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Lung abscess due to coexisting Mycobacterium tuberculosis and anaerobic bacteria in a cavitary bronchogenic carcinoma
Correspondence
there was no history of irradiation and immunosuppressive therapy. In the differentiation of a cavitated malignant neoplasm from an abscess, the thickness and contour of the wall are imp0rtant.j Even though the incidence has decreased with antibiotics, abscesses encountered today are most likely to be caused by pyogenic bacteria, particularly anaerobic microorganisms of oral flora.’ In our patient, where there was no history of aspiration. we believed that not only was bronchogenic carcinoma a factor predisposing to lung abscess, but that tuberculosis and anaerobic bacteria played additional roles. In the literature, the occurrence of air-fluid level in tuberculosis cavity is unusual. However, Cohen et al reported 18 cases of proven active cavitary tuberculosis where air-fluid levels occurred during the active phase of the disease.s Pholson et al isolated tuberculosis in 4 of 89 patients with lung abscess.h None of them reported tuberculosis in a malign cavity. Underlying disease such as carcinoma may have predisposed our patient to the development of tuberculosis superinfection. Although mycobacteriosis is relatively uncommon in cancer patients, if it is present atypical mycobacteria should be looked for, as they cause more than 50% of mycobacteriosis in these patients. In our patient, BACTEC and Loweinstein culture ruled out atypical mycobacteriosis.
Lung abscess due to coexisting Mycobacterium tuberculosis and anaerobic bacteria in a cavitary bronchogenic carcinoma We report a case of a 42-year-old man with squamous cell carcinoma of the bronchus who presented with an air-fluid pulmonary cavity. Cultures of abscess material yielded M. tuberculosis and anaerobic bacteria. This case demonstrated the occurrence of coexisting anaerobes and M. tuberculosis as potential pathogens in cancer patients with decreased host defences. A 42-year-old man was admitted to hospital suffering from chills and fever. Fever, chills, sweating, purulent sputum, mild haemoptysis, left thoracic pain, general malaise and weight-loss had developed 1 month earlier with a 20 pack-year smoking history. On examination the patient appeared pale, with a temperature of 40°C. Examination of the lungs showed diminished breath sounds on the left upper lung field and riles in the left lower lung field. PPD was positive. X-ray of the chest revealed a large abscess with an airfluid level and infiltration in the left upper lobe: the remaining lung fields were clear. Computerized tomography (CT) showed abscess and atelectasis. Sputum smear demonstrated leukocytes and acid-fast staining was negative. Bronchoscopy was performed because of irregularity in the abscess wall and unusual localisation of the abscess. Inflammatory endobronchial changes and left upper lobe bronchus obstruction with necrotic tissue were observed. CT- guided fine needle aspiration of this abscess revealed pus and the abscess cavity was drained with a chest tube. anaerobic gram(-) coccus (veilonella) was isolated by anaerobic culture of the pus. Acid-fast stain was positive in this fluid. Cytologic examination of the needle aspiration material of the abscess wall was considered as squamous cell carcinoma of the bronchus. This malignancy was proven by bronchoscopic biopsy of the bronchogenic necrotic tissue. 14-day-BACTEC procedure and 25day-Lowenstein culture of the pus identified M. tuberculosis. Symptomatic response was favorable to a combination of antituberculosis and anti-anaerobic therapy. The patient was unable to undergo surgery because of the mediastinal lymph nodes and pulmonary artery invasion. Radiation therapy could not be applied because of inappropriate localisation and infection. The patient was managed conservatively and chest X-ray showed no change with antituberculosis therapy for 8 months. Bronchogenic carcinoma cavitates in 2-16% of cases, especially in squamous cell carcinoma.’ Irradiation and immunosuppressive therapy may be predisposing factors for lung abscess in patients with lung cancer.? In our case.
References I, Chaudhuri M R. Primary pulmonary cavitating carcinomas. Thorax 1973: 28: 354. 2. Joss R A, Goldberg R S, Yates J W, Krakoff I H. Lung abscess following corticosteroid therapy for central nervous system metastases. Med Pediatr Oncol 198 I; 9: 279. 3. Woodring J H, Fried A M. Chuanp V P. Solitary cavities of the lung: diagnostic implications of cavity wall thickness. Am J Radio1 1980: 135: 1269. Barlett J. Gorbach S, Tally F. Finegold S. Bacteriology and treatment of primary lung abscess. Am Rev Respir Dis 1974; 109: 5 IO. Cohen J R, Amorosa J K, Smith P R. The air-fluid level in cavitary pulmonary tuberculosis. Radiology 1978: 1?7(2): 31.5. Pholson E, McNamara J J. Char C, Kurata L. Abscess: a changing pattern of the disease. Am J Surg 1985: 150. 97. Feld R, Bodey G P, Groschel D. Mycobacteriosis in patients with malignant disease. Arch Int Med 1976: I36t I): 67.
