Massive pulmonary gangrene: a severe complication of Klebsiella pneumonia Lawrence Knight, md,
frcp[c]; Robert G. Fraser,
Summary: Massive pulmonary gangrene developed in two patients. Review of
the literature reveals 10 other case reports of pulmonary gangrene complicating lobar pneumonia. Among the total of 12 patients whose cases have now been reported, all 4 patients who were treated nonsurgically died and the 8 who underwent surgical resection of the gangrenous lung survived. The present report emphasizes the necessity of early recognition and appropriate surgical treatment for a successful outcome. Resume: Gangrene pulmonaire massive: complication grave d'une pneumonie
Klebsiella Deux malades ont ete frappes par une gangrene pulmonaire massive. Une revue de la litterature porte sur 10 autres cas de cette complication d'une pneumonie lobaire. Du total des 12 malades dont les cas ont ete publies, les 4 malades qui n'avaient subi qu'un traitement medical sont decedes et les 8 autres chez lesqueJs on avait res6que le poumon gangrene ont survecu. Le present rapport souligne la necessitS d'un diagnostic precoce et d'une operation appropriee pour obtenir une issue favorable. a
Gangrene of the lung was described by Osler in 1897,1 yet little has subsequent¬ ly been written about this entity. Mas¬ sive pulmonary gangrene may occur as an unusual severe complication of lobar pneumonia, Klebsiella pneumo¬ niae being the most frequently implic¬ ated etiologie agent. It has been sug¬ gested that early recognition of this complication and prompt surgical re¬ moval of the gangrenous lung may be of critical importance for survival. Among 10 patients whose cases have been reported,2"8 the 4 who were treated nonsurgically died, whereas the 6 who underwent surgical resection of the gan¬ grenous lung survived. The present re¬ port, which describes the cases of two additional patients, emphasizes the ne-
md,
frcp[c]; Hugh G. Robson,
frcp[c]
gangrene was made cessity of early recognition and appro¬ nosis of pulmonary radiologically on the 19th hospital day, priate surgical treatment for a success¬ when a tomogram of the left lower
ful outcome.
Case reports Case 1
A 37-year-old black man entered Royal Victoria Hospital on July 19, 1970 with a 1-day history of chills, increasing shortness of breath, left-sided pleuritic chest pain and cough productive of tenacious bloody sputum. The patient had consumed a large amount of alcohol in the preceding week. He had a history of pneumonia 10 years earlier. On admission the patient appeared severely ill: his temperature was 39°C, blood pressure 100/70 mm Hg, pulse rate 120 beats/min and respiratory rate 48/ min. Important physical signs included flaring of the alae nasi, shallow respiration and splinting of the left chest. Bronchial breathing and rales were audible over the left posterior hemithorax and right ante¬ rior midlung field. Initial gram-staining of the sputum showed many neutrophils and gram-nega¬ tive rods. K. pneumoniae was grown from the sputum but blood cultures were nega¬ tive. Hemoglobin concentration was 15.1
g/dl. Leukocyte count was 2900/mm3 (dif¬ ferential: neutrophils 35%, lymphocytes 20%, monocytes 6%, metamyelocytes 6% and bands 33%). Arterial blood gas values were as follows: Po2 52 mm Hg, Pco2 29 mm Hg and pH 7.49. Antimicrobial therapy was initiated with cloxacillin and gentamicin but was changed to cephalothin, 12 g/day intravenously, and kanamycin, 1 g/day intramuscularly, on the 2nd hospital day. The initial chest radiograph revealed bilateral homogeneous consolidation, more extensive on the left (Fig. IA). The diag¬
From the departments of medicine and diagnostic radiology, Royal Victoria Hospital and faculty of medicine, McGill University,
Montreal Reprint requests to: Dr. H. G. Robson, 3775
md,
FIG. IA.Case 1. Bilateral homogeneous consolidation, more extensive on left. University St., Montreal, Que. H3A 2B4 196 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
lobe (anteroposterior projection) (Fig. 1) showed a crescent of air separating a large central mass of lung from the rest of the lower lobe. The patient underwent a left lower lobectomy on the 24th hospital
day. The resected specimen (Fig. 2) con¬ tained an abscess cavity measuring 11 x 9x7 cm; K. pneumoniae was cultured from a single large mass of necrotic lung within the abscess. Numerous blood vessels close to the abscess wall showed acute vasculitis and complete obstructing throm¬ bosis. There was no evidence of blood vessel invasion by microorganisms. The patient's condition improved imme¬ diately after operation. Despite the con¬ tinued presence of K. pneumoniae in the sputum he felt well. Antimicrobials were discontinued on hospital day 61, 16 days after he had first become afebrile. He again became febrile on hospital day 66, when a radiograph showed extension of the consolidation of the right upper lobe and numerous radiolucent areas within the consolidated parenchyma. Therapy with cephalothin and kanamycin was reinstituted. Antimicrobial therapy was dis¬ continued on hospital day 103 and the
patient
was
discharged.
