Empyema is a serious pleural condition characterized by the accumulation of pus in the pleural cavity, contributing to significant global morbidity and mortality. It has been recognized since ancient times, with records from over 5000 years ago in Egypt and detailed descriptions by Hippocrates around 2000 years ago. Commonly developing as a complication of bacterial pneumonia, its incidence is rising despite medical advances and antimicrobial availability, leading to prolonged hospital stays and increased morbidity.1 Contributing factors include delayed treatment initiation, improper antibiotic use, malnutrition, and low socioeconomic conditions. In India, around 65,000 cases of pleural effusion occur annually, with empyema accounting for 5–10% of these cases. India, bearing the highest global burden of tuberculosis (TB), sees TB as the primary cause of pleural effusions, unlike developed countries where malignant and parapneumonic effusions predominate.2 Tubercular empyema, a severe form of pleural TB, arises from untreated or poorly managed tuberculous pleuritis or rupture of a subpleural focus. It contributes to 7–10% of pleural effusions in TB-endemic areas and is more frequent in younger or immunocompromised individuals. Management involves prolonged anti-TB therapy and often surgical intervention like thoracostomy or decortication.3 The leading causative organisms differ geographically: Streptococcus pneumoniae dominates in developed nations, while Staphylococcus aureus is more common in developing regions. Empyema progresses through three stages—exudative (1–3 days) with sterile effusion, fibrinopurulent (4–14 days) with bacterial invasion and loculations, and organizational (>14 days) where fibrous tissue restricts lung expansion.4 Symptoms include fever, pleuritic chest pain, cough, dyspnea, weight loss, and, in children, abdominal pain and vomiting. Radiological tools such as chest X-rays, ultrasound, and CT scans are essential for diagnosis and management planning.5 The study assesses empyema management at a tertiary care center, focusing on clinical, radiological, and etiological aspects. Treatment combines antibiotics and pleural fluid drainage (e.g., intercostal tubes), with intrapleural fibrinolytic therapy for loculated cases6. In unresponsive situations, VATS is used; thoracotomy is reserved for advanced fibrosis. Early intervention enhances outcomes, though delayed diagnosis, drug resistance, and socioeconomic factors worsen prognosis. Mortality is 5–7%, but timely care improves survival.7

Study Design: This cross-sectional observational study was conducted over 1.5 years in the Department of Respiratory Medicine at Mahatma Gandhi Medical College & Hospital, Jaipur. It included patients diagnosed with lung empyema from both outpatient and inpatient settings. Participants presented with clinical features of pleuropulmonary infections—such as fever, cough, pleuritic chest pain, and possible hemoptysis—supported by relevant radiological findings. Inclusion Criteria: The study included patients aged 18 years and above who were diagnosed with lung empyema at the Department of Respiratory Medicine, Mahatma Gandhi Hospital, Jaipur. Eligibility required the presence of clinical features suggestive of pleuropulmonary infections, such as fever, cough, pleuritic chest pain, with or without hemoptysis, supported by appropriate radiological evidence. Exclusion Criteria: Patients who declined to provide written informed consent were excluded from the study. Data collection was conducted using a predesigned proforma and managed in Microsoft Excel spreadsheets. Relevant statistical analyses were applied to interpret the data effectively and ensure accurate study findings. Procedure: Approval was obtained from the Institutional Ethical Committee prior to commencing the study. Patients diagnosed with lung empyema exhibiting features of pleuropulmonary infections were included. Written informed consent was obtained from all selected patients. A detailed history was taken, followed by a thorough physical examination in accordance with the inclusion and exclusion criteria. Necessary laboratory investigations were carried out to establish a final diagnosis, and the results were recorded accordingly.

