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Lung Abscesses; a Five-Year Evaluation
Lu ng Ab scesses; a Fiv e-Year Ev alu ation R IC H ARD
D.
SHA FRO N, M .D. ANIl C HA RLE S
Mia mi, Florida I NTR OD UCT ION A LT H OUG H ANT l mOT ICS HAV E DRA lIIATI C-
n
ally cha nge d t he in cid en ce and m orta lity o f lung abscess, th e mor bidi ty and prolon ged cou rse still m ak e this a seri ous di sease. O ver th e pas t five year s, 55 cases of lung abscesses wer e ad mitt ed to J ackson M em orial H ospi tal. A rev iew of th ese cases was und ertak en to uncover a ny fact ors t hat mig ht infl uen ce t he cou rse and mor talit y ra te in thi s d isease. Fac tors that hav e been discove red to be associated wit h a poo r progn osis arc: a bsc ess es th at have been pres in t l on g er th an ' ig h t wee ks, th ose grea ter th an 6 ern in size or with a thick wall , failur e of feve r to retu rn to norm al in two wee ks, and low er lob e absc esses:" Rum bau gh and Prior' foun d that non e of seve n pat ient s with sym ptom s present for mor e t ha n fou l' weeks resolved on con serv ative th erap y and th at non e with bro nch iectas is resolved. M ETH ODS
All reco rds with a final disc harg e di agnosis of lung abscess wer e reviewe d to ru le out u nde rlying disease reco gniz abl e at th e time of disch a rge. This excl ude d cases of ca rcin oma of th e lung , tube rcul osis , pulmon ary .m bolism and pen etra ting c h es t wou nds associa ted with abscess, Abscesses th at wer e subseq ue ntly, at a lat er adm is"ion, discover ed to be seco nda ry to ano the r d isea se wer e incl uded . Lun g abscess was d iagnosed b y x-ra y exa mina tion h y a den sity with air fluid level , findin gs at ope ration or b y postm ortem exa min atio n . These
t1 ~e. S ex. Ra ce
sO
T he age ra nge w as from se v e n to I I yea rs wit h th e pea k n u m ber . tl fi rn III ic d ecad e ( Fig. I ) . Ther e wer e 40 m al -s a nd 15 fem ales ( 73 per cen t mal e ) ; 3 3 \ vcre w hite and 22 Ne gro, wh ich par all els the adm ission ratio to thi s hospi tal.
Predisposing Factors
Table I lists th e fa ctors felt t o play a role in path ogen esis of th e absC cs.<;. O~le. hall of all the cas 's we re kn own a\co ho hcs, altho ug h a hist ory of alco ho lic stu por , coma or l I eI :m.um tr emen s was 0 Iit am . ccI 'In only . two . P eri 0 d s of uncon s .iou sncs s we re a prevalen t fact or in 14 pati mts incl uding those cases of epilepsy , a nest h .sia , st ro kc, or ence p ha lopa thy . Se ve r a l un usu al ~rc disp osin g ca uses wer e fou nd. On e patl cnt. develop ed an abscess in th e righ t u PPC\ lobe a fter its vasc ula r su pply was d ecre ascl by usin g thi s b ran ch of th e righ t pulm onar y arte ry fo r su rg .ica I co rre ctio S . n 0 f tl"ln . ' -, position of th e grea t vessels ( Fig. 2 ) . The re wa s one case of a h sc css occ u rring threc mo nt hs a fter ton sille ct om v, The la tter is ;t dim inis hing ca use of hl11:~ absc esses- T\'J ~ cases occ urre d seco nda ry to an cso phage
Alcohol Poor oral hygiene Epilepsy An esthesia (pos tope ra tive) St roke (acu te ) r: mcra lized sepsis Pr ior abscesses or pneu mon ia Unre cogn ized tub er culo sis
III
I:
TAT E, J R ., IIl.D. , I' .G .C .I'.
cases we re eva luated £01' age , sex, race , pred ispo sing factors, sym p toms, loca ti on , baCter iolo gy, ther apy and resu lts.
Ui
F IG U RE
F.
Age incid ence .
12
4
2 2
2 2
t I I t
t
\, .. l-uuv ') \ . • .••. I
L U :-:C AD SCE S SI'; S
I l J{ I "t
I.I O II ,I' \' .
FI' :l'Iu : :!:\ : :\ hsCt'ss. r i/-: h l 1I1'1'"r 1( 1)('. d c\'"J0l'i li/-: ill a 19 -)'" ar-0Id woma n onc vcar a fter Ihe su pe rio r ,',,"a ":I\ 'a ' ';IS a lla SI"" " ",,,
1I 11t! Sig ns
TIll' sym p to ms of llln g a bscess a nd t heir Irc qu cn cv arc listed in T able 2 . Symptoms were o f shorter duratio n th an usua lly sta ted I a nd thi s p rohahly rcll crt cd t he large n umher of a cu te cata stro p hes occ u rri ng in ou r groll p. i.c.• stro kes, a nesth .sia , epile psy. etc. Onl y 2H pn cen t o f the cases w ith kn own dura tion had sym p to ms lo n g e r th a n one m ont h .
Locntion :\ hsCl':ses were m ost co m mo n o n th e r ight sid (' with Iou r cases occ u r ring in t he rig ht m iddle lo ln- (T a ble -l). Elev en o f th e ca ses had mul tiph- abscesses wit h fo ur of th ese ill\ 'oh-in g m o re t han o ne lobe ( Fig .
:q .
1I111'/n i l/log y
ant! other procedur es
:\ ('J'o h ic a nd an a er obi c cu ltu res we re '1',\ 11 1.1,:
2 - SY M I 'TO ~ IS A :" 1l SII : N S
COII/-:h 5 1' 111 11111
Chills a ud f" \" 'r Pa in 1I" lIlflPI)'sis W" it;h t loss S\\" 'al s Chl hhill /-: o f di g its
80 per ce n t 56 per cc n t ,17 per ce n t 42 per cen t 38 per c .nt 18 per cen t 15 pe r cent 5 per cen t
d on e o n 51 of t he 55 pa tients. Spiro chetal o rga nisms were not reporte d . Mu ltiple o rga n isms w er e reco vered in 47 of t he 5 1 cases from initi a l sputu m o r b ron chi a l washings. In th e rem a ining four, a lp ha stre ptococcu s was recovered in th ree and Pseudo rno nas in o ne, Table 5 lists orga nisms recovered. th eir in ciden ce and a ' ociation with fat a l cases.
Th era/)y Two pa tients were trea ted surgica lly by resecti on because ca rc ino m a co uld not be ru led out . Th ree pat ients ha d p neum o ne ctomi es o r lob ect om y for n on-cl eari n ~ w it h two exp iring in the immedi at e posto per a tivc per iod. One wa s tr eated mcd icallv w it h incom p lete healing and had a lobe~tom \' 15 m onths lat er for recurrent infecti ons. 1;1 one, a needl e was p la ccd p er cutaneousl\' int o th e ca vity to in still a ntibioti cs. A JW I' ce n t pn cumot liora x occ u rre rI rc q ll i ri n ~
40
T o\II I. E :I
D lIRo\ TI O ~ OF S\'~II'TO~IS
U p to 1 week 1 to -) week s
1 month to :l l1Iollths l\l on' tha n :1 mon ths ' n kno\\'n
16 18 10 4
7
t '1.
D i ·C J
S II AF RON AND TAT E
F((;UJu: 2B: upper lobe.