Berrin Ceyhan Turgay Celikel Faculty of Medicine Department of Pulmonary Medicine Volkan Korten Fucuty C$Medicine Department of Ir$ectious Diseases Marmaru Uwi~w-sity Hospital Altonixde Istanbul Tlltke~ 407
there was no history of irradiation and immunosuppressive therapy. In the differentiation of a cavitated malignant neoplasm from an abscess, the thickness and contour of the wall are imp0rtant.j Even though the incidence has decreased with antibiotics, abscesses encountered today are most likely to be caused by pyogenic bacteria, particularly anaerobic microorganisms of oral flora.’ In our patient, where there was no history of aspiration. we believed that not only was bronchogenic carcinoma a factor predisposing to lung abscess, but that tuberculosis and anaerobic bacteria played additional roles. In the literature, the occurrence of air-fluid level in tuberculosis cavity is unusual. However, Cohen et al reported 18 cases of proven active cavitary tuberculosis where air-fluid levels occurred during the active phase of the disease.s Pholson et al isolated tuberculosis in 4 of 89 patients with lung abscess.h None of them reported tuberculosis in a malign cavity. Underlying disease such as carcinoma may have predisposed our patient to the development of tuberculosis superinfection. Although mycobacteriosis is relatively uncommon in cancer patients, if it is present atypical mycobacteria should be looked for, as they cause more than 50% of mycobacteriosis in these patients. In our patient, BACTEC and Loweinstein culture ruled out atypical mycobacteriosis.
Lung abscess due to coexisting Mycobacterium tuberculosis and anaerobic bacteria in a cavitary bronchogenic carcinoma We report a case of a 42-year-old man with squamous cell carcinoma of the bronchus who presented with an air-fluid pulmonary cavity. Cultures of abscess material yielded M. tuberculosis and anaerobic bacteria. This case demonstrated the occurrence of coexisting anaerobes and M. tuberculosis as potential pathogens in cancer patients with decreased host defences. A 42-year-old man was admitted to hospital suffering from chills and fever. Fever, chills, sweating, purulent sputum, mild haemoptysis, left thoracic pain, general malaise and weight-loss had developed 1 month earlier with a 20 pack-year smoking history. On examination the patient appeared pale, with a temperature of 40°C. Examination of the lungs showed diminished breath sounds on the left upper lung field and riles in the left lower lung field. PPD was positive. X-ray of the chest revealed a large abscess with an airfluid level and infiltration in the left upper lobe: the remaining lung fields were clear. Computerized tomography (CT) showed abscess and atelectasis. Sputum smear demonstrated leukocytes and acid-fast staining was negative. Bronchoscopy was performed because of irregularity in the abscess wall and unusual localisation of the abscess. Inflammatory endobronchial changes and left upper lobe bronchus obstruction with necrotic tissue were observed. CT- guided fine needle aspiration of this abscess revealed pus and the abscess cavity was drained with a chest tube. anaerobic gram(-) coccus (veilonella) was isolated by anaerobic culture of the pus. Acid-fast stain was positive in this fluid. Cytologic examination of the needle aspiration material of the abscess wall was considered as squamous cell carcinoma of the bronchus. This malignancy was proven by bronchoscopic biopsy of the bronchogenic necrotic tissue. 14-day-BACTEC procedure and 25day-Lowenstein culture of the pus identified M. tuberculosis. Symptomatic response was favorable to a combination of antituberculosis and anti-anaerobic therapy. The patient was unable to undergo surgery because of the mediastinal lymph nodes and pulmonary artery invasion. Radiation therapy could not be applied because of inappropriate localisation and infection. The patient was managed conservatively and chest X-ray showed no change with antituberculosis therapy for 8 months. Bronchogenic carcinoma cavitates in 2-16% of cases, especially in squamous cell carcinoma.’ Irradiation and immunosuppressive therapy may be predisposing factors for lung abscess in patients with lung cancer.? In our case.
References I, Chaudhuri M R. Primary pulmonary cavitating carcinomas. Thorax 1973: 28: 354. 2. Joss R A, Goldberg R S, Yates J W, Krakoff I H. Lung abscess following corticosteroid therapy for central nervous system metastases. Med Pediatr Oncol 198 I; 9: 279. 3. Woodring J H, Fried A M. Chuanp V P. Solitary cavities of the lung: diagnostic implications of cavity wall thickness. Am J Radio1 1980: 135: 1269. Barlett J. Gorbach S, Tally F. Finegold S. Bacteriology and treatment of primary lung abscess. Am Rev Respir Dis 1974; 109: 5 IO. Cohen J R, Amorosa J K, Smith P R. The air-fluid level in cavitary pulmonary tuberculosis. Radiology 1978: 1?7(2): 31.5. Pholson E, McNamara J J. Char C, Kurata L. Abscess: a changing pattern of the disease. Am J Surg 1985: 150. 97. Feld R, Bodey G P, Groschel D. Mycobacteriosis in patients with malignant disease. Arch Int Med 1976: I36t I): 67.
Berrin Ceyhan Turgay Celikel Faculty of Medicine Department of Pulmonary Medicine Volkan Korten Fucuty C$Medicine Department of Ir$ectious Diseases Marmaru Uwi~w-sity Hospital Altonixde Istanbul Tlltke~ 407