• What is it:
  • Empyema is
    • The collection of pus
    • Within the pleural cavity,
    • Typically resulting from an infection.
• What causes it:
  • Commonly caused by bacterial infections, such as pneumonia.
  • It may arise as a complication of:
    • Thoracic surgery.
    • Trauma.
    • Esophageal rupture.
  • Less common causes include:
    • Tuberculosis.
    • Fungal infections.
• What is the result:
  • Empyema leads to:
    • Inflammation of the pleura.
    • Pleural thickening and fibrosis.
  • This may:
    • Restrict lung expansion.
    • Impair respiratory function.
  • If untreated, it can:
    • Progress to sepsis.
    • Form a chronic empyema.
• How is it diagnosed:
  • Clinical findings:
    • Symptoms include:
      • Fever.
      • Chest pain.
      • Dyspnea.
      • Malaise.
    • Physical exam findings may reveal:
      • Decreased breath sounds.
      • Dullness to percussion.
      • Pleural rub.
  • Imaging studies:
    • Chest X-ray shows:
      • Pleural effusion with loculation.
    • Chest CT identifies:
      • Pleural thickening.
      • Septations.
      • Fluid collections.
    • Ultrasound confirms:
      • Loculated pleural fluid.
      • Fluid characteristics.
      • Guides thoracentesis.
  • Laboratory tests:
    • Pleural fluid analysis shows:
      • High white cell count.
      • Low glucose levels.
      • Elevated LDH.
    • Cultures often identify:
      • The causative pathogen.
• How is it treated:
  • Medical management:
    • Empiric antibiotics target suspected pathogens.
    • Antibiotics are adjusted based on culture results.
  • Drainage:
    • Chest tube placement evacuates infected fluid.
    • Fibrinolytics may break down adhesions in loculated effusions.
  • Interventional radiology (IR):
    • Diagnosis:
      • IR-guided thoracentesis aids in fluid sampling.
    • Treatment:
      • Image-guided chest tube placement drains complex collections.
      • IR techniques are valuable for patients unsuitable for surgery.
  • Surgical intervention:
    • Decortication is considered for:
      • Chronic empyema.
      • Cases where IR and chest tube drainage fail.
• Radiological implications:
  • Chest X-ray and CT are essential for:
    • Identifying pleural effusions.
    • Detecting complications.
  • Ultrasound is critical for:
    • Guiding thoracentesis.
    • Assessing fluid characteristics.
  • MRI may assess:
    • Chronic empyema.
    • Complex pleural fibrosis.
• Key points and pearls:
  • You should remember:
    • Empyema is a complication of infections like pneumonia.
    • It requires prompt diagnosis and drainage to prevent complications.
    • Interventional radiology plays a key role in:
      • Diagnosis.
      • Minimally invasive treatment.
    • Early intervention improves outcomes.
    • Chronic pleural damage can be avoided with timely care.

Paraseptal emphysema is characterized by the destruction and
dilation of the alveoli located near the pleura, along the lung
margins, and adjacent to the interlobular septa. This type of
emphysema predominantly affects the upper lung zones and can be
found in isolation or alongside other forms of emphysema, such as
centrilobular or panlobular emphysema. The pathogenesis involves
the breakdown of alveolar walls, leading to the formation of
subpleural bullae or cyst-like spaces that can predispose patients
to spontaneous pneumothorax (collapsed lung) if these bullae
rupture. Patients with paraseptal emphysema may present with
shortness of breath, but symptoms can vary widely depending on
the extent of lung involvement. Diagnosis is primarily made using
high-resolution CT (HRCT) scans, which show enlarged airspaces
near the lung periphery, and may sometimes reveal bullae. While
paraseptal emphysema is often seen in smokers, it can also occur
in younger, otherwise healthy individuals, particularly when
associated with bullous disease (Etesami)