Lung abscess

Dr Ayush Goel and Dr Abhijit Datir et al.

Lung abscess is a circumscribed collection of pus within the lung, is are potentially life
threatening. They are often complicated to manage and difficult to treat.
Epidemiology
As a result of the widespread availability of antibiotics, the incidence of lung abscesses has
dramatically reduced. Similarly, mortality has reduced. The elderly, immunocompromised,
malnourished, debilitated and of course those who do not have access to antibiotics are
particularly susceptible and have the worst prognosis 6. Particularly due to increased number of
immunocompromised (secondary to HIV / AIDS and iatrogenic immunosuppression) the rate has
once more increased7.
Clinical presentation
Lung abscesses are divided according to their duration into acute (< 6 weeks) and chronic (> 6
weeks) 7. Presentation is usually non-specific and generally similar to a non-cavitating chest
infection. Symptoms include fever, cough and shortness of breath. Peripheral abscesses may
also cause pleuritic chest pain 7.
If chronic, symptoms are more indolent and include weight loss and constitutional symptoms. In
some cases erosion into a bronchial vessel may result in sudden and potentially life threatening
massive haemoptysis.
Pathology
It is convenient to divide lung abscesses into primary and secondary as they differ not only in
aetiology, but also microbiology and prognosis.
A primary abscess is one which develops as a result of primary infection of the lung. They most
commonly arise from aspiration, necrotising pneumonia or chronic pneumonia, e.g. pulmonary
tuberculosis 7.
In patients who develop abscesses as a result of aspiration, mixed infections are most common,
including anaerobes.
Some organisms are particularly prone to causes significant necrotising pneumonia resulting in
cavitation and abscess formation. These include 1:

Staphylococcus aureus
Klebsiella sp - Klebsiella pneumonia

Pseudomonas sp

Proteus sp

In immunocompromised patients additional organisms may also be implicated including7:

Candida albicans - pulmonary candidiasis

Legionella micdadei & Legionella pneumophila

Pneumocystis carinii (uncommon) - pneumocystis jirovecii pneumonia

A secondary abscess is one which develops as a result of another condition. Examples include:

bronchial obstruction: bronchogenic carcinoma, inhaled foreign body

haematogeneous spread: bacterial endocarditis, IVDU

direct extension from adjacent infection: mediastinum, subphrenic, chest wall

Also sometimes grouped with secondary abscesses are colonisation of pre-existing cavities with
organisms 7.
Radiographic features
As aspiration is the most common cause of pulmonary abscesses it is no surprise that the superior
segment of the right lower lobe is the most common site of infection 6.
Plain film

The classical appearance of a pulmonary abscess is a cavity containing an air-fluid level. In

general abscesses are round in shape, and appear similar in both frontal and lateral projections.
Additionally all margins are equally well seen, although adjacent consolidation may make
assessment of this difficult. These features are helpful in distinguishing a pulmonary abscess
from an empyema (see empyema vs pulmonary abscess)
CT

CT is the most sensitive and specific imaging modality to diagnose a lung abscess. Contrast
should be administered, as this enables the identification of the abscess margins, which can
otherwise blend with surrounding consolidated lung.
Abscesses vary in size, and are generally rounded in shape. The may contain only fluid or have
an air-fluid level. Typically there is surrounding consolidation, although with treatment the cavity
will persist longer than consolidation.

The wall of the abscess is typically thick and the luminal surface irregular.
Bronchial vessels and bronchi can be traced as far as the wall of the abscess, whereupon they are
truncated.
Ultrasound

Ultrasound does not play a routine role in the assessment of lung abscesses as any aerated
intervening lung will prevent visualisation. Peripheral abscesses abutting the pleura or with only
compressed or consolidated lung may however be visible, and should not be mistaken for an
empyema 4. Consolidated lung may mimic a fluid collection with low level echoes.
Treatment and prognosis
Lung abscesses are usually managed with prolonged antibiotics and physiotherapy with postural
drainage 2. Bronchoscopy may be beneficial in establishing bronchial patency to improve
drainage 3. In cases that are refractory to conservative management, or those complicated by
haemoptysis, empyema or suspected malignancy, surgical resection is the 'traditional' definitive
treatment 5. Percutaneous drainage under CT guidance has also been advocated in selected cases
3
.
Larger abscesses (> 4cm in diameter) are less likely to be cured with medical management only
and have a higher mortality irrespective of treatment 3,6.
Complications
Complications of surgery or percutaneous drainage include :

empyema
bronchopleural fistula

haemorrhage (from chest wall or from lung)

Despite treatment abscesses continue to have high mortality (15-20%) 3, 6 *. This is particularly
the case in nosocomial infections, which account for the majority of deaths, presumably due to
the combined effect of pre-existent illness and higher prevalence virulent of antibiotic resistant
strains, particularly P aeruginosa (mortality rate of 83%), S aureus (50%) and Klebsiella
pneumoniae (44%) 6.
Differential diagnosis
General imaging differential considerations include

empyema - see empyema vs pulmonary abscess

bronchogenic carcinoma (cavitating)

pulmonary metastasis - with necrosis

pulmonary cavitating granulomatous disease (e.g granulomatosis with polyangitis)

large infected pneumatocoele - infected emphysematous bullus

cavitating pneumonia / necrotising pneumonia

Other considerations on plain film include

pulmonary tuberculosis
hiatus hernia (especially for a retrocardiac abscess)

References
Synonyms & Alternative Spellings
Edit Article Share

Article Information:
System: Chest
Tags: lungs, abscess, infectiousdisease

Figure 1: pulmonary abscess - gross pathology

Case 1

Case 2

Case 3

Case 4

Case 5: with concurrent splenic abscess

Case 6: patient with AML

Case 7

Case 8

Case 9

Case 10: tuberculous abscess

Case 11: with multiple other pathology

Case 12

Imaging Differential Diagnosis

Hiatal hernia

Granulomatosis with polyangitis

Pleural empyema

Cavitating bronchogenic carcinoma

Pyopneumothorax
20052015 Radiopaedia.org Designed and developed by TrikeApps