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A 75-Year-Old Woman With Fever and a Right Upper Lobe Pulmonary MassWoman With Fever and Right Upper Lobe Mass FREE TO VIEW

Jose L. Cardenas-Garcia, MD; Anup K. Singh, MD; Seth J. Koenig, MD, FCCP
Author and Funding Information

From the Division of Pulmonary, Critical Care, and Sleep Medicine, Hofstra North Shore-LIJ School of Medicine, New Hyde Park, NY.

CORRESPONDENCE TO: Jose L. Cardenas-Garcia, MD, 410 Lakeville Rd, Ste 107, New Hyde Park, NY 11042; e-mail: jdecardenasg@gmail.com


Reproduction of this article is prohibited without written permission from the American College of Chest Physicians. See online for more details.


Chest. 2015;147(1):e1-e4. doi:10.1378/chest.14-1161
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Published online

A 75-year-old woman presented to the ED complaining of dyspnea, fever, and a productive cough for 1 week. A recent diagnosis was made of a poorly differentiated squamous cell lung cancer of the right upper lobe with a large endotracheal lesion. On physical examination in the ED, her vital signs were as follows: BP, 112/72 mm Hg; heart rate, 78 beats/min; temperature, 39.1°C; and oxygen saturation, 94% on room air. She appeared cachectic, with good dentition, and in mild respiratory distress. Auscultation revealed coarse rhonchi on the right anterior and posterior upper chest. Initial laboratory results were only significant for leukocytosis (15,400 cells/μL), with 93% of neutrophils; her basic metabolic and liver function panels were unremarkable. The initial chest radiograph was read as “unchanged right upper lung mass.”

The patient was admitted to the medical floors with a diagnosis of pneumonia and was started on broad-spectrum antibiotics, with mild improvement of her dyspnea and cough. Six days after her admission, she developed acute onset of severe respiratory distress and hypoxemia. New laboratory tests were only remarkable for worsening leukocytosis (28,430 cells/μL), and a repeated chest radiograph showed a dependent air-fluid level within a cavitary lesion (Fig 1). The medical ICU was consulted for management of the patient’s respiratory failure and sepsis. After clinical evaluation, a goal-directed ultrasound examination was performed (see Videos 1-10).

Case Patient Video 1

Ultrasound Examination

Running Time: 2:00

Figure Jump LinkFigure 1 –  Chest radiograph showing a circular mass in the right upper lung field with air-fluid level.Grahic Jump Location
Question: After reviewing this patient’s history, physical examination, and ultrasound images, what is the most likely diagnosis?
Answer: Hypoxic respiratory failure due to a large area of alveolar consolidation developing into a lung abscess. A large left pleural effusion possibly contributed to the respiratory failure.

Discussion Video 2

Discussion Video

Running Time: 6:49

Our patient had hypoxic respiratory failure that was multifactorial in nature (progression of lung mass into an abscess, a right-sided alveolar consolidation, and large left pleural effusion). Videos 1 to 6 demonstrate the presence of right anterior B-lines with irregular sliding pleura and a normal A-line pattern elsewhere, suggesting the focal nature of the infectious process and ruling out pneumothorax. Video 7 shows a large left pleural effusion, which was drained and found to be malignant. Videos 8 through 10 show normal left ventricular function, with mild apical ballooning not sufficient to produce cardiogenic pulmonary edema, no pericardial effusion, both normal motion of the interventricular septum and right ventricular size, and marked variation of the inferior vena cava, thus making pulmonary edema, cardiac tamponade, and acute massive pulmonary embolism less likely.

Lung abscess is defined by the presence of necrosis of pulmonary tissue secondary to a microbial infection. It can occur as a complication of any severe pneumonia, aspiration pneumonia, or postobstructive pneumonia or secondary to cavitation and infection of a malignant neoplasm (particularly squamous cell carcinoma). Up to one-third of lung abscesses are associated with empyema, and bronchopleural fistula (BPF) is not uncommon. Prompt diagnosis helps to limit complications. Drainage is necessary in addition to antibiotics if clinical improvement is inadequate.

