Percutaneous
Downloaded from www.ajronline.org by 114.44.135.176 on 09/13/15 from IP address 114.44.135.176. Copyright ARRS. For personal use only; all rights reserved
DIXIE
J. ARONBERG,’
Drainage
STUART
S. SAGEL,
R. GILBERT
Since entering the antibiotic era, pulmonary abscess has generally not been a therapeutic problem. When medical therapy fails, surgical drainage or resection of the cavity is
usually
curative
[1].
However,
surgery
may
in clinical
the
drainage
methods,
who
responded
of a complicated
lung
Case W. S., a 63-year-old
and hemoptysis.
Chest
man,
to
percutaneous
abscess.
radiography
technique,
weight
loss,
disclosed
chest
a left hilar mass,
was
for 2 weeks
but there
Fig.
631
Received August 28, 1978; accepted after revision , All authors: Mallinckrodt Institute of Radiology, 10. Address reprint requests to 0. J. Aronberg.
AJR 132:282-283, © 1979 American
F#{149}bruary 1979 Roentgen
Ray Society
I. LEE
radiographs.
orifice
Complete
precluded
obstruction
drainage
of
of
the
October Washington
no.
8 French
pigtail
angio-
with
with
vaseline-impregnated
necrotic
debris,
gauze.
necessitating
The
intermittent
catheter
irriga-
The patient improved clinically and the fluid within the cavity resolved. He was discharged 5 days later on oral penicillin therapy with the catheter in place, and it was removed after 2 weeks. Repeat radiography showed a residual cystic structure
cavity in superior
17, 1978. University
guided
tion.
was no change
1.-Abscess
a fluoroscopicaily
sealed
clogged
Late in the course of irradiation the patient developed chills, fever, and a large cavitary mass with an air-fluid level in the superior segment of the left lower lobe (fig. 1). Antibiotics were intravenously
or chest
segmental
JONG
graphic catheter was placed into the abscess cavity (fig. 2) to establish drainage. This method is modified from the percutaneous nephrostomy placement procedure [2]. The catheter was secured to the skin with sutures, and the skin-catheter interface
pain,
an infiltrate in the superior segment of the left lower lobe, and a left pleural effusion. Adenocarcinoma was found by bronchoscopic biopsy. Fluid from a thoracentesis also revealed malignant cells. For 2 months, radiation therapy to 6,000 rad was delivered to opposing 8 x 9 cm portals.
administered
status
superior
AND
date due to the poor prognosis of his underlying disease, his severely compromised pulmonary function status, and the prior high-dose radiation therapy. Using percutaneous Seldinger
Report suffered
JOST,
cavity by fiberoptic bronchoscopy. Percutaneous needle aspiration of the cavity with an 18-gauge needle was performed to try to establish the infecting organism, and 150 ml of purulent material was obtained; culture yielded a mixed growth of diphtheroids, Staphylococcus aureus, and beta-hemolytic streptococcus. Additional antibiotics administered for several days had no effect. At this time the patient was not considered a surgical candi-
subject
some patients to substantial hazard and in the poor operative risk patient, percutaneous drainage of the abscess may be an effective alternate treatment. This case report describes a patient, refractory to the usual treatment
of Lung Abscess
School
282
segment
of left lower lobe.
of Medicine,
510 South
Kingshighway
Boulevard,
St. Louis,
0361-803X/79/1322-0282
Missouri
$0.00
Downloaded from www.ajronline.org by 114.44.135.176 on 09/13/15 from IP address 114.44.135.176. Copyright ARRS. For personal use only; all rights reserved
AJR:132,
February
1979
CASE
2.-A,
Fig.
without
fluid
symptoms
content.
After placement
The patient
6 months
is alive
after percutaneous
of drainage
without
catheter
catheter.
[1].
The
risk
for
veloping
this
patient
seemed
cently
used
to
treat
pyogonic
emphasized
in the
tuberculous
lung
lesions
abscesses
radiologic
[4-6],
abscess cavity.
and
more
has
not
a persistent
pecially
because
therapy;
fortunately
sinus
of
the
this
tract
preceding
did
was
considered,
high-dose
esradiation
not occur.
REFERENCES 1
.