C'i
or
the Che..t
Superi or vcna cav og ra m demonstrnt ing the a nastotuo sis a nd the lac k of pe rf usio n o f th e righ t
a chest tub e. The pati ent's abscess healed in two a nd one-ha lf months. T he rem a ind er of the pati .nts were treat ed medicallv with a variety of a ntibiotics. An cillarv measu res included expectorants, p os t ur al d rainage, I PPB, ae r oso ls , including mu colytic a nd proteolytic enzymes a nd hronchoscopy. R ES ULT S
'~'ahle G lists our results. T went y-eigh t
pa t l e~lts healed sym ptoma tica lly a nd radi og-
rapl~l ea ll y . Four pat ients w e r e ulti m ately surgIcal. cures. In three, th e lun g abscess was ultllnatcly found to be du e to eithe r carcinoma (one case ) or tub ercu losis (two cases ) . Of the six not followed-up to c1osl~ re, two were tran sferred to ano ther hosplla~ a nd four were discharged asym ptom atr c, hut did not retu rn to clinic Of th e ~ ~~ p~t tients discharged as he~tlcd m'ed ically, : \\ e i e followed less th an six months, and 1:) mor e th an six mont hs. O ne pat ient expircd one an d one-ha lf vears later in the IIpe ra t i n.~ room for eme~gency lobectom y for rnas....'v(: hemopt ysis. His a b sc css had healed leaving fibrotic changes whi ch was '1'... 111.1-: 1 - - l.or:"'1'10 • 01" An sca s s R i ~ h t u pp e r lob e
Riulu mid d le lohe Riuht lowe- r lohe I...rt u pper lobe I.eft I',wer lobe
20
415
a
10
the site of bleed ing . Fou r p.u ients ex pired of o ther d iseases d uring follo w-up. O f th e 28 pati en ts h c a lc d medi call y, 22 of t he a bscesses were closed by two mon th s a nd only six took longer. All six sho wed prog rcssivc hea ling d uring t his t ime. An a na lysis of th ' ca uses of dcat h shows tha t o nly two cases di ed as a result of prog ression o f a bscesses a nd respi ra tory insu fficien cy eig ht da y: a nd o ne mont h a fter thera py sta rted . Two pa ti .nts ex pired in less than 2,\· hours. T h rc . pa tien ts had m asT A III.I ; ::i O IU:A :>: ISM S C III .T lIR EI> I N 5 1 OF 55 C ,\ S ES A :>: I> T H E m A s s () r: IA1'I O :'o/ WITII 1\ I 01lTA I.I 1' Y
Orga nism S tn'p tl)('occi D ip h theroi ds I le rrc lla N ei sseria ~li r:r oc o ('(: n s
IJ .
//11 , ' /1 III u u ae
S t aph ylococ cu r (Il" r' IH Pst'lId '1II1011 as Pro te us Esc herich ia A ", ,,b((ct,,, kle b sie lla Pa ra uo lo n Se rra tia
No. Cases Cu lture d
:-':0. Fa ta l C a st's
41
6
17
,I
H 5
2 2
7
2
II
3 3
7 6 6 II
,~
1 4
2 2
- - -- - - - - - - -- -
In 1,1 exp ira tio ns 3 cu lt u res wen: not re po r ted , :3 we re associated with so-ca lled no upath og c ns ( S t re pt,,!:occi . l Ie rr c lla , N e i s s e r ia , D . pn eu m on iac ) wh r-n -as 7 g rew o u t one O f' m ore of th e pa t ho ge n ic group. (S. (( U"'lH, Ps- ud omon as, Prote us, B, coli, A r ro b acte r k le bsiella } ,
/ l,l o nl'; ")\ . •
°. ,. I
I. U ~ I :
1.1H lU l y . I' Jr. "f.
A BSCESS ES
T able 7 li sis du ra tion o f sym ptorns prior to d ia g-nosis ill p a t ient.' cx p iri n u a nd re flects th e s .riousuc s o f t he basic d is .ase as w ell as the to xiciry o f th ese pa tie nts.
:1: " Ia n . 'I:) )" 'a rs « ld. p n 's"nt ing wi rh in r il;h t midd l« lu"e an d lef t lo wer lo be b e h ind til" hea rt , flCI H E
a}," " ' SSt ' S
si\" h cm op tys is. p rn ha h lv s l'c o n d a r y 10 e rosio n of ; 1 p u lm o u a rv \'t~sscl h y t he infecrion . T w o ex p ire d ill ih« im m edi a te posto pcr.u iv« pn io d , T h ree p.u icn ts had illacleq u. uc a n t ih io tic ih c rapv ' OI 11~ d yillg o f s ' psis, 0 11 ' o f 1\I'Illopt ys is a nd 0 111' ill th e p osto pc rati v« pni od , Five pat ie n ts ex pi red [rom t h e ir ba sic cl i s e a s r- pro{'e.'s st ro ke , fr a c ture ' I)f Ir-mur a nd puh lloll ;,ry e m bolism . ga llg re nous l ~ ll t e ro c o l i t i s , 7f) per r e u t h urns, a nd th ro m bov -d r ig h t km o ra l a n n y, Th ere w a s O l J( ~ l.u c dl'at h (H'I'h aps .u t rib u u-d t,) t he a bscess. Th is p.u ir ut d ied o ne .md Olle h a lf vca rs a fter ahs('('ss ,.Jos('d lea\'illg fih ro s is, su bs eq u c n t lv h a vi nt; m a 'si\'t' h cmopt vsis, S ix o f l fi p at ients who d il'd h ad m u lt iple ce n t in cick-n r c as co m p a re d w it h I I o f :l:l {'a St'S ( 2,\ pl'r cc n t ) with m u ltipk- a hSI'('SSI 'S, E i ~ h t had a hscesses in th ' rig ht lo w er lol l(', two ill t lJ(' ldl lower lohe, I n {'l IIlt raSl, o n lv six \\'(' 1'1' ill Ilu : u pper lo hes or midd le lo ll(': 0 111' pati ent ha d d iffu st: a hsu'ss fonll at il ,n ill all lo hcs. This (;7 (W I' ce n t Illorta lit y in lo w e r " .I)(' ahs('('sst'S co n t ra-a s w it h the 11:i pIT rr -n t illl'id l'n('(' o f lowe r l oht ~ ;11 N 'eSSI'S ill th e sc ries .
a bscesses for ;, [10 p n
D rs c u s sro x In a na lyz ing a s c r i c s o f ca ses o f lung ; t h~I't'.'ses , the III .thod o f selection m ust be ke p t in mi nd . Thus in the p resent revi ew , a ll c a~es w it h the fin al cod ed di a gnu cs uf IUllg a hsecs:-;e:-; were in cl u d ed . Th is m ea nt t hat tw o cases d iscovered a t postmortem cx .uni n. u io n were r .vi 'wed. This a lso inelud ed th re e ca ics di s c ha r ge d from the hospital as lung a bscess who in th e suhsequcn t mo n t hs we re fo und to ha ve t ube rcu illsis o r ca rcillUllIa a s the ct iology-c-a 5 pe r c e n t incide nce . T he resu lts o f a rc, sex, ra ce , a n d predi spusin g Ia rr o rs in o u r se ries d o n ot differ s ig n i f ic a n t l ~' fro m t hat IT\ 'i 'we d h y o t hers . '1'", " Ilf o ur cases w ere .eco nd a rv 10 ' 0ph a ge;d lesillns in th e a bsence o f sym p to m s refera ble 10 obstru cting lesio ns o f the esop ha gll s ( F i~ . .l j . I t is I ~O\\' o u r poli cy to d o ro u t ine h.uim u sw a llo ws 0 11 a ll c as e s o f I lI n ~ a !>sce:-;s in whi c h there is nil definite h isto rv o r ;ls pi ra tio n o r unco nsc io usness. Th ;' SYlll p tll llls W 'IT sim ila r to . Iha t c:' lit her series." "· a lt ho ug h the du ra tion w J mu ch less ( 7 1 per c e n t w it h sym p to n ., lr-« th a n o ne m ont h }. Srh wc p pc a nd co :leag lles' rc p(ut cd :I!) per cen t o f cases a ~ an il e , i.c . k-ss th a n six week s, H ens hel a nd a ssllc ia te/ not ed a m ean in te rva l from o n set o r sVlll p to lllS 10 di a ~ n osis o f GO and G1 t!a\'s ill 'fa ta l a nd non fata l cases respec tively. 'I'1;e reaslln for t he rel.uivcly h igh in cid cn ' o f so -ca llcd " a cu te" cas 's in t h e pr 'Sent ~cri cs is not rea d ily a p pa r nu . On e possihl e ex pl.m .u io u is th a t v Ty few o f o u r pa t ie n ts ( n n lv tw o reco rd ed ) ha d recei ved a ntibi . Ilt ic rhcrapv prior to di agnosis whi ch mi gh t ha \'(' llIodi fi 'd th e {'Im rs ' , This, in tu rn , "1",\ 111. ":
T AII I. !.
Ii
R I : S I · I. T S
1(..;I1" d S" l'gic a l E x p in 'd Ca n ';n"l lIa " I' 11I1,..rnd " sis di scO)\"' !'I'd !':O) ("II" w· " I' " " s"I'\ 'a li" ,, t OJ hea li" g
28
4J.I :1 6
7
f) I ' KAT IO :-; O F SY~I I' T O~ I S I N 1' ,\ T n : :-;T S E X I' IR I :-;t;
:\ hsc.'ss de vel o ped in h usp ita l I ' p to 1 we('k I ",,,,'k ( 0 I 1I111111 h I lJlo .lt h t o) :11!l' lIl1hs \ 1,, 1'" Ihall :1 lIl" lIlh s
6 4 2
D i..c,·.Hc.....
