Necrotizing pneumonia (NP), also known as cavitary pneumonia or cavitatory necrosis, is a rare but severe complication of
lung
The lungs are the primary organs of the respiratory system in humans and most other animals, including some snails and a small number of fish. In mammals and most other vertebrates, two lungs are located near the backbone on either side of t ...
parenchymal
Parenchyma () is the bulk of functional substance in an animal organ or structure such as a tumour. In zoology it is the name for the tissue that fills the interior of flatworms.
Etymology
The term ''parenchyma'' is New Latin from the word ...
infection
An infection is the invasion of tissues by pathogens, their multiplication, and the reaction of host tissues to the infectious agent and the toxins they produce. An infectious disease, also known as a transmissible disease or communicable dise ...
.
In necrotizing pneumonia, there is a substantial
liquefaction
In materials science, liquefaction is a process that generates a liquid from a solid or a gas or that generates a non-liquid phase which behaves in accordance with fluid dynamics.
It occurs both naturally and artificially. As an example of the ...
following death of the lung tissue, which may lead to
gangrene
Gangrene is a type of tissue death caused by a lack of blood supply. Symptoms may include a change in skin color to red or black, numbness, swelling, pain, skin breakdown, and coolness. The feet and hands are most commonly affected. If the ga ...
formation in the lung.
In most cases patients with NP have
fever
Fever, also referred to as pyrexia, is defined as having a body temperature, temperature above the human body temperature, normal range due to an increase in the body's temperature Human body temperature#Fever, set point. There is not a single ...
,
cough
A cough is a sudden expulsion of air through the large breathing passages that can help clear them of fluids, irritants, foreign particles and microbes. As a protective reflex, coughing can be repetitive with the cough reflex following three pha ...
and
bad breath
Bad breath, also known as halitosis, is a symptom in which a noticeably unpleasant breath odour is present. It can result in anxiety among those affected. It is also associated with depression and symptoms of obsessive compulsive disorder.
Th ...
, and those with more indolent infections have weight loss.
Often patients clinically present with acute respiratory failure.
The most common pathogens responsible for NP are ''
Streptococcus pneumonia'', ''
Staphylococcus aureus
''Staphylococcus aureus'' is a Gram-positive spherically shaped bacterium, a member of the Bacillota, and is a usual member of the microbiota of the body, frequently found in the upper respiratory tract and on the skin. It is often positive ...
'', ''
Klebsiella pneumoniae
''Klebsiella pneumoniae'' is a Gram-negative, non-motile, encapsulated, lactose-fermenting, facultative anaerobic, rod-shaped bacterium. It appears as a mucoid lactose fermenter on MacConkey agar.
Although found in the normal flora of the mouth ...
''.
Diagnosis is usually done by chest imaging, e.g.
chest X-ray
A chest radiograph, called a chest X-ray (CXR), or chest film, is a projection radiograph of the chest used to diagnose conditions affecting the chest, its contents, and nearby structures. Chest radiographs are the most common film taken in med ...
,
CT scan. Among these CT scan is the most sensitive test which shows loss of lung architecture and multiple small thin walled cavities.
Often cultures from
bronchoalveolar lavage
Bronchoalveolar lavage (BAL) (also known as bronchoalveolar washing) is a diagnostic method of the lower respiratory system in which a bronchoscope is passed through the mouth or nose into an appropriate airway in the lungs, with a measured amoun ...
and blood may be done for identification of the causative organism(s).
It is primarily managed by
supportive care
Symptomatic treatment, supportive care, supportive therapy, or palliative treatment is any medical therapy of a disease that only affects its symptoms, not the underlying cause. It is usually aimed at reducing the signs and symptoms for the comfor ...
along with appropriate antibiotics.
However, if patient develops severe complications like
sepsis
Sepsis, formerly known as septicemia (septicaemia in British English) or blood poisoning, is a life-threatening condition that arises when the body's response to infection causes injury to its own tissues and organs. This initial stage is follo ...
or fails to medical therapy, surgical resection is a reasonable option for saving life.
History
NP in adults was first described in the 1940s, whereas in children it was reported later in 1994.
Necrotizing pneumonia is an ancient disease which was once a leading cause of death in both adults and children.