WKKM FIG. 1B.Case 1. Anteroposterior
tomographic view on hospital day 19, showing crescent of air separating large central mass of lung from rest of lower lobe (arrows).
The patient was last seen 7 months after his hospital discharge; he complained only of slight dyspnea on exertion. Chest radio¬ graphy demonstrated some bilateral scarring in the midlung zones, and pulmonary function testing revealed a mild restrictive
pattern.
Case 2 A 50-year-old white man was admitted to Royal Victoria Hospital on May 25, 1972 with a 5-day history of fever, in¬ creasing dyspnea, right-sided pleuritic chest pain and cough productive of tenacious brown sputum. He had lost about 9 kg of weight during the previous year because
of undernutrition, but denied alcohol ingestion. He had a history of pneumonia 14 years earlier. He appeared moderately ill: his temper¬ ature was 38.3 °C, blood pressure 120/80 mm Hg, pulse rate 124 beats/min, respira¬ tory rate 28/min. Bronchial breathing and rales were audible over the right upper lobe. His hemoglobin concentration was 13.5 g/dl. The leukocyte count was 1500/mm3
(differential: neutrophils 19%, lympho¬ cytes 17%, monocytes 12%, metamyelocytes 12%, myelocytes 4%, bands 36%). The serum albumin concentration was 1.22 g/dl. Arterial blood gas values were the following: Po2 64 mm Hg, Pco2 29 Hg and pH 7.51. The smear of the sputum revealed many gram-negative rods mm
and
neutrophils;
K.
pneumoniae, type 1
cultured. Blood cultures were negative. The initial chest radiograph (Fig. 3A) revealed homogeneous consolidation of most of the right upper lobe, containing a prominent air bronchogram. During the following 2 weeks multiple areas of radiolucency appeared within the consolidated lung, which by hospital day 16 had coalesced into a large abscess cavity con¬ taining an irregular mass of necrotic lung was
FIG. 2.Case 1. Resected left lower lobe with large abscess cavity containing single large mass of necrotic lung.
FIG. 3A.Case 2. Homogeneous consolidation of most of right upper lobe, containing prominent air
bronchogram.
(Fig. 3B). The patient was treated with cephapirin sodium, 18 g/day intravenously, kanamy¬ cin, 1 g/day intramuscularly, and supplemental oxygen. He became afebrile on hospital day 15. At thoracotomy on hos¬ pital day 23 a right pneumonectomy was required because the necrotizing process had involved all three lobes of the right lung. Fig. 4 shows the mass of gangrenous lung in the large right upper lobe abscess cavity from which K. pneumoniae, type 1 was grown. Microscopic examination showed that the architecture of the lung was unrecognizable in many sections, and in others the ghosts of alveolar walls could be discerned. Blood vessels were necrotic, although no evidence of vessel invasion by organisms was apparent. The patient was discharged on hospital day 44, 1 week after antimicrobial therapy had been dis¬
The patient was readmitted 5 weeks later for open drainage of a right-sided empyema from which K. pneumoniae was cultured. He was last seen 3 months later, when he felt well and had no respiratory
complaints.
