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![PATHOGENESIS
1. Aspiration
2. Hematogenous spread - Septic embolization during bacteremia (eg,
tricuspid valve endocarditis, intravascular catheters, intravenous (IV)
drug use, or Lemierre syndrome [ie, jugular vein suppurative
thrombophlebitis])
3. Direct extension- Extension of an empyema, subphrenic, or
mediastinal abscess or a tracheo- or broncho-esophageal fistula.](https://image.slidesharecdn.com/physicon-final-240204233844-4d41db34/85/Polymicrobial-lung-abscess-pptx-56-320.jpg)
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Polymicrobial lung abscess.pptx
- 1. PHYSICIAN CONFERENCE Dr.MAGESH RAJASEKARAN Final YearResident,IIM Prof.Dr.Samuel Dinesh Unit-M6
- 2.
- 3. CASE VIGNETTE A Fiftytwo year gentleman, Mr.Sivakumar, known case of T2DM, came to RGGGH with complaints of Cough with expectoration– 3 months Coughing up blood – 1 month Fever – 1 month Breathlessness- 1 month
- 4. HISTORY OF PRESENTINGILLNESS Patient was apparently normal before 3 months. Following which he developed • COUGH – 3 MONTHS - initially non productive then productive - chronic in nature - no diurnal/seasonal/postural variation - no aggravating or relieving factors • EXPECTORATION– 3 MONTHS - 30-50 ml in quantity - purulent in nature, foul smelling - blood tinged occasionally
- 5. HISTORY OF PRESENTINGILLNESS • HEMOPTYSIS – 1 MONTH - 5-6 episodes in a day - fresh blood - 20-30 ml in a day - associated with purulent sputum • BREATHLESSNESS– 1 MONTH - insidious in onset - progressive in nature - MMRC Grade II-IV - Aggravated on exertion - Relieved by rest - Not associated with Orthopnea/ PND
- 6. HISTORY OF PRESENTINGILLNESS • FEVER – 1 MONTH - high grade - intermittent - not associated with evening rise of temperature - associated with chills - relieved by anti-pyretics
- 7. HISTORY OF PRESENTINGILLNESS • No H/O Wheeze • No H/O Night sweats • No H/O Hoarseness of voice • No H/O Pedal edema • No H/O Loss of weight • No H/O Loss of appetite • No H/O Reduced urine output • No H/O Regurgitation of food
- 8. PAST HISTORY Patientis a known case of Type 2 Diabetes mellitus – 10 years on OHAs Patient is a known case of Renal failure- unclassified – not on any treatment Not a known case of Systemic hypertension/ Coronary artery disease/ Bronchial asthma/ Hypothyroid/ Seizure disorder No history of contact with open case of Tuberculosis No History of Exanthematous fever No History of Aspiration
- 9. PERSONAL HISTORY Takesmixed diet Normal bladder habits Normal sleep and appetite Used to Alcohol consumption Not used to smoking or tobacco chewing No other adverse social habits
- 10. FAMILY HISTORY NoH/O similar illness in the family members No H/O any open case of Tuberculosis in the family
- 11. . Cough 01 Expectoration 02 . Hemoptysis 03 . Breathlessness 04 . SUMMARYOF HISTORY Co-morbids 06 Type 2 Diabetes Mellitus Renal failure Fever 05 .
- 12. GENERAL EXAMINATION Patientis Conscious, Oriented, Co-operative, Afebrile Moderately built and nourished Comfortable at rest Pallor present Clubbing present Bilateral pitting pedal edema present, extending up to mid calf No cyanosis Not icteric No generalised lymphadenopathy JVP - Normal
- 13. GENERAL EXAMINATION Halitosispresent No Gynaecomastia No External markers of Tuberculosis No External markers of Bronchogenic carcinoma
- 14. VITALS PULSE –81/minute, regular rhythm, Normal in volume and no special character Palpable in all peripheral vessels BLOOD PRESSURE – 130/80 mm of Hg, Measured in Right upper arm, in sitting posture RESPIRATORY RATE – 16/minute, Abdomino-thoracic type SATURATION – 98% in room air CBG – 142 mg/dL Temperature – 98.7 F
- 15. EXAMINATION OF THE RESPIRATORYSYSTEM UPPER RESPIRATORY TRACT: Oral Cavity Poor oral hygiene Dental caries seen NOSE No DNS/Nasal polyps No Sinus tenderness PHARYNX No Post nasal drip
- 16. RESPIRATORY SYSTEM INSPECTION TRACHEA :Appears to be midline APICAL IMPULSE – appears to be normal CHEST WALL Appears symmetrical No visible pulsations/sinus/scars
- 17. RESPIRATORY MOVEMENTS AREA RIGHTLEFT UPPER ANTERIOR CHEST REDUCED Normal LOWER ANTERIOR CHEST REDUCED Normal UPPER POSTERIOR CHEST REDUCED Normal LOWER POSTERIOR CHEST REDUCED Normal
- 18. PALPATION TRACHEA : Inmidline APICAL IMPULSE - Left 5th Intercostal space half an inch medial to the midclavicular line SPINE Normal position No spinal tenderness
- 19. RESPIRATORY MOVEMENTS AREA RIGHTLEFT UPPER ANTERIOR CHEST REDUCED Normal LOWER ANTERIOR CHEST REDUCED Normal UPPER POSTERIOR CHEST REDUCED Normal LOWER POSTERIOR CHEST REDUCED Normal
- 20. VOCAL FREMITUS AREAS RIGHTLEFT Supra clavicular INCREASED Normal Infra clavicular INCREASED Normal Mammary INCREASED Normal Axillary Normal Normal Infra-axillary DECREASED DECREASED Suprascapular DECREASED Normal Interscapular DECREASED Normal Infrascapular DECREASED DECREASED
- 21. PERCUSSION DEFERRED in viewof patient having persistent hemoptysis.
