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Year : 1999  |  Volume : 9  |  Issue : 3  |  Page : 152-153
Pyogenic empyema necessitatis with bronchopleural fistula

Department of Radiodiagnosis and Imaging, Command Hospital, Pune, India

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How to cite this article:
Singh H, Rastogi V, Khanna S K, Satija L. Pyogenic empyema necessitatis with bronchopleural fistula. Indian J Radiol Imaging 1999;9:152-3

How to cite this URL:
Singh H, Rastogi V, Khanna S K, Satija L. Pyogenic empyema necessitatis with bronchopleural fistula. Indian J Radiol Imaging [serial online] 1999 [cited 2020 May 25];9:152-3. Available from:

Empyema necessitatis is a collection of inflammatory tissue that usually extends directly from the pleural cavity into the thoracic wall forming a mass in the extrapleural soft tissues [1]. It is an extrapleural transthoracic extension of an inflammatory process.

A twenty-five years old man presented with a 15 days history of pain in the left shoulder (scapular region) and subsequent development of swelling over the left anterior chest wall of five days duration. Physical examination revealed wasting of the left chest wall musculature with a diffuse tender swelling over the superior part. Chest radiograph revealed a homogeneous oval opacity abutting the left chest wall in the upper zone suggesting a pleural origin. The patient developed a productive cough with purulent foul-smelling sputum. A chest radiograph on day three showed the presence of an air-fluid level in the opacity forming an abscess. On day four, the radiograph [Figure - 1] revealed marked increase in the size of the abscess cavity with extension into the chest wall. A large amount of air was seen within the abscess extending into the chest wall suggesting communication with the bronchial tree. A diagnosis of empyema necessitatis with bronchopleural fistula was made.

CT of the chest on day eight demonstrated flattening of the left anterior chest wall with a hypotrophic pectoralis major muscle. There was consolidation of the left upper lobe with reduction in volume. It revealed a loculated empyema in the left upper zone with a large component of air communicating medially with the apico posterior segmental bronchi and laterally with the anterolateral chest wall deep to the muscle planes [Figure - 2]. Needle aspiration and sputum culture showed growth of Staphylococcus aureus. The aspirate proved negative for mycobacteria and HIV. Response to antibiotics was dramatic.

We have described a rare case of pyogenic empyema with simultaneous development of bronchopleural fistula and empyema necessitatis. The empyema developing into a bronchopulmonary fistula is not an uncommon complication [2].

Empyema necessitatis is an uncommon complication of pleural empyema.  Mycobacterium tuberculosis Scientific Name Search  the most frequent cause and is responsible for 73% cases of empyema necessitatis [3]. The cause may be pyogenic/fungal infection, malignancy or lymphoma [1], [4]. The empyema may also extend into the paravertebral soft tissues, vertebral column and rarely the esophagus and the pericardium [1],[3]. CT is helpful in detecting this uncommon complication and may demonstrate the communication between the pleura and chest wall [2].

   References Top

1.Bhatt GM, Austin MH. CT Demonstration of empyema necessitatis. J Comput Assit Tomogr 1985; 9:1108-1109.   Back to cited text no. 1    
2.Reed CE. Pneumonectomy for chronic infection: fraught with danger? Ann Thoracic Surgery 1995; 59: 408-411.   Back to cited text no. 2  [PUBMED]  [FULLTEXT]
3.Gibbens DT, Argy N. Chest case of the day: tuberculosis empyema necessitatis. AJR 1991; 156: 1295-1296.   Back to cited text no. 3  [PUBMED]  
4.Nishaiyama N, Kinoshita, Kobayashi Y, et al (Japan) 1996; 34: 579-585.   Back to cited text no. 4    

Correspondence Address:
Hariqbal Singh
Department of Radiodiagnosis and Imaging, Command Hospital, Pune
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Source of Support: None, Conflict of Interest: None

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[Figure - 1], [Figure - 2]

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