The characteristics and significance of thoracic lymphadenopathy in parapneumonic effusion and empyema

Internal thoracic lymphadenopathy and pulmonary tuberculosis

OBJECTIVE

Internal thoracic lymphadenopathy (ITL) has been associated with malignancies and non-tuberculous empyema. However, the association between ITL and active pulmonary tuberculosis (PTB) and the correlation between ITL and other imaging characteristics of active PTB has not been examined.

MATERIALS AND METHODS

A retrospective cohort study comprising 137 adults with active PTB who had a concomitant chest CT over a seven-year period was conducted. Two thoracic radiologists evaluated for ITL as well as nine other imaging characteristics of active tuberculosis, including total lung involvement (as measured by a total severity score), number of nodules, presence of tree-in-bud nodularity, highest extent of tree-in-bud nodularity in a lobe, miliary pattern, cavitary lesions, pleural effusion, lymphadenopathy (excluding internal thoracic lymph nodes), and empyema. The Wilcoxon rank-sum test and chi-squared tests were used to assess the correlation between ITL and additional imaging findings.

RESULTS

Internal thoracic lymphadenopathy was present in 50 of 137 cases (36.5%); most commonly bilateral (19.0%) or isolated on the right side (13.7%), and less commonly isolated on the left side (3.7%). Pleural effusion, lymphadenopathy (apart from internal thoracic compartment), and empyema all showed statistically significant correlations with ITL (p-values of <0.0001).

CONCLUSIONS

While the presence of ITL - particularly when accompanied by other imaging findings such as pleural effusion - may prompt a radiologist to first consider malignancy, active PTB should be an additional consideration in the appropriate clinical context.

Role of interventional pulmonology in the management of complicated parapneumonic pleural effusions and empyema

Pleural infection is a major problem that affects 80,000 cases per year in the UK and USA. It is increasing in incidence, and in an ageing population, it presents a complex challenge that requires a combination of medical therapies and may lead to the need for surgery. This article focuses on the role of the interventional pulmonologist in the diagnosis and management of pleural infection. In particular, we examine the role of pleural ultrasound in diagnostics, thoracocentesis and real-time guided procedures, and the current management strategies, including the controversial role of medical thoracoscopy.

Pneumonia in the immunocompetent patient

Pneumonia is an acute inflammation of the lower respiratory tract. Lower respiratory tract infection is a major cause of mortality worldwide. Pneumonia is most common at the extremes of life. Predisposing factors in children include an under-developed immune system together with other factors, such as malnutrition and over-crowding. In adults, tobacco smoking is the single most important preventable risk factor. The commonest infecting organisms in children are respiratory viruses and Streptoccocus pneumoniae. In adults, pneumonia can be broadly classified, on the basis of chest radiographic appearance, into lobar pneumonia, bronchopneumonia and pneumonia producing an interstitial pattern. Lobar pneumonia is most commonly associated with community acquired pneumonia, bronchopneumonia with hospital acquired infection and an interstitial pattern with the so called atypical pneumonias, which can be caused by viruses or organisms such as Mycoplasma pneumoniae. Most cases of pneumonia can be managed with chest radiographs as the only form of imaging, but CT can detect pneumonia not visible on the chest radiograph and may be of value, particularly in the hospital setting. Complications of pneumonia include pleural effusion, empyema and lung abscess. The chest radiograph may initially indicate an effusion but ultrasound is more sensitive, allows characterisation in some cases and can guide catheter placement for drainage. CT can also be used to characterise and estimate the extent of pleural disease. Most lung abscesses respond to medical therapy, with surgery and image guided catheter drainage serving as options for those cases who do not respond.

Imaging of Pleural Disease

Imaging plays an important role in the diagnosis and subsequent management of patients with pleural disease. The presence of a pleural abnormality is usually suggested following a routine chest x-ray, with a number of imaging modalities available for further characterization. This article describes the radiographic and cross-sectional appearances of pleural diseases, which are commonly encountered in every day practice. The conditions covered include benign and malignant pleural thickening, pleural effusions, empyema and pneumothoraces. The relative merits of CT, MRI and PET in the assessment of these conditions and the role of image-guided intervention are discussed.