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==Historical perspective==
*In 1904 Guillemot first put weight to the theory that aspirated oropharyngeal organisms were responsible for cause of lung abscess<ref name="Pediatric thoracic surgery">{{cite book |last=Lima |first=Mario |date=01/24/2011 |title=Pediatric thoracic surgery Softcover reprint of hardcover 1st ed. 2009 |location= Harvard Medical School |publisher=Springer London |page=145 |isbn= 978-8847052017}}​</ref>
*In 1920-1930 Harold Neuhof, was the first thoracic surgeon to develop a valid and reliable therapeutic concept of new one-stage open drainage operation for surgery of acute pulmonary abscess.<ref name="pmid17858299">{{cite journal |vauthors=Neuhof H, Hurwitt E |title=ACUTE PUTRID ABSCESS OF THE LUNG : VII. RELATIONSHIP OF THE TECHNIC OF THE ONE-STAGE OPERATION TO RESULTS |journal=Ann. Surg. |volume=118 |issue=4 |pages=656–64 |year=1943 |pmid=17858299 |pmc=1617784 |doi= |url=}}</ref>
*In 1938 first cutaneous drain of lung abscess was performed.<ref name="pmid22347342">{{cite journal |vauthors=Wali SO |title=An update on the drainage of pyogenic lung abscesses |journal=Ann Thorac Med |volume=7 |issue=1 |pages=3–7 |year=2012 |pmid=22347342 |pmc=3277038 |doi=10.4103/1817-1737.91552 |url=}}</ref>
*In 1942 Brock added evidence in stating that aspirated contents gravitated to the dependents part of the lungs
*In 1946,owing to the advent of antibiotics, and treatment of acute putrid lung abscess with penicillin showed good results and henceforth patients received antibiotics rather than surgical procedures<ref name="pmid17858299">{{cite journal |vauthors=Neuhof H, Hurwitt E |title=ACUTE PUTRID ABSCESS OF THE LUNG : VII. RELATIONSHIP OF THE TECHNIC OF THE ONE-STAGE OPERATION TO RESULTS |journal=Ann. Surg. |volume=118 |issue=4 |pages=656–64 |year=1943 |pmid=17858299 |pmc=1617784 |doi= |url=}}</ref>


==Pathophysiology==
{{CMG}}{{AE}}{{ADG}}
===Pathogenesis===
*Aspiration of  bacteria from the oro-pharnynx, secondary to altered level of consciousness, absent gag reflex or inability to swallow is the primary pathogenesis in the development of lung abscess.
*In healthy individuals, defense mechanisms cope up with the small amounts of aspirates with no effects, however, in conditions like alcoholism, diabetis mellitus, and immunocompromised state these defense mechanisms can be compromised leading to decreased activity of alveolar macrophages and mobility of leukocytes predisposing patients to developng abscess. <ref name="pmid5683476">{{cite journal |vauthors=Green LH, Green GM |title=Differential suppression of pulmonary antibacterial activity as the mechanism of selection of a pathogen in mixed bacterial infection of the lung |journal=Am. Rev. Respir. Dis. |volume=98 |issue=5 |pages=819–24 |year=1968 |pmid=5683476 |doi=10.1164/arrd.1968.98.5.819 |url=}}</ref>.
*In secondary lung abscess, abscess formation depends on the underlying lung disease and predisposing factors such as bronchial obstruction from benign or malignant intrabronchial lesions or extrinsic compression of bronchus (eg:middle lobe syndrome) results in distal abscess formation due to decrease oropharyngeal clearance due to decreased clearance mechanisms and favouring abscess formation.
*Localization of the aspirate results in pneumonitis <ref name="pmid15599270">{{cite journal |vauthors=Brook I |title=Anaerobic pulmonary infections in children |journal=Pediatr Emerg Care |volume=20 |issue=9 |pages=636–40 |year=2004 |pmid=15599270 |doi= |url=}}</ref>
*Inflammatory mediators along with bacterial toxins and proteolytic enzymes from neutrophils are released leading to rupture of small blood vessels resulting in the formation of colliquative necrosis <ref name="pmid22388585">{{cite journal |vauthors=Tsai YF, Ku YH |title=Necrotizing pneumonia: a rare complication of pneumonia requiring special consideration |journal=Curr Opin Pulm Med |volume=18 |issue=3 |pages=246–52 |year=2012 |pmid=22388585 |doi=10.1097/MCP.0b013e3283521022 |url=}}</ref><br>
 
==== Location of abscess ====
*The right lung is more commonly affected than the left lung because is of it more angulation than the left bronchi.
*The most common location is the posterior segment of the right apical lobe or apical segments of lower lobes of both the lungs.<ref name="pmid8324127">{{cite journal |vauthors=Bartlett JG |title=Anaerobic bacterial infections of the lung and pleural space |journal=Clin. Infect. Dis. |volume=16 Suppl 4 |issue= |pages=S248–55 |year=1993 |pmid=8324127 |doi= |url=}}</ref>
*Lateral part of the posterior segment of upper lobe of  the right lung is more commonly involved in alcoholics.
 
===Genetics===
*Congenital diseases such as cystic fibrosis, vasculitis, pulmonary sequestration and bronchial cysts are associated with increased the risk of lung abscess in children.<ref name="pmid3715782">{{cite journal |vauthors=Canny GJ, Marcotte JE, Levison H |title=Lung abscess in cystic fibrosis |journal=Thorax |volume=41 |issue=3 |pages=221–2 |year=1986 |pmid=3715782 |pmc=460300 |doi= |url=}}</ref>
 
===Gross Morphology===
*In acute lung abscess, the lesions are well circumscribed filled with necrotic debris and do not demonstrate well-defined borders with the surrounding lung parenchyma.<ref name="pmid26366400">{{cite journal |vauthors=Kuhajda I, Zarogoulidis K, Tsirgogianni K, Tsavlis D, Kioumis I, Kosmidis C, Tsakiridis K, Mpakas A, Zarogoulidis P, Zissimopoulos A, Baloukas D, Kuhajda D |title=Lung abscess-etiology, diagnostic and treatment options |journal=Ann Transl Med |volume=3 |issue=13 |pages=183 |year=2015 |pmid=26366400 |pmc=4543327 |doi=10.3978/j.issn.2305-5839.2015.07.08 |url=}}</ref>
*In chronic long standing abscess, the lesions are irregular and filled with grayish thick debris.
 
===Microscopic Findings===
*In acute lung abscess, neutrophilic granulocytes are demonstrated with dilated blood vessels and inflammatory edema.<ref name="pmid26366400">{{cite journal |vauthors=Kuhajda I, Zarogoulidis K, Tsirgogianni K, Tsavlis D, Kioumis I, Kosmidis C, Tsakiridis K, Mpakas A, Zarogoulidis P, Zissimopoulos A, Baloukas D, Kuhajda D |title=Lung abscess-etiology, diagnostic and treatment options |journal=Ann Transl Med |volume=3 |issue=13 |pages=183 |year=2015 |pmid=26366400 |pmc=4543327 |doi=10.3978/j.issn.2305-5839.2015.07.08 |url=}}</ref>
*In chronic lung abscess, biopsy specimen demonstrates lymphocytes, plasma cells, and histiocytes  around a layer of pyogenic membrane surounding the abscess cavity which is filled with pus.


{{SK}}
==Overview==
==Historical Perspective==
*
==Classification==
==Classification==
*Lung abscess can be classified into three types based on duration of symptoms,  etiology and  mode of spread as follows: 
==Pathophysiology==
 
==Epidemiology and Demographics==
===Based on duration of symptoms===
==Screening==
*'''Acute:''' If the duration of symptoms is less than 4-6 weeks before presenting to medical care.<ref name="pmid18158141">{{cite journal |vauthors=Puligandla PS, Laberge JM |title=Respiratory infections: pneumonia, lung abscess, and empyema |journal=Semin. Pediatr. Surg. |volume=17 |issue=1 |pages=42–52 |year=2008 |pmid=18158141 |doi=10.1053/j.sempedsurg.2007.10.007 |url=}}</ref>
==Natural History, Complications, and Prognosis==
*'''Chronic:''' If the symptoms persists for more than 6 weeks.
===Natural history===
 
===Based on Etiology===
*'''Primary:''' When the abscess develops after lung infection in previously healthy persons or in patients prone to aspiration <ref>{{cite book | last = Bennett | first = John | title = Mandell, Douglas, and Bennett's principles and practice of infectious diseases | publisher = Elsevier/Saunders | location = Philadelphia, PA | year = 2015 | isbn = 978-1455748013 }}</ref>
*'''Secondary:''' Abscess formation in patients due to complications of a co-existing lung disease such as post obstructive process (bronchial obstruction due to tumor , foreign body or enlarged lymphnodes) and systemic process resulting in decreased immune response like HIV, and patients on immunosuppressantss and corticosteroids.
 
