The diagnosis of a parapneumonic effusion is usually suggested by typical findings on conventional posteroanterior and lateral chest radiographs. Lateral decubitus radiographic views are extremely valuable in the detection of subpulmonic effusions and can distinguish free from loculated pleural effusions. 11 Other radiographic findings suggestive of a pleural effusion or empyema include lower lung zone opacification, blunting of the costophrenic angle, and elevated hemidiaphragm with subpulmonic effusions. Extension of the air-fluid level to the chest wall, a tapering border of the air-fluid collection, thickened pleura, and the presence of edema in the extrapleural tissues suggest the presence of an empyema rather than a lung abscess. Virtually all patients with a parapneumonic effusion should undergo a diagnostic thoracentesis. Microbiologic analysis of the pleural fluid provides important information and helps determine whether drainage is necessary. Infected parapneumonic effusions typically have a pH less than 7.20, a lactate dehydrogenase level greater than 1000 IU/L, and a glucose level lower than 40 mg/dL. 17 Neutropenia, neutrophilia, hypoxia, azotemia, anemia, acidosis, thrombocytopenia, disseminated intravascular coagulopathy, or evidence of multiorgan failure are findings associated with severe infection.

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