Epidemiology; clinical presentation; and evaluation of parapneumonic effusion and empyema in children
- Ibrahim A Janahi, MD
Ibrahim A Janahi, MD
- Professor of Pediatrics
- Weill-Cornell Medical College, Qatar
- Khoulood Fakhoury, MD
Khoulood Fakhoury, MD
- Assistant Professor of Pediatrics
- Baylor College of Medicine
- Section Editors
- Gregory Redding, MD
Gregory Redding, MD
- Section Editor — Pediatric Pulmonology
- Professor of Pediatrics
- University of Washington School of Medicine
- Sheldon L Kaplan, MD
Sheldon L Kaplan, MD
- Editor-in-Chief — Pediatrics
- Section Editor — Pediatric Infectious Diseases
- Professor and Vice Chairman for Clinical Affairs
- Baylor College of Medicine
Simple parapneumonic effusion is defined as pleural effusion associated with lung infection (ie, pneumonia). These effusions result from the spread of inflammation and infection to the pleura. Much less commonly, infections in other adjacent areas (eg, retropharyngeal, vertebral, abdominal, and retroperitoneal spaces) may spread to the pleura resulting in the development of effusion. Parapneumonic effusions or empyema affect 2 to 12 percent of children with pneumonia, and up to 28 percent of those requiring hospitalization [1,2].
Early in the course of parapneumonic effusion, the pleura becomes inflamed; subsequent leakage of proteins, fluid, and leukocytes into the pleural space forms the effusion. At the time of formation, the pleural effusion is usually sterile with a low leukocyte count. With time, bacteria invade the fluid, resulting in empyema, which is defined as the presence of grossly purulent fluid in the pleural cavity. The development of pleural empyema is determined by a balance between host resistance, bacterial virulence, and timing of presentation for medical treatment .
The epidemiology, etiology, pathophysiology, clinical presentation, and evaluation of parapneumonic effusion and empyema in children will be reviewed here. The management of parapneumonic effusion and empyema in children is discussed separately. (See "Management and prognosis of parapneumonic effusion and empyema in children".)
The evaluation and management of parapneumonic effusion in adults also are discussed separately. (See "Diagnostic evaluation of a pleural effusion in adults: Initial testing" and "Imaging of pleural effusions in adults" and "Parapneumonic effusion and empyema in adults".).
Between 1962 and 1980, empyema was reported to occur in approximately 0.6 percent of children with bacterial pneumonia, despite early diagnosis and treatment . However, the number of children with complicated pneumonia appears to be increasing, and effusion now occurs in about 2 to 12 percent of community-acquired pneumonia in Europe and the United States [1,2,5]. In children younger than two years of age, pneumonia hospitalizations complicated by empyema increased twofold from 3.5 cases per 100,000 children in 1996 through 1998 to 7.0 cases per 100,000 children in 2005 through 2007 . Rates of pneumococcal and streptococcal empyema remained stable, whereas rates of staphylococcal and other or unspecified empyema increased 4.08- and 1.89-fold, respectively. Similarly in patients two to four years of age, the rate of pneumonia complicated by empyema almost tripled from 3.7 to 10.3/100,000 with 2.17, 2.80, 3.76, and 3.09-fold increases in rates of pneumococcal, streptococcal, staphylococcal, and other or unspecified empyema, respectively. Similar increases have been seen in the United Kingdom [7-9], and Scandinavia .
- Byington CL, Spencer LY, Johnson TA, et al. An epidemiological investigation of a sustained high rate of pediatric parapneumonic empyema: risk factors and microbiological associations. Clin Infect Dis 2002; 34:434.
- Bradley JS, Byington CL, Shah SS, et al. The management of community-acquired pneumonia in infants and children older than 3 months of age: clinical practice guidelines by the Pediatric Infectious Diseases Society and the Infectious Diseases Society of America. Clin Infect Dis 2011; 53:e25.
- Tuomanen EI, Austrian R, Masure HR. Pathogenesis of pneumococcal infection. N Engl J Med 1995; 332:1280.
- Chonmaitree T, Powell KR. Parapneumonic pleural effusion and empyema in children. Review of a 19-year experience, 1962-1980. Clin Pediatr (Phila) 1983; 22:414.
- Li ST, Tancredi DJ. Empyema hospitalizations increased in US children despite pneumococcal conjugate vaccine. Pediatrics 2010; 125:26.
- Grijalva CG, Nuorti JP, Zhu Y, Griffin MR. Increasing incidence of empyema complicating childhood community-acquired pneumonia in the United States. Clin Infect Dis 2010; 50:805.
