Aaa Pott's Disease

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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 courseof 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 thenatural 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 andnow 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 tothe mounting frequency of opportunistic lung abscesses.

For excellent patient education resources, visit eMedicine'sInfections 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 ofpatient 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 bronchogeniccarcinoma 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 gram-negative organisms. However, lung cavities may not always be due to an underlying infection.

Factors contributing to lung abscess
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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. Althoughlung 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 areadministered 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 ofinflammation 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
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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 tothe hilar and mediastinal lymph nodes, and these too may become purulent.

Bacteriology of lung abscess

Gram-negative organisms

Bacteroides species

Fusobacterium species

Proteus species

Aerobacterspecies

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, productivecough, weight loss, general malaise, and night sweats. Initially, foul sputum is not observed in thecourse 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 theexpectoration 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, andunremitting 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. Clubbingof 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


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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 anecrotic 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 thelung, the individual may develop a cough and expectorate a chocolate or anchovy pastelike 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 obviousoral 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 specialstaining 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 arecontaminants 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


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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 distinctivecharacteristic 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 interpretationis 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 gram-negative. 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 theextent 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 beperformed 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 shouldnot 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 forculture 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 aneasy, 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


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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 lungabscess.

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 carcinomatousabscess is usually thicker and more irregular than that of the primary abscess is helpful. Further, foulsputum, 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

atelectasisbut otherwise appears as a primary abscessearly bronchoscopy is recommended in allcases.

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.1Intravenous therapy is appropriate


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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 inapproximately 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.1After initial

antibiotic therapy, the clinical and radiographic response is gradual. The fever generally subsides in 4-7days, 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).

DrainageMost 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 positionsbased 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 respiratorydistress 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. Successfulmedical therapy resolves symptoms with no radiographic evidence or only a residual thin-walled cystic

cavity (


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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 ofspillage 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-satisfactorymethod 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 alung 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 lungabscesses. 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 medicaltreatment, 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 thetremendous 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 surgerybecause 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 ofsepsis) is

beneficial in selected patients who do not respond to adequate medical therapy.2

These are ventilator-dependent 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.
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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 abscessappears 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 multiorganinvolvement 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 orwithout 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 pathologicevent 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 withan 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, infectedlung, 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 lungabscess, amoebic lung abscess

Madainnah
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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 (


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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 haveperiodontal 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 oropharyngealinfection followed by septic thrombophlebitis of the internal jugular vein, is a rare cause of lung

abscesses. The oral anaerobeF necrophorum is the most common pathogen.

Microbiology


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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 arethe 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 arePeptostreptococcus species,Bacteroidesspecies,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.2In a series of 90 patients with community-acquired lung

abscess in Taiwan, anaerobes were recovered from just 28 patients (31%); the predominant bacterium

wasK 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 previousreports.

Nonbacterial and atypical bacterial pathogens may also cause lung abscesses, usually in the

immunocompromised host. These microorganisms include parasites (eg,Paragonimus andEntamoeba

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 90-

95%.

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.3The 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 retrospectivestudy reported the overall mortality rate of lung abscesses caused by mixed gram-positive and gram-

negative bacteria at approximately 20%.5

Sex

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


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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 tomonths.

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 maybe 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 ofthe 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 38.5C 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, andpyopneumothorax 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.


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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 Pneumococcal InfectionsEmpyema, Pleuropulmonary Pneumocystis Carinii

Pneumonia

Hydatid Cysts Pneumonia, Aspiration

Infective Endocarditis Pneumonia, Bacterial

Lung Cancer, Non-Small Cell Pneumonia, FungalLung Cancer, Oat Cell (Small Cell) Pulmonary Embolism

Mycetoma Sarcoidosis

Mycobacterium Avium-Intracellulare

Thrombophlebitis, Septic

Mycobacterium Chelonae Tuberculosis

Mycobacterium Kansasii Wegener GranulomatosisNocardiosis

Other Problems to Be Considered

Cavitating lung cancer

Localized empyema

Infected bulla containing a fluid levelInfected congenital pulmonary lesion, such as bronchogenic cyst or sequestration

Pulmonary hematoma
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Cavitating pneumoconiosis

Hiatus hernia

Lung parasites (eg, hydatid cyst,Paragonimus infection)

ActinomycosisWegener 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 cavitywith 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 cavitatingcarcinoma.

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 formsacute 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 ]


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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.


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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 ]


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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 ]


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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 ill-defined 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 ]


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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


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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 foranaerobic 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 foranaerobic culture because the oral cavity is extensively colonized with anaerobes. Blood cultures areinfrequently 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 oforganisms 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 inpneumonia. 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, thecontents 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.


