P o t t ' s d i s e a s e i n c h i l d r e n i s a s e r i o u s c o n d i t i o n t h a t a f t

Introduction
A lung abscess is a subacute infection that destroys lung parenchyma. Further, chest radiographs reveal one or more cavities, often with an air-fluid level. Because the development of a cavity requires some amount of prior tissue damage and necrosis, presumably, lung abscesses usually begin as a localized pneumonia. Before the availability of antibiotics, the etiology of a typical abscess was complications after oral surgical procedures (ie, tonsillectomy), resulting in aspiration of infected material into the lungs. In the absence of satisfactory antibiotic treatment, this event usually led to a lung abscess or to a necrotizing pneumonia with or without pleural empyema. Prior to the availability of antibiotics, the clinical course of a patient with a lung abscess would gradually worsen. Fifty years ago, the mortality rate was greater than 50%, and many patients were left with significant residual symptomatic disease. Most patients underwent surgery during the latter stages of the disease, and the results were discouraging. The availability of effective antibiotic therapy for primary lung abscess has drastically modified the natural history of the disease and diminished the role of surgery. Operative indications are less frequent in current practice, and these procedures are undertaken electively for chronic illnesses only after medical therapy has been unsuccessful. In addition to antibiotics, pulmonary care has advanced and now includes postural drainage. Currently, bronchoscopy is occasionally used as an adjunct to expedite drainage and to identify underlying occult lesions such as foreign bodies and malignancies. In the last 2 decades, the increasing use of corticosteroids, immunosuppressive drugs, and chemotherapeutic agents has changed the natural milieu of the oropharyngeal cavity and contributed to the mounting frequency of opportunistic lung abscesses. For excellent patient education resources, visit eMedicine's Infections Center, Lung and Airway Center, Pneumonia Center, and Procedures Center. Also, see eMedicine's patient education articles Bacterial Pneumonia, Abscess, Antibiotics, and Bronchoscopy.

Classification, Etiology, and Pathophysiology
Classification Lung abscesses are considered acute or chronic depending on the duration of symptoms at the time of patient presentation. The arbitrary dividing time is 4-6 weeks. Primary lung abscess are commonly observed in patients who are predisposed to aspiration or in otherwise healthy individuals, whereas secondary lung abscesses represent complications of a preexisting local lesion such as a bronchogenic carcinoma or a systemic disease (eg, HIV infection) that compromises immune function. Etiology Lung abscesses have numerous infectious causes. Anaerobic bacteria continue to be accountable for most cases. These bacteria predominate in the upper respiratory tract and are heavily concentrated in areas of oral-gingival disease. Other bacteria involved in lung abscesses are gram-positive and gramnegative organisms. However, lung cavities may not always be due to an underlying infection. Factors contributing to lung abscess

• Oral cavity disease • Periodontal disease • Gingivitis • Altered consciousness • Alcoholism • Coma • Drug abuse • Anesthesia • Seizures • Immunocompromised host • Steroid therapy • Chemotherapy • Malnutrition • Multiple trauma • Esophageal disease • Achalasia • Reflux disease • Depressed cough and gag reflex • Esophageal obstruction • Bronchial obstruction • Tumor • Foreign body • Stricture • Generalized sepsis Pathogenesis Aspiration of infectious material is the most frequent etiologic mechanism in the development of pyogenic lung abscess. Aspiration due to dysphagia (eg, achalasia) or to compromised consciousness (eg, alcoholism, seizure, cerebrovascular accident, head trauma) appears to be a predisposing factor. Poor oral hygiene, dental infections, and gingival disease are also common in these patients. Although lung abscesses can occur in edentulous patients, an occult carcinoma should be considered. Edentulous patients very seldom, if ever, develop a putrefied abscess because they lack periodontal flora. Patients with alcoholism and those with chronic illnesses frequently have oropharyngeal colonization with gram-negative bacteria, especially when they undergo prolonged endotracheal intubation and are administered agents that neutralize gastric acidity. A pyogenic lung abscess can also develop from aspiration of infectious material from the oropharynx into the lung when the cough reflex is suppressed in a patient with gingivodental disease. Pathology Abscesses generally develop in the right lung and involve the posterior segment of the right upper lobe, the superior segment of the lower lobe, or both. This is due to gravitation of the infectious material from the oropharynx into these dependent areas. Initially, the aspirated material settles in the distal bronchial system and develops into a localized pneumonitis. Within 24-48 hours, a large area of inflammation results, consisting of exudate, blood, and necrotic lung tissue. The abscess frequently connects with a bronchus and partially empties. After pyogenic pneumonitis develops in response to the aspirated infected material, liquefactive

necrosis can occur secondary to bacterial proliferation and an inflammatory reaction to produce an acute abscess. As the liquefied necrotic material empties through the draining bronchus, a necrotic cavity containing an air-fluid level is created. The infection may extend into the pleural space and produce an empyema without rupture of the abscess cavity. The infectious process can also extend to the hilar and mediastinal lymph nodes, and these too may become purulent. Bacteriology of lung abscess • Gram-negative organisms • Bacteroides species • Fusobacterium species • Proteus species • Aerobacter species • Escherichia coli • Gram-positive organisms • Peptostreptococcus species • Microaerophilic streptococcus • Clostridium species • Staphylococcus species • Actinomyces species • Opportunistic organisms • Candida species • Legionella species • Mycobacterium species

Clinical Features
Generally, most of the patients admitted to the hospital with a diagnosis of lung abscess have had symptoms for at least 2 weeks. These patients typically have an intermittent febrile course, productive cough, weight loss, general malaise, and night sweats. Initially, foul sputum is not observed in the course of the infection; however, after cavitation occurs, putrid expectorations are quite prevalent. The odor of the breath and sputum of a patient with an anaerobic lung abscess is often quite pronounced and noxious and may provide a clue to the diagnosis. Hemoptysis may occasionally follow the expectoration of putrid sputum. Primary lung abscesses that occur following staphylococcal suppurative pneumonia in infants and children lack the typical indolent recurrent course of the more common postaspiration infections. Their onset tends to be abrupt and more threatening, producing chills, fever, tachycardia, tachypnea, and unremitting production of putrid sputum. The sputum is rarely without odor because an anaerobic infection has no indolent course. The physical findings are similar to those of pneumonia, with or without a pleural effusion. Auscultation may reveal coarse rhonchi and absent breath sounds. Clubbing of the fingers is sometimes noted.

