LUNG ABSCESS.pdf

absecss

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Lung AbscessLung Abscess
Presented by Dr. Deena AbdePresented by Dr. Deena Abdell Hadi Hadi
Directed by Dr. Abdul-Rahman Abu RubbDirected by Dr. Abdul-Rahman Abu Rubb

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BackgroundBackground
:Definition:Definition
Necrosis Necrosis of the pulmonary tissue & of the pulmonary tissue & formation of formation of
cavitiescavities containing containingnecrotic debrisnecrotic debris or or fluid fluid
.caused by microbial infection.caused by microbial infection
The formation of multiple small )> 2 cm( The formation of multiple small )> 2 cm(
abscesses is occasionally referred to as abscesses is occasionally referred to as
necrotizing pneumonianecrotizing pneumonia or or.lung gangrene.lung gangrene

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Failure to recognize & treat lung abscess is associated Failure to recognize & treat lung abscess is associated
.with poor clinical out-come.with poor clinical out-come
Lung abscess was a devastating disease in the Lung abscess was a devastating disease in thepre-pre-
antibiotic eraantibiotic era , when 1/3 of the patients died, another , when 1/3 of the patients died, another
1/3 recovered, & the remainder developed 1/3 recovered, & the remainder developed
debilitating illnesses debilitating illnesses ]i.e. recurrent abscesses, ]i.e. recurrent abscesses,
.]chronic empyema, bronchiectasis.]chronic empyema, bronchiectasis

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In the early post-antibiotic period, In the early post-antibiotic period,sulfonamidessulfonamides didn‘t didn‘t
improve the out-come of patients with lung abscess improve the out-come of patients with lung abscess
until the until thepenicillin'spenicillin's & &tetracycline'stetracycline's. were available. were available
Although Althoughresectional surgeryresectional surgery was often considered a was often considered a
treatment option in the past, treatment option in the past, the role of surgery has the role of surgery has
greatly diminished over time coz most patients with greatly diminished over time coz most patients with
un-complicated lung abscess eventually respond to un-complicated lung abscess eventually respond to
.prolonged antibiotic therapy.prolonged antibiotic therapy

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Lung abscesses can be classified based on theLung abscesses can be classified based on the duration duration
& the likely & the likelyetiologyetiology..
Acute abscessesAcute abscesses are less than 4-6 wks oldare less than 4-6 wks old , whereas , whereas
chronic abscesseschronic abscesses .are of longer duration.are of longer duration
Primary abscessPrimary abscess is isinfectiousinfectious in origin, caused by in origin, caused by
aspiration or pneumoniaaspiration or pneumonia . in the healthy host . in the healthy host

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Secondary AbscessSecondary Abscess: is caused by: is caused by
.)Pre-existing condition )obstruction -.)Pre-existing condition )obstruction -
.Spread from an extra-pulmonary site -.Spread from an extra-pulmonary site -
.Bronchiectasis -.Bronchiectasis -
.An immuno-compromised state -.An immuno-compromised state -
Lung abscesses can be further characterized by the Lung abscesses can be further characterized by the
responsible pathogen, such as responsible pathogen, such asStaphylococcusStaphylococcus lung lung
abscessabscess & & anaerobic anaerobic or orAspergillusAspergillus . lung abscess . lung abscess

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PathophysiologyPathophysiology
Lung abscess arises as a Lung abscess arises as a complication of aspiration complication of aspiration
.pneumonia caused by mouth anaerobes .pneumonia caused by mouth anaerobes
A bacterial inoculums from theA bacterial inoculums from the gingival crevicegingival crevice
reaches the lower airwaysreaches the lower airways , & infection is initiated , & infection is initiated
coz the bacteria aren‘t cleared by the patient‘s host coz the bacteria aren‘t cleared by the patient‘s host
.defense mechanism .defense mechanism

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Abscesses generally develop in the Abscesses generally develop in theright lungright lung and and
involve the involve the posterior segment of the right upper posterior segment of the right upper
lobelobe , the , thesuperior segment of the lower lobesuperior segment of the lower lobe , or , or
both. This is both. This is due to gravitation of the infectious due to gravitation of the infectious
material from the oropharynx into these dependent material from the oropharynx into these dependent
.areas .areas

