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Lung abscess

Changed by Francis Deng, 25 Nov 2023
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Disclosures - updated 30 Oct 2023: Nothing to disclose

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

Epidemiology

As a result of the widespread availability of antibiotics, the incidence of lung abscesses has been dramatically reduced. Mortality has similarly been reduced. The elderly, immunocompromised, malnourished, debilitated, and, of course, those who do not have access to antibiotics are particularly susceptible and have the worst prognosis 6. The rate is on the rise, though, particularly due to an increased number of immunocompromised patients (secondary to HIV/AIDS and iatrogenic immunosuppression) 7.

Clinical presentation

Lung abscesses are divided, according to their duration, into acute (<6 weeks) and chronic (>6 weeks) 7. The presentation is usually non-specific and generally similar to a non-cavitating chest infection. Symptoms include fever, cough and shortness of breath. Peripheral abscesses may also cause pleuritic chest pain 7.  

If chronic, symptoms are more indolent and include weight loss and constitutional symptoms. In some cases, erosion into a bronchial vessel may result in a sudden and potentially life-threatening massive haemoptysis.

Pathology

Usually, occurs from liquefactive necrosis of tissue. 

It is convenient to divide lung abscesses into primary and secondary as they differ not only in aetiology but also in microbiology and prognosis.

A primary abscess is one that develops as a result of a primary infection of the lung. These most commonly arise from aspiration, necrotising pneumonia or chronic pneumonia, e.g. in the setting of pulmonary tuberculosis 7 or immunodeficiency 10.

In patients who develop abscesses as a result of aspiration, mixed infections are most common, including anaerobes.

Some organisms are particularly prone to causing significant necrotising pneumonia resulting in cavitation and abscess formation. These include 1:

In immunocompromised patients, additional organisms may also be implicated, including 7:

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

The colonisation of pre-existing cavities with organisms is also sometimes grouped with secondary abscesses 7.

Radiographic features

As aspiration is the most common cause of pulmonary abscesses, the superior segment of the right lower lobe is the most common site of infection 6.

Plain radiograph

The classical appearance of a pulmonary abscess is a cavity containing a gas-fluid level. In general, abscesses are round in shape and appear similar in both frontal and lateral projections. Additionally, all margins are equally well seen, although adjacent consolidation may make the assessment of this difficult. These features are helpful in distinguishing a pulmonary abscess from an empyema (see empyema vs pulmonary abscess).

Ultrasound

Ultrasound does not play a routine role in the assessment of lung abscesses as any aerated intervening lung will prevent visualisation. Peripheral abscesses abutting the pleura or with only compressed or consolidated lung may, however, be visible, and should not be mistaken for an empyema 4. The consolidated lung may mimic a fluid collection with low-level echoes.

CT

CT is the most sensitive and specific imaging modality to diagnose a lung abscess. Contrast should be administered, as this enables the identification of the abscess margins, which may otherwise blend with the surrounding consolidated lung.

Abscesses vary in size and are generally rounded in shape. They may contain only fluid or a gas-fluid level. Typically there is surrounding consolidation, although with treatment the cavity will persist longer than the consolidation. 

The wall of the abscess is typically thick and the luminal surface irregular.

Bronchial vessels and bronchi can be traced as far as the wall of the abscess, whereupon they are truncated.

{{youtube:https://www.youtube.com/watch?v=jtwOSdAH5sM:jtwOSdAH5sM}}

Treatment and prognosis

Lung abscesses are usually managed with prolonged antibiotics and physiotherapy with postural drainage 2. Bronchoscopy may be beneficial in establishing bronchial patency to improve drainage 3. In cases that are refractory to conservative management or those complicated by haemoptysis, empyema or suspected malignancy, surgical resection is the 'traditional' definitive treatment 5. Percutaneous drainage under CT guidance has also been advocated in selected cases (e.g. patients refractory to conventional therapy) 3-9.