Table No- 1 Distribution of patients according to Chief Complaints. Chief Complaints No. of Patients Percentage Cough Present 99 99 Absent 1 1 Haemoptysis Present 15 15 Absent 85 85 Fever Present 94 94 Absent 6 6 Dyspnea Present 99 99 Absent 1 1 LoW Present 99 99 Absent 1 1 LoA Present 99 99 Absent 1 1 Chest Pain Present 96 96 Absent 4 4 The majority of patients were aged 46–60 years (35%), with a mean age of 53.87 ± 18.05 years. Most were skilled workers (53%), and 55% resided in urban areas. Common symptoms included cough, dyspnea, weight/appetite loss (all 99%), chest pain (96%), fever (94%), and haemoptysis (15%). Other age groups ranged from 11–26% of the sample, with housewives, government employees, and students making up the remaining occupations. Table No- 2 Distribution of patients according to GPE. GPE No. of Patients Percentage Pallor Present 85 85 Absent 15 15 Icterus Present 44 44 Absent 56 56 Cyanosis Present 2 2 Absent 98 98 Clubbing Present 14 14 Absent 86 86 Lymphadenopathy Present 5 5 Absent 95 95 Pedal Edema Present 15 15 Absent 85 85 On General Physical Examination, pallor was seen in 85% of patients, icterus in 44%, clubbing in 14%, pedal edema in 15%, lymphadenopathy in 5%, and cyanosis in 2%. A history of alcohol use was reported by 72% of patients, while 27% had a history of smoking. Table No- 3 Distribution of patients according to Final Diagnosis. Final Diagnosis No. of Patients Percentage Bacterial Empyema 29 29 Empyema of undetermined etiology 39 39 Tubercular Empyema 32 32 Total 100 100 The table presents the distribution of patients based on the final diagnosis. Out of the total cases, 29 patients (29%) were diagnosed with bacterial empyema, 39 patients (39%) had Empyema of undetermined etiology, and 32 patients (32%) were diagnosed with tubercular empyema. Table No- 4 Distribution of patients according to Empyema. Pyogenic (Bacterial) Infections Bacterial Empyema Empyema of undetermined etiology Tubercular Empyema Total P-Value No. of Patients Percentage No. of Patients Percentage No. of Patients Percentage No. of Patients Pyogenic C/S E. coli 1 3.57 0 0 0 0.00 1 0.35 Klebsiella Pneumoniae 2 7.14 0 0 1 33.33 3 Pseudomonas Aeruginosa 11 39.29 0 0 2 66.67 13 Staphylococcus Aureus 2 7.14 0 0 0 0.00 2 Steptococcus Pneumoniae 12 42.86 0 0 0 0.00 12 In pyogenic empyema, Streptococcus pneumoniae was most common (42.86%), followed by Pseudomonas aeruginosa (39.29%), Klebsiella pneumoniae and Staphylococcus aureus (7.14% each), and E. coli (3.57%). No organisms were isolated in empyema of unknown etiology. In tubercular empyema, Pseudomonas aeruginosa was found in 66.67% and Klebsiella pneumoniae in 33.33% of culture-positive cases. The overall distribution of organisms across the three groups was statistically significant (P = 0.35), highlighting varied microbial patterns among different empyema types. Table No- 5 Distribution of patients according to Empyema Pyogenic (Bacterial) Infections Bacterial Empyema Empyema of undetermined etiology Tubercular Empyema Total P-Value No. of Patients Percentage No. of Patients Percentage No. of Patients Percentage No. of Patients AFB Positive 0 0 0 0 27 96.43 28 <0.0001 Negative 29 40.28 39 54.17 5 6.94 72 CBNAAT Positive 0 0 0 0.00 30 93.75 32 <0.0001 Negative 29 42.65 39 57.35 2 2.94 68 AFB staining was positive in 96.43% of tubercular empyema cases, while all bacterial and undetermined empyema cases were AFB negative. CBNAAT showed similar results, with 93.75% positivity in tubercular empyema and no positivity in the other groups. These findings indicate a strong association between test results and empyema type, with statistically significant differences across groups (p < 0.0001), supporting the diagnostic value of AFB and CBNAAT in tubercular empyema. Chest X-ray findings among 100 patients showed consolidation was most common in tubercular empyema (53.33%). Fibrosis (80%) and cavitary lesions (77.27%) were also more prevalent in tubercular cases. Cavitary lesions showed a statistically significant association with tubercular empyema (p < 0.0001). Other findings—collapse, fibrosis, consolidation, and calcified lesions—did not differ significantly among groups. Mass lesions were rare, with only one case seen in the tubercular group.

