Imaging

Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology.

The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend. Those who care for patients with pulmonary, critical care or sleep disorders rely heavily on chest radiology and pathology to determine diagnoses. The Southwest Journal of Pulmonary, Critical Care & Sleep publishes case-based articles with characteristic chest imaging and related pathology. The editor of this section will oversee and coordinate the publication of a core of the most important chest imaging topics. In doing so, they encourage the submission of unsolicited manuscripts. It cannot be overemphasized that both radiologic and pathologic images must be of excellent quality. As a rule, 600 DPI is sufficient for radiographic and pathologic images. Taking pictures of plain chest radiographs and CT scans with a digital camera is strongly discouraged. The figures should be cited in the text and numbered consecutively. The stain used for pathology specimens and magnification should be mentioned in the figure legend.

Rick Robbins, M.D. Rick Robbins, M.D.

Medical Image of the Week: Empyema Necessitans

Figure 1. Panel A: chest radiograph on admission showed mass like lesion centered at the right upper lobe. Panel B: Coronal CT cut showing loculated fluid collection demonstrating peripheral rim enhancement. There is extension of pleural fluid into the soft tissues of the adjacent right chest wall (white arrow).

 

Figure 2. Panel A: chest radiograph after VATS decortication and antibiotic course shows resolution. Panel B: axial CT cut after completion of therapy shows complete resolution.

 

A previously healthy 46-year-woman was evaluated for two week history of right shoulder pain, associated pleuritic chest pain and dyspnea.

Chest radiograph showed right apical mass (Figure 1A). Imaging  showed loculated fluid collection with extension into the soft tissues of the adjacent right chest wall suggestive of empyema necessitans (Figure 1B).

Chest Tube placement was done along with broad spectrum antibiotics. Blood and pleural fluid cultures showed methicillin-resistant Staphylococcus aureus (MRSA). Due to persistence of loculation despite antibiotics, she underwent a video-assisted-thoracoscopic surgery (VATS) for decortication and further drainage of the effusion.

Symptoms and radiologic findings improved and she was discharged with intravenous antibiotics to complete a six week course. Chest imaging at six week period showed complete resolution (Figure 2).

Empyema necessitans, defined by the extension of an empyema through the parietal pleura, into surrounding tissue is becoming rare with the routine drainage of empyema and antibiotics use. Common causative pathogens include Mycobacterium tuberculosis, Actinomyces israelii, Streptococcus pneumoniae, and Staphylococcus aureus (1). Surgical treatments for thoracic empyema include chest tube drainage, debridement via VATS, decortication, open window thoracostomy, and thoracoplasty (2).

Kai Rou Tey MD1, Bhupinder Natt MD2

1Department of Internal Medicine - South Campus and 2Department of Pulmonary, Critical Care, Allergy and Sleep

University of Arizona College of Medicine

Tucson, AZ USA

References

  1. Kono SA, Nauser TD. Contemporary empyema necessitatis. Am J Med. 2007;120(4):303-5. [CrossRef] [PubMed]
  2. Molnar TF. Current surgical treatment of thoracic empyema in adults. Eur J Cardiothorac Surg. 2007;32(3):422-30. [CrossRef] [PubMed] 

Cite as: Tey KR, Natt B. Medical image of the week: empyema necessitans. Southwest J Pulm Crit Care. 2015;11(6):271-2. doi: http://dx.doi.org/10.13175/swjpcc139-15 PDF 

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