LUNG
ABSCESS
Dr. Manoj Kumar
Assistant Professor of Pulmonary Medicine
Swami Rama Himalayan University
Jollygrant
Definition
A lung abscess is a localized area of destruction
of lung parenchyma (usually >2 cm in diameter)
inwhich infectionby pyogenic organism
resultsin tissue necrosis and s
manifestedradiologically asa cavitysuppuration
withair
fluid level.
Classification…
Lung abscesses can be classified
based on the duration & the likely etiology
Acute abscess
Chronic abscess
Classification…
Clinically useful during initial evaluation
Acute:
A lung abscess is defined as acute if the patient presents with
symptoms of < 2 weeks duration. Patients with an acute lung
abscess are less likely to have an underlying neoplasm, but are
more likely to have an infection caused by a virulent aerobic
bacterial agent (e.g. S. aureus)
Classification…
Clinically useful during initial evaluation
Chronic:
A chronic lung abscess is defined by symptoms lasting for > 4 to 6
weeks. Patients more like to have an underlying neoplasm or
infection with a less virulent anaerobic agent
Classification…
Classification…
Primary abscess is infectious in origin, caused by aspiration or
pneumonia in the healthy host. Mostly result from necrosis in an
existing parenchymal process, usually untreated or aspiration
pneumonia
Classification…
Secondary abscess is caused by
Pre-existing condition eg bronchiectasis
Bronchial obstruction (eg- aspirated foreign body)
An immuno-compromised state
Spread from an extra-pulmonary site
Abscess that complicates either a septic vascular embolus (eg- right
sided endocarditis)
Demographic Profile
Age
Lung abscesses likely to occur more commonly in elderly
patients because of
Increased incidence of periodontal disease
Increased prevalence of dysphagia
Aspiration
Sex
A male predominance is reported in published case
series.
Common sites
Abscesses generally develop in the right lung
Posterior segment of the right upper lobe is affected most
commonly
Followed by the apical segment of either lower lobe or both.
If the patient is lying on his/her side
The posterolateral parts of the upper lobe tend to receive the
aspirate
When aspiration has occurred with the patient lying supine
The apical segments of the lower lobes tend to receive the aspirate
Association with
neoplasia
Neoplastic
■ 8-18% of lung abscess are associated
with neoplasms in all age groups
(approx30% in patients > 45 yrs)
■ Primary squamous cell carcinoma is
the malignancy most often associated
with abscess formation
■ Others include
▪ Metastatic carcinoma (Colorectal
carcinoma, Renal cell
carcinoma)
▪ Lymphoma (Hodgkin’s disease)
Causes of Lung abscess
(A) Aspiration
A) Aspiration of infected material containing oropharyngeal
flora (commonest cause)
Organisms are anaerobic and aerobic
May be due to
▪ Dental/ periodontal sepsis esp following tooth
extraction, tonsillectomy and nasal operation
▪ Paranasal sinus infection
Causes of Lung abscess
(A) Aspiration…
Depressed conscious level /Unconscious patient
Alcoholism/ Sedative drug abuse
Anaesthesia (General)
Epilepsy/seizure disorders
Head injury
Cerebrovascular accident (CVA)
Diabetic coma
Other prostrating illness
Causes of Lung abscess (A) Aspiration…
Disturbances of swallowing
Oesophageal stricture (benign or malignant)
Oesophageal motility disorders (eg- Systemic sclerosis,
Neuromuscular disease, eg- bulbar/pseudobulbar palsy,
myasthenia gravis, amyotrophic lateral sclerosis)
Causes…
B) Necrotizing Pneumonia / Inadequately Treated Pneumonia
Aerobic bacteria (eg- Staphylococcus aureus, Strepto. Pneumoniae,
Streptococcus milleri/intermedius, Klebsiella pneumoniae,
Pseudomonas aeruginosa )
Anaerobic bacteria
Others:
■ Mycobacteria
■ Fungal
■ Parasites
Causes…
C) Mechanical Bronchial obstruction by
▪ Tumour (Bronchial carcinoma/ Adenoma)
▪ Foreign body
▪ Enlarged lymphnodes
▪ Congenital abnormality – bronchial
stenosis
D) Pre-existing lung disease
▪ Bronchiectasis
▪ Cystic fibrosis
Causes…
F) Extension from extra-pulmonary abscess/( transdiaphragmatic
spread)
liver abscess
subphrenic abscess
Mediastinal abscess
G) Trauma/ Post traumatic
Infected pulmonary haematoma
Contaminated foreign body
H) Immunodeficiency
Primary or
Organisms commonly
isolated…
Anaerobes – are usually part of a polymicrobial flora .
