Respiratory Medicine CME 4 (2011) 157e159

Contents lists available at ScienceDirect

Respiratory Medicine CME

journal homepage: www.elsevier.com/locate/rmedc

Case Report

A pulmonary abscess, beware of lung cancer!

L.E.L. Hendriks a, b, *, M.M.H. Hochstenbag b, U.C. Lalji c, A.-M.C. Dingemans b
a
Department of Pulmonology, Atrium Medical Centre Parkstad, H. Dunantstraat 5, 6401 CX Heerlen, The Netherlands
b
Department of Pulmonology, Maastricht University Medical Centreþ, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands
c
Department of Radiology, Maastricht University Medical Centreþ, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands

a r t i c l e i n f o a b s t r a c t

Article history: A pulmonary abscess is defined as necrosis of the pulmonary parenchym caused by microbial infections.
Received 4 May 2011 The most common organisms are anaerobe bacteria. Local conditions, host resistance and infecting
Accepted 5 May 2011 agents all play a role in the formation of pulmonary abscesses. An underlying endobronchial obstructing
lung cancer predisposes for the development of a pulmonary abscess. The diagnosis of lung cancer can
Keywords: often be made with computed tomography (CT) of the chest combined with bronchoscopy and cyto-
Non-small cell lung cancer
logical analysis of the abscess fluid. We present two patients with a pulmonary abscess caused by an
Pulmonary abscess
underlying lung cancer. Although in both cases the differential diagnosis was malignancy at first
presentation, the diagnosis could not be made definitively prior to surgery, despite intensive investi-
gations with even CT guided biopsies and mediastinoscopy.
Ó 2011 Elsevier Ltd. All rights reserved.

1. Introduction diagnosis consisted of primary pulmonary abscess with reactive

A pulmonary abscess is defined as necrosis of the pulmonary
parenchym caused by microbial infections. The most common
organisms are anaerobe bacteria. An underlying endobronchial
obstructing lung cancer predisposes for the development of
a pulmonary abscess. The diagnosis of lung cancer can often be
made with computed tomography (CT) of the chest combined with
bronchoscopy and cytological analysis of the abscess fluid. We
present two patients with a pulmonary abscess caused by an
underlying lung cancer not diagnosed prior to surgery despite
extensive diagnostic procedures.
2. Cases
Patient A., a 56-year old man, was hospitalized with fever,
shortness of breath, coughing with streaks of blood and weight
loss. His medical history revealed a surgical resection of
a pT2N0M0 squamous cell carcinoma of the left tonsillar region
a year before presentation. He smoked 20 cigarettes a day. CT of
the chest showed a cavitating process in the right lower lobe with
ipsilateral mediastinal lymphadenopathy (Fig. 1A). The differential
* Corresponding author. Department of Pulmonology, Maastricht University
Medical Centreþ, P. Debyelaan 25, 6229 HX Maastricht, The Netherlands. Tel.: þ31
0 43 3875047; fax: þ31 0 43 3875051.
E-mail address: lizzahendriks@yahoo.com (L.E.L. Hendriks).
mediastinal lymphadenopathy or secondary pulmonary abscess
due to lung cancer. Amoxicilline/clavulanic acid and ciprofloxacin
were started. Because of the suspicion of an underlying malig-
nancy additional investigations were performed. A whole body
18-fludeoxyglucose-positron emission tomography combined with
diagnostic computed tomography (18FDG-PET-CT) showed 18FDG
uptake in the right lower lobe and mediastinal lymph nodes (4R,
4L, 7, 8, 3, 2R, 1). Bronchial edema with narrowing of the bronchus
intermedius and a large amount of purulent secretion was seen on
bronchoscopy. On cytological examination, atypical and inflam-
matory cells were seen, not enough evidence for a diagnosis of
malignancy. Bacterial cultures were negative. Because of the
atypical cells in the cytological specimen a CT-guided biopsy was
performed of the process in the right lower lobe. Histological
examination showed inflammatory cells compatible with active
inflammation, no malignant cells were seen. Antibiotic therapy
was continued for more than two months without evident clinical
and radiological improvement. Although all investigations for
malignancy were negative the suspicion remained. The patient
was discussed in our multidisciplinary oncology meeting and it
was decided to perform a mediastinoscopy with lymph node
sampling followed by a resection of the right lower lobe if no
lymph node metastasis were found. None of the sampled lymph
nodes showed a malignancy. At thoracotomy, however, a lobec-
tomy or even pneumonectomy was not possible due to massive
adhesions of the lung with the thoracic wall and spinal column.

1755-0017/$36.00 Ó 2011 Elsevier Ltd. All rights reserved.

