Lung Abscess
1
Background
:Definition
Necrosis of the pulmonary tissue & formation of
cavities containing necrotic debris or fluid
.caused by microbial infection
The formation of multiple small (< 2 cm)
abscesses is occasionally referred to as
.necrotizing pneumonia or lung gangrene
2
Failure to recognize & treat lung abscess is associated
.with poor clinical out-come
Lung abscess was a devastating disease in the pre-
antibiotic era, when 1/3 of the patients died, another
1/3 recovered, & the remainder developed
debilitating illnesses [recurrent abscesses, chronic
.empyema, bronchiectasis]
3
In the early post-antibiotic period, sulfonamides didn’t
improve the outcome of patients with lung abscess
.until the penicillin's & tetracycline's were available
Although resectional surgery was often considered as
a treatment option in the past, the role of surgery
has greatly diminished over time coz most patients
with uncomplicated lung abscess eventually respond
.to prolonged antibiotic therapy
4
Lung abscesses can be classified based on the duration
.& etiology
Acute abscesses are less than 4-6 weks old, whereas
.chronic abscesses are of longer duration
Primary abscess is infectious in origin, caused by
.aspiration or pneumonia in the healthy host
5
:Secondary Abscess is caused by
.Preexisting condition (obstruction) -
.Spread from an extra-pulmonary site -
.Bronchiectasis -
.An immunocompromised state -
Lung abscesses can be further characterized by the
responsible pathogen, such as Staphylococcus lung
.abscess & anaerobic or Aspergillus lung abscess
6
Pathophysiology
Lung abscess arises as a complication of aspiration
.pneumonia caused by mouth anaerobes
A bacterial inoculums from the gingival crevice reach
the lower airways, & infection is initiated coz the
bacteria aren’t cleared by the patient’s host defense
.mechanism
7
Abscesses generally develop in the right lung and
involve the posterior segment of the right upper
lobe, the superior segment of the lower lobe, or
both. This is due to gravitation of the infectious
material from the oropharynx into these dependent
.areas
8
Initially, the aspirated material settles in the distal
bronchial system and develops into a localized
pneumonitis. Within 24-48 hours, a large area of
inflammation results, consisting of exudate, blood,
and necrotic lung tissue. The abscess frequently
.connects with bronchus and partially empties
9
Other mechanisms for lung abscess formation
: include
:Septic emboli to the lung ,caused by
.Bacteremia )1
.Tricuspid valve endocarditis )2
10
Microbiology
Anaerobes are recovered in up to 89% of the patients,
46% of patients with lung abscess have only a
mixture of anaerobes, while 43% of patients have
.a mixture of anaerobes & aerobes
The most common anaerobes are Peptosretococcus,
Bacteroids, Fusobacterium species &
.Microaerophilic streptococcus
11
Other organisms that may infrequently cause
lung abscess include Staphylococcus aureus,
Streptococcus pyogens, Streptococcus
pneumoniae (rarely), Klebsiella pneumoniae,
Hemophilus influenza, Actinomyces species,
.Nocardia species & Gm negative bacilli
12
. Non-bacterial pathogens may also cause lung abscesses
:Theses micro-organisms include
.Parasites [Paragonimus , Entamoeba] )1
Fungi [Aspergillus , Cryptococcus , )2
. Histoplasma , Blastomyces , Coccidioides]
.Mycobacterium )3
13
History
:Anaerobic infection
Patients often present with indolent symptoms that )1
.evolve over a period of weeks to months
The usual symptoms are fever , cough with sputum )2
.production , night sweats , anorexia & weight loss
The expectorated sputum characteristically is foul )3
.smelling & bad tasting
.Patients may develop hemoptysis or pleurisy )4
14
:Other bacterial pathogens
These patients generally present with conditions )1
that are more emergent in nature & are usually
.treated while they have bacterial pneumonia
Cavitation occurs subsequently as parenchymal )2
.necrosis ensues