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Initially, the aspirated material settles in the distal Initially, the aspirated material settles in the distal
bronchial system and develops into a localized bronchial system and develops into a localized
pneumonitis. Within 24-48 hours, a large area of pneumonitis. Within 24-48 hours, a large area of
inflammation results, consisting of exudate, blood, inflammation results, consisting of exudate, blood,
and necrotic lung tissue. The abscess frequently and necrotic lung tissue. The abscess frequently
.connects with a bronchus and partially empties .connects with a bronchus and partially empties

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Other mechanisms for lung abscess formation Other mechanisms for lung abscess formation
: include: include
:Septic emboli to the lung ,caused by:Septic emboli to the lung ,caused by
)1 )1.Bacteremia.Bacteremia
)2 )2 .Tricuspid valve endocarditis .Tricuspid valve endocarditis

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MicrobiologyMicrobiology
Anaerobes are recovered in up to 89% of the patients, Anaerobes are recovered in up to 89% of the patients,
46%46% of patients with lung abscess had only a of patients with lung abscess had only a
mixture of mixture ofanaerobesanaerobes isolated from sputum isolated from sputum
cultures while cultures while43%43% of patients had a mixture of of patients had a mixture of
anaerobesanaerobes & &.aerobes.aerobes
The most common anaerobes are The most common anaerobes arePeptosretococcus,Peptosretococcus,
BacteroidsBacteroids , ,FusobacteriumFusobacterium species & species &
.Microaerophilic streptococcus.Microaerophilic streptococcus

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Other organisms that may infrequently cause Other organisms that may infrequently cause
lung abscess include lung abscess include Staphylococcus aureus, Staphylococcus aureus,
Streptococcus pyogens, Streptococcus Streptococcus pyogens, Streptococcus
pneumoniae pneumoniae)rarely(,)rarely(, Klebsiella pneumoniae, Klebsiella pneumoniae,
Hemophilus influenza, Actinomyces species, Hemophilus influenza, Actinomyces species,
.Nocardia species, & Gm negative bacilli.Nocardia species, & Gm negative bacilli

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. Non-bacterial pathogens may also cause lung abscesses. Non-bacterial pathogens may also cause lung abscesses
:Theses micro-organisms include:Theses micro-organisms include
)1)1 ParasitesParasites ] ]Paragonimus , EntamoebaParagonimus , Entamoeba.].]
)2)2 Fungi Fungi]] Aspergillus , Cryptococcus , Aspergillus , Cryptococcus ,
Histoplasma , Blastomyces , Coccidioides Histoplasma , Blastomyces , Coccidioides.].]
)3)3 .Mycobacterium.Mycobacterium

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HistoryHistory
:Anaerobic infection:Anaerobic infection
Patients often present with indolent symptoms that )1 Patients often present with indolent symptoms that )1
.evolve over a period of weeks to months.evolve over a period of weeks to months

The usual symptoms are )2 The usual symptoms are )2 fever fever , ,cough with sputumcough with sputum
productionproduction , ,night sweatsnight sweats , ,anorexiaanorexia & &weight lossweight loss..
The expectorated )3 The expectorated )3 sputum sputum characteristically is characteristically isfoulfoul
.smelling & bad tasting .smelling & bad tasting
Patients may develop )4 Patients may develop )4.hemoptysis or pleurisy.hemoptysis or pleurisy

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:Other bacterial pathogens:Other bacterial pathogens
These patients generally present with conditions )1 These patients generally present with conditions )1
that are more emergent in nature & are usually that are more emergent in nature & are usually
.treated while they have bacterial pneumonia.treated while they have bacterial pneumonia
)2 )2 Cavitation occurs subsequently as parenchymal Cavitation occurs subsequently as parenchymal
.necrosis ensues.necrosis ensues
Abscesses from fungi, )3 Abscesses from fungi, )3 Nocardia Nocardia & Mycobacteria & Mycobacteria
tend to have an indolent course & gradually tend to have an indolent course & gradually
.progressive symptoms.progressive symptoms

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PhysicalPhysical
Patients may have Patients may havelow-grade fever in anaerobiclow-grade fever in anaerobic
infectionsinfections & &.temperature < 38.5 C in other infections.temperature < 38.5 C in other infections
Generally, Generally,evidence of gingival disease is presentevidence of gingival disease is present..
Clinical findings of consolidation may be presentClinical findings of consolidation may be present : :
]decreased breath sounds, dullness to percussion, ]decreased breath sounds, dullness to percussion,
.]bronchial breath sounds, course inspiratory crackles .]bronchial breath sounds, course inspiratory crackles

