Abscess of lung with pneumonia - Clinicals, Diagnosis, and Management

Pulmonology

Clinicals - History

Fact Explanation
A diagnosed patient with pneumonia Lung abscess is usually suspected when a diagnosed patient with lower respiratory tract infection fails to respond to the conventional and, assumed as adequate antibiotics. The commonest causative organisms for lung abscesses are the anaerobic bacteria (in cases of aspiration pneumonia), aerobic bacteria (rare but in cases of community aqcuired pneumonia), and Mycobacterium. A lung abscess develops when a bacterial infection causes necrosis and produces cavities in the lung parenchyma. A diagnosed patient with pneumonia
Lung abscess is usually suspected when a diagnosed patient with lower respiratory tract infection fails to respond to the conventional and, assumed as adequate antibiotics. The commonest causative organisms for lung abscesses are the anaerobic bacteria (in cases of aspiration pneumonia), aerobic bacteria (rare but in cases of community aqcuired pneumonia), and Mycobacterium. A lung abscess develops when a bacterial infection causes necrosis and produces cavities in the lung parenchyma.
A risk factor for developing pneumonia and lung abscess The commonest risk factors for aspiration pneumonia are are alcoholism related stupor, neurological disability, advanced age and lung malignancies. Once pneumonia is there, the predisposing factors for development of a lung abscess are immunosuppression, steroid therapy, carcinoma at a distant site, alcoholism, and lung cancer. It's more common in males than females. A risk factor for developing pneumonia and lung abscess
The commonest risk factors for aspiration pneumonia are are alcoholism related stupor, neurological disability, advanced age and lung malignancies. Once pneumonia is there, the predisposing factors for development of a lung abscess are immunosuppression, steroid therapy, carcinoma at a distant site, alcoholism, and lung cancer. It's more common in males than females.
Fever Some patients present with fever of unknown origin and some patients present with high fever with chills. Fever is one of the commonest symptoms in lung abscess. Fever
Some patients present with fever of unknown origin and some patients present with high fever with chills. Fever is one of the commonest symptoms in lung abscess.
Cough with sputum production Productive cough with variable sputum is one of the commonest features in lung abscess. The sputum may be colored, depending on the infected organism, and foul-smelling. There can be tinges of blood also. Cough with sputum production
Productive cough with variable sputum is one of the commonest features in lung abscess. The sputum may be colored, depending on the infected organism, and foul-smelling. There can be tinges of blood also.
Chest pain Chest pain of pleuritic nature is a common feature in lung abscess and pneumonia. But chest pain should be evaluated since it can be a feature of other complications as well. Chest pain
Chest pain of pleuritic nature is a common feature in lung abscess and pneumonia. But chest pain should be evaluated since it can be a feature of other complications as well.
Non-specific B-symptoms Night sweats, low grade fever and weight loss has also been reported in chronic lung abscesses. Non-specific B-symptoms
Night sweats, low grade fever and weight loss has also been reported in chronic lung abscesses.

