – for her teaching and guidance • Veronica Fernandes, MD – for her feedback on the presentation • Emily Hanson – for technical support and guidance • Douglas Hsu, MD – for assistance in finding companion patient images 41