12. Pulmonary infections-lung abscess and gangraena.

Lung abscess
The chest radiograph shows a cavity with a fluid level or in myecetoma a fungal ball.
Most acute abscesses resolve with appropriate antibiotic therapy and postural
drainage. Surgery is avoided. Small radiologically sited drains are used sometimes in
the intensive care unit.
Causes of lung abscess
Specific pneumonia
1. Streptococcal
2. Staphylococcal
3. Pneumococcal
4. Klebsiella spp.
5. Anaerobic
Bronchial obstruction
1. Carcinoma
2. Carcinoid
3. Foreign body
4. Postoperative atelectasis
Chronic respiratory sepsis
1. Sinusitis
2. Tonsillitis
3. Dental infection
4. Septicaemia
Penetrating lung injury
Lung Abscess
The incidence of lung abscess is decreasing in frequency as a result of use of
antibiotics. A lung abscess may occur from an infection behind a blocked bronchus.
The infection is usually anaerobic and may be associated with alcohol abuse, a
debilitated or elderly individual, or esophageal disease with aspiration.
Lung abscess used to occur after tonsillectomy or tooth extraction, but this has
become a rare event.
Hematogenous spread from bacteremia may occur if congestive heart failure or
debilitating disease is present, such as in the very old, the very young, patients who
use intravenous drugs, and patients on corticosteroids.
These areasof infection are usually multiple and rarely require operative intervention.
Staphylococcus bacteremia is frequently associated with lung abscess. Necrotizing
pneumonia from Klebsiella may rapidly destroy the involved lung with minimal
surrounding reaction. This cause is decreasing with use of antibiotics.
Rupture of a lung abscess may yield empyema and pneumothorax. Lung abscess may
also be superimposed on structural abnormalities, for example, as a bronchogenic
cyst, sequestration, bleb, or tuberculosis or fungal cavities.
In patients with aspiration progressing to lung abscess, the location is more commonly
found on the right than the left. The location may occur in the lateral divisions of the

anterior and posterior segments of the upper lobe, the axillary subsegment, or the
superior segment of the lower lobe.
Clinical features are similar to those of pneumonia, including fever, cough,
leukocytosis, pleuritic pain, and sputum production.
The chest radiograph and the CT scan of the chest may demonstrate a rounded area of
consolidation early and an air-fluid level on upright or decubitus chest radiography
later.
The differential diagnosis includes loculated empyema, which may be treated with
drainage, epiphrenic diverticulum (in which the patient is not septic), or tuberculosis
or fungus cavity.
These cavities do not retain fluid, so no air-fluid level is present; however, they may
contain debris or a fungus ball.
Aspergillus may present in this manner.
Medical management is with antibiotics and pulmonary care (e.g., re-expansion).
Bronchoscopy may be performed for diagnosis to rule out foreign body, stenosis, or
cancer. It also may be used for treatment to assist in drainage of the cavity either
directly or by way of transbronchial catheterization of the cavity.
Most patients (85% to 95%) respond to medical management with rapid decrease in
fluid, collapse of the walls, and complete healing in 3 to 4 months.
Patients with long-standing symptoms greater than 3 months before treatment or
cavities greater than 4 to 6 cm are less likely to respond.
Surgical therapy is indicated for persistent cavity (>2 cm and thick walled) after 8
weeks of medical therapy, failure to clear sepsis, hemoptysis (often small sentinel
hemorrhage before a massive hemorrhage), and to exclude cancer.
If a lung abscess ruptures into the pleural cavity, simple drainage may suffice, with
the patient being managed for empyema or bronchopleural fistula.
Lobectomy is typically required; the mortality rate is 1% to 5%.
Occasionally, external drainage may be required in critically ill patients if pleural
symphysis has occurred.

Gangrene of the Lung.

Definition.A Putrefactive Necrosis of the Lung, either circumscribed or diffuse.
Etiology:
Gangrene of the lung can only occur where the organ has previously been weakened,
hence is always a secondary affection. Putrefactive bacteria thrive in the necrotic soil,
but whether the cause or the result of the necrosis is a mooted question. It may follow:

lobar pneumonia,

aspiration-pneumonia,

broncho-pneumonia,

fetid bronchitis,

thrombosis of the pulmonary artery,

rupture of a bronchus,

from an ulcerated or cancerous esophagus,

from pressure due to tumors or thoracic aneurism,

and from sepsis due to protracted adynamic fevers.

