SciELO - Scientific Electronic Library Online

vol.15 número3Actualização em doença pulmonar tromboembólicaQuilotórax: A propósito de um caso clínico índice de autoresíndice de assuntosPesquisa de artigos
Home Pagelista alfabética de periódicos  

Serviços Personalizados




Links relacionados

  • Não possue artigos similaresSimilares em SciELO


Revista Portuguesa de Pneumologia

versão impressa ISSN 0873-2159

Rev Port Pneumol v.15 n.3 Lisboa maio 2009


Thoracic empyema – A review based on three cases reports


Antonio Murinello* 1

A Manuel Figeiredo* 2

Júlio Semedo** 3

Helena Damásio* 4

N Carrilho Ribeiro*** 5

Helena Peres**** 6




Complicated parapneumonic effusion is one in which an invasive procedure is necessary for its resolution and empyema means pus in the pleural space. An early diagnosis and therapy of these conditions results in less morbidity and mortality. CT of the chest is important to study complex pleural effusions. Loculated effusions, those occupying more than 50% of the thorax, or which show positive Gram stain or bacterial culture, or a purulent effusion with a pH below 7.20, with a glucose level below 60 mg/dl or a LDH level more than three times the upper limit of normal for serum, are indications for an invasive procedure. These characteristics result from the evolution of a not well treated parapneumonic effusion, through the three stages: (1) exsudative; (2) fibrinopurulent; (3) fibrotic. Depending on the stage therapeutic methods vary from therapeutic thoracentesis, insertion of a chest tube with or without instillation of fibrinolytics, video-assisted thoracoscopic surgery, and lung decortication. A review of all these aspects are done based on a series of three cases reports with very different clinical presentation: one patient with empyema by Streptococcus pyogenes and that died rapidly due to massive hemoptysis; a patient with empyema due to acute pneumonia developing during an airflight; a patient with empyema and bacteraemia by Streptococcus pneumonia leading to the diagnosis of an unknown HIV infection.

Key-words: Empyema, parapneumonic effusion, Streptococcus pyogenes, pneumococcus, HIV.



Empiema torácico – Revisão baseada em três casos clínicos


O derrame parapneumónico caracteriza-se pela necessidade de um processo invasivo para a sua resolução e o empiema pela presença de pus na cavidade pleural. Em ambos os casos, o diagnóstico por TAC e o tratamento precoces resultando em menores morbilidade e mortalidade. São indicação para um tratamento invasivo os derrames loculados, os que ocupam mais de 50% do tórax, os que revelam coloração por Gram e exame cultural positivos, ou derrames com pH inferior a 7,20, glucose inferior a 60 mg/dl, e nível de DHL superior a três vezes o limite normal no soro. Estas características resultam da evolução através de três estádios dos derrames incorrectamente tratados: 1) exsudativo; 2) fibrino-purulento; 3) fibrótico. Dependendo do estádio evolutivo, a abordagem terapêutica varia entra toracentese terapêutica, colocação de drenagem torácica com ou sem instilação de fibrinolíticos, cirurgia toracoscópica vídeo-assistida e decorticação pulmonar. Os autores fazem uma revisão do estudo destas situações baseados em três casos clínicos com apresentações muito dispares: uma doente com empiema por Streptococcus pyogenes que faleceu rapidamente por hemoptise maciça; um doente com empiema resultante de pneumonia aguda ocorrida durante um voo de avião; uma doente com empiema e bacteriemia por Streptococcus pneumoniae conduzindo a diagnóstico até então desconhecido de infecção por VIH.

Palavras-chave: Empiema, derrame parapneumónico, Streptococcus pyogenes, pneumococos, VIH, avião.



Full text only available in PDF format.

Texto completo disponível apenas em PDF.




1. Heffner JE, Klein J. Parapneumonic effusions and empyema. Semin Resp Crit Care Med 2001; 22: 591-606.        [ Links ]

2. Chu MA, Dewar LR, Burgess JJ, Busse EG. Empyema thoracis: lack of awareness results in a prolonged clinical course. J Canadien de Chirurgie 2001; 44: 284-288.

3. Evans AL, Gleeson FV. Radiology in pleural disease: state of the art. Respirology 2004; 9: 300 -312.

4. Ahmed RA, Marrie TJ, Huang JQ. Thoracic empyema in patients with community -acquired pneumonia. Am J Med 2006; 119: 877 -883.

