Lung Abscess
Prepared & presented by: Dr :WADIE MADI
‫د‬:‫مادي‬ ‫وديع‬
Respiratory Department.
Tripoli Medical Centre.
...
Background:
 Definition of Lung Abscess is:
-Necrosis of the pulmonary tissue & formation of cavities
containing necrotic...
 Epidemiology: IN U.S.A
 Frequency: the frequency of lung abscess in the
general population not known.(MEDSCAPE.COM.USA
...
Classification
 Duration of symptoms prior to diagnosis;
 Acute < 1 month
 Chronic > 1 month
 Primary lung abscess or ...
Etiology:
 Bacteria
o mouth flora anaerobes :Pepto strepto,Fuso bacterium nucleatum,
also Staph aureus, . Strepto pyogene...
2-Noninfectious Causes
Vasculitis
Wegener's granulomatosis, rheumatoid lung nodule
Airway disease
Bullae, blebs,cystic f...
Pathophysiology
 Most occur as a complication of aspiration pneumonia ,
due to anaerobic bacteria that are normal oral fl...
Histopatholgy of lung abscess
:Risk Factors for lung abscess
 Predisposition to aspiration
 stroke, IV drug abuser , general anesthesia, dysphasia, re...
 Esophageal disease:
-Achalasia
-Reflux disease(GERD)
-Depressed cough and gag reflex
-Esophageal obstruction.
 Other pr...
1-Clinical features
 Symptoms include : fever, night sweating, cough and Pleuritic
chest pain, cough is often non product...
Patients may have low-grade fever in anaerobic infections &
temperature > 38.5 C in other infections.
Clinical findings ...
Amebic lung abscess
Patients who develop an amebic lung abscess often have symptoms
associated with a liver abscess.
These...
2-Laboratory Studies
Sputum for gram stain, culture & sensitivity
If tuberculosis is suspected, ZeilNelsen and mycobacte...
3-Radiological diagnosis
- Chest films may also reveal associated primary lesions,
e.g., a bronchogenic carcinoma.
- Malig...
PA and lateral chest
radiographs 3 weeks later show
decreased size of lung abscess
and development of cavitation
with flui...
Pneumococcal pneumonia
complicated by lung necrosis
and abscess formation.
A lateral chest radiograph shows
air-fluid leve...
A 54-year-old patient developed cough with foul-smelling sputum
production. A chest radiograph shows lung abscess in the l...
 CT scan:
- Better in lung anatomy visualization to identify empyema from lung
infarction.
- An abscess is rounded radio-...
Contrast-enhanced (CT)
scan demonstrates large
focal area of decreased
attenuation with rim
enhancement (arrow)
characteri...
4-Procedures
Flexible fiberoptic
bronchoscopy
is performed to
exclude bronchogenic
carcinoma whenever
bronchial obstructio...
 Cavitating lung cancer
 Localized empyema
 Infected congenital pulmonary lesion:
e.g bronchogenic cyst or sequestratio...
Surgical
treatment
Prognosis
Medical
treatment
Treatment
Treatment
Treatment of lung abscess is guided by the available microbiology and knowledge
of the underlying or associated ...
In hospitalized patients who have aspirated and developed a lung abscess
antibiotic therapy should include coverage agains...
Response to therapy
 Clinical improvement, decrease fever, within 3-4 days after initiating ABX
. therapy.
 Defervescenc...
Complications of lung abscess
 Rupture into pleural space causing Empyema
 Pleural fibrosis
 Trapped lung
 Respiratory...
Surgical intervention
 Surgery is rarely required for patients with uncomplicated lung
abscess
The usual indications for ...
THANK
YOU
Lung abscess (د وديع مادي)
Lung abscess (د وديع مادي)
Lung abscess (د وديع مادي)
Lung abscess (د وديع مادي)
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Lung abscess (د وديع مادي)

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it was my first presentation about lung abscess ,also i had presented it at special day ( my birthday) place in Tripoli medical center,in respiratory department unit B .(د وديع مادي)

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Lung abscess (د وديع مادي)

  1. 1. Lung Abscess Prepared & presented by: Dr :WADIE MADI ‫د‬:‫مادي‬ ‫وديع‬ Respiratory Department. Tripoli Medical Centre.  UNIT B TUESDAY 11th/March/2014
  2. 2. Background:  Definition of Lung Abscess is: -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. - It manifests radiographically as a cavity with an air – fluid levels.
