5.9 ZSFG pearls: lung abscesses and gram positive rods

  • An uncomplicated parapneumonic effusion is characterized b normal glucose, normal pH and low cell count, and these normally will layer out with a lateral decub CXR (“simple” or free’ flowing” is the radiologic description)
    • These may subsequently become complicated effusions with thickening and formation of loculations and empyema. If this persists for weeks, the empyema may form a thick “pleural peel”
  • Empyemas are now rare complications of CAP (around 1% of cases) and bacteria associated with aspiration are the most common cause (strep milleri is the most commonly cultured pathogen)
  • Lung abscesses are another CAP complication commonly associated with aspiration
    • Most abscesses are managed conservatively with prolonged antibiotics, but more aggressive intervention should be pursued in patients who are elderly, have a large cavity, a long duration of symptoms prior to therapy, lower lobe abscesses or multiple abscesses (this patient had all of these!)
      • Remember to involve all the pertinent services in these cases, including pulm, IR and CT surgery


BPF pearls from last month:

  • Post-operative complications are by the far the most common cause of bronchopleural fistula, which is a very rare condition, but other etiologies include lung necrosis due to infection, persistent pneumothorax, radiation and TB.
  • Symptoms can mimic TB and include fever, productive cough and hemoptysis
  • The two main treatment strategies are mechanical plugs (with a balloon, gel foam, sclerosants, etc) and placement of a one-way valve.



Friday catch up pearl – Sanjay Saint’s mnemonic for remember the gram-positive rods:

Clumsy – Clostridium

Bacteria – Bacillus anthracis

Act – Actinomyces

Like – Listeria

Lazy – Lactobacillus

Error-prone – Erisipelothrix

Cornballs – Corynebacterium





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