Lung abscess differential diagnosis: Difference between revisions

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Lung abscess must be differentiated from other cavitary lesions that cause cough, fever with chills and rigor and chest pain such as malignancy, tuberculosis, Wegener's granulomatosis, rheumatoid nodules.
Lung abscess must be differentiated from other cavitary lesions that cause cough, fever with chills and rigor and chest pain such as malignancy, tuberculosis, Wegener's granulomatosis, rheumatoid nodules.


==Differntial diagnosis==
==Differential diagnosis==




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!Causes of
!Causes of
lung cavities
lung cavities
!Differntiating Features
!Differentiating Features
!Differntiating lab findings
!Differentiating lab findings
!Diagnosis  
!Diagnosis  
confirmation
confirmation
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*Elderly male or female <ref name="pmid4353362">{{cite journal |vauthors=Chaudhuri MR |title=Primary pulmonary cavitating carcinomas |journal=Thorax |volume=28 |issue=3 |pages=354–66 |year=1973 |pmid=4353362 |pmc=470041 |doi= |url=}}</ref>
*Elderly male or female <ref name="pmid4353362">{{cite journal |vauthors=Chaudhuri MR |title=Primary pulmonary cavitating carcinomas |journal=Thorax |volume=28 |issue=3 |pages=354–66 |year=1973 |pmid=4353362 |pmc=470041 |doi= |url=}}</ref>
*Associated with a low-grade fever, absence of leukocytosis, minimal systemic complaints,
*Presents with a low-grade fever, absence of leukocytosis, systemic complaints weight loss,fatigue.
*Absence of factors that predispose to gastric content aspiration, no response to antibiotics within 10 days,  
*Absence of factors that predispose to gastric content aspiration, no response to antibiotics within 10 days,  
*Follows a deteriorating course. 
*Hemoptysis is commonly associated with bronchogenic carcinoma
*Hemoptysis is commonly associated with bronchogenic carcinoma
*Weight loss,fatigue,
|
|
*A coin-shaped lesion with thick wall(>15mm) is seen on X-ray with less ground glass opacities.<ref name="pmid8572761">{{cite journal |vauthors=Mouroux J, Padovani B, Elkaïm D, Richelme H |title=Should cavitated bronchopulmonary cancers be considered a separate entity? |journal=Ann. Thorac. Surg. |volume=61 |issue=2 |pages=530–2 |year=1996 |pmid=8572761 |doi=10.1016/0003-4975(95)00973-6 |url=}}</ref> <ref name="pmid16183941">{{cite journal |vauthors=Onn A, Choe DH, Herbst RS, Correa AM, Munden RF, Truong MT, Vaporciyan AA, Isobe T, Gilcrease MZ, Marom EM |title=Tumor cavitation in stage I non-small cell lung cancer: epidermal growth factor receptor expression and prediction of poor outcome |journal=Radiology |volume=237 |issue=1 |pages=342–7 |year=2005 |pmid=16183941 |doi=10.1148/radiol.2371041650 |url=}}</ref>
*A coin-shaped lesion with thick wall(>15mm) is seen on X-ray with less ground glass opacities.<ref name="pmid8572761">{{cite journal |vauthors=Mouroux J, Padovani B, Elkaïm D, Richelme H |title=Should cavitated bronchopulmonary cancers be considered a separate entity? |journal=Ann. Thorac. Surg. |volume=61 |issue=2 |pages=530–2 |year=1996 |pmid=8572761 |doi=10.1016/0003-4975(95)00973-6 |url=}}</ref> <ref name="pmid16183941">{{cite journal |vauthors=Onn A, Choe DH, Herbst RS, Correa AM, Munden RF, Truong MT, Vaporciyan AA, Isobe T, Gilcrease MZ, Marom EM |title=Tumor cavitation in stage I non-small cell lung cancer: epidermal growth factor receptor expression and prediction of poor outcome |journal=Radiology |volume=237 |issue=1 |pages=342–7 |year=2005 |pmid=16183941 |doi=10.1148/radiol.2371041650 |url=}}</ref>
*Sputum cytology shows malignant cells  
*Sputum cytology shows malignant cells  
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|
*CT and bronchoscope identifies the lesions
*Biopsy of lung
*Biopsy confirms it
|-
|-
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*Tuberculsosis
*Tuberculosis
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*Systemic symptoms of fatigue, malaise, anorexia, and weight loss, as well as a low-grade fever with night sweats
