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Key Features

Essentials of Diagnosis

  • High fever, malaise, and weight loss in the setting of pneumonia

  • Chest radiographs and CT scans usually reveal lung cavities, often with air-fluid levels

General Considerations

  • Characterized by thick-walled cavities that form from inflammation and central necrosis following an initial pulmonary infection

  • Occurs in a previously well child or one prone to aspiration; may be caused by

    • Staphylococcus aureus and other staphylococci

    • Streptococcus pneumoniae and streptococci

  • May be seen in children with immunosuppression or underlying lung or systemic disease; may be caused by

    • Anaerobic and gram-negative organisms

    • Nocardia

    • Mycobacteria

    • Legionella species

    • Fungi (Candida and Aspergillus)

  • May also occur via embolic spread

Clinical Findings

Symptoms and Signs

  • High fever

  • Malaise

  • Weight loss

  • In infants, evidence of respiratory distress can be present

Differential Diagnosis

  • Loculated pyopneumothorax

  • Neoplasms

  • Plasma cell granuloma

  • Infected congenital cysts and sequestrations

  • Pneumatoceles, non–fluid-filled cysts, are common in children with empyema and usually resolve over time


Laboratory Findings

  • Elevated peripheral white blood cell count with a neutrophil predominance

  • Elevated erythrocyte sedimentation rate or C-reactive protein

  • Blood cultures are rarely positive except in the immunocompromised patient

  • Sputum stains and cultures may confirm the diagnosis


  • Chest radiographs usually reveal single or multiple thick-walled lung cavities. Air-fluid levels can be present. Local compressive atelectasis, pleural thickening, or adenopathy may also occur.

  • Chest CT scan may provide better localization and understanding of the lesions.

Diagnostic Procedure

  • Direct percutaneous aspiration of material for stains and cultures guided by fluoroscopy or ultrasonography or CT imaging should be considered in the severely compromised or ill


  • Broad-spectrum intravenous antibiotics for uncomplicated abscesses in immunocompetent patients

  • Additional coverage for anaerobic gram-negative organisms and fungi should be provided for others

  • Prolonged therapy with 2–3 weeks of intravenous antibiotics followed by oral therapy may be required

  • Attempts to drain abscesses via bronchoscopy have caused life-threatening airway compromise

  • Surgical drainage or lobectomy is occasionally required, primarily in immunocompromised patients



  • Rare

  • However, mediastinal shift, tension pneumothorax, and spontaneous rupture can occur

  • Diagnostic maneuvers such as radiology-guided lung puncture to drain and culture the abscess may also cause a pneumothorax or a bronchopulmonary fistula.


  • Radiographic resolution may be very slow (6 weeks–5 years); otherwise recovery occurs in most patients without long-term sequelae

  • In the immunocompromised or medically complex patient, outlook depends on the underlying disorder


Chan  PC  et al: Clinical ...

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