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Empyema

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]

Overview

Overview

Empyema may be classified according to the etiology, anatomical location, and pathological course of the disease.[1] Primary thoracic empyema occurs most commonly as iatrogenic empyema without associated pneumonia whereas secondary empyema occurs more commonly secondary to pneumonia. Empyema necessitans is a spontaneous discharge of an empyema that has burrowed through the parietal pleura into the chest wall to form a subcutaneous abscess that may eventually rupture through the skin.[2][3] On the basis of anatomical location, empyema may be classified depending on the affected organ including the following: gallbladder empyema,[4][5] subdural empyema,[6][7][8][9][10][11][12][13] joint empyema,[14][15][16] and empyema cystitis.[17][18] Empyema is most frequently caused by bacteria. Causes may be tuberculous or nontuberculous. Tuberculous empyema is the most common cause of empyema necessitans with majority of affected patients immunocompromised.[19][20] There are 3 stages of empyema which are important in terms of the laboratory findings. These are exudative, fibrinopurulent, and organizing.[21]

Empyema classification

Empyema classification

Classification by Organ System or Location of Empyema

Pleural empyema

Pleural empyema is also called empyema thoracis. Thoracic empyema arises from an infection within the lung. It must be differentiated from an abscess, which is a collection of necrotic and suppurated tissue located in the parenchyma of an organ.[22] Empyema is most commonly used to refer to pus collection in the pleural cavity although several other organs can be affected including the brain, gallbladder, joints, and urinary bladder. Thoracic empyema arises from an infection within the lung, often associated with parapneumonic effusions. Parapneumonic effusions may be uncomplicated or complicated effusions. Complicated parapneumonic effusion results when bacteria invade the pleural space with a resultant formation of an empyema.

Gallbladder empyema

Gallbladder empyema is also called suppurative cholecystitis which may complicate acute/chronic cholecystitis whereby pus collects in the gall bladder lumen. It is common in people with diabetes and atherosclerotic disease.[4][5] Gallbladder empyema normally results from an obstruction of the cystic duct hampering drainage of bile from the gall bladder, which becomes secondarily infected.

Subdural empyema

Subdural empyema is a life-threatening infection, consisting of a localized collection of purulent material, typically unilateral, between the dura mater and the arachnoid mater. Subdural empyema may be classified according to location of the infection into 2 groups: intracranial and spinal, with intracranial being the more common of the two groups, accounting for 95% of subdural empyema patients.[23][24] Subdural empyema accounts for approximately 15-25% of focal central nervous system infections. In 2014, the incidence of subdural empyema was estimated to be less than 1 case per 100,000 individuals, with a male predominance.[25] The most common pathogens of intracranial subdural empyema are anaerobic and microaerophilic Streptococci, compared to spinal subdural epmyema, which may be caused by either Streptococci or Staphylococcus aureus.[24] If left untreated, subdural empyema frequently evolves into severe fever, headache, nausea, vomiting, seizures, coma, and subsequent death. Complications to subdural empyema include status epilepticus, neurological deficits, and thrombosis. Prognosis is generally good with antimicrobial therapy. Physical examination of patients with subdural empyema is usually remarkable for fever, facial pain, and altered mental status.[26][27][28] MRI is the primary imaging study of epidural abscess, with CT scan as a secondary alternative. Treatment of subdural empyema requires a combined medical and surgical approach. In order to evacuate the pus, burr hole placement or craniotomy may be used to treat the subdural empyema. The preferred surgical mainstay of treatment for subdural empyema is craniotomy.

Subdural empyema  is rare, however it may complicate one-third of all intracranial infections. Subdural empyema may follow pansinusitis, mastoiditis, orbital cellulitis, and after surgery for lumbar lipomyelomeningocele manifesting with seizures, focal neurological deficits and altered mentatal status and possible progression to coma.[6][7][8][9][10][11][12][13]

Joint empyema

This usually occurs after superimposed infection of the sinovial fluid following some procedures (e.g. post-lumbar or sacroiliac discectomy and instrumentation or surgery).[14][15][16]

Empyema cystitis

This type of empyema may complicate a dysfunctional[17][18] or an obstructed[29] urinary bladder. Empyema cystis may be treated by intermittent self-catherterization[30] or vaginal vesicostomy for empyema of dysfunctional bladder.[31]