Chidi
CC,
consecutive
Mendelsohn HJ: cases. J Thorac
Lung abscess: results of 90 Cardiovasc Sung 69: 168-172,
1974
prohibitive. Alternate drainage methods include both transbronchial [3] (which was precluded in this case by bronchial obstruction) and percutaneous catheter techniques. Percutaneous tube drainage of cavitary lesions, first
well within
although this may occur spontaneously as well. This risk should also be reduced when preexisting pleural adhesions are present. In this patient the possibility of de-
drainage.
Discussion
disease
B, Catheter
pulmonary
Lung abscess today is largely a medical disease [1]. In our case, the presence of a proximal obstructing lesion inhibiting drainage was primarily responsible for developrnent of this refractory abscess. Resecting the abscess (lobectomy) has been the recommended treatment for patients unresponsive to medical therapy; however, surgical mortality is high in patients with associated debilitating
283
REPORTS
re-
been
literature.
The potential complications of percutaneous catheter drainage, primarily pneumothorax [7], probably parallel needle aspiration biopsy. The risk of pneumothorax is undoubtedly greatly diminished in subacute or chronic abscesses because of the development of pleurodesis. There is a theoretical potential for causing an empyema,
2. Barbaric lostomy: 3. Marquis catheter 4. Monaldi
JL, Wood B: Emergency percutaneous nephropyea series and review. AJR 128 :453-458, 1977 J: Treatment of lung abscess by transbronchial drainage. Radiology 107:61-62, 1973 V: Endocavitary aspiration in the treatment of lung abscess. Chest 29 : 1 93-201 , 1956 5. Morris JF, Okies JE: Enterococcal lung abscess: medical and surgical therapy. Chest 65:688-691 , 1974 6. Vainrub B, Musher DM, Guinn GA, Young EJ, Septimus EJ, Travis LL: Percutaneous drainage of lung abscess. Am Rev RespirDis 117:153-160, 1978 7. Sagel 55, Fergusson TB, Forrest JV, Roper CL, Weldon CS, Clark biopsy.
RE:
Ann
Percutaneous
Thorac
transthoracic
Sung.
In press,
aspiration
1978
needle
Downloaded from www.ajronline.org by 114.44.135.176 on 09/13/15 from IP address 114.44.135.176. Copyright ARRS. For personal use only; all rights reserved
DIXIE
J. ARONBERG,’
Drainage
STUART
S. SAGEL,
R. GILBERT
Since entering the antibiotic era, pulmonary abscess has generally not been a therapeutic problem. When medical therapy fails, surgical drainage or resection of the cavity is
usually
curative
[1].
However,
surgery
may
in clinical
the
drainage
methods,
who
responded
of a complicated
lung
Case W. S., a 63-year-old
and hemoptysis.
Chest
man,
to
percutaneous
abscess.
radiography
technique,
weight
loss,
disclosed
chest
a left hilar mass,
was
for 2 weeks
but there
Fig.
631
Received August 28, 1978; accepted after revision , All authors: Mallinckrodt Institute of Radiology, 10. Address reprint requests to 0. J. Aronberg.
AJR 132:282-283, © 1979 American
F#{149}bruary 1979 Roentgen
Ray Society
I. LEE
radiographs.
orifice
Complete
precluded
obstruction
drainage
of
of
the
October Washington
no.
8 French
pigtail
angio-
with
with
vaseline-impregnated
necrotic
debris,
gauze.
necessitating
The
intermittent
catheter
irriga-
The patient improved clinically and the fluid within the cavity resolved. He was discharged 5 days later on oral penicillin therapy with the catheter in place, and it was removed after 2 weeks. Repeat radiography showed a residual cystic structure
cavity in superior
17, 1978. University
guided
tion.
was no change
1.-Abscess
a fluoroscopicaily
sealed
clogged
Late in the course of irradiation the patient developed chills, fever, and a large cavitary mass with an air-fluid level in the superior segment of the left lower lobe (fig. 1). Antibiotics were intravenously
or chest
segmental
JONG
graphic catheter was placed into the abscess cavity (fig. 2) to establish drainage. This method is modified from the percutaneous nephrostomy placement procedure [2]. The catheter was secured to the skin with sutures, and the skin-catheter interface
pain,
an infiltrate in the superior segment of the left lower lobe, and a left pleural effusion. Adenocarcinoma was found by bronchoscopic biopsy. Fluid from a thoracentesis also revealed malignant cells. For 2 months, radiation therapy to 6,000 rad was delivered to opposing 8 x 9 cm portals.
