Ann Thorac Surg 2009;87:310-311. doi:10.1016/j.athoracsur.2008.05.077
© 2009 The Society of Thoracic Surgeons
Case Reports
Massive Necrotizing Pneumonia With Pulmonary Gangrene
Chih-Hao Chen, MDa,
Wen-Chien Huang, MDa,
Tung-Ying Chen, MDb,
Tzu-Ti Hung, BNa,
Hung-Chang Liu, MDa,
Chao-Hung Chen, MDa,*
a Department of Thoracic Surgery, Mackay Memorial Hospital, Taipei City, Taiwan
b Department of Pathology, Mackay Memorial Hospital, Taipei City, Taiwan
Accepted for publication May 27, 2008.
* Address correspondence to Dr Chao-Hung Chen, No 92, Section 2, Chung Shan North Rd, Taipei City, 10449, Taiwan (Email: musclenet2003{at}yahoo.com.tw).
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Abstract
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Pulmonary gangrene is an extremely rare and severe complication of pneumonia. It is very rarely seen in community-acquired pneumonia. A 49-year-old immunocompetent man was admitted with community-acquired pneumonia caused by Klebsiella pneumonia. His condition rapidly deteriorated with ensuing pulmonary gangrene and septic shock. He was successfully managed by emergency pneumonectomy.
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Introduction
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Pneumonia is a primarily medical disease that usually does not require surgery. However, in rare cases it may progress to massive necrosis and pulmonary gangrene for which surgery may be lifesaving.
A 49-year-old man was previously healthy, with no history of diabetes mellitus, liver cirrhosis, hematologic disease and other pulmonary disease. He had not recently traveled abroad. Five days prior to admission, he noted a productive cough and mild chest discomfort. The symptoms were relatively mild and he did not seek medical care until the symptoms worsened and he noted dyspnea on walking. On presentation to the emergency room, his temperature was 38.2°C, his heart rate was 120, his respiratory rate was 33, and his blood pressure was 84/50 mm Hg. On chest auscultation, there were crackles in the left hemithorax. On room air, his PaO2 was 50 mm Hg. He was believed to be in an impending respiratory failure, and therefore he was immediately intubated and was admitted to the intensive care unit. A chest roentgenogram showed infiltrates and patchy consolidation of the left middle and lower lung fields (Fig 1). Despite 3 days of treatment with antibiotics and mechanical ventilation, the patient's condition deteriorated. Computed tomography on the third hospital day showed massive necrosis of the left upper and lower lobes, as well as a small pleural effusion (Figs 2A and 2B). The patient was in shock unresponsive to high-dose pressors. We performed an emergency standard left posterolateral thoracotomy. On opening the thorax, purulent, foul-smelling pleural effusion drained and was sent for culture. The left lung was a completely consolidated, firm mass, making dissection of the hilar structures very difficult, but a pneumonectomy was finally completed. During the operation, the patient's blood pressure was maintained by both dopamine and norepinephrine in high doses. Two days after the operation, the patient's blood pressure gradually stabilized and inotropes were tapered. Cultures of blood, sputum, and necrotic lung and pleural fluid all grew Klebsiella pneumoniae that was sensitive to all antibiotics tested, including beta-lactam, amino glycosides, and quinolones. On postoperative day 6, the patient was successfully weaned from the ventilator and extubated. The chest tube was removed on postoperative day 10, and the patient was discharged 3 weeks after the operation.
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Fig 1. Preoperative chest roentgenogram on admission with patchy infiltrates involving the lower two thirds of the left lung field. The right lung is spared.
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Fig 2. Chest computed tomography on the third hospital day showing (A) consolidation and multiple, irregular, hypodense areas in the lung parenchyma, indicating necrosis in the left lung. (B) There is a small pleural effusion.
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The gross surgical specimen was a firm mass with consolidation of most parts of the lung (Fig 3A). It weighed 2,150 gm. On the cut surface, extensive consolidation was present with obstructed bronchi and multiple abscesses (Fig 3B). Pathology sections showed multiple abscesses and thrombosis in the pulmonary vessels.
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Fig 3. Gross appearance of the resected specimen. (A) Entire left lung. (B) Cut surface of the lung demonstrating thrombosis in the pulmonary arteries, nearly total consolidation, multiple small abscess, narrowing of bronchi, and necrosis in the upper lobe.
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Comment
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This is a case of fulminant, necrotizing pneumonia with pulmonary gangrene that was successfully managed by pneumonectomy. Resection of any portion of the lung is rarely indicated in patients with pneumonia. The spectrum of lung infection ranges from mild disease with few symptoms and minor infiltrates on roentgenogram to lobar pneumonia, lung abscess, necrosis and gangrene, and adult respiratory distress syndrome. Treatment of most of these conditions is medical, except in the rare instances when necrosis ensues.
There is controversy as to the indications and best timing of surgery for pulmonary necrosis [1, 2]. Reports in the literature are very limited, and there is insufficient evidence to determine which patients are most likely to benefit from surgery. Procedures that have been reported include one-stage lung resection, drainage of necrotic tissues followed by resection, and drainage only.
K pneumoniae, pneumococci, and Aspergillus are pathogens commonly implicated in necrotizing pneumonia and pulmonary gangrene [3, 4]. If lung infection progresses to necrosis of large areas and pulmonary gangrene, antibiotics are no longer effective because of inadequate perfusion, so that the infection is uncontrolled. Although it would seem reasonable to proceed immediately to resection of the gangrenous lung, a group from Israel proposed a two-stage protocol [2]. They recommended fenestration and drainage of the empyema first, followed by resection of the gangrenous lung after a cleaner field has been established. In our experience, in patients with empyema, lung necrosis, or lung abscess limited to a single lobe, tube drainage is safe and may rapidly ameliorate sepsis. If the sepsis is well controlled, it may not be necessary to operate at all where the lung tissue is still viable [5]. However, this is not the case where necrosis, abscess, or consolidation that involves multiple lobes has occurred. In such a situation, radical resection of the infected material is considered lifesaving. Antibiotics in such a situation are ineffective because of inadequate perfusion to the source of the infection. Our patient's sepsis could not be controlled until we resected the gangrenous lung. This case demonstrates that once lung necrosis and gangrene have developed, even when the pathogen is sensitive to the antibiotics used, a radical resection is indicated and, in all probability, lifesaving as well.
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References
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- Reimel BA, Krishnadasen B, Cuschieri J, et al. Surgical management of acute necrotizing lung infections Can Respir J 2006;13:369-373.[Medline]
- Refaely Y, Weissberg D. Gangrene of the lung: treatment in two stages Ann Thorac Surg 1997;64:970-973discussion 973–4.[Abstract/Free Full Text]
- Penner C, Maycher B, Long R. Pulmonary gangrene: a complication of bacterial pneumonia Chest 1994;105:567-573.[Medline]
- Hammond JM, Lyddell C, Potgieter PD, Odell J. Severe pneumococcal pneumonia complicated by massive pulmonary gangrene Chest 1993;104:1610-1612.[Medline]
- Postma MH, le Roux BT. The place of external drainage in the management of lung abscess S Afr J Surg 1986;24:156-158.[Medline]
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Abstract
Introduction