Its clinical features were presumably first outlined by
Hippocrates
Hippocrates of Kos (; grc-gre, Ἱπποκράτης ὁ Κῷος, Hippokrátēs ho Kôios; ), also known as Hippocrates II, was a Greek physician of the classical period who is considered one of the most outstanding figures in the history of ...
.
Later, in 1826,
René Laennec
René-Théophile-Hyacinthe Laennec (; 17 February 1781 – 13 August 1826) was a French physician and musician. His skill at carving his own wooden flutes led him to invent the stethoscope in 1816, while working at the Hôpital Necker ...
described these features in a more detailed fashion in his seminal work ''De l’auscultation médiate ou Traité du Diagnostic des Maladies des Poumon et du Coeur'' (''A treatise on the diseases of the chest, and on mediate auscultation'').
Although availability of appropriate antibiotics had made NP a rare disease, over the last two decades it has emerged as a severe complication of childhood pneumonia.
Causative organisms
The most common pathogens responsible for NP are ''
Streptococcus pneumonia'', ''
Staphylococcus aureus
''Staphylococcus aureus'' is a Gram-positive spherically shaped bacterium, a member of the Bacillota, and is a usual member of the microbiota of the body, frequently found in the upper respiratory tract and on the skin. It is often positive ...
'', ''
Klebsiella pneumoniae
''Klebsiella pneumoniae'' is a Gram-negative, non-motile, encapsulated, lactose-fermenting, facultative anaerobic, rod-shaped bacterium. It appears as a mucoid lactose fermenter on MacConkey agar.
Although found in the normal flora of the mouth ...
''.
Other pathogens which are less likely to cause NP are bacteria like ''
Haemophilus influenzae
''Haemophilus influenzae'' (formerly called Pfeiffer's bacillus or ''Bacillus influenzae'') is a Gram-negative, non-motile, coccobacillary, facultatively anaerobic, capnophilic pathogenic bacterium of the family Pasteurellaceae. The bacteria ...
'',
Streptococcus anginosus group, ''
Pseudomonas aeruginosa
''Pseudomonas aeruginosa'' is a common encapsulated, gram-negative, aerobic–facultatively anaerobic, rod-shaped bacterium that can cause disease in plants and animals, including humans. A species of considerable medical importance, ''P. aerugi ...
'', ''
Mycoplasma pneumoniae
''Mycoplasma pneumoniae'' is a very small bacterium in the class Mollicutes. It is a human pathogen that causes the disease mycoplasma pneumonia, a form of atypical bacterial pneumonia related to cold agglutinin disease. ''M. pneumoniae'' is char ...
'', ''
Acinetobacter baumannii
''Acinetobacter baumannii'' is a typically short, almost round, rod-shaped ( coccobacillus) Gram-negative bacterium. It is named after the bacteriologist Paul Baumann. It can be an opportunistic pathogen in humans, affecting people with compromi ...
'', ''
Streptococcus pyogenes
''Streptococcus pyogenes'' is a species of Gram-positive, aerotolerant bacteria in the genus ''Streptococcus''. These bacteria are extracellular, and made up of non-motile and non-sporing cocci (round cells) that tend to link in chains. They are ...
'', ''
Stenotrophomonas maltophilia
''Stenotrophomonas maltophilia'' is an aerobic, nonfermentative, Gram-negative bacterium. It is an uncommon bacterium and human infection is difficult to treat. Initially classified as ''Bacterium bookeri'', then renamed ''Pseudomonas maltophil ...
'', anaerobes like ''
Fusobacterium nucleatum
''Fusobacterium nucleatum'' is a Gram negative, anaerobic oral bacterium, commensal to the human oral cavity, that plays a role in periodontal disease. This organism is commonly recovered from different monocultured microbial and mixed infection ...
'' and ''
Bacteroides fragilis
''Bacteroides fragilis'' is an anaerobic, Gram-negative, pleomorphic to rod-shaped bacterium. It is part of the normal microbiota of the human colon and is generally commensal, but can cause infection if displaced into the bloodstream or surroun ...
''; fungi like
''
Aspergillus
' () is a genus consisting of several hundred mold species found in various climates worldwide.
''Aspergillus'' was first catalogued in 1729 by the Italian priest and biologist Pier Antonio Micheli. Viewing the fungi under a microscope, Miche ...
