Pulmonary Abscess in Children

Dr.Padmesh. V

Lung infection

Destroys lung parenchyma

Cavitations and central necrosis

Localized areas of thick-walled purulent material Lung abscess

• Primary lung abscess:• Occur in previously healthy patients with no

underlying medical disorders.• Usually solitary.

• Secondary lung abscess:• Occur in patients with underlying or predisposing

conditions• May be multiple.

• PATHOLOGY AND PATHOGENESIS• Predisposing conditions:• Aspiration (of infected material or FB)• Pneumonia / Hematogenous seeding from other sites• Cystic fibrosis• Gastroesophageal reflux • Tracheoesophageal fistula• Immunodeficiencies • Postoperative complications of tonsillectomy and

adenoidectomy• Seizures• Neurologic and other conditions associated with

impaired mucociliary defense.

• PATHOLOGY AND PATHOGENESIS:

Aspiration of infected material or foreign body

Pneumonitis impairs drainage of fluid or aspirated material

Inflammatory vascular obstruction

Tissue necrosis, liquefaction

Abscess formation

• PATHOLOGY AND PATHOGENESIS

Aspiration in recumbent position

Right & Left upper lobes and apical segment of the right lower lobes most likely.

Aspiration in upright position

Posterior segments of upper lobes most likely

• PATHOLOGY AND PATHOGENESIS

• Primary abscesses: Most often on Right side.

• Secondary lung abscesses, esp in immunocompromised : Predilection for left side.

• Organisms: Both anaerobic and aerobic organisms.

• Anaerobic bacteria:• Bacteroides spp., • Fusobacterium spp.,• Peptostreptococcus spp.,

• Aerobic bacteria:• Streptococcus spp., • Staphylococcus aureus • Escherichia coli • Klebsiella pneumoniae• Pseudomonas aeruginosa• Mycoplasma pneumoniae (Very rare)

• Fungi can cause lung abscess,esp in immunocompromised.

• CLINICAL MANIFESTATIONS: Symptoms• Cough, • Fever, • Dyspnea, • Chest pain, • Vomiting,• Sputum production, • Weight loss, • Hemoptysis.

• CLINICAL MANIFESTATIONS: Signs• Tachypnea• Dyspnea• Retractions with accessory muscle use• Decreased breath sounds • Dullness to percussion in affected area • Crackles • Occasionally a prolonged expiratory phase on

auscultation

• Diagnosis:• Chest X Ray: Parenchymal inflammation with a

cavity containing an air–fluid level .

• Diagnosis:• Chest CT scan: Abscess is usually a thick-walled lesion with a low-density center progressing to an air–fluid level.

• Diagnosis:

• Gram stain of sputum: Early clue. • Sputum cultures: Yield mixed bacteria, therefore

not always reliable.

• Attempts to avoid contamination from oral flora include direct lung puncture, percutaneous (aided by CT guidance) or transtracheal aspiration, and bronchoalveolar lavage specimens obtained bronchoscopically.

• Diagnosis:

• Bronchoscopic aspiration should be avoided as it can be complicated by massive intrabronchial aspiration.

• To avoid invasive procedures in previously normal hosts, empiric therapy can be initiated in the absence of culturable material.

• Differential Diagnosis:

• Abscesses should be distinguished from pneumatoceles.

• Pneumatoceles often complicate severe bacterial pneumonias.

• Pneumatoceles: Thin- and Smooth-walled, localized air collections with or without air–fluid level.

• Pneumatoceles often resolve spontaneously with treatment of specific cause of the pneumonia.

• TREATMENT:

• Conservative management.• 2-3 wk course of parenteral antibiotics for

uncomplicated cases, followed by oral antibiotics to complete a Total of 4-6 wk.

• Aerobic and anaerobic coverage.

• Include penicillinase-resistant agent active against S.aureus and anaerobic coverage, typically clindamycin or ticarcillin/clavulanic acid.

• If Gram-negative bacteria are suspected or isolated, an aminoglycoside should be added.

• TREATMENT

• Early CT-guided percutaneous aspiration or drainage.

• Severely ill or those who fail to improve after 7-10 days of antibiotics Surgical intervention.

• Minimally invasive CT guided percutaneous aspiration.

• Thorascopic drainage.

• In rare complicated cases Thoracotomy with surgical drainage or lobectomy and/or decortication.

• PROGNOSIS

• Excellent.

• Presence of aerobic organisms may be a negative prognostic indicator, particularly in those with secondary lung abscesses.

• Most become asymptomatic within 7-10 days, although fever can persist for as long as 3 wk.

• Radiologic abnormalities usually resolve in 1-3 mo but can persist for years.

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The End!