Differential Diagnosis

Differential Diagnosis

Causes of

lung cavities

Differentiating Features Differentiating radiological findings Diagnosis

confirmation

  • CXR and CT demonstrates cavities in the upper lobe of the lung
  • Sputum smear positive for acid-fast bacilli and nucleic acid amplification tests (NAAT) is used on sputum or any sterile fluid for rapid diagnosis and is positive for mycobacteria.
  • Any age group
  • Acute, fulminant life threating complication of prior infection
  • >100.4 °F fever, with hemodynamic instability
  • Worsening pneumonia-like symptoms
  • CBC is positive for causative organism
  • Children and elderly are at risk
  • Empyema appears lenticular in shape and has a thin wall with smooth luminal margins
  • Pulmonary nodules with cavities and infiltrates are a frequent manifestation on CXR
  • Elderly females of 40-50 age group
  • Manifestation of rheumatoid arthritis
  • Presents with other systemic symptoms including symmetric arthritis of the small joints of the hands and feet with morning stiffness are common manifestations
  • Pulmonary nodules with cavitation are located in the upper lobe (Caplan syndrome) on X-ray
  • On CXR bilateral adenopathy and coarse reticular opacities are seen
  • CT of the chest demonstrates extensive hilar and mediastinal adenopathy
  • Additional findings on CT include fibrosis (honeycomb, linear, or associated with bronchial distortion), pleural thickening, and ground-glass opacities.[38]
  • Common appearance on CT is patchy consolidation,often accompanied by ground-glass opacities and nodules.[42]
  • Exclusively afflicts smokers, with a peak age of onset of between 20 and 40 years
  • Clinical presentation varies, but symptoms generally include months of dry cough, fever, night sweats, and weight loss
  • Skin is involved in 80% of the cases, scaly erythematous rash is typical
  • Thin-walled cystic cavities are the usual radiographic manifestation, observed in over 50% of patients by either CXR or CT scans.[44]
  • Biopsy of the lung

Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1] Associate Editor(s)-in-Chief: Prince Tano Djan, BSc, MBChB [2]

Overview

Empyema must be diffrentiated from pneumonia, lung abscess, lung cancer and parapneumonic effusions on the basis of the presentation, physical examination findings, chest xray, ultrasound and CT scan findings. For instance on ultrasound, empyema is positive for suspended microbubble sign, air fluid level, curtains sign and loss of gliding sign but these are negative in a lung abscess.

Again empyema is differentiated from a lung abscess in that empyema on CT scan is seen as a lung mass whose cavity is regular with smooth well-defined boundary and shape changes with change in patient’s position.[1] Mass may resolve on antibiotics. The split pleura sign is present[2] (most reliable sign to differentiate empyema from lung abscess).[3]

Differential diagnosis

Empyema must be diffrentiated from pneumonia, lung abscess, lung cancer and parapneumonic effusions as shown below:

Variable Empyema Thoracis Lung abscess Pleural effusion Pneumonia Lung cancer
Presentation Variable presentation

but may follow long standing pneumonia

Usually has history of aspiration pneumonia, alcoholics, drug abusers, seizure disorder, have undergone recent general anesthesia, or have a nasogastric or endotracheal tube. Usually follows pneumonia as a complication presents with fever, pleuritc chest pain, cough mostly asymptomatic but may

have cough productive with

hemoptysis and

chronic history of smoking

Causes In general any bacteria

can cause an empyema, however different bacteria are associated

with different rates of empyema formation.[1]  Common causes include bacteroides, fusobacterium, 

haemophilus influenzae, pneumococcal infections,

staphylococcus aureus,

streptococcus, TB

Lung abscess is commonly caused by bacterial infections and these include bacteroides, peptostreptococcus and prevotella mostly after aspiration Common causes of transudative pleural effusion include;[1][2][3][4][5] left ventricular failure, Nephrotic syndrome, and cirrhosis, while common causes of exudative pleural effusions[6] are bacterial pneumonia and malignancy Pneumonia can result from a variety of causes, including infection with bacteria, viruses, fungi, parasites, and chemical injury to the lungs Direct cause of lung cancers

is DNA mutations that often

result in either activation

of proto-oncogenes

(e.g. K-RAS) or the inactivation of tumors suppressor genes

(e.g. TP53) or both. The risk of these genetic mutations may be increased following exposure to environmental components example smoking

Laboratory findings The pleural fluid typically has a low pH (<7.20),

low glucose (<60 mg/dL), and contains infectious organisms.