Discussion Osler1 described gangrene of the lung complication of a variety of condi¬ tions when necrotic areas undergo putrefaction: as a consequence of lobar as a
pneumonia,
or
following aspiration,
bronchiectasis or perforation of a bronchus by cancer of the esophagus. He described the lung as "converted into a horribly offensive greenish-black mass, torn and ragged in the centre". Table I lists the pertinent details of the 10 published case reports of pul¬ monary gangrene complicating lobar pneumonia. This entity has been given various labels such as spontaneous amputation,5 massive sequestrum of the lung2 and massive necrosis of the lung.8 Of the 10 reported cases 7 involved an upper lobe, 5 on the right side; the
offending organism was K. pneumoniae in 5 cases. All four patients with lung gangrene who received only medical therapy died, whereas all patients who had surgical intervention survived. In a number of the early cases it was reported that the necrotic lung was expelled, after coughing, through the incision at the time of open drainage for a suspected empyema. The radiologic manifestations of mas¬ sive pulmonary gangrene are dramatic and virtually diagnostic. The process begins with homogeneous consolidation of lung parenchyma, frequently with a bulging interlobar fissure if K. pneumo¬ niae
or
Streptococcus pneumoniae is the
continued.
FIG. 3B.Case 2. Appearance 2 weeks after that in Fig. 3A, showing large abscess cavity containing irregular mass of necrotic right upper lobe.
FIG. A.Case 2. Resected right lung with large upper lobe abscess cavity containing mass of gangrenous lung.
CMA JOURNAL/JANUARY 25, 1975/VOL. 112 197
etiologic agent, which suggests increased volume of the affected lobe. Within a few days multiple small irregular translucencies appear throughout the consolidated lung; these tend to coalesce into a single large cavity containing one or more irregular fragments of detached lung tissue. In the case reported by Brock2 the radiograph showed a crescent of air separating a mass of lung tissue from the pleura. In Fig. lB a crescent of air separates the necrotic lung from adjacent lung tissue. The gross pathologic features of lung gangrene are distinctive and differ from those of other forms of lung abscess. A piece of ragged, necrotic, but nonliquefied lung tissue lies detached inside a large abscess cavity, which often involves an entire lobe. Humphreys3 remarked that although the lung was necrotic its microscopic architecture was retained. He assumed that the process was secondary to thrombosis in pulmonary vessels. Other cases have shown extensive vascular thrombosis.2'4 The lung in our case 1 revealed acute vasculitis in many vessels, often associated with complete obstructing thrombosis, but without evidence of invasion of blood vessels by organisms. In case 2 the vessels were so necrotic and distorted that the presence of thrombosis could not be adequately assessed. Thomas and Brewster,8 in their report of a gangrenous left upper lobe that was extruded at thoracotomy, considered the surgical intervention as lifesaving. Danner, McFarland and Felson4 believed that early surgical intervention may be crucial in preventing a fatal outcome. Of the 12 patients whose cases have now been collected, all 4 patients treated medically died, whereas the 8 who were treated by a combined medical and surgical regimen survived. Two of the four medically treated patients who died were reported before the antibiotic era. In case 1 thoracotomy was necessary because the patient remained severely ill, with hectic fever and progression of the lesion, despite intensive antimicro-
bial and supportive therapy. A similar, though less extensive, disease process in the right upper lobe fortunately cleared without surgical intervention but required an extension of hospitalization for intensive antimicrobial therapy totalling 37 days. In case 2, because of the extent of the disease and because of our experience with case 1, thoracotomy was scheduled as soon as the debilitated patient's condition and preoperative status were considered acceptable. The mortality of pneumonia due to K. pneumoniae in the preantibiotic era was 50 to 80% .. Because the disease often occurs in a debilitated host and may be associated with drug resistance of the organism, the prognosis even now must remain guarded. The complication of pulmonary gangrene must further increase the severity of this disease. One of our two patients (case 2) was only moderately ill on admission, so that adequate medical therapy to prepare him for surgery was feasible. It is conceivable that optimum medical treatment alone might *be effective, for a less extensive but similar process in case 1 resolved without surgical intervention. Nevertheless, we are impressed with the need for early surgical intervention and long-term antimicrobial therapy in the treatment of massive lung gangrene.