Empyema is an infectious pleural disease characterized by pus accumulation, commonly secondary to pneumonia, though other causes include trauma, malignancy, and immunosuppression. Symptoms include fever, chest pain, cough, and dyspnea. Diagnosis involves pleural fluid analysis; treatment includes antibiotics and drainage. This study assesses clinico-radiological and etiological profiles.8 In the present study cough was the most common symptom in 99% of patients, with dyspnea, weight loss, and loss of appetite also reported by 99%. Chest pain affected 96%, fever 94%, and haemoptysis was noted in 15% of cases. The high prevalence of cough, dyspnea, weight loss, and loss of appetite (99%) reflects the typical clinical presentation of empyema, driven by underlying infection and systemic inflammation. Chest pain (96%) and fever (94%) are common due to pleural irritation and ongoing infection, while haemoptysis (15%) may indicate associated lung pathology or advanced disease. Similarly, Meena P et al9 reported that fever was the most frequently observed symptom, present in 94% of the cases, closely followed by respiratory distress (87%) and cough (85%). Chest pain was seen in 37% of the patients, whereas abdominal pain and vomiting were considerably less common, reported in only 10% and 7% of the cohort, respectively. In a similar observation, Shekhar H et al10 noted that breathlessness (77.1%) and cough (60.4%) were predominant clinical features, especially among those with mixed infections and tubercular empyema. Fever occurred in 62.5% and chest pain in 70.8%, with constitutional symptoms such as fatigue and malaise noted in 43.8%—primarily in tuberculous cases. Hemoptysis was found in just 6.3% of patients. The table outlines the final diagnostic distribution among the study participants, revealing that 29% were identified with bacterial empyema, while 32% were diagnosed with tubercular empyema. However 39%had empyema of undetermined etiology, highlighting the diagnostic challenges in a subset of cases.In a similar study, Shekhar H et al10 emphasized the importance of imaging, reporting that contrast-enhanced CT was utilized in 83.3% of cases to better delineate empyema characteristics and related complications. Likewise, Sharma G et al11 noted that tubercular empyema was confirmed in half of the cases via AFB staining or CBNAAT detection of MTB. Chest X-ray findings showed consolidation (53.33%), fibrosis (80%), and cavitary lesions (77.27%) were most common in tubercular empyema, with cavitary lesions significantly associated (p < 0.0001); other abnormalities showed no significant group differences, and mass lesions were rare. Similarly, Sony A K et al12 reported lung collapse in 35 patients and consolidation in 19, with fibrosis affecting 17 patients and mediastinal lymphadenopathy in 9. They also observed cavity formation and lung abscesses each in 5 patients, while mediastinal shift, pneumatocele, and loculations were found in 22, 15, and 21 cases respectively. Likewise, Banga A et al13 reported ultrasonographic grading of empyema with Grade 2 seen in 52% of patients, Grade 3 in 44%, and Grade 4 in 4%. Likewise, their CECT chest findings revealed lung collapse as the most frequent abnormality (35%), followed by consolidation (19%), fibrosis (17%), along with mediastinal lymphadenopathy and cavitary lesions

This study reveals that empyema primarily affects middle-aged to elderly males, particularly skilled workers and urban residents. Common symptoms included cough, dyspnea, weight loss, and anorexia. Many patients had a history of tuberculosis or comorbidities like COPD and diabetes, with alcohol use more frequent than smoking. Tubercular empyema was the most common cause, followed by bacterial infections, though many cases remained undiagnosed. Diagnostic clarity relied heavily on radiological and microbiological tools such as AFB smear and CBNAAT. The findings stress the need for comprehensive evaluation for effective empyema management in tertiary care.

1. Singh M, Singh SK, Chowdhary SK. Management of Empyema thoracis in children. Indian Pediatr. 2002;39:145-57. 2. Lee YG. Ongoing search for effective intrapleural therapy for empyema: is streptokinase the answer? Am J Respir Crit Care Med. 2004;170:1-9. 3. Park K. Text book of preventive and social medicine. Epidemiology of Tuberculosis. 18th edition 2005, Bansarilal publications Park. Text book of preventive and social medicine. Epidemiology of Tuberculosis. 18th edition, Bansarilal publications, 2005. 4. Ozcelik C, Inci I, Nizam O, Onat S. Intrapleural fibrinolytic treatment of multiloculated postpneumonic pediatric empyemas. Ann Thoracic Surg. 2003;76(6);1849-53. 5. Chen J, Chou M, Wang L, Luh S, Tsai T. Video-assisted thoracoscopic surgery in the treatment of complicated parapneumonic effusions or empyemas. Chest. 2015;127:1427e1432. 6. Maziah W, Choo KE, Ray JG, Ariffin WW. Empyema thoracis in hospitalized children in Kelantan, Malaysia. J Trop Pediat. 1995;41(3):185-8. 7. Mowlem A, Cross FS. Surgical complications of staphylococcal pneumonia in infancy and childhood. Dis Chest. 1966;50(2):133-41. 8. Jaffé A, Cohen G. Thoracic empyema. Archives of disease in childhood. 2003;88(10):839-41. 9. Meena P, Jain PK, Sharma A, Sharma BS. A study on clinical profile and etiological agents of empyema in hospitalised children in Jaipur. Int J ContempPediatr 2019;6:2433-7. 10. Shekhar H, Sharma N, Singh SK, Garg PK, Bhatt S, Saha R, Verma AK. Clinico-radiological profile of the patients with empyema thoracis: A prospective analytical study, Indian Journal of Tuberculosis, 2021;03:007. 11. Sharma G, Garg D, Garg V. Clinico-Radiological, Etiologicaland Microbiological Profile Of Empyema Thoracis: A Cross-Sectional Study. International Journal Of Scientific Research 2023; 12(11):3-4. 12. Sony AK. A study of Clinico-radiological and etiological profile of pleural effusion patients diagnosed at tertiary care hospital. Journal of Cardiovascular Disease Research 2024; 15(09). 13. Banga A, Khilnani GC, Sharma SK, Dey AB, Wig N, Banga N. A study of empyema thoracis and role of intrapleural streptokinase in its management. BMC Infect Dis. 2004;4:1e8