Therefore, the diagnosis relies on the presence of pus or organisms on gram stain. A positive bacteria culture from pleural fluid is not needed to make diagnosis of empyema.[4][5]

Raised inflammatory markers ( eg high ESR, CRP) are usual but not specific The most widely used criteria is to differentiate between exudate and transudate using the light’s criteria. Fluid is exudate when:
  • Pleural fluid protein/serum protein ratio >0.5
  • Fluid/serum lactic dehydrogenase (LDH) ratio >0.6
  • Fluid LDH greater than 2/3 the upper limits of normal of the serum LDH
 Laboratory findings are non specific example leukocytosis, sputum samples for gram staining and culture. Other tests include urine antigen test, PCR, C-reactive protein and procalcitonin The laboratory findings are 

non specific including:

neutropenia, hyponatremia,

hypokalemia, hypercalcemia,

respiratory acidosis,

hypercarbia, hypoxia, and

tumor cells in sputum and

pleural effusion cytology.

Physical examination On examination, the following

findings may be seen:[6][7][8]

Lateral chest wall swelling

and tenderness, clubbing of the fingernails, dull percussion note, r

educed breath sounds on the affected side of the chest, egophony, coarse crackles, increased tactile fremitus,

mediastinal shift to opposite side with large empyema

Chest examination shows features of consolidation such as localised dullness on percussion, bronchial breath sound etc.

Dental decay is common especially in alcoholics and children. Clubbing is present in one third of patients.

Bulging of the intercostal spaces,

decreased chest expansion

bronchovesicular breath sounds

of decreased intensity, egophony,

dullness to percussion,

decreased or absent fremitus.

Physical examination increased respiratory rate, low oxygen saturation, difficulty breathing, bronchial breathe sounds, increased tactile fremitus crackling sounds, or increased whispered pectoriloquy.  Physical examination findings are non specific and may include decreased/absent breath sounds, pallor, low-grade fever, tachypnea and cachezia.
CXR Chest X ray of empyema shows air-fluid level continuos homogenous pattern from the mediastinum to the chest wall forming obtuse angle with the lung parenchyma.[9]

Chest xray shows often unilateral cavity containing an air-fluid level and consolidation of lung parenchyema.

A homogenous opacification is noted at the affected side. The costophrenic angle is obliterated with a meniscus. CXR shows areas of diffused opacities. CXR may show lung mass, widening of the mediastinum, atelectasis, or pleural effusion.
Chest ultrasound Ultrasound in empyema is positive

for suspended microbubble sign,

air fluid level, curtains sign

and loss of gliding sign.[10]

Ultrasound in lung abscess is negative for suspended microbubble sign, curtains sign and loss of gliding sign but air fluid level may be seen,.[11] Ultrasonography is helpful in making diagnosis of pleural effusion particularly in differentiating effusion from masses.[12] The extended thoracic spine sign on sonography has high sensitivity and specificity for diagnosing pleural effusion.[13] Chest or upper abdominal ultrasound may show subpulmonic effusion as shown below.[14][15][16] Not reqiured unless complicated with empyema USG is helpful in guiding biopsy, staging and estimating prognosis. It may show hypo- and hyperechogenic masses.[17][18][19]
CT scan Seen as a lung mass whose cavity

is regular with smooth

and regular lumen, well-defined

boundary and shape changes

with change in patient’s position.[1]

Mass may resolve on antibiotics The split pleura sign is present[2]

(most reliable sign to differentiate

empyema from lung abscess)[3]

Lung mass whose cavity is rregular with undulated lumen, irregular-poorly defined boundary and shape does not change with change in patient’s position.[20] Mass may resolve on antibiotics In most cases CT imaging may not provide additional information that would influence the clinical decision-making process.[21][22] [23] CT scan shows heterogeneous opacification of the affected side and cardiomediastinal shift to the opposite site in unilateral effusion.[24]
  • CT findings in pneumonia include:[1]
 Seen as a spiculated irregular solid mass that does not resolve on antibiotics

