Monday, October 10, 2016

Lung Abscess - Case Based Study

A 50-year-old male who is a heavy drinker with a history of squamous cell carcinoma of the neck presents to your office complaining of abdominal pain. He has been coughing and expectorating bloody sputum and notes a low-grade fever, chills, and mild dyspnea starting about 1 week ago. He denies nausea, emesis, and chest pain. His squamous cell carcinoma was treated with external beam radiation several years ago.
Examination reveals an afebrile male in mild distress. His vital signs are normal, and his lungs sound clear. The abdominal exam reveals only mild epigastric tenderness
The chest x-ray is shown below:
Findings (  cavitary lesion right upper lobe)

Q 1. Considering this 50-year-old with a cough what will be your next step: 
A) This gentleman will need the ICU.”
B)  This gentleman will need a respiratory isolation room.”
C)  Send this gentleman home with metronidazole.”
D) Work up this gentleman as an outpatient.”

Answer And Discussion

The correct answer is “B.” This gentleman will need a respiratory isolation room.”

Because he is expectorating bloody sputum and has a cavitary lesion on chest x-ray (right upper lobe), this patient should be admitted to a respiratory isolation room until tuberculosis is ruled
out. He will need further evaluation and possibly intravenous antibiotic therapy, both of which may be accomplished during his hospitalization.
“A” is incorrect. There is no need to send this patient to the ICU based on his current picture. “C” is also incorrect. Metronidazole alone is not an appropriate therapy for this patient even if this is bacterial (see below).


Q 2.  What is the best next step in the diagnosis of this process?
A) Bronchoscopy.
B) Sputum cultures
C) Blood cultures.
D) Chest CT.
E) Open lung biopsy.

Answer And Discussion
The correct answer is “D.” Chest CT.

The chest x-ray demonstrates a cavitary lesion in the right upper lobe. Chest CT is warranted for further characterization of the lesion. From history, exam, and chest x-ray, it is not possible to determine whether the lesion is an abscess or a malignant process. An indolent course with lowgrade fever is characteristic of lung abscess. However, the preexisting squamous cell carcinoma has potential to have spread to the lungs, and squamous cell carcinoma is known to cause cavitations. Culture of sputum and blood, including evaluation of first morning sputum for AFB, will be an essential part of the assessment but may not yield as much information as chest CT, and sputum culture should be done in conjunction with cytology and Gram stain. Bronchoscopy should
be postponed until CT results are available. Bronchoscopic biopsy is potentially detrimental if the lesion is an abscess since the airway could flood with pus if the entire cavity wall is penetrated.

Chest CT further confirms a parenchymal abscess in the right upper lobe with cavitation and air within the cavity. Bronchoscopy reveals pus in the airway and extrinsic compression of the bronchi. A lavage sample is obtained, but biopsies are not taken due to the clinical impression that this is a lung abscess.

Q 3. What organisms are most commonly isolated in lung abscesses?
A) Anaerobic bacteria.
B) Aerobic bacteria.
C) Tuberculosis.
D) Mixed aerobic/anaerobic bacteria.

Answer And Discussion
The correct answer is “A.”  Anaerobic bacteria.

Anaerobes are isolated most often, followed by mixed anaerobic/aerobic bacteria, followed by aerobic bacteria alone (especially staphylococci).

Gram stain of sputum demonstrates gram-positive cocci and gram-negative rods. Cultures are pending. Tuberculin skin test is negative.

Q 4. What is the most appropriate therapy for this patient?
A) Refer for surgical drainage.
B) Oral levofloxacin.
C) Intravenous clindamycin.
D) Intravenous metronidazole.
E) Intravenous ceftriaxone.

Answer And Discussion
The correct answer is “C.” Intravenous clindamycin.

Most lung abscesses are polymicrobial, but the most important aspect in treatment appears to be the use of an antibiotic active against anaerobes. Intravenous clindamycin is the usual choice for lung abscess due to its coverage of anaerobes and Streptococcus pneumoniae. Metronidazole is less effective, failing in up to 50% of cases of putrid lung abscess. A beta-lactam with beta-lactamase inhibitor (e.g., piperacillin/tazobactam) is another good choice. Ceftriaxone and levofloxacin offer poor coverage of anaerobes. Surgical drainage of lung abscesses is needed in only 5–10% of cases. Most resolve with just antibiotics.


2 comments:

  1. Hello, my name is Betty. i was diagnosed of HIV virus 4 years back. Before then, i was dating this Derrick guy. we had something great going on. Our love life only lasted for 8 months. the sixth and seven month of our relationship, i began feeling very weak every now and then. But i never suspected anything until I kept on experiencing different symptoms like having sore throats, constant headache, body weakness e.t.c. I decided to go for a medical check up. I was tested HIV positive. when the doctor broke the news to me, it was as if my whole world had crumbled. it dawned on me then that Derrick has been lying to me. i was very mad to an extent i almost committed suicide. But there was nothing i could do, other than weep and weep. ever since then, i have been spending heavily on medications, going from one medical clinic or the other so I can look healthy. Though since i was a kid, i love herbs a lot. i take herbal tea with grandma while growing so i am quite familiar with herbs. early last year, i was on the internet and on a particular health blog, to check for herbal medication as alternative. I saw many comments and read many testimonies. Until i came across a particular testimony on how Dr.ugo cured a patient from herpes simplex virus using pure natural herbs. i reached out to the doctor because I also was thinking Herpes had no cure. I told him about my HIV status.He encouraged me not to panic that he will help me get my deliverance. he prepared some herbs and sent them to me. The herbs were in four 70ml bottles and I took them morning and night. i used as he directed, and in less than three weeks, i started having appetite to eat plenty of food and i gained back my strength. the fourth week,I consumed all the herbal meds. He encouraged me to go for a test which i did. This time, the result was negative. I quickly contacted the doctor and informed him of the news. I immediately asked him to prepare for Derrick too. He did and sent it. Today, me and Derrick are HIV free. All thanks goes to God Almighty for healing us through Dr.Ugo. if you are having any kind of sickness at all, Dr.Ugo is the right person to talk to and i assure you, you will be glad you did. His email: ugoherbalhome@gmail.com you can also write him on WhatsApp +2348104990619.

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  2. Nice blog
    Have been totally convinced that HIV,and many others dangerous diseases can be best cured using the Herbal Medicine. Dr.Akpu the great and powerful herbalist cured me with his Herbal remedy. I'm Linda,15 years from Texas. I was born with HIV. I lost parents at my teenager age when I was 4th. I had to grew up with my mum only Sister, whom I loved so much. She was so worried about my life as my condition was her mature problem in life. I had taken lots of antiviral treatment to get ride of the virus not believing what there said HIV has no cure. I was on the internet when i came across blogs of testimony about a lady who where cured of a 7 years diagnose of Herpes by this powerful Herbalist, Dr.Akpu.I wrote down his mail @ Dr.akpupowerherbscenter@gmail.com
    I told my Aunt,luckily it was the same Dr,we where referred to few months back by my pastor in church whom members have being testifying about of his cure We did contacted him and explained my problem to him.He prepared the medicine and sent to me with details of how to use and apply. After a while, I began to feel more strong than never before, I felt so lucky and happy when my Doctor congratulated me that he could found no HIV virus again in me. I knew I was free cos my body was so strong. His herbal medicine should have saved my parents life, i said!
    Thanks so much for reading my article, you should share your testimony if you have cure as well
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