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8/11/2019 130225 Fok Lung Abscess Kalabay
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LUNG ABSCESS
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Definition
• Lung parenchyma in an area of infection
undergoes necrosis communication
with bronchi cavitation with formation of
air-fluid level. Chronic process.
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Lung abscess with bronchopleural
fistula
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Causative agents of lung abscess
• Most commonly: combination of anaerobeand microaerophilic bacteria(Fusobacterium nucleatum) , often in
association with aerobes• Common in staphylococcal, Klebsiella,
Pseudomonas, pneumococci,Haemophilus influenzae and otherpneumonias, except for those caused byMycoplasma pneumoniae
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↓ Destructive pneumococcal pneumonia
Right lower lobe abscess in an alcoholic ↓
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Pulmonary tuberculosis presenting
as a lung abscess
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Lung abscess caused by Entamoeba histolytica
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Aspiration as a cause of lung abscess
• Aspiration of the contents of the mouth material plugs off a bronchus or bronchiole anaerobic environment the anaerobicbacteria that are always present grow.
Aspiration occurs:
• During an episode of unconsciousness(alcohol, drug overdose, head trauma,anesthesia, seizure, coma from any cause)
• Neuromuscular disease of oropharynx or
esophagus• Following operative procedure in the mouth.
• Poor oral hygiene.
• Gag reflex may be absent.
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Other pathogenesis of lung abscess
• Obstructive disease of the bronchus: tumor(Lung abscess in edentulous patient withnormal oral hygiene - tumor suggested).Bronchiectasis: predisposing factor.
• Subdiaphragmatic process: e.g., amebic
abscess of the liver right lower lobeinfection
• Metastasis from suppurative pelvic or jugularthrombophlebitis (usually caused byanaerobes)
• Metastasis from right-sided endocarditis(Staphylococcus - IV drug abusers)
• Metastasis from bacteremia from other sites.
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Clinical findings of lung abscess
A. Symptoms:
• Fever, cough productive of purulent sputum withor without blood, pleuritic chest pain (ifempyema developed).
• Lung abscess: History of fever, anorexia, weightloss, malaise, cough for days or weeks or evenmonths, with or without an initial acute onset.
B. Physical examination:
• Chest: dullness, amphoric breathing, rales (butoften negative). Clubbing of the finger mayoccur.
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Clubbing of the fingers in lung disease
• Chronic: Bronchiectasis, lung abscess, emphysema, chronic bronchitis
• Acute: lung cancer
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Laboratory findings of lung abscess
• Microscopic examination of the sputum: manyPMN leukocytes, a mixed flora of gram positivecocci in chain, gram negative bacilli, gramnegative cocci, and/or gram positive bacilli.
• Culture of the sputum: "normal flora" (no value!).Most commonly isolated: Fusobacterium,Peptostreptococcus, Peptococcus organisms,microphilic streptococci, Bacteroidesmelaninogenicus, Streptococcus pneumoniae.
• Blood culture.
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Chest X-ray in lung abscess
• Infiltrate ofpneumonia, often with
multiple cavities.
Well-defined cavities,
a rim of infiltrate.
• Air-fluid level -
patients lying on their
back.• Pleural effusion
empyema
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LUNG ABSCESS
• Development of pulmonarysymptoms about 1-2 weeksafter possible aspiration,bronchial obstruction, orprevious pneumonia
• Septic fever and sweats• Periodic sudden expectoration
of large amount of purulentsputum (sometimeshemoptysis)
• X-ray density with centralradiolucency and fluid level
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Radiography in lung abscess
• Chest X-ray and CT: lung abscess, necrotizing
pneumonia, empyema
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Differential diagnosis of lung
abscess
• Cavitating carcinoma
• Tuberculosis
• Fungal infection• Wegener granulomatosis
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Treatment of lung abscess• Antibiotics:
– Penicillin G: 1 -2 million units IV every 4 hours.
– Penicillin V: 0.5 - 1 g p.o. every 6 hours (afterimprovement with IV penicillin G).
– Clindamycin: 600 mg IV every 8 hours untilimprovement, then 300 mg p.o. every 6 hours.
– Other antibiotics: ampicillin, cephalotin, cefazolin,cephalexin, ampicillin-sulbactam, cefoxitin, penicillinG + metronidazole or ticarcillin-clavulinic acid.
– Antibiotics should be continued until the chest x-raystabilizes - a month or more.
• Postural drainage• Bronchoscopy: free airways
• Empyema should be drained!
• Septic phlebitis: heparin therapy, vein ligation
• Surgical treatment: lobectomy