=== Based on mode of spread ===
'''Bronchiogenic:''' Abscess formation is due to aspiration and inhalation.<ref name="pmid18158141">{{cite journal |vauthors=Puligandla PS, Laberge JM |title=Respiratory infections: pneumonia, lung abscess, and empyema |journal=Semin. Pediatr. Surg. |volume=17 |issue=1 |pages=42–52 |year=2008 |pmid=18158141 |doi=10.1053/j.sempedsurg.2007.10.007 |url=}}</ref>
*Aspiration of oropharyngeal secretions
*Bronchial obstruction by tumor
*Foreign body, congenital malformations, and enlarged lymph nodes
'''Hematogenic:''' Abscess formation due to dissemination of causative agents from other infected sites
*Infective endocarditis
*Abdominal sepsis
*Septic thromboembolism
 
==Risk Factors==
Factors resulting in altered level of consciousness and decreased immune response play a key role in the development of lung abscess :
 
===Common Risk Factors===
*Alcoholism<ref name="pmid6859981">{{cite journal |vauthors=Hagan JL, Hardy JD |title=Lung abscess revisited. A survey of 184 cases |journal=Ann. Surg. |volume=197 |issue=6 |pages=755–62 |year=1983 |pmid=6859981 |pmc=1352910 |doi= |url=}}</ref>
*Seizure disorder
*Artificial ventilation
*Coma
*Neuromuscular disorders with bulbar dysfunction
*Nocturnal aspiration
*Bronchial obstruction
*Gingivo-dental sepsis
*Diabetes mellitus
*Immunosuppression
 
===Less Common Risk factors===
*Drug abuse
*Malnutrition
*Mental retardation
*Gastroesophageal reflux disease
 
==Epidemiology==
 
*The incidence and mortality from lung abscess have greatly declined during the past several decades due to the widespread use of antibiotics and the availability of other treatment options.
*Incidence also declined in the late 1940s and 1950s, after the practice of performing oral surgery and tonsillectomy in the sitting position was abandoned, as it became clear that this could result in lung abscess formation.<ref name="pmid14039097">{{cite journal |vauthors=SCHWEPPE HI, KNOWLES JH, KANE L |title=Lung abscess. An analysis of the Massachusets General Hospital cases from 1943 through 1956 |journal=N. Engl. J. Med. |volume=265 |issue= |pages=1039–43 |year=1961 |pmid=14039097 |doi=10.1056/NEJM196111232652104 |url=}}</ref>
*Lung abscess accounts for up to 4.0 to 5.5 per 10,000 hospital admissions each year in the US.
*It occurs at any age, but most frequently from the sixth to eighth decades, and is predominantly seen in men. <ref name="pmid4834618">{{cite journal |vauthors=Bartlett JG, Finegold SM |title=Anaerobic infections of the lung and pleural space |journal=Am. Rev. Respir. Dis. |volume=110 |issue=1 |pages=56–77 |year=1974 |pmid=4834618 |doi=10.1164/arrd.1974.110.1.56 |url=}}</ref>
 
==Causes==
Lung abscess may be caused by either by a necrotizing infection of lung parenchyma or necrosis of an infarcted lung tissue and cavitation in the necrotic tissue by malignant lesions
===Microbiology===
* About 90% of the lung abscess is caused by polymicrobial infection.<ref name="pmid28705">{{cite journal |vauthors=Cesar L, Gonzalez C, Calia FM |title=Bacteriologic flora of aspiration-induced pulmonary infections |journal=Arch. Intern. Med. |volume=135 |issue=5 |pages=711–4 |year=1975 |pmid=28705 |doi= |url=}}</ref> <ref name="pmid22209937">{{cite journal |vauthors=Bartlett JG |title=Anaerobic bacterial infection of the lung |journal=Anaerobe |volume=18 |issue=2 |pages=235–9 |year=2012 |pmid=22209937 |doi=10.1016/j.anaerobe.2011.12.004 |url=}}</ref>
* Anaerobes are the predominant pathogens involved in primary lung abscess, followed by Streptococcus pneumoniae.
 
* Klebsiella pneumoniae is the more commonly seen in alcoholics.<ref name="pmid15824979">{{cite journal |vauthors=Wang JL, Chen KY, Fang CT, Hsueh PR, Yang PC, Chang SC |title=Changing bacteriology of adult community-acquired lung abscess in Taiwan: Klebsiella pneumoniae versus anaerobes |journal=Clin. Infect. Dis. |volume=40 |issue=7 |pages=915–22 |year=2005 |pmid=15824979 |doi=10.1086/428574 |url=}}</ref>
 
* Staphylococcus aureus is the most common pathogen responsible for lung abscess in children with cystic fibrosis.<ref name="urlwww.iosrjournals.org">{{cite web |url=http://www.iosrjournals.org/iosr-jdms/papers/Vol14-issue3/Version-1/D014311314.pdf |title=www.iosrjournals.org |format= |work= |accessdate=}}</ref>
The following table elaborates the most common etiological pathogens responsible for lung abscess <ref name="pmid4850729">{{cite journal |vauthors=Lorber B, Swenson RM |title=Bacteriology of aspiration pneumonia. A prospective study of community- and hospital-acquired cases |journal=Ann. Intern. Med. |volume=81 |issue=3 |pages=329–31 |year=1974 |pmid=4850729 |doi= |url=}}</ref>
 
{| align=center
|-
|
{{familytree/start |summary=Sample 1}}
{{familytree | | | | | | | | | | | | | | | A01 |A01=Polymicrobial}}
{{familytree | | | | | | | | | | | |,|-|-|-|^|-|-|-|-|-|-|-|-|v|-|-|-|-|-|.|}}
{{familytree | | | | | | | | | | | B01 | | | | | | | | | | | B02 | | | | B03 ||B01=Bacterial|B02=Fungal|B03=Parasites}}
{{familytree | | | | | |,|-|-|-|-|-|^|-|-|-|-|-|.| | | | | | |!| | | | | |!| }}
{{familytree | | | | | C01 | | | | | | | | | | C02 | | | | | C03 | | | | C04 ||C01=Anerobic|C02=Aerobic |C03=Histoplasma<br>Blastomyces<br>Coccidoides<br>Aspergillus<br>Cryptococcus|C04=Entamoeba histolytica<br>Paragominus Westermani}}
{{familytree | | |,|-|-|^|-|-|.| | | | | |,|-|-|^|-|-|.}}
{{familytree | | D01 | | | | D02 | | | | D03 | | | | D04 |D01=Gram Negative|D02=Gram Positive|D03=Gram Positive|D04=Gram Negative}}
{{familytree | | |!| | | | | |!| | | | | |!| | | | | |!|}}
{{familytree | | E01 | | | | E02 | | | | E03 | | | | E04 |E01=Bacteroides fragilis<br>Fusobacterum capsulatum<br>Fusobacterum necrophorum|E02=Peptostreptococcus<br>Microerophilic streptococci<br>Actinomyces|E03=Staphyloccocus areus(including MRSA)<br>Streptococcous Pneumonia<br>Streptococcus Pyogens<br>Nocardia|E04=Klebsiella pneumoniae<br>Heamophillus influenza type B<br>Pseudomonas aeurongiosa<br>Escherichia coli<br>Legionella Pneumophilia<br>Acinetobacter spp<br>}}
{{familytree/end}}
|}
 
==Natural History, Prognosis and Complications==
===Natural History===
* Lung abscess can occur at any age but  most frequently seen in the fifth decades, with risk factors or underlying other lung disorders.<ref name="pmid423274">{{cite journal |vauthors=Adebonojo SA, Osinowo O, Adebo O |title=Lung abscess: a review of three-years' experience at the University College Hospital, Ibadan |journal=J Natl Med Assoc |volume=71 |issue=1 |pages=39–43 |year=1979 |pmid=423274 |pmc=2537236 |doi= |url=}}</ref>
* Clinical manifestations include fever, productive cough, pleuritic chest pain and occasional episodes of hemoptysis, typically developing 8-14 days after aspiration.
* The progression of the abscess is dependent on two factors: immune status of the patient and antibiotic therapy.
* In immunocompetent patients with adequate treatment abscess resolves forming a granulation tissue scar, without treatment  the abscess progressively worsens and can result in septicemia, hemorrhage, and death.
 
=== Prognosis ===
The prognosis of lung abscess is good with appropriate antibiotic treatment with a high success rate. The outcomes depend on the other associated conditions underlying lung abscess. The mortality rate of lung abscess is as high as 75% in patients with underlying immunocompromised state and bronchial obstruction favoring poor prognosis
The following factors are considered to be associated with poor prognosis among patients.<ref name="pmid10084487">{{cite journal |vauthors=Hirshberg B, Sklair-Levi M, Nir-Paz R, Ben-Sira L, Krivoruk V, Kramer MR |title=Factors predicting mortality of patients with lung abscess |journal=Chest |volume=115 |issue=3 |pages=746–50 |year=1999 |pmid=10084487 |doi= |url=}}</ref>
* Large size cavities(>6cms)
*Old age
*Necrotizing pneumonia
*Prolonged symptoms
*Abscess due to aerobic bacteria and hospital acquired
*Bronchial obstruction due to tumors or foreign body (secondary abscess)
*Immuncompromised individuals
 
===Complications===
===Complications===
Without treatment, lung abscess can result in the following complications:
*
*Hemorrhage <ref name="pmid8346503">{{cite journal |vauthors=Philpott NJ, Woodhead MA, Wilson AG, Millard FJ |title=Lung abscess: a neglected cause of life threatening haemoptysis |journal=Thorax |volume=48 |issue=6 |pages=674–5 |year=1993 |pmid=8346503 |pmc=464615 |doi= |url=}}</ref>
===Prognosis===
*Pyopneumothorax
*Pleural empyema<ref name="pmid27208219">{{cite journal |vauthors=Schattner A, Dubin I, Gelber M |title=Double jeopardy - concurrent lung abscess and pleural empyema |journal=QJM |volume=109 |issue=8 |pages=545–6 |year=2016 |pmid=27208219 |doi=10.1093/qjmed/hcw078 |url=}}</ref>
*Fibrosis and calcification of lung tissue
*Mediastinal, pleural and cutaneous fistulas
*Sepsis
 
==Diagnosis==
==Diagnosis==
===History and symptoms===
===History and symptoms===
Following past medical history is evident in patients with lung abscess.
*
*There may be a history of a condition associated with a risk of gastric content aspiration, such as dysphagia associated with neurologic disease (e.g., stroke, bulbar dysfunction) or esophageal disease (stricture, malignancy, and reflux), or poor dentition and gingivitis.
*There may also be a recent history of pneumonia, general anesthesia, nasogastric or endotracheal tube insertion, tooth extraction or other dental surgery, or oropharyngeal surgery.
*Risk factors for pulmonary embolism should be investigated in a patient suspected of this diagnosis.
*Underlying chronic illness predisposing to lung abscess (e.g., COPD, bronchiectasis, diabetes mellitus, scleroderma, esophageal diverticulum, liver and kidney disease) or immunosuppression (e.g., chemotherapy, organ transplantation, corticosteroid therapy, HIV infection) should also be noted.
 