5. Light RW. Parapneumonic effusions and empyema. Proceedings Am Thor Soc 2006; 3: 75 -80.

6. Coote N, Kay E. Surgical versus non -surgical management of pleural empyema. Cochrane Database Syst Rev 2005; 19(4): CD001956.

7. Luh SP, Chou MC, Wang LS, Chen JY, Tsai TP. Video -assisted thoracoscopic surgery in the treatment of complicated parapneumonic effusions or empyemas: outcome of 234 patients. Chest 2005; 127: 1427-1432.

8. Chen K -Y, Hsueh PR, Liaw YS, Yang PC, Kuh KT. A 10 -year experience with bacteriology of acute thoracic empyema: emphasis on Klebsiella pneumonia in patients with diabetes mellitus. Chest 117: 1685 -1689.

9. Martella AT, Santos GH. Decortication for chronic postpneumonic empyema. J Am Coll Surg 1995; 180: 573 -576.

10. Sharma S, Harding G. Streptococcus group A infections. In Internet: topic2184.htm.

11. Johnson JL. Pleurisy, fever, and rapidly progressive pleural effusion in a healthy, 29 -year-old physician. Chest 2991; 119: 1266 -1269.

12. Basiliere JL, Bistrong HW, Spence WF. Streptococcal pneumonia. Recent outbreaks in military recruit populations. Am J Med 1968; 44: 580 -589.

13. Muller MP, Low DE, Green KA, Simor AE, Loeb M, Gregson D, et al. Clinical and epidemiological features of group A streptococcal pneumonia in Ontario, Canada. Arch Int Med 2003; 163: 467 -472.

14. McMurray JJ, Fraser DM. Fatal Streptococcus pyogenes pneumonia. J Royal Soc Med 1987; 80: 525 -6.

15. Buckingham SC, King MD, Miller ML. Incidence and etiologies of complicated parapneumonic effusions in children, 1966 to 2001. Pediatr Infect Dis 2003; 22: 499 -504.

16. Thaarup J, Ellerman -Eriksen S, Stjernholm J. Neonatal pleural empyema with group A streptococci. Acta Pediatr 1997; 86: 769 -771.

17. Barnham M, Weightman NC, Anderson AW, Pagan FS, Chapman ST. Review of 17 cases of pneumonia caused by Streptococcus pyogenes. Euro J Clin Microbiol Infect Dis 1999; 18: 506 -509.

18. Mohanty S, Das BK, Kapil A. Pleural empyema due to a group A beta -hemolytic streptococci in an adult. Indian J Med Sci 2005; 59: 213 -214.

19. Khatib R, Siwick J. Pyopneumothorax: a complication of Streptococcus pyogenes pharyngitis. Scand J Infect Dis 2000; 32: 564 -565.

20. Guimaraes CA. Massive hemoptysis. In Pearson FG, (Ed.). Thoracic Surgery. Churchill Livingstone; USA, 1995: 581 -585.

21. Johnson JL. Manifestations of haemoptysis. How to manage minor, moderate, and massive bleeding. Postgrad Med 2002; 112: 101 -113.

22. Metin M, Sayar A, Turna A, Solak O, Erkan L, Dincer SI, et al. Emergency surgery for massive haemoptysis. Acta Chir Belg 2005; 105: 639 -643.

23. Stoll JF, Bettmen M. Bronchial artery embolization to control haemoptysis: a review. Cardiovasc Interv  Radiol 1988; 11: 263 -269.

24. Ashraf O. Hemoptysis, a developing world perspective. BMC Pulm Med 2006; 6: 1.

25. Aiyappan V, Muthiah M. Massive haemoptysis in intravenous drug users: Case report and review of the literature. Ann Thor Med 2997; 2: 36.

26. Capron F. Pulmonary hemorrhage syndromes. In: Haselton PS (Ed.). Spencer’s pathology of the lung. 5th ed. McGraw -Hill Co.; USA, 1996:865 -874.

27. Nakada H, Maemoto T, Kitazawa K, Honda A, Shimuzu Y, Ooe K. Fulminant group A streptococcal infection accompanied by massive pulmonary hemorrhage and subsequent asphyxia. A case report. Kasenshogaku Zasshi 1994; 68: 1428 -1432 (in Japanese; abstract in English).

