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• W2111569344 abstract "Timely diagnosis of pleural space infections and rapid initiation of effective pleural drainage for those patients with complicated parapneumonic effusions or empyema represent keystone principles for managing patients with pneumonia. Advances in chest imaging provide opportunities to detect parapneumonic effusions with high sensitivity in patients hospitalized for pneumonia and to guide interventional therapy. Standard radiographs retain their primary role for screening patients with pneumonia for the presence of an effusion to determine the need for thoracentesis. Ultrasonography and CT scanning, however, have greater sensitivity for fluid detection and provide additional information for determining the extent and nature of pleural infection. MRI and PET scan can image pleural disease, but their role in managing parapneumonic effusions is not yet clearly defined. Effective application of chest images for patients at risk for pleural infection, however, requires a comprehensive understanding of the unique features of each modality and relative value. This review presents the diagnostic usefulness and clinical application of chest imaging studies for evaluating and managing pleural space infections in patients hospitalized for pneumonia. Timely diagnosis of pleural space infections and rapid initiation of effective pleural drainage for those patients with complicated parapneumonic effusions or empyema represent keystone principles for managing patients with pneumonia. Advances in chest imaging provide opportunities to detect parapneumonic effusions with high sensitivity in patients hospitalized for pneumonia and to guide interventional therapy. Standard radiographs retain their primary role for screening patients with pneumonia for the presence of an effusion to determine the need for thoracentesis. Ultrasonography and CT scanning, however, have greater sensitivity for fluid detection and provide additional information for determining the extent and nature of pleural infection. MRI and PET scan can image pleural disease, but their role in managing parapneumonic effusions is not yet clearly defined. Effective application of chest images for patients at risk for pleural infection, however, requires a comprehensive understanding of the unique features of each modality and relative value. This review presents the diagnostic usefulness and clinical application of chest imaging studies for evaluating and managing pleural space infections in patients hospitalized for pneumonia. 2-[18F]-fluoro-2-deoxy-glucose positron emission tomography pyothorax-associated lymphoma video-assisted thoracoscopic surgery Because of the considerable morbidity and mortality of empyema, all patients hospitalized with pneumonia should undergo a careful evaluation to identify the presence of a parapneumonic effusion and determine whether pleural fluid needs to be drained.1Colice GL Curtis A Deslauriers J et al.Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline.Chest. 2000; 118: 1158-1171Abstract Full Text Full Text PDF PubMed Scopus (518) Google Scholar Thoracic imaging represents an important component of this evaluation.1Colice GL Curtis A Deslauriers J et al.Medical and surgical treatment of parapneumonic effusions: an evidence-based guideline.Chest. 2000; 118: 1158-1171Abstract Full Text Full Text PDF PubMed Scopus (518) Google Scholar, 2Davies CW Gleeson FV Davies RJ Pleural Diseases Group Standards of Care Committee British Thoracic Society BTS guidelines for the management of pleural infection.Thorax. 2003; 58: ii18-ii28Crossref PubMed Scopus (282) Google Scholar Recent advances in imaging techniques have revolutionized the management of pleural infections by improving the detection of infected fluid and guiding and monitoring therapeutic interventions. The present review compares the diagnostic usefulness of imaging modalities and how they can contribute to management decisions for patients with pneumonia complicated by parapneumonic effusions.Normal Pleural MembranesIn health, imaging studies cannot visualize the pleural space against the diaphragm and chest wall3Im JG Webb WR Rosen A Gamsu G Costal pleura: appearances at high-resolution CT.Radiology. 1989; 171: 125-131Crossref PubMed Scopus (79) Google Scholar because pleural membranes are only 0.2 to 0.4 mm thick and physiologic volumes (4 to 18 mL)4Noppen M De Waele M Li R et al.Volume and cellular content of normal pleural fluid in humans examined by pleural lavage.Am J Respir Crit Care Med. 2000; 162: 1023-1026Crossref PubMed Scopus (121) Google Scholar of pleural fluid form a thin 5- to 10- μ m layer.5Henschke CI Davis SD Romano PM Yankelevitz DF Pleural effusions: pathogenesis, radiologic evaluation, and therapy.J Thorac Imaging. 