*Any age group
*Symptoms include productive cough,night sweats ,fever and weight loss.
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|
*Xray shows cavities in the upper lobe of the lung
*CXR and CT demonstrates cavities in the upper lobe of the lung.
*On CT cavitating lesions are seen in the upper lobes accompanied by parenchymal infiltrates .
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*Sputum smear and culture in Lowenstein-Jensen media is  positive for acid-fast bacilli.
*Sputum smear positive for acid-fast bacilli and culture in Lowenstein-Jensen media grows mycobacteria.
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|-
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*Necrotizing Pneumonia
*Necrotizing Pneumonia
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*Acute, fulminant infection with rapid progression  
*Any age group
*Acute, fulminant infection with rapid progression
*>100.4F fever, with hemodynamic instability 
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*Multiple cavities are seen on xray
*CXR demonstrates multiple cavitary lesions
*Pleural effusion and empyema are common findings.
*Pleural effusion and empyema are common findings.
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|
*Causative organisms include Streptococcus pneumoniae,Staphylococcus aureus, Klebsiella pneumoniae, and Pseudomonas species.
*CBC is positive for causative organism .  
|-
|-
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*Loculated empyema
*Loculated empyema
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*dullness to percussion, decreased breath sounds, and reduced vocal resonance on examination
*Pleuritic chest pain, dry cough, fever with chills
*Dullness to percussion decreased breath sounds, and reduced vocal resonance on examination
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*Empyema appears lenticular in shape, and has a thin wall with smooth luminal margins and a smooth exterior wall.
*Empyema appears lenticular in shape and has a thin wall with smooth luminal margins.
|
|
*Thoracocentesis
*Thoracocentesis
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*Granulomatosis with polyangiitis (Wegener's)<ref name="pmid10377211">{{cite journal |vauthors=Langford CA, Hoffman GS |title=Rare diseases.3: Wegener's granulomatosis |journal=Thorax |volume=54 |issue=7 |pages=629–37 |year=1999 |pmid=10377211 |pmc=1745525 |doi= |url=}}</ref>
*Granulomatosis with polyangiitis (Wegener's)<ref name="pmid10377211">{{cite journal |vauthors=Langford CA, Hoffman GS |title=Rare diseases.3: Wegener's granulomatosis |journal=Thorax |volume=54 |issue=7 |pages=629–37 |year=1999 |pmid=10377211 |pmc=1745525 |doi= |url=}}</ref>
|
|
*Women are more commonly effected that man.
*Upper respiratory tract: perforation of nasal septum,chronic sinusitis, otitis media,mastoditis.<ref name="pmid12541109">{{cite journal |vauthors=Lee KS, Kim TS, Fujimoto K, Moriya H, Watanabe H, Tateishi U, Ashizawa K, Johkoh T, Kim EA, Kwon OJ |title=Thoracic manifestation of Wegener's granulomatosis: CT findings in 30 patients |journal=Eur Radiol |volume=13 |issue=1 |pages=43–51 |year=2003 |pmid=12541109 |doi=10.1007/s00330-002-1422-2 |url=}}</ref>
*Upper respiratory tract: perforation of nasal septum,chronic sinusitis, otitis media,mastoditis.<ref name="pmid12541109">{{cite journal |vauthors=Lee KS, Kim TS, Fujimoto K, Moriya H, Watanabe H, Tateishi U, Ashizawa K, Johkoh T, Kim EA, Kwon OJ |title=Thoracic manifestation of Wegener's granulomatosis: CT findings in 30 patients |journal=Eur Radiol |volume=13 |issue=1 |pages=43–51 |year=2003 |pmid=12541109 |doi=10.1007/s00330-002-1422-2 |url=}}</ref>
*Lower respiratory tract: hemoptysis, cough,dyspnea.
*Lower respiratory tract: hemoptysis, cough,dyspnea.
*Renal: hematuria, red cell casts
*Renal: hematuria, red cell casts
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*Pulmunory nodules with cavities and infiltrates are a frequent manifestation on CXR.
*Pulmonary nodules with cavities and infiltrates are a frequent manifestation on CXR.