Conservative treatment is less likely to be successful in the case of larger abscesses (>4 cm in diameter). These have a higher mortality rate, irrespective of treatment 3,6. 

Complications

Complications of surgery or percutaneous drainage include : 

Despite treatment, abscesses continue to have a high mortality rate (15-20%) 3,6. This is particularly the case with nosocomial infections, which account for the majority of deaths, presumably due to the combined effect of pre-existing illness and the higher prevalence of virulent antibiotic-resistant strains, especially P. aeruginosa (mortality rate of 83%), S. aureus (50%), and Klebsiella pneumoniae (44%) 6.

Differential diagnosis

General imaging differential considerations include:

Other considerations on plain film include

  • -<p><strong>Lung abscesses </strong>are circumscribed collections of pus within the lungs. They are often complicated to manage and difficult to treat and, in some cases, maybe life-threatening.</p><h4>Epidemiology</h4><p>As a result of the widespread availability of antibiotics, the incidence of lung abscesses has been dramatically reduced. Mortality has similarly been reduced. The elderly, immunocompromised, malnourished, debilitated, and, of course, those who do not have access to antibiotics are particularly susceptible and have the worst prognosis <sup>6</sup>. The rate is on the rise, though, particularly due to an increased number of immunocompromised patients (secondary to <a href="/articles/hivaids">HIV/AIDS</a> and iatrogenic <a href="/articles/immunosuppression">immunosuppression</a>) <sup>7</sup>.</p><h4>Clinical presentation</h4><p>Lung abscesses are divided, according to their duration, into <strong>acute </strong>(&lt;6 weeks) and <strong>chronic </strong>(&gt;6 weeks) <sup>7</sup>. The presentation is usually non-specific and generally similar to a non-cavitating chest infection. Symptoms include fever, cough and shortness of breath. Peripheral abscesses may also cause <a href="/articles/pleuritic-pain">pleuritic chest pain</a> <sup>7</sup>.  </p><p>If chronic, symptoms are more indolent and include weight loss and constitutional symptoms. In some cases, erosion into a bronchial vessel may result in a sudden and potentially life-threatening <a href="/articles/haemoptysis-1">massive haemoptysis.</a></p><h4>Pathology</h4><p>Usually, occurs from <a href="/articles/liquefactive-necrosis">liquefactive necrosis</a> of tissue. </p><p>It is convenient to divide lung abscesses into primary and secondary as they differ not only in aetiology but also in microbiology and prognosis.</p><p>A <strong>primary abscess </strong>is one that develops as a result of a primary infection of the lung. These most commonly arise from <a href="/articles/aspiration" title="Aspiration">aspiration</a>, <a href="/articles/necrotising-pneumonia" title="Necrotising pneumonia">necrotising pneumonia</a> or chronic pneumonia, e.g. in the setting of <a href="/articles/tuberculosis-pulmonary-manifestations-1">pulmonary tuberculosis</a> <sup>7</sup> or immunodeficiency<sup> 10</sup>.</p><p>In patients who develop abscesses as a result of aspiration, mixed infections are most common, including anaerobes.</p><p>Some organisms are particularly prone to causing significant necrotising pneumonia resulting in cavitation and abscess formation. These include <sup>1</sup>:</p><ul>
  • -<li><p><em>Staphylococcus aureus</em></p></li>
  • -<li><p><em>Klebsiella</em> sp: <a href="/articles/klebsiella-pneumonia">Klebsiella pneumonia</a></p></li>
  • -<li><p><em>Pseudomonas</em> sp</p></li>
  • -<li><p><em>Proteus</em> sp</p></li>
  • -</ul><p>In immunocompromised patients, additional organisms may also be implicated, including <sup>7</sup>:</p><ul>