S HAF RON AN D T AT E
may be a reflection of th e socio-eco nom ic sta tus of th e m aj ority of ou r p ati ents or a ~row i ng a wa re ness of ph ysicians in the past five yea rs to ut ilize chest x- ra y exam inat io ns !>rior to th erapy of a n u p pe r respirato ry infection, b ron chitis, etc, Severa l papers ha ve co rrelated dura ti on of sym pto ms with survival. A nde rso n a nd McD o,nald ' stated th at sym p to ms g rea ter tha~ eight weeks duration gave a poor p rognOSIS, Rumbau gh and Prior" found non e o f seven pat ients with sym ptoms g rea te r th an four weeks resolved on conserv a tive th erapy. H owever, as noted above, H en schel a n d co-workers' found no difference in duration of sym ptoms in his fatal and n onfatal ~rou ps, In th e pr esent series, on ly tw o pau cnts wh o expired had sym pto ms lon ger th an one month pri or to di agn osis, This is not significa ntly differ ent from th e 29 p er cent of tl i c entire . , s e n, es with sym p to ms lon ger thaa n one m ont h , a n d iIS m contrast to ~!le Anderson and M cDon ald' series. , he loca tion of a bscesses correla tes well SCI" 3,< '[ 1ic g reate r mCI ' id ence with other series. 01) ' ' I . of uppe r 1 ri I" e mvo vcment, espe cia lly of th e ~ It upper lob e, is seen , Of inter est however, is the g rea te r fa tali tv ra te in ' low er lob e ,a bsc I . . ces.,>es, :" \ Il( erson a nd M eDon ald" concluded tha t low er lob e a bscesses had a
til(:
,,(
Che«
poo r p rog nosis, The dilli .u lt v in o b ta in ing proper postu ral dra in a ge in low T lob ' a bscess is a p pa re n t a nd th e retained p urulent m a teri a l wi ll g ive a n unfa vo ra ble co urse. Sudden 111 a ss i v e h .morrhage» ca n occu r wit h exsa ngu ina tio n. Bro c k' points o u t th a t co m po u nd o r multiple a bscesses a re m ore frequ ent in th e low er lob es bccau T th e o rificcs o f the three basal seg m en ta l b ronchi 01 1" clo se tog et he r a nd a lm ost eq ua lly well placed to receive in f .ctcd m at eri a l fr o m o ne a not her, Simi la rly. d rain ag e from th e a p ica l b ron ch us ca n x pill in to t he ba sal b ronchi, These factors d e ma n d surgica l co nsu lta tio n m u ch q uic ker t ha n th ose a bscesses in area s th at drai n wel l. Bact .riologic st ud ies in rela tion to m orta lity ha ve sho w n a va riety o f o p in io ns. J en sen a nd Arndru p' fo u nd t hat t he d eat hs in their se ries o c curr ed in p at ie n ts w h o g rew S/a l l hyloco ccl/ s aI/ H'Il S. C o lifor m o r Prote us o rg a n is m s a nd t h at no d eat hs occu rre d in cases wit h S t re ptoco cci, P neumococci o r II, inlluenzae a lone . H enschel a nd associa tes' I' ' port t ha t the p atients w ho di ed did not h a v e sig n ifica ntly diff Tent ba ct eri olog ic findi ngs fro m t hose w ho su rvived . The isol a tio n of o ne o f t he p at hogcn i ,gro ups of orga nism s in t he p resent se ries was associa ted wit h a worsen ed p rognosis,
I\lJG 10,1962 (' lll UIU ' -l : M '7 , ,I I . .I 'I ' ' I a n,;) y' ars " ( • p r .sc n tcc with a left lowe r lobe ab scess. 0 111' mo nt h la n-r II... '\ I>, n ' r< 11' \ 5 , l lIIlI st (' ' ''tft' t I I I r d £"11 d dil d ' , . ,' .' • a, l ("ILrnuorna. : ., , l ll l ie 110 - I C I a te eso ph ag us ( a r m w ) was tilt' first du,' to a ll «h stru c t iu« "s""II"I'" rv , :"l "
V'.lurnc- ~ \, , "). I
J .llI Uar )' , JI)6 H
LU NG A BS CESS ES
Thc.,; ' includ ed S l a /Jll)' l ococc us aurcus, Ps 'udon lOn:ls, Pro teus, , I crobac ter klebsiella a nd E. coli, T hese were in itial cult ures, This cm ph :L,;izes th e need for ade quate culture and sensiti\ 'ity stud ies from go od specim ens ~) Illai n ed Irom sp utum o r bron chi al washIIlgs. Repeat cultu res d uring th erapy arc a mu st for d tect nm of su perinfe ction or dev '(opme nt of resisten t stra ins. T he most im po rtan t fa ctor in medi ca l Illa na g ' Ill .nt of lung a bscesses appea rs to b · prolon ged a nd in tensive a ntibiot ic th era py. I 0 co rrela tion as to type of a ntibiotic Used a nd outcom e co uld be det ermined . Three fat ali ties occu rred in pati ents wit h inadeq ua te a nti biotic th erapy, i.e., eithe r th erapy int errupte d o r de laye d becau se of lIlista ken d iagn osis o r th er apy discont inued beror ' there wa s com plete heal ing of the a bscess a nd /o r the inflamm at ory rea ction. T he num ber of p roced u res d on e in the pr :Sellt series W :L'i not eno ug h to eva lua te ade quat oly su rg ica l th erapy. The two fatalities occu rred in ex tre me lv tox ic patients. Most series ha d a hig her percent age of sl.lrgica l proced ures for cu re wit h mort a lity Ig ures from 0 per ce nt • 'II to 15 per cen t 'J" " plica tion rat es were high (8 per cent Com · per cent" to 42 per cent" }. Wolcot t 2'1 to lla bo ra to rs" recom mend surgery for co a nd r 'sid ua l thick-wa lled cavities a f te I' thre e Weeks a nd found th at the thin wa ll cavities usua lly heal. Progressive improvem ent e\'e ry two w .cks on x-ra y films is felt to be a min im ulll requirem ent to contin ue m~d ica J tlTatlll ent ; othe rwise sur gica l resccn on mu st b ' co nsidere d . O ur policy is to follow th e asy m pto ma tic pa tients wit h a cav it)' while co ntinuing a ntibiotic therapy. T !le longc."t persiste nce of a ca vity in our series Was five months a lt ho ug h Wolcott a nd a: soC"iatc.,," r 'po rt a closu re afte r on~ a nd onc-ha lf yea rs. Two pati en ts with persls~e n t inflamm at o rv r c a c t io n and / or bron clu ectasi ' were foilow ed . On e had a n un even tfu l (ob ccton l\' 13 mon ths lat er a nd on e expired one a nd 'one -ha lf vcars la ter with massive !tcmopt ysis, Pa t ien~s treat ed wit h recu.lTe llt infe ctio ns, pers isten t sympto ms o r persi stent x-ray cha ngcs sho uld he restud ied , includ -
ing bron ch og rams, a nd strong co nsidera tion given to resection of the in volved a rea . SU M M A RY A ND CONC LUSION S
The case records of 55 pati ents with lun g a bscesses a t a large county-university hospita l in th e past five yea rs were reviewed . The age, sex, predisp osing factors , sym ptoms, ba ct eriolog y a n d loca tion did not a p p ea I' sig nifican tly different from other series. The diagn osis was made earl ier in this series than in th ose rep orted reporte d previou sly ; 7 1 per c e n t of pati ents had symp toms of less than one month 's d uration . Fa ctors tha t a ppe a red to ind icate a poor progn osis were mu ltip le a bscesses, lower lob e a bscesses or presence of one of th e socalled pathog en ic bacteria on initia l culturc, T hera p" s h 0 u ld be p rolonge d and int ensive anci contin ued un til the a bscess has closed . T he pati ent should be given a n ade q ua te tria l to close the ca ~i ty on med~ ical manag em ent. H owever, If sym I~toms pro g ress, if the ab scess : nlarges or If no respo nse is made a fte r SIX ~vee ks to two mo nths, surgica l i n tc rv c n t io n sh~u ld be mo re stro ngly conside red . Lat e su ~glcal resection mav be necessa ry in the pat ient who has closed ' his a bs c ess bu t has recurre nt infectio ns or resid ua l bronchiectasis. R ES U ~I E N
Sc revisan 55 casos de ah ceso p ulmona r obs..rva dos en lin hospitul publico-universitario. Lo relnti vo a edad, sexo , [a crores p rcd isponent es, loca lizario n, sinto mas r ba ct criol ogla no pa rece di ferir <1.. 10 obscrvado en otras series sim ilare s. EI di agnostico fllc mas precoz en es ta serie q ue otr as p reVian 1l'111 e rc po rta da s : I'll el 71 % d e 10 5 casos la du ra cinn d e los sinto mas fllc d e mcn os de 11I1 Illes. Los faciorcs indicnrivos d e 1111 III a I pronosrico Iueron a bcesos mul tipl es, ab ccsos d el lobule inferi or >' p resencia de las lla mad as ba ct irias pa t6genas en cl cultivo inicial. La tera peutica d ebe cI SCI' intcusiva, prolongada y cominua dn hasra cierre del a bccso.
