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POINT: Does Spontaneous Bacterial Empyema Occur? YesDoes Spontaneous Bacterial Empyema Occur? Yes FREE TO VIEW

Yu Kuang Lai, MD; Glenn Eiger, MD, FCCP; Robert A. Fischer, MD
Author and Funding Information

From the Department of Internal Medicine (Drs Lai and Eiger), and the Department of Infectious Disease (Dr Fischer), Einstein Medical Center.

CORRESPONDENCE TO: Yu Kuang Lai, MD, Department of Internal Medicine, Einstein Medical Center, 5501 Old York Rd, Klein 363, Philadelphia, PA 19141; e-mail: laijulie@einstein.edu


FINANCIAL/NONFINANCIAL DISCLOSURES: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(5):1207-1208. doi:10.1378/chest.14-1764
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Empyema, or pus in the pleural cavity, is a well-known complication of bacterial pneumonia caused by direct invasion of bacteria into the pleural cavity. It was first described by Hippocrates around 500 bc and has been well recognized throughout medical history. However, since 1976, numerous reports have described an unusual form of pleural fluid infection in the absence of underlying pneumonia. This condition has been mainly seen in patients with decompensated cirrhosis. In view of the absence of a contiguous infection, and perhaps by analogy with spontaneous bacterial peritonitis (SBP), the term spontaneous bacterial empyema (SBEM) was coined for this disease. SBEM has not been studied as extensively as SBP, despite the fact that it may confer a high mortality rate. This discrepancy leads to these questions: Does SBEM exist? Since underlying liver disease is common to both SBP and SBEM, is SBEM simply a direct extension of underlying SBP? Is it a complication of bacterial pneumonia? Or is it an independent clinical condition?

The history of SBEM parallels the earlier discovery of SBP. SBP was first described in German and French literature between 1907 and 1958. However, Conn1 in 1964 was the first to coin the term SBP, when he described five cases of spontaneous peritonitis and bacteremia in patients with decompensated cirrhosis. All patients had typical features of sepsis, septic shock, or both, accompanied by ascites containing elevated numbers of polymorphonuclear leukocytes with or without the presence of bacteria. After administration of antibiotics, resolution of clinical symptoms and cytologic improvement in the ascitic fluid were observed. Subsequently, numerous cases of SBP were described, and it has become a well-recognized entity. Similarly, but only many years later, SBEM was first described by Flaum2 in 1976, when he reported a patient with cirrhosis with preexisting right hepatic hydrothorax who developed right-sided empyema, in the setting of sterile ascites and absence of pneumonia. A respectable number of reports of SBEM have since emerged, including 11 cases of SBEM by Xiol et al,3 demonstrating clinical and cytologic improvement in pleural fluid after administration of antibiotics in patients with cirrhosis presenting with sepsis, despite the absence of pneumonia, SBP, or both.

Pleural effusions are observed in 4% to 10% of patients with cirrhosis in the absence of cardiopulmonary disease4; this condition is termed hepatic hydrothorax. The pleural fluid is transudative, with low cell counts and low protein concentration. Hepatic hydrothorax results when formation of ascitic fluid exceeds absorption by peritoneal lymphatics, with fluid migration from the peritoneal cavity through diaphragmatic defects into the pleural cavity.3,4 In theory, infection of this pleural fluid could result from extension of SBP, as demonstrated by Baylor et al.5 However, other mechanisms for infection of hepatic hydrothorax are suggested by numerous case reports in which SBP or even ascites was absent.3,6-8 In fact, up to 40% of SBEM cases occur in patients without SBP.8 Therefore, an alternative pathogenesis—hematogenous seeding of pleural fluid—has been hypothesized. Low complement and protein levels and resultant reduced opsonic activity have been found in pleural fluid, which predispose to the development of empyema,9 just as the same features in ascites predispose to the development of peritonitis. Thus, spontaneous infection of pleural fluid is a plausible mechanism. In conclusion, there is a compelling theoretical rationale, supported by clinical evidence, that SBEM, although occurring by a similar mechanism to SBP, is a different entity.