  • -<li><p><em>Candida albicans: </em><a href="/articles/pulmonary-candidiasis">pulmonary candidiasis</a></p></li>
  • -<li><p><em>Legionella micdadei </em>and<em> Legionella pneumophila: </em><a href="/articles/legionella-pneumonia">Legionella pneumonia</a></p></li>
  • -<li><p><em>Pneumocystis jirovecii </em>(uncommon): <a href="/articles/pulmonary-pneumocystis-jirovecii-infection-2">Pneumocystis jirovecii pneumonia</a></p></li>
  • -</ul><p>A <strong>secondary abscess</strong> is one that develops as a result of another condition. Examples include:</p><ul>
  • -<li><p>bronchial obstruction: <a href="/articles/lung-cancer-3">bronchogenic carcinoma</a>, <a href="/articles/airway-foreign-bodies-in-adults" title="Airway foreign bodies in adults">inhaled foreign body</a><a href="/articles/foreign-body-inhalation-series-paediatric" title="Foreign body inhalation series (paediatric)"> </a></p></li>
  • -<li><p>haematogenous spread: <a href="/articles/bacterial-endocarditis">bacterial endocarditis</a>, <a href="/articles/intravenous-drug-user">intravenous drug use</a></p></li>
  • -<li><p>direct extension from adjacent infection: mediastinum, subphrenic, chest wall</p></li>
  • -</ul><p>The colonisation of pre-existing cavities with organisms is also sometimes grouped with secondary abscesses <sup>7</sup>.</p><h4>Radiographic features</h4><p>As aspiration is the most common cause of pulmonary abscesses, the superior segment of the right lower lobe is the most common site of infection <sup>6</sup>.</p><h5>Plain radiograph</h5><p>The classical appearance of a pulmonary abscess is a cavity containing a gas-fluid level. In general, abscesses are round in shape and appear similar in both frontal and lateral projections. Additionally, all margins are equally well seen, although adjacent consolidation may make the assessment of this difficult. These features are helpful in distinguishing a pulmonary abscess from an empyema (see <a href="/articles/empyema-vs-pulmonary-abscess-2">empyema vs pulmonary abscess</a>).</p><h5>Ultrasound</h5><p>Ultrasound does not play a routine role in the assessment of lung abscesses as any aerated intervening lung will prevent visualisation. Peripheral abscesses abutting the pleura or with only compressed or consolidated lung may, however, be visible, and should not be mistaken for an empyema <sup>4</sup>. The consolidated lung may mimic a fluid collection with low-level echoes.</p><h5>CT</h5><p>CT is the most sensitive and specific imaging modality to diagnose a lung abscess. Contrast should be administered, as this enables the identification of the abscess margins, which may otherwise blend with the surrounding consolidated lung.</p><p>Abscesses vary in size and are generally rounded in shape. They may contain only fluid or a gas-fluid level. Typically there is surrounding consolidation, although with treatment the cavity will persist longer than the consolidation. </p><p>The wall of the abscess is typically thick and the luminal surface irregular.</p><p>Bronchial vessels and bronchi can be traced as far as the wall of the abscess, whereupon they are truncated.</p><p>{{youtube:https://www.youtube.com/watch?v=jtwOSdAH5sM}}</p><h4>Treatment and prognosis</h4><p>Lung abscesses are usually managed with prolonged antibiotics and physiotherapy with postural drainage <sup>2</sup>. Bronchoscopy may be beneficial in establishing bronchial patency to improve drainage <sup>3</sup>. In cases that are refractory to conservative management or those complicated by haemoptysis, empyema or suspected malignancy, surgical resection is the 'traditional' definitive treatment <sup>5</sup>. Percutaneous drainage under CT guidance has also been advocated in selected cases (e.g. patients refractory to conventional therapy) <sup>3-9</sup>.</p><p>Conservative treatment is less likely to be successful in the case of larger abscesses (&gt;4 cm in diameter). These have a higher mortality rate, irrespective of treatment <sup>3,6</sup>. </p><h5>Complications</h5><p>Complications of surgery or percutaneous drainage include : </p><ul>