Debe proporc ionarsc .11 pacicnte una prueba tera peurira ad ccunda , d ir igida a ob tcncr eI cierrc
d e la ra vidad pOI' cl tra uu u icn to mcdi co. Sin ('mhargo , si los sin tomas cm pcora n, si ..I ab r eso aum en ta de ramaiio 0 si no ha y respllesla ad cruad a en ' I lcnni no d e 6 scma na s a 2 moses,
18
S H AF RON A:-
deb e c()n~ i dera rse mas se ria me nte el tra ta micn to qui rllrgi co . La cirugia tardia pued e se r ncccsaria en los ca sos en q ue se ha olnen ido el c ierre d el a h e es' ), pero qu e pre scn tan c piso d ios de inf eccion rccurrc u tes 0 bronchi ect asia residual. R "I'I' RI': NCI'S
F., M xr.co t.xr, j. A . ANIJ W VI.If., R. I I. : " Lung ab scess : a st ud y o f 148 ca ses d uc t" a sp ira tio n," D is. Ch est, 43 :620 , 1963. ~ ~,~ \ l> lmSON , M . N. A N II M cD o N A l.lJ , K . . E. : 1 yogell ic IUlIg abscess," N ew Y ark Sta te ] . u .«, 6 1:402, 1961. :1 R t:~tIlA IJr:II . I. F. AND P RIOR, .J. A . : " L u ng ~hsce~s --a revi ew of 41 cases ," Ann. I n t. Jyf ed ., :)5 : :!2:I, 1961. ·1 S (al\n:I' !'I:. I I. I., K ~ OWI. E S , J. H . AN Il KA N E, /..: " LulIg ab scess " N ew Eng l ] M ed 265 . 1039, 1961. ' . . ., ' B " n :O: II Alm , W .
5 FII'l:n, W. R., J-[ USI'8YF., K., Clllm Es Tlm , C. A:oI I> Mn. I.I,: n , M .: " P r imary l u n g abscess ,' A rch. l ilt . M ed., 107 :6 68 , 1961. .
G 111'::-: 5(:11 1:1. . E. 0 ., \ \ ' ,\l S II R I: :'oI . n. A. AN? (;"A 5 1·:n, r..1. : " Lu ng abso- ss as S" " l1 ill a IIIUIIIc ip a l h osp it al ." J) ir. 40 : 625 , 1961. 'al 1II ~I II nO C K , I'v , C . : "I '1I" an at o m yw f III, . br on( 195,1 Iff', ' . O x fo rd , n ivcrsi ry Press, . Lfl~~ d.oll . "e ifi~ II J El' s t, N, II. I', . A"I> A~t fln l1l' . I'.. : N OllsPCI 'r ab scess o f th e lu n g : 129 c ases ," A cl fl 1/ .
cs.«.
Sc nn d ., 127 : '111 7 i964 '. ll ll C 9 D I."JA ~, NI.'. . .. n'\.. , I " , A:"IJ . ' I', 1( ,. M ,\ :'oI . 0 ... " C hn60? '6' pu lrllfl lla ry su p p u ratio n, " Dis. C h" , I, J. -. 1959 . . , 10 D \ ' FFY , T . J. ,\ :'01 0 C Il A FI' A S , I. : " P;IlI':6~ IUlIg ahscc ss,;' A mer. ] . u,«. Sci ., 2·13: - ' 191;2. II ( •'0 1,/1 II , f \ . , ( ,"UI. ST , .J. I :; ]...'xn'1"1D... If." , . ,'S , r ;oo; and
12
R. A . : " P r im a ry lUll!!; abscess , Cfl rd i" ufls. Surg, ,n : 383, 196·L W .,
Cot
RY,
10 •
x x o BA U~\' in t he th eral! }' o f
O . II.
lun g abs ce ss: a t\~'e llt}'- }'car su rvey, " ti «. ,10: I. 1961.
GIlt' S/'
Fo r rep rints , pl e a se write: D r. Ta te , J a c kso n M e m orial H osp ita l, Mi ami ,
INII ALATI O N T HE RA PY W ITH C YC LOSER INE I 'I:hls article reports t he resu lts o bta ined In 188 I·a tlen ts wit h chron ic pulm on ary tubercu los is who were treated with cycloseri ne In th e routine m a nner a nd a lso by Inha lation or t he dr ug . T he treatmom Was mai nta ined (or a bo u t t wo m ont hs. T he autho r (oun d th ut cycloser ine Inha la ti on in cr ea sed th e ellleac y o r th e dru g. pa r tl eul arly In d llll cult a nd
N.
W OL COTT,
r; . I., : "C ha ugi ru; conce pts
.
I'
LM O NA R Y T
BERC UI. O SI S
com plica ted ca se s. In mos t pa t le rtt s , th e coug h and expl'eto ralion t'Hhe r d lsap Pt'a red o r wn s gn'atly trn prO\'ell. The s pu tu m eo n vc rslon r ate was 1.5 ti llle s h igh er. K ui.rx , N . M. : " Inhalation Ih elJp y with ( yel" ",,'; lIe in pullIl'mMy tubercul.. , i,, " 1' , . bl ,'1II1 . / T.b", " I. IIJ f.USSR), ~ : .10, 196 7 ,
PAP ILL AR Y M US C LES AFTE R MITR AL VA LVE R EPI.AC E?\IENT
T h,. • morpholog y o( t he pupll1nry mu scles or the left vent ricle wa s st ud ied in 19 dog s alter repla cemun t o( the m itral v a I \ 'C wit h a Sta r r-Edwards pru sth esls. I! th e cho rda e tendi noae a nd lea flets Were excised at o pe ration, th e papll1 a ry muscl es u nlle rwen t a t ro phy and were replaced by llbrous tissue.
(( th e cho rd a e ten d ln ea e a nd It'a ll'l s were leCt Inta ct, th e pa pillary m u scles re mai ned m o r ph ol og icall Y norm a ).
I\ ~ Hnu , G . K' . KU N, ) . W . ~ NlJ Trrus, J. L. : " FJ IC of
pJpill.u)'
valve ;"
rnu~t.lcs
/\1 11) '"
J fter Ilf {)'\thC't il" rcpb t.cmcnt of m it ra l CIi". Pros ., ·L!: l IO. 196 7.
I'II YS[ OLO G IC STU DY O F M ACL EOO'S SYN D ROr..1E Seven pati en ts with Macle od' s syn dro mc or abno rma l t ra nsra dia ncy of one lung have been lnvest h:at<:d wit h s pecia l ref uren eo to region a l lun g (un ctio n. T~ e I,r in elp al a bno rma lity wa s rou nd to be ohst ru rt,o n o( th e ai rways. Th is was sev ere in t he a ((('eted lun g. but was ot te n present In t he other lun g as we ll. Alt ho ugh Iun ct lon a l Impairm ent of th e a ffected lu ng wa s seve re , It wa s by no m ea ns unl(orm l>' d istrib ut ed ther e : th e hlood I:ases we re o nly s llgh ll y a bno rmal a t rest . and hypercapn ia . In pa rlIcu la r, was not a Ieature, During exercise. arte ri al Ol(yge n tenslo ns tcnd ed to (a ll. We have a lll! nt pled to a sse ss ai r c ntry ste t hosco pically in ti ll! six regions o r th e lun gs subs eq uent ly
su rve veu b v t he s c l n t i l l a t l o n cou n te rs . Broad ly s P,-· a k~i n g'. ih e cttn tca l a sse ss me n ts a~ ree with th e vt-nt.Ilnt lo n indices. h ut th e d iscr im in a ti on obta in a hl., wit h th e s te t hos co pe is, a s wo u ld he ex pec te d. de penden t u po n rath er coa r se co nt rasts . W e ha ve co me to re g:a rd th e rad io a cti ve xeno n s tud ies as nn ex tensio n o( ca re fu l cli n ica l li nd r ad lol oJ.: lc assess-
m vnt to w hic h It a drts precis ion a nd In SOIl1l! ca ses revea ls un su sp ected d ls t urban cc s n( per(u sl on lind ven tlla tlo n . and parti cu la r ly reg io nal vari ations III gas m lx lng . N ~"I N. ) . 1\. ~N lJ PRIMP., F. ) . : " II phy siolor,icJi stu dy of M Jd c•.,t!·\ synd rom e, " 'Th orax , 22 : I ·IH, 1967.