There are notable differences between SBEM and empyema derived from parapneumonic effusion. First and most obviously, parapneumonic empyemas usually occur with an underlying pneumonia but without prior hydrothorax, whereas SBEM occurs in the opposite situation. Second, the continuum of exudative, fibrinopurulent, and organizing phases are not observed in SBEM as they are in parapneumonic empyema. Third, most cases of SBEM do not have the typical grossly purulent fluid of a parapneumonic empyema; the fluid in SBEM is usually yellowish and transparent. Parapneumonic empyemas are always exudative, but almost 50% of SBEM fluids are transudative despite positive cultures.3 Hence, SBEM is arguably a misnomer. Some authors have used the term spontaneous bacterial pleuritis instead of SBEM.10,11 Nevertheless, the term SBEM is widely accepted and has been used in most reports. Fourth, treatment of empyema requires drainage, whereas treatment of SBEM consists of IV antibiotics and albumin; drainage is rarely required unless the fluid is grossly purulent. In fact, thoracostomy tubes should be avoided in SBEM, particularly in the patient with cirrhosis, as they may result in life-threatening fluid depletion, protein loss, and electrolyte imbalance. Given these distinctions, it is clear that SBEM is distinct from parapneumonic empyema. Perhaps the most convincing evidence that SBEM occurs independently of both cirrhosis and pneumonia are case reports of SBEM occurring in patients without cirrhosis, in whom an underlying pneumonia was ruled out.12,13

In conclusion, we believe that SBEM does exist and is not merely a variant of parapneumonic empyema or SBP. It is a serious complication in a patient with cirrhosis and portends a poor prognosis. Therefore, if a patient with cirrhosis with hepatic hydrothorax undergoes clinical deterioration without an obvious source, diagnostic thoracentesis should be performed.

Abbreviations

CXR

chest radiography

SBEM

spontaneous bacterial empyema

SBP

spontaneous bacterial peritonitis

Conn HO. Spontaneous peritonitis and bacteremia in Laennec’s cirrhosis caused by enteric organisms. A relatively common but rarely recognized syndrome. Ann Intern Med. 1964;60:568-580. [CrossRef] [PubMed]
 
Flaum MA. Spontaneous bacterial empyema in cirrhosis. Gastroenterology. 1976;70(3):416-417. [PubMed]
 
Xiol X, Castellote J, Baliellas C, et al. Spontaneous bacterial empyema in cirrhotic patients: analysis of eleven cases. Hepatology. 1990;11(3):365-370. [CrossRef] [PubMed]
 
Lazaridis KN, Frank JW, Krowka MJ, Kamath PS. Hepatic hydrothorax: pathogenesis, diagnosis, and management. Am J Med. 1999;107(3):262-267. [CrossRef] [PubMed]
 
Baylor PA, Bobba VV, Ginn PD, Gitlin N, Gitlin N. Recurrent spontaneous infected pleural effusion in a patient with alcoholic cirrhosis, hepatic hydrothorax, and ascites. West J Med. 1988;149(2):216-217. [PubMed]
 
Abba AA, Laajam MA, Zargar SA. Spontaneous neutrocytic hepatic hydrothorax without ascites. Respir Med. 1996;90(10):631-634. [CrossRef] [PubMed]
 
Lam ST, Johnson ML, Kwok RM, Bassett JT. Spontaneous bacterial empyema: not your average empyema. Am J Med. 2014;127(7):e9-e10. [CrossRef] [PubMed]
 
Xiol X, Castellví JM, Guardiola J, et al. Spontaneous bacterial empyema in cirrhotic patients: a prospective study. Hepatology. 1996;23(4):719-723. [CrossRef] [PubMed]
 
Sese E, Xiol X, Castellote J, Rodríguez-Fariñas E, Tremosa G. Low complement levels and opsonic activity in hepatic hydrothorax: its relationship with spontaneous bacterial empyema. J Clin Gastroenterol. 2003;36(1):75-77. [CrossRef] [PubMed]
 