  • -<li><p><a href="/articles/pleural-empyema-1">empyema</a></p></li>
  • -<li><p><a href="/articles/bronchopleural-fistula-2">bronchopleural fistula</a></p></li>
  • -<li><p>haemorrhage (from chest wall or the lung)</p></li>
  • -<li><p><a href="/articles/pneumothorax">pneumothorax</a> <sup>11</sup></p></li>
  • -</ul><p>Despite treatment, abscesses continue to have a high mortality rate (15-20%) <sup>3,6</sup>. This is particularly the case with nosocomial infections, which account for the majority of deaths, presumably due to the combined effect of pre-existing illness and the higher prevalence of virulent antibiotic-resistant strains, especially <em>P. aeruginosa</em> (mortality rate of 83%), <em>S. aureus</em> (50%), and <em>Klebsiella pneumoniae</em> (44%) <sup>6</sup>.</p><h4>Differential diagnosis</h4><p>General imaging differential considerations include:</p><ul>
  • -<li><p><a href="/articles/pleural-empyema-1">empyema</a> (see <a href="/articles/empyema-vs-pulmonary-abscess-2">empyema vs pulmonary abscess</a>)</p></li>
  • -<li><p><a href="/articles/lung-cancer-3">bronchogenic carcinoma </a>(cavitating)</p></li>
  • -<li><p><a href="/articles/pulmonary-metastasis">pulmonary metastasis</a>: with necrosis</p></li>
  • -<li><p>pulmonary cavitating granulomatous disease (e.g. <a href="/articles/granulomatosis-with-polyangiitis">granulomatosis with polyangiitis</a>)</p></li>
  • -<li><p>large infected <a href="/articles/pneumatocele-1">pneumatocele</a>: infected emphysematous bulla</p></li>
  • -<li><p><a href="/articles/cavitating-pneumonia">cavitating pneumonia</a> / <a href="/articles/necrotising-pneumonia">necrotising pneumonia</a></p></li>
  • -</ul><p>Other considerations on plain film include</p><ul>
  • -<li><p><a href="/articles/pulmonary-tuberculosis">pulmonary tuberculosis</a></p></li>
  • -<li><p><a href="/articles/hiatus-hernia">hiatus hernia</a> (especially for a retrocardiac abscess)</p></li>
  • +<p><strong>Lung abscesses </strong>are circumscribed collections of pus within the lungs. They are often complicated to manage and difficult to treat and, in some cases, maybe life-threatening.</p><h4>Epidemiology</h4><p>As a result of the widespread availability of antibiotics, the incidence of lung abscesses has been dramatically reduced. Mortality has similarly been reduced. The elderly, immunocompromised, malnourished, debilitated, and, of course, those who do not have access to antibiotics are particularly susceptible and have the worst prognosis <sup>6</sup>. The rate is on the rise, though, particularly due to an increased number of immunocompromised patients (secondary to <a href="/articles/hivaids">HIV/AIDS</a> and iatrogenic <a href="/articles/immunosuppression">immunosuppression</a>) <sup>7</sup>.</p><h4>Clinical presentation</h4><p>Lung abscesses are divided, according to their duration, into <strong>acute </strong>(&lt;6 weeks) and <strong>chronic </strong>(&gt;6 weeks) <sup>7</sup>. The presentation is usually non-specific and generally similar to a non-cavitating chest infection. Symptoms include fever, cough and shortness of breath. Peripheral abscesses may also cause <a href="/articles/pleuritic-pain">pleuritic chest pain</a> <sup>7</sup>.  </p><p>If chronic, symptoms are more indolent and include weight loss and constitutional symptoms. In some cases, erosion into a bronchial vessel may result in a sudden and potentially life-threatening <a href="/articles/haemoptysis-1">massive haemoptysis.