1989; 4: 49-60Crossref PubMed Scopus (24) Google Scholar The invaginations of visceral pleura composing the interlobar and accessory fissures appear as linear or curvilinear lines. Interlobar loculated fluid may simulate parenchymal or intrapleural neoplasms (pseudotumors) (Fig 1). The peripheral pleural surfaces adjacent to the chest wall include the costal pleurae that compose the majority of the pleural surface in contact with the ribs, the mediastinal pleurae, and the diaphragmatic pleurae situated medially and inferiorly, respectively. What may appear to represent costal pleural membranes on CT images is actually a combination of visceral and parietal pleurae, physiologic pleural fluid, fascia, and the innermost intercostal muscles (Fig 1C).Standard RadiographsStandard chest radiographs survey the entire pleural space, underlying lung, mediastinum, chest wall, and spine for potential causes and complications of the pleural process. The presence of a lung cavity situated medial to pleural fluid collections, for instance, identifies a lung abscess (Fig 2).Figure 2Frontal chest radiograph that demonstrates an air-fluid level within rounded density (arrow) that suggested a lung abscess in a patient with multiloculated empyema involving the right apex and paramediastinal pleurae. Contrast-enhanced CT scan (B) through the lower thorax showed fluid collections in the major fissure (F) and posteriorly with a cavitary abscess in the right lower lobe (arrow). The hilum is poorly defined on the frontal radiograph because of a paramediastinal fluid collection confirmed by CT scan (CT image not shown).View Large Image Figure ViewerDownload Hi-res image Download (PPT)The radiographic appearance of infected pleural fluid collections depends on the volume and viscosity of pleural fluid, the patient's position, and presence of pleural loculations. Of special note are difficulties of detecting and assessing subpulmonic effusions (Fig 3),6Schwarz MI Marmorstein BL A new radiologic sign of subpulmonic effusion.Chest. 1975; 67: 176-178Crossref PubMed Scopus (14) Google Scholar nondependent loculations that simulate masses or airspace densities on frontal projections (Fig 4), loculated collections along mediastinal pleural reflections (Fig 5), and effusions on portable radiographs (Figure 5, Figure 6, Figure 7).Figure 3Frontal (A) and lateral (B) radiographs demonstrate a subpulmonic effusion with apparent elevation of the right diaphragm with a laterally displaced apex (arrow in A). In B, note the sloping interface (white arrows) between the effusion (*) and the middle lobe anterior to the major fissure (solid arrow). This appearance results from the oblique interface between the subpulmonic effusion and the middle lobe anterior to the major fissure, as the lung-fluid interface fails to create a sharp tangent to the lateral x-ray beam and therefore is not evident radiographically.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 4Frontal radiograph (A) of a patient with multilocular empyema demonstrating obscuration of the left hemidiaphragm by lung consolidation and pleural fluid and an ill-defined density in the medial, midlung field (arrow). The lateral view (B) demonstrates a nondependent loculated empyema (arrows) with the “d-sign.”View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 5Supine portable radiograph (A) in a patient with large posterior bilateral pleural effusions that demonstrates increased density over both lung fields. The CT scan (B) shows the large effusions layering posteriorly. Passive atelectasis of the left and right lung (arrows) is demonstrated in this contrast-enhanced study. The homogeneity of the atelectatic lung on all sections excludes lung necrosis or abscess There is no evidence of parietal pleural thickening or enhancement on this CT level.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 6Portable radiograph (A) of a large left pleural effusion in a patient with mediastinal lymphoma (note mediastinal widening and obscuration of aortic arch) that demonstrates crescentic fluid density (arrow) over the lung apex. A contrast-enhanced CT scan (B) shows the left pleural effusion with the enhancing atelectatic left lung sharply delineated from the effusion.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Figure 7Frontal radiograph of a patient with a pleural effusion that collects within an incomplete right major fissure, which creates a perihilar lucency outlined peripherally by a circumscribed concave opacity.