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

[ CLOSE WINDOW ]

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


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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.12Someclinical 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 inpublished trials. Several anaerobes may produce beta-lactamase (eg, various species of

Bacteroides andFusobacterium) 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 therapyshould include coverage against S aureus andEnterobacterandPseudomonas 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 shorterantibiotic 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 undergofurther diagnostic studies to determine the cause of failure.

Considerations in patients with poor response to antibiotic therapy include bronchial obstruction
http://www.guideline.gov/summary/summary.aspx?doc_id=5291&nbr=003615&string=lung+AND+abscesshttp://www.guideline.gov/summary/summary.aspx?doc_id=5291&nbr=003615&string=lung+AND+abscess


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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 todifferentiate 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 indicationsfor 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 usuallyconsidered. 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 ofcommunity 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


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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; antibiotic-associated 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; associatedwith 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. Dosing

Interactions

Contraindications

Precautions

Adult

2 g IV q6-8h


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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

Documented hypersensitivity

Dosing

Interactions Contraindications

Precautions

Pregnancy


Precautions

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

Penicillin G (Pfizerpen)

Interferes with synthesis of cell wall mucopeptide during active multiplication, resulting in bactericidalactivity against susceptible microorganisms.

Dosing

Interactions

Contraindications

Precautions

Adult

2 million U IV q4h

Pediatric

150,000 U/kg/d IV divided q4h

Dosing


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Interactions

Contraindications

Precautions

Probenecid can increase effects of penicillin; coadministration of tetracyclines can decrease effects ofpenicillin

Dosing Interactions

Contraindications

Precautions

Documented hypersensitivity

Dosing

Interactions

Contraindications

Precautions

Pregnancy


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 forClostridium difficile enterocolitis). Not

standard practice to use metronidazole alone because some anaerobic cocci and most microaerophilicstreptococci are resistant.

Dosing

Interactions

Contraindications

Precautions

Adult

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


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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, gagreflexes), 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 riskof 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


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obstruction secondary to carcinoma.

Patient Education

For excellent patient education resources, visit eMedicine's Infections Center, Lung and AirwayCenter, Pneumonia Center, andProcedures 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 lungneoplasm, lung infarction, or Wegener granulomatosis.

Abscess Incision & Drainage

Medical Encyclopedia:


Sponsored Links

AbscessesRelax. Take a deep breath. We have the answers you seek.

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More about Abscess Incision & Drainage:Purpose

PrecautionsPreparationAftercare

RisksNormal 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 drainagetube 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 2448 hours toabsorb 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 DrainageTop

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 aprofessional 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 hospitaloperating

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?

AbscessIncision&Drainage
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Definition

An abscess is an infected skin nodule containingpus. It may need to be drained via anincision (cut) if

the pus does not resolve with treatment by antibiotics. This allows the pus to escape, the infection to be

treated, and theabscess to heal.

Purpose

An abscess is a pus-filled sore, usually caused by abacterial infection. The pus is comprised of bothliving 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 thearmpit or the groin. However, they may develop in any organ, and are commonly found inthe 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 canpenetrate the

source of infection from the blood, the cavity itself may require draining. Once an abscess has fullyformed, 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.

DemographicsAbcess 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 medicaloffice 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.
http://topic/nodulehttp://topic/pushttp://topic/pushttp://topic/pushttp://topic/incisionhttp://topic/incisionhttp://topic/antibiotichttp://topic/abscesshttp://topic/abscesshttp://topic/sorehttp://topic/bacteriahttp://topic/armpithttp://topic/armpithttp://topic/groinhttp://topic/penetratehttp://topic/antibiotichttp://topic/tallyhttp://topic/nodulehttp://topic/pushttp://topic/incisionhttp://topic/antibiotichttp://topic/abscesshttp://topic/sorehttp://topic/bacteriahttp://topic/armpithttp://topic/groinhttp://topic/penetratehttp://topic/antibiotichttp://topic/tally


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This lung abscess is a build-up of fluid near the lung (A). To drain it, the patient is placed on his or herside, 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 abscesscavity. 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 andirrigate the wound thoroughly with saline. If it is not too large or deep, the doctor may simply pack the

abscess wound with gauze for 2448 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 asteriledressing. 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 orultrasound 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 almostinvisible. 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 requirea second incision and drainage procedure. This is frequently due to retained epithelial cells that line theabscess cavity.

Normal Results

Most abscesses heal after drainage alone. Others may require more prolonged drainage and antibiotic

drug treatment.