</a></p><h4>Pathology</h4><p>Usually, occurs from <a href="/articles/liquefactive-necrosis">liquefactive necrosis</a> of tissue. </p><p>It is convenient to divide lung abscesses into primary and secondary as they differ not only in aetiology but also in microbiology and prognosis.</p><p>A <strong>primary abscess </strong>is one that develops as a result of a primary infection of the lung. These most commonly arise from <a href="/articles/aspiration" title="Aspiration">aspiration</a>, <a href="/articles/necrotising-pneumonia" title="Necrotising pneumonia">necrotising pneumonia</a> or chronic pneumonia, e.g. in the setting of <a href="/articles/tuberculosis-pulmonary-manifestations-1">pulmonary tuberculosis</a> <sup>7</sup> or immunodeficiency<sup> 10</sup>.</p><p>In patients who develop abscesses as a result of aspiration, mixed infections are most common, including anaerobes.</p><p>Some organisms are particularly prone to causing significant necrotising pneumonia resulting in cavitation and abscess formation. These include <sup>1</sup>:</p><ul>
  • +<li><p><em>Staphylococcus aureus</em></p></li>
  • +<li><p><em>Klebsiella</em> sp: <a href="/articles/klebsiella-pneumonia">Klebsiella pneumonia</a></p></li>
  • +<li><p><em>Pseudomonas</em> sp</p></li>
  • +<li><p><em>Proteus</em> sp</p></li>
  • +</ul><p>In immunocompromised patients, additional organisms may also be implicated, including <sup>7</sup>:</p><ul>
  • +<li><p><em>Candida albicans: </em><a href="/articles/pulmonary-candidiasis">pulmonary candidiasis</a></p></li>
  • +<li><p><em>Legionella micdadei </em>and<em> Legionella pneumophila: </em><a href="/articles/legionella-pneumonia">Legionella pneumonia</a></p></li>
  • +<li><p><em>Pneumocystis jirovecii </em>(uncommon): <a href="/articles/pulmonary-pneumocystis-jirovecii-infection-2">Pneumocystis jirovecii pneumonia</a></p></li>
  • +</ul><p>A <strong>secondary abscess</strong> is one that develops as a result of another condition. Examples include:</p><ul>
  • +<li><p>bronchial obstruction: <a href="/articles/lung-cancer-3">bronchogenic carcinoma</a>, <a href="/articles/airway-foreign-bodies-in-adults" title="Airway foreign bodies in adults">inhaled foreign body</a><a href="/articles/foreign-body-inhalation-series-paediatric" title="Foreign body inhalation series (paediatric)"> </a></p></li>
  • +<li><p>haematogenous spread: <a href="/articles/bacterial-endocarditis">bacterial endocarditis</a>, <a href="/articles/intravenous-drug-user">intravenous drug use</a></p></li>
  • +<li><p>direct extension from adjacent infection: mediastinum, subphrenic, chest wall</p></li>
  • +</ul><p>The colonisation of pre-existing cavities with organisms is also sometimes grouped with secondary abscesses <sup>7</sup>.</p><h4>Radiographic features</h4><p>As aspiration is the most common cause of pulmonary abscesses, the superior segment of the right lower lobe is the most common site of infection <sup>6</sup>.</p><h5>Plain radiograph</h5><p>The classical appearance of a pulmonary abscess is a cavity containing a gas-fluid level. In general, abscesses are round in shape and appear similar in both frontal and lateral projections. Additionally, all margins are equally well seen, although adjacent consolidation may make the assessment of this difficult. These features are helpful in distinguishing a pulmonary abscess from an empyema (see <a href="/articles/empyema-vs-pulmonary-abscess-2">empyema vs pulmonary abscess</a>).</p><h5>Ultrasound</h5><p>Ultrasound does not play a routine role in the assessment of lung abscesses as any aerated intervening lung will prevent visualisation. Peripheral abscesses abutting the pleura or with only compressed or consolidated lung may, however, be visible, and should not be mistaken for an empyema <sup>4</sup>. The consolidated lung may mimic a fluid collection with low-level echoes.