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Chest UltrasonographyFor ultrasonographic chest examination, a narrow footprint linear or sector transducer is typically used. A high-frequency linear transducer (5-7.5 MHz) provides high-resolution intercostal scanning, but is limited in penetration for patients with thick chest walls and does not provide a large field of view for visualization of the pleural space and underlying lung.7Evans AL Gleeson FV Radiology in pleural disease: state of the art.Respirology. 2004; 9: 300-312Crossref PubMed Scopus (88) Google Scholar For most patients, a convex or sector transducer of intermediate frequency (3-4 MHz) provides the best compromise between near-field resolution of the lung-pleura interface, a wider evaluation of large effusions, and assessment of the parietal pleura and lung parenchyma.8Wernecke K Sonographic features of pleural disease.AJR Am J Roentgenol. 1997; 168: 1061-1066Crossref PubMed Scopus (20) Google Scholar, 9McLoud TC Flower CDR Imaging the pleura: sonography, CT, and MR imaging.AJR Am J Roentgenol. 1991; 156: 1145-1153Crossref PubMed Scopus (185) Google Scholar, 10Beckh S B ölcskei PL Lessnau KD Real-time chest ultrasonography: a comprehensive review for the pulmonologist.Chest. 2002; 122: 1759-1773Abstract Full Text Full Text PDF PubMed Scopus (142) Google ScholarNormal pleural membranes are too thin to be visualized even by high-resolution ultrasonography. The interface between the normal visceral pleura and underlying lung produces the “pleural stripe” which is a thin echogenic line projecting internal to the ribs (Fig 8). It moves craniocaudally with respiration on ultrasonograph.7Evans AL Gleeson FV Radiology in pleural disease: state of the art.Respirology. 2004; 9: 300-312Crossref PubMed Scopus (88) Google Scholar Another ultrasonography finding in normal patients is the comet-tail artifact, which is seen deep to the pleural stripe and results from subpleural interlobular septae in normally aerated lung at its interface with the pleural surface. In patients with underlying consolidation or atelectasis of the lung, particularly in the presence of pleural effusion, the visceral pleura is visible as an echogenic line thinner than the previously mentioned pleural interface. Focal pleural masses associated with an effusion are readily seen and biopsied with ultrasonography guidance.11Chang DB Yang PC Luh KT Kuo SH Yu CJ Ultrasound-guided pleural biopsy with Tru-Cut needle.Chest. 1991; 100: 1328-1333Abstract Full Text Full Text PDF PubMed Scopus (93) Google Scholar, 12Adams RF Gleeson FV Percutaneous image-guided cutting-needle biopsy of the pleura in the presence of a suspected malignant effusion.Radiology. 2001; 219: 510-514Crossref PubMed Scopus (80) Google Scholar Ultrasonography allows characterization of pleural fluid collections with septations and loculations being better appreciated than on CT scan, but pleural thickening and the extent of pleural disease throughout the thorax are more difficult to assess.Figure 8Sonogram of a normal patient shows a thin echogenic interface between the normal visceral pleura and underlying lung deep to the ribs that produces the normal pleural stripe (arrows).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Ultrasonography is more sensitive (5 mL fluid detectable) than decubitus radiography.13Tayal VS Nicks BA Norton HJ Emergency ultrasound evaluation of symptomatic nontraumatic pleural effusions.Am J Emerg Med. 2006; 24: 782-786Abstract Full Text Full Text PDF PubMed Scopus (22) Google Scholar, 14Mathis G Thoraxsonography — Part I: Chest wall and pleura.Ultrasound Med Biol. 1997; 23: 1131-1139Abstract Full Text PDF PubMed Scopus (107) Google Scholar, 15Kocijancic I Vidmar K Ivanovi-Herceg Z Chest sonography versus lateral decubitus radiography in the diagnosis of small pleural effusions.J Clin Ultrasound. 2003; 31: 69-74Crossref PubMed Scopus (73) Google Scholar, 16Feller-Kopman D Therapeutic thoracentesis: the role of ultrasound and pleural manometry.Curr Opin Pulm Med. 2007; 13: 312-318Crossref PubMed Scopus (56) Google Scholar, 17Vignon P Chastagner C Berkane V et al.Quantitative assessment of pleural effusion in critically ill patients by means of ultrasonography.Crit Care Med. 2005; 33: 1757-1763Crossref PubMed Scopus (165) Google Scholar, 18Balik M Plasil P Waldauf P et al.Ultrasound estimation of volume of pleural fluid in mechanically ventilated patients.Intensive Care Med. 2006; 32: 318-321Crossref PubMed Scopus (208) Google Scholar Pleural effusions typically appear as triangular anechoic collections immediately above the diaphragm (Fig 9) that change shape with respiration and outline the underlying echogenic, airless posterior costophrenic sulcus. Portable chest ultrasonograph examination is particularly useful to detect and quantify pleural fluid collections in supine critically ill patients.19Lichtenstein DA Menu Y A bedside ultrasound sign ruling out pneumothorax in the critically ill. Lung sliding.Chest. 