Lung Abscess

Lung abscess
DEFINITION
• Necrosis of the pulmonary tissue and formation of

cavities containing necrotic debris or fluid caused by
microbial infection.
• Formation of multiple small (< 2 cm) abscesses is
referred to as necrotizing pneumonia or lung gangrene.
• Both lung abscess and necrotizing pneumonia are
manifestations of a similar pathologic process.
CLASSIFICATION
Based on
• Duration
Acute or chronic. Acute abscesses <6 weeks old

• Likely etiology
Primary abscesses are infectious in origin, caused by aspiration or pneumonia in the

healthy host.
Secondary abscesses are caused by a preexisting condition (eg, obstruction)

• Responsible pathogen
Staphylococcus lung abscesses and anaerobic abscess or Aspergillus lung abscess

RISK FACTORS
• Periodontal disease
• High alcohol intake
• Diabetes mellitus.
• Elderly patients increased prevalence
periodontal disease
dysphagia and aspiration.

RISK FACTORS
• Periodontal disease
• Dysphagia
• Inability to protect their airways from aspiration
Alcohol abuse
CVA
General anaesthetic
Seizures
Neurodegenerative disorders
encephalopathy
CAUSES OF LUNG ABSCESS
Post-
Post Septic
Aspiration pneumonic Miscellaneous
Obstructive emboli
infection
PATHOPHYSIOLOGY
• The most common mechanism of abscess aspiration of

oropharyngeal contents
• Infrequently pneumonia may progress to abscess formation
• Infectious complication of a preexisting bulla or lung cyst.
• Secondary to carcinoma of the bronchus. The bronchial obstruction
causes postobstructive pneumonia, which may lead to abscess
formation.
PATHOPHYSIOLOGY
• Pneumonia progression:
K pneumoniae
S aureus (may result in multiple abscesses)
Streptococcus pneumoniae
PATHOPHYSIOLOGY
• Other mechanisms
• 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.
PATHOPHYSIOLOGY
• Small zones of necrosis develop within the consolidated segments in
pneumonia.
• These areas may coalesce to form single or multiple areas of suppuration,
which are referred to as lung abscesses.
• With antibiotic therapy at an early stage healing results with no residual
changes.
• Progressive inflammation erodes into the adjacent bronchi and contents
expectorated as sputum.
• Subsequently, fibrosis occurs, which causes a dense scar and separates the
abscess.
• Spillage of pus into the bronchial tree may disseminate the infection.
PATHOPHYSIOLOGY
aspiration of mouth anaerobes from

periodontal disease
Failure of host defence

mechanisms to clear bacteria
aspiration pneumonitis and

progression to tissue necrosis 7-
14 days
The white arrows mark
areas of abscess
formation in the upper
lobe of this lung.
The liquefactive necrosis of an abscess is apparent, because the purulent contents

are draining out to leave a cavity. On a CXR the liquefied central contents of an
abscess can appear as an "air-fluid level".
MICROBIOLOGY
• Anaerobic bacteria are the most significant pathogens in lung

abscess. The most common agents are
Peptostreptococcus species
Bacteroides species
Fusobacterium species
microaerophilic streptococci.
• Aerobic bacteria may infrequently cause lung abscess

• Nonbacterial and atypical bacterial pathogens- usually in the
immunocompromised host
HISTORY
• Symptoms depend on cause

• May be asymptomatic in the early stages.
Anaerobic infection/Fungi/Nocardia/ Mycobacteria species

• Indolent symptoms over weeks to months.
• Fever, cough with sputum production, night sweats, anorexia, and weight
loss.
• Anaerobes: Sputum foul smelling/ bad tasting/ large amounts
• May develop hemoptysis or pleurisy
HISTORY
Other pathogens in lung abscess

• More acute in nature and are usually treated while they
have bacterial pneumonia.
• Cavitation occurs as parenchymal necrosis ensues
EXAMINATION FINDINGS
• Depend on the organisms involved, the severity and extent of the disease, and the
patient's health status and comorbidities.
• Low-grade fever in anaerobic infections and>38.5°C in other infections
• Digital clubbing may develop rapidly.
• Gingivitis and/or periodontal disease
• Clinical findings of concomitant consolidation may be present
• The amphoric or cavernous breath sounds
• Evidence of pleural friction rub
• Signs of pleural effusion, empyema, and pyopneumothorax if present
LAB INVESTIGATIONS
• Full haemogram with differential WC count

• Sputum for
Gram stain, culture, and sensitivity
ova and parasite whenever a parasitic cause suspected.

