Empyema Necessitans (EN) on Chest Wall Physical Examination Pulmonary teaching case: you are called to the bedside of a 60yo man who was admitted for pneumonia a week ago. You were called because “he coughed and now his chest is PULSATING!” This is what you see at the site of a previously removed chest drain - What’s the diagnosis? This is Empyema necessitans (EN): EN is a rare complication of an infected pleural effusion where purulent fluid “escapes” the pleura and erodes into the chest wall, causing an extrapleural fluid collection that communicates with the pleural space. Because Empyema necessitans communicates with the pleural space, fluid can move back & forth with respiration, as seen here. With inspiration, negative intra-thoracic pressure pulls the fluid into the chest. With expiration, positive intra-thoracic pressure pushes fluid out. Empyema necessitans (EN) is rare but it may be more commonly seen with certain invasive organisms: - Mycobacteria: TB (most common) - Fungus: Actinomyces, Blastomyces, Aspergillus, Mucormycosis - Bacteria: Staph, Strep, Nocardia, Fusobacterium Treatment of empyema necessitans includes: - antimicrobials (make sure you are covering the right bug!) - drainage of the pleural effusion (decompression & source control) - in some cases surgery is required Nick Mark MD @nickmmark #Empyema #Necessitans #EN #Chest #PhysicalExam #clinical #video #pulmonary #respiratory