  3. 3.  Epidemiology: IN U.S.A  Frequency: the frequency of lung abscess in the general population not known.(MEDSCAPE.COM.USA  Mortality & morbidity : most patients with primary lung abscess improve with antibiotics , with cure rates documented at 90-95%.(MEDSCAPE.COM.USA).  Incidence : sex: male< female Age: lung abscess likely occur more commonly in elderly patients bcz increase incidence of periodontal diseases.(MEDSCAPE.COM.USA)  In U.K(affect all age groups slight more in young adults (P.DR-ANTHONY J FREW ,MD SOUTHAMPTON.UK)
  4. 4. Classification  Duration of symptoms prior to diagnosis;  Acute < 1 month  Chronic > 1 month  Primary lung abscess or Secondary lung abscess; Primary lung abscess:  used when abscess develops in individuals prone to aspiration or in general good health  60-80% of lung abscess is primary (50% of these associated with putrid sputum) Secondary lung abscess: obstructive airway neoplasm as a complication of intrathoracic surgery or systemic condition/treatment that compromises host immune defense mechanisms . Putrid lung abscess (foul odor of expectorated sputum)
  5. 5. Etiology:  Bacteria o mouth flora anaerobes :Pepto strepto,Fuso bacterium nucleatum, also Staph aureus, . Strepto pyogenes, Pseudomonas aeruginosa, Klebsiella pneumoniae , Strepto pneumoniae • gram-negative bacilli, such as E. coli , Homophiles influenza type B  Mycobacteria • M. tuberculosis, (TUBERCULOUS LUNG ABSCESS) ,M. kansasii,)  Fungi • Aspergillus spp., Histoplasma capsulatum, Pneumocystis carinii,  Parasites • Entamoeba histolytica, Paragonimus westermani, 1-infectious Causes
  6. 6. 2-Noninfectious Causes Vasculitis Wegener's granulomatosis, rheumatoid lung nodule Airway disease Bullae, blebs,cystic fibrosis ,bronchiectasis (usually thin-walled) Neoplasms Primary lung cancer, metastatic carcinoma, lymphoma Septic embolism Infective endocarditis due to S. aureus, Jugular venous septic phlebitis due to Fusobacterium necrophorum (Lemierre syndrome) Pulmonary infarction Due to bland embolus (may be secondarily infected in <5%) Etiology:
  7. 7. Pathophysiology  Most occur as a complication of aspiration pneumonia , due to anaerobic bacteria that are normal oral flora.  studies of patients with known time of aspiration suggest that tissue necrosis with lung abscess formation takes at least 1 week and up to 2 weeks to develop.  Aspirated bacteria are carried by gravity to dependent portions of the lung. Due to bronchus/carina anatomy, occur most frequently in posterior segment of RtUL then posterior segment of LtUL and then the superior segments of RtUL/LtLL.
  8. 8. Histopatholgy of lung abscess
  9. 9. :Risk Factors for lung abscess  Predisposition to aspiration  stroke, IV drug abuser , general anesthesia, dysphasia, respiratory muscle dysfunction, tooth extractiont ,seizers,alcoholics .  45% of health adults aspirate during sleep(1ml of saliva with > 109 live bacteria.)  Poor dentition with gingivitis  Airway Obstruction: -Neoplasm, Foreign bodies, extrinsic compression (enlarged lymph node).  Immunocompromised patients: - Steroid ,chemotherapy -Malnutrition , HIV ,AIDS,DM - Multiple trauma
  10. 10.  Esophageal disease: -Achalasia -Reflux disease(GERD) -Depressed cough and gag reflex -Esophageal obstruction.  Other processes:  bronchiectasis,  secondary infection from bland pulmonary infarction/PE,  septic emboli from Tri V endocarditis  suppurative phlebitis Lemierre syndrome: septic phlebitis of the neck (Fusobacterium) with embolic infection in the lung may complicate oropharyngeal infection (peritonsillar abscess)
  11. 11. 1-Clinical features  Symptoms include : fever, night sweating, cough and Pleuritic chest pain, cough is often non productive at first then produce mucoid or mucopurulent expectorate from bronchial inflammation close to the abscess area and sometimes there is blood streaking Symptoms  Weigh loss,, anaemia, and clubbing or pulmonary osteo arthropathy, hymptosis in 1/3 of cases,  The onset may be abrupt or gradual.
  12. 12. Patients may have low-grade fever in anaerobic infections & temperature > 38.5 C in other infections. Clinical findings of consolidation may be present: [decreased breath sounds, dullness in percussion, bronchial breath sounds, course inspiratory crackles]. Evidence of pleural friction rub signs of associated pleural effusion, empyema & pyo-pneumothorax may be present. Signs include :[dullness to percussion, contralateral mediastinal shifting & absent breath sounds over the effusion]. Signs  Digital clubbing may develop rapidly.
  13. 13. Amebic lung abscess Patients who develop an amebic lung abscess often have symptoms associated with a liver abscess. These may include right upper quadrant pain and fever. After perforation of the liver abscess into the lung, the patient may develop a cough and expectorate a chocolate–like sputum that has no odor.
