Lung abscess

Dr Yuranga Weerakkody◉ and R Bronson et al.

Lung abscesses are circumscribed collections of pus within the lungs. They
are often complicated to manage and difficult to treat and, in some cases, may
be life-threatening.

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 . Particularly due to an increased number of
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immunocompromised (secondary to HIV/AIDS and iatrogenic

immunosuppression) the rate has once more increased . 7

Clinical presentation
Lung abscesses are divided according to their duration into acute (<6 weeks)
and chronic (>6 weeks) . The presentation is usually non-specific and
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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 a sudden and potentially life-threatening massive haemoptysis.

Pathology
Usually, occurs from liquefactive necrosis of tissue.

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 , immunodeficiency .
7 10

In patients who develop abscesses as a result of aspiration, mixed infections

are most common, including anaerobes.

Some organisms are particularly prone to causing 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
including :
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 Candida albicans: pulmonary candidiasis

 Legionella micdadei and Legionella pneumophila: Legionella pneumonia
 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

 haematogenous spread: bacterial endocarditis, IV drug use
 direct extension from adjacent infection: mediastinum, subphrenic, chest
wall
Also sometimes grouped with secondary abscesses is the colonisation of pre-
existing cavities with organisms .
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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 .
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Plain radiograph
The classical appearance of a pulmonary abscess is a cavity containing a
gas-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 the assessment of this
difficult. These features are helpful in distinguishing a pulmonary abscess from
an empyema (see empyema vs pulmonary abscess).

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 . The
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consolidated lung may mimic a fluid collection with low-level echoes.

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 a gas-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.

Treatment and prognosis

Lung abscesses are usually managed with prolonged antibiotics and
physiotherapy with postural drainage . Bronchoscopy may be beneficial in
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establishing bronchial patency to improve drainage . In cases that are

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refractory to conservative management or those complicated by haemoptysis,

empyema or suspected malignancy, surgical resection is the 'traditional'
definitive treatment . Percutaneous drainage under CT guidance has also
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been advocated in selected cases (e.g. patients refractory to conventional

therapy) .3-9

Larger abscesses (>4 cm 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 the lung)
Despite treatment, abscesses continue to have a 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 the higher prevalence of virulent 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
polyangiitis)
 large infected pneumatocele: infected emphysematous bulla
 cavitating pneumonia / necrotising pneumonia