===Symptoms===
Presentation of lung abscess depends upon on the duration of symptoms, it can be acute or chronic <br>
'''Acute presentation'''
*High fever (>101°F [>38.5°C]),
*Productive cough with purulent sputum, and pleuritic chest pain. <ref name="pmid15986068">{{cite journal |vauthors=Chan PC, Huang LM, Wu PS, Chang PY, Yang TT, Lu CY, Lee PI, Chen JM, Lee CY, Chang LY |title=Clinical management and outcome of childhood lung abscess: a 16-year experience |journal=J Microbiol Immunol Infect |volume=38 |issue=3 |pages=183–8 |year=2005 |pmid=15986068 |doi= |url=}}</ref>
*Large amounts of purulent secretions are expectorated in the second or third week of the disease.
*Putrid sputum is present in about 50% of patients. (foul-smelling sputum is highly suggestive of an anaerobic infection)<ref>{{cite book | last = Grippi | first = Michael | title = Fishman's pulmonary diseases and disorders | publisher = McGraw-Hill Education | location = New York | year = 2015 | isbn = 978-0071807289 }}</ref>
'''Chronic presenation'''
Symptoms are present for several weeks or longer before presentation and include
*Profound weight loss, malaise
*Low-grade fever, night sweats,
*Productive cough
*These symptoms mimic those of malignancy(hematologic malignancies).
*Massive hemoptysis can be present in chronic lung abscess.<ref name="pmid8346503">{{cite journal |vauthors=Philpott NJ, Woodhead MA, Wilson AG, Millard FJ |title=Lung abscess: a neglected cause of life threatening haemoptysis |journal=Thorax |volume=48 |issue=6 |pages=674–5 |year=1993 |pmid=8346503 |pmc=464615 |doi= |url=}}</ref>
 
===Physical examination===
===Physical examination===
General exam
===Laboratory findings===
*Findings include fever.
==Treatment==
*A poor nutritional state may be evident with cachexia and pallor secondary to anemia is seen in chronic cases.
===General measures===
* Poor oral hygiene, gingival disease with associated halitosis may be present.
Good hygiene which include retracting the foreskin regularly and gentle cleansing of entire glans, preputial sac, and foreskin were found effective in treating the diseases.
*Finger clubbing presents in chronic abscess.
===Medical Therapy===
*Gag reflex may be absent in patients with an underlying neurologic disorder such as stroke.
===Surgery===
 
===Photodynamic therapy===
===Respiratory system===
===Miscellaneous therapies===
*Dullness to percussion
==Prevention==
*Decreased breath sounds on the side of lung abscess
===Primary Prevention===
*Bronchial breath sounds on auscultation
===Secondary prevention===
*Inspiratory crackles 
*Localised crepitations
 
==Laboratory findings==
Diagnosis of lung abscess is made based on clinical symptoms, physical examination, radiographic studies and bacterial culture.CBC and CXR should be part of the initial evaluation of all patients with a suspected lung abscess.<br>
'''CBC'''
*Pronounced leukocytosis (usually >15,000 WBC/microliter) is often present.
*Anemia of chronic disease is found with chronic abscesses.
'''Chest X ray'''
*Consolidation is evident in a segmental or lobar distribution with central cavitation and an air-fluid level.
*The cavity wall is typically thick and irregular.
 
===Microbial testing===
* To identify etiologic agent and to initiate appropriate antibiotic therapy
 
*When patients present with typical symptoms of fever with chills, cough with purulent sputum for more than 2 weeks and with risk factors of aspiration it is appropriate to suspect anaerobes as a possible pathogen.<ref name="pmid857717">{{cite journal |vauthors=Bartlett JG |title=Diagnostic accuracy of transtracheal aspiration bacteriologic studies |journal=Am. Rev. Respir. Dis. |volume=115 |issue=5 |pages=777–82 |year=1977 |pmid=857717 |doi=10.1164/arrd.1977.115.5.777 |url=}}</ref>
*Sputum, blood, empyema and lower respiratory secreations are generally collected for microbial testing.
*Cultures of the sputum for anaerobic bacteria is not recommended because of its contamination by the normal flora in the oral cavity and long wait time for culture to grow. The only cultures that can give a positive result for anaerobes is empyema
*It is often difficult to get uncontaminated sputum specimens as both upper respiratory tract and lower respiratory tract along oral cavity is contaminated with various flora.
*The only methods available for obtaining uncontaminated specimens are trans-tracheal aspirates (TTA), transthoracic needle aspirates (TTNA), culture of pleural fluid, or blood cultures are recommended before administration of empiric antibiotics 
*Sputum analysis and culture is recommended for finding out aerobic and other causative agents of lung abscess.The contamination of the sputum sample can be minimized by
**Obtaining the sputum sample prior to antibiotic treatment.<ref name="pmid7477199">{{cite journal |vauthors=Bartlett JG, Mundy LM |title=Community-acquired pneumonia |journal=N. Engl. J. Med. |volume=333 |issue=24 |pages=1618–24 |year=1995 |pmid=7477199 |doi=10.1056/NEJM199512143332408 |url=}}</ref>
**Rinsing the mouth prior to expectoration
**NPO for one to two hours prior to expectoration
**Inoculation of the culture media immediately after the specimen is obtained
*All patients should undergo routine blood cultures.
 
 
 
{{familytree/start}}
{{familytree | | | | | | | | | A01 | | | | | | | | | | | | | | | |A01=Sputum Analysis}}
{{familytree | | | | | | | | | |!| | | | | | | | | | | | | | | | | | | | }}
{{familytree | |,|-|-|-|v|-|-|-|+|-|-|-|v|-|-|-|.| | | | | | | | | | | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | | | | | | | | | | }}
{{familytree | B01 | | B02 | | B03 | | B04 | | B05 | | | | | | |B01=Acid Fast Stain|B02=Culture on Sabourad's medium|B03=Direct Microscopic Examination for sulphur granules|B04=Gentain Voilet Stain|B05=Aerobic Culture}}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | | | | | | | | | | }}
{{familytree | |!| | | |!| | | |!| | | |!| | | |!| | | | | | | | | | | | }}
{{familytree | C01 | | C02 | | C03 | | C04 | | C05 | C01=Tuberculosis | C02= Yeast and Fungi|C03= Actinomyces and other mycelia of Fungi| C04=Fusiform Bacteria and Spirochetes| C05= Pyogenic organsims}}
{{familytree/end}}
* Interpretation of sputum cultures in these cases must take into account the clinical features of the patient, concentrations of the different organisms found in the culture and Gram stain, and the antibiotics the patient has received.
 
===Chest Xray===
*An irregularly shaped thick walled cavity with an air-fluid level is typically seen in lung abscess on chest xray. [[Image:Lung-abscess-1.jpeg|right|Lung abscess|500px]]<ref>Case courtesy of A.Prof Frank Gaillard, <a href="https://radiopaedia.org/">Radiopaedia.org</a>. From the case <a href="https://radiopaedia.org/cases/15517">rID: 15517</a></ref>
*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. <ref name="urlwww.ijpsi.org">{{cite web |url=http://www.ijpsi.org/Papers/Vol4(2)/E042037041.pdf |title=www.ijpsi.org |format= |work= |accessdate=}}</ref> <ref name="pmid4689444">{{cite journal |vauthors=Groff DB, Marquis J |title=Treatment of lung abscess by transbronchial catheter drainage |journal=Radiology |volume=107 |issue=1 |pages=61–2 |year=1973 |pmid=4689444 |doi=10.1148/107.1.61 |url=}}</ref>
*The extent of the air-fluid level within a lung abscess is often the same in posteroanterior or lateral views.
*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
*Up to one-third of lung abscesses may be accompanied by an empyema.<ref name="pmid6602513">{{cite journal |vauthors=Stark DD, Federle MP, Goodman PC, Podrasky AE, Webb WR |title=Differentiating lung abscess and empyema: radiography and computed tomography |journal=AJR Am J Roentgenol |volume=141 |issue=1 |pages=163–7 |year=1983 |pmid=6602513 |doi=10.2214/ajr.141.1.163 |url=}}</ref>
*Repeat chest radiographs must be obtained to determine the response of antimicrobial therapy.
 
