Morning Report 1/29/18 – Necrotizing Pneumonia

Thank you, Chuka, for presenting a case of a middle-aged man with sub-acute lightheadedness and dizziness found to be hypotensive with a significant leukocytosis and AKI found to have significant cavitary lung lesions, multiple PEs and moderate pneumothorax.

  1. Here’s a basic approach to cavitary lung lesions:

C = cancer – specifically bronchogenic carcinoma (most frequently SCC), cavitary pulmonary mets

A = autoimmune – granulomas – GPA, RA, sarcoid

V = vascular – both bland and septic pulmonary emboli with infarction

I = infection – primarily bacterial, fungal, pulmonary abscess, TB

necrotizing infxns: staph, anaerobic bacteria, mycobacteria, fungi (cocci, histo, blasto, aspergillus, crypto, mucor, PCP)

T = trauma – pneumatoceles

Y = youth – CPAM (congenital pulmonary airway malformation), pulmonary sequestration, bronchogenic cyst2

2.  Quick DDx for Shock:

Distributive: sepsis, anaphylaxis, vasopeglia (AI, neurogenic)

Cardiogenic: pump, rhythm, mechanical

Hypovolemic: hemorrhagic vs. volume depleted

Obstructive: PE, PTX, tamponade

3. Necrotizing pneumonia with pulmonary gangrene.

  • The options for treatment in patients with persistent sepsis and necrotizing pneumonia are limited. It’s important to ensure appropriate antimicrobial coverage (including assessing the MIC for any antibiotic you’re using!).
  • Chest tube drainage is often insufficient once a patient has progressed to pulmonary gangrene.
  • Unfortunately, there are no practice guidelines to direct the care of patients with necrotizing pneumonia, and determining if and when surgical intervention is needed is challenging.
  • Here is a case series of 5 patients with necrotizing pneumonia with pulmonary gangrene and here is a retrospective review of 35 patients who received pulmonary resection.

4.  Combined use of intrapleura tPT and DNase to improve fluid drainage in patients with pleural infections reduced the frequency of surgical referral and duration of hospital stay in the Mist 2 Trial.

Cavitary Lung Lesions Evernote: https://www.evernote.com/shard/s462/sh/324714f0-2b78-4e60-a214-7254dbeaa89c/90f6ec503f50e4696e8490fde035551c

 

 

 

 

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