D.
SHA FRO N, M .D. ANIl C HA RLE S
Mia mi, Florida I NTR OD UCT ION A LT H OUG H ANT l mOT ICS HAV E DRA lIIATI C-
n
ally cha nge d t he in cid en ce and m orta lity o f lung abscess, th e mor bidi ty and prolon ged cou rse still m ak e this a seri ous di sease. O ver th e pas t five year s, 55 cases of lung abscesses wer e ad mitt ed to J ackson M em orial H ospi tal. A rev iew of th ese cases was und ertak en to uncover a ny fact ors t hat mig ht infl uen ce t he cou rse and mor talit y ra te in thi s d isease. Fac tors that hav e been discove red to be associated wit h a poo r progn osis arc: a bsc ess es th at have been pres in t l on g er th an ' ig h t wee ks, th ose grea ter th an 6 ern in size or with a thick wall , failur e of feve r to retu rn to norm al in two wee ks, and low er lob e absc esses:" Rum bau gh and Prior' foun d that non e of seve n pat ient s with sym ptom s present for mor e t ha n fou l' weeks resolved on con serv ative th erap y and th at non e with bro nch iectas is resolved. M ETH ODS
All reco rds with a final disc harg e di agnosis of lung abscess wer e reviewe d to ru le out u nde rlying disease reco gniz abl e at th e time of disch a rge. This excl ude d cases of ca rcin oma of th e lung , tube rcul osis , pulmon ary .m bolism and pen etra ting c h es t wou nds associa ted with abscess, Abscesses th at wer e subseq ue ntly, at a lat er adm is"ion, discover ed to be seco nda ry to ano the r d isea se wer e incl uded . Lun g abscess was d iagnosed b y x-ra y exa mina tion h y a den sity with air fluid level , findin gs at ope ration or b y postm ortem exa min atio n . These
t1 ~e. S ex. Ra ce
sO
T he age ra nge w as from se v e n to I I yea rs wit h th e pea k n u m ber . tl fi rn III ic d ecad e ( Fig. I ) . Ther e wer e 40 m al -s a nd 15 fem ales ( 73 per cen t mal e ) ; 3 3 \ vcre w hite and 22 Ne gro, wh ich par all els the adm ission ratio to thi s hospi tal.
Predisposing Factors
Table I lists th e fa ctors felt t o play a role in path ogen esis of th e absC cs.<;. O~le. hall of all the cas 's we re kn own a\co ho hcs, altho ug h a hist ory of alco ho lic stu por , coma or l I eI :m.um tr emen s was 0 Iit am . ccI 'In only . two . P eri 0 d s of uncon s .iou sncs s we re a prevalen t fact or in 14 pati mts incl uding those cases of epilepsy , a nest h .sia , st ro kc, or ence p ha lopa thy . Se ve r a l un usu al ~rc disp osin g ca uses wer e fou nd. On e patl cnt. develop ed an abscess in th e righ t u PPC\ lobe a fter its vasc ula r su pply was d ecre ascl by usin g thi s b ran ch of th e righ t pulm onar y arte ry fo r su rg .ica I co rre ctio S . n 0 f tl"ln . ' -, position of th e grea t vessels ( Fig. 2 ) . The re wa s one case of a h sc css occ u rring threc mo nt hs a fter ton sille ct om v, The la tter is ;t dim inis hing ca use of hl11:~ absc esses- T\'J ~ cases occ urre d seco nda ry to an cso phage
Alcohol Poor oral hygiene Epilepsy An esthesia (pos tope ra tive) St roke (acu te ) r: mcra lized sepsis Pr ior abscesses or pneu mon ia Unre cogn ized tub er culo sis
III
I:
TAT E, J R ., IIl.D. , I' .G .C .I'.
cases we re eva luated £01' age , sex, race , pred ispo sing factors, sym p toms, loca ti on , baCter iolo gy, ther apy and resu lts.
Ui
F IG U RE
F.
Age incid ence .
12
4
2 2
2 2
t I I t
t
\, .. l-uuv ') \ . • .••. I
L U :-:C AD SCE S SI'; S
I l J{ I "t
I.I O II ,I' \' .
FI' :l'Iu : :!:\ : :\ hsCt'ss. r i/-: h l 1I1'1'"r 1( 1)('. d c\'"J0l'i li/-: ill a 19 -)'" ar-0Id woma n onc vcar a fter Ihe su pe rio r ,',,"a ":I\ 'a ' ';IS a lla SI"" " ",,,
1I 11t! Sig ns
TIll' sym p to ms of llln g a bscess a nd t heir Irc qu cn cv arc listed in T able 2 . Symptoms were o f shorter duratio n th an usua lly sta ted I a nd thi s p rohahly rcll crt cd t he large n umher of a cu te cata stro p hes occ u rri ng in ou r groll p. i.c.• stro kes, a nesth .sia , epile psy. etc. Onl y 2H pn cen t o f the cases w ith kn own dura tion had sym p to ms lo n g e r th a n one m ont h .
Locntion :\ hsCl':ses were m ost co m mo n o n th e r ight sid (' with Iou r cases occ u r ring in t he rig ht m iddle lo ln- (T a ble -l). Elev en o f th e ca ses had mul tiph- abscesses wit h fo ur of th ese ill\ 'oh-in g m o re t han o ne lobe ( Fig .
:q .
1I111'/n i l/log y
ant! other procedur es
:\ ('J'o h ic a nd an a er obi c cu ltu res we re '1',\ 11 1.1,:
2 - SY M I 'TO ~ IS A :" 1l SII : N S
COII/-:h 5 1' 111 11111
Chills a ud f" \" 'r Pa in 1I" lIlflPI)'sis W" it;h t loss S\\" 'al s Chl hhill /-: o f di g its
80 per ce n t 56 per cc n t ,17 per ce n t 42 per cen t 38 per c .nt 18 per cen t 15 pe r cent 5 per cen t
d on e o n 51 of t he 55 pa tients. Spiro chetal o rga nisms were not reporte d . Mu ltiple o rga n isms w er e reco vered in 47 of t he 5 1 cases from initi a l sputu m o r b ron chi a l washings. In th e rem a ining four, a lp ha stre ptococcu s was recovered in th ree and Pseudo rno nas in o ne, Table 5 lists orga nisms recovered. th eir in ciden ce and a ' ociation with fat a l cases.
Th era/)y Two pa tients were trea ted surgica lly by resecti on because ca rc ino m a co uld not be ru led out . Th ree pat ients ha d p neum o ne ctomi es o r lob ect om y for n on-cl eari n ~ w it h two exp iring in the immedi at e posto per a tivc per iod. One wa s tr eated mcd icallv w it h incom p lete healing and had a lobe~tom \' 15 m onths lat er for recurrent infecti ons. 1;1 one, a needl e was p la ccd p er cutaneousl\' int o th e ca vity to in still a ntibioti cs. A JW I' ce n t pn cumot liora x occ u rre rI rc q ll i ri n ~
40
T o\II I. E :I
D lIRo\ TI O ~ OF S\'~II'TO~IS
U p to 1 week 1 to -) week s
1 month to :l l1Iollths l\l on' tha n :1 mon ths ' n kno\\'n
16 18 10 4
7
t '1.
D i ·C J
S II AF RON AND TAT E
F((;UJu: 2B: upper lobe.