Clinicals - Examination

Fact Explanation
Fever Because of necro-inflammation in the lung parenchyma. IT could be a low grade nocturnal fever in cases of chronic lung abscesses, or high fever with chills in acute lung abscess and bacterial pneumonia. It's one of the commonest presentations. Fever
Because of necro-inflammation in the lung parenchyma. IT could be a low grade nocturnal fever in cases of chronic lung abscesses, or high fever with chills in acute lung abscess and bacterial pneumonia. It's one of the commonest presentations.
Digital clubbing Nail clubbing develops sub-acutely in chronic suppurative conditions like lung abscess and empyema. It should be evaluated according to the stage of clubbing. Digital clubbing
Nail clubbing develops sub-acutely in chronic suppurative conditions like lung abscess and empyema. It should be evaluated according to the stage of clubbing.
Cyanosis Since there is an inflammation of the lung tissue which is important in gas exchange, there is going to be an oxygen un-saturation of blood, evident as bluish discolouration of tongue, mucus membranes (central cyanosis) and nail beds (peripheral cyanosis) . Cyanosis
Since there is an inflammation of the lung tissue which is important in gas exchange, there is going to be an oxygen un-saturation of blood, evident as bluish discolouration of tongue, mucus membranes (central cyanosis) and nail beds (peripheral cyanosis) .
Poor oral hygiene One of the commonest risk factor for lung abscess following aspiration pneumonia. Poor oral hygiene
One of the commonest risk factor for lung abscess following aspiration pneumonia.
Tachypnea Due to hypoxia and sympathetic stimulation. Taken alone, it has no diagnostic value in pneumonia. Tachypnea
Due to hypoxia and sympathetic stimulation. Taken alone, it has no diagnostic value in pneumonia.
Features of respiratory distress In severe pneumonia or the infection progressing to acute respiratory distress syndrome. Use of accessory muscles for breathing, tachypnea and tracheal tug are common findings. Features of respiratory distress
In severe pneumonia or the infection progressing to acute respiratory distress syndrome. Use of accessory muscles for breathing, tachypnea and tracheal tug are common findings.
Features of lung consolidation The features of lung damage and consolidation might be obvious in respiratory system examination such as reduced lung expansion, reduced air entry, more pronounced vocal resonance and dull note for percussion. Features of lung consolidation
The features of lung damage and consolidation might be obvious in respiratory system examination such as reduced lung expansion, reduced air entry, more pronounced vocal resonance and dull note for percussion.

Investigations - Diagnosis

Fact Explanation
Complete blood count To detect leucocytosis or leucopenia together with shifts of differential count. It can direct the diagnosis to the probable causative organism groups. Complete blood count
To detect leucocytosis or leucopenia together with shifts of differential count. It can direct the diagnosis to the probable causative organism groups.
Sputum for microbiological studies Examination of sputum is important in identifying the causative micro-organism. In the cases where the patient is able to produce sputum, then properly labeled sputum in the specific container should be sent for microscopy. But when the patient is unable to do so, sputum induction should be performed. The required microbiological studies are Gram stain, culuture and antibiotic sensitivity. Sputum for microbiological studies
Examination of sputum is important in identifying the causative micro-organism. In the cases where the patient is able to produce sputum, then properly labeled sputum in the specific container should be sent for microscopy. But when the patient is unable to do so, sputum induction should be performed. The required microbiological studies are Gram stain, culuture and antibiotic sensitivity.
Sputum for acid-fast bacilli If tuberculous abscess is suspected. But sputum may not be positive unless the abscess ruptures into an airway. Sputum for acid-fast bacilli
If tuberculous abscess is suspected. But sputum may not be positive unless the abscess ruptures into an airway.
Chest X-ray The main radiological feature in plain erect chest X-ray is a cavity with an irregular inside layer and air-fluid level. Most of the time the cavities are round in shape, and there is a thick area of consoliation around the cavity. These cavitatory lesions are seen in other conditions as well, i.e. infected bulla, cavitary tumor, mycobacterial infection, pulmonary infarction, pulmonary sequestration, and vasculitis. Chest X-ray
The main radiological feature in plain erect chest X-ray is a cavity with an irregular inside layer and air-fluid level. Most of the time the cavities are round in shape, and there is a thick area of consoliation around the cavity. These cavitatory lesions are seen in other conditions as well, i.e. infected bulla, cavitary tumor, mycobacterial infection, pulmonary infarction, pulmonary sequestration, and vasculitis.
Contranst-enhanced computed-tomography of chest More reliable than an X-ray. Vascularity also can be viewed in cases where malignancy is suspected. Contranst-enhanced computed-tomography of chest
More reliable than an X-ray. Vascularity also can be viewed in cases where malignancy is suspected.

