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Longtime smoker with fever and cough.

Our appreciation is extended to Dr. Daniel Sova,
Indiana University Department of Radiology,
for contributing this case.

History:  Longtime smoker with fever and cough.
Click these images to enlarge them.

Click for galleryClick for galleryPlease respond to the following with TRUE or FALSE.
There are findings compatible with pneumonia

True or False
There are findings compatible with pleural effusion

True or False
There are findings compatible with an anterior mediastinal mass

True or False
There are findings compatible with emphysema

True or False
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Longtime smoker with fever and cough.

A CT scan was also performed on the patient. Click these images to enlarge them.

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What is in your differential diagnosis for the salient CT finding above? Please derive your list before proceeding (differential revealed on an upcoming page).

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Longtime smoker with fever and cough.

Here are additional images from the same CT scan just shown. Click to enlarge.

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Before proceeding, please determine what you think of the salient finding on these images.

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Longtime smoker with fever and cough.



Back to the first CT images (click to enlarge again). Can you select the actual diagnosis?

Lung abscess.Bronchogenic carcinoma.Wegener's granulomatosis.Histoplasmosis.Septic embolus.Click for galleryClick for gallery
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Longtime smoker with fever and cough.

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Findings:  Chest x-ray: Right upper lobe airspace disease, right middle lobe airspace disease, right pleural effusion. CT Chest: There is severe centrilobular emphysema. There is a 1.2 cm spiculated semisolid nodule within the right upper lobe. There is a 4.2 cm peripherally enhancing low-density collection within or abutting the right major fissure


Differential diagnosis for the dominant (necrotic appearing) lesion:

  • Lung abscess
  • Malignancy (bronchogenic carcinoma, lymphoma, metastases)
  • Septic emboli (with lung abscess)
  • Wegener's granulomatosis
  • Fungal infection (histoplasmosis)
  • TB
Diagnosis:  Lung abscess

Still unresolved is the status of the smaller R apical lesion.  The patient was treated for his lung abscess and was lost to follow up despite multiple attempts to further evaluate and monitor this lesion.  Over a year later, the patient returned with new complaints.

Click these images to enlarge them. 

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Findings:  The site of the lung abscess shows a scar.  There is now a large malignant R apical mass that abuts the chest wall.

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Longtime smoker with fever and cough.

Key points - Lung abscess:

  • Inner cavity is irregular/nodular/spiculated in cancer but smooth or shaggy in abscess. Outer wall is thick and irregular.
  • Cavity wall is usually greater than 4mm.If the wall is greater than 15mm, suggests malignancy. Less than 4mm thick wall favors cystic lesions (bulla, LAM, pneumatocele, coccidiomycoses)
  • Often contains air-fluid levels ~75%, though air fluid level is not specific for abscess. These can be seen with invasive aspergillosis, cancer, and sometimes Wegener's.
  • It is very common to see reactive mediastinal and hilar lymphadenopathy.
  • Time course guides diagnosis - acute processes favor infection or trauma, subacute or chronic favors malignancy or immunologic.
  • Definitions:
    • Abscess - collection of pus in the lung with formation of a new cavity
    •  Empyema - collection of pus in the pleural space (or other anatomic space)
  • Most common cause of abscess is aspiration pneumonia with abscess formation usually occurring 7-14 days after inciting event.
  • Treatment is antibiotics (clindamycin) for several weeks. Treatment of empyema on the other hand involves thoracostomy tube and antibiotics.

References:

  1. Mayo Clinic Proceedings June 2003 vol. 78 no. 6 744-752.
  2. Up-to-date. Lung Abscess. August 8, 2011.
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Longtime smoker with fever and cough.


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