Pleural effusion with fever, suspected empyema
Recommended: CT Chest with IV contrast is the preferred imaging study for pleural effusion with fever, suspected empyema. Look for enhancing pleura (split pleura sign), loculations, gas.
Recommended study
CT Chest with IV contrast
Look for enhancing pleura (split pleura sign), loculations, gas. Thoracentesis confirms.
If the default doesn't apply
Bedside drainage planning
US
Pleural Ultrasound (loculation mapping)
No contrast
Watch-outs
Free-flowing vs loculated
Free-flowing exudate can be drained simply; loculated empyema usually needs intrapleural fibrinolytics (tPA / DNase) or surgical decortication.
Pleural fluid pH < 7.2 or glucose < 40
Drainage indication regardless of imaging — call thoracic surgery if persistent.
Pearls
- Light's criteria distinguish exudate from transudate on thoracentesis.
- Air-fluid level within the pleural space + bronchopleural fistula is a serious complication.
- Tuberculous empyema is uncommon but consider in endemic areas / immigrants / immunocompromised.