References

  1. ↑ 1.0 1.1 Baber CE, Hedlund LW, Oddson TA, Putman CE (1980). “Differentiating empyemas and peripheral pulmonary abscesses: the value of computed tomography”. Radiology. 135 (3): 755–8. doi:10.1148/radiology.135.3.7384467. PMID 7384467.
  2. ↑ 2.0 2.1 Stark DD, Federle MP, Goodman PC, Podrasky AE, Webb WR (1983). “Differentiating lung abscess and empyema: radiography and computed tomography”. AJR Am J Roentgenol. 141 (1): 163–7. doi:10.2214/ajr.141.1.163. PMID 6602513.
  3. ↑ 3.0 3.1 Kraus GJ (2007). “The split pleura sign”. Radiology. 243 (1): 297–8. doi:10.1148/radiol.2431041658. PMID 17392263.
  4. ↑ Mavroudis C, Ganzel BL, Cox SK, Polk HC (1987). “Experimental aerobic-anaerobic thoracic empyema in the guinea pig”. Ann Thorac Surg. 43 (3): 298–302. PMID 3548615.
  5. ↑ Perez VP, Caierão J, Fischer GB, Dias CA, d’Azevedo PA (2016). “Pleural effusion with negative culture: a challenge for pneumococcal diagnosis in children”. Diagn Microbiol Infect Dis. 86 (2): 200–4. doi:10.1016/j.diagmicrobio.2016.07.022. PMID 27527890.
  6. ↑ Atay S, Banki F, Floyd C (2016). “Empyema necessitans caused by actinomycosis: A case report”. Int J Surg Case Rep. 23: 182–5. doi:10.1016/j.ijscr.2016.04.005. PMC 5022073. PMID 27180228.
  7. ↑ Gomes MM, Alves M, Correia JB, Santos L (2013). “Empyema necessitans: very late complication of pulmonary tuberculosis”. BMJ Case Rep. 2013. doi:10.1136/bcr-2013-202072. PMC 3863066. PMID 24326441.
  8. ↑ Kuan YC, How SH, Yeen WC, Ng TH, Fauzi AR (2011). “Empyema thoracis complicated by pneumothorax necessitans manifesting as lobulated, localized subcutaneous emphysematous swellings”. Ann Thorac Surg. 91 (6): 1969–71. doi:10.1016/j.athoracsur.2010.11.075. PMID 21619994.
  9. ↑ Moffett BK, Panchabhai TS, Nakamatsu R, Arnold FW, Peyrani P, Wiemken T; et al. (2016). “Comparing posteroanterior with lateral and anteroposterior chest radiography in the initial detection of parapneumonic effusions”. Am J Emerg Med. 34 (12): 2402–2407. doi:10.1016/j.ajem.2016.09.021. PMID 27793503.
  10. ↑ Lin FC, Chou CW, Chang SC (2004). “Differentiating pyopneumothorax and peripheral lung abscess: chest ultrasonography”. Am J Med Sci. 327 (6): 330–5. PMID 15201646.
  11. ↑ Lin FC, Chou CW, Chang SC (2004). “Differentiating pyopneumothorax and peripheral lung abscess: chest ultrasonography”. Am J Med Sci. 327 (6): 330–5. PMID 15201646.
  12. ↑ Invalid <ref> tag; no text was provided for refs named pmid21345104