28. Chantepie A, Robert M, Pelletier, Gold F, Mercier C, Lacombe A, et al. Mycotic aneurism of bronchial artery. A propos of a case in an infant. Chir Pediatr (French) 1980; 21: 407 -410.

29. Enting D, van der Werf TS, Prins TR, Zijlstra JG, Lightenberg JJ, Tulleken JE. Massive hemoptysis: primary care, diagnosis and treatment. Ned Tijdschr Geneeskd 2004; 148: 1582 -1586.

30. Ong TH, Eng P. Massive hemoptysis requiring intensive care. Intensive Cre Med 2003; 29: 317 -320.

31. Swanson KL, Johnson CM, Prakash UB, et al. Bronchial artery embolization: Experience with 54 patients. Chest 2002; 121: 789 -795.

32. Gourin A, Garzon AA. Operative treatment of massive hemoptysis. Ann Thorac Surg 1974; 18: 52 -60.

33. Walkinshaw DS. Passenger aircraft indoor air quality challenges and solutions II: Presentation to the ASHRAE Ottawa Valley Chapter Meeting 2008. Internet:

34. Brecher CW, Aviram G, Boiselle PM. CT and radiography of bacterial respiratory infections. AJR 2003; 180: 1203 -1209.

35. Centers for Disease Control. 1993 revised classification system for hiv infection and expanded surveillance case definition for AIDS among adolescents and adults. Morb Mortal WKLY Rep 1992; 41: 1 -19.

36. Noskin GA, Glassroth J. Bacterial pneumonia associated with HIV -1 infection. Clin Chest Med 1996; 17: 713 -7723.

37. Hirschtick RE, Glassroth J, Jordan MC, et al. Bacterial pneumonia in persons infected with the human deficiency virus. New Engl J Med 1995; 333: 845-851.

38. Rimland D, Navin TR, Lennox JA, et al. Prospective study of etiologic agents of community acquired pneumonia in HIV infection. AIDS 2002; 16: 85 -95.

39. Joseph J, Strange C, Sahn SA. Pleural effusions in hospitalized patients with AIDS. Ann Int Med 1993; 118: 856 -859.

40. Borge JH, Michavila IA, Mendez JM, Rodriguez FC, Grinan NP, Cerrato RV. Thoracic empyema in HIV -infected patients: Microbiology, management and outcome. Chest 1998; 113: 732 -738.

41. Suay VG, Cordero PJ, Martinez E, Soler JJ, Perpina M, Greses JV, et al. Parapneumonic effusions secondary to community -acquired bacterial pneumonia in human immunodeficiency virus -infected patients. Eur Resp J 1995; 8: 1934 -1939.

42. Khwaja S, Rosenbaum DH, Paul MC, Bhojani RA, Estrera AS, Wait MA, et al. Surgical treatment of thoracic empyema in HIV -infected patients: severity and treatment modality is associated withCD4 count status. Chest 2005; 128: 246 -249.

43. Lee -Chiong TL Jr. Treating empyema without surgery. Postgraduate Med 1997; 101: 195 -204.

44. Asbaugh DG. Empyema thoracis, factors influencing morbidity and mortality. Chest 1991; 99: 1162-1165.

45. Andrews NC, Parker EF, Shaw RR, Wilson NJ, Webb RR. Management of nontuberculous empyema. Am Rev Resp Dis 1962; 85: 935 -936.

46. Pothula V, Krellenstein DJ. Early aggressive surgical management of parapneumonic empyemas. Chest 1994; 105: 832 -836.



1 Chefe de Serviço Graduado de Medicina Interna/Unit Head, Internal Medicine graduate

2 Interno de Especialidade de Medicina Interna/Intern, Internal Medicine

3 Assistente Hospitalar Graduado de Pneumologia/Consultant, Pulmonology graduate

4 Assistente Hospitalar Graduada de Medicina Interna/Consultant, Internal Medicine graduate

5 Director de Serviço de Radiologia/Director, Radiology Unit

6 Assistente Hospitalar Graduada de Patologia Clínica/Unit Consultant, Clinical Pathology graduate


Institutions and units:

* Hospital Curry Cabral – Internal Medicine

** Hospital Pulido Valente – Pneumology

*** Hospital Curry Cabral – Radiology

**** Hospital Curry Cabral – Pathology


Recebido para publicação/received for publication: 08.10.27

Aceite para publicação/accepted for publication: 08.12.16