OR The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: publications@acr.org Workup of Pleural Effusion or Pleural Disease Discussion of Procedures by Variant Variant 1: Recent pneumonia with suspected parapneumonic effusion or empyema. Initial imaging. CT Chest With IV Contrast Current American Association for Thoracic Surgery consensus guidelines recommend CT chest with intravenous (IV) contrast in cases of suspected parapneumonic effusion (class IIa) [13]. A recent meta-analysis reported 5 chest CT findings most commonly associated with the diagnosis of empyema: pleural enhancement (sensitivity 84%, 95% confidence interval [CI], 62%-94%; specificity 83%, 95% CI, 75%-89%), pleural thickening (sensitivity 68%, 95% CI, 56%-77%; specificity 87%, 95% CI, 80%-92%), loculation (sensitivity 52%, 95% CI, 44%-59%; specificity 89%; 95% CI, 82%-94%), extrapleural fat proliferation (sensitivity 53%, 95% CI, 47%-60%; specificity 91%, 95% CI, 82%-96%), and increased attenuation of the extrapleural fat (sensitivity 39%, 95% CI, 32%-48%; specificity 97%, 95% CI, 94%-98%) [14]. Of note, these pooled sensitivities and specificities include CT chest with IV contrast or CT chest without IV contrast. Pleural enhancement has the highest area under curve for the diagnosis of empyema (0.86) and for distinguishing between simple parapneumonic effusion and empyema (0.83) [14].
Workup of Pleural Effusion or Pleural Disease. OR The American College of Radiology seeks and encourages collaboration with other organizations on the development of the ACR Appropriateness Criteria through representation of such organizations on expert panels. Participation on the expert panel does not necessarily imply endorsement of the final document by individual contributors or their respective organization. Reprint requests to: publications@acr.org Workup of Pleural Effusion or Pleural Disease Discussion of Procedures by Variant Variant 1: Recent pneumonia with suspected parapneumonic effusion or empyema. Initial imaging. CT Chest With IV Contrast Current American Association for Thoracic Surgery consensus guidelines recommend CT chest with intravenous (IV) contrast in cases of suspected parapneumonic effusion (class IIa) [13]. A recent meta-analysis reported 5 chest CT findings most commonly associated with the diagnosis of empyema: pleural enhancement (sensitivity 84%, 95% confidence interval [CI], 62%-94%; specificity 83%, 95% CI, 75%-89%), pleural thickening (sensitivity 68%, 95% CI, 56%-77%; specificity 87%, 95% CI, 80%-92%), loculation (sensitivity 52%, 95% CI, 44%-59%; specificity 89%; 95% CI, 82%-94%), extrapleural fat proliferation (sensitivity 53%, 95% CI, 47%-60%; specificity 91%, 95% CI, 82%-96%), and increased attenuation of the extrapleural fat (sensitivity 39%, 95% CI, 32%-48%; specificity 97%, 95% CI, 94%-98%) [14]. Of note, these pooled sensitivities and specificities include CT chest with IV contrast or CT chest without IV contrast. Pleural enhancement has the highest area under curve for the diagnosis of empyema (0.86) and for distinguishing between simple parapneumonic effusion and empyema (0.83) [14].