Investigations - Management

Fact Explanation
Hemoglobin level The pre-operative hemoglobin count allows the surgeon to correct it with blood before any surgical procedure. Post-operative hemoglobin count is an important predictor in mortality. Hemoglobin level
The pre-operative hemoglobin count allows the surgeon to correct it with blood before any surgical procedure. Post-operative hemoglobin count is an important predictor in mortality.
Platelet count Both low and high platelet counts are associated with undesirable outcomes following a surgery. Platelet count
Both low and high platelet counts are associated with undesirable outcomes following a surgery.
Renal functions Investigations to assess renal functions i.e. urine full report, serum creatine, blood urea, serum electrolytes, should be evaluated before the surgery to prevent acute renal failure happening post-operatively. Renal functions
Investigations to assess renal functions i.e. urine full report, serum creatine, blood urea, serum electrolytes, should be evaluated before the surgery to prevent acute renal failure happening post-operatively.
Liver functions To assess the fitness of the liver. The required investigations are mainly transaminases. Liver functions
To assess the fitness of the liver. The required investigations are mainly transaminases.
Lung functions Lung functions are a must in all the patients before any procedure or major surgery since lung functions are already deranged because of the illness. Lung functions
Lung functions are a must in all the patients before any procedure or major surgery since lung functions are already deranged because of the illness.
Electrocardiogram To assess cardiac status and some pulmonary abnormalities, i.e. pulmonary hypertension. Electrocardiogram
To assess cardiac status and some pulmonary abnormalities, i.e. pulmonary hypertension.

Management - Supportive

Fact Explanation
Optimize co-morbid conditions Presence of co-morbid conditions increases the morbidity and mortality in any medical condition. In emergency setting, of-course there isn't much valuable time left for dwelling on prolonged history taking. In cases where the elderly or immobilized patients aspirating frequently, and also in cases where lung abscess is secondary to another lung disease such as lung carcinoma, ensuring that the patient's quality of life is improved is important. Medical and surgical palliative care should be discussed with different specialists, so sometimes a multi-disciplinary team is needed. Most important are chest physiotherapy, stenting the airways, analgesics and antipyretics. All these include de-briefing the patient and the family previous to them. Optimize co-morbid conditions
Presence of co-morbid conditions increases the morbidity and mortality in any medical condition. In emergency setting, of-course there isn't much valuable time left for dwelling on prolonged history taking. In cases where the elderly or immobilized patients aspirating frequently, and also in cases where lung abscess is secondary to another lung disease such as lung carcinoma, ensuring that the patient's quality of life is improved is important. Medical and surgical palliative care should be discussed with different specialists, so sometimes a multi-disciplinary team is needed. Most important are chest physiotherapy, stenting the airways, analgesics and antipyretics. All these include de-briefing the patient and the family previous to them.

Management - Specific

Fact Explanation
Prolonged course of antibiotics Prolonged (1-3 months) oral antibiotics are the commonest mode of management. Oral clindamicin is the drug of choice. Metronidazole, moxifloxacin are also valuable. Even though it is so, medical treatment can be failed if the patient has poor prognostic factors, such as a large abscess cavity (> 6 cm), compromised immunity, neoplasm, advanced age, reduced level of consciousness, or infection with certain aerobic pathogens (Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus). Prolonged course of antibiotics
Prolonged (1-3 months) oral antibiotics are the commonest mode of management. Oral clindamicin is the drug of choice. Metronidazole, moxifloxacin are also valuable. Even though it is so, medical treatment can be failed if the patient has poor prognostic factors, such as a large abscess cavity (> 6 cm), compromised immunity, neoplasm, advanced age, reduced level of consciousness, or infection with certain aerobic pathogens (Klebsiella pneumoniae, Pseudomonas aeruginosa, Staphylococcus aureus).
Surgical drainage Some almost 20% of the patients with lung abscesses require surgical or percutaneous drainage due to medical treatment failure at some point. CT-guided drainage offers best option and highest success rate. Endoscopy, ultrasound also can be used. Surgical drainage
Some almost 20% of the patients with lung abscesses require surgical or percutaneous drainage due to medical treatment failure at some point. CT-guided drainage offers best option and highest success rate. Endoscopy, ultrasound also can be used.
Open surgery Indicated in cases where there is a malignancy predisposing the lung cavitation (or suspected of a malignancy) or there are multiple cavities. Open surgery
Indicated in cases where there is a malignancy predisposing the lung cavitation (or suspected of a malignancy) or there are multiple cavities.

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