Clinical Types
Anaerobic necrotizing pneumonia Usually, anaerobic necrotizing pneumonia is chiefly restricted to one pulmonary segment or lobe, although it may progress to encompass an entire lung or both lungs. This type of anaerobic lung

infection is the most serious. The inflammatory process often spreads quickly and causes destruction characterized by greenish staining of the lung and a huge amount of putrid tissue, resulting in pulmonary gangrene. These patients are gravely ill with a progressive septic course. Leukocytosis is obvious, and the sputum is putrid. Secondary lung abscess In cases of secondary lung abscess, the fundamental process (eg, bacteremia, endocarditis, septic thrombophlebitis, subphrenic infection) is generally apparent along with the pulmonary pathology. Infections below the diaphragm may extend to the lung or pleural space by way of the lymphatics, either directly through the diaphragm or via defects in it. The most typical hematogenous lung abscesses are observed in persons with staphylococcal bacteremia, especially in children. These abscesses are multiple and are located in the periphery of the lung. Infections may arise in or posterior to an obstruction (eg, an enlarged mediastinal lymph node) and migrate to the lungs. Septic emboli from bacterial endocarditis or emboli from deep pelvic veins may result in metastatic lung abscess. Septic emboli are suggested when multiple lesions appear over an extended period. Fewer than 5% of bland pulmonary infarcts become secondarily infected. Secondary infection of infarcts is suggested if fever and leukocytosis are present. Abscess formation may also occur within a necrotic pulmonary tumor. Amebic lung abscess Patients who develop an amebic lung abscess often have symptoms associated with a liver abscess. These may include right upper quadrant pain and fever. After perforation of the liver abscess into the lung, the individual may develop a cough and expectorate a chocolate or anchovy paste–like sputum that has no odor. The patient may give a history of diarrhea and travel outside the country.

Diagnosis and Workup
Diagnosis The diagnosis of a typical lung abscess can usually be confirmed based on history and physical examination findings. Approximately 10-20% of patients with anaerobic lung abscess have no obvious oral cavity disease or predisposition to aspiration, which are the 2 most important factors in the development of anaerobic lung infection. Evaluation of expectorated sputum is the first step in the diagnosis of a patient with a lung abscess. Perform a Gram stain and culture for both gram-positive and gram-negative organisms and special staining for acid-fast bacteria and fungi. Generally, in patients with a typical anaerobic lung abscess, sputum analysis is not useful, but the analysis is helpful to exclude other causes of lung abscess (eg, tuberculosis, aerobic bacteria). The sputum Gram stain in patients with anaerobic lung abscesses often shows numerous polymorphonuclear leukocytes along with a mixture of bacteria, some of which are contaminants of oral flora. Because of the presence of anaerobes in the oral cavity, cultures of these microorganisms are not worthwhile. Regular aerobic culture of expectorated sputum should always be performed. When a single predominant organism is cultured, it is accepted to be the pathogen. Empyema fluid, if accessible, provides an excellent medium. Occasionally, particularly with metastatic lung abscesses, blood culture findings may be positive. Most patients never have appropriate specimens obtained for culture; most are treated empirically and do well despite the lack of exact microbiologic

culture results. Chest radiographs The chest radiograph of a lung abscess is not pathognomic in the early stages, ie, before communication is achieved between the abscess cavity and draining bronchus. An area of thick pneumonic consolidation precedes the emergence of the typical cavitary air-fluid form. The distinctive characteristic of lung abscess, the air-fluid level, can only be observed on a chest x-ray film taken with the patient upright or in the lateral decubitus position. In the presence of associated pleural thickening, atelectasis, or pneumothorax, the air-fluid level may be obscured. When better anatomic interpretation is required, CT scans have proven very useful. Opportunistic lung abscesses are more difficult to diagnose. They occur in patients at the extremes of age and in patients with multiple medical problems. Under these conditions, multiple abscesses often evolve, and most of these are nosocomial. Typically, the microbial flora in these patients is gramnegative. Similar to aspiration-induced lung abscess, cavitation is generally apparent on chest radiographs 2 weeks after the onset of cough, fever, and pleuritic chest pain. Chest CT scan images are valuable for demonstrating cavitation within an area of consolidation, for evaluating the thickness and regularity of the abscess wall, and for determining the exact position of the abscess with regard to the chest wall and bronchus. CT scan images can also aid in evaluating the extent of bronchial involvement proximal or distal to the abscess. Invasive diagnostic procedures Invasive diagnostic techniques occasionally recommended to diagnose lung abscesses include transtracheal aspirates, transthoracic aspirates, and fiberoptic bronchoscopy. These procedures must be performed prior to the institution of antibiotic therapy in order to acquire dependable microbiological data. The indications and comparative benefits of such procedures are controversial and depend to a great extent on operator ability. Most pulmonologists believe that these diagnostic procedures should not be performed routinely in patients with possible anaerobic lung abscesses; they should be reserved for patients with atypical presentations. Fiberoptic bronchoscopy is a useful adjunct in the diagnostic evaluation of patients with lung abscess. Secretions obtained from the lower respiratory tract via either lavage or brush can be submitted for culture and sensitivity. Rigid, sterile, and aseptic technique is crucial (eg, use of lidocaine without preservatives, minimal use of topical anesthetic, specimen transport under anaerobic conditions, avoidance of delays in processing), although prior or concurrent antibiotic therapy can cause confusing results. Thus, in patients who have a classic history and radiological presentation of anaerobic lung abscess, the medically sound decision may be to start with empirical antibiotic therapy without prior bronchoscopy. However, for patients with atypical presentations or unclear diagnoses, bronchoscopy should be considered. Bronchoscopy may also be used to exclude the presence of a foreign body or neoplasm. If no specimens are available for analysis and diagnosis, percutaneous transtracheal aspiration is an easy, safe, and dependable way of establishing the specific cause of a lung abscess. This procedure should be avoided in patients with coagulation disorders or bleeding tendencies and in those for whom it is difficult to provide adequate oxygenation. For patients with amebic liver abscess, Entamoeba histolytica may be recovered from the sputum. The vast majority of patients with extraintestinal amebiasis have high titers of hemoagglutinin in the serum. Differential diagnosis

Cavitary lesions in the lung parenchyma have several causes, but a patient with an acute presentation of an illness with air-fluid levels should elicit consideration of a lung abscess. Lung parenchymal cystic lesions and secondarily infected bullae can occasionally confuse the picture. The prior existence of these lesions, as documented by old radiographs and the segmental location, are not typical of lung abscess. Patients with squamous cell bronchial carcinomas can also present with cavitary lesions that are sometimes difficult to differentiate from lung abscesses. Realizing that the wall of the carcinomatous abscess is usually thicker and more irregular than that of the primary abscess is helpful. Further, foul sputum, no response to antibiotics, and the absence of fever may help distinguish the 2 entities. Because an abscess distal to bronchial obstruction usually occurs in an area of lobar pneumonitis and atelectasis—but otherwise appears as a primary abscess—early bronchoscopy is recommended in all cases. Differential diagnoses of a cavitary lung lesion • Anaerobic infection • Gram-negative bacteria • Pseudomonas species • Legionella species • Haemophilus influenzae species • Gram-positive bacteria • Staphylococcus species • Streptococcus species • Mycobacterium species • Fungi • Parasitic • E histolytica • Paragonimus westermani • Septic • Embolism • Cavitary infarction • Bland infarction • Wegener vasculitis • Neoplasms • Bronchogenic carcinoma • Metastatic carcinoma • Lymphoma • Sequestration • Bulla with fluid • Empyema with air fluid levels

