This is  a PA chest Xray Of a 67 years old man who has been suffering from a Stroke for 2years admitted to the hospital having  Fever , Productive cough and stabing pain in the right  side of the chest for 6weeks duration.He further told that sputum was foul smelling.No history of hemoptysis.
On general examination he was febrile,emaciated and had finger and toe clubbing.
Oh his respiratory sytem examination  there was decreased breath sounds, dullness to percussion, and course inspiratory crackles in the lower region of the right chest.

Identify the Chest Xray annd What is the Dx?


ANSWER

LUNG ABSCESS IN THE LOWER LOBE OF THE RIGHT LUNG DUE to ASPIRATION


A lung abscess is a confined area of suppuration within the lung parenchyma. It is more common in alcoholics and in elderly, debilitated patients who are prone to aspiration, and in intravenous drug abusers. Males are affected slightly more often than females.The incidence of lung abscess has declined in the recent past due to the greater efficacy of antibiotics in the treatment of lower respiratory tract infection.


Organisms
* Anaerobic bacteria: Peptostreptococcus, Bacteroides, Fusobacterium species,
* Microaerophilic streptococcus : Streptococcus milleri
* Aerobic bacteria: Staphylococcus, Klebsiella, Haemophilus, Pseudomonas, Escherichia coli, Streptococcus, Mycobacteria
* Fungi: Candida, Aspergillus
* Parasites: Entamoeba histolytica

CAUSES

Aspiration of gastric secretion
Septic emboli
Necrotizing pneumonia
Vasculitis: Wegener's granulomatosis
Necrotizing tumors:primary squamous carcinoma of the lung is the commonest

MORPHOLOGY

Abscesses due to aspiration are more common on the right, due to the more vertical right bronchus, and most often, are single.
In pneumonia or bronchiectasis are usually multiple, basal and diffusely scattered
Septic emboli and pyemic abscesses are usually multiple and may affect any region of the lung

CLINICAL FEATURES

Symptoms and signs of a pneumonitis:
  • shivers
  • fever
  • pleuritic chest pain
  • malaise and fatigue


Discharge of the abscess into a bronchus:
  • cough
  • the sputum is copious and foul smelling
  • the sputum is initially blood-stained but may become green or brown with time


Finger clubbing
Signs of a pleural effusion or consolidation
Pleural rub

INVESTIGATIONS

Leucocytosis
High ESR, CRP
Sputum or Transtracheal of Transbronchial aspirates can also be cultured
Chest radiography:may reveal one or more circular lesions of almost any size which may cavitate and show fluid levels Chest ultrasound:can identify a fluid collection
Fibre-optic bronchoscopy:permits sampling for bacteriology and for histological diagnosis of any obstructive lesions

TREATMENT

Broadspectrum antibiotic
      gentamicin,benzylpenicillin,metronidazole
Pulmonary physiotherapy
postural drainage
Percutaneous drainage of a lung abscess
Lung resection in selective patients

COMPLICATIONS

Bronchial:
  • bronchiectasis
  • bronchial stenosis
  • rupture with spread of infection
  • haemorrhage and a bronchopleural fistula
Parenchymal:
  • overdistension of the alveoli
  • collapse
  • secondary infection
Empyema
Distant spread: sepsis, brain abscesses, mediastinitis

PROGNOSIS

Usually excellent unless there is a debilitating underlying condition
Mortality from lung abscess is about 5%



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32 comments

  1. D(x): Lung Abscess.

     
  2. Anonymous Says:
  3. PULMONARY EMBOLISM

     
  4. Anonymous Says:
  5. let me guess...it's looks like abscess in lower right side..

     
  6. Anonymous Says:
  7. its lung abscess....

     
  8. Anonymous Says:
  9. may be bronchectasis

     
  10. Anonymous Says:
  11. LUNG ABCEES

     
  12. Anonymous Says:
  13. arash from iran

    lung abscess due to aspiration pneumonia

     
  14. Anonymous Says:
  15. how about lung Carcinoma

     
  16. Anonymous Says:
  17. this patient has finger and toe clubbing, so it surely has chronic lung disease could be bronchiectasis, and regarding fever,smell sputum it is an acute might be lung abcess, should confirm it with FBC, so it is Lung abcess with primar of chronic lung disease and lung cell carcinoma also be considered

     
  18. Anonymous Says:
  19. lung abscess. i would not expect air fluid level in ca. generally an abscess produce this appearance. Also, a secondarily infected hydatid cyst can be considered on this PA chest graphy

     
  20. Anonymous Says:
  21. bronchectasis


    saadey............

     
  22. Anonymous Says:
  23. lung abscess

     
  24. AhmedCo Says:
  25. pneumonia

     
  26. Anonymous Says:
  27. think its pneumonia

     
  28. sharimi Says:
  29. more like lung abscess,air fluid levels in rt base with right silhouette sign...broncheictasis is best diagnosed with CT,not CXR..

     
  30. Anonymous Says:
  31. Lung Abscess in right base.

     
  32. Anonymous Says:
  33. emaciated patient with finger clubbing... this mean have either TB or bronchiectesis
    now presented with lung abscess due to fungal infection or unaerobic bacterial infection
    regrards
    Dr Azhar

     
  34. Admin Says:
  35. Answer- Lung Abscess In the Right Lower lobe of the Lung followed by aspirational pneumonia
    In this Xray at the upper level of the opacified area you can appreciate the air fluid level which is more suggestive of lung abscess.

     
  36. Anonymous Says:
  37. lung abscess

     
  38. Anonymous Says:
  39. dr_islam , SUDAN
    Lung abscess is the most likely diagnosis.

     
  40. matteo Says:
  41. Aspiration pneumonia due to stroke

     
  42. Anonymous Says:
  43. Lung abcess

     
  44. Anonymous Says:
  45. X-ray shows a lung abscess but on clinical pic. it's ch. lung dz.... should take FBC .....
    most likely it's Lung Abscess

     
  46. Anonymous Says:
  47. bronchiectesis
    now presented with lung abscess due to fungal infection or unaerobic bacterial infection

    Read more: http://medispot123.blogspot.com/2010/03/old-man-with-fever-and-productive-cough.html#ixzz0h9XO8Gc4

     
  48. Anonymous Says:
  49. pneumonia

     
  50. Anonymous Says:
  51. pneumonia

     
  52. chucky style Says:
  53. may b lung abscess

     
  54. Anonymous Says:
  55. can be a lung abscess

     
  56. Anonymous Says:
  57. It is lung abscess

     
  58. Anonymous Says:
  59. Could we take a lateral view CX-rays before make a dx?? If we must making dx on this cx-rays, i think we're just considered only on a few differential diagnosis :
    1. Lung abscess
    2. Carcinoma of the lung

     
  60. Anonymous Says:
  61. Aspiration pneumonia(suppurative) clubbing develops relatively quickly in aspiration pneumonia(10-14 days)

     
  62. Anonymous Says:
  63. pneumonia or lung cancer

     

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