C'i
or
the Che..t
Superi or vcna cav og ra m demonstrnt ing the a nastotuo sis a nd the lac k of pe rf usio n o f th e righ t
a chest tub e. The pati ent's abscess healed in two a nd one-ha lf months. T he rem a ind er of the pati .nts were treat ed medicallv with a variety of a ntibiotics. An cillarv measu res included expectorants, p os t ur al d rainage, I PPB, ae r oso ls , including mu colytic a nd proteolytic enzymes a nd hronchoscopy. R ES ULT S
'~'ahle G lists our results. T went y-eigh t
pa t l e~lts healed sym ptoma tica lly a nd radi og-
rapl~l ea ll y . Four pat ients w e r e ulti m ately surgIcal. cures. In three, th e lun g abscess was ultllnatcly found to be du e to eithe r carcinoma (one case ) or tub ercu losis (two cases ) . Of the six not followed-up to c1osl~ re, two were tran sferred to ano ther hosplla~ a nd four were discharged asym ptom atr c, hut did not retu rn to clinic Of th e ~ ~~ p~t tients discharged as he~tlcd m'ed ically, : \\ e i e followed less th an six months, and 1:) mor e th an six mont hs. O ne pat ient expircd one an d one-ha lf vears later in the IIpe ra t i n.~ room for eme~gency lobectom y for rnas....'v(: hemopt ysis. His a b sc css had healed leaving fibrotic changes whi ch was '1'... 111.1-: 1 - - l.or:"'1'10 • 01" An sca s s R i ~ h t u pp e r lob e
Riulu mid d le lohe Riuht lowe- r lohe I...rt u pper lobe I.eft I',wer lobe
20
415
a
10
the site of bleed ing . Fou r p.u ients ex pired of o ther d iseases d uring follo w-up. O f th e 28 pati en ts h c a lc d medi call y, 22 of t he a bscesses were closed by two mon th s a nd only six took longer. All six sho wed prog rcssivc hea ling d uring t his t ime. An a na lysis of th ' ca uses of dcat h shows tha t o nly two cases di ed as a result of prog ression o f a bscesses a nd respi ra tory insu fficien cy eig ht da y: a nd o ne mont h a fter thera py sta rted . Two pa ti .nts ex pired in less than 2,\· hours. T h rc . pa tien ts had m asT A III.I ; ::i O IU:A :>: ISM S C III .T lIR EI> I N 5 1 OF 55 C ,\ S ES A :>: I> T H E m A s s () r: IA1'I O :'o/ WITII 1\ I 01lTA I.I 1' Y
Orga nism S tn'p tl)('occi D ip h theroi ds I le rrc lla N ei sseria ~li r:r oc o ('(: n s
IJ .
//11 , ' /1 III u u ae
S t aph ylococ cu r (Il" r' IH Pst'lId '1II1011 as Pro te us Esc herich ia A ", ,,b((ct,,, kle b sie lla Pa ra uo lo n Se rra tia
No. Cases Cu lture d
:-':0. Fa ta l C a st's
41
6
17
,I
H 5
2 2
7
2
II
3 3
7 6 6 II
,~
1 4
2 2
- - -- - - - - - - -- -
In 1,1 exp ira tio ns 3 cu lt u res wen: not re po r ted , :3 we re associated with so-ca lled no upath og c ns ( S t re pt,,!:occi . l Ie rr c lla , N e i s s e r ia , D . pn eu m on iac ) wh r-n -as 7 g rew o u t one O f' m ore of th e pa t ho ge n ic group. (S. (( U"'lH, Ps- ud omon as, Prote us, B, coli, A r ro b acte r k le bsiella } ,
/ l,l o nl'; ")\ . •
°. ,. I
I. U ~ I :
1.1H lU l y . I' Jr. "f.
A BSCESS ES
T able 7 li sis du ra tion o f sym ptorns prior to d ia g-nosis ill p a t ient.' cx p iri n u a nd re flects th e s .riousuc s o f t he basic d is .ase as w ell as the to xiciry o f th ese pa tie nts.
:1: " Ia n . 'I:) )" 'a rs « ld. p n 's"nt ing wi rh in r il;h t midd l« lu"e an d lef t lo wer lo be b e h ind til" hea rt , flCI H E
a}," " ' SSt ' S
si\" h cm op tys is. p rn ha h lv s l'c o n d a r y 10 e rosio n of ; 1 p u lm o u a rv \'t~sscl h y t he infecrion . T w o ex p ire d ill ih« im m edi a te posto pcr.u iv« pn io d , T h ree p.u icn ts had illacleq u. uc a n t ih io tic ih c rapv ' OI 11~ d yillg o f s ' psis, 0 11 ' o f 1\I'Illopt ys is a nd 0 111' ill th e p osto pc rati v« pni od , Five pat ie n ts ex pi red [rom t h e ir ba sic cl i s e a s r- pro{'e.'s st ro ke , fr a c ture ' I)f Ir-mur a nd puh lloll ;,ry e m bolism . ga llg re nous l ~ ll t e ro c o l i t i s , 7f) per r e u t h urns, a nd th ro m bov -d r ig h t km o ra l a n n y, Th ere w a s O l J( ~ l.u c dl'at h (H'I'h aps .u t rib u u-d t,) t he a bscess. Th is p.u ir ut d ied o ne .md Olle h a lf vca rs a fter ahs('('ss ,.Jos('d lea\'illg fih ro s is, su bs eq u c n t lv h a vi nt; m a 'si\'t' h cmopt vsis, S ix o f l fi p at ients who d il'd h ad m u lt iple ce n t in cick-n r c as co m p a re d w it h I I o f :l:l {'a St'S ( 2,\ pl'r cc n t ) with m u ltipk- a hSI'('SSI 'S, E i ~ h t had a hscesses in th ' rig ht lo w er lol l(', two ill t lJ(' ldl lower lohe, I n {'l IIlt raSl, o n lv six \\'(' 1'1' ill Ilu : u pper lo hes or midd le lo ll(': 0 111' pati ent ha d d iffu st: a hsu'ss fonll at il ,n ill all lo hcs. This (;7 (W I' ce n t Illorta lit y in lo w e r " .I)(' ahs('('sst'S co n t ra-a s w it h the 11:i pIT rr -n t illl'id l'n('(' o f lowe r l oht ~ ;11 N 'eSSI'S ill th e sc ries .
a bscesses for ;, [10 p n
D rs c u s sro x In a na lyz ing a s c r i c s o f ca ses o f lung ; t h~I't'.'ses , the III .thod o f selection m ust be ke p t in mi nd . Thus in the p resent revi ew , a ll c a~es w it h the fin al cod ed di a gnu cs uf IUllg a hsecs:-;e:-; were in cl u d ed . Th is m ea nt t hat tw o cases d iscovered a t postmortem cx .uni n. u io n were r .vi 'wed. This a lso inelud ed th re e ca ics di s c ha r ge d from the hospital as lung a bscess who in th e suhsequcn t mo n t hs we re fo und to ha ve t ube rcu illsis o r ca rcillUllIa a s the ct iology-c-a 5 pe r c e n t incide nce . T he resu lts o f a rc, sex, ra ce , a n d predi spusin g Ia rr o rs in o u r se ries d o n ot differ s ig n i f ic a n t l ~' fro m t hat IT\ 'i 'we d h y o t hers . '1'", " Ilf o ur cases w ere .eco nd a rv 10 ' 0ph a ge;d lesillns in th e a bsence o f sym p to m s refera ble 10 obstru cting lesio ns o f the esop ha gll s ( F i~ . .l j . I t is I ~O\\' o u r poli cy to d o ro u t ine h.uim u sw a llo ws 0 11 a ll c as e s o f I lI n ~ a !>sce:-;s in whi c h there is nil definite h isto rv o r ;ls pi ra tio n o r unco nsc io usness. Th ;' SYlll p tll llls W 'IT sim ila r to . Iha t c:' lit her series." "· a lt ho ug h the du ra tion w J mu ch less ( 7 1 per c e n t w it h sym p to n ., lr-« th a n o ne m ont h }. Srh wc p pc a nd co :leag lles' rc p(ut cd :I!) per cen t o f cases a ~ an il e , i.c . k-ss th a n six week s, H ens hel a nd a ssllc ia te/ not ed a m ean in te rva l from o n set o r sVlll p to lllS 10 di a ~ n osis o f GO and G1 t!a\'s ill 'fa ta l a nd non fata l cases respec tively. 'I'1;e reaslln for t he rel.uivcly h igh in cid cn ' o f so -ca llcd " a cu te" cas 's in t h e pr 'Sent ~cri cs is not rea d ily a p pa r nu . On e possihl e ex pl.m .u io u is th a t v Ty few o f o u r pa t ie n ts ( n n lv tw o reco rd ed ) ha d recei ved a ntibi . Ilt ic rhcrapv prior to di agnosis whi ch mi gh t ha \'(' llIodi fi 'd th e {'Im rs ' , This, in tu rn , "1",\ 111. ":
T AII I. !.
Ii
R I : S I · I. T S
1(..;I1" d S" l'gic a l E x p in 'd Ca n ';n"l lIa " I' 11I1,..rnd " sis di scO)\"' !'I'd !':O) ("II" w· " I' " " s"I'\ 'a li" ,, t OJ hea li" g
28
4J.I :1 6
7
f) I ' KAT IO :-; O F SY~I I' T O~ I S I N 1' ,\ T n : :-;T S E X I' IR I :-;t;
:\ hsc.'ss de vel o ped in h usp ita l I ' p to 1 we('k I ",,,,'k ( 0 I 1I111111 h I lJlo .lt h t o) :11!l' lIl1hs \ 1,, 1'" Ihall :1 lIl" lIlh s
6 4 2
D i..c,·.Hc.....