Pathology.In the diffuse, when due to lobar pneumonia or the plugging of a large
branch of the pulmonary artery, a large part; of the lung becomes a dark, greenish
brown, or a black, fetid, pultaceous mass, from the center of which softening rapidly
proceeds, forming an irregular cavity, containing a foul-smelling, disgusting, greenish
fluid.
In the circumscribed form, the disease may involve one or both lungs, usually
selecting the dependent portions, and the right more often than the left. The part
affected assumes a dark-brown or greenish hue, becomes soft, and early assumes a
fetid purplish mass; necrosis beginning in the center, a cavity soon forms. If located
near the pleura, putrefaction may occur, giving rise to pyopneumothorax. A bronchitis
is always an accompanying lesion, the bronchi containing an offensive and often
putrid mucus.
Not infrequently there is found in connection with this lesion, abscess of the brain,
liver, and spleen.
Symptoms.In addition to the symptoms of the primary disease, the cough becomes
more pronounced, and is attended by profuse expectoration of a peculiarly offensive
character. When allowed to stand, the expectorated material separates into three
layers; the upper, a yellowish, turbid brown froth; the middle layer, a clear watery
fluid; and the bottom layer, the heavier material, blood, pus, and shreds of lung tissue.
The microscope reveals putrefactive bacteria, pus, elastic tissue, fat, crystals, and
granular material.

The respiration is slightly increased in frequency, and the breath is offensive. Where
erosion of the blood-vessels occurs, hemorrhages take place, sometimes of an
alarming character.
There is some fever present in all cases; the patient loses flesh and strength, becomes
anemic, chills and night-sweats follow, and the evidence of sepsis is pronounced.
There is dullness on percussion in the earlier stages, followed by the sign of cavity
formation in later stages.
Diagnosis.The intense fetor of sputum and breath, the character of the
expectoration, the septic fever, and great emaciation, are symptoms that can hardly
mislead one in naming the disease.
3. Diagnostic laboratory blood test
A complete cell count and biochemistry is mandatory. Elevated white blood cells with
shiftto- left usually indicates for systemic inflammation or infection.
C-reactive protein, erythrocyte sedimentation rate and procalcitonin are also useful
infection indicators.
Blood culture is obtained if bacteremia is likely and serology test will be useful in
some instances of infection.
4. Sputum analysis
Obtaining adequate sputum for possible pathogens is essential to guide the use of
antibiotics. Prior to identifying the definite culprit pathogen, empiric antibiotics of
broadspectrum should be started as soon as possible.
Four common pathogens encountered in community-acquired pneumonia are
Streptococcus pneumonia, Haemophilus influenzae, Staphylococcus aureus and
Mycoplasma pneumoniae. Among the common pathogens, Streptococcus pneumonia
occupied more than 50% of all cases.
Gram stain, Acid-fast stain and rapid antigen test can assist differential diagnosis. A
positive gram stain for diplococcic has near 100% sensitivity for pneumococcal
infection but the specificity is poor (less than
5%).
Recently, polymerase chain reaction (PCR) becomes more and more popular in
detection of some pathogens, from throat swab or sputum, yielding rapid result to
guide our treatment strategy.
A multiplex PCR allows us to detect tuberculosis, Legionella spp, Mycoplasma
pneumoniae and C. Pneumonia. However, due to higher costs, such test is not
routinely applicable.
5. Bronchoscopy
Bronchoscopy is a useful tool to help evaluate the condition of trachea and bronchus.
Lobar torsion, most commonly encountered in right middle lobe following resection
of right upper lobe, and subsequent lobar gangrene can be diagnosed under
bronchoscopic findings of total obliteration of bronchial orifice.