1995; 108: 1345-1348Abstract Full Text Full Text PDF PubMed Scopus (565) Google ScholarFigure 9The frontal radiograph (A) suggests a right parapneumonic effusion, which is confirmed by sonographic evidence (B) of a characteristic triangular anechoic fluid collection immediately above the diaphragm. Eff = effusion; L = lung; Li = liver.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Chest ultrasonography can also suggest the nature of fluid collections. Four typical internal echogenicity patterns of pleural effusion on sonography have been described: (1) homogeneously anechoic (Fig 10A), (2) complex nonseptated with internal echogenic foci (Fig 10B), (3) complex septated (Fig 10C), and (4) homogeneously echogenic (Fig 10D).20Yang P-C Luh K-T Chang D-B et al.Value of sonography in determining the nature of pleural effusion: analysis of 320 cases.AJR Am J Roentgenol. 1992; 159: 29-33Crossref PubMed Scopus (365) Google Scholar Although transudative pleural effusions are typically anechoic, as many as 55% of proven transudative pleural effusions will have a complex nonseptated appearance.21Chen HJ Tu CY Ling SJ et al.Sonographic appearances in transudative pleural effusions: not always an anechoic pattern.Ultrasound Med Biol. 2008; 34: 362-369Abstract Full Text Full Text PDF PubMed Scopus (36) Google Scholar Conversely, although most complicated parapneumonic effusions and empyemas contain internal echoes or appear entirely echogenic, up to 27% of exudative effusions are anechoic.20Yang P-C Luh K-T Chang D-B et al.Value of sonography in determining the nature of pleural effusion: analysis of 320 cases.AJR Am J Roentgenol. 1992; 159: 29-33Crossref PubMed Scopus (365) Google ScholarFigure 10Sonographic appearance of parapneumonic effusions with the patterns of homogeneously anechoic (asterisk denotes fluid) (A), complex nonseptated with internal echogenic foci (B), complex septated (C), and homogeneously echogenic (D). Most complicated parapneumonic effusions and empyemas have internal echoes or appear entirely echogenic. “L” denotes lung and curved arrow identifies the diaphragm.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Uniformly echogenic collections typically contain blood or debris and almost invariably indicate the presence of an empyema in patients who appear clinically infected.22Tu CY Hsu WH Hsia TC et al.Pleural effusions in febrile medical ICU patients: chest ultrasound study.Chest. 2004; 126: 1274-1280Abstract Full Text Full Text PDF PubMed Scopus (74) Google Scholar Large, discrete, primary loculations of pleural fluid establish the presence of visceral to parietal pleural adhesions and suggest empyema in appropriate settings.23Lomas DJ Padley SG Flower CDR The sonographic appearances of pleural fluid.Br J Radiol. 1993; 66: 619-624Crossref PubMed Scopus (44) Google Scholar Evidence by ultrasonography of secondary loculations or septations within pleural fluid collections (honeycomb appearance) has no diagnostic value.CT ScanMultidetector CT scan allows acquisition of contiguous 1- to 3-mm sections through the chest during one breath hold and provides high-resolution imaging of the pleura with multiplanar coronal and sagittal reconstructions that assist the evaluation of complex pleural abnormalities adjacent to lung, mediastinal, and chest wall lesions (Fig 11).24Ravenel JG McAdams HP Multiplanar and three-dimensional imaging of the thorax.Radiol Clin North Am. 2003; 41: 475-489Abstract Full Text Full Text PDF PubMed Scopus (23) Google Scholar Intravenous contrast allows differentiation of pleural membranes from parenchymal processes for patients with empyema and associated pulmonary infections or neoplasms.7Evans AL Gleeson FV Radiology in pleural disease: state of the art.Respirology. 2004; 9: 300-312Crossref PubMed Scopus (88) Google Scholar Obtaining images 20 to 60 s after contrast infusion allows the best visualization of pulmonary vasculature and separation of lung from pleural abnormalities.7Evans AL Gleeson FV Radiology in pleural disease: state of the art.Respirology. 