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Pulmonary Gangrene: Complication of Severe Bacterial Pneumonia FREE TO VIEW

Vishesh Paul, MD; Sidney Tessler, MD; Taek Yoon, MD; Yizhak Kupfer, MD
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Maimonides Medical Center, Brooklyn, NY

Chest. 2014;145(3_MeetingAbstracts):104A. doi:10.1378/chest.1826462
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SESSION TITLE: Infectious Disease Case Reports Posters II

SESSION TYPE: Case Report Poster

PRESENTED ON: Sunday, March 23, 2014 at 01:15 PM - 02:15 PM

INTRODUCTION: Pulmonary gangrene is a severe life threatening complication of pulmonary infection in which a part of lung tissue is devitalized. It can occur rarely after bacterial pneumonia, and may require surgical removal of dead tissue.

CASE PRESENTATION: A 38-year-old male with history of chronic alcohol abuse was brought to the hospital, because he was found unresponsive on street, with vomitus over him. He was intubated for airway protection. His initial vitas were- T: 103.2 F, HR: 124/min, RR: 22/min, BP: 100/60 mm Hg. He had bronchial breath sounds over the right anterior chest. Clinical examination was confirmed with the chest X ray that showed a large right upper lobe infiltrate, causing a bulging fissure sign. Initial labs were significant for WBC- 26K/UL, platelet count- 60K/UL, and alcohol level of 380 mg/dL¬¬¬¬. He was admitted to Medical ICU with a diagnosis of acute respiratory failure secondary to lobar pneumonia. His respiratory cultures grew Klebsiella pneumoniae. His conditioned worsened over the next few days leading to septic shock and renal failure. His chest CT scan showed necrotizing pneumonia. Imaging done a few days later showed formation of small cavities, which then coalesced to form a large cavity on the third CT scan. Patient was coughing out dead tissue in the endotracheal tube. Thoracic surgery was consulted for possible lobectomy, but as a patent bronchus was leading into the necrotic tissue, decision was made for medical management. Over the next few days, patient received tracheostomy, came off vasopressors and was transferred to respiratory care unit. He was eventually decannulated, and was discharged after 3 months of hospitalization.

DISCUSSION: Pulmonary gangrene is a rare complication of severe lung infection, characterized by sloughing of lung parenchyma (1), similar to bony sequestrum in osteomyelitis. It occurs as a complication of bacterial lobar pneumonia, tuberculosis or mucormycosis. The primary pathological features that distinguish pulmonary gangrene from necrotizing pneumonia and lung abscess are the extent of necrosis, and thrombosis of vessels. Thrombosis of vessels of the bronchial and pulmonary circulation leads to large areas of necrosis (1). Radiographically, it begins as a lobar consolidation, followed by formation of small cavities, which coalesce to form a large cavity (2). Necrotic lung debris can be seen inside the cavity. Thus the description “mass within the cavity” has been given to this hallmark roentgen pattern. Here both mass and the cavity are the consequence of infection induced tissue necrosis (2). The acute course, lobar configuration and radiological progression are pathognomic of massive pulmonary gangrene. Most patients require surgery, as antibiotics don’t effectively penetrate the avascular area. Sometimes pulmonary gangrene can be managed medically, if the bronchus leading to the cavity is patent and patient is able to cough out dead tissue. Surgery should be considered if medical therapy is failing. Irrespective of the treatment strategy, pulmonary gangrene is a condition with a high mortality, and early identification and surgical drainage may be life saving.

CONCLUSIONS: Irrespective of the treatment strategy, pulmonary gangrene is a condition with a high mortality, and early identification and surgical drainage may be life saving.

Reference #1: Penner, C., B. Maycher, and Richard Long. "Pulmonary gangrene. A complication of bacterial pneumonia." CHEST Journal 105.2 (1994): 567-573.

Reference #2: Reich, Jerome M. "Pulmonary gangrene and the air crescent sign." Thorax 48.1 (1993): 70-74.

DISCLOSURE: The following authors have nothing to disclose: Vishesh Paul, Sidney Tessler, Taek Yoon, Yizhak Kupfer

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