Based on the known history of right upper lobe lung cancer and the characteristics of the chest radiograph (a well-rounded radiopacity with air-fluid level, clearly outlined minor fissure, and well-defined right costophrenic angle), the diagnosis of a lung abscess complicating a cavitating tumor was made. In some cases, it is difficult to differentiate lung abscess from empyema. Chest radiography alone is not useful when the empyema presents with an air-fluid level1; and although CT scan of the chest is valuable in the diagnosis of lung abscess, thoracic ultrasonography allows the treating physician to both follow the progression or regression of disease without repeated radiation and allow bedside therapeutic intervention with insertion of chest tube drainage if necessary.2 In this regard, chest ultrasonography is helpful to identify a lung abscess, typically described as a round or oval hypoechoic lesion with irregular outer margins with a hyperechoic ring3,4 (Videos 3, 4).1,5 Ultrasound findings suggestive of empyema include the split pleural sign, its wall characteristics, and the lesion shape. The split pleural sign is defined as thickened visceral and parietal pleura separated by empyema and is uncommon.5 Ultrasonographic wall characteristics (smooth vs irregular in empyema and lung abscess, respectively) and lesion shape (lenticular in empyema vs oval in lung abscess) are associated with high interobserver variability.5 Chen and colleagues5 found that septations and passive atelectasis were specific for empyemas but had low sensitivity (40% and 47%, respectively). The presence of color Doppler ultrasound signals in the pericavitary consolidation was the most useful and specific finding for identifying lung abscesses (sensitivity, 94%; specificity, 100%; positive predictive value, 100%; and negative predictive value, 94%) without interobserver variability (Video 11). This finding will not be present in patients with empyema, since compressive atelectasis causes a local reduction of blood flow.

In the majority of patients with lung abscess, conservative management with long-term broad-spectrum antibiotics and spontaneous drainage via the airways are sufficient (success rate of 89%-90%).6 More invasive management includes percutaneous or endoscopic drainage and surgery (lobectomy/pneumonectomy). Percutaneous transthoracic drainage (PTTD) may be performed in patients with lung abscess > 4 cm in diameter who are poor surgical candidates and have failed medical treatment.6,7 PTTD has the advantage that it avoids the need of thoracotomy and provides an immediate sample for fluid analysis.3,7 Without treatment, complications of lung abscess may occur, which are aspiration of pus to other parts of the lung parenchyma and rupture of the abscess to the pleural cavity.

Our patient failed to improve with conservative management and was not a candidate for an operative procedure; therefore, a decision was made to perform a palliative ultrasound-guided PTTD of the lung abscess (Figs 2, 3, Videos 12, 13). Preprocedural planning includes determination of puncture goal, site of puncture, direction of the needle/chest tube insertion, and puncture pathway.2 Different methods of ultrasound-guided chest tube insertion exist, including real-time insertion with visualization of the needle entering the lung cavity or a mark and stick approach, as was done in this case. Regardless of the needle insertion method, visualization of the guidewire within the lung cavity should be sought to confirm proper placement (Video 12). The ideal size of the chest tube for PTTD is 10F to 14F.8

Figure Jump LinkFigure 2 –  Chest radiograph post procedure showing the right chest tube tip inside the lung abscess.Grahic Jump Location
Figure Jump LinkFigure 3 –  Purulent fluid obtained during the chest tube insertion; subsequently it grew Staphylococcus species.Grahic Jump Location

The incidence of complications from PTTD of lung abscess is low. These include intrapleural spread of infection resulting in empyema and BPF. These complications may be avoided by looking for the absence of lung sliding at the area to be punctured (this occurs because of the local inflammatory process resulting in pleural adhesion) (Video 4) as well as avoiding areas of normal aeration,9 using the shortest pathway of chest tube insertion, and passing through solid, homogenous, infiltrated, or atelectatic tissue.2 Clogging of the chest tube requiring tube exchange is the most common complication, but this can be avoided with daily irrigation using 5 to 15 mL of normal saline. Pneumothorax, hemothorax, and intrabronchial hemorrhage are rare complications.7 Ultrasound-guided PTTD has its limitations: If the abscess is not visible percutaneously on ultrasound or the pathway for the chest tube is not safe, other invasive procedures for drainage (bronchoscopy, endoluminal sonography) or CT scan-guided PTTD should be used.2

Our patient was afebrile 24 h after drainage with marked improvement of her clinical symptoms and laboratory values. She tolerated the chest tube well, and there were no side effects from the tube drainage. Cultures from the lung abscess grew Staphylococcus species. Finally, the chest tube was removed 10 days after insertion, and the patient was discharged to home hospice.

  • 1. Chest ultrasonography is a valuable adjunct to chest CT scan to both diagnose and plan therapeutic intervention in patients with lung abscess who fail medical therapy and are poor surgical candidates.

  • 2. The presence of a color Doppler signal within the suspected lung abscess accurately distinguishes it from a complex pleural effusion or empyema.

  • 3. The lack of lung sliding adjacent to the abscess cavity suggests pleural adhesion and decreases the risk of BPF, thus allowing safe chest tube insertion.

Financial/nonfinancial disclosures: The authors have reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Other contributions:CHEST worked with the authors to ensure that the Journal policies on patient consent to report information were met.

