Tuberculous empyema

This usually arises when a tuberculous cavity in the lung ruptures into the pleural space. The physical signs are those of a pleural effusion, but aspiration reveals thick white or yellow pus. If the pus is too thick to remove using a needle and syringe, use an intercostal drain. Send the pus to the laboratory for examination for TB and also for Gram stain and bacterial culture. If facilities are available, closed pleural biopsy is useful for histological diagnosis.

The main differential diagnosis is bacterial empyema, when the patient is usually more acutely ill and toxic. It may be possible to confirm bacterial empyema by Gram stain or culture of the aspirated pus.

A succussion splash is a splashing sound heard with the stethoscope while shaking the patient's chest. A succussion splash indicates a pyopneumothorax (pus and air in the pleural space). After CXR confirmation, insert a chest drain with underwater seal.

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