Non Resolving Lung Abscess - The Hidden Truth

Case Report

Austin J Pulm Respir Med 2016; 3(1): 1041.

Non Resolving Lung Abscess - The Hidden Truth

Sandhya AS¹, Prajapat B²* and Bherwani S³

¹Department of Chest and Tuberculosis, Pt. B D Sharma Postgraduate Institute of Medical Sciences, India

²Department of Pulmonary and Critical Care Medicine, Pt. B D Sharma Postgraduate Institute of Medical Sciences, India

³Department of Medicine, Lady Hardinge Medical College, India

*Corresponding author: Brijesh Prajapat, Department of Pulmonary and Critical Care Medicine, Pt. B D Sharma Postgraduate Institute of Medical Sciences, India

Received: April 20, 2016; Accepted: May 31, 2016; Published: June 01, 2016


Pulmonary embolism rarely present with infarction and cavitation and when it does the condition mimics other common conditions like tuberculosis, malignancy, necrotizing pneumonia etc. that creates a diagnostic dilemma even for an astute clinician. A high degree of suspicion must be kept in mind while dealing with non responding lung abscess.

Keywords: Lung abscess; Pulmonary embolism; Cavity; Lung cancer; Tuberculosis


Pulmonary embolism is the most serious clinical presentation of venous thromboembolism and is a major cause of morbidity, mortality and hospitalizations. The epidemiology is difficult to determine as most of the cases remain undiagnosed. It does not commonly present with cavitation because of the dual blood supply of the lung; however, cavitation may complicate 4–7% of all pulmonary infarctions. Pulmonary cavitations are usually due to infections, malignancies or immunological diseases and a high index of suspicion is needed to diagnose pulmonary embolism in these cases. We present a case of an 80 yr old male patient who presented with chest pain, fever and hemoptysis with chest x-ray showing cavitation. Patient was treated on the lines of lung abscess but CT scan done showed pulmonary embolism in the right main pulmonary artery.

Case Report

An 80-year-old male presented to the emergency department with chief complaints of right sided chest pain for 25 days, cough with expectoration and fever of 15 days duration and hemoptysis for 5 days. Patient had developed acute onset of right sided pleuritic chest pain followed by cough with whitish expectoration which later turned purulent. Patient also had intermittent fever associated with chills but no rigors. Patient developed hemoptysis 5 days before his presentation to the emergency. For the above complaints he took medications from local medical practitioner but was not relieved. As his breathlessness and general condition worsened he presented to the emergency department of our hospital. His past history was unremarkable with no prior history of tuberculosis, any prolonged medication or hospitalization or surgical intervention. There was no history of orthopnea or Paroxysmal nocturnal dyspnoea. Patient was a chronic smoker having 60 years history of hukka and bidi smoking and took alcohol occasionally.

On examination patient was febrile, alert, of average built with good nutritional status. He was normotensive with HR of 98/min, RR of 28/min and SpO2 of 94% on room air. Auscultation revealed coarse crepts on right side. Laboratory investigations showed hemoglobin of 14 g/dl, total leucocyte count of 14000/cumm, blood urea of 122 mg/dl and serum creatinine of 0.93 mg/dl. Liver function tests were within normal limits (SGPT-22IU, SGOT- 30IU, ALK phosphatase – 45IU). Chest X-ray (Figure 1) showed a thick walled cavity involving the right upper and middle zone with air fluid level and surrounding consolidation. A diagnosis of right lung abscess was made and patient started on intravenous antibiotics along with symptomatic treatment. His HIV, HbsAg and HCV were non reactive. Sputum for AFB was negative and sputum for pyogenic culture showed citrobacter and his antibiotics were changed according to the sensitivity report. Patient had relief in his fever, cough and hemoptysis and his chest X-ray (Figure 2) also started showing resolution. But there was no significant improvement in his breathlessness and generalized weakness. Contrast enhanced CT scan of the chest was done when patient remained symptomatic after two weeks of antibiotic therapy. CT scan (Figure 3) revealed pulmonary embolism involving the right main pulmonary artery incompletely occluding the artery. His troponin T was negative, CPK-MB was 92 u/l and serum pro BNP level was 124.7. Echocardiography showed RA/RV dilated with grade 1 diastolic dysfunction. The diagnosis was revised as sub massive pulmonary embolism with infected cavity and he was started on enoxaparin and antibiotics as per his sensitivity reports.