Abscess in Fissure

September 14, 2005
Bijoy E. John, MD

A 70-year-old man-nursing home resident-had had a cough, fever, and copious foul-smelling sputum for 1 week. Hemoptysis was noted off and on during the previous 3 days. The patient had no recent weight loss. A chest x-ray film and a CT scan showed an air-fluid level in the left oblique fissure of the lung as well as pleural thickening and infiltrates in the left lower zone.

A 70-year-old man-nursing home resident-had had a cough, fever, and copious foul-smelling sputum for 1 week. Hemoptysis was noted off and on during the previous 3 days. The patient had no recent weight loss. A chest x-ray film and a CT scan (A and B) showed an air-fluid level in the left oblique fissure of the lung as well as pleural thickening and infiltrates in the left lower zone. A sputum culture grew polymicrobial flora. The patient was treated with appropriate intravenous antibiotics, and a second chest film taken 3 weeks later showed complete resolution of the condition (C).

Dr. Bijoy E. John of Nashville, Tenn, writes that an abcess restricted to the fissure is rare and is usually a direct extension from a pulmonary focus, usually from an area of pneumonia,1 as seen in this patient. Presenting symptoms include fever, cough, hemoptysis, and pleuritic chest pain. A variety of organisms are implicated including Staphylococcus species, Streptococcus pneumoniae, anaerobic streptococci, Hemophilus influenzae, and Klebsiella species. Abcesses develop predominantly in middle-aged and elderly patients.2 Because of the high prevalence of anaerobic organisms and penicillin resistance, clindamycin is superior to penicillin in managing these abcesses.3

Bronchoscopy is indicated if there isa suggestion of underlying lung malignancy. To drain a nonhealing abcess, rigid bronchoscopy is preferred to prevent contamination. Other procedures for nonhealing abscesses include closed-chest drainage, decortication, and thoractomy. The prognosis depends on the patient's age and immunologic status, the size of the abscess, and the degree of brochial obstruction.

REFERENCES:
1.
Yaacog I, Ariffin Z. Empyema thoracis and lung abscess. Singapore Med J. 1991;32:63-66.
2. Estera AS, Platt MR, Mills LJ, Shaw RR. Primary lung abscess. J Thorac Cardiovasc Surg. 1980;79:275-282.
3. Levison ME, Mangura CT, Lorber E, et al. Clindamycin compared with penicillin for the treatment of anaerobic lung abscess. Ann Intern Med. 1983;98:466-471.

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