Physical examination findings can vary as well.
- Auscultation reveals crackles, decreased breath sounds, and, possibly, a pleural rub, if the process is recognized before a large amount of fluid accumulates.
- Dullness to percussion and decreased breath sounds are likely but difficult to elicit in the younger child, who, because of discomfort, may be less cooperative with the examination.
- Physical findings and presentation may vary depending on the organism and the duration of the illness.
- Increased pleural permeability associated with pneumonia or lung abscesses, as well as contiguous infections of the esophagus, mediastinum, or subdiaphragmatic region, may extend to involve the pleura.
- Similarly, retropharyngeal, retroperitoneal, or paravertebral processes may extend to adjacent structures and involve the pleura, as well.
- Host factors that contribute to alterations in pleural permeability, such as noninfectious inflammatory diseases, infection, trauma, or malignancy, may allow accumulation of fluid in the pleural space, which becomes secondarily infected.
- The bacteriology of the pleural space varies with patient age. In the pediatric population, the most common implicated organisms are S pneumoniae, S aureus, and group A streptococci. H influenzae is rarely observed since the advent of the H influenzae B vaccine.
- Because of the use of oral antibiotics before the recognition of the parapneumonic effusion, most specimens cultured are sterile; thus, the relative incidences of the aforementioned organisms are not known.
- Anaerobic infections secondary to aspiration and fungal or mycobacterial infections in immunosuppressed patients are also reported.
- Finally, Mycoplasma pneumoniae, viruses, and atypical pneumonias can also present with exudative pleural effusions, although mononuclear cells primarily characterize them.
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