'' sp. and ''
Histoplasma capsulatum
''Histoplasma capsulatum'' is a species of dimorphic fungus. Its sexual form is called ''Ajellomyces capsulatus''. It can cause pulmonary and disseminated histoplasmosis.
''H. capsulatum'' is "distributed worldwide, except in Antarctica, but m ...
''; viruses like
Influenza
Influenza, commonly known as "the flu", is an infectious disease caused by influenza viruses. Symptoms range from mild to severe and often include fever, runny nose, sore throat, muscle pain, headache, coughing, and fatigue. These symptoms ...
and
Adenovirus
Adenoviruses (members of the family ''Adenoviridae'') are medium-sized (90–100 nm), nonenveloped (without an outer lipid bilayer) viruses with an icosahedral nucleocapsid containing a double-stranded DNA genome. Their name derives from the ...
.
Children
Apart from ''Streptococcus pneumonia'' (also known as ''Pneumococcus pneumoniae''), several other organisms have appeared to cause necrotizing pneumonia in children since 2002.
Most of the aforementioned organisms have been reported to be associated with childhood NP, except that, ''K. pneumoniae'' is not a common cause in children.
However, ''Pneumococci'' and ''S. aureus'' are frequently responsible for it.
Pneumococcal conjugate vaccine
Pneumococcal conjugate vaccine is a pneumococcal vaccine and a conjugate vaccine used to protect infants, young children, and adults against disease caused by the bacterium ''Streptococcus pneumoniae'' (pneumococcus). It contains purified capsul ...
(PCV7) covering serotypes 4, 6B, 9V, 14, 18C, 19F, and 23F was introduced in the USA in 2000.
Consequently, non-PCV7 serotypes like 3, 5, 7F 19A emerged as new threats. Of this, serotypes 3 and 19A were particularly associated with NP.
In 2010 PCV7 was replaced by a 13-valent pneumococcal conjugate vaccine (PCV13). PCV13 includes all PCV7 serotypes plus six additional serotypes (1, 3, 5, 6A, 7F & 19A).
Panton–Valentine leukocidin
Panton–Valentine leukocidin (PVL) is a Cytotoxicity, cytotoxin—one of the Pore forming toxins#Beta-pore-forming toxins, β-pore-forming toxins. The presence of PVL is associated with increased virulence of certain strains (isolates) of ''St ...
(PVL) producing ''S. aureus'' strains are oftentimes responsible for life-threatening necrotizing pneumonia in previously healthy children and young adults.
These PVL-producing strains are frequently methicillin resistant (MRSA).
In developing countries with high rates of HIV infection,
Mycobacterium tuberculosis
''Mycobacterium tuberculosis'' (M. tb) is a species of pathogenic bacteria in the family Mycobacteriaceae and the causative agent of tuberculosis. First discovered in 1882 by Robert Koch, ''M. tuberculosis'' has an unusual, waxy coating on its c ...
is the common cause of NP in children.
Adults
Adults are more commonly affected by community-acquired ''Staphylococcus aureus'', ''S. pneumoniae'' and ''K. pneumoniae''.
Gram-negative organisms like ''K. pneumoniae'' and ''P. aeruginosa'' are usually associated with Pulmonary gangrene.
Predisposing risk factors
Adults
Necrotizing pneumonia typically occurs in adult males who have coexisting health problems like
diabetes mellitus
Diabetes, also known as diabetes mellitus, is a group of metabolic disorders characterized by a high blood sugar level ( hyperglycemia) over a prolonged period of time. Symptoms often include frequent urination, increased thirst and increased ap ...
,
alcohol use disorder
Alcoholism is, broadly, any drinking of alcohol that results in significant mental or physical health problems. Because there is disagreement on the definition of the word ''alcoholism'', it is not a recognized diagnostic entity. Predomin ...
, and
corticosteroid
Corticosteroids are a class of steroid hormones that are produced in the adrenal cortex of vertebrates, as well as the synthetic analogues of these hormones. Two main classes of corticosteroids, glucocorticoids and mineralocorticoids, are involv ...
therapy.
Other risk factors may include
smoking
Smoking is a practice in which a substance is burned and the resulting smoke is typically breathed in to be tasted and absorbed into the bloodstream. Most commonly, the substance used is the dried leaves of the tobacco plant, which have bee ...
,
gastrectomy
A gastrectomy is a partial or total surgical removal of the stomach.