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Evidence of pleural friction rub signs of associated Evidence of pleural friction rub signs of associated
pleural effusion, empyema & pyo-pneumothorax may pleural effusion, empyema & pyo-pneumothorax may
be present. Signs includebe present. Signs include: :
dullness to percussion, contralateral mediastinal shifting]dullness to percussion, contralateral mediastinal shifting]
.]& absent breath sounds over the effusion.]& absent breath sounds over the effusion
.Digital clubbing may develop rapidly .Digital clubbing may develop rapidly

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CausesCauses
The bacterial infection may reach the lungs in The bacterial infection may reach the lungs in
several ways .that most common is several ways .that most common is
.aspiration of oro-pharyngeal contents.aspiration of oro-pharyngeal contents

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Factors contributing to lung abscess Factors contributing to lung abscess
Oral cavity diseaseOral cavity disease
Periodontal disease Periodontal disease
GingivitisGingivitis
Altered consciousness] inability toAltered consciousness] inability to protect theirprotect their
]airways coz of an absent gag reflex]airways coz of an absent gag reflex
Alcoholism Alcoholism
Coma Coma
Drug abuse Drug abuse
Anesthesia Anesthesia
SeizuresSeizures

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Immunocompromised hostImmunocompromised host
Steroid chemotherapy Steroid chemotherapy
Malnutrition Malnutrition
Multiple traumaMultiple trauma
Esophageal disease Esophageal disease
Achalasia Achalasia
Reflux disease Reflux disease
Depressed cough and gag reflex Depressed cough and gag reflex
Esophageal obstructionEsophageal obstruction

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Bronchial obstruction Bronchial obstruction
Tumor Tumor
Foreign body Foreign body
StrictureStricture
Generalized sepsisGeneralized sepsis

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patients with 1ry lung disorderspatients with 1ry lung disorders
.Septic emboli from tricuspid endocarditis.Septic emboli from tricuspid endocarditis
.Vasculitic disorders .Vasculitic disorders
.Cavitating lung malignancies.Cavitating lung malignancies
.Pulmonary cystic diseases.Pulmonary cystic diseases

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The following infectious etiologies of pneumonia The following infectious etiologies of pneumonia
infrequently progress to parenchymal necrosis & lung infrequently progress to parenchymal necrosis & lung
:abscess formation:abscess formation
- -.Pseudomonas aerugenosa.Pseudomonas aerugenosa
.Klebsiella pneumoniae -.Klebsiella pneumoniae -
Staph. aureus - Staph. aureus -.))may result in multiple abscesses.))may result in multiple abscesses
.Strept. Pneumonia -.Strept. Pneumonia -
.Nocardia species -.Nocardia species -
.Fungal species -.Fungal species -

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An abscess may occur An abscess may occur 2ry to bronchial 2ry to bronchial
carcinomacarcinoma , the , the bronchial obstruction causes bronchial obstruction causes
post-obstructive pneumonia which may lead post-obstructive pneumonia which may lead
to abscess formationto abscess formation..

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Differential DiagnosisDifferential Diagnosis
Alcoholism )1Alcoholism )1
Pleuro-pulmonary )2 Pleuro-pulmonary )2
. Empyema . Empyema
.Hydatid Cysts )3.Hydatid Cysts )3
.Lung Cancer )4.Lung Cancer )4
.Mycobacterium )5.Mycobacterium )5
Pneumococcal )6 Pneumococcal )6
. infections. infections
Pneumocystis Carnii )7 Pneumocystis Carnii )7
.pneumonia.pneumonia
.Aspiration pneumonia )8.Aspiration pneumonia )8
.Bacterial pneumonia )9.Bacterial pneumonia )9
.Fungal pneumonia )10.Fungal pneumonia )10
.Pulmonary embolism )11.Pulmonary embolism )11
.Sarcoidosis )12.Sarcoidosis )12
.T.B )13.T.B )13