Year 1921
1. OSLER W: The Principles and Practice of Medicine. New York, Appleton, 1897, p 584 2. BROCK RC: Studies in lung abscess. Guys Hosp Rep 95: 40, 1946 3. HUMPHREYS DR: Spontaneous lobectomy. Dr Med J II: 185, 1945 4. DANNER PK, MCFARLAND DR, FELsoN B: Massive pulmonary gangrene. Am J Roentgenol Radium Ther Nuci Med 103: 548, 1968 5. LENOBLE E, JEGAT Y: Gangrene limit.e . une portion du poumon droit avec amputation spontan6e du lobe sup6rieur. Bull Mem
Soc Med Hop Paris 46: 591, 1922
6. HYDE L, HYDE B: Primary Friedlander pneumonia. Am I Med Sci 205: 660, 1943 7. TAYLOR JW: Spontaneous lobectomy. Br Med I II: 500, 1944 8. THOMAS JH, BREWSTER OM: Friedlander pneumonia with massive necrosis of lung. Br Med I II: 817, 1952 9. TURCE M, PETER5DORF RG: Kiebsiella infec-
tion (chap 148), in Harrison's Principles of
internal Medicine, sixth ed, edited by WINThOSE MM, THORN GW, ADAMS RD. et a!, New York, McGraw, 1970, p 810
6 7 3
1943 1944 1945
2
1946
8 4
1952 1968
Means of establishing diagnosis Autopsy
Lobe involved Organism Therapy RUL ? Staphylococcus Medical
Outcome Death
Autopsy Open drainage Open drainage Open drainage Thoracotomy
RUL LIL RLL RUL
Medical Surgical Surgical Surgical Surgical
Death Survival Survival Survival Survival
K. pneumoniae Surgical S. pneumoniae Medical S. pneumoniae Surgical Medical
Survival Death Survival Death
Thoracotomy Autopsy Thoracotomy Autopsy
? Streptococcus pneumoniae RMLI RLL, LLL Kiebsiella pneumoniae
LUL RUL LUL
K. pneumoniae K. pneumoniae K. pneumoniae ? K. pneumoniae
? S. pneumoniae
198 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
DRU)RAL is a sustained-action tableted preparation for twice-a-day administration which provides effective relief of symptoms of nasal congestion. Each tablet contains 6mg dexbrompheniramine maleate N.E. and 120mg d-isoephedrine sulphate. These two active components are distributed equally between the tablet's outer coating and a sustainedrelease inner core.
m
References
Table I-Lung gangrene: summary of 10 previously reported cases Reference No. 5
SCHERINO
DRIXORAL tablets are indicated for relief of symptoms of upper respiratory mucosal congestion in seasonal and perennial nasal allergies, acute rhinitis and rhinosinusitis, acute and subacute sinusitis, eustachian tube blockage, and secretory otitis media. [email protected]. DRIXORAL tablets should not be given to children under 12 years of age and should not be administered to pregnant women.
m5
Due to the d-isoephedrine content of DRIXORAL, it should be used with caution in patients with hypertension, coronary artery disease and hyperthyroid ism.
ADW.
Mild drowsiness and skin rash have been observed occasionally in patients receiving DRIXORAL.
[email protected]:
There is no specific antidote tor DRIXORAL. Specific therapy will depend on the predominant symptoms observed. [email protected]: For adults and for children 12 or more years of age-one DRIXORAL tablet in the morning and one at bedtime. In exceptional cases, administration of one tablet every 8 hours may be required. Full information is available on request from Schering Corporation Limited, Pointe Claire, Quebec H9R 1 B4.