Medical Treatment
The current management of anaerobic lung abscesses includes prolonged antibiotic therapy. Because effective broad-spectrum antibiotics are available, primary or nonspecific abscesses can frequently be arrested in the early stage of suppurative pneumonitis. Whereas penicillin has always been the antibiotic of choice, recent trials show clindamycin to be superior.1 Intravenous therapy is appropriate

for adults until an initial clinical response is observed, after this time, oral therapy is safe. Although the overall efficacy of penicillin seems to diminish with time, it presently remains a practical drug for most patients, especially if clindamycin is contraindicated. Tetracycline is considered inadequate therapy because most anaerobes are resistant to it. Similarly, metronidazole is ineffective in approximately 50% of patients, presumably because of the contribution of aerobic bacteria. Therefore, if this agent is to be used, combine it with either a penicillin derivative or a cephalosporin.1 After initial antibiotic therapy, the clinical and radiographic response is gradual. The fever generally subsides in 4-7 days, but normalization of the chest radiograph may require 2 months. Antibiotics in lung abscess • Anaerobic organisms1 • First choice - Clindamycin (Cleocin 3) • Alternative - Penicillin • Oral therapy - Clindamycin, metronidazole (Flagyl), amoxicillin (Amoxil) • Gram-negative organisms • First choices - Cephalosporins, aminoglycosides, quinolones • Alternatives - Penicillins and cephalexin (Biocef) • Oral therapy - Trimethoprim/sulfamethoxazole (Septra) • Pseudomonal organisms: First choices include aminoglycosides, quinolones, and cephalosporin. • Gram-positive organisms • First choices - Oxacillin (Bactocill), clindamycin, cephalexin, nafcillin (Nafcil), and amoxicillin • Alternatives - Cefuroxime (Ceftin) and clindamycin • Oral therapy - Vancomycin (Lyphocin) • Nocardial organisms: First choices include trimethoprim/sulfamethoxazole and tetracycline (Sumycin). Drainage Most lung abscesses communicate with the tracheobronchial tree early in the course of the infection and drain spontaneously during the course of therapy. Dependent drainage (with appropriate positions based on the pulmonary segment) is commonly advocated using chest physical therapy and sometimes bronchoscopy. Bronchoscopy can also facilitate abscess drainage by aspiration of the appropriate bronchus through the bronchoscope. Transbronchial drainage by catheterization of the appropriate bronchus under fluoroscopy has been successful. Generally, augmenting this passive drainage with invasive procedures is unnecessary. In fact, attempts at therapeutic bronchoscopy may sometimes produce adverse consequences. Reports have been received of bronchoscopy-induced release of large amounts of purulent material from the involved lung segment into other parts of the lung, occasionally inducing acute respiratory failure, acute respiratory distress syndrome (ARDS), or both. Course of treatment If treatment is started in the acute stage of the disease and is continued for 4-6 weeks, approximately 85-95% of patients with anaerobic lung abscesses respond to medical management alone. Successful medical therapy resolves symptoms with no radiographic evidence or only a residual thin-walled cystic cavity (<2 cm after 4-6 wk of antibiotic therapy). The success of medical therapy is dependent on the duration of symptoms and the size of the cavity

before the initiation of therapy. Antibiotic therapy is rarely successful if symptoms are present for longer than 12 weeks before the initiation of antibiotic therapy or if the original diameter of the cavity is more than 4 cm. When patients with lung abscesses do not respond to proper medical therapy, consider the probability of an underlying malignancy.

Surgical Treatment
Contraindications to surgery Several important factors must be considered prior to undertaking surgery. Because of the high risk of spillage of the abscess into the contralateral lung, it is almost essential that a double-lumen tube be used to protect the airway. If this is not available, surgery poses a very high risk of abscess in the other lung and a risk of ARDS. In such cases, postponing the surgery is a wise decision. Another, less-satisfactory method to deal with this problem includes positioning the patient in the prone position. The surgeon must be skilled in resecting the abscess and in rapid clamping of the bronchus to prevent spillage into the trachea. These factors are extremely important when dealing with the surgical aspects of treating a lung abscess. If doubt persists, postponing the surgery is best. Surgical treatment is now rarely necessary and is almost never the initial choice in the treatment of lung abscesses. In current practice, fewer than 15% of patients need surgical intervention for the unchecked disease and for complications that occur in both the acute and chronic stages of the disease. Surgical management is reserved for specific indications such as little or no response to medical treatment, inability to eliminate a carcinoma as a cause, critical hemoptysis, and complications of lung abscess (eg, empyema, bronchopleural fistula). In addition, if after 4-6 weeks of medical treatment a notable residual cavity remains and the patient is symptomatic, surgical resection is advocated. The results of surgery are difficult to assess because of the varying patient population and the tremendous increase in illicit drug abuse, alcoholism, AIDS, and infections by gram-negative and opportunistic organisms. These factors have increased the incidence of lung abscess and the associated morbidity. A great deal of caution is needed during anesthesia when patients with lung abscess undergo surgery because spillage of the abscess material into the uninvolved lung can occur. Therefore, a double-lumen endotracheal tube is used in all cases. Indications for surgery • Probable carcinoma • Significant hemoptysis Percutaneous drainage Percutaneous drainage of a complicated abscess (ie, one associated with fever and signs of sepsis) is beneficial in selected patients who do not respond to adequate medical therapy.2 These are ventilatordependent patients who are not candidates for extensive thoracic procedures. Other indications for drainage include ongoing sepsis despite adequate antimicrobial therapy, progressively enlarging lung abscess in imminent danger of rupture, failure to wean from mechanical ventilation, and contamination of the opposite lung. In current practice, most of these lung abscesses are drained under CT guidance.2 Results achieved with percutaneous drainage show it to be safe and effective compared to surgery. Percutaneous drainage is rarely complicated by empyema, hemorrhage, or bronchopleural fistula.

Although a few patients who undergo percutaneous drainage develop bronchopleural fistulas, most of these fistulas close spontaneously with resolution of the abscess cavity. Percutaneous drainage may be used to stabilize and prepare critically ill patients for surgery. Abscess from gram-negative and opportunistic bacteria Hospital-acquired gram-negative infections are usually due to nosocomial organisms (eg, Pseudomonas, Enterobacter, Proteus). Patients with these infections are often elderly, debilitated with numerous major medical disorders, or have sustained multiple trauma. These patients are typically treated in a critical care unit. The infection is usually with a resistant organism originating from a single source. The lung abscess appears rapidly as an area of pneumonitis with associated pleural involvement. These patients often require percutaneous drainage as an emergency procedure. Unfortunately, the infection is systemic and often out of control, and the pulmonary pathology represents only one aspect of a multiorgan involvement with a rapidly deteriorating course. Among fungal infections, Candida albicans has become a major organism in lung abscesses. Fungal infections are difficult to treat, and amphotericin/fluconazole and surgical drainage remain the only modalities of treatment; however, at best, they have had only limited success.

