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Lung Abscess

Author: Nader Kamangar, MD, FACP, FCCP, FCCM, FAASM; Chief Editor: Ryland
P Byrd Jr, MD

Background
Lung abscess is defined as necrosis of the pulmonary tissue and 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. Both lung abscess and necrotizing pneumonia are manifestations of a similar
pathologic process. Failure to recognize and treat lung abscess is associated with poor clinical
outcome.
In the 1920s, approximately one third of patients with lung abscess died; Dr David Smith
postulated that aspiration of oral bacteria was the mechanism of infection. He observed that
the bacteria found in the walls of the lung abscesses at autopsy resembled the bacteria noted
in the gingival crevice. A typical lung abscess could be reproduced in animal models via an
intratracheal inoculum containing, not 1, but 4 microbes, thought to be Fusobacterium
nucleatum, Peptostreptococcus species, a fastidious gram-negative anaerobe, and, possibly,
Prevotella melaninogenicus.
Lung abscess was a devastating disease in the preantibiotic era, when one third of the patients
died, another one third recovered, and the remainder developed debilitating illnesses such as
recurrent abscesses, chronic empyema, bronchiectasis, or other consequences of chronic
pyogenic infections. In the early postantibiotic period, sulfonamides did not improve the
outcome of patients with lung abscess until the penicillins and tetracyclines were available.
Although resectional surgery was often considered a treatment option in the past, the role of
surgery has greatly diminished over time because most patients with uncomplicated lung
abscess eventually respond to prolonged antibiotic therapy.
Lung abscesses can be classified based on the duration and the likely etiology. Acute
abscesses are less than 4-6 weeks old, whereas chronic abscesses are of longer duration.
Primary abscess is infectious in origin, caused by aspiration or pneumonia in the healthy host;
secondary abscess is caused by a preexisting condition (eg, obstruction), spread from an
extrapulmonary site, bronchiectasis, and/or an immunocompromised state. Lung abscesses
can be further characterized by the responsible pathogen, such as Staphylococcus lung
abscess and anaerobic or Aspergillus lung abscess.
See the image below.

A thick-walled lung abscess.

Pathophysiology
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. A bacterial inoculum from the gingival crevice reaches
the lower airways, and infection is initiated because the bacteria are not cleared by the
patient's host defense mechanism. This results in aspiration pneumonitis and progression to
tissue necrosis 7-14 days later, resulting in formation of lung abscess.
Other mechanisms for lung abscess formation include bacteremia or tricuspid valve
endocarditis, causing septic emboli (usually multiple) to the lung. Lemierre syndrome, an
acute oropharyngeal infection followed by septic thrombophlebitis of the internal jugular
vein, is a rare cause of lung abscesses. The oral anaerobe F necrophorum is the most common
pathogen.
Microbiology
Because of the difficulty obtaining material uncontaminated by nonpathogenic bacteria
colonizing the upper airway, lung abscesses rarely have a microbiologic diagnosis.
Published reports since the beginning of the antibiotic area have established that anaerobic
bacteria are the most significant pathogens in lung abscess. In a study by Bartlett et al in
1974, 46% of patients with lung abscesses had only anaerobes isolated from sputum cultures,
while 43% of patients had a mixture of anaerobes and aerobes. [1] The most common
anaerobes are Peptostreptococcus species, Bacteroides species, Fusobacterium species, and
microaerophilic streptococci.
Aerobic bacteria that may infrequently cause lung abscess include Staphylococcus aureus,
Streptococcus pyogenes, Streptococcus pneumoniae (rarely), Klebsiella pneumoniae,
Haemophilus influenzae, Actinomyces species, Nocardia species, and gram-negative bacilli.
Challenging current expert opinion, a study by Wang et al suggested that the bacteriologic
characteristics of lung abscess have changed.[2] In a series of 90 patients with communityacquired lung abscess in Taiwan, anaerobes were recovered from just 28 patients (31%); the
predominant bacterium was K pneumoniae, in 30 patients (33%). Another significant finding
was that the rate of resistance of anaerobes and Streptococcus milleri to clindamycin and
penicillin increased compared with previous reports.[3]
Nonbacterial and atypical bacterial pathogens may also cause lung abscesses, usually in the
immunocompromised host. These microorganisms include parasites (eg, Paragonimus and
Entamoeba species), fungi (eg, Aspergillus, Cryptococcus, Histoplasma, Blastomyces, and
Coccidioides species), and Mycobacterium species.
Epidemiology
Frequency
United States
The frequency of lung abscess in the general population is not known.