administered
status
superior
AND
date due to the poor prognosis of his underlying disease, his severely compromised pulmonary function status, and the prior high-dose radiation therapy. Using percutaneous Seldinger
Report suffered
JOST,
cavity by fiberoptic bronchoscopy. Percutaneous needle aspiration of the cavity with an 18-gauge needle was performed to try to establish the infecting organism, and 150 ml of purulent material was obtained; culture yielded a mixed growth of diphtheroids, Staphylococcus aureus, and beta-hemolytic streptococcus. Additional antibiotics administered for several days had no effect. At this time the patient was not considered a surgical candi-
subject
some patients to substantial hazard and in the poor operative risk patient, percutaneous drainage of the abscess may be an effective alternate treatment. This case report describes a patient, refractory to the usual treatment
of Lung Abscess
School
282
segment
of left lower lobe.
of Medicine,
510 South
Kingshighway
Boulevard,
St. Louis,
0361-803X/79/1322-0282
Missouri
$0.00
Downloaded from www.ajronline.org by 114.44.135.176 on 09/13/15 from IP address 114.44.135.176. Copyright ARRS. For personal use only; all rights reserved
AJR:132,
February
1979
CASE
2.-A,
Fig.
without
fluid
symptoms
content.
After placement
The patient
6 months
is alive
after percutaneous
of drainage
without
catheter
catheter.
[1].
The
risk
for
veloping
this
patient
seemed
cently
used
to
treat
pyogonic
emphasized
in the
tuberculous
lung
lesions
abscesses
radiologic
[4-6],
abscess cavity.
and
more
has
not
a persistent
pecially
because
therapy;
fortunately
sinus
of
the
this
tract
preceding
did
was
considered,
high-dose
esradiation
not occur.
REFERENCES 1
.
Chidi
CC,
consecutive
Mendelsohn HJ: cases. J Thorac
Lung abscess: results of 90 Cardiovasc Sung 69: 168-172,
1974
prohibitive. Alternate drainage methods include both transbronchial [3] (which was precluded in this case by bronchial obstruction) and percutaneous catheter techniques. Percutaneous tube drainage of cavitary lesions, first
well within
although this may occur spontaneously as well. This risk should also be reduced when preexisting pleural adhesions are present. In this patient the possibility of de-
drainage.
Discussion
disease
B, Catheter
pulmonary
Lung abscess today is largely a medical disease [1]. In our case, the presence of a proximal obstructing lesion inhibiting drainage was primarily responsible for developrnent of this refractory abscess. Resecting the abscess (lobectomy) has been the recommended treatment for patients unresponsive to medical therapy; however, surgical mortality is high in patients with associated debilitating
283
REPORTS
re-
been
literature.
The potential complications of percutaneous catheter drainage, primarily pneumothorax [7], probably parallel needle aspiration biopsy. The risk of pneumothorax is undoubtedly greatly diminished in subacute or chronic abscesses because of the development of pleurodesis. There is a theoretical potential for causing an empyema,
2. Barbaric lostomy: 3. Marquis catheter 4. Monaldi
JL, Wood B: Emergency percutaneous nephropyea series and review. AJR 128 :453-458, 1977 J: Treatment of lung abscess by transbronchial drainage. Radiology 107:61-62, 1973 V: Endocavitary aspiration in the treatment of lung abscess. Chest 29 : 1 93-201 , 1956 5. Morris JF, Okies JE: Enterococcal lung abscess: medical and surgical therapy. Chest 65:688-691 , 1974 6. Vainrub B, Musher DM, Guinn GA, Young EJ, Septimus EJ, Travis LL: Percutaneous drainage of lung abscess. Am Rev RespirDis 117:153-160, 1978 7. Sagel 55, Fergusson TB, Forrest JV, Roper CL, Weldon CS, Clark biopsy.
RE:
Ann
Percutaneous
Thorac
transthoracic
Sung.
In press,
aspiration
1978
needle