Complications and Prognosis
Complications Approximately one third of lung abscesses are complicated by empyema. This may be observed with or without bronchopleural fistulas. Hemoptysis is a common complication of a lung abscess and can be treated with bronchial artery embolization. Occasionally, the hemoptysis can be massive, thus requiring urgent surgery. Brain abscess may also be a complication in patients who receive inadequate treatment. Prognosis The prognosis of patients with lung abscesses depends on the underlying or predisposing pathologic event and the speed with which appropriate therapy is established. Negative prognostic factors include a large cavity (>6 cm), necrotizing pneumonia, multiple abscesses, immunocompromise, age extremes, associated bronchial obstruction, and aerobic bacterial pneumonia. The mortality rate associated with an anaerobic lung abscess is less than 15%, although it is slightly higher in patients with necrotizing anaerobic pneumonia and pneumonia caused by gram-negative bacteria. The prognosis associated with amebic lung abscess is good when treatment is prompt.

Keywords
lung abscess, aspiration, pneumonia, anaerobic bacteria, antibiotic therapy, percutaneous drainage, bronchoscopy, empyema, alcoholism, seizures, poor oral hygiene, bronchogenic neoplasm, infected lung, pyogenic lung abscess, lung abscesses, oral surgery, dysphagia, achalasia, dental infection, gingival disease, gum disease, bad oral hygiene, gingivodental disease, lung necrosis, necrotic lung tissue, anaerobic necrotizing pneumonia, pulmonary gangrene, amebiasis, amoebiasis, amebic lung abscess, amoebic lung abscess Madainnah

Background
Lung abscess is defined as necrosis of the pulmonary tissue and formation of cavities containing necrotic debris or fluid caused by microbial infection. The formation of multiple small (<2 cm) abscesses is occasionally referred to as necrotizing pneumonia or lung gangrene. Both lung abscess and necrotizing pneumonia are manifestations of a similar pathologic process. Failure to recognize and treat lung abscess is associated with poor clinical outcome. In the 1920s, approximately one third of patients with lung abscess died; Dr David Smith postulated that aspiration of oral bacteria was the mechanism of infection. He observed that the bacteria found in the walls of the lung abscesses at autopsy resembled the bacteria noted in the gingival crevice. A typical lung abscess could be reproduced in animal models via an intratracheal inoculum containing, not 1, but 4 microbes, thought to be Fusobacterium nucleatum, Peptostreptococcus species, a fastidious gramnegative anaerobe, and, possibly, Prevotella melaninogenicus. Lung abscess was a devastating disease in the preantibiotic era, when one third of the patients died, another one third recovered, and the remainder developed debilitating illnesses such as recurrent abscesses, chronic empyema, bronchiectasis, or other consequences of chronic pyogenic infections. In the early postantibiotic period, sulfonamides did not improve the outcome of patients with lung abscess until the penicillins and tetracyclines were available. Although resectional surgery was often considered a treatment option in the past, the role of surgery has greatly diminished over time because most patients with uncomplicated lung abscess eventually respond to prolonged antibiotic therapy. Lung abscesses can be classified based on the duration and the likely etiology. Acute abscesses are less than 4-6 weeks old, whereas chronic abscesses are of longer duration. Primary abscess is infectious in origin, caused by aspiration or pneumonia in the healthy host; secondary abscess is caused by a preexisting condition (eg, obstruction), spread from an extrapulmonary site, bronchiectasis, and/or an immunocompromised state. Lung abscesses can be further characterized by the responsible pathogen, such as Staphylococcus lung abscess and anaerobic or Aspergillus lung abscess.

A thick-walled lung abscess. [ CLOSE WINDOW ]

A thick-walled lung abscess.

Pathophysiology
Most frequently, the lung abscess arises as a complication of aspiration pneumonia caused by mouth anaerobes. The patients who develop lung abscess are predisposed to aspiration and commonly have periodontal disease. A bacterial inoculum from the gingival crevice reaches the lower airways, and infection is initiated because the bacteria are not cleared by the patient's host defense mechanism. This results in aspiration pneumonitis and progression to tissue necrosis 7-14 days later, resulting in formation of lung abscess. Other mechanisms for lung abscess formation include bacteremia or tricuspid valve endocarditis, causing septic emboli (usually multiple) to the lung. Lemierre syndrome, an acute oropharyngeal infection followed by septic thrombophlebitis of the internal jugular vein, is a rare cause of lung abscesses. The oral anaerobe F necrophorum is the most common pathogen. Microbiology

Because of the difficulty obtaining material uncontaminated by nonpathogenic bacteria colonizing the upper airway, lung abscesses rarely have a microbiologic diagnosis. Published reports since the beginning of the antibiotic area have established that anaerobic bacteria are the most significant pathogens in lung abscess. In a study by Bartlett et al in 1974, 46% of patients with lung abscesses had only anaerobes isolated from sputum cultures, while 43% of patients had a mixture of anaerobes and aerobes.1 The most common anaerobes are Peptostreptococcus species, Bacteroides species, Fusobacterium species, and microaerophilic streptococci. Aerobic bacteria that may infrequently cause lung abscess include Staphylococcus aureus, Streptococcus pyogenes, Streptococcus pneumoniae (rarely), Klebsiella pneumoniae, Haemophilus influenzae, Actinomyces species, Nocardia species, and gram-negative bacilli. Challenging current expert opinion, a study by Wang et al suggested that the bacteriologic characteristics of lung abscess have changed.2 In a series of 90 patients with community-acquired lung abscess in Taiwan, anaerobes were recovered from just 28 patients (31%); the predominant bacterium was K pneumoniae, in 30 patients (33%). Another significant finding was that the rate of resistance of anaerobes and Streptococcus milleri to clindamycin and penicillin increased compared with previous reports. Nonbacterial and atypical bacterial pathogens may also cause lung abscesses, usually in the immunocompromised host. These microorganisms include parasites (eg, Paragonimus and Entamoeba species), fungi (eg, Aspergillus, Cryptococcus, Histoplasma, Blastomyces, and Coccidioides species), and Mycobacterium species.

Frequency
United States The frequency of lung abscess in the general population is not known.

Mortality/Morbidity
Most patients with primary lung abscess improve with antibiotics, with cure rates documented at 9095%. Host factors associated with a poor prognosis include advanced age, debilitation, malnutrition, human immunodeficiency virus infection or other forms of immunosuppression, malignancy, and duration of symptoms greater than 8 weeks.3 The mortality rate for patients with underlying immunocompromised status or bronchial obstruction who develop lung abscess may be as high as 75%.4 Aerobic organisms, frequently hospital acquired, are associated with poor outcomes. A retrospective study reported the overall mortality rate of lung abscesses caused by mixed gram-positive and gramnegative bacteria at approximately 20%.5

Sex
A male predominance for lung abscess is reported in published case series.

Age
Lung abscesses likely occur more commonly in elderly patients because of the increased incidence of periodontal disease and the increased prevalence of dysphagia and aspiration. However, a case series from an urban center with high prevalence of alcoholism reported a mean age of 41 years.6

Clinical
History
Symptoms depend on whether the abscess is caused by anaerobic or other bacterial infection.  Anaerobic infection in lung abscess  Patients often present with indolent symptoms that evolve over a period of weeks to months.  The usual symptoms are fever, cough with sputum production, night sweats, anorexia, and weight loss.  The expectorated sputum characteristically is foul smelling and bad tasting.  Patients may develop hemoptysis or pleurisy  Other pathogens in lung abscess  These patients generally present with conditions that are more emergent in nature and are usually treated while they have bacterial pneumonia.  Cavitation occurs subsequently as parenchymal necrosis ensues.  Abscesses from fungi, Nocardia species, and Mycobacteria species tend to have an indolent course and gradually progressive symptoms.

