LUNG ABSCESS

- Pus-containing necrotic lesions of the

lung parenchyma that often contain an
air-fluid level; Represents necrosis and
cavitation of the lung following
microbial infection.
- ―Pulmonary abscess‖ is a local
suppurative process within the lung
characterized by necrosis of lung
tissue.
- A similar process with multiple small cavities less than 2
cm in diameter has been designated necrotizing
pneumonia by some clinicians.
- Associated with infections caused by pyogenic bacteria,
mycobacteria, fungi and parasites
- May also complicate pulmonary infarction, primary and
metastatic malignancies, and the necrotic conglomerate
lesions of silicosis and coal miners’ pneumoconiosis
- Lung abscesses can be single or multiple but usually are
marked by a single dominant cavity >2 cm in diameter.
- Lung abscesses can also be characterized
- Acute (<4–6 weeks in duration)
- Chronic (~40% of cases)
Types of Lung Abscess and Microbiology
Etiology and Pathogenesis 1. Primary lung abscesses
- Any pathogen may produce abscess. The commonly - Usually arise from aspiration, are often caused
isolated organisms include aerobic and anaerobic principally by anaerobic bacteria, and occur in the
streptococci, S. aureus and a host of gram-negative absence of an underlying pulmonary or systemic
organisms; polymicrobial etiology. condition.
- Anaerobes are the exclusive isolates in about 60% - Pneumonitis develops initially
of cases. These organisms are normally found in the - Over a period of 7–14 days, the anaerobic bacteria
oral cavity and include Bacteroides, Fusobacterium and produce parenchymal necrosis and cavitation
Peptococcus. - A putrid lung abscess refers to foul-smelling breath,
- Other causative agents are introduced by the following sputum, or empyema and is essentially diagnostic
mechanisms: of an anaerobic lung abscess
1. Aspiration of infective materials (most common
frequent cause). Most common among patients with 2. Secondary lung abscesses
depressed cough reflexes. Gastric contents, due to - Arise in the setting of an underlying condition, such as a
its acidity, add to the irritant role of the food particle post-obstructive process (e.g., a bronchial foreign body
and in the course of aspiration, mouth organisms or tumor) or a systemic process (e.g., HIV infection or
may be introduced. another immunocompromising condition)
 increased salivary proteolytic activity which
destroys fibronectin glycoprotein coating of the Morphology
surface mucosa
 50% of healthy individuals aspirate
oropharyngeal secretions during sleep
2. Antecedent primary bacterial infection. Post-
pneumonic abscess formations are usually
associated with S. aureus, K. pneumonia and type 3
pnemococcus.
3. Septic embolism. Infected emboli from
thrombophlebitis or venous circulation or from
vegetations of infective bacterial endocarditis on the
right side of the heart may be trapped in the lung.
4. Neoplasia. Secondary infection is particularly Figure 1. Pyemic lung abscess with complete destruction of underlying
common (postobstructive pneumonia). parenchyma within focus of involvement (Robbins).
5. Miscellaneous. Direct traumatic penetration of the
lungs, spread of infection and hematogenous - Varying diameters; cavities develop when necrotic lung
seeding may all lead to lung abscess. tissue is discharged (<2cm in diameter); lung abscess
- When all these causes are excluded, lung abscess usually measures >2cm in diameter.
formation is referred to as “primary cryptogenic” lung - May affect any part of the lungs; may be single or
abscess. multiple
- Middle-aged men > middle-aged women. - Pulmonary abscess due to
- The major risk factor for primary lung abscesses is aspiration are more common on
aspiration. the right (the more vertical main
bronchus) and are most often
single.
Medicine 4- Lung Abscess
January 21, 2020
Prepared by: Balmadrid, Boddula, Borkhatariya, Borromeo, Briz, Camato, Camilo, Camonayan, Chemmankuzhiyil, Chabhadiya,
Chovatiya, Cloza, Conde Page 1
 - Posterior upper lobes and superior segment of lower
lobes) - the most common locations, given the
predisposition of aspirated materials to be deposited in
these areas.
- Generally, the right lung is affected more commonly than
the left because the right mainstem bronchus is less
angulated.
- In pneumonia or bronchiectasis, abscesses are usually
multiple, basal and diffusely scattered.
- For septic emboli and pyemic abscesses, by their
haphazard nature of their genesis, are multiple and may
affect any region of the lungs.
- Cavity may or may not be filled up with suppurative
debris.
- Superimposed saprophytic infections are prone to
flourishing within the already necrotic debris of the
abscess cavity and continued infection may be
designated as gangrene of the lung.
- The cardinal histologic change in all abscesses is
suppurative destruction of the lung parenchyma
within the central area of cavitation (Figure 1).
- In chronic cases, considerable fibroplastic proliferation
produces a fibrous wall.
Imaging Studies and Diagnosis
- Chest radiograph: consolidation with radiolucency
and surrounding wall or border.
- Chest radiograph usually detects a thick-walled
cavity with an air-fluid level
- Confirmed by roentgenography and bronchoscopy.
- Gram’s stain and culture, may yield a pathogen
