Lung Abscess in a 12-year-old Child Identified Using Point-of-care Ultrasound in Emergency Medicine Department: A Case Report

INTRODUCTION

A lung abscess is defined as a localised region of lung parenchyma destruction where infections by pyogenic organisms cause tissue necrosis and suppuration.¹ On a colour Doppler, they typically have air-fluid levels, a distinct capsular structure, posterior enhancement, hypoechoic or anechoic characteristics, and no interior vascularity. There may be one or more of them.^1,2 Low-level echoes from the consolidated lung may mimic a fluid collection. Approximately, 80% of lung abscesses are initial, whilst subsequent lung abscesses are linked to immunosuppression, extrapulmonary infection, sepsis, malignancy, or surgical complications.^2,3 The overall reported mortality rate varies between 1% and 38.2%.^3,4 Microbial infection of the lung results in necrosis of the pulmonary parenchyma, which can be classified as acute (less than 1 month old) or chronic (more than 1 month old) depending on the duration.¹ In most cases, the initial infection is caused by aspiration of oral contents. A Japanese study indicated that Streptococcus spp. (59.8%), Anaerobes (26.2%), and Gemella spp. (9.8%) were present in community-acquired lung abscesses. When lung abscesses spread to the chest wall, Mycobacterium tuberculosis and Actinomycetes species were more common.^2,4 With this background, in our case study, we present a 12-year-old male child with lung abscess that was diagnosed with point-of-care ultrasound (POCUS) without any delay for the treatment.

CASE DESCRIPTION

A 12-year-old male child presented to the emergency medicine department with complaints of cough, cold, and fever for 2 weeks and right-sided chest pain for 1 week. Cough was insidious and productive in nature with mucoid in consistency and was not foul smelling. Fever was high-grade and continuous in nature. The patient felt better on taking medication and on further enquiry, gave a history of recent consumption of beef and pork. He also complained of breathlessness on exertion, with no history of fast breathing, orthopnoea, weight loss, or loss of appetite. The patient had a previous history of fever 6 months back, was admitted to a private hospital nearby, and was administered intravenous antibiotics. There is no history of contact with tuberculosis patients, and he is immunised till date.

On examination upon arrival, his heart rate was 111/min, blood pressure was 100/80 mm Hg with saturation of 98% on room air, respiratory rate 20/min, blood sugar level of 98 mg/dL, and temperature of 102°F. Furthermore, his weight was 40 kg, height was 152 cm, and the body mass index (BMI) was 17.31 kg/m² and he was active and alert. On examination of the respiratory system, he had reduced breath sounds in the right mammary, inframammary, and intrascapular region. Other systemic examinations were normal. Symptomatic treatment was given initially, and the patient was stabilised. Electrocardiogram (ECG) recording was normal.

Bedsides, POCUS was done using a linear transducer with frequency (5–10 MHz) in the anteroposterior aspect of the chest and it showed an oval-shaped lesion of size 8 × 6 × 2 cm, with irregular hypoechoic outer margin and an anechoic core in the right lung with posterior enhancement and no internal vascularity on colour Doppler (Fig. 1). A chest X-ray (CXR) was done, and it revealed right lung abscess (Fig. 2) and later computerised tomography (CT) thorax which revealed a right lung abscess with an approximate size of 9 × 6.7 × 5.5 cm (vol 135cc) and 5 mm wall thickness in the posterior segment of the right upper lobe (Figs 3 and 4) and further advised for diagnostic bronchoscopy.

Laboratory investigation was done and was found to be normal, the details of which are presented in Table 1. Blood and sputum culture had no growth, paediatric and pulmonology opinion was obtained, and he was started on intravenous (IV) antibiotic, Inj. amoxicillin and clavulanic acid 1 gram IV twice a day (BD) (45 mg/kg/day BD), along with Inj. clindamycin 600 mg IV thrice a day (TDS). On the 2nd day of admission, the patient had a few episodes of haemoptysis (Table 2). Bronchoscopy was done on the 4th day of admission, and broncho-alveolar lavage (BAL) sample was sent for investigation; Gram staining resulted in no growth, negative for acid-fast bacilli (AFB), cartridge-based nucleic acid amplification test (CBNAAT) was negative; cytopathology analysis showed fluid WBC – 90 cells/mm³, followed by which, an antibiotic was hiked to Inj. piperacillin and tazobactam 4.5 g IV TDS (100 mg/kg). IV antibiotic was continued for another 6 days, and the patient clinically improved and was discharged on 10th day of admission with oral antibiotics (Fig. 5).