Physical
The findings on physical examination of a patient with lung abscess are variable. Physical findings may be secondary to associated conditions such as underlying pneumonia or pleural effusion. The physical examination findings may also vary depending on the organisms involved, the severity and extent of the disease, and the patient's health status and comorbidities.  Patients with lung abscesses may have low-grade fever in anaerobic infections and temperatures higher than 38.5°C in other infections.  Generally, patients with in lung abscess have evidence of gingival disease.  Clinical findings of concomitant consolidation may be present (eg, decreased breath sounds, dullness to percussion, bronchial breath sounds, course inspiratory crackles).  The amphoric or cavernous breath sounds are only rarely elicited in modern practice.  Evidence of pleural friction rub and signs of associated pleural effusion, empyema, and pyopneumothorax may be present. Signs include dullness to percussion, contralateral shift of the mediastinum, and absent breath sounds over the effusion.  Digital clubbing may develop rapidly.

Causes
The bacterial infection may reach the lungs in several ways. The most common is aspiration of oropharyngeal contents.

 Patients at the highest risk for developing lung abscess have the following risk factors:  Periodontal disease  Seizure disorder  Alcohol abuse  Dysphagia  Other patients at high risk for developing lung abscess include individuals with an inability to protect their airways from massive aspiration because of a diminished gag or cough reflex, caused by a state of impaired consciousness (eg, from alcohol or other CNS depressants, general anesthesia, or encephalopathy).  Infrequently, the following infectious etiologies of pneumonia may progress to parenchymal necrosis and lung abscess formation:  Pseudomonas aeruginosa  K pneumoniae  S aureus (may result in multiple abscesses)  Streptococcus pneumoniae  Nocardia species  Fungal species  An abscess may develop as an infectious complication of a preexisting bulla or lung cyst.  An abscess may develop secondary to carcinoma of the bronchus; the bronchial obstruction causes postobstructive pneumonia, which may lead to abscess formation.

Differential Diagnoses
Alcoholism Empyema, Pleuropulmonary Pneumococcal Infections Pneumocystis Carinii Pneumonia Hydatid Cysts Pneumonia, Aspiration Infective Endocarditis Pneumonia, Bacterial Lung Cancer, Non-Small Cell Pneumonia, Fungal Lung Cancer, Oat Cell (Small Cell) Pulmonary Embolism Mycetoma Sarcoidosis Mycobacterium AviumThrombophlebitis, Septic Intracellulare Mycobacterium Chelonae Tuberculosis Mycobacterium Kansasii Wegener Granulomatosis Nocardiosis

Other Problems to Be Considered
Cavitating lung cancer Localized empyema Infected bulla containing a fluid level Infected congenital pulmonary lesion, such as bronchogenic cyst or sequestration Pulmonary hematoma

Cavitating pneumoconiosis Hiatus hernia Lung parasites (eg, hydatid cyst, Paragonimus infection) Actinomycosis Wegener granulomatosis and other vasculitides Cavitating lung infarcts Cavitating sarcoidosis

Workup
Laboratory Studies
• • • • • A complete white blood cell count with differential may reveal leukocytosis and a left shift. Obtain sputum for Gram stain, culture, and sensitivity. If tuberculosis is suspected, acid-fast bacilli stain and mycobacterial culture is requested. Blood culture may be helpful in establishing the etiology. Obtain sputum for ova and parasite whenever a parasitic cause for lung abscess is suspected.

Imaging Studies
 Chest radiography7  A typical chest radiographic appearance of a lung abscess is an irregularly shaped cavity with an air-fluid level inside. Lung abscesses as a result of aspiration most frequently occur in the posterior segments of the upper lobes or the superior segments of the lower lobes.  The wall thickness of a lung abscess progresses from thick to thin and from ill-defined to well-circumscribed as the surrounding lung infection resolves. The cavity wall can be smooth or ragged but is less commonly nodular, which raises the possibility of cavitating carcinoma.  The extent of the air-fluid level within a lung abscess is often the same in posteroanterior or lateral views. The abscess may extend to the pleural surface, in which case it forms acute angles with the pleural surface.  Anaerobic infection may be suggested by cavitation within a dense segmental consolidation in the dependent lung zones.  Lung infection with a virulent organism results in more widespread tissue necrosis, which facilitates progression of underlying infection to pulmonary gangrene.  Up to one third of lung abscesses may be accompanied by an empyema.

Pneumococcal pneumonia complicated by lung necrosis and abscess formation. [ CLOSE WINDOW ]

Pneumococcal pneumonia complicated by lung necrosis and abscess formation.

A lateral chest radiograph shows air-fluid level characteristic of lung abscess. [ CLOSE WINDOW ]

A lateral chest radiograph shows air-fluid level characteristic of lung abscess.

A 54-year-old patient developed cough with foul-smelling sputum production. A chest radiograph shows lung abscess in the left lower lobe, superior segment. [ CLOSE WINDOW ]

A 54-year-old patient developed cough with foul-smelling sputum production. A chest radiograph shows lung abscess in the left lower lobe, superior segment.

A 42-year-old man developed fever and production of foul-smelling sputum. He had a history of heavy alcohol use, and poor dentition was obvious on physical examination. Chest radiograph shows lung abscess in the posterior segment of the right upper lobe. [ CLOSE WINDOW ]

A 42-year-old man developed fever and production of foul-smelling sputum. He had a history of heavy alcohol use, and poor dentition was obvious on physical examination. Chest radiograph shows lung abscess in the posterior segment of the right upper lobe.

Chest radiograph of a patient who had foul-smelling and bad-tasting sputum, an almost diagnostic feature of anaerobic lung abscess. [ CLOSE WINDOW ]

Chest radiograph of a patient who had foul-smelling and bad-tasting sputum, an almost diagnostic feature of anaerobic lung abscess.  Computed tomography7,8  CT scanning of the lungs may help visualize the anatomy better than chest radiography. CT scanning is very useful in the identification of concomitant empyema or lung infarction.  On CT scans, an abscess often is a rounded radiolucent lesion with a thick wall and illdefined irregular margins.  The vessels and bronchi are not displaced by the lesion, as they are by an empyema.  The lung abscess is located within the parenchyma compared with loculated empyema, which may be difficult to distinguish on chest radiographs.  The lesion forms acute angles with the pleural surface chest wall.