===CT Scan===
*CT is helpful in differentiating the cavitation of abscess that cannot be clearly delineated on the chest radiograph from empyema and other cavitary lesions.<ref name="pmid6602513">{{cite journal |vauthors=Stark DD, Federle MP, Goodman PC, Podrasky AE, Webb WR |title=Differentiating lung abscess and empyema: radiography and computed tomography |journal=AJR Am J Roentgenol |volume=141 |issue=1 |pages=163–7 |year=1983 |pmid=6602513 |doi=10.2214/ajr.141.1.163 |url=}}</ref>
*On CT scan lung abscess is visualized as a rounded radiolucent lesion with a thick wall and ill-defined irregular margins, and is located within the parenchyma compared with loculated empyema, which may be difficult to distinguish on chest radiographs. <ref name="Mayer1982">{{cite journal|last1=Mayer|first1=Thom|title=Computed Tomographic Findings of Neonatal Lung Abscess|journal=Archives of Pediatrics & Adolescent Medicine|volume=136|issue=1|year=1982|pages=39|issn=1072-4710|doi=10.1001/archpedi.1982.03970370041010}}</ref>
*Computed tomography (CT) lung is considered as the gold standard not only for the diagnosis of lung abscess but also for guiding therapeutic procedures such as trans-thoracic drainage of localized lung abscess .<ref name="BouhemadZhang2007">{{cite journal|last1=Bouhemad|first1=Bélaïd|last2=Zhang|first2=Mao|last3=Lu|first3=Qin|last4=Rouby|first4=Jean-Jacques|journal=Critical Care|volume=11|issue=1|year=2007|pages=205|issn=13648535|doi=10.1186/cc5668}}</ref>
*CT scan is very helpful in excluding endobronchial obstruction due to malignancy or foreign body and provides additional information about size and location of the abscess,
 
===Ultrasound===
*Ultrasound has a minimal role in diagnosing lung abscess .
*Lung abscess appears as a rounded hypoechoic lesion with an outer margin on ultrsound.
*Lung abscesses which are peripheral and with pleural contact or included inside a lung consolidation are detectable using bedside lung ultrasonography.
 
===Other diagnostic tests===
'''Echocardiogram'''
*It is done to rule out lung abscess suspected secondary to septic embolism from right-sided (e.g., tricuspid valve) bacterial endocarditis.
*It reveals vegetations on the affected valve.
'''Rapid ELISA for D-dimer and V/Q scan'''
*It is done in patients when lung abscess is secondary to infection of an infarct-related pulmonary embolus.
*D-dimer is elevated in pulmonary embolism, care must be taken to consider other conditions associated with elevated d dimer.
*V/Q mismatch is seen in seen in patients with PE
'
 
==Medical treatment==
*The mainstay of management for lung abscess is : hospital admission for chest drain and systemic antibiotics
*Empiric treatment should be commenced after culture samples are obtained.
*The choice of empiric antibiotics should be determined on the basis of the possible risk of multi-drug resistant causative bacteria, and culture results.
 
{| class="wikitable"
! colspan="2" rowspan="2" |Pathogens
!Age group specific therapy
|-
!Adult
|-
| rowspan="2" |Empiric
|Anaerobes and microaerophilic streptococci
|
*Ampicillin +sulbactum  3g IV q6h <ref name="pmid8296141">{{cite journal |vauthors=Germaud P, Poirier J, Jacqueme P, Guerin JC, Benard Y, Boutin C, Brambilla C, Escamilla R, Zuck P |title=[Monotherapy using amoxicillin/clavulanic acid as treatment of first choice in community-acquired lung abscess. Apropos of 57 cases] |language=French |journal=Rev Pneumol Clin |volume=49 |issue=3 |pages=137–41 |year=1993 |pmid=8296141 |doi= |url=}}</ref> <ref name="pmid12649717">{{cite journal |vauthors=Fernández-Sabé N, Carratalà J, Dorca J, Rosón B, Tubau F, Manresa F, Gudiol F |title=Efficacy and safety of sequential amoxicillin-clavulanate in the treatment of anaerobic lung infections |journal=Eur. J. Clin. Microbiol. Infect. Dis. |volume=22 |issue=3 |pages=185–7 |year=2003 |pmid=12649717 |doi=10.1007/s10096-003-0898-2 |url=}}</ref>
      (or)
*Imipenem+cilastin  500 mg IV q6h
      (or)
*Meropenem    1-2 g IV q8h
|-
|2nd alternnative
|Clindamycin  IV 600 mg q8h<ref name="pmid14759242">{{cite journal |vauthors=Allewelt M, Schüler P, Bölcskei PL, Mauch H, Lode H |title=Ampicillin + sulbactam vs clindamycin +/- cephalosporin for the treatment of aspiration pneumonia and primary lung abscess |journal=Clin. Microbiol. Infect. |volume=10 |issue=2 |pages=163–70 |year=2004 |pmid=14759242 |doi= |url=}}</ref><ref name="pmid6838068">{{cite journal |vauthors=Levison ME, Mangura CT, Lorber B, Abrutyn E, Pesanti EL, Levy RS, MacGregor RR, Schwartz AR |title=Clindamycin compared with penicillin for the treatment of anaerobic lung abscess |journal=Ann. Intern. Med. |volume=98 |issue=4 |pages=466–71 |year=1983 |pmid=6838068 |doi= |url=}}</ref>
150 to 300 mg orally four times daily
|-
| rowspan="6" |Pathogen directed
|[[MSSA]]
|[[Nafcillin]] 2 g IV q4h <u>'''OR'''</u> [[Oxacillin]] 2 g IV q4h '''<u>OR</u>''' [[Cefazolin]] 2 g IV q8h
|-
|[[MRSA]]
|
*[[Linezolid]] 600 mg q12h IV/PO ± [[Rifampin]] 300 mg po/IV bid<ref name="WunderinkNiederman2012">{{cite journal|last1=Wunderink|first1=R. G.|last2=Niederman|first2=M. S.|last3=Kollef|first3=M. H.|last4=Shorr|first4=A. F.|last5=Kunkel|first5=M. J.|last6=Baruch|first6=A.|last7=McGee|first7=W. T.|last8=Reisman|first8=A.|last9=Chastre|first9=J.|title=Linezolid in Methicillin-Resistant Staphylococcus aureus Nosocomial Pneumonia: A Randomized, Controlled Study|journal=Clinical Infectious Diseases|volume=54|issue=5|year=2012|pages=621–629|issn=1058-4838|doi=10.1093/cid/cir895}}</ref>
*vancomycin (15 mg/kg x2 i.v., with dose adapted according to optimal serum levels (15-20 mcg/ml)
|-
|Actinomyces
|Intravenous penicillin G (10 to 20 million units daily in divided doses every four to six hours) for 4 to 6 weeks, 
|-
|Nocardia .spp
|TMP-SMX 15 mg/kg IV of the trimethoprim component per day in three or four divided doses 
'''PLUS'''
 
Amikacin 7.5 mg/kg IV every 12 hours 
|-
|Fungi
|Amphotericin B  3-5mg/kg/day/IV
|-
|Parasite
|Albendazole is dosed 10 to 15 mg/kg per day in two divided doses; the usual dose for adults is 400 mg twice daily.
one to three months may be appropriate, depending clinical factors; up to six months may be required.
|}
 
*Monotherapy with metronidazole should be avoided due to inadequate coverage for aerobic and microaerophilic Streptococci, such as Streptococcus milleri.<ref name="pmid7025777">{{cite journal |vauthors=Perlino CA |title=Metronidazole vs clindamycin treatment of anerobic pulmonary infection. Failure of metronidazole therapy |journal=Arch. Intern. Med. |volume=141 |issue=11 |pages=1424–7 |year=1981 |pmid=7025777 |doi= |url=}}</ref>
 
*Clinical improvement is reflected in the subsidence of fever (within the first 3-4 days) and complete defervescence within 7-10 days.Persistent fever can be explained by treatment failure due to uncommon pathogens (multidrug resistant common bacteria, mycobacteria, fungi)or by the presence of an alternative diagnosis (e.g. endobronchial obstruction, vasculitis) that requires further diagnostic workup (e.g. bronchoscopy, transdermal or surgical lung biopsy).<ref name="pmid20389050">{{cite journal |vauthors=Takayanagi N, Kagiyama N, Ishiguro T, Tokunaga D, Sugita Y |title=Etiology and outcome of community-acquired lung abscess |journal=Respiration |volume=80 |issue=2 |pages=98–105 |year=2010 |pmid=20389050 |doi=10.1159/000312404 |url=}}</ref>
*The duration of treatment with antibiotics is not well defined, according to many experts, the optimal duration of antimicrobial therapy is 3-6 weeks, whereas others take the timing of radiological response into consideration. <ref name="pmid20389050">{{cite journal |vauthors=Takayanagi N, Kagiyama N, Ishiguro T, Tokunaga D, Sugita Y |title=Etiology and outcome of community-acquired lung abscess |journal=Respiration |volume=80 |issue=2 |pages=98–105 |year=2010 |pmid=20389050 |doi=10.1159/000312404 |url=}}</ref>
*In that case, the length of antibiotic treatment depends on complete radiological resolution or stabilization to a small residual lesion.
*Treatment interval may then be prolonged to several months (more than 2),6 especially when the initial lesion is of large size (maximum diameter more than 6cm).
 