2004; 9: 300-312Crossref PubMed Scopus (88) Google ScholarFigure 11Pyopneumothorax due to bronchopleural fistula complicating lung abscess. (A) Upright chest radiograph shows a large right hydropneumothorax with small air-fluid level in consolidated right mid lung (arrow). (B) Contrast-enhanced CT shows a cavity with air-fluid level (white arrow) reflecting an abscess within the consolidated middle lobe. There is a large right hydropneumothorax with thickening and enhancement of the parietal pleura (black arrow). (C) Sagittal reformatted image through the middle lobe abscess shows a large bronchopleural fistula (white arrows) extending posterosuperiorly from the abscess cavity to the posterior hydropneumothorax. Purulent material was recovered at surgery.View Large Image Figure ViewerDownload Hi-res image Download (PPT)CT scan cannot visualize normal pleura against the chest wall because pleural membranes blend in with endothoracic fascia and intercostal muscles.3Im JG Webb WR Rosen A Gamsu G Costal pleura: appearances at high-resolution CT.Radiology. 1989; 171: 125-131Crossref PubMed Scopus (79) Google Scholar In the paravertebral regions, a thin line representing the pleural layers and pleural space may be visible because the innermost intercostal muscle is absent in this region. The interlobar and accessory fissures are visible in cross section as curvilinear opacities on thin-section axial, sagittal, and coronal reformatted images. Visualization of a thin layer of tissue along the internal margin of the inner cortices of the ribs is abnormal and indicates the presence of pleural thickening or effusion. An exception to this rule exists along the right and left parasternal portions of the costal pleural surfaces, where the transversus thoracis muscles are seen as symmetric thin soft-tissue densities, and along the lower posterior costal pleural surface, where the subcostalis muscles are variably seen as thin linear opacities internal to the lower posterior ribs. These densities are easily distinguished from pleural thickening (Fig 12).Figure 12A patient with two chest tubes in the right hemithorax that drain a parapneumonic effusion. There is asymmetric thickening of the right posterolateral chest wall and expansion of the extrapleural fat (black straight arrow) due to edema, findings commonly observed with empyemas. A small amount of pleural fluid remains posteriorly (curved arrow). The left hemithorax demonstrates the normal appearance of the inner cortices of the ribs wherein no tissue can be visualized adjacent to the lung (arrowhead). In contrast, the finding of even a thin layer of tissue along the inner rib cortices establishes pleural thickening or effusion (white arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Chest CT scan is more sensitive than chest radiography for detecting small pleural effusions.7Evans AL Gleeson FV Radiology in pleural disease: state of the art.Respirology. 2004; 9: 300-312Crossref PubMed Scopus (88) Google Scholar Because CT scan provides an unimpeded view of the entire pleural surface, the underlying lung parenchyma, and the adjacent mediastinum and chest wall, it is the ideal modality for determining the extent of pleural infection and the nature of fluid collections.The signs of pleural fluid on CT scan parallel those observed on conventional radiography. Small, free-flowing effusions appear as meniscoid collections of water attenuation along the posterior pleural surfaces. Small effusions form a sharp interface with the lower lobe. Large effusions cause passive atelectasis of adjacent lung and produce on non-contrasted studies an irregular interface with aerated lung. With contrast, the atelectatic lung undergoes enhancement and becomes sharply delineated from the effusion (Fig 6B). As effusions increase in volume, they extend farther cranially up the posterior pleural surface, eventually extending over the lung apex. They also extend along the lateral margins of the lung and into interlobar fissures. Large effusions produce extensive passive atelectasis of the lung and often produce contralateral shift of the heart and mediastinum.Loculated effusions appear as lenticular masses of fluid attenuation, most often situated in the dependent portions of the costal pleural space along the lower posterior pleural surface. Medially situated fluid collections adjacent to the mediastinum are easily delineated on CT scan. Loculated fluid collections within the major or minor fissures produce pseudotumors, which can simulate underlying lung cancer or abscess on standard radiographs (Fig 1C).5Henschke CI Davis SD Romano PM Yankelevitz DF Pleural effusions: pathogenesis, radiologic evaluation, and therapy.J Thorac Imaging. 