DR.QR.L
frcp[c]; Robert G. Fraser,
Summary: Massive pulmonary gangrene developed in two patients. Review of
the literature reveals 10 other case reports of pulmonary gangrene complicating lobar pneumonia. Among the total of 12 patients whose cases have now been reported, all 4 patients who were treated nonsurgically died and the 8 who underwent surgical resection of the gangrenous lung survived. The present report emphasizes the necessity of early recognition and appropriate surgical treatment for a successful outcome. Resume: Gangrene pulmonaire massive: complication grave d'une pneumonie
Klebsiella Deux malades ont ete frappes par une gangrene pulmonaire massive. Une revue de la litterature porte sur 10 autres cas de cette complication d'une pneumonie lobaire. Du total des 12 malades dont les cas ont ete publies, les 4 malades qui n'avaient subi qu'un traitement medical sont decedes et les 8 autres chez lesqueJs on avait res6que le poumon gangrene ont survecu. Le present rapport souligne la necessitS d'un diagnostic precoce et d'une operation appropriee pour obtenir une issue favorable. a
Gangrene of the lung was described by Osler in 1897,1 yet little has subsequent¬ ly been written about this entity. Mas¬ sive pulmonary gangrene may occur as an unusual severe complication of lobar pneumonia, Klebsiella pneumo¬ niae being the most frequently implic¬ ated etiologie agent. It has been sug¬ gested that early recognition of this complication and prompt surgical re¬ moval of the gangrenous lung may be of critical importance for survival. Among 10 patients whose cases have been reported,2"8 the 4 who were treated nonsurgically died, whereas the 6 who underwent surgical resection of the gan¬ grenous lung survived. The present re¬ port, which describes the cases of two additional patients, emphasizes the ne-
md,
frcp[c]; Hugh G. Robson,
frcp[c]
gangrene was made cessity of early recognition and appro¬ nosis of pulmonary radiologically on the 19th hospital day, priate surgical treatment for a success¬ when a tomogram of the left lower
ful outcome.
Case reports Case 1
A 37-year-old black man entered Royal Victoria Hospital on July 19, 1970 with a 1-day history of chills, increasing shortness of breath, left-sided pleuritic chest pain and cough productive of tenacious bloody sputum. The patient had consumed a large amount of alcohol in the preceding week. He had a history of pneumonia 10 years earlier. On admission the patient appeared severely ill: his temperature was 39°C, blood pressure 100/70 mm Hg, pulse rate 120 beats/min and respiratory rate 48/ min. Important physical signs included flaring of the alae nasi, shallow respiration and splinting of the left chest. Bronchial breathing and rales were audible over the left posterior hemithorax and right ante¬ rior midlung field. Initial gram-staining of the sputum showed many neutrophils and gram-nega¬ tive rods. K. pneumoniae was grown from the sputum but blood cultures were nega¬ tive. Hemoglobin concentration was 15.1
g/dl. Leukocyte count was 2900/mm3 (dif¬ ferential: neutrophils 35%, lymphocytes 20%, monocytes 6%, metamyelocytes 6% and bands 33%). Arterial blood gas values were as follows: Po2 52 mm Hg, Pco2 29 mm Hg and pH 7.49. Antimicrobial therapy was initiated with cloxacillin and gentamicin but was changed to cephalothin, 12 g/day intravenously, and kanamycin, 1 g/day intramuscularly, on the 2nd hospital day. The initial chest radiograph revealed bilateral homogeneous consolidation, more extensive on the left (Fig. IA). The diag¬
From the departments of medicine and diagnostic radiology, Royal Victoria Hospital and faculty of medicine, McGill University,
Montreal Reprint requests to: Dr. H. G. Robson, 3775
md,
FIG. IA.Case 1. Bilateral homogeneous consolidation, more extensive on left. University St., Montreal, Que. H3A 2B4 196 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
lobe (anteroposterior projection) (Fig. 1) showed a crescent of air separating a large central mass of lung from the rest of the lower lobe. The patient underwent a left lower lobectomy on the 24th hospital
day. The resected specimen (Fig. 2) con¬ tained an abscess cavity measuring 11 x 9x7 cm; K. pneumoniae was cultured from a single large mass of necrotic lung within the abscess. Numerous blood vessels close to the abscess wall showed acute vasculitis and complete obstructing throm¬ bosis. There was no evidence of blood vessel invasion by microorganisms. The patient's condition improved imme¬ diately after operation. Despite the con¬ tinued presence of K. pneumoniae in the sputum he felt well. Antimicrobials were discontinued on hospital day 61, 16 days after he had first become afebrile. He again became febrile on hospital day 66, when a radiograph showed extension of the consolidation of the right upper lobe and numerous radiolucent areas within the consolidated parenchyma. Therapy with cephalothin and kanamycin was reinstituted. Antimicrobial therapy was dis¬ continued on hospital day 103 and the
patient
was
discharged.