  13. ↑ Dickman E, Terentiev V, Likourezos A, Derman A, Haines L (2015). “Extension of the Thoracic Spine Sign: A New Sonographic Marker of Pleural Effusion”. J Ultrasound Med. 34 (9): 1555–61. doi:10.7863/ultra.15.14.06013. PMID 26269297.
  14. ↑ Almeida FA, Eiger G (2008). “Subpulmonic effusion”. Intern Med J. 38 (3): 216–7. doi:10.1111/j.1445-5994.2007.01619.x. PMID 18290818.
  15. ↑ Connell DG, Crothers G, Cooperberg PL (1982). “The subpulmonic pleural effusion: sonographic aspects”. J Can Assoc Radiol. 33 (2): 101–3. PMID 7107669.
  16. ↑ Halvorsen RA, Thompson WM (1986). “Ascites or pleural effusion? CT and ultrasound differentiation”. Crit Rev Diagn Imaging. 26 (3): 201–40. PMID 3536306.
  17. ↑ Mroz RM, Korniluk M, Swidzinska E, Dzieciol J, Czaban J, Panek B; et al. (2010). “Lung mass in a 28-year-old male: a case report of a rare tumor”. Eur J Med Res. 15 Suppl 2: 95–7. PMC 4360372. PMID 21147631.
  18. ↑ Torun E, Fidan A, Cağlayan B, Salepçi T, Mayadağli A, Salepçi B (2008). “[Prognostic factors in small cell lung cancer]”. Tuberk Toraks. 56 (1): 22–9. PMID 18330751.
  19. ↑ Filon E, Kodur E, Cygan M (1989). “[Ultrasonographic examination of the adrenal glands for detection of lung cancer metastasis]”. Nowotwory. 39 (3–4): 157–61. PMID 2700089.
  20. ↑ Baber CE, Hedlund LW, Oddson TA, Putman CE (1980). “Differentiating empyemas and peripheral pulmonary abscesses: the value of computed tomography”. Radiology. 135 (3): 755–8. doi:10.1148/radiology.135.3.7384467. PMID 7384467.
  21. ↑ Corcoran JP, Acton L, Ahmed A, Hallifax RJ, Psallidas I, Wrightson JM; et al. (2016). “Diagnostic value of radiological imaging pre- and post-drainage of pleural effusions”. Respirology. 21 (2): 392–5. doi:10.1111/resp.12675. PMID 26545413.
  22. ↑ Federle MP, Mark AS, Guillaumin ES (1986). “CT of subpulmonic pleural effusions and atelectasis: criteria for differentiation from subphrenic fluid”. AJR Am J Roentgenol. 146 (4): 685–9. doi:10.2214/ajr.146.4.685. PMID 3485341.
  23. ↑ Halvorsen RA, Thompson WM (1986). “Ascites or pleural effusion? CT and ultrasound differentiation”. Crit Rev Diagn Imaging. 26 (3): 201–40. PMID 3536306.
  24. ↑ Wolverson MK, Crepps LF, Sundaram M, Heiberg E, Vas WG, Shields JB (1983). “Hyperdensity of recent hemorrhage at body computed tomography: incidence and morphologic variation”. Radiology. 148 (3): 779–84. doi:10.1148/radiology.148.3.6878700. PMID 6878700.


