Murinello Antonio, Figeiredo A Manuel, Semedo Júlio, Damásio Helena, Carrilho Ribeiro N, Peres Helena
Hospital Curry Cabral - Internal Medicine.
Rev Port Pneumol. 2009 May-Jun;15(3):507-19.
Complicated parapneumonic effusion is one in which an invasive procedure is necessary for its resolution and empyema means pus in the pleural space. An early diagnosis and therapy of these conditions results in less morbidity and mortality. CT of the chest is important to study complex pleural effusions. Loculated effusions, those occupying more than 50% of the thorax, or which show positive Gram stain or bacterial culture, or a purulent effusion with a pH below 7.20, with a glucose level below 60 mg/dl or a LDH level more than three times the upper limit of normal for serum, are indications for an invasive procedure. These characteristics result from the evolution of a not well treated parapneumonic effusion, through the three stages: (1) exsudative; (2) fibrinopurulent; (3) fibrotic. Depending on the stage therapeutic methods vary from therapeutic thoracentesis, insertion of a chest tube with or without instillation of fibrinolytics, video-assisted thoracoscopic surgery, and lung decortication. A review of all these aspects are done based on a series of three cases reports with very different clinical presentation: one patient with empyema by Streptococcus pyogenes and that died rapidly due to massive hemoptysis; a patient with empyema due to acute pneumonia developing during an airflight; a patient with empyema and bacteraemia by Streptococcus pneumonia leading to the diagnosis of an unknown HIV infection.
复杂性类肺炎性胸腔积液是指需要通过侵入性操作才能使其消退的积液，而脓胸是指胸膜腔内有脓液。对这些病症进行早期诊断和治疗可降低发病率和死亡率。胸部CT对于研究复杂性胸腔积液很重要。局限性胸腔积液、占据胸腔超过50%的积液、革兰氏染色或细菌培养呈阳性的积液、pH值低于7.20、葡萄糖水平低于60mg/dl或乳酸脱氢酶水平超过血清正常上限三倍的脓性积液，均为进行侵入性操作的指征。这些特征是未经妥善治疗的类肺炎性胸腔积液经过三个阶段演变的结果：（1）渗出性；（2）纤维脓性；（3）纤维化。根据所处阶段不同，治疗方法从治疗性胸腔穿刺术、插入胸管（有无注入纤维蛋白溶解剂）、电视辅助胸腔镜手术到肺剥脱术不等。基于三例临床表现差异很大的病例报告，对所有这些方面进行了综述：一例因化脓性链球菌导致脓胸并因大量咯血迅速死亡的患者；一例在飞行过程中因急性肺炎发展为脓胸的患者；一例因肺炎链球菌导致脓胸和菌血症并进而诊断出未知HIV感染的患者。