1 Gram-negative bacilli making up the genus Bacteroides,notably
Bacteroides fragilis. Prevotella and Porphyromonas.
2. Gram-positive cocci, mainly Peptostreptococcus and anaerobic or
microaerophilic streptococci.
3 .Long thin Gram-negative rods comprising Fusobacterium species,
particularly F. nucleatum and F. necrophorum.
Organisms commonly
isolated…
Aerobic: Aerobic organisms tend to cause lung abscesses as part of a
necrotizing pneumonia.
Gram-positive aerobes
Staph. aureus , Strep. pyogenes (syn. Group A streptococcus, β haemolytic
streptococcus) , Strep. pneumoniae , Strep. intermedius, Strep. constellatus
and Strep. Anginosus.
Gram-negative aerobes
Klebsiella pneumoniae, Pseudomonas aeruginosa , Haemophilus influenzae,
Escherichia coli, Acinetobacter species, Proteus species and Legionella
species.
Organisms commonly
isolated…
■ Mixed – ■ Fungus
▪ Common ▪ Histoplasmosis
▪ In majority of cases, a ▪ Aspergillosis
mixed bacterial flora can ▪ Coccidiodes
be found. ▪ Cryptococcus
■ Mycobacteria (rare)
■ Parasites
▪ Mycobacterium ▪ Entamoeba histolytica
tuberculosis
▪ Paragonimus westermanii
▪ Mycobacterium kansasii
▪ Mycobacterium intracellularis
Symptoms …
Patients present with
Severe cough
Profuse foul smelling sputum, may be foetid
There may be large amounts of purulent sputum once a
bronchial communication has been established
Putrid sputum is a highly specificsymptoms that is
pathognomonic for anaerobic infection
Haemoptysis (25% of patients) – not uncommon and may be life-
threatening
Symptoms …
■ Chest pain (pleuritic or deep-seated aching discomfort
■ Fever – usually high with chill & rigor, profuse night sweating
■ Constitutional upset like- malaise, weakness
■ Weight loss (60% of patients) – with an average loss of between 15 &
lbs
20
■ Anorexia
■ Symptoms of associated disease process eg-
▪ Bronchial obstruction due to lung cancer
▪ Oesophageal obstruction due to achalasia
▪ Right-sided endocarditis
■ Dyspnoea
Symptoms …
■ History
Includes risk factors for aspiration, eg-
▪ Alcoholism
▪ Drug overdose
▪ Seizures
▪ Head injury
▪ Stroke
■ Absence of such risk factors should prompt a search for a diagnosis
other than primary lung abscess
Sign
s
There is no signs specific for lung abscess
Patient is toxic with high temperature & Halitosis
Clubbing may develop within few weeks if treatment is
inadequate
usually in 10% cases after 3 weeks
Signs…
On chest exam
■ Evidence of consolidation
■ Dullness to percussion and diminished breath sounds, if the abscess
is large and situated near the surface of the lung
■ The ‘amorphic’ or ‘cavernous’ breath sound traditionally
associated with lung cavities are rarely elicited in modern practice
Investigation
s
1.CBC
2.X-ray chest P/A view & lateral
view 3.Sputum examination :
Gram staining
C/S (aerobic & anaerobic)
AFB, fungus & malignant cells
4. FOB
5.CT scan of chest in some cases
6.Blood sugar
Imaging
Studies…
X-ray chest
Radiographic abnormality may start with
a pneumonic infiltrate
followed by the development of one or
more spherical areas of more
homogeneous density in which air-fluid
levels often arise
indicating the formation of a bronchial
communication
Abscess
cavities/multilocular
Imaging
Studies
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
Imaging Studies/ Thoracic
CT
Better in lung anatomy visualization to identify empyema
from lung abscess
An abscess is rounded radio-lucent lesion with a thin wall
& ill-defined irregular margins