- Rees JH, Spencer DA, Parikh D, Weller P. Increase in incidence of childhood empyema in West Midlands, UK. Lancet 1997; 349:402.
- Playfor SD, Smyth AR, Stewart RJ. Increase in incidence of childhood empyema. Thorax 1997; 52:932.
- Roxburgh CS, Youngson GG, Townend JA, Turner SW. Trends in pneumonia and empyema in Scottish children in the past 25 years. Arch Dis Child 2008; 93:316.
- Yu D, Buchvald F, Brandt B, Nielsen KG. Seventeen-year study shows rise in parapneumonic effusion and empyema with higher treatment failure after chest tube drainage. Acta Paediatr 2014; 103:93.
- Schultz KD, Fan LL, Pinsky J, et al. The changing face of pleural empyemas in children: epidemiology and management. Pediatrics 2004; 113:1735.
- Byington CL, Hulten KG, Ampofo K, et al. Molecular epidemiology of pediatric pneumococcal empyema from 2001 to 2007 in Utah. J Clin Microbiol 2010; 48:520.
- Hardie W, Bokulic R, Garcia VF, et al. Pneumococcal pleural empyemas in children. Clin Infect Dis 1996; 22:1057.
- Freij BJ, Kusmiesz H, Nelson JD, McCracken GH Jr. Parapneumonic effusions and empyema in hospitalized children: a retrospective review of 227 cases. Pediatr Infect Dis 1984; 3:578.
- Wheeler JG, Jacobs RF. Pleural effusions and empyema. In: Textbook of Pediatric Infectious Diseases, 6th, Feigin RD, Cherry JD, Demmler-Harrison GJ, Kaplan SL (Eds), Saunders, Philadelphia 2009. p.325.
- Hoff SJ, Neblett WW, Edwards KM, et al. Parapneumonic empyema in children: decortication hastens recovery in patients with severe pleural infections. Pediatr Infect Dis J 1991; 10:194.
- Lewis KT, Bukstein DA. Parapneumonic empyema in children: diagnosis and management. Am Fam Physician 1992; 46:1443.
- Ampofo K, Herbener A, Blaschke AJ, et al. Association of 2009 pandemic influenza A (H1N1) infection and increased hospitalization with parapneumonic empyema in children in Utah. Pediatr Infect Dis J 2010; 29:905.
- Golladay ES, Wagner CW. Management of empyema in children. Am J Surg 1989; 158:618.
- Brook I. Microbiology of empyema in children and adolescents. Pediatrics 1990; 85:722.
- Bryant RE, Salmon CJ. Pleural empyema. Clin Infect Dis 1996; 22:747.
- Balfour-Lynn IM, Abrahamson E, Cohen G, et al. BTS guidelines for the management of pleural infection in children. Thorax 2005; 60 Suppl 1:i1.
- Alkrinawi S, Chernick V. Pleural infection in children. Semin Respir Infect 1996; 11:148.
- Tan TQ, Mason EO Jr, Wald ER, et al. Clinical characteristics of children with complicated pneumonia caused by Streptococcus pneumoniae. Pediatrics 2002; 110:1.
- Blaschke AJ, Heyrend C, Byington CL, et al. Molecular analysis improves pathogen identification and epidemiologic study of pediatric parapneumonic empyema. Pediatr Infect Dis J 2011; 30:289.
- Yu J, Salamon D, Marcon M, Nahm MH. Pneumococcal serotypes causing pneumonia with pleural effusion in pediatric patients. J Clin Microbiol 2011; 49:534.
- Strachan RE, Cornelius A, Gilbert GL, et al. Bacterial causes of empyema in children, Australia, 2007-2009. Emerg Infect Dis 2011; 17:1839.
- Olarte L, Barson WJ, Barson RM, et al. Pneumococcal Pneumonia Requiring Hospitalization in U.S. Children in the 13-Valent Pneumococcal Conjugate Vaccine Era. Clin Infect Dis 2017.
- Antachopoulos C, Tsolia MN, Tzanakaki G, et al. Parapneumonic pleural effusions caused by Streptococcus pneumoniae serotype 3 in children immunized with 13-valent conjugated pneumococcal vaccine. Pediatr Infect Dis J 2014; 33:81.
- Hardie WD, Roberts NE, Reising SF, Christie CD. Complicated parapneumonic effusions in children caused by penicillin-nonsusceptible Streptococcus pneumoniae. Pediatrics 1998; 101:388.
- Quintero DR, Fan LL. Approach to pleural effusions and empyemas. Paediatr Respir Rev 2004; 5 Suppl A:S151.
