Empyema: Symptoms, Types, Causes and Treatment

Empyema is a serious medical condition characterized by the accumulation of pus within a naturally existing body cavity, most commonly the pleural space surrounding the lungs. This infection can develop quickly, lead to severe complications, and requires prompt recognition and effective management. In this article, we delve into the symptoms, types, causes, and treatments of empyema, synthesizing evidence from recent clinical research to provide a clear and up-to-date resource.

Symptoms of Empyema

Understanding the symptoms of empyema is crucial for timely diagnosis and intervention. While the clinical presentation can vary depending on the affected area and patient age, several hallmark symptoms consistently emerge across studies.

Symptom	Description	Frequency/Significance	Source
Fever	Elevated temperature, often persistent	Most common presenting symptom	2 3 4
Cough	Productive or dry, sometimes with purulent sputum	Highly prevalent, especially in thoracic empyema	2 3
Chest Pain	Pleuritic, sharp, or localized	Common in pleural empyema, sometimes severe	2 3 5
Breathlessness	Shortness of breath, dyspnea	Indicates respiratory compromise	3 5
Purulent Discharge	Pus from sinuses, pleura, or surgical drains	Diagnostic hallmark in localized empyema	1 2
Weight Loss	Unintentional loss, often with anorexia	Seen in prolonged or severe cases	2
Hiccups	Persistent, unexplained	Rare but notable atypical presentation	5

Table 1: Key Symptoms

Common Clinical Features

Empyema often presents with general signs of infection—fever and malaise—alongside more specific local symptoms. In pleural empyema, which is the most frequently discussed type, cough and chest pain are particularly prominent. Breathlessness is a marker of more advanced disease due to compromised lung function 2 3.

• Fever is almost universal, reflecting the body’s response to infection 2 3 4.
• Cough may be dry or, more often, productive, indicating underlying pneumonia or bronchopulmonary involvement 2 3.
• Chest pain, especially pleuritic in nature, is common and may sometimes radiate to the back or abdomen 2 4 5.
• Breathlessness arises as the collection of pus reduces lung expansion 3 5.

Localized and Atypical Presentations

Some forms of empyema, such as maxillary sinus empyema or gallbladder empyema, have more localized symptoms. For example:

• Maxillary sinus empyema often features unilateral facial pain and purulent nasal discharge, but not always nasal obstruction or general malaise 1.
• Gallbladder empyema may mimic biliary colic at first, but can progress to severe systemic illness if untreated 4.

Rarely, empyema may present with atypical symptoms such as persistent hiccups, which should raise suspicion in the context of unexplained fever 5.

Systemic Manifestations

Prolonged cases or those with significant systemic involvement may cause:

• Weight loss and anorexia, especially in children and immunocompromised individuals 2 3.
• Malaise and fatigue as non-specific but important warning signs.

Types of Empyema

Empyema is not a single disease but a spectrum of conditions, each with distinct patterns depending on the anatomical site and the stage of disease. Recognizing these types is vital for targeted management.

Type	Defining Features	Common Sites/Stages	Source
Pleural Empyema	Pus in pleural space, often post-pneumonia	Thoracic cavity	2 3 6 10
Maxillary Sinus	Pus in maxillary sinus, facial pain, rhinorrhea	Paranasal sinuses	1
Gallbladder Empyema	Pus in gallbladder, linked to cholecystitis	Gallbladder	4
Acute (Exudative)	Free-flowing infected fluid	Early phase	10 15
Fibrinopurulent	Loculated pus, fibrin deposits, septations	Intermediate phase	6 10 15
Organizing	Thick peel, lung restriction, chronic symptoms	Late phase	10 15

Table 2: Empyema Types and Stages

Pleural Empyema

The most common and clinically significant form, pleural empyema, is typically a complication of bacterial pneumonia but may also arise after thoracic surgery, trauma, or other infections 2 3 6 10. It progresses through three classic phases:

• Acute/Exudative Phase: Thin, free-flowing infected fluid.
• Fibrinopurulent Phase: Increased viscosity, loculations, and fibrin deposition.
• Organizing Phase: Formation of a thick fibrous peel encasing the lung, restricting its expansion 6 10 15.