Morbidity and Mortality Rates
http://topic/epithelizehttp://topic/epithelizehttp://topic/irrigatehttp://topic/salinityhttp://topic/gauzehttp://topic/stitchhttp://topic/sterilehttp://topic/sterilehttp://topic/tomographyhttp://topic/ultrasoundhttp://topic/ultrasoundhttp://topic/antiseptichttp://topic/inflammationhttp://topic/epithelial-cellshttp://topic/epithelizehttp://topic/irrigatehttp://topic/salinityhttp://topic/gauzehttp://topic/stitchhttp://topic/sterilehttp://topic/tomographyhttp://topic/ultrasoundhttp://topic/antiseptichttp://topic/inflammationhttp://topic/epithelial-cells


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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 causesmall superficial abscesses to resolve. The degree of epithelialization usually determines if the abscess

reappears.

Pott disease

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Pott's DiseaseClassification and external resources

ICD-10 A18.0,M49.0

ICD-9 015.0

MeSH D014399

Tuberculosis of the spine in an Egyptianmummy

Pott's disease, is a presentation of extrapulmonary tuberculosis that affects thespine, a kind oftuberculous arthritis of the intervertebral joints. It is named afterPercivall Pott(1714-1788), a London

surgeon who trained at St Bartholomew's Hospital, London. The lowerthoracic and upperlumbar
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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. Potts disease results

from haematogenous spread of tuberculosis from other sites, often pulmonary. The infection then

spreads from two adjacent vertebrae into the adjoining intervertebral discspace. If only one vertebra isaffected, 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 formsand 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, ormuscle weaknessof 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)
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[edit] Prevention

Controlling the spread of tuberculosis infection can prevent tuberculous spondylitis and arthritis.

Patients who have a positivePPD 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 taketheir 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 abscessesor 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 inWilliam Golding's "The Spire" probably suffered and died as a result of this disease. 18th-century

English poets Alexander Pope and William Ernest Henleyboth 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 lefthim hunchbacked. The Sicilianmafia bossLuciano 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:

Potts diseaseTop

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n.pr

A spinal curvature (kyphosis) resulting from tuberculosis.
http://w/index.php?title=Pott_disease&action=edit&section=4http://wiki/Mantoux_testhttp://wiki/Mantoux_testhttp://w/index.php?title=Pott_disease&action=edit&section=5http://wiki/Tuberculosis_treatmenthttp://wiki/Analgesichttp://wiki/Surgeryhttp://wiki/Abscesshttp://wiki/Abscesshttp://w/index.php?title=Pott_disease&action=edit&section=6http://wiki/Hunchback_of_Notre_Damehttp://wiki/Henrik_Ibsenhttp://wiki/Henrik_Ibsenhttp://wiki/William_Goldinghttp://wiki/Alexander_Popehttp://wiki/William_Ernest_Henleyhttp://wiki/William_Ernest_Henleyhttp://wiki/Anna_Roosevelt_Cowleshttp://wiki/Anna_Roosevelt_Cowleshttp://wiki/Theodore_Roosevelthttp://wiki/Chick_Webbhttp://wiki/Sicilyhttp://wiki/Mafiahttp://wiki/Luciano_Leggiohttp://wiki/Luciano_Leggiohttp://wiki/Once_Upon_a_Time_in_the_Westhttp://library/Dental%20Dictionary-cid-64020http://opt/scribd/conversion/tmp/scratch2704/smb://http://main/what_content.jsphttp://main/health.jsphttp://main/health.jsphttp://library/Dental+Dictionary-cid-64020http://w/index.php?title=Pott_disease&action=edit&section=4http://wiki/Mantoux_testhttp://w/index.php?title=Pott_disease&action=edit&section=5http://wiki/Tuberculosis_treatmenthttp://wiki/Analgesichttp://wiki/Surgeryhttp://wiki/Abscesshttp://w/index.php?title=Pott_disease&action=edit&section=6http://wiki/Hunchback_of_Notre_Damehttp://wiki/Henrik_Ibsenhttp://wiki/William_Goldinghttp://wiki/Alexander_Popehttp://wiki/William_Ernest_Henleyhttp://wiki/Anna_Roosevelt_Cowleshttp://wiki/Anna_Roosevelt_Cowleshttp://wiki/Theodore_Roosevelthttp://wiki/Chick_Webbhttp://wiki/Sicilyhttp://wiki/Mafiahttp://wiki/Luciano_Leggiohttp://wiki/Once_Upon_a_Time_in_the_Westhttp://library/Dental%20Dictionary-cid-64020http://opt/scribd/conversion/tmp/scratch2704/smb://http://main/what_content.jsphttp://main/health.jsphttp://library/Dental+Dictionary-cid-64020


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Medical Dictionary:

tuberculous spondylitis

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n.

A spinal infection associated with tuberculosis and characterized by a sharp angulation of thespine

where tubercle lesions are present. Also calledPott's disease.

WordNet:

Pott's disease

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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
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Documents

Aaa Pott's Disease