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Clinical Infection & Immunity

Case Report

Volume 4, Number 2, October 2019, pages 37-39

Post-Traumatic Lung Abscess: A Rare Condition in a Young Patient Presenting With Dyspnea and Fever

A pulmonary abscess is a suppurative lesion caused by pyogenic microorganisms, characterized by tissue necrosis and cavity formation in the lung parenchyma [1]. It may result from direct inoculation via inhalation and trauma, transmission of infection from the diaphragm or mediastinum, and hematogenous transmission [2].

The most important risk factor is the aspiration of infected material in the oropharynx. This condition is frequently seen in patients without cough reflex, who take sedatives or alcohol, or with sinusitis, coma, sepsis, epilepsy, head trauma, cerebrovascular diseases, diabetic coma, and other general conditions [3, 4]. Bronchial obstruction due to malignancy, inflammation, and foreign bodies in the lung may contribute to the abscess by preventing the removal of aspirated oropharyngeal material [1, 3].

Patients with a pulmonary abscess typically have symptoms of an upper respiratory tract infection, including a high fever, cough, and toxic appearance. Chest pain and shortness of breath may accompany these [4, 5]. The physical findings are those of early pneumonia. During the early stages of the disease, leukocytosis and an increased sedimentation rate are observed. As a result of the toxic effects of infection, hypochromic anemia can develop [6].

In lung X-rays, a lung abscess appears as a cavity with an air-fluid level. Cavitary images are monitored more easily using thorax computed tomography (CT) [6, 7].

Here, we present a rare case of a patient admitted to the emergency department (ED) with a high fever and shortness of breath who was diagnosed with a post-traumatic lung abscess based on imaging methods.

A 40-year-old man was admitted to the ED with a fever and shortness of breath. He had been in a pedestrian traffic accident 3 weeks earlier and was transported to the ED by the emergency medical service but was discharged on the same day.

He had been taking an inhaled bronchodilator and beta-2 agonist to treat bronchial asthma. In the previous 10 days, his complaints had become more frequent, and he developed an intermittent fever. At presentation, he appeared toxic. He had a blood pressure of 140/90 mm Hg, pulse of 98/min, respiratory rate of 22/min, pulse oximetry SpO₂ of 96%, and temperature of 38.1 °C. The breath sounds were decreased in the left lung, and crepitant rales were detected in the right lung. The hemogram showed a hemoglobin level of 10.6 g/dL, hematocrit level of 31.8%, platelet count of 358,000/mm³, and C-reactive protein level of 13.8 IU/L. Blood gas analysis showed pH 7.427, pCO₂ 43 mm Hg, HCO₃ 25.7 mEq/L, and PO₂ 85.8 mm Hg. A posteroanterior chest X-ray showed diffuse consolidation with an air-fluid level on the left side (Fig. 1).

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Figure 1. The posteroanterior chest X-ray shows consolidation in the left lung, with an air-fluid level.

Thoracic CT showed a 15 × 12 cm cavitating lesion identified as a thick-walled abscess in the left lower lung (Fig. 2). The patient was referred to the Department of Chest Disease with a preliminary diagnosis of lung abscess. The patient was given parenteral penicillin and metronidazole for 2 weeks. Postural drainage was performed three or four times daily for 10 min. The patient was discharged on day 15 of hospitalization with no complaints and a normal physical examination.

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Figure 2. The cavitary appearance on thorax CT is consistent with an abscess.

Clinically, lung abscesses present with a high fever, cough, and toxic appearance. Chest pain may accompany the findings. During the early stages, a pulmonary abscess shows signs of pneumonic consolidation on lung X-rays, which often show a cavity with air-fluid levels [3, 4]. The gold standard for diagnosis is thoracic CT, which also shows a cavity with air-fluid levels [7]. Empirical therapy using a combination of amoxicillin clavulanate, chloramphenicol, or penicillin-metronidazole is recommended because the causative microorganisms are rarely Gram-positive aerobes. The recommended treatment is intravenous penicillin (12 - 18 million U/day) with metronidazole (2 g/day) added for resistant pathogens [6, 8]. The duration of treatment is at least 2 - 3 weeks. An important step in the treatment of abscesses is drainage. The patient undergoes postural drainage three or four times daily for 10 min each on an empty stomach, during which the patient is instructed to make three or four deep inspirations and expirations and to cough. This facilitates the removal of purulent infected sputum [8]. Our patient presented to the ED with shortness of breath and a high fever. On physical examination, his respiratory sounds were decreased on the left side. He had a history of trauma approximately 3 weeks previously. The laboratory examination revealed anemia and leukocytosis. The chest X-ray revealed a large area of consolidation in the left chest.

In conclusion, a pulmonary abscess can develop rarely after chest trauma and should be included in the differential diagnosis of patients presenting with shortness of breath and a high fever.

Acknowledgments

None to declare.

Financial Disclosure

None to declare.

Conflict of Interest

The authors declare that there are no conflicts of interest associated with this manuscript.

Informed Consent

Written informed consent was obtained from the patient who participated in this study.

Author Contributions

Study conception and design: OS and ODS; data analysis and explanation: OS and ODS; study implementation and manuscript writing: OS and ODS. All authors approved the final version of the paper.

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