Maxillary Sinus Empyema

This form is characterized by accumulation of pus within the maxillary sinus. Patients often experience unilateral facial pain and purulent rhinorrhea, with less emphasis on systemic symptoms 1.

Gallbladder Empyema

A severe complication of acute cholecystitis, gallbladder empyema involves pus formation within the gallbladder, often requiring surgical intervention. Symptoms may initially mimic less severe gallbladder disease but can rapidly progress to sepsis if left untreated 4.

Other Anatomical Sites

Empyema can develop in any body cavity where pus accumulates, including the peritoneal, pelvic, and cerebral spaces, but these are less common and often have unique clinical presentations.

Classification by Stage

The triphasic model is widely accepted for pleural empyema:

• Exudative: Early, potentially reversible with antibiotics and drainage.
• Fibrinopurulent: Intermediate, with increasing complexity and need for intervention.
• Organizing: Chronic, requiring surgical decortication for cure 10 15.

Causes of Empyema

Empyema arises when an infection leads to the collection of pus in a body cavity. Understanding the underlying causes and risk factors is essential for prevention and targeted therapy.

Cause/Risk Factor	Details/Pathway	Notable Organisms / Risks	Source
Bacterial Pneumonia	Most common, leads to parapneumonic effusion	S. pneumoniae, S. aureus	3 9 10 11
Post-Surgery/Trauma	Complication after thoracic, abdominal surgery	Polymicrobial, often nosocomial	2 9 12 14
Dental/Oral Infections	Spread to pleural space via bloodstream	Anaerobes, Fusobacterium, Streptococcus	8
Chronic Illness	Diabetes, alcoholism, malignancy	Increased susceptibility	9 4
Immunosuppression	Reduced defense mechanisms	More severe, varied pathogens	14
Gallstones/Cholecystitis	Obstruction and bacterial overgrowth	E. coli, Klebsiella, mixed flora	4
Malnutrition (children)	Weak immune response	Increased risk, particularly S. aureus	3
Idiopathic	No identifiable source	Diverse organisms	9

Table 3: Causes and Risk Factors

Infectious Causes

• Bacterial infection is the leading cause, with pneumonia being the primary precursor for pleural empyema 3 9 10 11.
  • Streptococcus pneumoniae and Staphylococcus aureus are consistently identified as the most common pathogens, with S. aureus particularly common in children and in post-surgical cases 3 11.
  • The use of vaccines has shifted the prevalence of certain bacterial subtypes, with new serotypes of S. pneumoniae and increased S. aureus incidence in some populations 11.

Polymicrobial and Anaerobic Infections

• Many empyemas are polymicrobial, especially after surgery or trauma, and may include both aerobes and anaerobes 2 7 9 12.
• Anaerobic bacteria are often implicated when empyema develops secondary to dental or oral infections, suggesting hematogenous spread 8.

Non-Infectious and Secondary Causes

• Postoperative empyema is a significant risk, particularly after thoracic or abdominal procedures 2 9 12 14.
• Gallbladder empyema is typically associated with persistent gallstones and bacterial overgrowth, most often involving enteric organisms 4.

Underlying Risk Factors

• Chronic diseases such as diabetes, alcoholism, and malignancy can impair immune defenses and increase the risk of empyema 9 4.
• Malnutrition, especially in children, has been shown to predispose to more severe disease and may impact recovery 3.
• Immunosuppression dramatically increases both the risk and severity of empyema, with higher mortality rates reported in this group 14.

Idiopathic Cases

In some patients, no clear source of infection is found, and these cases may have a broader spectrum of causative organisms 9.

Treatment of Empyema

Effective treatment of empyema hinges on both eradicating the infection and removing accumulated pus to restore organ function. Decisions are guided by the type, stage, and severity of empyema, as well as patient-specific factors.