 
 
==Surgical Therapy==
 
====Indications====
*Abscess > 6 cm in diameter
*If symptoms last more than 12 weeks with appropriate therapy
 
====Surgical Options====
*Options for surgery includes: Chest tube drainage and surgical resection of the lung abscess with the surrounding lung tissue
 
===Chest tube drainage===
*Percutaneous and endoscopic drainage techniques are considered as a first-line management, especially for patients who are not candidates for surgery <ref name="KelogrigorisTsagouli2011">{{cite journal|last1=Kelogrigoris|first1=M|last2=Tsagouli|first2=P|last3=Stathopoulos|first3=K|last4=Tsagaridou|first4=I|last5=Thanos|first5=L|title=Ct-guided percutaneous drainage of lung abscesses: review of 40 cases|journal=Journal of the Belgian Society of Radiology|volume=94|issue=4|year=2011|pages=191|issn=1780-2393|doi=10.5334/jbr-btr.583}}</ref>
*ACR-SIR-SPR practice guideline for specifications and performance of image-guided percutaneous drainage/aspiration of abscesses and fluid collections (PDAFC) had submiited guidelines on image-guided percutaneous drainage/aspiration of abscesses and fluid collections.
====Percutaneous drainage====
{| class="wikitable"
!Type of chest drain
!Indications
!Procedure
!Complications
!Advantages
|-
|Percutaneous thoracocentesis
|
*It is the treatment of choice for patients who have failed to respond to antibiotic therapy .<ref name="pmid1987590">{{cite journal |vauthors=vanSonnenberg E, D'Agostino HB, Casola G, Wittich GR, Varney RR, Harker C |title=Lung abscess: CT-guided drainage |journal=Radiology |volume=178 |issue=2 |pages=347–51 |year=1991 |pmid=1987590 |doi=10.1148/radiology.178.2.1987590 |url=}}</ref>
 
*Patients who are unsuitable for surgical intervention (e.g. due to severe immunodeficiency or mechanical ventilation).
 
*Lung abscesses with diameters greater than 4-8 cm
|
*Performed under fluoroscopic, ultrasound or computed tomography guidance.(CT is generally preferred due to additional information provided about location, content and wall-thickness of the abscess.)
*Two techniques of insertion of chest tube employed: Seldinger, and Trochar
 
*Seldinger technique of insertion the tube is considered as it is  safer and it permits greater control in the positioning of the drainage tube and  is accompanied by fewer complications<ref name="pmid10765396">{{cite journal |vauthors=Erasmus JJ, McAdams HP, Rossi S, Kelley MJ |title=Percutaneous management of intrapulmonary air and fluid collections |journal=Radiol. Clin. North Am. |volume=38 |issue=2 |pages=385–93 |year=2000 |pmid=10765396 |doi= |url=}}</ref>
 
*Chest tube drainage with trocar is highly effective surgical procedure and is recommended for thoracic surgeries
* Drainage duration varies but a minimum of 4-5 weeks are required and is done according to radiographic findings.Chest tubes should    not be flushed in order to avoid bronchogenic spread of the pus.<ref name="KelogrigorisTsagouli2011">{{cite journal|last1=Kelogrigoris|first1=M|last2=Tsagouli|first2=P|last3=Stathopoulos|first3=K|last4=Tsagaridou|first4=I|last5=Thanos|first5=L|title=Ct-guided percutaneous drainage of lung abscesses: review of 40 cases|journal=Journal of the Belgian Society of Radiology|volume=94|issue=4|year=2011|pages=191|issn=1780-2393|doi=10.5334/jbr-btr.583}}</ref>
* The usage of intra-cavitary fibrinolytic agents (streptokinase, urokinaze) is not recommended, due to possibility of    bronchopulmonary or bronchopleural fistula can occur.<ref name="pmid18513667">{{cite journal |vauthors=Hogan MJ, Coley BD |title=Interventional radiology treatment of empyema and lung abscesses |journal=Paediatr Respir Rev |volume=9 |issue=2 |pages=77–84; quiz 84 |year=2008 |pmid=18513667 |doi=10.1016/j.prrv.2007.12.001 |url=}}</ref>
|      
*Technique related includes :advancing of the guidewire through the thicked-wall abscess may cause bending or rupture of the guidewire or the catheter.<ref name="pmid3047789">{{cite journal |vauthors=Silverman SG, Mueller PR, Saini S, Hahn PF, Simeone JF, Forman BH, Steiner E, Ferrucci JT |title=Thoracic empyema: management with image-guided catheter drainage |journal=Radiology |volume=169 |issue=1 |pages=5–9 |year=1988 |pmid=3047789 |doi=10.1148/radiology.169.1.3047789 |url=}}</ref>
 
*Hemothorax, hemoptysis, pyopneumothorax and fistula formation between the pleural cavity and the abscess resulting in empyema.
 
*Less significant complications are those related to bending or leaking of the drainage catheter.
| rowspan="2" |
*These techniques demonstrated benefits even in patients without contraindications to surgery. More specifically, cases of primary lung abscess that were treated by Yellin A et al during a 5-year period (1978-1982) underwent successful percutaneous drainage, without any complications or relapse after 2-5 years of monitoring.<ref name="pmid39774692">{{cite journal |vauthors=Yellin A, Yellin EO, Lieberman Y |title=Percutaneous tube drainage: the treatment of choice for refractory lung abscess |journal=Ann. Thorac. Surg. |volume=39 |issue=3 |pages=266–70 |year=1985 |pmid=3977469 |doi= |url=}}</ref>
*Percutaneous drainage of lung abscesses is characterized by high therapeutic effectiveness and preservation of functional lung tissue, it is a minimally invasive method with fewer complications and lower mortality rates (approximately 4%) in comparison to surgical management.<ref name="pmid123743592">{{cite journal |vauthors=Wali SO, Shugaeri A, Samman YS, Abdelaziz M |title=Percutaneous drainage of pyogenic lung abscess |journal=Scand. J. Infect. Dis. |volume=34 |issue=9 |pages=673–9 |year=2002 |pmid=12374359 |doi= |url=}}</ref>
*In case of pleural space obliteration, with peripheral localization of lung abscess, it is possible to perform pneumostomy or cavernostomy-open drainage of abscess(Monaldi procedure) but it is limited due to it invasiveness.
|-
|Endoscopic thoracic drainage
|
*Pateints with poor general condition,
*Coagulopathies
*For the abscesses with central locations in lungs.
|
*A guidewire is inserted into the cavity through the working channel of a flexible bronchoscope.Once guidewire location has been ascertained by fluoroscopy, a 7 French pigtail catheter is advanced.
*If infusion of contrast medium via the catheter confirms its proper positioning, the guidewire and bronchoscope are withdrawn and the catheter tip is stabilized at the nasal wall.
 
*Subsequently, the cavity is flushed daily with normal saline solution through the catheter, along with antibiotic infusions (e.g. gentamicin or amphotericin in confirmed fungal infections).<ref name="pmid15821219">{{cite journal |vauthors=Herth F, Ernst A, Becker HD |title=Endoscopic drainage of lung abscesses: technique and outcome |journal=Chest |volume=127 |issue=4 |pages=1378–81 |year=2005 |pmid=15821219 |doi=10.1378/chest.127.4.1378 |url=}}</ref>
*The catheter remains open for the rest of the day, thus ensuring the drainage of the abscess.
*In a small number of patients with recurrent lung abscesses, endoscopic drainage was performed with the help of laser.<ref name="pmid19883156">{{cite journal |vauthors=Shlomi D, Kramer MR, Fuks L, Peled N, Shitrit D |title=Endobronchial drainage of lung abscess: the use of laser |journal=Scand. J. Infect. Dis. |volume=42 |issue=1 |pages=65–8 |year=2010 |pmid=19883156 |doi=10.3109/00365540903292690 |url=}}</ref>
*The catheter is inserted through a bronchoscope and laser is used in order to perforate the wall of the abscess through the airway and to lead the catheter inside the cavity. The catheter is removed after 4-6 days with immediate improvement of clinical status and radiological imaging within the first 24 hours
|
*Spillage of necrotic detritus in other parts of the lungs
|}
 
===Surgical Intervention ===
*Surgerical resection is considered in about 10% of the patients when the chest drain has failed to improve symptoms.
 
==== Indications ====
* Hemoptysis,
*Prolonged sepsis and febricity,<ref name="pmid22115254">{{cite journal |vauthors=Schweigert M, Dubecz A, Stadlhuber RJ, Stein HJ |title=Modern history of surgical management of lung abscess: from Harold Neuhof to current concepts |journal=Ann. Thorac. Surg. |volume=92 |issue=6 |pages=2293–7 |year=2011 |pmid=22115254 |doi=10.1016/j.athoracsur.2011.09.035 |url=}}</ref>
*Bronchopleural fistula,
*Rupture of abscess in the pleural cavity with pyopneumothorax/empyema.
*Unsuccessfully treated lung abscess more than 6 weeks,
*Suspicion of cancer,
*Cavitary lesion larger than 6 cm,
*Leukocytosis despite the use of antibiotics.
 