  14. 14. 2-Laboratory Studies Sputum for gram stain, culture & sensitivity If tuberculosis is suspected, ZeilNelsen and mycobacterial culture is requested.  Routine investigations: e.g CBC may show leukocytosis, blood glucose , LFT , RFT, U/E/C. Obtain sputum for ova if parasitic is suspected
  15. 15. 3-Radiological diagnosis - Chest films may also reveal associated primary lesions, e.g., a bronchogenic carcinoma. - Malignant abcess shows eccentric cavitations with thick rough irregular walls.  Chest X-ray - Irregularly sharp cavity with an air-fluid level inside. - Lung abscess as a result of aspiration most frequently occur in posterior segments of the upper lobes or superior segments of lower lobes.
  16. 16. PA and lateral chest radiographs 3 weeks later show decreased size of lung abscess and development of cavitation with fluid level . The patient was a 43-year-old woman with lung abscess secondary to Haemophilus infection
  17. 17. Pneumococcal pneumonia complicated by lung necrosis and abscess formation. A lateral chest radiograph shows air-fluid level characteristic of lung abscess.
  18. 18. A 54-year-old patient developed cough with foul-smelling sputum production. A chest radiograph shows lung abscess in the left lower lobe, superior segment.
  19. 19.  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.
  20. 20. Contrast-enhanced (CT) scan demonstrates large focal area of decreased attenuation with rim enhancement (arrow) characteristic of lung abscess. Because empyema with an air-fluid level could be mistaken for parenchymal abscess, a CT scan may be used to differentiate this process from lung abscess
  21. 21. 4-Procedures Flexible fiberoptic bronchoscopy is performed to exclude bronchogenic carcinoma whenever bronchial obstruction is suspected. Blood culture & Microbiology. Transtracheal aspirate Bronchoalveolar lavage with quantitative cultures
  22. 22.  Cavitating lung cancer  Localized empyema  Infected congenital pulmonary lesion: e.g bronchogenic cyst or sequestration  Pulmonary hematoma  Cavitating pneumoconiosis  Hiatus hernia  Lung parasites (eg, hydatid cyst, Paragonimus infection)  Actinomycosis  Wegener granulomatosis and other vasculities  Cavitating lung infarcts  Cavitating sarcoidosis Differential diagnosis
  23. 23. Surgical treatment Prognosis Medical treatment Treatment
  24. 24. Treatment Treatment of lung abscess is guided by the available microbiology and knowledge of the underlying or associated conditions. No treatment recommendations have been issued by major societies specifically for lung abscess; Medical therapy Clindamycin Is T.O.C [shown to be superior over parenteral penicillin coz several anaerobes may produce B-lactamase therefore develop penicillin resistance]. Metronidazole is an effective drug against anaerobic bacteria, a failure rate of 50% has been reported.  May combine both Metronidazole & Penicillin Other options: carbopenems, quionlones with good anaerobic activity (Moxiflox, Gatiflox) Anaerobic lung infection
  25. 25. In hospitalized patients who have aspirated and developed a lung abscess antibiotic therapy should include coverage against S aureus and Enterobacter and Pseudomonas species. Duration of therapy  Although the duration of therapy is not well established, most clinicians generally prescribe antibiotic therapy for 4-6 weeks.  Expert opinion suggests that antibiotic treatment should be continued until the chest radiograph has shown either the resolution of lung abscess or presence of a small stable lesion. The risk of relapse exists with a shorter antibiotic regimen.
  26. 26. Response to therapy  Clinical improvement, decrease fever, within 3-4 days after initiating ABX . therapy.  Defervescence is expected in 7-10 days. Persistent fever beyond this time indicates therapeutic failure, and these patients should undergo further diagnostic studies to determine the cause of failure. Causes of delayed response to antibiotics Large cavity size ( > 6 cm in diameter) usually requires prolonged therapy.. lung infarction cavitating neoplasm, The infection of a preexisting sequestration, cyst, or bulla bronchial obstruction with a foreign body
  27. 27. Complications of lung abscess  Rupture into pleural space causing Empyema  Pleural fibrosis  Trapped lung  Respiratory failure  Bronchopleural fistula  Pleural cutaneous fistula(T.B) In a patient with coexisting empyema and lung abscess, Draining the empyema while continuing prolonged antibiotic therapy is often necessary.
  28. 28. Surgical intervention  Surgery is rarely required for patients with uncomplicated lung abscess The usual indications for surgery are -- failure to respond to medical management, -- suspected neoplasm, or -- congenital lung malformation.  The surgical procedure performed is neither lobectomy or pneumonectomy. 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.
  29. 29. THANK YOU

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