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References

References

  1. ↑ Light RW (1995). “A new classification of parapneumonic effusions and empyema”. Chest. 108 (2): 299–301. PMID 7634854.
  2. ↑ Gomes MM, Alves M, Correia JB, Santos L (2013). “Empyema necessitans: very late complication of [[pulmonary tuberculosis]]”. BMJ Case Rep. 2013. doi:10.1136/bcr-2013-202072. PMC 3863066. PMID 24326441. URL–wikilink conflict (help)
  3. ↑ Ahmed SI, Gripaldo RE, Alao OA (2007). “Empyema necessitans in the setting of pneumonia and parapneumonic effusion”. Am J Med Sci. 333 (2): 106–8. PMID 17301589.
  4. ↑ 4.0 4.1 Watanabe Y, Nagayama M, Okumura A, Amoh Y, Katsube T, Suga T; et al. (2007). “MR imaging of acute biliary disorders”. Radiographics. 27 (2): 477–95. doi:10.1148/rg.272055148. PMID 17374864.
  5. ↑ 5.0 5.1 O’Connor OJ, Maher MM (2011). “Imaging of cholecystitis”. AJR Am J Roentgenol. 196 (4): W367–74. doi:10.2214/AJR.10.4340. PMID 21427298.
  6. ↑ 6.0 6.1 Miller ES, Dias PS, Uttley D (1987). “Management of subdural empyema: a series of 24 cases”. J Neurol Neurosurg Psychiatry. 50 (11): 1415–8. PMC 1032550. PMID 2891793.
  7. ↑ 7.0 7.1 Yüksel MO, Gürbüz MS, Karaarslan N, Caliskan T (2016). “Rapidly progressing interhemispheric subdural empyema showing a three-fold increase in size within 12 hours: Case report”. Surg Neurol Int. 7 (Suppl 37): S872–S875. doi:10.4103/2152-7806.194495. PMC 5154207. PMID 27999711.
  8. ↑ 8.0 8.1 Yocum D (2016). “Fusobacterium nucleatum: An unusual cause of subdural empyema”. JAAPA. 29 (12): 1–4. doi:10.1097/01.JAA.0000508216.58368.74. PMID 27898560.
  9. ↑ 9.0 9.1 Guan J, Spivak ES, Wilkerson C, Park MS (2016). “Subdural Empyema in the Setting of Multimodal Intracranial Monitoring”. World Neurosurg. doi:10.1016/j.wneu.2016.10.133. PMID 27826090.
  10. ↑ 10.0 10.1 Byrne N, Plonsker JH, Tan LA, Byrne RW, Munoz LF (2016). “Orbital Cellulitis with Pansinusitis and Subdural Empyema”. J Emerg Med. doi:10.1016/j.jemermed.2016.05.067. PMID 27751703.
  11. ↑ 11.0 11.1 Pallangyo P, Lyimo F, Nicholaus P, Kain U, Janabi M (2016). “Spontaneous Subdural Empyema Following a High-Parasitemia Falciparum Infection in a 58-Year-Old Female From a Malaria-Endemic Region: A Case Report”. J Investig Med High Impact Case Rep. 4 (3): 2324709616666567. doi:10.1177/2324709616666567. PMC 5011302. PMID 27635411.
  12. ↑ 12.0 12.1 Doan N, Patel M, Nguyen HS, Mountoure A, Shabani S, Gelsomino M; et al. (2016). “Intracranial subdural empyema mimicking a recurrent chronic subdural hematoma”. J Surg Case Rep. 2016 (9). doi:10.1093/jscr/rjw158. PMC 5029463. PMID 27651110.
  13. ↑ 13.0 13.1 Nguyen HS, Foy A, Havens P (2016). “Intracranial subdural empyema after surgery for lumbar lipomyelomeningocele: A rare complication”. Surg Neurol Int. 7 (Suppl 12): S301–4. doi:10.4103/2152-7806.182388. PMC 4879841. PMID 27274400.
  14. ↑ 14.0 14.1 Bayraktutan U, Sade R, Kantarci M (2016). “Septic arthritis and empyema of the sacroiliac joint after lumbar discectomy and instrumentation”. Spine J. 16 (7): e417–8. doi:10.1016/j.spinee.2015.12.033. PMID 26769350.
  15. ↑ 15.0 15.1 Schneider MM, Preiss S, Harder LP, Salzmann GM (2015). “[Destructive chondrolysis following intraarticular application of lavasorb (polihexanid) for treatment of knee empyema]”. MMW Fortschr Med. 157 (8): 47–8. doi:10.1007/s15006-015-3033-2. PMID 26012684.
  16. ↑ 16.0 16.1 Oheim R, Gille J, Schoop R, Badih S, Grimme CH, Schulz AP; et al. (2014). “Surgical therapy of extensive knee joint empyema: mid-term results after two-stage versus one-stage procedures”. Knee Surg Sports Traumatol Arthrosc. 22 (12): 3150–6. doi:10.1007/s00167-013-2754-y. PMID 24217715.
