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 !