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*Rheumatoid nodule  
*Rheumatoid nodule  
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*Symmetric arthritis of the small joints of the hands and feet with morning stiffness are common manifestations.
*Manifestation of rheumatoid nodules.
*Presents with other systemic symptoms incluing symmetric arthritis of the small joints of the hands and feet with morning stiffness are common manifestations.
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*Pulmonary nodules with cavitation are located in the upper lobe (Caplan syndrome) on Xray.
*Pulmonary nodules with cavitation are located in the upper lobe (Caplan syndrome) on Xray.
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*Bell palsy,
*Bell palsy,
*Epithelioid granulomas containing microscopic Schaumann and asteroid bodies,  
*Epithelioid granulomas containing microscopic Schaumann and asteroid bodies,  
*Uveitis,
*Hypercalcemia
|  
|  
*On chest Xray bilateral adenopathy and coarse reticular opacities are seen.  
*On chest Xray bilateral adenopathy and coarse reticular opacities are seen.  

Revision as of 20:05, 6 February 2017

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Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1];Associate Editor(s)-in-Chief: Aditya Ganti M.B.B.S. [2]

Overview

Lung abscess must be differentiated from other cavitary lesions that cause cough, fever with chills and rigor and chest pain such as malignancy, tuberculosis, Wegener's granulomatosis, rheumatoid nodules.

Differential diagnosis

Causes of

lung cavities

Differentiating Features Differentiating lab findings Diagnosis

confirmation

  • Malignancy (Primary lung cancer)[1]
  • Elderly male or female [1]
  • Presents with a low-grade fever, absence of leukocytosis, systemic complaints weight loss,fatigue.
  • Absence of factors that predispose to gastric content aspiration, no response to antibiotics within 10 days,
  • Hemoptysis is commonly associated with bronchogenic carcinoma
  • A coin-shaped lesion with thick wall(>15mm) is seen on X-ray with less ground glass opacities.[2] [3]
  • Sputum cytology shows malignant cells
  • Biopsy of lung
  • Tuberculosis
  • Any age group
  • Symptoms include productive cough,night sweats ,fever and weight loss.
  • CXR and CT demonstrates cavities in the upper lobe of the lung.
  • Sputum smear positive for acid-fast bacilli and culture in Lowenstein-Jensen media grows mycobacteria.
  • Necrotizing Pneumonia
  • Any age group
  • Acute, fulminant infection with rapid progression
  • >100.4F fever, with hemodynamic instability
  • CXR demonstrates multiple cavitary lesions
  • Pleural effusion and empyema are common findings.
  • CBC is positive for causative organism .
  • Loculated empyema
  • Pleuritic chest pain, dry cough, fever with chills
  • Dullness to percussion decreased breath sounds, and reduced vocal resonance on examination
  • Empyema appears lenticular in shape and has a thin wall with smooth luminal margins.
  • Thoracocentesis
  • Granulomatosis with polyangiitis (Wegener's)[4]
  • Women are more commonly effected that man.
  • Upper respiratory tract: perforation of nasal septum,chronic sinusitis, otitis media,mastoditis.[5]
  • Lower respiratory tract: hemoptysis, cough,dyspnea.
  • Renal: hematuria, red cell casts
  • Pulmonary nodules with cavities and infiltrates are a frequent manifestation on CXR.
  • Positive for P-ANCA
  • Biopsy of the tissue involved shows necrotizing granulomas [4]
  • Rheumatoid nodule
  • Manifestation of rheumatoid nodules.
  • Presents with other systemic symptoms incluing symmetric arthritis of the small joints of the hands and feet with morning stiffness are common manifestations.
  • Pulmonary nodules with cavitation are located in the upper lobe (Caplan syndrome) on Xray.
  • Positive for both rheumatoid factor and anticyclic citrullinated peptide antibody
  • Sarcoidosis
  • More common in African-American females.
  • Often asymptomatic except for enlarged lymph nodes.[6]
  • Associated with restrictive lung disease (interstitial fibrosis),
  • Erythema nodosum,
  • Lupus pernio (skin lesions on face resembling lupus),
  • Bell palsy,
  • Epithelioid granulomas containing microscopic Schaumann and asteroid bodies,
  • On chest Xray bilateral adenopathy and coarse reticular opacities are seen.
  • CT of the chest demonstrates extensive hilar and mediastinal adenopathy
  • Additional findings on CT include fibrosis (honeycomb, linear, or associated with bronchial distortion), pleural thickening, and ground-glass opacities.[7]
  • Non-caseating granuloma on lung biopsy
  • Bronchiolitis obliterans (Cryptogenic organizing pneumonia)[8][9]
  • It is a pathological diagnosis
  • And is triggered by drug or toxin exposure, autoimmune diseases,viral infections, or radiation injury but is most often idiopathic
  • Presents with fever, cough, weight loss, and dyspnea over weeks to months, similar to many infectious diseases[10]
  • Common appearance on CT is patchy consolidation,often accompanied by ground-glass opacities and nodules.[11]
  • Langerhan'scell histiocytosis[12]
  • Exclusively afflicts smokers, with a peak age of onset of between 20 and 40 years.
  • Clinical presentation varies, but symptoms generally include months of drycough, fever, night sweats, and weight loss.
  • Thin-walled cystic cavities are the usual radiographic manifestation, observed in over 50% of patients by either plain chest radiography or computed tomography scans.[13]
  • Biopsy of the lung