- 22. AUSCULTATION- breath sounds AREASRIGHT LEFT Supra clavicular Cavernous Vesicular Infra clavicular Cavernous Vesicular Mammary Cavernous Vesicular Axillary Vesicular Vesicular Infra-axillary Absent Absent Suprascapular Cavernous Vesicular Interscapular Absent vesicular Infrascapular Absent Absent
- 23. VOCAL RESONANCE AREAS RIGHTLEFT Supra clavicular INCREASED Normal Infra clavicular INCREASED Normal Mammary INCREASED Normal Axillary Normal Normal Infra-axillary DECREASED DECREASED Suprascapular DECREASED Normal Interscapular DECREASED Normal Infrascapular DECREASED DECREASED
- 24. ADVENTITIOUS SOUNDS COARSE EXPIRATORYCREPITATIONS POST TUSSIVE CREPITATIONS Heard over Right Supra clavicular, infra clavicular, Mammary and Right Supra-scapular regions
- 25. OTHER SYSTEM EXAMINATION CARDIOVASCULARSYSTEM • First and second heart sounds heard • No murmur GASTROINTESTINAL SYSTEM - Soft, Non tender - No clinical organomegaly CENTRAL NERVOUS SYSTEM • Conscious, oriented • Co-operative • Higher mental functions - Normal
- 26. DIFFERENTIAL DIAGNOSIS 1. TUBERCULOUSCAVITY 2. LUNG ABSCESS 3. CAVITY – FUNGAL BALL 4. PULMONARY MUCORMYCOSIS
- 27. INVESTIGATIONS CBC 18/06 21/0630/06 07/07 10/07 22/07 Hb 9.5 9.0 8.4 9.2 8.9 10.2 TC 19000 28,200 16000 17410 13300 9800 DC 76/15/11 833/11 67/21/8 73/18/7 79/15/5 49/33/15 Platelets 2,41,000 2,76,000 3,59,000 3,87,000 4,14,000 3,71,000
- 28. LIVER FUNCTION TESTS 18/0621/06 30/06 07/07 10/07 22/07 Bilirubin -Total 0.8 0.9 0.6 0.7 0.7 0.5 Bilirubin - Direct 0.6 0.5 0.4 0.4 0.4 0.3 AST 84 50 54 43 36 18 ALT 36 21 13 21 17 14 ALP 286 287 140 264 185 104 T.Protein 6.5 7.1 7.3 7.3 7.5 7.3 S. Albumin 2.2 4.0 3.9 3.8 3.4 4.0
- 29. RENAL FUNCTION TESTS 18/0621/06 30/06 07/07 10/07 22/07 RBS 111 164 167 134 195 150 UREA 79 69 47 114 84 39 Creatinine 3.1 2.7 2.5 3.9 2.8 1.8 Sodium 135 134 135 132 135 138 Potassium 4.9 5.6 4.1 4.5 4.1 4.3
- 30. OTHER INVESTIGATIONS • PT/INR,aPTT – within normal limits • BLOOD GROUPING – B POSITIVE • VIRAL MARKERS –HBV,HCV- Negative • ICTC – Negative • FEVER PROFILE – Negative • BLOOD CULTURE – Negative • URINE C/S - Negative • ECHOCARDIOGRAPHY – Normal study
- 31. SPUTUM ANALYSIS • AFB–Smear negative • KOH– No fungal elements seen • C/S– Few pus cells and epithelial cells seen GPC Pairs in long chain Throat commensals grown in culture • CBNAAT– MTB Not detected • FUNGAL C/S – RHIZOPUS grown in culture
- 32. PLEURAL FLUID ANALYSIS •GLUCOSE – 50 • LDH – 124 • PROTEIN – 3.2 • CELL COUNT- <15 cells • CYTOLOGY– • MODIFIED LIGHT’S CRITERIA – EXUDATIVE EFFUSION • AFB – Negative for AFB • ADA – within normal limits
- 33. PLEURAL FLUID ANALYSIS FUNGAL C/S – Aspergillus niger grown in culture PLEURAL FLUID C/S: ACIENETOBACTER species grown in culture SENSITIVE – Piptaz, Amikacin, Cefepime, Meropenem, Ceftazidime INTERMEDIATE –Ciprofloxacin RESISTANT – Gentamicin