A 42-year-old man developed fever and production of foul-smelling sputum. He had a history of heavy alcohol use, and poor dentition was obvious on physical examination. Lung abscess in the posterior segment of the right upper lobe was demonstrated on chest radiograph (see Image 6). CT scan shows a thin-walled cavity with surrounding consolidation. [ CLOSE WINDOW ]

A 42-year-old man developed fever and production of foul-smelling sputum. He had a history of heavy alcohol use, and poor dentition was obvious on physical examination. Lung abscess in the posterior segment of the right upper lobe was demonstrated on chest radiograph (see Image 6). CT scan shows a thin-walled cavity with surrounding consolidation.  Ultrasonography  Peripheral lung abscesses with pleural contact or included inside a lung consolidation are

detectable using lung ultrasonography at the bedside.  Lung abscess appears as a rounded hypoechoic lesion with an outer margin.  If a cavity is present, additional nondependent hyperechoic signs are generated by the gas-tissue interface.9

Procedures
Diagnostic material uncontaminated by bacteria colonizing the upper airway may be obtained for anaerobic culture from the following:        Blood culture Pleural fluid (if empyema present) Transtracheal aspirate Transthoracic pulmonary aspirate Surgical specimens Fiberoptic bronchoscopy with protected brush Bronchoalveolar lavage with quantitative cultures

Expectorated sputum and other methods of sampling the upper airway do not yield useful results for anaerobic culture because the oral cavity is extensively colonized with anaerobes. Blood cultures are infrequently positive in patients with lung abscess, and empyema is rare. The other modalities listed are invasive, costly, and require laboratory expertise. Bronchoscopy using a protected brush to obtain a specimen uncontaminated by the upper airway or quantitative culture of organisms from the bronchoalveolar lavage fluid has been advocated to establish bacteriologic diagnosis in lung abscess. However, the experience with this technique in diagnosis of anaerobic lung infections is limited and the diagnostic yield is uncertain. Perhaps most importantly, cultures obtained by any of these methods are unlikely to be positive after the initiation of antibiotics.10 Flexible fiberoptic bronchoscopy is performed to exclude bronchogenic carcinoma whenever bronchial obstruction is suspected.11

Histologic Findings
Lung abscesses begin as small zones of necrosis developing within the consolidated segments in pneumonia. These areas may coalesce to form single or multiple areas of suppuration, which are referred to as lung abscesses. If antibiotics interrupt the natural history at an early stage, the healing results in no residual changes. When the progressive inflammation erodes into the adjacent bronchi, the contents of the abscess are expectorated as malodorous sputum. Subsequently, fibrosis occurs, which causes a dense scar and separates the abscess. The abscess may still occur, and spillage of pus into the bronchial tree may disseminate the infection.

Histology of a lung abscess shows dense inflammatory reaction (low power). [ CLOSE WINDOW ]

Histology of a lung abscess shows dense inflammatory reaction (low power).

Histology of a lung abscess shows dense inflammatory reaction (high power).

Medical Care
Treatment of lung abscess is guided by the available microbiology and knowledge of the underlying or associated conditions. No treatment recommendations have been issued by major societies specifically for lung abscess; however, a guideline summary from the Infectious Diseases Society of America, Practice guidelines for outpatient parenteral antimicrobial therapy, is available.12 Some clinical trials referred to below have included patients with aspiration pneumonia with or without lung abscess. Antibiotic therapy  Standard treatment of an anaerobic lung infection is clindamycin (600 mg IV q8h followed by 150-300 mg PO qid). This regimen has been shown to be superior over parenteral penicillin in published trials. Several anaerobes may produce beta-lactamase (eg, various species of Bacteroides and Fusobacterium) and therefore develop resistance to penicillin.13  Although metronidazole is an effective drug against anaerobic bacteria, the experience with metronidazole in treating lung abscess has been rather disappointing because these infections are generally polymicrobial. A failure rate of 50% has been reported.14,15  In hospitalized patients who have aspirated and developed a lung abscess, antibiotic therapy should include coverage against S aureus and Enterobacter and Pseudomonas species.  Ampicillin plus sulbactam is well tolerated and as effective as clindamycin with or without a cephalosporin in the treatment of aspiration pneumonia and lung abscess.16  Moxifloxacin is clinically effective and as safe as ampicillin plus sulbactam in the treatment of aspiration pneumonia and lung abscess.17 Duration of therapy  Although the duration of therapy is not well established, most clinicians generally prescribe antibiotic therapy for 4-6 weeks.  Expert opinion suggests that antibiotic treatment should be continued until the chest radiograph has shown either the resolution of lung abscess or the presence of a small stable lesion.  The rationale for extended treatment maintains that risk of relapse exists with a shorter antibiotic regimen. Response to therapy  Patients with lung abscesses usually show clinical improvement, with improvement of fever, within 3-4 days after initiating the antibiotic therapy. Defervescence is expected in 7-10 days. Persistent fever beyond this time indicates therapeutic failure, and these patients should undergo further diagnostic studies to determine the cause of failure.  Considerations in patients with poor response to antibiotic therapy include bronchial obstruction

with a foreign body or neoplasm or infection with a resistant bacteria, mycobacteria, or fungi.  Large cavity size (ie, > 6 cm in diameter) usually requires prolonged therapy. Because empyema with an air-fluid level could be mistaken for parenchymal abscess, a CT scan may be used to differentiate this process from lung abscess.  A nonbacterial cause of cavitary lung disease may be present, such as lung infarction, cavitating neoplasm, and vasculitis. The infection of a preexisting sequestration, cyst, or bulla may be the cause of delayed response to antibiotics.

Surgical Care
Surgery is very rarely required for patients with uncomplicated lung abscesses. The usual indications for surgery are failure to respond to medical management, suspected neoplasm, or congenital lung malformation. The surgical procedure performed is either lobectomy or pneumonectomy. When conventional therapy fails, either percutaneous catheter drainage or surgical resection is usually considered. Endoscopic lung abscess drainage is considered if an airway connection to the cavity can be demonstrated. Success of this treatment represents an additional option other than percutaneous catheter drainage or surgical resection.18

Consultations
Consulting a pulmonary medicine or infectious diseases specialist is often helpful in workup and follow-up of patients with lung abscess.

Medication
Most abscesses develop secondary to aspiration and are caused by anaerobes. A history suggestive of community acquired pneumonia or a history of development of abscess in a hospitalized patient is important in deciding the appropriate antibiotic coverage.

Antibiotics
Empiric antimicrobial therapy must be comprehensive and should cover all likely pathogens suspected in this clinical setting.

Clindamycin (Cleocin) Lincosamides are used for treatment of serious skin and soft tissue staphylococcal infections. Also effective against aerobic and anaerobic streptococci, except enterococci. Inhibits bacterial growth, possibly by blocking dissociation of peptidyl t-RNA from ribosomes, causing RNA-dependent protein synthesis to arrest. • • • • Dosing Interactions Contraindications Precautions

Adult

600 mg IV q8h, followed by 150-300 mg PO qid
Pediatric

25-40 mg/kg/d IV divided tid/qid • • • • Dosing Interactions Contraindications Precautions

Increases duration of neuromuscular blockade induced by tubocurarine and pancuronium; erythromycin may antagonize effects of clindamycin; antidiarrheals may delay absorption • • • • Dosing Interactions Contraindications Precautions

Documented hypersensitivity; regional enteritis; ulcerative colitis; hepatic impairment; antibioticassociated colitis • • • • Dosing Interactions Contraindications Precautions

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions

Adjust dose in severe hepatic dysfunction; no adjustment necessary in renal insufficiency; associated with severe and possibly fatal colitis

Cefoxitin (Mefoxin) Second-generation cephalosporin indicated for gram-positive cocci and gram-negative rod infections. Infections caused by cephalosporin- or penicillin-resistant gram-negative bacteria may respond to cefoxitin. • • • •
Adult