- Gonzalez BE, Hulten KG, Dishop MK, et al. Pulmonary manifestations in children with invasive community-acquired Staphylococcus aureus infection. Clin Infect Dis 2005; 41:583.
- Alfaro C, Fergie J, Purcell K. Emergence of community-acquired methicillin-resistant Staphylococcus aureus in complicated parapneumonic effusions. Pediatr Infect Dis J 2005; 24:274.
- Freitas M, Castelo A, Petty G, et al. Viridans streptococci causing community acquired pneumonia. Arch Dis Child 2006; 91:779.
- Givan DC, Eigen H. Common pleural effusions in children. Clin Chest Med 1998; 19:363.
- Cowan MR, Primm PA, Scott SM, et al. Serious group A beta-hemolytic streptococcal infections complicating varicella. Ann Emerg Med 1994; 23:818.
- Moses AE, Ziv A, Harari M, et al. Increased incidence and severity of Streptococcus pyogenes bacteremia in young children. Pediatr Infect Dis J 1995; 14:767.
- Thaarup J, Ellermann-Eriksen S, Stjernholm J. Neonatal pleural empyema with group A Streptococcus. Acta Paediatr 1997; 86:769.
- Fine NL, Smith LR, Sheedy PF. Frequency of pleural effusions in mycoplasma and viral pneumonias. N Engl J Med 1970; 283:790.
- Michelow IC, Olsen K, Lozano J, et al. Epidemiology and clinical characteristics of community-acquired pneumonia in hospitalized children. Pediatrics 2004; 113:701.
- Rodgers BM, McGahren ED. Mediastinum and pleura. In: Principles and Practice of Pediatric Surgery, Oldham KT, Colombani PM, Foglia RP, Skinner MA (Eds), Lippincott Williams & Wilkins, Philadelphia 2005. p.929.
- Light RW, Girard WM, Jenkinson SG, George RB. Parapneumonic effusions. Am J Med 1980; 69:507.
- Potts DE, Taryle DA, Sahn SA. The glucose-pH relationship in parapneumonic effusions. Arch Intern Med 1978; 138:1378.
- Islam S, Calkins CM, Goldin AB, et al. The diagnosis and management of empyema in children: a comprehensive review from the APSA Outcomes and Clinical Trials Committee. J Pediatr Surg 2012; 47:2101.
- Harris M, Clark J, Coote N, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in children: update 2011. Thorax 2011; 66 Suppl 2:ii1.
- Mangete ED, Kombo BB, Legg-Jack TE. Thoracic empyema: a study of 56 patients. Arch Dis Child 1993; 69:587.
- Sahn SA. The differential diagnosis of pleural effusions. West J Med 1982; 137:99.
- Negus RA, Chachkes JS, Wrenn K. Tension hydrothorax and shock in a patient with a malignant pleural effusion. Am J Emerg Med 1990; 8:205.
- Shin MS, Rahn NH 3rd, Ho KJ. Tension hydrothorax: roentgenographic characteristics and pathogenetic consideration. South Med J 1981; 74:498.
- Prais D, Kuzmenko E, Amir J, Harel L. Association of hypoalbuminemia with the presence and size of pleural effusion in children with pneumonia. Pediatrics 2008; 121:e533.
- Wolach B, Morag H, Drucker M, Sadan N. Thrombocytosis after pneumonia with empyema and other bacterial infections in children. Pediatr Infect Dis J 1990; 9:718.
- Jaffé A, Balfour-Lynn IM. Management of empyema in children. Pediatr Pulmonol 2005; 40:148.
- Himelman RB, Callen PW. The prognostic value of loculations in parapneumonic pleural effusions. Chest 1986; 90:852.
- Light, RW. Pleural diseases. Lea & Febiger, Philadelphia1983.
- Yang PC, Luh KT, Chang DB, et al. Value of sonography in determining the nature of pleural effusion: analysis of 320 cases. AJR Am J Roentgenol 1992; 159:29.
- Eibenberger KL, Dock WI, Ammann ME, et al. Quantification of pleural effusions: sonography versus radiography. Radiology 1994; 191:681.
- Merriam MA, Cronan JJ, Dorfman GS, et al. Radiographically guided percutaneous catheter drainage of pleural fluid collections. AJR Am J Roentgenol 1988; 151:1113.
- Hunnam GR, Flower CD. Radiologically-guided percutaneous catheter drainage of empyemas. Clin Radiol 1988; 39:121.
- Stavas J, vanSonnenberg E, Casola G, Wittich GR. Percutaneous drainage of infected and noninfected thoracic fluid collections. J Thorac Imaging 1987; 2:80.