S HAF RON AN D T AT E
may be a reflection of th e socio-eco nom ic sta tus of th e m aj ority of ou r p ati ents or a ~row i ng a wa re ness of ph ysicians in the past five yea rs to ut ilize chest x- ra y exam inat io ns !>rior to th erapy of a n u p pe r respirato ry infection, b ron chitis, etc, Severa l papers ha ve co rrelated dura ti on of sym pto ms with survival. A nde rso n a nd McD o,nald ' stated th at sym p to ms g rea ter tha~ eight weeks duration gave a poor p rognOSIS, Rumbau gh and Prior" found non e o f seven pat ients with sym ptoms g rea te r th an four weeks resolved on conserv a tive th erapy. H owever, as noted above, H en schel a n d co-workers' found no difference in duration of sym ptoms in his fatal and n onfatal ~rou ps, In th e pr esent series, on ly tw o pau cnts wh o expired had sym pto ms lon ger th an one month pri or to di agn osis, This is not significa ntly differ ent from th e 29 p er cent of tl i c entire . , s e n, es with sym p to ms lon ger thaa n one m ont h , a n d iIS m contrast to ~!le Anderson and M cDon ald' series. , he loca tion of a bscesses correla tes well SCI" 3,< '[ 1ic g reate r mCI ' id ence with other series. 01) ' ' I . of uppe r 1 ri I" e mvo vcment, espe cia lly of th e ~ It upper lob e, is seen , Of inter est however, is the g rea te r fa tali tv ra te in ' low er lob e ,a bsc I . . ces.,>es, :" \ Il( erson a nd M eDon ald" concluded tha t low er lob e a bscesses had a
til(:
,,(
Che«
poo r p rog nosis, The dilli .u lt v in o b ta in ing proper postu ral dra in a ge in low T lob ' a bscess is a p pa re n t a nd th e retained p urulent m a teri a l wi ll g ive a n unfa vo ra ble co urse. Sudden 111 a ss i v e h .morrhage» ca n occu r wit h exsa ngu ina tio n. Bro c k' points o u t th a t co m po u nd o r multiple a bscesses a re m ore frequ ent in th e low er lob es bccau T th e o rificcs o f the three basal seg m en ta l b ronchi 01 1" clo se tog et he r a nd a lm ost eq ua lly well placed to receive in f .ctcd m at eri a l fr o m o ne a not her, Simi la rly. d rain ag e from th e a p ica l b ron ch us ca n x pill in to t he ba sal b ronchi, These factors d e ma n d surgica l co nsu lta tio n m u ch q uic ker t ha n th ose a bscesses in area s th at drai n wel l. Bact .riologic st ud ies in rela tion to m orta lity ha ve sho w n a va riety o f o p in io ns. J en sen a nd Arndru p' fo u nd t hat t he d eat hs in their se ries o c curr ed in p at ie n ts w h o g rew S/a l l hyloco ccl/ s aI/ H'Il S. C o lifor m o r Prote us o rg a n is m s a nd t h at no d eat hs occu rre d in cases wit h S t re ptoco cci, P neumococci o r II, inlluenzae a lone . H enschel a nd associa tes' I' ' port t ha t the p atients w ho di ed did not h a v e sig n ifica ntly diff Tent ba ct eri olog ic findi ngs fro m t hose w ho su rvived . The isol a tio n of o ne o f t he p at hogcn i ,gro ups of orga nism s in t he p resent se ries was associa ted wit h a worsen ed p rognosis,
I\lJG 10,1962 (' lll UIU ' -l : M '7 , ,I I . .I 'I ' ' I a n,;) y' ars " ( • p r .sc n tcc with a left lowe r lobe ab scess. 0 111' mo nt h la n-r II... '\ I>, n ' r< 11' \ 5 , l lIIlI st (' ' ''tft' t I I I r d £"11 d dil d ' , . ,' .' • a, l ("ILrnuorna. : ., , l ll l ie 110 - I C I a te eso ph ag us ( a r m w ) was tilt' first du,' to a ll «h stru c t iu« "s""II"I'" rv , :"l "
V'.lurnc- ~ \, , "). I
J .llI Uar )' , JI)6 H
LU NG A BS CESS ES
Thc.,; ' includ ed S l a /Jll)' l ococc us aurcus, Ps 'udon lOn:ls, Pro teus, , I crobac ter klebsiella a nd E. coli, T hese were in itial cult ures, This cm ph :L,;izes th e need for ade quate culture and sensiti\ 'ity stud ies from go od specim ens ~) Illai n ed Irom sp utum o r bron chi al washIIlgs. Repeat cultu res d uring th erapy arc a mu st for d tect nm of su perinfe ction or dev '(opme nt of resisten t stra ins. T he most im po rtan t fa ctor in medi ca l Illa na g ' Ill .nt of lung a bscesses appea rs to b · prolon ged a nd in tensive a ntibiot ic th era py. I 0 co rrela tion as to type of a ntibiotic Used a nd outcom e co uld be det ermined . Three fat ali ties occu rred in pati ents wit h inadeq ua te a nti biotic th erapy, i.e., eithe r th erapy int errupte d o r de laye d becau se of lIlista ken d iagn osis o r th er apy discont inued beror ' there wa s com plete heal ing of the a bscess a nd /o r the inflamm at ory rea ction. T he num ber of p roced u res d on e in the pr :Sellt series W :L'i not eno ug h to eva lua te ade quat oly su rg ica l th erapy. The two fatalities occu rred in ex tre me lv tox ic patients. Most series ha d a hig her percent age of sl.lrgica l proced ures for cu re wit h mort a lity Ig ures from 0 per ce nt • 'II to 15 per cen t 'J" " plica tion rat es were high (8 per cent Com · per cent" to 42 per cent" }. Wolcot t 2'1 to lla bo ra to rs" recom mend surgery for co a nd r 'sid ua l thick-wa lled cavities a f te I' thre e Weeks a nd found th at the thin wa ll cavities usua lly heal. Progressive improvem ent e\'e ry two w .cks on x-ra y films is felt to be a min im ulll requirem ent to contin ue m~d ica J tlTatlll ent ; othe rwise sur gica l resccn on mu st b ' co nsidere d . O ur policy is to follow th e asy m pto ma tic pa tients wit h a cav it)' while co ntinuing a ntibiotic therapy. T !le longc."t persiste nce of a ca vity in our series Was five months a lt ho ug h Wolcott a nd a: soC"iatc.,," r 'po rt a closu re afte r on~ a nd onc-ha lf yea rs. Two pati en ts with persls~e n t inflamm at o rv r c a c t io n and / or bron clu ectasi ' were foilow ed . On e had a n un even tfu l (ob ccton l\' 13 mon ths lat er a nd on e expired one a nd 'one -ha lf vcars la ter with massive !tcmopt ysis, Pa t ien~s treat ed wit h recu.lTe llt infe ctio ns, pers isten t sympto ms o r persi stent x-ray cha ngcs sho uld he restud ied , includ -
ing bron ch og rams, a nd strong co nsidera tion given to resection of the in volved a rea . SU M M A RY A ND CONC LUSION S
The case records of 55 pati ents with lun g a bscesses a t a large county-university hospita l in th e past five yea rs were reviewed . The age, sex, predisp osing factors , sym ptoms, ba ct eriolog y a n d loca tion did not a p p ea I' sig nifican tly different from other series. The diagn osis was made earl ier in this series than in th ose rep orted reporte d previou sly ; 7 1 per c e n t of pati ents had symp toms of less than one month 's d uration . Fa ctors tha t a ppe a red to ind icate a poor progn osis were mu ltip le a bscesses, lower lob e a bscesses or presence of one of th e socalled pathog en ic bacteria on initia l culturc, T hera p" s h 0 u ld be p rolonge d and int ensive anci contin ued un til the a bscess has closed . T he pati ent should be given a n ade q ua te tria l to close the ca ~i ty on med~ ical manag em ent. H owever, If sym I~toms pro g ress, if the ab scess : nlarges or If no respo nse is made a fte r SIX ~vee ks to two mo nths, surgica l i n tc rv c n t io n sh~u ld be mo re stro ngly conside red . Lat e su ~glcal resection mav be necessa ry in the pat ient who has closed ' his a bs c ess bu t has recurre nt infectio ns or resid ua l bronchiectasis. R ES U ~I E N
Sc revisan 55 casos de ah ceso p ulmona r obs..rva dos en lin hospitul publico-universitario. Lo relnti vo a edad, sexo , [a crores p rcd isponent es, loca lizario n, sinto mas r ba ct criol ogla no pa rece di ferir <1.. 10 obscrvado en otras series sim ilare s. EI di agnostico fllc mas precoz en es ta serie q ue otr as p reVian 1l'111 e rc po rta da s : I'll el 71 % d e 10 5 casos la du ra cinn d e los sinto mas fllc d e mcn os de 11I1 Illes. Los faciorcs indicnrivos d e 1111 III a I pronosrico Iueron a bcesos mul tipl es, ab ccsos d el lobule inferi or >' p resencia de las lla mad as ba ct irias pa t6genas en cl cultivo inicial. La tera peutica d ebe cI SCI' intcusiva, prolongada y cominua dn hasra cierre del a bccso.