Dosing Interactions Contraindications Precautions

2 g IV q6-8h

Pediatric

80-160 mg/kg/d IV divided q4-6h • • • • Dosing Interactions Contraindications Precautions

Probenecid may increase effects of cefoxitin; coadministration with aminoglycosides or furosemide may increase nephrotoxicity (closely monitor renal function) • • • • • • • • Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Documented hypersensitivity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions

Bacterial or fungal overgrowth of nonsusceptible organisms may occur with prolonged use or repeated treatment; caution in patients with previously diagnosed colitis

Penicillin G (Pfizerpen) Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidal activity against susceptible microorganisms. • • • •
Adult

Dosing Interactions Contraindications Precautions

2 million U IV q4h
Pediatric

150,000 U/kg/d IV divided q4h • Dosing

• Interactions • Contraindications • Precautions Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects of penicillin • • • • • • • • Dosing Interactions Contraindications Precautions Dosing Interactions Contraindications Precautions

Documented hypersensitivity

Pregnancy

B - Fetal risk not confirmed in studies in humans but has been shown in some studies in animals
Precautions

Caution in impaired renal function; traditional agent to treat lung abscess, but spectrum of activity is narrow

Metronidazole (Flagyl) Imidazole ring-based antibiotic active against various anaerobic bacteria and protozoa. Used in combination with other antimicrobial agents (except for Clostridium difficile enterocolitis). Not standard practice to use metronidazole alone because some anaerobic cocci and most microaerophilic streptococci are resistant. • • • •
Adult

Dosing Interactions Contraindications Precautions

Loading dose: 15 mg/kg IV (or 1 g for 70-kg adult) over 1 h Maintenance dose: 6 h following loading dose, infuse 7.5 mg/kg IV (or 500 mg for 70-kg adult) over 1 h q6-8h; not to exceed 4 g/d
Pediatric

Administer as in adults using body weight

Follow-up
Further Inpatient Care
• For the following reasons, inpatient care is advisable in patients with lung abscess: • Evaluation and management of patient's respiratory status • Administration of intravenous antibiotics • Drainage of the abscess or empyema as needed

Further Outpatient Care
• In patients who have small lung abscess, who are not clinically ill, and who are reliable, outpatient care may be considered after obtaining appropriate diagnostic studies such as sputum culture, blood culture, and blood work. • Following initial intravenous antibiotic therapy, the patient may be treated on an outpatient basis for completion of prolonged therapy, which is often required for cure.

Deterrence/Prevention
 Prevention of aspiration is important to minimize the risk of lung abscess. Early intubation in patients who have diminished ability to protect the airway from massive aspiration (cough, gag reflexes), should be considered.  Positioning the supine patient at a 30° reclined angle minimizes the risk of aspiration. Vomiting patients should be placed on their sides.  Improving oral hygiene and dental care in elderly and debilitated patients may decrease the risk of anaerobic lung abscess.

Complications
• Complications of pulmonary abscess • Rupture into pleural space causing empyema • Pleural fibrosis • Trapped lung • Respiratory failure • Bronchopleural fistula • Pleural cutaneous fistula • In a patient with coexisting empyema and lung abscess, draining the empyema while continuing prolonged antibiotic therapy is often necessary.

Prognosis
• The prognosis for lung abscess following antibiotic treatment is generally favorable. Over 90% of lung abscesses are cured with medical management alone, unless caused by bronchial

obstruction secondary to carcinoma.

Patient Education
• For excellent patient education resources, visit eMedicine's Infections Center, Lung and Airway Center, Pneumonia Center, and Procedures Center. Also, see eMedicine's patient education articles Bacterial Pneumonia, Antibiotics, and Bronchoscopy.

Miscellaneous
Medicolegal Pitfalls
• A lung abscess may be asymptomatic in a small proportion of patients in the early stages; a chest radiograph may be helpful. • In any patient who is producing foul-smelling or bad-tasting sputum, suspect a lung abscess. • A shorter course of antibiotics may increase risk of a relapse. Therefore, antibiotic therapy for anaerobic lung abscess is prolonged, often extending up to 6-8 weeks. • A lack of response to antibiotic therapy should lead to consideration of a cavitating lung neoplasm, lung infarction, or Wegener granulomatosis.

Abscess Incision & Drainage
Medical Encyclopedia:

Abscess Incision & Drainage
Sponsored Links Abscesses Relax. Take a deep breath. We have the answers you seek. www.RightHealth.com Home > Library > Health > Medical Encyclopedia

More about Abscess Incision & Drainage: Purpose Precautions Preparation Aftercare Risks Normal results Resources

Definition An infected skin nodule that contains pus may need to be drained via a cut if it does not respond to antibiotics. This allows the pus to escape, and the infection to heal. Description A doctor will cut into the lining of the abscess, allowing the pus to escape either through a drainage tube or by leaving the cavity open to the skin. How big the incision is depends on how quickly the pus is encountered. Once the abscess is opened, the doctor will clean and irrigate the wound thoroughly with saline. If it is not too large or deep, the doctor may simply pack the abscess wound with gauze for 24–48 hours to absorb the pus and discharge. If it is a deeper abscess, the doctor may insert a drainage tube after cleaning out the wound. Once the tube is in place, the surgeon closes the incision with simple stitches, and applies a sterile dressing. Drainage is maintained for several days to help prevent the abscess from reforming. — Carol A. Turkington

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Surgery Encyclopedia:

Abscess Incision and Drainage
Top Home > Library > Health > Surgical Encyclopedia Who Performs the Procedure and Where Is It Performed? Abscesses are most commonly incised and drained by general surgeons. Occasionally, a family physician or dermatologist may drain a superficial abscess. These procedures may be performed in a professional office or in an outpatient facility. The skin and surrounding area may be numbed by a topical anesthetic. Brain abscesses are usually drained by neurosurgeons. Thoracic surgeons drain abscesses in the lung. Otolaryngologists drain abscesses in the neck. These procedures are performed in a hospital operating room. General anesthesia is used. Questions to Ask the Doctor • How many abscess incision and drainage procedures has the physician performed? • What is the physician's complication rate?

Definition An abscess is an infected skin nodule containing pus. It may need to be drained via an incision (cut) if the pus does not resolve with treatment by antibiotics. This allows the pus to escape, the infection to be treated, and the abscess to heal. Purpose An abscess is a pus-filled sore, usually caused by a bacterial infection. The pus is comprised of both living and dead organisms. It also contains destroyed tissue due to the action of white blood cells that were carried to the area to fight the infection. Abscesses are often found in the soft tissue under the skin such as the armpit or the groin. However, they may develop in any organ, and are commonly found in the breast and gums. Abscesses are far more serious and call for more specific treatment if they are located in deep organs such as the lung, liver, or brain. Because the lining of an abscess cavity tends to interfere with the amount of drug that can penetrate the source of infection from the blood, the cavity itself may require draining. Once an abscess has fully formed, it often does not respond to antibiotics. Even if the antibiotic does penetrate into the abscess, it does not function as well in that environment. Demographics Abcess drainage is a minor and common surgical procedure that is often performed in a professional medical office. Accurate records concerning the number of procedures are kept in private medical office rather than hospital records. For these reasons, it is impossible to accurately tally the number of abscess incision and drainage procedures performed in a year. The procedure increases in frequency with increasing age.