</p><h5>CT</h5><p>CT is the most sensitive and specific imaging modality to diagnose a lung abscess. Contrast should be administered, as this enables the identification of the abscess margins, which may otherwise blend with the surrounding consolidated lung.</p><p>Abscesses vary in size and are generally rounded in shape. They may contain only fluid or a gas-fluid level. Typically there is surrounding consolidation, although with treatment the cavity will persist longer than the consolidation. </p><p>The wall of the abscess is typically thick and the luminal surface irregular.</p><p>Bronchial vessels and bronchi can be traced as far as the wall of the abscess, whereupon they are truncated.</p><p>{{youtube:jtwOSdAH5sM}}</p><h4>Treatment and prognosis</h4><p>Lung abscesses are usually managed with prolonged antibiotics and physiotherapy with postural drainage <sup>2</sup>. Bronchoscopy may be beneficial in establishing bronchial patency to improve drainage <sup>3</sup>. In cases that are refractory to conservative management or those complicated by haemoptysis, empyema or suspected malignancy, surgical resection is the 'traditional' definitive treatment <sup>5</sup>. Percutaneous drainage under CT guidance has also been advocated in selected cases (e.g. patients refractory to conventional therapy) <sup>3-9</sup>.</p><p>Conservative treatment is less likely to be successful in the case of larger abscesses (&gt;4 cm in diameter). These have a higher mortality rate, irrespective of treatment <sup>3,6</sup>. </p><h5>Complications</h5><p>Complications of surgery or percutaneous drainage include : </p><ul>
  • +<li><p><a href="/articles/pleural-empyema-1">empyema</a></p></li>
  • +<li><p><a href="/articles/bronchopleural-fistula-2">bronchopleural fistula</a></p></li>
  • +<li><p>haemorrhage (from chest wall or the lung)</p></li>
  • +<li><p><a href="/articles/pneumothorax">pneumothorax</a> <sup>11</sup></p></li>
  • +</ul><p>Despite treatment, abscesses continue to have a high mortality rate (15-20%) <sup>3,6</sup>. This is particularly the case with nosocomial infections, which account for the majority of deaths, presumably due to the combined effect of pre-existing illness and the higher prevalence of virulent antibiotic-resistant strains, especially <em>P. aeruginosa</em> (mortality rate of 83%), <em>S. aureus</em> (50%), and <em>Klebsiella pneumoniae</em> (44%) <sup>6</sup>.</p><h4>Differential diagnosis</h4><p>General imaging differential considerations include:</p><ul>
  • +<li><p><a href="/articles/pleural-empyema-1">empyema</a> (see <a href="/articles/empyema-vs-pulmonary-abscess-2">empyema vs pulmonary abscess</a>)</p></li>
  • +<li><p><a href="/articles/lung-cancer-3">bronchogenic carcinoma </a>(cavitating)</p></li>
  • +<li><p><a href="/articles/pulmonary-metastasis">pulmonary metastasis</a>: with necrosis</p></li>
  • +<li><p>pulmonary cavitating granulomatous disease (e.g. <a href="/articles/granulomatosis-with-polyangiitis">granulomatosis with polyangiitis</a>)</p></li>
  • +<li><p>large infected <a href="/articles/pneumatocele-1">pneumatocele</a>: infected emphysematous bulla</p></li>
  • +<li><p><a href="/articles/cavitating-pneumonia">cavitating pneumonia</a> / <a href="/articles/necrotising-pneumonia">necrotising pneumonia</a></p></li>
  • +</ul><p>Other considerations on plain film include</p><ul>
  • +<li><p><a href="/articles/pulmonary-tuberculosis">pulmonary tuberculosis</a></p></li>
  • +<li><p><a href="/articles/hiatus-hernia">hiatus hernia</a> (especially for a retrocardiac abscess)</p></li>

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