doi:10.1016/j.rmedc.2011.05.001
158 L.E.L. Hendriks et al. / Respiratory Medicine CME 4 (2011) 157e159
Finally an additional bronchoscopy showed pathological mucosa
of the right bronchus intermedius. Biopsy revealed a squamous
cell carcinoma. Three and a half months after first presentation the
patient was diagnosed with lung cancer, cT4N0MO, stage IIIa. Due
to inoperability treatment with concurrent chemo-radiotherapy
was planned.
Patient B, a 74-year old woman with a medical history of
rheumatoid arthritis, treated with methotrexate, and COPD GOLD
II was seen at the outpatient clinic and later on hospitalized
because of shortness of breath, malaise and fever. She was
a former smoker. CT of the chest showed a pulmonary mass in the
right lower lobe and ipsilateral mediastinal lymphadenopathy
(Fig. 1B), suggestive for a pulmonary abscess. Treatment with
amoxicilline/clavulanic acid was started. Because of the possibility
of an underlying malignancy additional investigations were per-
formed. On bronchoscopy there were no endobronchial abnor-
malities. Cytology and histology of brush, lavage and biopsy of the
right lower lobe showed an active infection and necrosis but no
malignant cells. A transthoracic CT-guided biopsy showed only
necrosis and no malignant cells. Bacterial cultures were positive
for Serratia Marcescens, sensitive to the given antibiotics. Despite
one month of adequate treatment her clinical condition did not
improve, she also developed pleural fluid. Because of the suspicion
of an empyema, a thoracotomy was performed. Only a large
amount of adhesions were seen but no evidence of empyema.
Biopsies were taken. No malignant cells were found and cultures
showed Serratia Marcescens. Antibiotics were continued, but after
a month of continued antibiotic treatment she developed fever
again. CT-scan of the chest was unchanged. Antibiotics were
empirically changed to piperacillin/tazobactam combined with
ciprofloxacin and a CT-guided drainage was performed. Again
Serratia Marcescens, sensitive to the given antibiotics, was iden-
tified. Cytologic examination of the pleural fluid showed no
malignant cells. Because of lack of clinical improvement and the
remaining suspicion of malignancy a second bronchoscopy was
performed with again biopsy, brushing and lavage of the right
Fig. 1. A) Chest CT patient A. B) Chest CT patient B.
lower lobe. No endobronchial abnormalities were seen. Biopsy and
lavage showed no malignant cells and no other explanation for the
clinical situation was found. Because her condition still did not
improve with adequate antibiotics and drainage, a right lower lobe
lobectomy was scheduled. A lobectomy or even pneumonectomy
was not possible due to a large amount of adhesions of the lung to
the thoracic wall. Biopsy of the right lower lobe during the
thoracotomy eventually revealed a squamous cell carcinoma three
and a half months after first presentation. A staging 18FDG-PET-CT
showed in addition to the primary tumor a lesion in the contra-
lateral lung. In the mean time the patient deteriorated and her
performance status was too poor to undergo further investigations
or anti-cancer treatment.
3. Discussion
Local conditions, host resistance and infecting agents all play
a role in the formation of pulmonary abscesses. The most common
risk factors for developing a pulmonary abscess are aspiration from
the nasopharynx, mouth or stomach, a prior pneumonia, a history
of alcohol abuse, bronchiectasiae, immunosuppression or
a (malignant) endobronchial obstruction.1 CT of the chest, bron-
choscopy and cytological analysis of the abscess fluid are often
helpful to diagnose the underlying lung cancer.
In case of a malignancy, bronchial obstruction and vascular
involvement with resulting ischemia lead to tumor necrosis. This
process is followed by suppurative obstructive pneumonia. Pre-
senting symptoms include cough, purulent sputum, fever, chest
pain and dyspnea.1
Ameuille (1923) first observed the association of pulmonary
abscess and lung cancer. In 8e17% of patients, an underlying lung
cancer is the cause of a cavitary pulmonary infiltrate or pulmonary
abscess. The incidence rises to 33% in patients older than 45 years.2 To
distinguish a noncarcinomatous pulmonary abscess from a carcino-
matous pulmonary abscess, radiologic imaging of the chest and
fiberoptic bronchoscopy can be used. The diagnostic accuracy of
a chest X-ray, however, is low. With CT, an irregular internal wall is
found more frequent in malignant cavitary nodules than in benign
ones.3
In 1979, Wallace et al. performed a fiberoptic bronchoscopy with
lavage in 46 patients diagnosed with a pulmonary abscess with or
without a proven underlying malignancy. A single bronchoscopy
combined with sputum cytology correctly diagnosed 22 of 25
patients with an underlying malignancy (88%). In the 21 patients
with a nonmalignant pulmonary abscess, inflammatory changes
did not result in any diagnostic error.2
The pulmonary abscesses in the two patients described above
didn’t respond to the administered (appropriate) antibiotics with
or without percutaneous drainage. Although in both cases the
differential diagnosis was malignancy at first presentation, the
diagnosis could not be made definitively prior to surgery, despite
intensive investigations with even CT guided biopsies and
mediastinoscopy. The diagnostic process is hindered by the fact
the infection can result in atypical cells in cytological specimen
without evidence of malignancy. These cases show that, when
a pulmonary abscess doesn’t improve with appropriate medical
management and there is a suspicion of lung cancer, results of
even invasive diagnostic procedures can be false negative and
misleading.
Conflict of interest
The authors do not have any actual or potential conflict of
interest including any financial, personal or other relationships
with other people or organizations within three years of beginning
 L.E.L. Hendriks et al. / Respiratory Medicine CME 4 (2011) 157e159 159

of the submitted work that could inappropriately influence, or be References

perceived to influence, their work.
1. Pohlson EC, McNamarra JJ, Char C, Kurata L. Lung abscess: a changing pattern of
the disease. Am J Surg 1985;150(1):97e101.
2. Wallace Jr RJ, Cohen A, Awe RJ, Greenberg D, Hadlock F, Park SK. Carcinomatous
Acknowledgment lung abscess. Diagnosis by bronchoscopy and cytopathology. JAMA
1979;242(6):521e2.
3. Honda O, Tsubamoto M, Inoue A, et al. Pulmonary cavitary nodules on computed
L. Hendriks has written the article, the other authors have tomography: differentation of malignancy and benignancy. J Comput Assist
provided patient histories and they also have given critical comments. Tomogr 2007;31(6):943e9.