Last reviewed: 6 Jul 2021
Last updated: 07 May 2021

Summary

Definition

History and exam

Key diagnostic factors

  • recent pneumonia
  • constitutional symptoms
  • pyrexia and rigors
  • dullness to percussion
  • reduced breath sounds and reduced vocal resonance
  • signs of sepsis

Other diagnostic factors

  • subacute presentation
  • productive cough
  • pleuritic chest pain
  • dyspnea

Risk factors

  • pneumonia
  • iatrogenic interventions in the pleural space
  • thoracic trauma
  • immunocompromised state
  • comorbid lung disease
  • male sex
  • older or young age

Diagnostic investigations

1st investigations to order

  • blood cultures
  • CRP
  • WBC count
  • chest x-ray
  • thoracentesis: pleural fluid appearance
  • thoracentesis: pleural fluid odor
  • thoracentesis: pleural fluid pH
  • thoracentesis: pleural fluid total protein concentration
  • thoracentesis: pleural fluid LDH level
  • thoracentesis: pleural fluid glucose concentration
  • thoracentesis: pleural fluid white cell differential
  • thoracentesis: pleural fluid microscopy, culture, and sensitivity
  • thoracic ultrasound

Investigations to consider

  • contrast-enhanced thoracic CT
  • MRI of thorax
  • PET scan
  • pleural fluid polymerase chain reaction (PCR)

Treatment algorithm

Contributors

Authors

Athanasia D. Pataka, MRCP

Assistant Professor of Respiratory Medicine

Respiratory Failure Unit

G Papanikolaou Hospital Thessaloniki

Aristotle University of Thessaloniki

Thessaloniki

Greece

Disclosures

ADP declares that she has no competing interests.

Renata L. Riha, BMedSc, MD, FRACP, FRCPE

Respiratory Consultant

Royal Infirmary

Edinburgh

Scotland

UK

Disclosures

RLR declares that she has no competing interests.

Najib M. Rahman, DPhil MSc FRCP

Professor of Respiratory Medicine

Director, Oxford Respiratory Trials Unit

Nuffield Department of Medicine, University of Oxford

Oxford

UK

Disclosures

NMR declares that Roche UK supplied clinical trial supplies and funding for the MIST2 trial that he conducted.

Acknowledgements

Dr Athanasia D. Pataka, Dr Renata L. Riha, and Dr Najib M. Rahman would like to gratefully acknowledge Dr Eleanor K. Mishra, a previous contributor to this topic. EKM declares that she has no competing interests.

Peer reviewers

Steven Sahn, MD

Professor of Medicine and Director

Division of Pulmonary/Critical Care/Allergy/Sleep Medicine

Medical University of South Carolina

Charleston

SC

Disclosures

SS declares that he has no competing interests.

Nicholas Maskell, MD

Senior Lecturer and Consultant Physician

North Bristol Lung Centre

Southmead Hospital

Bristol

UK

Disclosures

NM declares that he has no competing interests.

Y.C. Gary Lee, MBChB, PhD, FCCP, FRACP

Consultant Chest Physician and Senior Lecturer

Oxford Centre for Respiratory Medicine and University of Oxford Churchill Hospital

Oxford

UK

Disclosures

YCGL declares that he has no competing interests.

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