Mortality/Morbidity
Most patients with primary lung abscess improve with antibiotics, with cure rates
documented at 90-95%.
Host factors associated with a poor prognosis include advanced age, debilitation,
malnutrition, human immunodeficiency virus infection or other forms of immunosuppression,
malignancy, and duration of symptoms greater than 8 weeks. [4] The mortality rate for patients
with underlying immunocompromised status or bronchial obstruction who develop lung
abscess may be as high as 75%.[5]
Aerobic organisms, frequently hospital acquired, are associated with poor outcomes. A
retrospective study reported the overall mortality rate of lung abscesses caused by mixed
gram-positive and gram-negative bacteria at approximately 20%.[6]
Sex
A male predominance for lung abscess is reported in published case series.
Age
Lung abscesses likely occur more commonly in elderly patients because of the increased
incidence of periodontal disease and the increased prevalence of dysphagia and aspiration.
However, a case series from an urban center with high prevalence of alcoholism reported a
mean age of 41 years.[7]
History
Symptoms depend on whether the abscess is caused by anaerobic or other bacterial infection.

Anaerobic infection in lung abscess


o Patients often present with indolent symptoms that evolve over a period of
weeks to months.
o The usual symptoms are fever, cough with sputum production, night sweats,
anorexia, and weight loss.
o The expectorated sputum characteristically is foul smelling and bad tasting.
o Patients may develop hemoptysis or pleurisy

Other pathogens in lung abscess


o These patients generally present with conditions that are more emergent in
nature and are usually treated while they have bacterial pneumonia.
o Cavitation occurs subsequently as parenchymal necrosis ensues.

o Abscesses from fungi, Nocardia species, and Mycobacteria species tend to


have an indolent course and gradually progressive symptoms.
Physical
The findings on physical examination of a patient with lung abscess are variable. Physical
findings may be secondary to associated conditions such as underlying pneumonia or pleural
effusion. The physical examination findings may also vary depending on the organisms
involved, the severity and extent of the disease, and the patient's health status and
comorbidities.

Patients with lung abscesses may have low-grade fever in anaerobic infections and
temperatures higher than 38.5C in other infections.

Generally, patients with in lung abscess have evidence of gingival disease.

Clinical findings of concomitant consolidation may be present (eg, decreased breath


sounds, dullness to percussion, bronchial breath sounds, coarse inspiratory crackles).

The amphoric or cavernous breath sounds are only rarely elicited in modern practice.

Evidence of pleural friction rub and signs of associated pleural effusion, empyema,
and pyopneumothorax may be present. Signs include dullness to percussion,
contralateral shift of the mediastinum, and absent breath sounds over the effusion.

Digital clubbing may develop rapidly.

Causes
The bacterial infection may reach the lungs in several ways. The most common is aspiration
of oropharyngeal contents.

Patients at the highest risk for developing lung abscess have the following risk
factors:
o Periodontal disease
o Seizure disorder
o Alcohol abuse
o Dysphagia

Other patients at high risk for developing lung abscess include individuals with an
inability to protect their airways from massive aspiration because of a diminished gag
or cough reflex, caused by a state of impaired consciousness (eg, from alcohol or
other CNS depressants, general anesthesia, or encephalopathy).

Infrequently, the following infectious etiologies of pneumonia may progress to


parenchymal necrosis and lung abscess formation:
o Pseudomonas aeruginosa
o K pneumoniae
o S aureus (may result in multiple abscesses)
o Streptococcus pneumoniae
o Nocardia species
o Fungal species

An abscess may develop as an infectious complication of a preexisting bulla or lung


cyst.