This lung abscess is a build-up of fluid near the lung (A). To drain it, the patient is placed on his or her side, and an incision is made (B). A rib is exposed (C) and cut (D). The fluid in the abscess is suctioned (E), and the incision is closed around a temporary drainage tube (F). (Illustration by GGS Inc.) Description A doctor will cut into the lining of an abscess, allowing the pus to escape either through a drainage tube or by leaving the cavity open to the skin. The size of the incision depends on the volume of the abscess and how quickly the pus is encountered. Cells normally formed for the surface of the skin often migrate into an abscess. They line the abscess cavity. This process is called epithelialization. This lining prevents drugs from reaching an abscess. It also promotes recurrence of the abscess. The lining must be removed when an abscess is drained to prevent recurrence. Once an abscess is opened, the pus drained, and the epithelial lining removed, the doctor will clean and irrigate the wound thoroughly with saline. If it is not too large or deep, the doctor may simply pack the abscess wound with gauze for 24–48 hours to absorb the pus and discharge. If it is a deeper abscess, the doctor or surgeon may insert a drainage tube after cleaning out the wound. Once the tube is in place, the surgeon closes the incision with simple stitches and applies a sterile dressing. Drainage is maintained for several days to help prevent the abscess from reforming. The tube is removed, and the abscess allowed to finish closing and healing. Diagnosis/Preparation An abscess can usually be diagnosed visually, although an imaging technique such as a computed tomography (CT) scan or ultrasound may be used to confirm the extent of the abscess before drainage. Such procedures may also be needed to localize internal abscesses such as those in the abdominal cavity or brain. Prior to incision, the skin over an abscess will be cleansed by swabbing gently with an antiseptic solution. Aftercare Much of the pain around an abscess will be gone after the surgery. Healing is usually very rapid. After the drainage tube is removed, antibiotics may be continued for several days. Applying heat and keeping the affected area elevated may help relieve inflammation. Risks Any scarring is likely to become much less noticeable as time goes on, and eventually become almost invisible. Occasionally, an abscess within a vital organ (such as the brain) damages enough surrounding tissue that there is some permanent loss of normal function. Other risks include incomplete drainage and prolonged infection. Occasionally, an abscess may require a second incision and drainage procedure. This is frequently due to retained epithelial cells that line the abscess cavity. Normal Results Most abscesses heal after drainage alone. Others may require more prolonged drainage and antibiotic drug treatment. Morbidity and Mortality Rates

Morbidity associated with an abscess incision and drainage is very uncommon. Post-surgical problems are usually associated with infection or an adverse reaction to antibiotic drugs prescribed. Mortality is virtually unknown. Alternatives There is no reliable alternative to surgical incision and drainage of an abscess. Heat alone may cause small superficial abscesses to resolve. The degree of epithelialization usually determines if the abscess reappears.

Pott disease
From Wikipedia, the free encyclopedia
Jump to: navigation, search Pott's Disease Classification and external resources ICD-10 A18.0, M49.0 ICD-9 015.0 MeSH D014399

Tuberculosis of the spine in an Egyptian mummy Pott's disease, is a presentation of extrapulmonary tuberculosis that affects the spine, a kind of tuberculous arthritis of the intervertebral joints. It is named after Percivall Pott (1714-1788), a London surgeon who trained at St Bartholomew's Hospital, London. The lower thoracic and upper lumbar

vertebrae are the areas of the spine most often affected. Scientifically, it is called tuberculous spondylitis and it is most commonly localized in the thoracic portion of the spine. Pott’s disease results from haematogenous spread of tuberculosis from other sites, often pulmonary. The infection then spreads from two adjacent vertebrae into the adjoining intervertebral disc space. If only one vertebra is affected, the disc is normal, but if two are involved the disc, which is avascular, cannot receive nutrients and collapses. The disc tissue dies and is broken down by caseation, leading to vertebral narrowing and eventually to vertebral collapse and spinal damage. A dry soft tissue mass often forms and superinfection is rare.

Contents
[hide] • • • • • • • 1 Signs and symptoms 2 Diagnosis 3 Late complications 4 Prevention 5 Therapy 6 Cultural references 7 External links

[edit] Signs and symptoms
• • • • • • back pain fever night sweating anorexia weight loss Spinal mass, sometimes associated with numbness, paraesthesia, or muscle weakness of the legs

[edit] Diagnosis
• • • • • • • blood tests - elevated erythrocyte sedimentation rate tuberculin skin test radiographs of the spine bone scan CT of the spine bone biopsy MRI

[edit] Late complications
• • • • Vertebral collapse resulting in kyphosis Spinal cord compression sinus formation paraplegia (so called Pott's paraplegia)

[edit] Prevention
Controlling the spread of tuberculosis infection can prevent tuberculous spondylitis and arthritis. Patients who have a positive PPD test (but not active tuberculosis) may decrease their risk by properly taking medicines to prevent tuberculosis. To effectively treat tuberculosis, it is crucial that patients take their medications exactly as prescribed.

[edit] Therapy
• • • • • • • non-operative - antituberculous drugs analgesics immobilization of the spine region by rod (Hull) Surgery may be necessary, especially to drain spinal abscesses or to stabilize the spine Richards intramedullary hip screw - facilitating for bone healing Kuntcher Nail - intramedullary rod Austin Moore - intrameduallary rod (for Hemiarthroplasty)

[edit] Cultural references
The fictional Hunchback of Notre Dame had a gibbous deformity (humpback) that is thought to have been caused by tuberculosis. In Henrik Ibsen's play "A Doll's House," Dr. Rank suffers from "consumption of the spine." Furthermore, Jocelin, the Dean who wanted a spire on his cathedral in William Golding's "The Spire" probably suffered and died as a result of this disease. 18th-century English poets Alexander Pope and William Ernest Henley both suffered from Pott's disease. Anna Roosevelt Cowles, sister of president Theodore Roosevelt, suffered from Pott's Disease. Chick Webb, swing era drummer and band leader, was afflicted with tuberculosis of the spine as a child, which left him hunchbacked. The Sicilian mafia boss Luciano Leggio had Pott's disease and wore a brace. Morton, the railroad magnate in Once Upon a Time in the West, suffers from the disease and needs crutches to walk.

Dental Dictionary:

Pott’s disease
Top Home > Library > Health > Dental Dictionary n.pr A spinal curvature (kyphosis) resulting from tuberculosis.

Medical Dictionary:

tuberculous spondylitis
Top Home > Library > Health > Medical Dictionary n. A spinal infection associated with tuberculosis and characterized by a sharp angulation of the spine where tubercle lesions are present. Also called Pott's disease.

WordNet:

Pott's disease
Top Home > Library > Literature & Language > WordNet
Note: click on a word meaning below to see its connections and related words.

The noun has one meaning: Meaning #1: TB of the spine with destruction of vertebrae resulting in curvature of the spine