• For possible TB acid-fast bacilli stain and mycobacterial culture
• Blood culture
• ANCA, a serum ACE level and fungal serologies may be considered.
IMAGING
Chest radiography
• Irregularly shaped cavity with an air-fluid level
• If the abscess may extends to the pleural surface, it forms acute angles
with the pleural surface.
• Widespread tissue necrosis suggest virulent organism
• Up to 33% of lung abscesses accompanied by empyema
• Repeat CXR after treatment to determine response to therapy
INVESTIGATIONS
Pneumococcal pneumonia complicated
by lung necrosis and abscess formation.
A lateral chest x-ray shows air-fluid

level characteristic of lung abscess
with foul-smelling sputum production. A chest radiograph shows lung abscess
Chest x-ray of patient
with foul-smelling and
bad-tasting sputum, an
almost diagnostic
feature of anaerobic
lung abscess
IMAGING
Computed tomography
• Help visualize the anatomy better than chest radiography
• Very useful in the identification of concomitant empyema or lung infarction.
• Abscess often is a rounded radiolucent lesion with a thick wall and ill-defined irregular
margins.
• The vessels and bronchi are not displaced by the lesion, as they are by an empyema.
• The lung abscess is located within the parenchyma compared with loculated empyema,
which may be difficult to distinguish on chest radiographs.
• The abscess forms acute angles with the pleural surface chest wall
INVESTIGATIONS
sputum. He had a history of heavy alcohol use, and poor dentition was obviou
scan shows a thin-walled cavity with surrounding consolidation.
INVESTIGATIONS
Ultrasonography
• Can detect peripheral lung abscesses with pleural contact or
included inside a lung consolidation
Flexible fiberoptic bronchoscopy

• Performed to exclude bronchogenic carcinoma whenever
bronchial obstruction is suspected.
INVESTIGATIONS
Diagnostic material uncontaminated by bacteria colonizing the upper airway may be

obtained for anaerobic culture from the following:
• Blood culture: infrequently positive
• Pleural fluid (if empyema present)
• Fiberoptic bronchoscopy with protected brush
• Bronchoalveolar lavage with quantitative cultures
• Transtracheal aspirate
• CT-guided transthoracic needle aspirate
• Surgical specimens
PROGNOSIS
• Primary lung abscess cure rates with antibiotics 90-95%.

• Poor outcomes
• Host factors: advanced age, debilitation, malnutrition, HIV
infection, other forms of immunosuppression, malignancy,
and duration of symptoms > 8/52, bronchial obstruction
• Aerobic organisms
• Failure to recognize and treat lung abscess

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Lung abscess

• Necrosis of the pulmonary tissue and formation of

Acute or chronic. Acute abscesses <6 weeks old

Primary abscesses are infectious in origin, caused by aspiration or pneumonia in the

Secondary abscesses are caused by a preexisting condition (eg, obstruction)

Staphylococcus lung abscesses and anaerobic abscess or Aspergillus lung abscess

dysphagia and aspiration.

• The most common mechanism of abscess aspiration of

S aureus (may result in multiple abscesses)

aspiration of mouth anaerobes from

Failure of host defence

aspiration pneumonitis and

The liquefactive necrosis of an abscess is apparent, because the purulent contents

• Anaerobic bacteria are the most significant pathogens in lung

• Aerobic bacteria may infrequently cause lung abscess

• Symptoms depend on cause

Anaerobic infection/Fungi/Nocardia/ Mycobacteria species

Other pathogens in lung abscess

• Full haemogram with differential WC count

Gram stain, culture, and sensitivity

ova and parasite whenever a parasitic cause suspected.

A lateral chest x-ray shows air-fluid

Flexible fiberoptic bronchoscopy

Diagnostic material uncontaminated by bacteria colonizing the upper airway may be

• Blood culture: infrequently positive

• Pleural fluid (if empyema present)

• Fiberoptic bronchoscopy with protected brush

• Bronchoalveolar lavage with quantitative cultures

• CT-guided transthoracic needle aspirate

• Primary lung abscess cure rates with antibiotics 90-95%.

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