===Surgical resection===
*The surgical approach is thoracotomy and the extent of surgical resection depends on the size of the underlying lesion. <ref name="pmid22115254">{{cite journal |vauthors=Schweigert M, Dubecz A, Stadlhuber RJ, Stein HJ |title=Modern history of surgical management of lung abscess: from Harold Neuhof to current concepts |journal=Ann. Thorac. Surg. |volume=92 |issue=6 |pages=2293–7 |year=2011 |pmid=22115254 |doi=10.1016/j.athoracsur.2011.09.035 |url=}}</ref>
*Lobectomy is the most common type of surgical resection. Segmentectomies are performed in smaller abscesses (<2 cm), whereas a pneumonectomy should be performed in the presence of multiple abscesses or gangrene. <ref name="pmid9354511">{{cite journal |vauthors=Refaely Y, Weissberg D |title=Gangrene of the lung: treatment in two stages |journal=Ann. Thorac. Surg. |volume=64 |issue=4 |pages=970–3; discussion 973–4 |year=1997 |pmid=9354511 |doi= |url=}}</ref>,<ref name="pmid19101324">{{cite journal |vauthors=Chen CH, Huang WC, Chen TY, Hung TT, Liu HC, Chen CH |title=Massive necrotizing pneumonia with pulmonary gangrene |journal=Ann. Thorac. Surg. |volume=87 |issue=1 |pages=310–1 |year=2009 |pmid=19101324 |doi=10.1016/j.athoracsur.2008.05.077 |url=}}</ref>
*Open surgical drainage is employed either by creating a pouch-like cavity communicating with the thoracic wall through limited rib resection in case of thoracotomy contraindication.
*When sepsis cannot be controlled with conservative measures and in conditions that prohibit resection, debridement of the dead tissue is followed by immediate filling of the cavity with highly vascular tissue, or debridement and cavity fistulization into the pleural space followed by drainage by means of a chest tube is proposed.
*When the chronic inflammatory process of pulmonary infection causes incomplete re-expansion of the remaining lobes, it is quite possible that a portion of the pleural space will remain empty. Some thoracic surgeons recommend filling that space with a large pedicled ipsilateral latissimus dorsi muscle flap or omentum.
*In addition, bronchial stump reinforcement with a pedicled intercostal muscle flap or other highly vascular tissue may prevent the formation of a bronchopleural fistula.
*Cross-contamination of contralateral lung is the main complication to be feared of during surgery. Placement of a double-lumen endotracheal tube, prone positioning of the patient and artificial obstruction of the main bronchus before removing the abscess are the usual measures for preventing cross-contamination.
*Recently, a thoracoscopic technique (Video assisted thoracoscopic surgery: VATS) for abscess debridement and drainage has been effectively implemented in a small number of patients.53
 
==Differential diagnosis==
 
{| class="wikitable"
!Causes of
lung cavities
!Differntiating Features
!Differntiating lab findings
!Diagnosis
confirmation
|-
|
*Malignancy (Primary lung cancer)<ref name="pmid4353362">{{cite journal |vauthors=Chaudhuri MR |title=Primary pulmonary cavitating carcinomas |journal=Thorax |volume=28 |issue=3 |pages=354–66 |year=1973 |pmid=4353362 |pmc=470041 |doi= |url=}}</ref>
|
*Elderly male or female <ref name="pmid4353362">{{cite journal |vauthors=Chaudhuri MR |title=Primary pulmonary cavitating carcinomas |journal=Thorax |volume=28 |issue=3 |pages=354–66 |year=1973 |pmid=4353362 |pmc=470041 |doi= |url=}}</ref>
*Associated with a low-grade fever, absence of leukocytosis, minimal systemic complaints,
*Absence of factors that predispose to gastric content aspiration, no response to antibiotics within 10 days,
*Follows a deteriorating course. 
*Hemoptysis is commonly associated with bronchogenic carcinoma
*Weight loss,fatigue,
|
*A coin-shaped lesion with thick wall(>15mm) is seen on X-ray with less ground glass opacities.<ref name="pmid8572761">{{cite journal |vauthors=Mouroux J, Padovani B, Elkaïm D, Richelme H |title=Should cavitated bronchopulmonary cancers be considered a separate entity? |journal=Ann. Thorac. Surg. |volume=61 |issue=2 |pages=530–2 |year=1996 |pmid=8572761 |doi=10.1016/0003-4975(95)00973-6 |url=}}</ref> <ref name="pmid16183941">{{cite journal |vauthors=Onn A, Choe DH, Herbst RS, Correa AM, Munden RF, Truong MT, Vaporciyan AA, Isobe T, Gilcrease MZ, Marom EM |title=Tumor cavitation in stage I non-small cell lung cancer: epidermal growth factor receptor expression and prediction of poor outcome |journal=Radiology |volume=237 |issue=1 |pages=342–7 |year=2005 |pmid=16183941 |doi=10.1148/radiol.2371041650 |url=}}</ref>
*Sputum cytology shows malignant cells
|
*CT and bronchoscope identifies the lesions
*Biopsy confirms it
|-
|
*Tuberculsosis
|
*Systemic symptoms of fatigue, malaise, anorexia, and weight loss, as well as a low-grade fever with night sweats
|
*Xray shows cavities in the upper lobe of the lung
*On CT cavitating lesions are seen in the upper lobes accompanied by parenchymal infiltrates .
|
*Sputum smear and culture in Lowenstein-Jensen media is  positive for acid-fast bacilli.
|-
|
*Necrotizing Pneumonia
|
*Acute, fulminant infection with rapid progression
|
*Multiple cavities are seen on xray
*Pleural effusion and empyema are common findings.
|
*Causative organisms include Streptococcus pneumoniae,Staphylococcus aureus, Klebsiella pneumoniae, and Pseudomonas species.
|-
|
*Loculated empyema
|
*dullness to percussion, decreased breath sounds, and reduced vocal resonance on examination
|
*Empyema appears lenticular in shape, and has a thin wall with smooth luminal margins and a smooth exterior wall.
|
*Thoracocentesis
|-
|
*Granulomatosis with polyangiitis (Wegener's)<ref name="pmid10377211">{{cite journal |vauthors=Langford CA, Hoffman GS |title=Rare diseases.3: Wegener's granulomatosis |journal=Thorax |volume=54 |issue=7 |pages=629–37 |year=1999 |pmid=10377211 |pmc=1745525 |doi= |url=}}</ref>
|
*Upper respiratory tract: perforation of nasal septum,chronic sinusitis, otitis media,mastoditis.<ref name="pmid12541109">{{cite journal |vauthors=Lee KS, Kim TS, Fujimoto K, Moriya H, Watanabe H, Tateishi U, Ashizawa K, Johkoh T, Kim EA, Kwon OJ |title=Thoracic manifestation of Wegener's granulomatosis: CT findings in 30 patients |journal=Eur Radiol |volume=13 |issue=1 |pages=43–51 |year=2003 |pmid=12541109 |doi=10.1007/s00330-002-1422-2 |url=}}</ref>
*Lower respiratory tract: hemoptysis, cough,dyspnea.
*Renal: hematuria, red cell casts
|
*Pulmunory nodules with cavities and infiltrates are a frequent manifestation on CXR.
 