- Ramnath RR, Heller RM, Ben-Ami T, et al. Implications of early sonographic evaluation of parapneumonic effusions in children with pneumonia. Pediatrics 1998; 101:68.
- Donnelly LF, Klosterman LA. CT appearance of parapneumonic effusions in children: findings are not specific for empyema. AJR Am J Roentgenol 1997; 169:179.
- Coren ME, Ng V, Rubens M, et al. The value of ultrafast computed tomography in the investigation of pediatric chest disease. Pediatr Pulmonol 1998; 26:389.
- Calder A, Owens CM. Imaging of parapneumonic pleural effusions and empyema in children. Pediatr Radiol 2009; 39:527.
- Buckingham SC, King MD, Miller ML. Incidence and etiologies of complicated parapneumonic effusions in children, 1996 to 2001. Pediatr Infect Dis J 2003; 22:499.
- Boersma WG, Löwenberg A, Holloway Y, et al. Rapid detection of pneumococcal antigen in pleural fluid of patients with community acquired pneumonia. Thorax 1993; 48:160.
- Le Monnier A, Carbonnelle E, Zahar JR, et al. Microbiological diagnosis of empyema in children: comparative evaluations by culture, polymerase chain reaction, and pneumococcal antigen detection in pleural fluids. Clin Infect Dis 2006; 42:1135.
- Saglani S, Harris KA, Wallis C, Hartley JC. Empyema: the use of broad range 16S rDNA PCR for pathogen detection. Arch Dis Child 2005; 90:70.
- Eastham KM, Freeman R, Kearns AM, et al. Clinical features, aetiology and outcome of empyema in children in the north east of England. Thorax 2004; 59:522.
- Menezes-Martins LF, Menezes-Martins JJ, Michaelsen VS, et al. Diagnosis of parapneumonic pleural effusion by polymerase chain reaction in children. J Pediatr Surg 2005; 40:1106.
- Zheng X, O'Leary A, Uhl JR, et al. Rapid detection of Streptococcus pyogenes in pleural fluid samples from pediatric patients with empyema. J Clin Microbiol 2012; 50:2786.
- Gollomp K, Rankin SC, White C, et al. Broad-range bacterial polymerase chain reaction in the microbiologic diagnosis of complicated pneumonia. J Hosp Med 2012; 7:8.
- Utine GE, Pinar A, Ozçelik U, et al. Pleural fluid PCR method for detection of Staphylococcus aureus, Streptococcus pneumoniae and Haemophilus influenzae in pediatric parapneumonic effusions. Respiration 2008; 75:437.
- Thomson AH, Hull J, Kumar MR, et al. Randomised trial of intrapleural urokinase in the treatment of childhood empyema. Thorax 2002; 57:343.
- Mani CS, Murray DL. Acute pneumonia and its complications. In: Principles and Practice of Pediatric Infectious Diseases, 4th, Long SS, Pickering LK, Prober CG (Eds), Elsevier Saunders, Edinburgh 2012. p.235.
- Maskell NA, Butland RJ, Pleural Diseases Group, Standards of Care Committee, British Thoracic Society. BTS guidelines for the investigation of a unilateral pleural effusion in adults. Thorax 2003; 58 Suppl 2:ii8.
- Epstein DM, Kline LR, Albelda SM, Miller WT. Tuberculous pleural effusions. Chest 1987; 91:106.
- Hallman JR, Geisinger KR. Cytology of fluids from pleural, peritoneal and pericardial cavities in children. A comprehensive survey. Acta Cytol 1994; 38:209.
- Yam LT. Diagnostic significance of lymphocytes in pleural effusions. Ann Intern Med 1967; 66:972.
- Panitch HB, Papastamelos C, Schidlow DV. Abnormalities of the pleural space. In: Pediatric Respiratory Medicine, Taussig LM, Landau LI (Eds), Mosby, St. Louis 1999. p.1184.
- Dhawan A, Narang A, Singhi S. Hyponatraemia and the inappropriate ADH syndrome in pneumonia. Ann Trop Paediatr 1992; 12:455.
- Shann F, Germer S. Hyponatraemia associated with pneumonia or bacterial meningitis. Arch Dis Child 1985; 60:963.
- Bacterial infections
- CLINICAL PRESENTATION
- Symptoms and signs
- History and examination
- Radiologic evaluation
- - Plain radiographs
- - Ultrasonography
- - Chest CT
- Blood and sputum cultures
- Pleural fluid analysis
- - Microbial analysis
- - Other studies
- Other tests
- SOCIETY GUIDELINE LINKS
- SUMMARY AND RECOMMENDATIONS