Reference

  1. ↑ 1.0 1.1 Chaudhuri MR (1973). "Primary pulmonary cavitating carcinomas". Thorax. 28 (3): 354–66. PMC 470041. PMID 4353362.
  2. ↑ Mouroux J, Padovani B, Elkaïm D, Richelme H (1996). "Should cavitated bronchopulmonary cancers be considered a separate entity?". Ann. Thorac. Surg. 61 (2): 530–2. doi:10.1016/0003-4975(95)00973-6. PMID 8572761.
  3. ↑ Onn A, Choe DH, Herbst RS, Correa AM, Munden RF, Truong MT, Vaporciyan AA, Isobe T, Gilcrease MZ, Marom EM (2005). "Tumor cavitation in stage I non-small cell lung cancer: epidermal growth factor receptor expression and prediction of poor outcome". Radiology. 237 (1): 342–7. doi:10.1148/radiol.2371041650. PMID 16183941.
  4. ↑ 4.0 4.1 Langford CA, Hoffman GS (1999). "Rare diseases.3: Wegener's granulomatosis". Thorax. 54 (7): 629–37. PMC 1745525. PMID 10377211.
  5. ↑ Lee KS, Kim TS, Fujimoto K, Moriya H, Watanabe H, Tateishi U, Ashizawa K, Johkoh T, Kim EA, Kwon OJ (2003). "Thoracic manifestation of Wegener's granulomatosis: CT findings in 30 patients". Eur Radiol. 13 (1): 43–51. doi:10.1007/s00330-002-1422-2. PMID 12541109.
  6. ↑ Baughman RP, Teirstein AS, Judson MA, Rossman MD, Yeager H, Bresnitz EA, DePalo L, Hunninghake G, Iannuzzi MC, Johns CJ, McLennan G, Moller DR, Newman LS, Rabin DL, Rose C, Rybicki B, Weinberger SE, Terrin ML, Knatterud GL, Cherniak R (2001). "Clinical characteristics of patients in a case control study of sarcoidosis". Am. J. Respir. Crit. Care Med. 164 (10 Pt 1): 1885–9. doi:10.1164/ajrccm.164.10.2104046. PMID 11734441.
  7. ↑ Brauner MW, Grenier P, Mompoint D, Lenoir S, de Crémoux H (1989). "Pulmonary sarcoidosis: evaluation with high-resolution CT". Radiology. 172 (2): 467–71. doi:10.1148/radiology.172.2.2748828. PMID 2748828.
  8. ↑ Murphy J, Schnyder P, Herold C, Flower C (1998). "Bronchiolitis obliterans organising pneumonia simulating bronchial carcinoma". Eur Radiol. 8 (7): 1165–9. doi:10.1007/s003300050527. PMID 9724431.
  9. ↑ 9.0 9.1 Al-Ghanem S, Al-Jahdali H, Bamefleh H, Khan AN (2008). "Bronchiolitis obliterans organizing pneumonia: pathogenesis, clinical features, imaging and therapy review". Ann Thorac Med. 3 (2): 67–75. doi:10.4103/1817-1737.39641. PMC 2700454. PMID 19561910.
  10. ↑ Cordier JF, Loire R, Brune J (1989). "Idiopathic bronchiolitis obliterans organizing pneumonia. Definition of characteristic clinical profiles in a series of 16 patients". Chest. 96 (5): 999–1004. PMID 2805873.
  11. ↑ Lee KS, Kullnig P, Hartman TE, Müller NL (1994). "Cryptogenic organizing pneumonia: CT findings in 43 patients". AJR Am J Roentgenol. 162 (3): 543–6. doi:10.2214/ajr.162.3.8109493. PMID 8109493.
  12. ↑ Suri HS, Yi ES, Nowakowski GS, Vassallo R (2012). "Pulmonary langerhans cell histiocytosis". Orphanet J Rare Dis. 7: 16. doi:10.1186/1750-1172-7-16. PMC 3342091. PMID 22429393.
  13. ↑ Moore AD, Godwin JD, Müller NL, Naidich DP, Hammar SP, Buschman DL, Takasugi JE, de Carvalho CR (1989). "Pulmonary histiocytosis X: comparison of radiographic and CT findings". Radiology. 172 (1): 249–54. doi:10.1148/radiology.172.1.2787035. PMID 2787035.


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