Indications
Gastrectomies are performed to treat stomach cancer and perforations of the stomach wall.
In severe duodenal ulcers it may be necessary to remove the lower portio ...
, history of
substance use disorder
Substance use disorder (SUD) is the persistent use of drugs (including alcohol) despite substantial harm and adverse consequences as a result of their use. Substance use disorders are characterized by an array of mental/emotional, physical, and ...
or
HIV/AIDS
Human immunodeficiency virus infection and acquired immunodeficiency syndrome (HIV/AIDS) is a spectrum of conditions caused by infection with the human immunodeficiency virus (HIV), a retrovirus. Following initial infection an individual ...
.
Children
On the contrary, in most of the cases children of both sexes are affected equally.
Furthermore, it is unlikely that affected children have any underlying co-morbidities, but if any,
asthma
Asthma is a long-term inflammatory disease of the airways of the lungs. It is characterized by variable and recurring symptoms, reversible airflow obstruction, and easily triggered bronchospasms. Symptoms include episodes of wheezing, cou ...
is the most common chronic disorder followed by recurrent
otitis media
Otitis media is a group of inflammatory diseases of the middle ear. One of the two main types is acute otitis media (AOM), an infection of rapid onset that usually presents with ear pain. In young children this may result in pulling at the ear, ...
.
Relationship with viral infection
Group A streptococcus
Lancefield grouping is a system of classification that classifies catalase-negative Gram-positive cocci based on the carbohydrate composition of bacterial antigens found on their cell walls. The system, created by Rebecca Lancefield, was historic ...
such as ''S. pyogenes'', often preceded by
varicella infection, may cause severe
invasive infections and complicated childhood pneumonia.
Influenza virus
''Orthomyxoviridae'' (from Greek ὀρθός, ''orthós'' 'straight' + μύξα, ''mýxa'' 'mucus') is a family of negative-sense RNA viruses. It includes seven genera: ''Alphainfluenzavirus'', ''Betainfluenzavirus'', '' Gammainfluenzavirus'', ...
infection substantially increases the risk of developing necrotizing pneumonia in children mostly by PVL-producing ''S. aureus'' followed by ''S. pneumoniae''.
In the
USA
The United States of America (U.S.A. or USA), commonly known as the United States (U.S. or US) or America, is a country primarily located in North America. It consists of 50 states, a federal district, five major unincorporated territori ...
it is observed that NP has increased following
influenza
Influenza, commonly known as "the flu", is an infectious disease caused by influenza viruses. Symptoms range from mild to severe and often include fever, runny nose, sore throat, muscle pain, headache, coughing, and fatigue. These symptoms ...
owing to the emergence of MRSA strain
USA300
ST8:USA300 is a strain of community-associated methicillin-resistant ''Staphylococcus aureus'' (MRSA) that has emerged as a particularly antibiotic resistant epidemic that is responsible for rapidly progressive, fatal diseases including necro ...
infections.
[ ]
Additional imaging
![Necrotizing pneumonia](https://upload.wikimedia.org/wikipedia/commons/0/07/Necrotizing_pneumonia.webp)
a) Initial plain chest radiograph showing a dense right upper zone airspace opacity and
lingula airspace changes, consistent with multi-focal pneumonia. The following images were performed 24 h later. b) Plain chest radiograph with the patient intubated and ventilated revealing cavitation in the right mid to upper zones, pleural effusion and more general airspace changes bilaterally. c) Computed tomography (CT) scan, coronal view, demonstrating non-enhancing area (necrotic) thin-walled cavities within the right upper lobe and lingula. d) Lung ultrasonographic image displaying thin-walled cavities in the lingula region of the left lung. And this needs even more clarification.
[Text was copied fro]
this source
which is available unde
Attribution 4.0 International (CC BY 4.0)
See also
*
Lung abscess
Lung abscess is a type of liquefactive necrosis of the lung tissue and formation of cavities (more than 2 cm) containing necrotic debris or fluid caused by microbial infection.
This pus-filled cavity is often caused by aspiration, which may ...
*
Pneumonia
Pneumonia is an inflammatory condition of the lung primarily affecting the small air sacs known as alveoli. Symptoms typically include some combination of productive or dry cough, chest pain, fever, and difficulty breathing. The severity ...
Notes
References
{{reflist
Infectious diseases
Pneumonia