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Lab StudiesLab Studies
- -CBCCBC
- - Sputum Sputum for forgram staingram stain , ,culture & sensitivityculture & sensitivity..
If T.B. is suspected, - If T.B. is suspected, -acid fast bacilli stainacid fast bacilli stain & &
mycobacterial culturemycobacterial culture. is requested. is requested
- -Blood cultureBlood culture may be helpful in establishing the may be helpful in establishing the
. etiology. etiology
Obtain - Obtain -sputumsputum for forovaova & & parasite parasite whenever a whenever a
. parasitic cause for lung abscess is suspected. parasitic cause for lung abscess is suspected

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HistopathologyHistopathology
A thick-walled lung abscessA thick-walled lung abscess

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Histology of lung abscessHistology of lung abscess shows dense inflammatory shows dense inflammatory
reaction reaction((low power((low power

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Histology of lung abscess shows dense inflammatory Histology of lung abscess shows dense inflammatory
reaction reaction((high power((high power

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Imaging StudiesImaging Studies
:CXR:CXR
- -.Irregularly sharp cavity with an air-fluid level inside.Irregularly sharp cavity with an air-fluid level inside
Lung abscess as a result of aspiration most frequently -Lung abscess as a result of aspiration most frequently -
occur in the posterior segments of the upper lobes or occur in the posterior segments of the upper lobes or
.the superior segments of the lower lobe.the superior segments of the lower lobe

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The wall thickness of a lung abscess -The wall thickness of a lung abscess -
progresses from thick to thin and from ill-progresses from thick to thin and from ill-
defined to well-circumscribed as the defined to well-circumscribed as the
.surrounding lung infection resolves .surrounding lung infection resolves

- - The cavity wall can be smooth or ragged but The cavity wall can be smooth or ragged but
is less commonly nodular, which raises the is less commonly nodular, which raises the
.possibility of cavitating carcinoma.possibility of cavitating carcinoma

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The abscess may extend to the pleural surface, -The abscess may extend to the pleural surface, -
in which case it forms acute angles with the in which case it forms acute angles with the
.pleural surface.pleural surface
- - - Up to one third of lung abscesses may be Up to one third of lung abscesses may be
.accompanied by an empyema.accompanied by an empyema

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Pneumococcal pneumonia Pneumococcal pneumonia
complicated by lung necrosis & complicated by lung necrosis &
abscess formationabscess formation

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A lateral CXR shows air fluid level A lateral CXR shows air fluid level
((characteristic of lung abscess((characteristic of lung abscess

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A 54 yr old pt. developed cough with foul-A 54 yr old pt. developed cough with foul-
smelling sputum production. A CXR smelling sputum production. A CXR
.shows lung abscess in the left lower lobes.shows lung abscess in the left lower lobes

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A 42 y.o. man developed fever & production of foul-A 42 y.o. man developed fever & production of foul-
smelling sputum. He had a H/O heavy alcohol use & smelling sputum. He had a H/O heavy alcohol use &
poor dentition, CXR shows lung abscess in the post poor dentition, CXR shows lung abscess in the post
.segment of the Rt. up. lobe .segment of the Rt. up. lobe

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CXR of a patient who had foul-smelling & bad CXR of a patient who had foul-smelling & bad
tasting sputum, an almost diagnostic feature of tasting sputum, an almost diagnostic feature of
anaerobic lung abscessanaerobic lung abscess

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-:CT scan:CT scan
Better in lung anatomy visualization to identify -Better in lung anatomy visualization to identify -
.empyema from lung infarction.empyema from lung infarction
An abscess is rounded radio-lucent lesion with a think -An abscess is rounded radio-lucent lesion with a think -
.wall & ill-defined irregular margins.wall & ill-defined irregular margins

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A 42 yr old man developed fever & production of foul-A 42 yr old man developed fever & production of foul-
smelling sputum. He had a H/O heavy alcohol abuse & poor smelling sputum. He had a H/O heavy alcohol abuse & poor
dentition, CXR shows lung abscess in the post. Segment of dentition, CXR shows lung abscess in the post. Segment of
the Rt. Up. Lobe. CT scan shows a thin-walled cavity with the Rt. Up. Lobe. CT scan shows a thin-walled cavity with
.surrounding consolidation .surrounding consolidation

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ProceduresProcedures
Trans-tracheal aspirate or trans-thoracic needle -Trans-tracheal aspirate or trans-thoracic needle -
aspiration may provide microbiologic diagnosis, aspiration may provide microbiologic diagnosis,
obtaining pleural fluid and blood cultures in patients obtaining pleural fluid and blood cultures in patients
.with lung abscess is easier.with lung abscess is easier

Flexible fiberoptic bronchoscopy is performed to -Flexible fiberoptic bronchoscopy is performed to -
exclude bronchogenic carcinoma whenever bronchial exclude bronchogenic carcinoma whenever bronchial
obstruction is suspectedobstruction is suspected..