|
*Positive for P-ANCA
*Biopsy of the tissue involved shows necrotizing granulomas <ref name="pmid10377211">{{cite journal |vauthors=Langford CA, Hoffman GS |title=Rare diseases.3: Wegener's granulomatosis |journal=Thorax |volume=54 |issue=7 |pages=629–37 |year=1999 |pmid=10377211 |pmc=1745525 |doi= |url=}}</ref>
|-
|
*Rheumatoid nodule
|
*Symmetric arthritis of the small joints of the hands and feet with morning stiffness are common manifestations.
|
*Pulmonary nodules with cavitation are located in the upper lobe (Caplan syndrome) on Xray.
*Positive for both rheumatoid factor and anticyclic citrullinated peptide antibody
|
|-
|
*Sarcoidosis
|
*More common in African-American females.
*Often asymptomatic except for enlarged lymph nodes.<ref name="pmid11734441">{{cite journal |vauthors=Baughman RP, Teirstein AS, Judson MA, Rossman MD, Yeager H, Bresnitz EA, DePalo L, Hunninghake G, Iannuzzi MC, Johns CJ, McLennan G, Moller DR, Newman LS, Rabin DL, Rose C, Rybicki B, Weinberger SE, Terrin ML, Knatterud GL, Cherniak R |title=Clinical characteristics of patients in a case control study of sarcoidosis |journal=Am. J. Respir. Crit. Care Med. |volume=164 |issue=10 Pt 1 |pages=1885–9 |year=2001 |pmid=11734441 |doi=10.1164/ajrccm.164.10.2104046 |url=}}</ref>
*Associated with restrictive lung disease (interstitial fibrosis),
*Erythema nodosum,
*Lupus pernio (skin lesions on face resembling lupus),
*Bell palsy,
*Epithelioid granulomas containing microscopic Schaumann and asteroid bodies,
*Uveitis,
*Hypercalcemia
|
*On chest Xray bilateral adenopathy and coarse reticular opacities are seen.
*CT of the chest demonstrates extensive hilar and mediastinal adenopathy
*Additional findings on CT include fibrosis (honeycomb, linear, or associated with bronchial distortion), pleural thickening, and ground-glass opacities.<ref name="pmid2748828">{{cite journal |vauthors=Brauner MW, Grenier P, Mompoint D, Lenoir S, de Crémoux H |title=Pulmonary sarcoidosis: evaluation with high-resolution CT |journal=Radiology |volume=172 |issue=2 |pages=467–71 |year=1989 |pmid=2748828 |doi=10.1148/radiology.172.2.2748828 |url=}}</ref>
|
*Non-caseating granuloma on lung biopsy
|-
|
*Bronchiolitis obliterans (Cryptogenic organizing pneumonia)<ref name="pmid9724431">{{cite journal |vauthors=Murphy J, Schnyder P, Herold C, Flower C |title=Bronchiolitis obliterans organising pneumonia simulating bronchial carcinoma |journal=Eur Radiol |volume=8 |issue=7 |pages=1165–9 |year=1998 |pmid=9724431 |doi=10.1007/s003300050527 |url=}}</ref><ref name="pmid19561910">{{cite journal |vauthors=Al-Ghanem S, Al-Jahdali H, Bamefleh H, Khan AN |title=Bronchiolitis obliterans organizing pneumonia: pathogenesis, clinical features, imaging and therapy review |journal=Ann Thorac Med |volume=3 |issue=2 |pages=67–75 |year=2008 |pmid=19561910 |pmc=2700454 |doi=10.4103/1817-1737.39641 |url=}}</ref>
|
*It is a pathological diagnosis
*And is triggered by drug or toxin exposure, autoimmune diseases,viral infections, or radiation injury but is most often idiopathic
*Presents with fever, cough, weight loss, and dyspnea over weeks to months, similar to many infectious diseases<ref name="pmid2805873">{{cite journal |vauthors=Cordier JF, Loire R, Brune J |title=Idiopathic bronchiolitis obliterans organizing pneumonia. Definition of characteristic clinical profiles in a series of 16 patients |journal=Chest |volume=96 |issue=5 |pages=999–1004 |year=1989 |pmid=2805873 |doi= |url=}}</ref>
|
*Common appearance on CT is patchy consolidation,often accompanied by ground-glass opacities and nodules.<ref name="pmid8109493">{{cite journal |vauthors=Lee KS, Kullnig P, Hartman TE, Müller NL |title=Cryptogenic organizing pneumonia: CT findings in 43 patients |journal=AJR Am J Roentgenol |volume=162 |issue=3 |pages=543–6 |year=1994 |pmid=8109493 |doi=10.2214/ajr.162.3.8109493 |url=}}</ref>
|
*Lung biopsy<ref name="pmid19561910">{{cite journal |vauthors=Al-Ghanem S, Al-Jahdali H, Bamefleh H, Khan AN |title=Bronchiolitis obliterans organizing pneumonia: pathogenesis, clinical features, imaging and therapy review |journal=Ann Thorac Med |volume=3 |issue=2 |pages=67–75 |year=2008 |pmid=19561910 |pmc=2700454 |doi=10.4103/1817-1737.39641 |url=}}</ref>
|-
|
*Langerhan'scell histiocytosis<ref name="pmid22429393">{{cite journal |vauthors=Suri HS, Yi ES, Nowakowski GS, Vassallo R |title=Pulmonary langerhans cell histiocytosis |journal=Orphanet J Rare Dis |volume=7 |issue= |pages=16 |year=2012 |pmid=22429393 |pmc=3342091 |doi=10.1186/1750-1172-7-16 |url=}}</ref>
|
*Exclusively afflicts smokers, with a peak age of onset of between 20 and 40 years.
*Clinical presentation varies, but symptoms generally include months of drycough, fever, night sweats, and weight loss.
|
*Thin-walled cystic cavities are the usual radiographic manifestation, observed in over 50% of patients by either plain chest radiography or computed tomography scans.<ref name="pmid2787035">{{cite journal |vauthors=Moore AD, Godwin JD, Müller NL, Naidich DP, Hammar SP, Buschman DL, Takasugi JE, de Carvalho CR |title=Pulmonary histiocytosis X: comparison of radiographic and CT findings |journal=Radiology |volume=172 |issue=1 |pages=249–54 |year=1989 |pmid=2787035 |doi=10.1148/radiology.172.1.2787035 |url=}}</ref>
|
*Biopsy of the lung
|}
{| class="wikitable"
!Infectious agent
!Patient characteristics, comorbidities,
and/or risk factorsa
!Epidemiology
!Radiological findings
|-
|
'''Bacteria'''
*Actinomyces spp.<ref name="pmid19181645">{{cite journal |vauthors=Andreani A, Cavazza A, Marchioni A, Richeldi L, Paci M, Rossi G |title=Bronchopulmonary actinomycosis associated with hiatal hernia |journal=Mayo Clin. Proc. |volume=84 |issue=2 |pages=123–8 |year=2009 |pmid=19181645 |pmc=2664582 |doi=10.1016/S0025-6196(11)60819-7 |url=}}</ref>
|
*Male predominance,
*Poor oral hygiene
*Alcohloics
|
*Normal inhabitant of oral cavity,
*Gastrointesinal tract, and female reproductive tract
*Commonly involves infection of neck,thoracic region and abdomen pelvis.<ref name="pmid16582679">{{cite journal |vauthors=Yildiz O, Doganay M |title=Actinomycoses and Nocardia pulmonary infections |journal=Curr Opin Pulm Med |volume=12 |issue=3 |pages=228–34 |year=2006 |pmid=16582679 |doi=10.1097/01.mcp.0000219273.57933.48 |url=}}</ref>
*Infection of lungs is commonly resulted from the aspiration of actinomyces load from neck infection
|
*Pleural mass with wavy perisoteal reaction involving ribs is seen at the site of involvement on Xray
*Cavitary lesions are only appreciated on CT scan .<ref name="pmid6981958">{{cite journal |vauthors=Webb WR, Sagel SS |title=Actinomycosis involving the chest wall: CT findings |journal=AJR Am J Roentgenol |volume=139 |issue=5 |pages=1007–9 |year=1982 |pmid=6981958 |doi=10.2214/ajr.139.5.1007 |url=}}</ref>
|-
|
*Klebsiella spp.
|
*Alcoholism, corticosteroid use,
*Hematologic malignancy,
*Male predominance
|
*Nosocomial and community acquisition
|
*Bulging interlobar fissures, unilateral/bilateral infiltrates, abscess, cavitation
|-
|
*Nocardia spp.
|
*Chronic obstructive pulmonary disease,
*Corticosteroid use,
*HIV/AIDS (rare),
*Malignancy,posttransplant
|
*Soil organism
|
*Lobar consolidation, nodular infiltrate, solitary mass, cavitation
|-
|
*Staphylococcus aureus
|
*Debilitated hospitalized patients,
*Immunocompetent patients with extrapulmonary staphylococcal infection (e.g., skin infection with community-acquired MRSA)
|
*Community acquired or nosocomial
|
*Consolidation, pneumatocele, cavity
|-
|
*Mycobacterium tuberculosis
|
*Birth or prolonged residence in area of endemicity (developing world),
*Diabetes mellitus,
*Head and neck cancer,
*Hematologic malignancy,
*HIV/AIDS,
*Immunosuppressive therapy,tumor necrosis factor alpha antagonist use
|
*Spread from person to person through inhalation of droplet nuclei;
*More prevalent in developing countries
|
*Upper lobe infiltrates, cavity,miliary pattern, tuberculoma, hilar lymphadenopathy
|-
|
'''Fungus'''
*Aspergillus spp.
 
|
*Hematologic malignancy,
*HIV/AIDS, immunosuppressive therapy, malnutrition,
*Neutropenia posttransplant,
*Underlying pulmonary disease (asthma, cystic fibrosis)
*For invasive aspergillosis; alcoholism, chronic obstructive pulmonary disease, collagen vascular disease, diabetes mellitus, low-dose corticosteroid use, malnutrition, pnemoconiosis for semi-invasive; and prior tuberculosis or other cavity causing disease for aspergilloma
|
*Saprophytic fungi that grow on organic debris;
*Potential environmental exposure for hospitalized high-risk patients
|
*Invasive aspergillosis: macronodules, consolidation,halo sign, air-crescent sign,cavitation.
*Semi-invasive aspergillosis: progressive or chronic infiltrate, cavity with or without air-crescent sign,
*Aspergilloma:fungus ball in preexisting cavity
|-
|
*Blastomyces dermatitides
|
*black race, diabetes mellitus,
*Male gender, outdoor activity,
*Prior history of pneumonia
|
*Endemic to Mississippi and Ohio River valleys, Great Lakes, and St. Lawrence River region;
*Also found in parts of Mexico, Central and South America, Africa, and the Middle East
|
*Acute: Patchy alveolar opacities nodular densities;
*Chronic: Fibronodular upper lobe disease,smooth-walled cavities, solitary mass lesion, volume loss, calcification, fibrosis, miliary pattern
|-
|
*Coccidioides immitis
|
*Corticosteroid use,
*Diabetes mellitus,
*HIV/AIDS, malignancy,
*Black or Filipino race/ethnicity,
*Organ transplant
|
*Endemic to the southwestern United States and Mexico;
*Also be associated with occupational exposure (construction, archeological excavation) or extreme weather conditions in an area(i.e., duststorm)
|
*Acute: patchy opacities, multilobar consolidation, thick-walled cavities, pleural effusion, hilar lymphadenopathy;
*Chronic: thinwalled cavities, pleural effusion, pneumothorax, single or multiple nodules
|-
|
*Cryptococcus spp.
|
*Corticosteroid use,
*Diabetes mellitus,
*HIV/AIDS,hematologic malignancy,
*Organ transplant,
*Sarcoidosis
|
*Isolated from soil contaminated by pigeon and chicken excreta
|
*solitary or multiple nodules, alveolar consolidation,interstitial pattern, cavitation,lymphadenopathy, pleural effusion
|-
|
*Histoplasma capsulatum
|
*Heavy equipment operators,
*Poultry breeders
*Chronic obstructive pulmonary disease,
*Middle-aged men
 
|
*Endemic to the Ohio and Mississippi River valleys,Virginia, and Maryland;
*Grows well in soil that has been enriched by bird excreta
|
*Acute: scattered patchy or diffuse interstitial opacities, solitary pulmonary nodule, miliary pattern, hilar or mediastinal lymphadenopathy;
*Chronic:cavitation
|-
|
*Pneumocystis jirovecii
|
*Autoimmune disorders,
*Corticosteroid use,
*Hematologic malignancy,
*HIV/AIDS,
*Posttransplantation
|
*Ubiquitous fungi
|
*Bilateral alveolar/interstitial infiltrates, solitary or multiple nodules, pneumothorax, cavity,
|-
|
'''Parasites'''
*Echinococcus granulosus
|
|
*Endemic to Mediterranean region, Middle East, Africa, Latin America, southwest United States, southern Europe,
*Largely in livestockrearing areas; dogs are the definitive host
|
*Spherical homogenous masses with smooth borders surrounded by normal lung tissue, bullae,calcifications, cavity
|-
|
*Paragonimus westermani
|
|
*Zoonosis that is endemic to Japan, the Korean peninsula, the Philippines, and parts of China;
*May be acquired through eating freshwater crabs and raw boar meat
|
*Nodules, mediastinal lymphadenopathy, pleural effusion
|}
 