DISCUSSION

Patients with lung abscesses usually present 2–4 weeks following the symptom onset. Cough, fever, haemoptysis, pleuritic chest pain, weight loss, and night sweats are amongst some of the symptoms.^1,5,6 A cavitary lesion’s air-fluid level may be visible on a chest radiograph, suggesting that the abscess cavity and bronchiole were in communication. Cavitary lesions with and without bronchiolar communication can be diagnosed with chest CT.^1,6,7 The commonest reason for cavitary lung lesions is infection (bacterial, fungal, and parasitic), neoplastic, inflammatory, or foreign body aspiration.^1,2,4,5,7,8 Aspiration generally only causes one lung abscess; paranasal sinusitis, dental infections, and recurrent vomiting are amongst the other causes.^1,5,7,8 Staphylococcus aureus is the most common isolated etiologic pathogen of lung abscess in children.^2,4,9 About 75% of all lung abscesses, are located in the posterior segment of the right upper lobe or apical segment of the lower lobe of both lungs.^6,10 In the beginning cough is dry or non-productive but when the communication with bronchus is established, it becomes productive and sometimes haemoptysis is also noted.^5,6,10 Excavating tuberculosis, mycosis, pulmonary cysts, secondary infection to infected emphysematous bullae, or excavating bronchial cancer are indications of differential diagnosis.^6–8,10

Now coming to the treatment part after stabilising immediate life-threatening conditions, the next step is usually antibiotic therapy.^5,11 Inj. ampicillin-sulbactam, 3 grams IV TDS, or a carbapenem (imipenem, meropenem) were the appropriate choices.^4–6,12 Inj. Clindamycin (600 mg IV in 8 hours) is another option but is often avoided due to the risk of subsequent infection with Clostridium difficile.^5,12 Alternative options are Inj. amoxicillin and clavulanic acid (45 mg/kg/day BD), Inj. piperacillin and tazobactam 4.5 g IV TDS (100 mg/kg). For Methicillin-resistant Staphylococcus aureus (MRSA) it is recommended to use linezolid 600 mg IV BD or Vancomycin 15 mg/kg BD.^6,9 Drainage typically happens on its own because of the interplay between the abscess cavity and the tracheobronchial tree. Patients who do not respond to antibiotics may benefit from percutaneous drainage, transbronchial drainage, open abscess cavity drainage, or tissue plasminogen activator (TPA).^2,6 Lung abscesses can develop in any part of the lung.^7,8 Treatment with IV antibiotics can fail if the abscess is larger than 6 cm or if the patient has other contributing factors.^12,13

POCUS is a reliable non-invasive, radiation-free bedside procedure that is easy to use by an experienced ED physician. When a radiological expert is difficult to reach, it is especially useful.^14,15 Bedside lung ultrasound in emergency (BLUE) protocol is more accurate than CXR at differentiating consolidation and pleural effusion and diagnosing simple or complex effusion.^14,16 Even though X-rays are frequently used to look into respiratory problems, a CT scan of the thorax is necessary before they can be employed as a diagnostic tool. A patient can be scanned when they are lying down, sitting up, or on their side. If the patient is experiencing trouble breathing, it is best for them to be upright.^14,15 An empyema and a lung abscess can be differentiated from one another by the composition of the collection. Generally, they are not always anechoic, and hyperechoic septations which are commonly seen.¹⁵ Imaging, primarily CT, can be used to make the differentiation. Antibiotics are used to treat lung abscesses, whilst direct chest tube drainage is used to treat empyema. POCUS has many applications, such as early diagnosis, severity evaluation, anatomic and physiological monitoring, and guidance during procedures.¹⁵ On a colour Doppler, they show up as a well-defined capsular structure that is either hypoechoic or anechoic, has a posterior enhancement, and lacks internal vascularity. Low-level echoes from the consolidated lung may resemble a fluid collection.