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Medical CareMedical Care
:Antibiotic therapy:Antibiotic therapy
Anaerobic lung infection = - Anaerobic lung infection = -ClindamycinClindamycin ]shown to be ]shown to be
superior over parenteral penicillin coz several superior over parenteral penicillin coz several
anaerobes may produce B-lactamase & therefore anaerobes may produce B-lactamase & therefore
.]develop penicillin resistance .]develop penicillin resistance
Although - Although -metronidazolemetronidazole is an effective drug against is an effective drug against
anaerobic bacteria, a failure rate of 50% has been anaerobic bacteria, a failure rate of 50% has been
.reported.reported

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In hospitalized patients who have aspirated and -In hospitalized patients who have aspirated and -
developed a lung abscess, antibiotic therapy should developed a lung abscess, antibiotic therapy should
include coverage against include coverage againstS aureusS aureus and andEnterobacterEnterobacter
and andPseudomonasPseudomonas .species.species

- -CefoxitinCefoxitin is a second-generation cephalosporin that is a second-generation cephalosporin that
has gram-positive, gram-negative, and anaerobic has gram-positive, gram-negative, and anaerobic
coverage. This agent may be used when a coverage. This agent may be used when a
polymicrobial infection is suspected as cause of polymicrobial infection is suspected as cause of
.lung abscess.lung abscess

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:Duration of therapy:Duration of therapy
Most clinicians prescribe antibiotic therapy generally -Most clinicians prescribe antibiotic therapy generally -
for for.4-6 weeks.4-6 weeks
Current recommendations are that antibiotic -Current recommendations are that antibiotic -
treatment should be continued until the treatment should be continued until the chest chest
radiograph has shown either the resolution of lung radiograph has shown either the resolution of lung
.abscess or the presence of a small stable lesion.abscess or the presence of a small stable lesion

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:Response to therapy:Response to therapy

- - Patients show clinical improvement, with Patients show clinical improvement, with
improvement of fever, within 3-4 days after improvement of fever, within 3-4 days after
.initiating the antibiotic therapy.initiating the antibiotic therapy

Patients with poor response to antibiotic therapy -Patients with poor response to antibiotic therapy -
include bronchial obstruction with a foreign body or include bronchial obstruction with a foreign body or
neoplasm or infection with a resistant bacteria, neoplasm or infection with a resistant bacteria,
.Mycobacteria, or fungi.Mycobacteria, or fungi

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Surgical CareSurgical Care
Surgery is Surgery isvery rarely requiredvery rarely required for patients with for patients with
uncomplicated lung abscesses. The usual indications uncomplicated lung abscesses. The usual indications
for surgery are for surgery are failure to respond to medical failure to respond to medical
management, suspected neoplasm, or congenital management, suspected neoplasm, or congenital
lung malformation.lung malformation. The surgical procedure The surgical procedure
.performed is either lobectomy or pneumonectomy.performed is either lobectomy or pneumonectomy

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ComplicationsComplications
11.Rupture into pleural space causing empyema ).Rupture into pleural space causing empyema )
.Pleural fibrosis )2.Pleural fibrosis )2
.Trapped lung )3.Trapped lung )3
.Respiratory failure )4.Respiratory failure )4
.Bronchopleural fistula )5.Bronchopleural fistula )5
.Pleural cutaneous fistula)6.Pleural cutaneous fistula)6
In a patient with coexisting empyema and lung abscess, In a patient with coexisting empyema and lung abscess,
draining the empyema while continuing prolonged draining the empyema while continuing prolonged
.antibiotic therapy is often necessary.antibiotic therapy is often necessary

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PrognosisPrognosis
The prognosis for lung abscess following The prognosis for lung abscess following
antibiotic treatment is generally favorable. antibiotic treatment is generally favorable.
Over 90% of lung abscesses are cured with Over 90% of lung abscesses are cured with
medical management alone, unless caused by medical management alone, unless caused by
.bronchial obstruction secondary to carcinoma.bronchial obstruction secondary to carcinoma

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The EndThe End
Thank YouThank You