WKKM FIG. 1B.Case 1. Anteroposterior
tomographic view on hospital day 19, showing crescent of air separating large central mass of lung from rest of lower lobe (arrows).
The patient was last seen 7 months after his hospital discharge; he complained only of slight dyspnea on exertion. Chest radio¬ graphy demonstrated some bilateral scarring in the midlung zones, and pulmonary function testing revealed a mild restrictive
pattern.
Case 2 A 50-year-old white man was admitted to Royal Victoria Hospital on May 25, 1972 with a 5-day history of fever, in¬ creasing dyspnea, right-sided pleuritic chest pain and cough productive of tenacious brown sputum. He had lost about 9 kg of weight during the previous year because
of undernutrition, but denied alcohol ingestion. He had a history of pneumonia 14 years earlier. He appeared moderately ill: his temper¬ ature was 38.3 °C, blood pressure 120/80 mm Hg, pulse rate 124 beats/min, respira¬ tory rate 28/min. Bronchial breathing and rales were audible over the right upper lobe. His hemoglobin concentration was 13.5 g/dl. The leukocyte count was 1500/mm3
(differential: neutrophils 19%, lympho¬ cytes 17%, monocytes 12%, metamyelocytes 12%, myelocytes 4%, bands 36%). The serum albumin concentration was 1.22 g/dl. Arterial blood gas values were the following: Po2 64 mm Hg, Pco2 29 Hg and pH 7.51. The smear of the sputum revealed many gram-negative rods mm
and
neutrophils;
K.
pneumoniae, type 1
cultured. Blood cultures were negative. The initial chest radiograph (Fig. 3A) revealed homogeneous consolidation of most of the right upper lobe, containing a prominent air bronchogram. During the following 2 weeks multiple areas of radiolucency appeared within the consolidated lung, which by hospital day 16 had coalesced into a large abscess cavity con¬ taining an irregular mass of necrotic lung was
FIG. 2.Case 1. Resected left lower lobe with large abscess cavity containing single large mass of necrotic lung.
FIG. 3A.Case 2. Homogeneous consolidation of most of right upper lobe, containing prominent air
bronchogram.
(Fig. 3B). The patient was treated with cephapirin sodium, 18 g/day intravenously, kanamy¬ cin, 1 g/day intramuscularly, and supplemental oxygen. He became afebrile on hospital day 15. At thoracotomy on hos¬ pital day 23 a right pneumonectomy was required because the necrotizing process had involved all three lobes of the right lung. Fig. 4 shows the mass of gangrenous lung in the large right upper lobe abscess cavity from which K. pneumoniae, type 1 was grown. Microscopic examination showed that the architecture of the lung was unrecognizable in many sections, and in others the ghosts of alveolar walls could be discerned. Blood vessels were necrotic, although no evidence of vessel invasion by organisms was apparent. The patient was discharged on hospital day 44, 1 week after antimicrobial therapy had been dis¬
The patient was readmitted 5 weeks later for open drainage of a right-sided empyema from which K. pneumoniae was cultured. He was last seen 3 months later, when he felt well and had no respiratory
complaints.