Debe proporc ionarsc .11 pacicnte una prueba tera peurira ad ccunda , d ir igida a ob tcncr eI cierrc
d e la ra vidad pOI' cl tra uu u icn to mcdi co. Sin ('mhargo , si los sin tomas cm pcora n, si ..I ab r eso aum en ta de ramaiio 0 si no ha y respllesla ad cruad a en ' I lcnni no d e 6 scma na s a 2 moses,
18
S H AF RON A:-
deb e c()n~ i dera rse mas se ria me nte el tra ta micn to qui rllrgi co . La cirugia tardia pued e se r ncccsaria en los ca sos en q ue se ha olnen ido el c ierre d el a h e es' ), pero qu e pre scn tan c piso d ios de inf eccion rccurrc u tes 0 bronchi ect asia residual. R "I'I' RI': NCI'S
F., M xr.co t.xr, j. A . ANIJ W VI.If., R. I I. : " Lung ab scess : a st ud y o f 148 ca ses d uc t" a sp ira tio n," D is. Ch est, 43 :620 , 1963. ~ ~,~ \ l> lmSON , M . N. A N II M cD o N A l.lJ , K . . E. : 1 yogell ic IUlIg abscess," N ew Y ark Sta te ] . u .«, 6 1:402, 1961. :1 R t:~tIlA IJr:II . I. F. AND P RIOR, .J. A . : " L u ng ~hsce~s --a revi ew of 41 cases ," Ann. I n t. Jyf ed ., :)5 : :!2:I, 1961. ·1 S (al\n:I' !'I:. I I. I., K ~ OWI. E S , J. H . AN Il KA N E, /..: " LulIg ab scess " N ew Eng l ] M ed 265 . 1039, 1961. ' . . ., ' B " n :O: II Alm , W .
5 FII'l:n, W. R., J-[ USI'8YF., K., Clllm Es Tlm , C. A:oI I> Mn. I.I,: n , M .: " P r imary l u n g abscess ,' A rch. l ilt . M ed., 107 :6 68 , 1961. .
G 111'::-: 5(:11 1:1. . E. 0 ., \ \ ' ,\l S II R I: :'oI . n. A. AN? (;"A 5 1·:n, r..1. : " Lu ng abso- ss as S" " l1 ill a IIIUIIIc ip a l h osp it al ." J) ir. 40 : 625 , 1961. 'al 1II ~I II nO C K , I'v , C . : "I '1I" an at o m yw f III, . br on( 195,1 Iff', ' . O x fo rd , n ivcrsi ry Press, . Lfl~~ d.oll . "e ifi~ II J El' s t, N, II. I', . A"I> A~t fln l1l' . I'.. : N OllsPCI 'r ab scess o f th e lu n g : 129 c ases ," A cl fl 1/ .
cs.«.
Sc nn d ., 127 : '111 7 i964 '. ll ll C 9 D I."JA ~, NI.'. . .. n'\.. , I " , A:"IJ . ' I', 1( ,. M ,\ :'oI . 0 ... " C hn60? '6' pu lrllfl lla ry su p p u ratio n, " Dis. C h" , I, J. -. 1959 . . , 10 D \ ' FFY , T . J. ,\ :'01 0 C Il A FI' A S , I. : " P;IlI':6~ IUlIg ahscc ss,;' A mer. ] . u,«. Sci ., 2·13: - ' 191;2. II ( •'0 1,/1 II , f \ . , ( ,"UI. ST , .J. I :; ]...'xn'1"1D... If." , . ,'S , r ;oo; and
12
R. A . : " P r im a ry lUll!!; abscess , Cfl rd i" ufls. Surg, ,n : 383, 196·L W .,
Cot
RY,
10 •
x x o BA U~\' in t he th eral! }' o f
O . II.
lun g abs ce ss: a t\~'e llt}'- }'car su rvey, " ti «. ,10: I. 1961.
GIlt' S/'
Fo r rep rints , pl e a se write: D r. Ta te , J a c kso n M e m orial H osp ita l, Mi ami ,
INII ALATI O N T HE RA PY W ITH C YC LOSER INE I 'I:hls article reports t he resu lts o bta ined In 188 I·a tlen ts wit h chron ic pulm on ary tubercu los is who were treated with cycloseri ne In th e routine m a nner a nd a lso by Inha lation or t he dr ug . T he treatmom Was mai nta ined (or a bo u t t wo m ont hs. T he autho r (oun d th ut cycloser ine Inha la ti on in cr ea sed th e ellleac y o r th e dru g. pa r tl eul arly In d llll cult a nd
N.
W OL COTT,
r; . I., : "C ha ugi ru; conce pts
.
I'
LM O NA R Y T
BERC UI. O SI S
com plica ted ca se s. In mos t pa t le rtt s , th e coug h and expl'eto ralion t'Hhe r d lsap Pt'a red o r wn s gn'atly trn prO\'ell. The s pu tu m eo n vc rslon r ate was 1.5 ti llle s h igh er. K ui.rx , N . M. : " Inhalation Ih elJp y with ( yel" ",,'; lIe in pullIl'mMy tubercul.. , i,, " 1' , . bl ,'1II1 . / T.b", " I. IIJ f.USSR), ~ : .10, 196 7 ,
PAP ILL AR Y M US C LES AFTE R MITR AL VA LVE R EPI.AC E?\IENT
T h,. • morpholog y o( t he pupll1nry mu scles or the left vent ricle wa s st ud ied in 19 dog s alter repla cemun t o( the m itral v a I \ 'C wit h a Sta r r-Edwards pru sth esls. I! th e cho rda e tendi noae a nd lea flets Were excised at o pe ration, th e papll1 a ry muscl es u nlle rwen t a t ro phy and were replaced by llbrous tissue.
(( th e cho rd a e ten d ln ea e a nd It'a ll'l s were leCt Inta ct, th e pa pillary m u scles re mai ned m o r ph ol og icall Y norm a ).
I\ ~ Hnu , G . K' . KU N, ) . W . ~ NlJ Trrus, J. L. : " FJ IC of
pJpill.u)'
valve ;"
rnu~t.lcs
/\1 11) '"
J fter Ilf {)'\thC't il" rcpb t.cmcnt of m it ra l CIi". Pros ., ·L!: l IO. 196 7.
I'II YS[ OLO G IC STU DY O F M ACL EOO'S SYN D ROr..1E Seven pati en ts with Macle od' s syn dro mc or abno rma l t ra nsra dia ncy of one lung have been lnvest h:at<:d wit h s pecia l ref uren eo to region a l lun g (un ctio n. T~ e I,r in elp al a bno rma lity wa s rou nd to be ohst ru rt,o n o( th e ai rways. Th is was sev ere in t he a ((('eted lun g. but was ot te n present In t he other lun g as we ll. Alt ho ugh Iun ct lon a l Impairm ent of th e a ffected lu ng wa s seve re , It wa s by no m ea ns unl(orm l>' d istrib ut ed ther e : th e hlood I:ases we re o nly s llgh ll y a bno rmal a t rest . and hypercapn ia . In pa rlIcu la r, was not a Ieature, During exercise. arte ri al Ol(yge n tenslo ns tcnd ed to (a ll. We have a lll! nt pled to a sse ss ai r c ntry ste t hosco pically in ti ll! six regions o r th e lun gs subs eq uent ly
su rve veu b v t he s c l n t i l l a t l o n cou n te rs . Broad ly s P,-· a k~i n g'. ih e cttn tca l a sse ss me n ts a~ ree with th e vt-nt.Ilnt lo n indices. h ut th e d iscr im in a ti on obta in a hl., wit h th e s te t hos co pe is, a s wo u ld he ex pec te d. de penden t u po n rath er coa r se co nt rasts . W e ha ve co me to re g:a rd th e rad io a cti ve xeno n s tud ies as nn ex tensio n o( ca re fu l cli n ica l li nd r ad lol oJ.: lc assess-
m vnt to w hic h It a drts precis ion a nd In SOIl1l! ca ses revea ls un su sp ected d ls t urban cc s n( per(u sl on lind ven tlla tlo n . and parti cu la r ly reg io nal vari ations III gas m lx lng . N ~"I N. ) . 1\. ~N lJ PRIMP., F. ) . : " II phy siolor,icJi stu dy of M Jd c•.,t!·\ synd rom e, " 'Th orax , 22 : I ·IH, 1967.