Additional information: To analyze this case with the videos, see the online version of this article.

Lin FC, Chou CW, Chang SC. Differentiating pyopneumothorax and peripheral lung abscess: chest ultrasonography. Am J Med Sci. 2004;327(6):330-335. [CrossRef] [PubMed]
 
Blank W. Interventional chest sonography.. In:Mathis G., ed. Chest Sonography.3rd ed. Berlin Heidelberg, Germany: Springer; 2011:34-36.
 
Mathis G, Beckh S, Gorg C. Lung consolidation.. In:Mathis G., ed. Chest Sonography.3rd ed. Berlin Heidelberg, Germany: Springer; 2011:57-59.
 
Yang PC, Luh KT, Lee YC, et al. Lung abscesses: US examination and US-guided transthoracic aspiration. Radiology. 1991;180(1):171-175. [CrossRef] [PubMed]
 
Chen HJ, Yu YH, Tu CY, et al. Ultrasound in peripheral pulmonary air-fluid lesions: color Doppler imaging as an aid in differentiating empyema and abscess. Chest. 2009;135(6):1426-1432. [CrossRef] [PubMed]
 
Klein JS, Schultz S, Heffner JE. Interventional radiology of the chest: image-guided percutaneous drainage of pleural effusions, lung abscess, and pneumothorax. AJR Am J Roentgenol. 1995;164(3):581-588. [CrossRef] [PubMed]
 
Wali SO, Shugaeri A, Samman YS, Abdelaziz M. Percutaneous drainage of pyogenic lung abscess. Scand J Infect Dis. 2002;34(9):673-679. [CrossRef] [PubMed]
 
vanSonnenberg E, D’Agostino HB, Casola G, Wittich GR, Varney RR, Harker C. Lung abscess: CT-guided drainage. Radiology. 1991;178(2):347-351. [CrossRef] [PubMed]
 
Reuss J. Pleura.. In:Mathis G., ed. Chest Sonography.3rd ed. Berlin Heidelberg, Germany: Springer; 2011:34-36.
 

Figures

Figure Jump LinkFigure 1 –  Chest radiograph showing a circular mass in the right upper lung field with air-fluid level.Grahic Jump Location
Figure Jump LinkFigure 2 –  Chest radiograph post procedure showing the right chest tube tip inside the lung abscess.Grahic Jump Location
Figure Jump LinkFigure 3 –  Purulent fluid obtained during the chest tube insertion; subsequently it grew Staphylococcus species.Grahic Jump Location

Tables

Case Patient Video 1

Ultrasound Examination

Running Time: 2:00

Discussion Video 2

Discussion Video

Running Time: 6:49

References

Lin FC, Chou CW, Chang SC. Differentiating pyopneumothorax and peripheral lung abscess: chest ultrasonography. Am J Med Sci. 2004;327(6):330-335. [CrossRef] [PubMed]
 
Blank W. Interventional chest sonography.. In:Mathis G., ed. Chest Sonography.3rd ed. Berlin Heidelberg, Germany: Springer; 2011:34-36.
 
Mathis G, Beckh S, Gorg C. Lung consolidation.. In:Mathis G., ed. Chest Sonography.3rd ed. Berlin Heidelberg, Germany: Springer; 2011:57-59.
 
Yang PC, Luh KT, Lee YC, et al. Lung abscesses: US examination and US-guided transthoracic aspiration. Radiology. 1991;180(1):171-175. [CrossRef] [PubMed]
 
Chen HJ, Yu YH, Tu CY, et al. Ultrasound in peripheral pulmonary air-fluid lesions: color Doppler imaging as an aid in differentiating empyema and abscess. Chest. 2009;135(6):1426-1432. [CrossRef] [PubMed]
 
Klein JS, Schultz S, Heffner JE. Interventional radiology of the chest: image-guided percutaneous drainage of pleural effusions, lung abscess, and pneumothorax. AJR Am J Roentgenol. 1995;164(3):581-588. [CrossRef] [PubMed]
 
Wali SO, Shugaeri A, Samman YS, Abdelaziz M. Percutaneous drainage of pyogenic lung abscess. Scand J Infect Dis. 2002;34(9):673-679. [CrossRef] [PubMed]
 
vanSonnenberg E, D’Agostino HB, Casola G, Wittich GR, Varney RR, Harker C. Lung abscess: CT-guided drainage. Radiology. 1991;178(2):347-351. [CrossRef] [PubMed]
 
Reuss J. Pleura.. In:Mathis G., ed. Chest Sonography.3rd ed. Berlin Heidelberg, Germany: Springer; 2011:34-36.
 
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