  17. ↑ 17.0 17.1 Min Z (2014). “A forgotten complication of a defunctionalized urinary bladder: pyocystis”. Intern Emerg Med. 9 (6): 691–2. doi:10.1007/s11739-014-1060-0. PMID 24554081.
  18. ↑ 18.0 18.1 Szkodny A, Przybyla J (1975). “[Bladder empyema]”. Pol Przegl Chir. 47 (2A): 301–2. PMID 1118412.
  19. ↑ Babamahmoodi F, Davoodi L, Sheikholeslami R, Ahangarkani F (2016). “Tuberculous Empyema Necessitatis in a 40-Year-Old Immunocompetent Male”. Case Rep Infect Dis. 2016: 4187108. doi:10.1155/2016/4187108. PMC 4983337. PMID 27555974.
  20. ↑ Nishihara T, Hayama M, Okamoto N, Tanaka A, Nishida T, Shiroyama T; et al. (2016). “Endoscopic Bronchial Occlusion with Silicon Spigots for the Treatment of an Alveolar-pleural Fistula during Anti-tuberculosis Therapy for Tuberculous Empyema”. Intern Med. 55 (15): 2055–9. doi:10.2169/internalmedicine.55.6672. PMID 27477414.
  21. ↑ Strange C, Tomlinson JR, Wilson C, Harley R, Miller KS, Sahn SA (1989). “The histology of experimental pleural injury with tetracycline, empyema, and carrageenan”. Exp Mol Pathol. 51 (3): 205–19. PMID 2480911.
  22. ↑ Monteiro R, Alfaro TM, Correia L, Simão A, Carvalho A, Costa JN (2011). “[Lung abscess and thoracic empyema: retrospective analysis in an internal medicine department]”. Acta Med Port. 24 Suppl 2: 229–40. PMID 22849907.
  23. ↑ Agrawal, Amit; Timothy, Jake; Pandit, Lekha; Shetty, Lathika; Shetty, J.P. (2007). “A Review of Subdural Empyema and Its Management”. Infectious Diseases in Clinical Practice. 15 (3): 149–153. doi:10.1097/01.idc.0000269905.67284.c7. ISSN 1056-9103.
  24. ↑ 24.0 24.1 Greenlee JE (2003). “Subdural Empyema”. Curr Treat Options Neurol. 5 (1): 13–22. PMID 12521560.
  25. ↑ French H, Schaefer N (2014). “Intracranial Subdural Empyema: A 10-Year Case Series”. Oschner J. 12 (2). doi:10.1002/bip.360240911. PMID PMC4052585 Check |pmid= value (help).
  26. ↑ Hendaus, Mohammed A. (2013). “Subdural Empyema in Children”. Global Journal of Health Science. 5 (6). doi:10.5539/gjhs.v5n6p54. ISSN 1916-9744.
  27. ↑ Bruner DI, Littlejohn L, Pritchard A (2012). “Subdural empyema presenting with seizure, confusion, and focal weakness”. West J Emerg Med. 13 (6): 509–11. doi:10.5811/westjem.2012.5.11727. PMC 3555596. PMID 23358438.
  28. ↑ Mandell, Gerald L.; Bennett, John E. (John Eugene); Dolin, Raphael. (2010). Mandell, Douglas, and Bennett’s principles and practice of infectious disease. Philadelphia, PA: Churchill Livingstone/Elsevier. ISBN 0-443-06839-9.
  29. ↑ Sharon V, Kimche D, Kende L (1973). “[Empyema of the obstructed urinary bladder]”. Harefuah. 84 (2): 75–7. PMID 4704614.
  30. ↑ Herwig KR (1975). “Empyema cystis treated by intermittent self-catherterization”. J Urol. 113 (5): 719. PMID 1168734.
  31. ↑ Spence HM, Allen TD (1971). “Vaginal vesicostomy for empyema of the defunctionalized bladder”. J Urol. 106 (6): 862–4. PMID 5116304.
  32. ↑ 32.0 32.1 Chaudhuri MR (1973). “Primary pulmonary cavitating carcinomas”. Thorax. 28 (3): 354–66. PMC 470041. PMID 4353362.
  33. ↑ Mouroux J, Padovani B, Elkaïm D, Richelme H (1996). “Should cavitated bronchopulmonary cancers be considered a separate entity?”. Ann. Thorac. Surg. 61 (2): 530–2. doi:10.1016/0003-4975(95)00973-6. PMID 8572761.
  34. ↑ Onn A, Choe DH, Herbst RS, Correa AM, Munden RF, Truong MT, Vaporciyan AA, Isobe T, Gilcrease MZ, Marom EM (2005). “Tumor cavitation in stage I non-small cell lung cancer: epidermal growth factor receptor expression and prediction of poor outcome”. Radiology. 237 (1): 342–7. doi:10.1148/radiol.2371041650. PMID 16183941.
  35. ↑ 35.0 35.1 Langford CA, Hoffman GS (1999). “Rare diseases.3: Wegener’s granulomatosis”. Thorax. 54 (7): 629–37. PMC 1745525. PMID 10377211.
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