Complications of pneumonia

Empyema and parapneumonic effusion

A parapneumonic effusion is an effusion arising
secondary to a pneumonia.
Empyema occurs when the
parenchymal infection spreads to the pleural cavity.
Pleural effusions can be classified into uncomplicated
and complicated [50, 51].
Effusions such as simple parapneumonic effusions that will resolve with treatment
of the pneumonia are uncomplicated.
Complicated effusions are those that will not resolve without
drainage.
Drainage of
complicated pleural effusions is necessary to limit
pleural sepsis, allow re-expansion of the underlying
lung and to prevent long-term sequelae such as pleural
fibrosis and lung entrapment [50].
The evolution of a parapneumonic effusion can be
divided into three stages that represent a continuous
spectrum.
The first is the exudative
second stage,
the third stage in which
fibroblasts grow into the pleural fluid from both the
visceral and parietal pleura producing a thick pleural
peel.

The most
common method of treatment is a trial of closed-tube
thoracostomy drainage followed by surgical drainage if
unsuccessful.
Image-guided placement of thoracostomy tubes avoids
the complications of misplacement of a tube.
Ultrasound can confirm the presence of the effusion
and can be used to assess its character and guide drain
placement.
CT appearances are dependent on the pathophysiological
stage of the empyema.

Lung abscesses can occur secondary to pneumonia or

to a retained foreign body, the latter being more common
in children.
It can be difficult to differentiate between an empyema
and a lung abscess on imaging.

A lung abscess is
characteristically seen on CT as a thick-walled, spherical
cavity with adjacent lung destruction (Figure 14). Surrounding
consolidation might be seen with air bronchograms
tracking into the area, as opposed to being
displaced

Medical therapy (systemic antibiotics and physiotherapy

with postural drainage) is the initial treatment of
choice for lung abscess and is curative in most patients.

Ultrasound has been shown to be of value in both

aspirating fluid for microbiological assessment and
guiding catheter drainage in cases of lung abscess

In one large study, the presence of fever, raised

respiratory rate, sputum production throughout the day,
myalgia and night sweats, and the absence of sore throat
and rhinorrhoea were the only clinical features that
predicted CAP when used in a diagnostic algorithm [65].
British Thoracic Society (BTS) 2009 Pneumonia guidelines
indicate that it is only necessary to perform a chest
radiograph in patients with suspected CAP if one of
three criteria apply: the diagnosis is in doubt and a chest
radiograph will assist in the differential diagnosis;
progress for treatment of CAP is not satisfactory; or the
patient is considered at risk of underlying pathology
such as lung cancer [66].
All patients admitted to hospital
with suspected CAP should have a chest radiograph
performed as soon as possible to confirm or refute the
diagnosis [66].
Mimics of pneumonia on the chest radiograph include
conditions such as cryptogenic organising pneumonia,
eosinophilic pneumonia and pulmonary vasculitis [67].
Aspiration pneumonia can give rise to multifocal consolidation
affecting primarily the dependent portions of
the lungs and, in particular, the posterior segments of the
upper lobes and apical segments of the lower lobes.
Chest radiographs have been shown to be of little
value in predicting the causative pathogen, but are of use
in determining the extent of pneumonia and in detecting
complications such as parapneumonic effusions [68].
It is common practice to repeat the chest radiograph 6

weeks after the initial presentation; however, there is no

evidence to support this practice in patients who are
otherwise recovering satisfactorily.
A major concern is
whether the CAP is a complication of an underlying
condition such as lung cancer.
Latest guidelines therefore
recommend a repeat chest radiograph after 6 weeks for
all those patients who have persistence of symptoms,
physical signs or who are at higher risk of underlying
malignancy (especially smokers and those aged over 50
years, whether or not they have been admitted to
hospital) [66].
CT, with its
excellent contrast resolution, is the most sensitive
modality for evaluating lung parenchymal infections
[71].
The only definitive way to reach a specific diagnosis is
through demonstration of the infecting organism by
microscopic or molecular examination of stained smears
of sputum, pleural fluid or other biological material, or
by culture of respiratory secretions or blood [74].
Bronchoscopy with bronchoalveolar lavage is the most
commonly utilised procedure for obtaining fluid for
culture.