Streifler J, Pitlik S, Dux S, Garty M, Rosenfeld JB. Spontaneous bacterial pleuritis in a patient with cirrhosis. Respiration. 1984;46(4):382-385. [CrossRef] [PubMed]
 
Chesta J, Ponichik J, Brahm J, et al. Spontaneous bacterial pleuritis in 3 patients with liver cirrhosis [in Spanish]. Rev Med Chil. 1991;119(3):295-298. [PubMed]
 
Nguyen H, Gupta S, Eiger G. Spontaneous bacterial empyema in a noncirrhotic patient: an unusual scenario. Am J Med Sci. 2011;342(6):521-523. [CrossRef] [PubMed]
 
Chen WC, Huang JW, Chen KY, Hsueh PR, Yang PC. Spontaneous bilateral bacterial empyema in a patient with nephrotic syndrome. J Infect. 2006;53(3):e131-e134. [CrossRef] [PubMed]
 

Figures

Tables

References

Conn HO. Spontaneous peritonitis and bacteremia in Laennec’s cirrhosis caused by enteric organisms. A relatively common but rarely recognized syndrome. Ann Intern Med. 1964;60:568-580. [CrossRef] [PubMed]
 
Flaum MA. Spontaneous bacterial empyema in cirrhosis. Gastroenterology. 1976;70(3):416-417. [PubMed]
 
Xiol X, Castellote J, Baliellas C, et al. Spontaneous bacterial empyema in cirrhotic patients: analysis of eleven cases. Hepatology. 1990;11(3):365-370. [CrossRef] [PubMed]
 
Lazaridis KN, Frank JW, Krowka MJ, Kamath PS. Hepatic hydrothorax: pathogenesis, diagnosis, and management. Am J Med. 1999;107(3):262-267. [CrossRef] [PubMed]
 
Baylor PA, Bobba VV, Ginn PD, Gitlin N, Gitlin N. Recurrent spontaneous infected pleural effusion in a patient with alcoholic cirrhosis, hepatic hydrothorax, and ascites. West J Med. 1988;149(2):216-217. [PubMed]
 
Abba AA, Laajam MA, Zargar SA. Spontaneous neutrocytic hepatic hydrothorax without ascites. Respir Med. 1996;90(10):631-634. [CrossRef] [PubMed]
 
Lam ST, Johnson ML, Kwok RM, Bassett JT. Spontaneous bacterial empyema: not your average empyema. Am J Med. 2014;127(7):e9-e10. [CrossRef] [PubMed]
 
Xiol X, Castellví JM, Guardiola J, et al. Spontaneous bacterial empyema in cirrhotic patients: a prospective study. Hepatology. 1996;23(4):719-723. [CrossRef] [PubMed]
 
Sese E, Xiol X, Castellote J, Rodríguez-Fariñas E, Tremosa G. Low complement levels and opsonic activity in hepatic hydrothorax: its relationship with spontaneous bacterial empyema. J Clin Gastroenterol. 2003;36(1):75-77. [CrossRef] [PubMed]
 
Streifler J, Pitlik S, Dux S, Garty M, Rosenfeld JB. Spontaneous bacterial pleuritis in a patient with cirrhosis. Respiration. 1984;46(4):382-385. [CrossRef] [PubMed]
 
Chesta J, Ponichik J, Brahm J, et al. Spontaneous bacterial pleuritis in 3 patients with liver cirrhosis [in Spanish]. Rev Med Chil. 1991;119(3):295-298. [PubMed]
 
Nguyen H, Gupta S, Eiger G. Spontaneous bacterial empyema in a noncirrhotic patient: an unusual scenario. Am J Med Sci. 2011;342(6):521-523. [CrossRef] [PubMed]
 
Chen WC, Huang JW, Chen KY, Hsueh PR, Yang PC. Spontaneous bilateral bacterial empyema in a patient with nephrotic syndrome. J Infect. 2006;53(3):e131-e134. [CrossRef] [PubMed]
 
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