Ischemic bronchial wall can also be demonstrated under bronchoscope. With

brushing, lavage with saline (BAL) and punch biopsy of suspected endobronchial
lesion may also assist proper diagnosis prior to definitive treatment.
Imaging Radiography, CT, angiography, nuclear scanning.
Prognosis.Though not necessarily fatal, the disease is always grave. Where the
former health of the patient has been. good and there is no tubercular taint, and the
patient is young or in middle life, recovery will occasionally take place.
Treatment.The treatment is largely antiseptic, and the Eclectic materia medica is
rich in antiseptics. First in importance stands echinacea. This should be given every
one or two hours, two drams, to water four ounces, a teaspoonful at each dose.
Baptisia, sodium sulphite, hydrochloric acid, and potassium chlorate, with hydrastis,
will each have their special indications for use. Eucalyptus used with an atomizer will
be found useful as a local remedy. The appetite should be encouraged by nux vomica,
hydrastin, chionanthus, etc. The diet should be nourishing, easily digested, and given
at frequent intervals. Drainage by surgical means will have to be considered in some
cases.
Surgical treatment:
Adequate timing of surgical intervention isn't easy to determine because gangrenous
changes of lung often accompany with pleural infection including empyema thoracis and
chest wall infection.
Resection of lung, division of pulmonary vessels and bronchus in an infected pleural space is
risky for postoperative bleeding, prolonged air leaks due to bronchial rupture and persistent
pleural infection.
A two-stage approach had been proposed a reasonable strategy.With concomitant pleural
space infection, tube thoracostomy to allow drainage of purulent pleural effusion or
thoracoscopic deloculation and decortication to help cleaning of pleural space and prepare
for subsequent lung resection. However, infection may be overwhelming in some situations
and surgical intervention is emergent. The most appropriate timing should be judged
individually because such information in the literature is very limited.
If tube thoracostomy failed to alleviate systemic infection, prompt surgical intervention
should be started. If bronchial or vascular structure is fragile and necrotic, pleural or muscle
flap may be considered during operation. Extent of resection is according to the involved
lung tissues with normal lung spared. Gross appearance of gangrenous lung may be from
densely fibrotic to very fragile with foul smell.

Mycobacterial Infections
Tuberculosis infects approximately 7% of patients exposed, and it develops in 5% to
10% of those patients infected. A primary infection develops. The Exudative response
progresses to caseous necrosis. Postprimary tuberculosis tends to occur in apical and
posterior segments of the upper lobes and superior segments of the lower lobes.
Healing occurs with fibrosis and contracture. Extensive caseation with cavitation may

occur early. Coalescing areas of caseous necrosis may form cavities. There are
frequently incomplete septations and lobulations. Septations supplied by bronchial
arteries can cause hemoptysis if eroded and may be secondarily infected by other
organisms.
Bronchoscopy may be required for patients not responding to medical management.
Cancer should be excluded with a newly identified mass on chest radiography even
with a positive TB skin test and acid-fast bacillusnegative sputum.
Medical management is with isoniazid, rifampin, ethambutol, streptomycin, or
pyrazinamide. The initial treatment for the disease is combination therapy (e.g.,
isoniazid plus rifampin or other drugs).
Surgical therapy may be considered when medical therapy fails and persistent
tuberculosis-positive sputum remains as well as when surgically correctable residua of
tuberculosis may be of potential danger to the patient.
This is not the same management as for atypical mycobacteria; many of these patients
remain clinically well even with positive sputum.
Potential Indications for Surgery for Pulmonary Tuberculosis
Open positive cavity after 3 to 6 months of chemotherapy, especially if
resistant mycobacteria
Persistent positive sputum with pathology (destroyed lung, atelectasis,
bronchiectasis, bronchostenosis) amenable to resection
Negative sputum but destroyed lung, blocked cavity, tuberculomaconsider
for resection
Localized infection with atypical mycobacteria
Tuberculous bronchiectasis of lower and middle lobes (usually occurs in upper
lobesgood drainage; lower and middle lobes do not drain well)
Open negative cavities if thick walled, slow response, or unreliable patient
To exclude cancer
Recurrent or persistent hemoptysis: resection if greater than 600 mL of blood
is lost in 24 hours or less
Pleural disease where indicated

Surgical options include resection, which is the procedure of choice in most instances.
Pleural adhesions and granulomas in peribronchial nodes and chronic inflammation
make resection difficult. Preservation of lung tissue should be a goal of the treatment.
Surgical complications are doubled if the sputum is positive for mycobacteria
tuberculosis and decreased if remaining lung tissue is fully expanded.
Infectious complications include empyema, bronchopleural fistula, endobronchial
spread of the disease, and higher mortality.
Thoracoplasty or collapse therapy is infrequently required. Thoracoplasty may be
used to control the postresection empyema space and, rarely, if ever, to manage
parenchymal disease alone. This technique may be used in patients who fail medical
management and who were not otherwise candidates for resection.

Patients with extensive disease and positive sputum or chronic active endobronchial
disease may also be considered.
Plombage may be preferred over staged conventional thoracoplasty, because it
requires only one operation; there is no paradoxical chest motion and chest wall
deformity.
Cavernostomy, or external drainage of a tuberculous cavity with a chest tube or open
drainage, may be used to control a large cavity with positive sputum or massive
bleeding in a patient who was unable to tolerate resection or collapse therapy.