CONCLUSION

The use of POCUS in diagnosing a massive lung abscess in a 12-year-old male child in the emergency room provided several significant benefits. It allowed for the rapid identification of a life-threatening condition, ensuring timely intervention. This diagnostic approach was cost-effective, and importantly, involved no radiation exposure, which is particularly advantageous for paediatric patients. Additionally, it facilitated a quicker understanding of the underlying cause of the illness compared with traditional X-ray or CT methods.

ORCID

Sruthi P https://orcid.org/0009-0001-5841-0171

REFERENCES

1. Sabbula BR, Rammohan G, Athavale A, et al. Lung Abscess. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2023 [cited 2024 Jan 18]. Available from: http://www.ncbi.nlm.nih.gov/books/NBK555920/.

2. Ko Y, Tobino K, Yasuda Y, et al. A community-acquired lung abscess attributable to Streptococcus pneumoniae which extended directly into the chest wall. Intern Med 2017;56(1):109–113. DOI: 10.2169/internalmedicine.56.7398.

3. Desai H, Agrawal A. Pulmonary emergencies: Pneumonia, acute respiratory distress syndrome, lung abscess and empyema. Med Clin North Am 2012;96(6):1127–1148. DOI: 10.1016/j.mcna.2012.08.007.

4. Ito Y, Toyoshima H, Susuki T, et al. Lung abscess caused by Streptococcus pneumoniae serotype 6B. Respir Med Case Rep 2018;23:71–73. DOI: 10.1016/j.rmcr.2017.11.010.

5. Patrawalla A, Dever LL. Lung abscess. In: Cunha CB, Cunha CB, editors. Schlossberg’s Clinical Infectious Disease [Internet]. Oxford University Press; 2021 [cited 2024 Jan 18]. DOI: 10.1093/med/9780190888367.003.0035

6. Kuhajda I, Zarogoulidis K, Tsirgogianni K, et al. Lung abscess-etiology, diagnostic and treatment options. Ann Transl Med 2015;3(13):183. DOI: 10.3978/j.issn.2305-5839.2015.07.08.

7. Yousef L, Yousef A, Al-Shamrani A. Lung abscess case series and review of the literature. Children (Basel) 2022;9(7):1047. DOI: 10.3390/children9071047.

8. Yen CC, Tang RB, Chen SJ, et al. Pediatric lung abscess: A retrospective review of 23 cases. J Microbiol Immunol Infect 2004;37(1):45–49. PMID: 15060687.

9. David MZ, Daum RS. Community-associated methicillin-resistant Staphylococcus aureus: Epidemiology and clinical consequences of an emerging epidemic. Clin Microbiol Rev 2010;23(3):616–687. DOI: 10.1128/CMR.00081-09.

10. Moreira Jda S, Camargo Jde J, Felicetti JC, et al. Lung abscess: Analysis of 252 consecutive cases diagnosed between 1968 and 2004. J Bras Pneumol 2006;32(2):136–143. DOI: 10.1590/s1806-37132006000200009.

11. Vaudaux P, Waldvogel FA. Gentamicin inactivation in purulent exudates: Role of cell lysis. J Infect Dis 1980;142(4):586–593. DOI: 10.1093/infdis/142.4.586.

12. Yu H. Management of pleural effusion, empyema, and lung abscess. Semin Intervent Radiol 2011;28(1):75–86. DOI: 10.1055/s-0031-1273942.

13. Piccolo F, Popowicz N, Wong D, Lee YCG. Pleural tissue plasminogen activator and deoxyribonuclease therapy for pleural infection. J Thorac Dis 2015;7(6):999–1008. DOI: 10.3978/j.issn.2072-1439.2015.01.30.

14. Giachetti E, Raffaldi I, Delmonaco AG, Tardivo I, Versace A, Bondone C, et al. Point-of-care ultrasound in the pediatric emergency department to diagnose lung abscess. Pediatr Neonatol 2023;64(1):83–84. DOI: 10.1016/j.pedneo.2021.11.015.

15. Moore CL, Copel JA. Point-of-care ultrasonography. N Engl J Med 2011;364(8):749–757. DOI: 10.1056/NEJMra0909487.

16. Huyler A, Mackenzie D, Wilson CN. Lung abscess diagnosed by ultrasound. Clin Exp Emerg Med 2022;9(1):70–71. DOI: 10.15441/ceem.21.069.