Abscesses from fungi, Nocardia & Mycobacteria )3
tend to have an indolent course & gradually
.progressive symptoms
15
Physical
Patients may have low-grade fever in anaerobic
.infections & temperature > 38.5 C in other infections
.Generally, evidence of gingival disease is present
Clinical findings of consolidation may be present:
[decreased breath sounds, dullness to percussion,
.bronchial breath sounds, course inspiratory crackles]
16
Evidence of pleural friction rub signs of associated
pleural effusion, empyema & pyopneumothorax may
: be present. Signs include
dullness to percussion, contralateral mediastinal shifting[
.]& absent breath sounds over the effusion
.Digital clubbing may develop rapidly
17
Digital clubbing
18
Causes
The bacterial infection may reach the lungs in
several ways. That most common is
.aspiration of oropharyngeal contents
19
Factors contributing to lung abscess
Oral cavity disease
Periodontal disease
Gingivitis
Altered consciousness[ inability to protect their airways
coz of an absent of the cough reflex]
Alcoholism
Coma
Drug abuse
Anesthesia
Seizures
20
Immunocompromised host
Steroid chemotherapy
Malnutrition
Multiple trauma
Esophageal disease
Achalasia
Reflux disease
Depressed cough and gag reflex
Esophageal obstruction
21
Bronchial obstruction
Tumor
Foreign body
Stricture
Generalized sepsis
22
Patients with 1ry lung disorders
.Septic emboli from tricuspid endocarditis
.Vasculitic disorders
.Cavitating lung malignancies
.Pulmonary cystic diseases
23
The following infectious etiologies of pneumonia
infrequently progress to parenchymal necrosis & lung
:abscess formation
.Pseudomonas aerugenosa -
.Klebsiella pneumoniae -
.Staph. aureus (may result in multiple abscesses) -
.Strept. Pneumonia -
.Nocardia species -
.Fungal species -
24
An abscess may occur 2ry to bronchial
carcinoma, the bronchial obstruction causes
post-obstructive pneumonia which may lead
.to abscess formation
25
Differential Diagnosis
Alcoholism )1 Pneumocystis Carnii )7
Pleuropulmonary )2 .pneumonia
. Empyema .Aspiration pneumonia )8
.Hydatid Cysts )3 .Bacterial pneumonia )9
.Lung Cancer )4 .Fungal pneumonia )10
.Mycobacterium )5 .Pulmonary embolism )11
Pneumococcal )6 .Sarcoidosis )12
. infections .T.B )13
26
Lab Studies
CBC (complete blood count) -
.Sputum for gram stain, culture & sensitivity -
If T.B. is suspected, acid fast bacilli stain & -
. mycobacterial culture is requested
Blood culture may be helpful in establishing the -
. etiology
Obtain sputum for ova & parasite whenever a -
. parasitic cause for lung abscess is suspected
27
Histopathology
A thick-walled lung abscess
28
Histology of lung abscess shows dense inflammatory
reaction (low power)
29
Histology of lung abscess shows dense inflammatory
reaction (high power)
30
Imaging Studies
:CXR
.Irregularly sharp cavity with an air-fluid level inside -
Lung abscess as a result of aspiration most frequently -
occur in the posterior segments of the upper lobes or
.the superior segments of the lower lobe
31
The wall thickness of a lung abscess -
progresses from thick to thin and from ill-
defined to well-circumscribed as the
.surrounding lung infection resolves
The cavity wall can be smooth or ragged but is -
less commonly nodular, which raises the
.possibility of cavitating carcinoma
32
The abscess may extend to the pleural surface, in -
which case it forms acute angles with the pleural
.surface
Up to one third of lung abscesses may be - -
.accompanied by an empyema
33
Pneumococcal pneumonia
complicated by lung necrosis &
abscess formation
34
A lateral CXR shows air fluid level
(characteristic of lung abscess)
35
A 54 yr old pt. developed cough with foul-
smelling sputum production. A CXR
.shows lung abscess in the left lower lobes
36
A 42 y.o. man developed fever & production of foul-
smelling sputum. He had a H/O heavy alcohol use &
poor dentition, CXR shows lung abscess in the post
.segment of the Rt. up. lobe
37
