Empyema necessitans is a rare complication of pleural empyema characterized by the dissection of pus through the soft tissues of the chest wall and eventually through the skin. The skin manifestation may appear as a superficial abscess.
A 63-year-old woman presented to the Emergency Department (ED) with a chief complaint of dyspnea, dry cough, and a cutaneous nodule on her right chest wall. Three weeks prior to her ED visit, she underwent an exploratory thoracotomy and chest tube placement. The chest tube was removed 2 weeks later. Her physical examination was significant for decreased breath sounds over her right lung fields and a painful, fluctuant, and erythematous nodule on the right chest wall where the chest tube had previously been inserted. Externally, the dermal findings appeared to be a superficial abscess. A chest X-ray study showed a large pleural effusion in her right hemithorax. Point-of-care ultrasound (POCUS) performed by an emergency physician showed evidence of a tract extending from the nodule toward the pleural space that led to the correct diagnosis and treatment of empyema necessitans.
Why Should an Emergency Physician Be Aware of This?
It is important to distinguish between a superficial abscess, which requires local drainage, and empyema necessitans, which requires either chest tube drainage, open drainage, or even decortication in specific cases. In such cases, POCUS can facilitate a rapid, accurate diagnosis, and lead to the correct treatment.
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Published online: October 13, 2020
Accepted: September 3, 2020
Received in revised form: August 2, 2020
Received: June 9, 2020
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