Imaging Studies/ Thoracic
CT
Thoracic CT may be very helpful in accurately defining the
extent and disposition of both lung abscesses and empyemas
Also may demonstrate the multiple small air cavities of
necrotizing pneumonia
Ultrasound or CT may also be helpful in guiding percutaneous
diagnostic thin-needle aspiration of lung abscesses
Investigations/FOB
(Contd)
Criteria for Bronchoscopy to exclude an underlying carcinoma
in patients with lung cavities
Mean oral temp <100 ºF
Absence of systemic symptoms
Absence of predisposing factors for aspiration, and
Mean leukocyte count <11000/ mm3
When more than 3 of these factors are present in a patient with
lung abscess, an underlying carcinoma is likely
Investigations…/Sputum examination
Sputum examination
✔ Gram staining & C/S (both aerobic & anaerobic)
✔Repeated isolation of a predominant organism suggests that this may
be a true pathogen
✔ ZN stain for AFB and AFB C/S
✔ GXP for MTB/Rif
✔ cytology for malignant cell
✔ Stain and culture for Fungus
Investigations (Contd)
Blood cultures
Serology may sometimes be helpful, especially to exclude
hydatid disease or amoebiasis.
More invasive methods if the presentation is atypical or the
patient is not responding to therapy.
Differential
diagnosis/Clinically
Consolidation (during resolution stage), usually no clubbing
Bronchiectasis
Bronchial carcinoma, usually Squamous cell carcinoma
Pulmonary tuberculosis (without causing abscess)
Rare infections, including – Actinomycosis, Nocardiasis, Fungal
pneumonia
Differential
diagnosis…/Radiologically
Classically the empyema is
seen on the lateral chest
Xray as a ‘D-shaped’
opacity with the
convexity projecting
anteriorly from the
posterior chest wall
Treatment
Principles:
Sputum is sent for C/S
& broad-spectrum antibiotic should be started
Postural drainage & chest physiotherapy
Surgery
Treatment of the cause if any
Treatme
nt…
Antibiotic Regimen For Aspiration Pneumonia
Clindamycin + fluoroquinolone
Clindamycin + aminoglycosides
Clindamycin + third/fourth generation cepalosporin
Imipenem/meropenem
Treatme
nt…
Antimicrobial options for common infecting bacteria
Organism Antimicrobial options
Staph. aureus Flucloxacillin, clindamycin
Pseudomonas aeruginosa Ciprofloxacin, piperacillin-
tazobactam, aztreonam,
meropenem, aminoglycosides,
ceftazidime/cefepime
Enterobacter spp. Ciprofloxacin, meropenem,
aminoglycosides
Treatme
nt…
Duration of therapy
Although the duration of Antimicrobial therapy is not well
established
most clinicians generally prescribe antibiotic therapy for a total of
4-8 weeks
Treatment
…
Aspiration/drainage of pus
■If no response to medical therapy (in 1-10% cases),
percutaneous aspiration under USG/CT guided may
be required
Surgical treatment
Surgery is very rarely required for patients with
uncomplicated lung abscesses
Approx. 10% of lung abscess require surgical intervention
Chest
physiotherapy
encouragement of cough & mobilization of secretions are
potentially useful intervention.
Adequate drainage of the lung abscess is an important part of
management.
An air-fluid level implies the presence of a communication
from the abscess cavity to the tracheobronchial tree.
Chest physiotherapy…
Chest physiotherapy & postural drainage may be helpful in helping
the patient to clear purulent material
and postural drainage can be applied with the affected pulmonary
segments uppermost
Significant pulmonary haemorrhage may occur
THANK
YOU !