- 36. RADIOLOGICAL INVESTIGATIONS • CHESTX-RAY PA VIEW - Walled off cavity with air fluid levels - Bilateral costo-phrenic angles blunted • CT CHEST - F/S/O Cavitatory pneumonia with - Bilateral pleural effusion (L>R) • ULTRASOUND ABDOMEN - Liver – Normal echoes - Right Grade 1 RPD - Left moderate pleural effusion •
- 38. CT CHEST-REPEAT (07/07/22) Multiplecollection with air fluid levels noted in Right Upper, Middle lobe with Upper lobe collapse Bilateral pleural effusion – Right>Left Consolidation noted in superior segment of Right lower lobe F/S/O LUNG ABSCESS
- 40. LUNG ABSCESS with FUNGALINFECTION BILATERAL MODERATE PLEURAL EFFUSION
- 41.
- 42. WHY THIS CASE? ●This is a straightforward diagnosis ● But the intricacies involved in the management of this particular patient owing to poly-microbial infections
- 43. PATIENT MONITORING Week 2 Week1 Pleural fluid C/s Aspergillus Niger beta galactomannan levels elevated Week 3 Week 4
- 44. TREATMENT: • Nasal Oxygen •Inj Meropenem 500 mg IV BD • Inj.Tranexamic acid 500 mg IV bd • Inj. Frusemide 40 mg IV bd • Inj Human Insulin SC • T. Voriconazole 100 mg OD – 10 days
- 45. PATIENT MONITORING Week 2 SputumC/S – RHIZOPUS spp Sensitive to Liposomal Amphotericin B Week 1 Pleural fluid C/s Aspergillus Niger beta galactomannan levels elevated Week 3 Week 4
- 46. TREATMENT: • Nasal Oxygen •Inj Meropenem 500 mg IV BD • Inj.Tranexamic acid 500 mg IV bd • Inj. Frusemide 40 mg IV bd • Inj Human Insulin SC • Inj.Liposomal Amphotericin B – 24 days
- 47. PATIENT MONITORING Week 2 SputumC/S – RHIZOPUS spp Sensitive to Liposomal Amphotericin B Week 1 Pleural fluid C/s Aspergillus Niger beta galactomannan levels elevated Week 3 Pus C/S – Acienetobacter spp Pigtail failed to drain the pus. Hence the patient was put on ICD Week 4
- 48. TREATMENT: • Nasal Oxygen •Inj Meropenem 500 mg IV BD • Inj.Tranexamic acid 500 mg IV bd • Inj. Frusemide 40 mg IV bd • Inj Human Insulin SC • T. Voriconazole 100 mg OD – 10 days • Inj.Liposomal Amphotericin B – 24 days • ICD drain and ICD care
- 49. EXPERT OPINIONS THORACIC MEDICINE •Continue same line of management • Pleural fluid analysis • BRONCHIAL ARTERY EMBOLISATION – for recurrent hemoptysis CARDIOTHORACIC SURGERY OPINION • ICD Insertion since drain by pigtail catheter failed • Appropriate Antibiotics as per C/S reports • ICD care
- 50. PATIENT MONITORING Week 2 SputumC/S – RHIZOPUS spp Sensitive to Liposomal Amphotericin B Week 1 Pleural fluid C/s Aspergillus Niger beta galactomannan levels elevated Week 3 Pus C/S – Acienetobacter spp Pigtail failed to drain the pus. Hence the patient was put on ICD Week 4&5 Patient recovered well Sepsis recovered ICD removed
- 52. FOLLOW UP Patient hasbeen advised regular follow up in General medicine and Thoracic medicine OPD.
- 53.