An abscess may develop secondary to carcinoma of the bronchus; the bronchial


obstruction causes postobstructive pneumonia, which may lead to abscess formation.

Differential Diagnoses

Alcoholism

Empyema, Pleuropulmonary

Hydatid Cysts

Infective Endocarditis

Lung Cancer, Non-Small Cell

Lung Cancer, Oat Cell (Small Cell)

Mycetoma

Mycobacterium Avium-Intracellulare

Mycobacterium Chelonae

Mycobacterium Kansasii

Nocardiosis

Pneumococcal Infections

Pneumocystis Carinii Pneumonia

Pneumonia, Aspiration

Pneumonia, Bacterial

Pneumonia, Fungal

Pulmonary Embolism

Sarcoidosis

Thrombophlebitis, Septic

Tuberculosis

Wegener Granulomatosis

Laboratory Studies

A complete white blood cell count with differential may reveal leukocytosis and a left
shift.

Obtain sputum for Gram stain, culture, and sensitivity.

If tuberculosis is suspected, acid-fast bacilli stain and mycobacterial culture is


requested.

Blood culture may be helpful in establishing the etiology.

Obtain sputum for ova and parasite whenever a parasitic cause for lung abscess is
suspected.

Imaging Studies

Chest radiography[8]
o A typical chest radiographic appearance of a lung abscess is an irregularly
shaped cavity with an air-fluid level inside. Lung abscesses as a result of
aspiration most frequently occur in the posterior segments of the upper lobes
or the superior segments of the lower lobes.
o The wall thickness of a lung abscess progresses from thick to thin and from illdefined to well-circumscribed as the surrounding lung infection resolves. The
cavity wall can be smooth or ragged but is less commonly nodular, which
raises the possibility of cavitating carcinoma.

o The extent of the air-fluid level within a lung abscess is often the same in
posteroanterior or lateral views. The abscess may extend to the pleural surface,
in which case it forms acute angles with the pleural surface.
o Anaerobic infection may be suggested by cavitation within a dense segmental
consolidation in the dependent lung zones.
o Lung infection with a virulent organism results in more widespread tissue
necrosis, which facilitates progression of underlying infection to pulmonary
gangrene.
o Up to one third of lung abscesses may be accompanied by an empyema. See
the images below.

o
Pneumococcal pneumonia complicated by lung necrosis and abscess
formation.

A lateral chest radiograph shows air-fluid level characteristic of lung abscess.

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.

A 42-year-old man developed fever and production of foul-smelling sputum.


He had a history of heavy alcohol use, and poor dentition was obvious on
physical examination. Chest radiograph shows lung abscess in the posterior
segment of the right upper lobe.

Chest radiograph of a patient who had foul-smelling and bad-tasting sputum,


an almost diagnostic feature of anaerobic lung abscess.

Computed tomography[8, 9]
o CT scanning of the lungs may help visualize the anatomy better than chest
radiography. CT scanning is very useful in the identification of concomitant
empyema or lung infarction.
o On CT scans, an abscess often is a rounded radiolucent lesion with a thick
wall and ill-defined irregular margins.
o The vessels and bronchi are not displaced by the lesion, as they are by an
empyema.
o The lung abscess is located within the parenchyma compared with loculated
empyema, which may be difficult to distinguish on chest radiographs.
o The lesion forms acute angles with the pleural surface chest wall. See the
image below.

A 42-year-old man developed fever and production of foul-smelling sputum.


He had a history of heavy alcohol use, and poor dentition was obvious on
physical examination. Lung abscess in the posterior segment of the right upper
lobe was demonstrated on chest radiograph. CT scan shows a thin-walled
cavity with surrounding consolidation.

Ultrasonography
o Peripheral lung abscesses with pleural contact or included inside a lung
consolidation are detectable using lung ultrasonography at the bedside.
o Lung abscess appears as a rounded hypoechoic lesion with an outer margin.
o If a cavity is present, additional nondependent hyperechoic signs are generated
by the gas-tissue interface.[10]

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