A 60 Year Old Man With Fever, Productive cough and Weight Loss

A 60 year old man is referred to a pulmonary specialist with the complains of high grade fever with chills, a productive cough for about 4 weeks and a history of  weight loss. The patient complains of a purulent sputum which is sometime streaked with blood and about a tablespoon full in quantity. His wife says that she has noticed a foul smell from his breath.

Patient has brought the following X ray with him that was done a day before:

Chest x-ray demonstrates a large intrapulmonary cavity with an irregular air/fluid level interiorly. The wall of the cavity is ill-defined, ranging from very thin and smooth laterally to somewhat nodular superomedially. 

The Patient is diagnosed as a case of Lung Abscess

Case Discussion:

Lung Abscess:

Lung abscess is defined as a cavitating area of localized , suppurative infection within the lung.

Causes: A lung abscess may occur due to :

• Inadequately treated pneumonia.
• Aspiration ( secondary to alcoholism, esophageal obstruction, bulbar palsy etc).
• Bronchial obstruction (secondary to tumor or foreign body)
• Pulmonary infarction
• Septic emboli (septecimia, right heart endocarditis, IV drug use)
• spread from a subphrenic or hepatic abscess

Clinical Signs and Symptoms: Patients may present with:

• Swinging fever.
• Productive cough
• Purulent and a foul smelling sputum
• Pleuritic chest pain
• Malaise
• Weight loss
• hemoptysis.
• Night sweats.

On examination the signs are non specific and resemble those of  pneumonia and may include:

• Decreased breath sounds.
• High grade fever
• Crackles over the affected area
• dullness to percussion in the presence of effusion

Diagnosis:

Blood workup may show anemia and neutrophillia.

Blood and sputum cultures should be sent before starting the antibiotics. 

Chest X ray will often show a cavity with a fluid level.

Ct scan should be considered to exclude obstruction and to see any underlying tumors.

Bronchoscopy may be done to obtain diagnostic specimens. 

Treatment:

1. Antibiotics as indicated by culture and sensitivity.

2. Before the culture results clindamycin is the drug of choice because it has excellent activity against streptococci and anareobic organisms.

3. Antibiotics should be continues for about 4 to 8 weeks.

4. Postural drainage is helpful in draining the infected sputum.

5. In severe cases surgical excision of the infected lobe may be required.