1989; 4: 49-60Crossref PubMed Scopus (24) Google ScholarThe attenuation of pleural fluid collections provides some diagnostic information but does not allow definite distinction between infected and uninfected effusions. Most infected pleural fluid collections have attenuation similar to water (ie, 0 Hounsfield units), whereas collections with high protein content and bloody effusions may have attenuations of soft tissue (ie, 30-50 Hounsfield units) (Fig 13). The detection of air in the pleural space, in the absence of recent thoracentesis, chest tube placement, or surgical intervention, almost invariably indicates pleural infection, most often a necrotizing pneumonia or abscess with rupture into the pleural space. Spontaneous or posttraumatic rupture of the esophagus or central airways can likewise produce a hydropneumothorax. The detection of small air bubbles within a pleural collection is specific for an infected pleural fluid collection.Figure 13CT image of a patient with a subpleural lung abscess (upper short arrow) and an adjacent region (lower short arrow) of either loculated pleural fluid of high attenuation or pleural thickening. Additional high-attenuation pleural fluid or thickening is seen posteriorly (long arrow).View Large Image Figure ViewerDownload Hi-res image Download (PPT)Conditions that thicken the pleura render them visible on CT scan. Parietal pleural thickening almost always indicates the presence of a pleural exudate, although this finding is not specific for infection.25Aquino SL Webb WR Gushiken BJ Pleural exudates and transudates: diagnosis with contrast-enhanced CT.Radiology. 1994; 192: 803-808Crossref PubMed Scopus (113) Google Scholar Even without contrast, thickening of the parietal pleura in a patient with pleural infection is easily detected by CT scan. Pleural infection typically produces smooth, uniform pleural thickening almost always limited to the costal and diaphragmatic pleural surfaces. The detection of mediastinal pleural thickening or nodules along thickened parietal pleural surfaces on CT scan suggests pleural malignancy. Although thickening of the parietal pleura underlying the ribs is relatively specific for an exudative pleural effusion, patients with transudative effusions and preexisting underlying pleural fibrosis or pleural malignancy will also demonstrate this finding. In patients with infected pleural fluid collections, the identification of a thickened, enhancing rim of parietal and visceral pleura surrounding a loculated pleural fluid collection on contrast-enhanced CT scan (split pleura sign) (Fig 14) is reliable evidence of empyema.25Aquino SL Webb WR Gushiken BJ Pleural exudates and transudates: diagnosis with contrast-enhanced CT.Radiology. 1994; 192: 803-808Crossref PubMed Scopus (113) Google ScholarFigure 14A CT image of a patient with empyema demonstrating enhancing rims of parietal and visceral pleurae (short arrows) surrounding a loculated pleural fluid collection (split pleura sign). Note the hypertrophied extrapleural fat (long arrows) due to the chronic thickening and retraction of the pleural layers, which are commonly associated with empyemas.View Large Image Figure ViewerDownload Hi-res image Download (PPT)Increased attenuation of extrapleural fat and thickening of the fat layer ≥ 3 mm is seen in 60% of empyemas.25Aquino SL Webb WR Gushiken BJ Pleural exudates and transudates: diagnosis with contrast-enhanced CT.Radiology. 1994; 192: 803-808Crossref PubMed Scopus (113) Google Scholar, 26Takasugi JE Godwin JD Teefey SA The extrapleural fat in empyema: CT appearance.Br J Radiol. 1991; 64: 580-583Crossref PubMed Scopus (34) Google Scholar Patients with transudates have normal-appearing extrapleural tissue.26Takasugi JE Godwin JD Teefey SA The extrapleural fat in empyema: CT appearance.Br J Radiol. 1991; 64: 580-583Crossref PubMed Scopus (34) Google Scholar Although similar extrapleural changes are noted in 27% of patients with malignant pleural processes, the majority of such patients have a complicating pleural infection or a history of prior pleurodesis.27Waite RJ Carbonneau RJ Balikian JP Umali CB Pezzella AT Nash G Parietal pleural changes in empyema: appearances at CT.Radiology. 1990; 175: 145-150Crossref PubMed Scopus (134) Google ScholarCT scan evaluates the underlying lung, adjacent chest wall including ribs and spine, the diaphragm, and the subphrenic space. Pneumonia, lung abscess, or obstructing malignancy are readily evident on contrast-enhanc" @default.
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• W2111569344 modified "2023-10-13" @default.
• W2111569344 title "Diagnostic Utility and Clinical Application of Imaging for Pleural Space Infections" @default.
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