- In non-resolving pneumonia, a simple chest radiograph
may demonstrate pleural effusion, cavitation, or new
changes.
- In progressive pneumonia, clinical deterioration and the
extension of the radiographic image may appear during
the first 72 hours after the initiation of satisfactory
treatment.
- Pulmonary CT scans provide a more detailed study of
the parenchyma, interstitium, pleura, and mediastinum.
- The appearance of nodular images with the halo sign
(i.e., a nodule surrounded by a halo of ground-glass
attenuation, especially near the pleura) on CT scan is
suggestive of pulmonary aspergillosis or mucormycosis.
- Nodules of similar appearance have also been
described in cytomegalovirus infection, Wegener's
granulomatosis, Kaposi's sarcoma, and hemorrhagic
metastasis.
- Chest radiography of P. jirovecii pneumonia shows
characteristic ground-glass opacities consistent with
interstitial pneumonia. Infection by Nocardia spp., M.
tuberculosis, or Q fever may result in nodules or multiple
masses with or without cavitation.
- Diffuse or mixed interstitial and alveolar opacities
may be due to viral infections or M. pneumoniae.
- Other imaging studies, such as perfusion-ventilation
scintigraphy, may be performed according to the clinical
suspicion of pulmonary embolism. Spiral CT scans and
pulmonary arteriography complement this diagnostic
procedure
- When an abscess is discovered, it is important to rule
out an underlying carcinoma, as this is present in 10 to
15% of cases.
- In secondary lung abscess, mpirical therapy fails to
elicit a response,
Medicine 4- Lung Abscess
January 21, 2020
Prepared by: Balmadrid, Boddula, Borkhatariya, Borromeo, Briz, Camato, Camilo, Camonayan, Chemmankuzhiyil, Chabhadiya,
Chovatiya, Cloza, Conde
Clinical Course
- Manifestations are much like those of bronchiectasis
and are characterized by cough, fever, copious amounts
of foul-smelling purulent or sanguineous sputum.
- A more chronic and indolent presentation
o Night sweats, fatigue, and anemia is often
observed with anaerobic lung abscesses.
- A subset of patients with putrid lung abscesses
o Discolored phlegm and foul-tasting or foul-
smelling sputum.
- Patients with lung abscesses due to non-anaerobic
organisms, such as S. aureus,
o More fulminant course characterized by high
fevers and rapid progression.
- Fever, chest pain, weight loss, dyspnea, anorexia are
common
- Clubbing of the digits may appear within weeks
Laboratory Findings
- Increased WBC, +/-anemia, hypoalbuminemia
Treatment
- (1) Clindamycin (600 mg IV three times daily; then, with
the disappearance of fever and clinical improvement,
300 mg PO four times daily)
- (2) An IV-administered β-lactam/β-lactamase
combination, followed—once the patient’s condition is
stable - by orally administered amoxicillin-clavulanate.
- Continued until imaging demonstrates that the lung
abscess has cleared or regressed to a small scar.
- For secondary lung abscess, antibiotic coverage should
be directed at the identified pathogen, and a prolonged
course (until resolution of the abscess is documented).
- It take as long as 7 days for patients receiving
appropriate therapy to defervesce, as many as 10–20%
of patients may not respond at all, with continued fevers
and progression of the abscess cavity on imaging.
- An abscess >6–8 cm in diameter is less likely to
respond to antibiotic therapy without additional
interventions.
Complications
- The course of abscess is variable. With antimicrobial
therapy, most resolve with no major sequelae.
- Complications include extension of the infection into the
pleural cavity, haemorrhage, development of brain
abscess or meningitis from septic emboli and (rarely)
reactive secondary amyloidosis; extension to the pleural
space with development of empyema, life-threatening
hemoptysis, and massive aspiration of lung abscess
contents.
Prognosis
- Primary abscesses
o Mortality rates as low as 2%
o Other poor prognostic factors include
o age >60,
o the presence of aerobic bacteria,
o sepsis at presentation,
o symptom duration of >8 weeks
o abscess size >6 cm.
- Secondary abscesses
o Mortality rates are generally higher—as high as
75%
Page 2
Prevention
- Vaccinations
- Mitigation of underlying risk factors may be the best
approach to prevention of lung abscesses,
o airway protection
o oral hygiene
o minimized sedation with elevation of the head
of the bed for patients at risk for aspiration.
- Prophylaxis against certain pathogens in at-risk patients
(e.g., recipients of bone marrow or solid organ
transplants or patients whose immune systems are
significantly compromised by HIV infection)

Pneumonia and Influenza Vaccination Recommendation

- Prevention of pneumonia may be possible by
administering the pneumococcal and influenza (during
hnflu season) vaccines for eligible patients.
- The recommendations for administration of live,
attenuated influenza vaccine are healthy persons from 5
to 49 years including health care providers and
household contacts of high-risk patients.
- We usually advise influenza vaccine in patients 60 years
and above but high contact persons like the health care
providers are given the flu vaccine.

Medicine 4- Lung Abscess

January 21, 2020
Prepared by: Balmadrid, Boddula, Borkhatariya, Borromeo, Briz, Camato, Camilo, Camonayan, Chemmankuzhiyil, Chabhadiya,
Chovatiya, Cloza, Conde Page 3