Some of the characteristics on CT scan are thickening of the pleura (present in approximately 80% to 100% patients), pleural enhancement, split pleural sign, bubbles in the absence of tube drainage, and septations. CT scan can also be diagnostic and therapeutic, thoracentesis and tube thoracotomy can be performed under this modality. CT scan ideallyВ is done with intravenous (IV) contrast to enhance the pleura. It may be an alternative option after a chestВ -ray or ultrasound. Some empyema characteristics found with ultrasound are homogenous echogenicity, anechoic effusion with hyperechoic septation, pleural thickening and split pleural, separation of the parietal, and visceral pleural by the fluid.Д¬T scan of the chest must be done in patients with empyema. Ultrasound can be useful in guiding a chest tube placement during thoracentesis. Ultrasound is increasingly common because of its benefits, namely because it is widely available, it can be done at a patient's bedside, it is more sensitive at identifying pleural effusions than an x-ray, it allows differentiation between parenchyma and pleural fluid, and it also has a therapeutic use. If anВ effusion is suspected with the chest x-ray, the next step is an ultrasound. On anВ x-ray, some of the characteristics of a pleural effusion are bluntedВ due to costodiaphragmatic angles and lungs filled with radiolucent fluid (depending on the size of the effusion). A certain amount of fluid needs to be present to be detected, usually 75 ml in a lateral view, and approximately 175 ml in an anterior view. It is a widely available and simple test, but it is not 100% sensitive. To evaluate for the presence ofВ any pleural effusion, the first test that should be ordered is a chest x-ray. Patients with a scoreВ ofВ more than 5 had poor outcomes.Дue to the lack of specificity in a clinical presentation, more testsВ are needed to establish a diagnosis. The parameters included in the system are kidney function ( Renal), age, presence or albescence of pus, hospital-acquired versus community-acquired infection, and albumin levels ( diet). Patients not improving with appropriateВ antibiotic therapy should be checked for the possibility of empyema.ДЄ scoring system has been developed to assess mortality in 3 months upon presentation of patients with empyema. However, symptoms and physical exam findings are unspecific. On physical exam there may be a dullness to percussion on the affected area, egophonia, increase palpable fremitus, and fine crackles. Research has shown that patients presented after a median of 15 days after the onset of symptoms. Patients with empyema may have symptoms for a more extended period. The presentation may be similar to pneumonia, and cough, sputum production, fever, and pleuritic-type chest pain may be present. Due to this discrepancy, it is always important to cover for anaerobe organisms despite negative cultures.ДЇungal empyema is rare and is associated with high mortality, the most common fungus associated with it is Candida species. The incidence of anaerobes when DNA amplification is implemented can be as high as 70%, when regular technics are used, the incidence can drop to 20%. aureusВ (MRSA)) and Pseudomonas are more common. In hospital-acquired empyema, Staphylococcus aureus, (methicillin-resistant S. In this setting, the presence ofВ gram-negative bacteria has been associated with increased comorbidities of patients with alcohol abuse, gastroesophageal reflux disease (GERD), and diabetes. For community-acquired empyema, gram-positive bacteria are more common, especially S treptococcus species. Also, comorbidities of the patients need to be taken into consideration. Дepending on if the infection is community-acquired or hospital-acquired, the bacteriology of empyema may change.

Seventy percent of patients with empyema have parapneumonic effusion, the other 30% of cases are related to trauma, post-thoracic surgery, esophageal ruptures, or cervical infections, and a small number are not related to previous pneumonia or intervention, this is known as primary empyema. Around 20% of patients with pneumonia will develop a parapneumonic effusion that may lead to empyema.

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