===Primary prevention===
Effective measures for the primary prevention of lung abscess include:
*Prevention of aspiration in high-risk individuals by providing proper attention towards airway protection, minimal sedation, and proper positioning of patients with elevation of the head in hospitalized patients.
*Prophylactic antibiotics against certain pathogens in at-risk patients e.g.recipients of bone marrow or solid organ transplants or patients whose immune systems are significantly compromised by HIV infection must be given.
*Improving oral hygiene and proper dental care in elderly and debilitated patients also helps in decreasing the risk of anaerobic lung abscess.
* Patients with esophageal disorders, such as scleroderma or a diverticulum, as well as those who have undergone esophageal or gastric surgery predisposing to regurgitation, should be instructed in how to minimize the risk of gastric content aspiration by proper sleep position and by avoiding overfilling the stomach before sleeping.
==Differential==
{| class="wikitable"
! rowspan="3" |Disease
! colspan="9" |Clinical features
Signs & symptoms
! rowspan="3" |Radiological Findings
! rowspan="3" |Characterstic feature
|-
| colspan="2" |Fever
| colspan="2" |Cough
| rowspan="2" |Hemoptysis
| rowspan="2" |Dyspnea
| rowspan="2" |Chest pain
| rowspan="2" |Weight loss
| rowspan="2" |Night sweats
|-
|High-grade
|Low grade
|Productive
|Dry   
|-
|Acute Lung abscess
|✔
|
|✔
|
|
|
|✔
|
|
|
* Air fluid level
|
* Purulent sputum
* H/o of prior infection or hospitalization
* Associated with risk factors like aspiration and alcoholism
|-
|Malignancy
(primary lung cancer)
|
|✔
|
|✔
|✔
|
|
|✔
|✔
|
* A coin-shaped lesion with thick wall(>15mm) is seen on CXR with less ground glass opacities <sup>[[Lung abscess differential diagnosis|[2][3]]</sup>
|
* Chronic smoker
* Elderly male or female
* Cough persisting for longer periods
* BAL positive for malignant cells
* CT gold standard
* Biopsy is required for confirmation and differnatiation
|-
|Pulmonary Tuberculosis
|✔
|
|✔
|
|✔
|
|
|
|✔
|
* CXR and CT demonstrates [[Internal|cavities]] in the upper lobe of the lung
|
* People in endemic at high risk
* Cough >2 weeks with hemoptysis characterstic
* Acid fast stain positive for mycobacteria
|-
|Necrotizing Pneumonia
|✔
|
|✔
|
|✔
|
|✔
|
|
|
* multiple cavitary lesions
|
* Acute life threatening condition
* Complication of pneumonia or lung abscess
* Multiple organisms responsible
* prompt treatment with antibiotics is required
* CBC positive for causative organism
|-
|Pneumonia and empyema
|✔
|
|✔
|
|✔
|✔
|✔
|
|
|
* homogeneous consolidation involving one, or less commonly, multiple lobes
|
* CBC positive for causative agent.
|-
|Bronchiectasis
|
|
|✔
|
|✔
|
|
|
|
|
* Specific findings include linear lucencies and parallel markings radiating from the hila (tram tracking) dilated bronchi, clustered cysts .
 
* general findings include increased pulmonary markings, honeycombing, atelectasis and pleural changes.
 
* CT helps is confirms the diagnosis and is considered gold stadard
|
|-
|Wegners granulomatosis
|
|
|✔
|
|✔
|✔
|
|
|
|
* Pulmonary nodules with cavities and infiltrates
|
* Seen mostly in Female age group of 40-55 years
* Associated with other auto immune diseases
* Other symptoms such as hematuria is present indicating kidney involvement
* Traid of Upper , lower respiratory tract and kidney disease
* Biopsy of involved organ confirms granulomas
|-
|Sarcoidosis
|✔
|
|✔
|
|✔
|
|
|✔
|✔
|
* Bilateral [[Lymphadenopathy|adenopathy]] and coarse reticular opacities are seen on CXR
|
* More common in African-american females
* Associated with other manifestations of restrictive lung disease
* Biposy of the lung  shows [[epithelioid]] [[granuloma]]<nowiki/>s containing microscopic [[Schaumann bodies|schaumann]] and asteroid bodies.
|-
|Rheumatoid nodule
|
|
|
|
|
|✔
|
|✔
|
|
* Pulmonary nodules with cavitation are located in the upper lobe are seen on CXR
|
* Seen in patients with rheumatoid arthritis
* Positive for Rheumatoid factor and Anticyclic citrullinated peptide 
|-
|Langerhans cell Histiocytosis
|
|
|
|
|
|✔
|✔
|✔
|
|
* Thin-walled cystic cavities on CXR
|
* Exclusively afflicts smokers, with a peak age of onset of between 20 and 40 years.
* Musculoskeletal and skin is involved
* Biopsy of the involved organ
|-
|Bronchiolitis obliterans
|
|
|✔
|
|✔
|✔
|✔
|
|
|
* Common appearance on CT is patchy [[Consolidation (medicine)|consolidation,]]<nowiki/>often accompanied by ground-glass opacities and nodules.
|
* Mimics [[asthma]], [[pneumonia]] and [[emphysema]]
* Risk is increased  with occupational exposure of industrial toxins
* Causes restrictive type of lung disease so FEV1/FVC is >80%
* Biopsy often confirms the diagnosis
|}
 
 
==Patient information==
==Overview==
Lung abscess happens when a substance that should not be in the lungs gets into the lungs and causes problems.
 
==What are the symptoms of lung abscess ?==
*Fever
*Cough – People might cough up mucus that smells bad, or is yellow
*Trouble breathing or catching your breath
*Fast breathing
*Noisy breathing (wheezing)
 
==What causes lung abscess?==
When the lungs fail to neutralize the bacteria or foreign bodies by coughing ,they gets accumulated in lungs and results in the following
*Damage the lung tissue
*Cause an infection
*Block an airway leading to pus filled cavity formation.
 
==Who are at high risk for lung abscess?==
Some people are more likely to get Lung abscess, such as those who:
*Are sleepy from surgery or have passed out from alcohol or drugs
*Have problems with swallowing, for example because of a stroke or brain damage
*Have certain conditions affecting their stomach or esophagus
 
==When to seek urgent medical care?==
Call your [[health care provider]] if:
*You develop symptoms of lung abscess
*You have lung abscess and the symptoms continue despite treatment
 
==Diagnosis==
Physical examination of lungs show pain and warmth ,tests include
*A chest X-ray
*A CT scan of your chest
*Lab tests – These can include blood or urine tests, or tests on a sample of the mucus
*Bronchoscopy.
*Tests to check for swallowing problems
 
==Treatment options==
*Treatment depends on your symptoms and what’s causing your Lung abscess. Most people need to be treated in the hospital, at least at first.
*If you have an infection, your doctor will treat it with antibiotic medicines. These medicines usually go into a vein through a tube (Intravenous). The antibiotic your doctor chooses will depends on  bacteria causing your infection.
*If an object is blocking your airway, your doctor can try to remove the object during bronchoscopy.
*If a harmful substance damaged your lungs, your doctor can use a suction device to suck out liquid from your lungs.
*Some people with Lung abscess need extra oxygen. Your doctor will give you extra oxygen if you are not getting enough oxygen when you breathe normally.
 
==Prognosis==
With treatment, the outcome for lung abscess is good.The outlook for those with an infection depends on:
*The patient's health
*The type of infection
 
==Complications==
Without treatment, lung abscess can result in the following complications:
*[[Hemorrhage]] <ref name="pmid8346503">{{cite journal |vauthors=Philpott NJ, Woodhead MA, Wilson AG, Millard FJ |title=Lung abscess: a neglected cause of life threatening haemoptysis |journal=Thorax |volume=48 |issue=6 |pages=674–5 |year=1993 |pmid=8346503 |pmc=464615 |doi= |url=}}</ref>
*Pyo[[pneumothorax]]
*[[Pleural empyema]]<ref name="pmid27208219">{{cite journal |vauthors=Schattner A, Dubin I, Gelber M |title=Double jeopardy - concurrent lung abscess and pleural empyema |journal=QJM |volume=109 |issue=8 |pages=545–6 |year=2016 |pmid=27208219 |doi=10.1093/qjmed/hcw078 |url=}}</ref>
*[[Fibrosis]] and [[calcification]] of lung tissue
*[[Mediastinum|Mediastinal]], [[pleural]] and [[Fistulas|cutaneous fistulas]]
*[[Sepsis]]
 
==References==
==References==
{{reflist|2}}

Revision as of 15:05, 13 February 2017


Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Synonyms and keywords:

Overview

Historical Perspective

Classification

Pathophysiology

Epidemiology and Demographics

Screening

Natural History, Complications, and Prognosis

Natural history

Complications

Prognosis

Diagnosis

History and symptoms

Physical examination

Laboratory findings

Treatment

General measures

Good hygiene which include retracting the foreskin regularly and gentle cleansing of entire glans, preputial sac, and foreskin were found effective in treating the diseases.

Medical Therapy

Surgery

Photodynamic therapy

Miscellaneous therapies

Prevention

Primary Prevention

Secondary prevention

References

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