Lung abscesses are caused due to microbial infection when an area of infected lung becomes necrotic, which results in the development of a cavity containing pus or necrotic debris within the lung itself (Figure 1). In contrast to pleural infection, the incidence and mortality rate of lung abscesses have steadily declined since antibiotic era. The case report presents a 43-year-old patient with multiple lung abscesses.
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43-year-old homeless male patient presented to emergency department of University Hospital in Kosice mostly with abdominal main. Acute abdomen was excluded by surgeon. Because of chest x-ray with bilateral pulmonary infiltrates, worse on the right side, the patient was admitted to Department of Pneumology and Phtiseology.
Current disease: Few days prior to presentation, patient´s symptoms worsened. He developed shortness of breath, productive cough with expectoration of pus and weakness. He didn´t eat anything and did not remember all the events from the couple of previous days. All he could remember was that somebody had called an ambulance for him.
The patients had a history of lung tuberculosis with no more detailed information. Chronically he was not treated for any diseases, he did not take any regular medication. He was homeless living in a garden shelter without electricity and pouring water. He admitted smoking 60 cigarettes a day and drinking of alcohol.
Physical examination revealed dyspnoea, low-grade fever, signs of acral cyanosis (pulse oximetry without oxygen inhalation was 77%), cachexia with low hygiene standard, pale conjunctives, white coated tongue, caries teeth. On lung auscultation there were decreased breath sounds with diffuse silent crackles over the right lung area, pulse rate was regular of 130/minute. Physical finding on abdominal region and lower limbs was normal.
Blood tests demonstrated increased C-reactive protein (CRP = 184 mg/l), normal white cell count, severe microcytic hypochromic anaemia (hemoglobin = 72,2 g/l), hypoproteinemia and hypochloremia.
The chest X ray on the day of admission showed huge right lung consolidation with maximum concentration on the edge of upper and middle zone where two thick-walled cavities (6 and 4 cm diameter) with an air-fluid level were recognized. Infiltrates were present also in right lower lung zone, left middle and lower lung zone (Figure 2). Computed tomography scans with contrast showed extensive fibro-cavernous changes of right lung with the presence of three cavitary lesions with air-fluid level and pneumonic infiltration of the right middle and lower lobe.
Because of X ray picture of multiple lung abscesses the patient was empirically treated with intravenous antibiotic combination (3rd generation cephalosporine, gentamicin, metronidazole). Antimycotic drug (fluconazole) was added later because of mycotic esophagitis diagnosed with endoscopy. Sputum cultures were reported as growing Klebsiella sp. Drug susceptibility tests showed good sensitivity to ongoing antibiotics. Mycobacterium tuberculosis was not detected in sputum, tuberculin skin test (Mantoux test) was negative. The patient required repeated blood transfusions due to anaemia. Besides that he also received nutritional support and oxygen therapy. His condition, laboratory parameters and repeated chest X rays were gradually improving (Figure 3-5). After 24-day stay he was discharged from hospital, He was recommended to continue in oral antibiotic therapy with quinolone for the next 21 days and chest X ray control performance in one month.
Multiple lung abscesses
The radiological appearances of a lung abscess may be mimicked by other pathologies, including: neoplastic lesions – excavating bronchial carcinoma, excavating tuberculosis, pulmonary vasculitis, pulmonary infarction, bullae and cysts, rheumatoid nodules, pneumoconiosis.
Most frequently, the lung abscess arises as a complication of aspiration pneumonia caused by mouth anaerobes. The patients who develop lung abscess are predisposed to aspiration and commonly have periodontal disease. Other mechanisms for lung abscess formation include bacteremia or tricuspid valve endocarditis causing septic emboli. Contributing factors for lung abscess are: elderly, dental/peridental infections, alcoholism, drug abuse, diabetes mellitus, coma, artificial ventilation, convulsions, neuromuscular disorders with bulbar disfunctions, malnutrition, therapy with corticosteroids, cytostatics or immunosuppressants, mental retardation, gastrooesophageal reflux disease, bronchial obstruction, inability to cough, sepsis.
In over 90% cases of lung abscess polymicrobial bacteria can be found. From anaerobic bacteria in lung abscess predominant isolates are Bacteroides sp., Porphyromonas sp., Fusobacterium and others. From aerobic bacteria predominant isolates in lung abscess are Staphylococcus aureus, Klebsiella sp., Pseudomonas aeruginosa, Streptococcus pneumoniae.
Symptoms may be acute or insidious in onset and commonly include cough, fever, chest pain, night sweats, weight loss and purulent or blood-stained sputum. There may be no specific examination findings or chest auscultation may mimic pneumonia. Anaemia is common in patients with chronic lung abscess and inflammatory markers are likely to be raised. Plain chest radiography classically demonstrates a well circumscribed opacity within the lung field, which often contains an air-fluid level. CT is usually required to distinguish a parenchymal abscess from empyema and may assist in the detection of neoplastic lesions.
Most patients are treated effectively with broad-spectrum antibiotics in the absence of a microbiological diagnosis. Blood cultures should be sent and sputum or bronchial washing fluid cultured if available but, frequently, no organism is identified.
A prolonged course of antibiotics is the foundation of treatment and, often, up to 8 weeks of treatment id required depending on clinical and radiological response. ß-lactam/ß-lactamase inhibitor in combination with clindamycin or metronidazole are the first choice of empiric treatment. General supporting measures include hyper caloric diet, correction of fluids and electrolytes and respiratory rehabilitation with postural drainage. Drainage procedures include percussion and positioning to increase drainage through the airways. Abscess greater than 6 cm in diameter or if symptoms lasts more than 12 weeks with appropriate therapy, have little chances for only conservative healing, and surgical therapy should be considered, if general condition allows. Options for surgery are: chest tube drainage or surgical resection of lung abscess with surrounding tissue.
Authors declare the case report will not be published in any national or international publications.
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citation: Trojová Ivana: Multiple lung abscesses. Multimedia support in the education of clinical and health care disciplines :: Portal of Pavol Jozef Šafárik University in Košice Faculty of Medicine [online] , [cit. 22. 10. 2019]. Available from WWW: https://portal.lf.upjs.sk/articles.php?aid=307. ISSN 1337-7000.