Discussion Osler1 described gangrene of the lung complication of a variety of condi¬ tions when necrotic areas undergo putrefaction: as a consequence of lobar as a
pneumonia,
or
following aspiration,
bronchiectasis or perforation of a bronchus by cancer of the esophagus. He described the lung as "converted into a horribly offensive greenish-black mass, torn and ragged in the centre". Table I lists the pertinent details of the 10 published case reports of pul¬ monary gangrene complicating lobar pneumonia. This entity has been given various labels such as spontaneous amputation,5 massive sequestrum of the lung2 and massive necrosis of the lung.8 Of the 10 reported cases 7 involved an upper lobe, 5 on the right side; the
offending organism was K. pneumoniae in 5 cases. All four patients with lung gangrene who received only medical therapy died, whereas all patients who had surgical intervention survived. In a number of the early cases it was reported that the necrotic lung was expelled, after coughing, through the incision at the time of open drainage for a suspected empyema. The radiologic manifestations of mas¬ sive pulmonary gangrene are dramatic and virtually diagnostic. The process begins with homogeneous consolidation of lung parenchyma, frequently with a bulging interlobar fissure if K. pneumo¬ niae
or
Streptococcus pneumoniae is the
continued.
FIG. 3B.Case 2. Appearance 2 weeks after that in Fig. 3A, showing large abscess cavity containing irregular mass of necrotic right upper lobe.
FIG. A.Case 2. Resected right lung with large upper lobe abscess cavity containing mass of gangrenous lung.
CMA JOURNAL/JANUARY 25, 1975/VOL. 112 197
etiologic agent, which suggests increased volume of the affected lobe. Within a few days multiple small irregular translucencies appear throughout the consolidated lung; these tend to coalesce into a single large cavity containing one or more irregular fragments of detached lung tissue. In the case reported by Brock2 the radiograph showed a crescent of air separating a mass of lung tissue from the pleura. In Fig. lB a crescent of air separates the necrotic lung from adjacent lung tissue. The gross pathologic features of lung gangrene are distinctive and differ from those of other forms of lung abscess. A piece of ragged, necrotic, but nonliquefied lung tissue lies detached inside a large abscess cavity, which often involves an entire lobe. Humphreys3 remarked that although the lung was necrotic its microscopic architecture was retained. He assumed that the process was secondary to thrombosis in pulmonary vessels. Other cases have shown extensive vascular thrombosis.2'4 The lung in our case 1 revealed acute vasculitis in many vessels, often associated with complete obstructing thrombosis, but without evidence of invasion of blood vessels by organisms. In case 2 the vessels were so necrotic and distorted that the presence of thrombosis could not be adequately assessed. Thomas and Brewster,8 in their report of a gangrenous left upper lobe that was extruded at thoracotomy, considered the surgical intervention as lifesaving. Danner, McFarland and Felson4 believed that early surgical intervention may be crucial in preventing a fatal outcome. Of the 12 patients whose cases have now been collected, all 4 patients treated medically died, whereas the 8 who were treated by a combined medical and surgical regimen survived. Two of the four medically treated patients who died were reported before the antibiotic era. In case 1 thoracotomy was necessary because the patient remained severely ill, with hectic fever and progression of the lesion, despite intensive antimicro-
bial and supportive therapy. A similar, though less extensive, disease process in the right upper lobe fortunately cleared without surgical intervention but required an extension of hospitalization for intensive antimicrobial therapy totalling 37 days. In case 2, because of the extent of the disease and because of our experience with case 1, thoracotomy was scheduled as soon as the debilitated patient's condition and preoperative status were considered acceptable. The mortality of pneumonia due to K. pneumoniae in the preantibiotic era was 50 to 80% .. Because the disease often occurs in a debilitated host and may be associated with drug resistance of the organism, the prognosis even now must remain guarded. The complication of pulmonary gangrene must further increase the severity of this disease. One of our two patients (case 2) was only moderately ill on admission, so that adequate medical therapy to prepare him for surgery was feasible. It is conceivable that optimum medical treatment alone might *be effective, for a less extensive but similar process in case 1 resolved without surgical intervention. Nevertheless, we are impressed with the need for early surgical intervention and long-term antimicrobial therapy in the treatment of massive lung gangrene.
