Lung Abscess Surgery Clinical Presentation

Updated: May 03, 2018
  • Author: Shabir Bhimji, MD, PhD; Chief Editor: Jeffrey C Milliken, MD  more...
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Presentation

History and Physical Examination

Lung abscesses are considered to be acute or chronic, depending on the duration of symptoms at the time of patient presentation. The arbitrary dividing time is 4-6 weeks. Primary lung abscess are commonly observed in patients who are predisposed to aspiration or in otherwise healthy individuals, whereas secondary lung abscesses represent complications of a preexisting local lesion such as a bronchogenic carcinoma or a systemic disease (eg, HIV infection) that compromises immune function.

Generally, most patients admitted to the hospital with a diagnosis of lung abscess have had symptoms for at least 2 weeks. These patients typically have an intermittent febrile course, productive cough, weight loss, general malaise, and night sweats.

Initially, foul sputum is not observed in the course of the infection; however, after cavitation occurs, putrid expectorations are quite prevalent. The odor of the breath and sputum of a patient with an anaerobic lung abscess is often quite pronounced and noxious and may provide a clue to the diagnosis. Hemoptysis may occasionally follow the expectoration of putrid sputum. In patients with chronic lung abscess, one may observe digital clubbing.

Primary lung abscesses that occur after staphylococcal suppurative pneumonia in infants and children lack the typical indolent recurrent course of the more common postaspiration infections. Their onset tends to be abrupt and more threatening, producing chills, fever, tachycardia, tachypnea, and unremitting production of putrid sputum. The sputum is rarely without odor, because an anaerobic infection has no indolent course.

The physical findings are similar to those of pneumonia, with or without a pleural effusion. Auscultation may reveal coarse rhonchi and absent breath sounds. Clubbing of the fingers is sometimes noted.

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Classification

Anaerobic necrotizing pneumonia

Usually, anaerobic necrotizing pneumonia is chiefly restricted to one pulmonary segment or lobe, though it may progress to encompass an entire lung or both lungs. This type of anaerobic lung infection is the most serious. The inflammatory process often spreads quickly and causes destruction characterized by greenish staining of the lung and a huge amount of putrid tissue, resulting in pulmonary gangrene. These patients are gravely ill with a progressive septic course. Leukocytosis is obvious, and the sputum is putrid.

Secondary lung abscess

In cases of secondary lung abscess, the fundamental process (eg, bacteremia, endocarditis, septic thrombophlebitis, or subphrenic infection) is generally apparent along with the pulmonary pathology. Infections below the diaphragm may extend to the lung or pleural space by way of the lymphatics, either directly through the diaphragm or via defects in it.

The most typical hematogenous lung abscesses are observed in persons with staphylococcal bacteremia, especially in children. These abscesses are multiple and are located in the periphery of the lung. Infections may arise in or posterior to an obstruction (eg, an enlarged mediastinal lymph node) and migrate to the lungs. Septic emboli from bacterial endocarditis or emboli from deep pelvic veins may result in metastatic lung abscess. Septic emboli are suggested when multiple lesions appear over an extended period.

Fewer than 5% of bland pulmonary infarcts become secondarily infected. Secondary infection of infarcts is suggested if fever and leukocytosis are present. Abscess formation may also occur within a necrotic pulmonary tumor.

Amebic lung abscess

Patients who develop an amebic lung abscess often have symptoms associated with a liver abscess. These may include right-upper-quadrant pain and fever. After perforation of the liver abscess into the lung, the individual may develop a cough and expectorate a chocolate or anchovy paste–like sputum that has no odor. The patient may give a history of diarrhea and travel outside the country.

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Complications

Potential complications of lung abscess include the following:

  • Hemothorax or pneumothorax (from chest tube insertion)
  • Hemoptysis (from invasion of the bronchus) - This common complication can often be treated with bronchial artery embolization; occasionally, it can be massive, necessitating urgent surgical intervention
  • Empyema - Approximately one third of lung abscesses are complicated by  empyema; this may be observed with or without bronchopleural fistulas
  • Sepsis
  • Bronchopleural fistula
  • Acute respiratory distress syndrome (ARDS)
  • Brain abscess - This may occur in patients who receive inadequate treatment for their lung abscess
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