- 54. LUNG ABSCESS • Alung abscess is circumscribed, purulent infection contained with the lung parenchyma • Most lung abscesses arise as a complication of aspiration. As such, they are typically poly-microbial and indolent in onset. • Less commonly, lung abscesses complicate acute mono-microbial infections with pyogenic bacteria. • Lung abscesses can also result from secondary infection of pre-existing lung cavities, bronchial obstruction, septic embolization, or direct extension from local infections such as empyema.
- 55. CLASSIFICATION PRIMARY LUNGABSCESSES result from direct infection of the pulmonary parenchyma in an otherwise healthy person. Most result from aspiration and, less commonly, from infection with pyogenic bacteria (eg, S. aureus). SECONDARY LUNG ABSCESSES occur when there is a predisposing condition such as bronchial obstruction (eg, foreign body, neoplasm), hematogenous spread (eg, right-sided endocarditis), or immunocompromise.
- 56. PATHOGENESIS 1. Aspiration 2. Hematogenousspread - Septic embolization during bacteremia (eg, tricuspid valve endocarditis, intravascular catheters, intravenous (IV) drug use, or Lemierre syndrome [ie, jugular vein suppurative thrombophlebitis]) 3. Direct extension- Extension of an empyema, subphrenic, or mediastinal abscess or a tracheo- or broncho-esophageal fistula.
- 57. 4. Bronchial obstruction– Endo-bronchial obstruction from a (eg, aneurysm, lymphadenopathy, tumor), bronchial stenosis, or from an inhaled foreign body may result in post-obstructive pneumonia that progresses to abscess formation presumably from poor local drainage. 5. Super-infection or spread of airway infection – May develop as a super-infection of pulmonary infarcts, congenital malformations, or lung contusion. Flares of bronchiectasis can lead to parenchymal infection that evolves into a lung abscess in a minority of patients.
- 59. PNEUMONIA CAUSED BYPYOGENIC BACTERIA 1. Staphylococcus aureus 2. Klebsiella pneumonia 3. Pseudomonas aeruginosa 4. Streptococcus pyogenes 5. Burkholderia pseudomallei 6. Hemophilus influenza type b 7. Legionella 8. Nocardia 9. Actinomycoces 10. Streptococcus pneumoniae
- 61. CLINICAL FEATURES- SYMPTOMS Fever Associatedwith chills Cough Productive Putrid and sour tasting Dyspnea Sometimes associated with hemoptysis (<10%)
- 62. Complete blood count Renalfunction test Liver function test Microbiological testing Medical history Risk factors, episodes of altered consciousness, neurological disesase Physical examination Upper airway Dysphagia Concomitant skin and renal disease Lab investigations Radiology Chest X ray – AP and lateral views CT- CHEST DIAGNOSTIC EVALUATION
- 64.
- 65. ADDITIONAL TESTING Bronchoscopy Trans thoracic needle aspiration Echocardiography Thoracocentesis
- 66.
- 67. DIFFERENTIAL DIAGNOSIS 1. Empyemawith air-fluid level (Hydropneumothorax) 2. Septic pulmonary emboli 3. Pulmonary embolism with infarction 4. Vasculitis (Granulomatosis with polyangitis) 5. Neoplasms 6. Pulmonary sequestration 7. Bullae or cysts with air fluid levels
- 68. DIFFERENTIAL DIAGNOSIS 08.Bronchiestasis 09.Cryptogenic organisingpneumonia 10.Sarcoidosis 11.Rheumatoid nodules 12.Pulmonary langerhan histiocytosis 13.Foreign body aspiration
- 69. Cefoperazone sulbactam 3gqid Imipenem or Meropenem Clindamycin 600 mg IV tds Moxifloxacin 400 mg od Levofloxacin 70 mg od with Metronidazole 500 mg tds Empirical antibiotics Invasive procedures Trans-thoracic catheter drainage Transbronchoscopic catheter drainage Lobectomy or Pneumonectomy using VATS TREATMENT
- 70. ASPERGILLUS Aseptate and unbranched Mostlygreen and black in color Disease causing ability is high DOC - VORICONAZOLE RHIZOPUS Has Rhizoid and a stolon Black color and looks like a cotton candy DOC – AMPHOTERICIN B
- 71.
- 72. circumscribed area ofpus or necrosis in the pulmonary parenchyma caused by microbial infection Definition 01 Causes 02 Aspiration Pyogenic bacteria Polymicrobial Diagnosis 03 Differential Diagnosis 04 TAKE HOME POINTS Review 06 Review the diagnosis if the treatment is not working. Treatment 05 Antibiotics Invasive procedures
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