CXR of a patient who had foul-smelling & bad
tasting sputum, an almost diagnostic feature of
anaerobic lung abscess
38
:CT scan -
Better in lung anatomy visualization to identify -
.empyema from lung infarction
An abscess is rounded radio-lucent lesion with a think -
.wall & ill-defined irregular margins
39
A 42 yr old man developed fever & production of foul-
smelling sputum. He had a H/O heavy alcohol abuse & poor
dentition, CXR shows lung abscess in the post. Segment of
the Rt. Up. Lobe. CT scan shows a thin-walled cavity with
.surrounding consolidation
40
Procedures
Trans-tracheal aspirate or trans-thoracic needle -
aspiration may provide microbiologic diagnosis,
obtaining pleural fluid and blood cultures in patients
.with lung abscess is easier
Flexible fiber-optic bronchoscopy is performed to -
exclude bronchogenic carcinoma whenever bronchial
.obstruction is suspected
41
Medical Care
:Antibiotic therapy
Anaerobic lung infection = Clindamycin [shown to be -
superior over parenteral penicillin coz several anaerobes
may produce B-lactamase & therefore develop penicillin
.resistance]
Although metronidazole is an effective drug against -
.anaerobic bacteria, a failure rate of 50% has been reported
42
In hospitalized patients who have aspirated and -
developed a lung abscess, antibiotic therapy should
include coverage against S aureus and Enterobacter
.and Pseudomonas species
Cefoxitin is a second-generation cephalosporin that -
has gram-positive, gram-negative, and anaerobic
coverage. This agent may be used when a
polymicrobial infection is suspected as cause of
.lung abscess
43
:Duration of therapy
Most clinicians prescribe antibiotic therapy generally -
.for 4-6 weeks
Current recommendations are that antibiotic -
treatment should be continued until the chest
radiograph has shown either the resolution of lung
.abscess or the presence of a small stable lesion
44
:Response to therapy
Patients show clinical improvement, with -
improvement of fever, within 3-4 days after
.initiating the antibiotic therapy
Patients with poor response to antibiotic therapy -
include bronchial obstruction with a foreign body or
neoplasm or infection with a resistant bacteria,
.Mycobacteria, or fungi
45
Surgical Care
Surgery is very rarely required for patients with
uncomplicated lung abscesses. The usual
indications for surgery are failure to respond to
medical management, suspected neoplasm, or
congenital lung malformation. The surgical
procedure performed is either lobectomy or
.pneumonectomy
46
Complications
.Rupture into pleural space causing empyema )1
.Pleural fibrosis )2
.Respiratory failure )3
.Bronchopleural fistula )4
.Pleural cutaneous fistula)5
In a patient with coexisting empyema and lung abscess,
draining the empyema while continuing prolonged
.antibiotic therapy is often necessary
47
Prognosis
The prognosis for lung abscess following
antibiotic treatment is generally favorable.
Over 90% of lung abscesses are cured with
medical management alone, unless caused by
.bronchial obstruction secondary to carcinoma
48
.Gangrene of lungs
The gangrene of lung is necrosis of
pulmonary tissues under act of toxins and
violation of feed, which does not have clear
.borders
49
All above mentioned, what are regard to the
acute abscess of lung, belongs and to the
gangrene of lung with that only a difference,
that acute intoxication of organism of patient
comes on the first place. The disease is
accompanied constantly by a high
temperature, which does not lowering long
time, or has vibrations, in the morning and in
the evening. A painful cough with especially
.foul sputum is characteristic
50
Treatment of patients with the
.gangrene of lung
Treatment at the gangrene of lungs is exact
the same, as well as at the acute abscess of
lung with that only a difference, that it must be
.more intensive
In the case of unsuccessful of conservative
therapy patients with the gangrene of lungs
.are subject to operative treatment
51