Treatment	Approach/Technique	Indication/Effectiveness	Source
Antibiotics	Broad-spectrum, tailored to cultures	First-line, always required	2 3 7
Thoracentesis	Needle aspiration of pus	Diagnostic, sometimes therapeutic	2 14
Tube Thoracostomy	Chest tube drainage	Mainstay for early/intermediate	2 6 12 14
Fibrinolytics	Intrapleural agents to break loculations	Adjunct with tube thoracostomy	17
VATS	Minimally invasive surgical drainage	Fibrinopurulent/loculated stage	15 16 17
Open Decortication	Surgical removal of fibrous peel	Organizing/chronic phase	6 10 15
Rib Resection	Surgical opening for drainage	Complex/postoperative cases	14
Cholecystectomy	Surgical removal of gallbladder	Gallbladder empyema	4
Individualized	Tailored to patient, stage, and etiology	Best outcomes, no single standard	15

Table 4: Treatment Approaches

Antibiotic Therapy

Antibiotics are always the cornerstone of empyema management. Initiation of broad-spectrum antibiotics is recommended while awaiting culture results, especially since many cases involve multiple organisms or resistant strains 2 3 7. Therapy is adjusted based on the sensitivity patterns of identified pathogens.

Drainage Techniques

• Thoracentesis can be diagnostic and may be curative in early, free-flowing empyema, but is often insufficient alone 2 14.
• Tube thoracostomy (chest tube drainage) is the standard for most uncomplicated cases but has a significant failure rate in more advanced or loculated empyema 2 6 12 14 17.
• Intrapleural fibrinolytics may be used to break down septations, facilitating drainage, but the evidence for mortality benefit is limited 17.

Surgical Management

When less invasive approaches fail, surgery becomes necessary:

• Video-Assisted Thoracoscopic Surgery (VATS): Minimally invasive, highly effective in the fibrinopurulent phase, associated with shorter hospital stays and fewer reinterventions 15 16 17.
• Open Decortication: Required in the organizing phase to remove the fibrous peel and allow lung re-expansion. This approach is often reserved for chronic or refractory cases 6 10 15.
• Rib Resection and Open Window Thoracostomy: Used for complex, persistent, or high-risk patients who cannot tolerate standard procedures 14 15.

Meta-analyses and randomized trials suggest that primary operative therapy (especially VATS) results in lower mortality, shorter hospital stays, and fewer complications compared to non-operative therapy, particularly in children and select adult populations 13 16 17.

Special Considerations

• Gallbladder empyema requires prompt surgical intervention—cholecystectomy—to prevent sepsis and organ failure 4.
• Individualized care is emphasized, given the disease’s complexity and variability. Optimal treatment depends on the empyema stage, patient comorbidities, and institutional expertise 15.

Controversies and Evolving Practice

There is no universally accepted gold standard for all cases. Treatment protocols continue to evolve, with a trend toward earlier surgical intervention, especially in complex or multiloculated empyema, and a personalized approach tailored to each patient’s needs 15 16 17.

Conclusion

Empyema remains a complex and potentially life-threatening condition that demands early recognition and a multidisciplinary approach for optimal outcomes. Key points include:

• Symptoms: Fever, cough, chest pain, and breathlessness predominate, but localized or atypical presentations (e.g., hiccups) can occur.
• Types: Most commonly pleural, but also affects sinuses and gallbladder; pleural empyema progresses through exudative, fibrinopurulent, and organizing stages.
• Causes: Bacterial pneumonia is the leading cause, but empyema may also develop after surgery, trauma, or in the context of chronic disease and immunosuppression.
• Treatment: Involves antibiotics and drainage, with surgery reserved for advanced or refractory cases. Early, individualized intervention improves outcomes.

Empyema is best managed with a flexible, evidence-informed approach tailored to the patient and the stage of disease, supported by ongoing advances in both medical and surgical care.