Year 1921
1. OSLER W: The Principles and Practice of Medicine. New York, Appleton, 1897, p 584 2. BROCK RC: Studies in lung abscess. Guys Hosp Rep 95: 40, 1946 3. HUMPHREYS DR: Spontaneous lobectomy. Dr Med J II: 185, 1945 4. DANNER PK, MCFARLAND DR, FELsoN B: Massive pulmonary gangrene. Am J Roentgenol Radium Ther Nuci Med 103: 548, 1968 5. LENOBLE E, JEGAT Y: Gangrene limit.e . une portion du poumon droit avec amputation spontan6e du lobe sup6rieur. Bull Mem
Soc Med Hop Paris 46: 591, 1922
6. HYDE L, HYDE B: Primary Friedlander pneumonia. Am I Med Sci 205: 660, 1943 7. TAYLOR JW: Spontaneous lobectomy. Br Med I II: 500, 1944 8. THOMAS JH, BREWSTER OM: Friedlander pneumonia with massive necrosis of lung. Br Med I II: 817, 1952 9. TURCE M, PETER5DORF RG: Kiebsiella infec-
tion (chap 148), in Harrison's Principles of
internal Medicine, sixth ed, edited by WINThOSE MM, THORN GW, ADAMS RD. et a!, New York, McGraw, 1970, p 810
6 7 3
1943 1944 1945
2
1946
8 4
1952 1968
Means of establishing diagnosis Autopsy
Lobe involved Organism Therapy RUL ? Staphylococcus Medical
Outcome Death
Autopsy Open drainage Open drainage Open drainage Thoracotomy
RUL LIL RLL RUL
Medical Surgical Surgical Surgical Surgical
Death Survival Survival Survival Survival
K. pneumoniae Surgical S. pneumoniae Medical S. pneumoniae Surgical Medical
Survival Death Survival Death
Thoracotomy Autopsy Thoracotomy Autopsy
? Streptococcus pneumoniae RMLI RLL, LLL Kiebsiella pneumoniae
LUL RUL LUL
K. pneumoniae K. pneumoniae K. pneumoniae ? K. pneumoniae
? S. pneumoniae
198 CMA JOURNAL/JANUARY 25, 1975/VOL. 112
DRU)RAL is a sustained-action tableted preparation for twice-a-day administration which provides effective relief of symptoms of nasal congestion. Each tablet contains 6mg dexbrompheniramine maleate N.E. and 120mg d-isoephedrine sulphate. These two active components are distributed equally between the tablet's outer coating and a sustainedrelease inner core.
m
References
Table I-Lung gangrene: summary of 10 previously reported cases Reference No. 5
SCHERINO
DRIXORAL tablets are indicated for relief of symptoms of upper respiratory mucosal congestion in seasonal and perennial nasal allergies, acute rhinitis and rhinosinusitis, acute and subacute sinusitis, eustachian tube blockage, and secretory otitis media. [email protected]. DRIXORAL tablets should not be given to children under 12 years of age and should not be administered to pregnant women.
m5
Due to the d-isoephedrine content of DRIXORAL, it should be used with caution in patients with hypertension, coronary artery disease and hyperthyroid ism.
ADW.
Mild drowsiness and skin rash have been observed occasionally in patients receiving DRIXORAL.
[email protected]:
There is no specific antidote tor DRIXORAL. Specific therapy will depend on the predominant symptoms observed. [email protected]: For adults and for children 12 or more years of age-one DRIXORAL tablet in the morning and one at bedtime. In exceptional cases, administration of one tablet every 8 hours may be required. Full information is available on request from Schering Corporation Limited, Pointe Claire, Quebec H9R 1 B4.
DR.QR.L
