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Self-Assessment Questions

Infectious Diseases

Lung Abscess and Empyema: Review Questions

Madhuri M. Sopirala, MD

Dr. Sopirala is an assistant professor of infectious diseases and assistant medical director of clinical epidemiology, Ohio State University Medical Center, Columbus, OH.



Choose the single best answer for each question.



Figure 1. Computed tomography scan of the patient described in questions 1 and 2.

 

Questions 1 and 2 refer to the following case.

A 56-year-old man presents to the emergency department (ED) complaining of blood-tinged sputum. The patient reports a 15-lb weight loss and productive cough with foul-smelling sputum over the last 2 months. He has had subjective fever and has awakened almost every night drenched in sweat. He drinks 10 beers every day. On physical examination, the patient has a blood pressure of 134/92 mm Hg, heart rate of 102 bpm, respiratory rate of 22 breaths/min, and temperature of 100°F. The patient has gingivitis and digital clubbing, and lung examination reveals coarse inspiratory crackles predominantly in the lower lobe of the right lung. Laboratory testing reveals a leukocyte count of 16,000 cells/µL with 93% polymorphonuclear neutrophils. Gram stain of a sputum specimen reveals numerous polymorphonuclear leukocytes with a mixture of gram-positive cocci in chains and gram-negative bacilli. Blood culture shows no growth of microorganisms. Chest radiograph is unremarkable, and a computed tomography scan shows a right-sided cavitary lung lesion (Figure 1).


1. What is the most appropriate initial step in the management of this patient?
  1. Clindamycin
  2. Parenteral penicillin
  3. Surgical drainage
  4. Surgical drainage and clindamycin
  5. Surgical drainage and penicillin
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2. Which of the following is the most likely cause of this patient’s lung abscess?

  1. Fusobacterium species and microaerophilic Streptococcus species
  2. Nocardia species
  3. Pseudomonas aeruginosa
  4. Staphylococcus aureus
  5. Streptococcus pneumoniae
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Figure 2. Gram stain of the specimen obtained from the patient described in questions 3 and 4 showing filamentous gram-positive bacilli.

 

Questions 3 and 4 refer to the following case.
A 68-year-old woman with a history of cerebrovascular accident with no residual loss of motor function and chronic bronchitis presents to the ED with shortness of breath, which has been progressively worsening for the last 4 months. She was treated with a 5-day course of azithromycin at least twice during the course of her illness without clinical improvement. A recent chest radiograph showed a cavitary lung lesion in the middle of a consolidative area in the left lower lobe. At this visit, bronchoscopy reveals granulomatous lesions and obstruction of the left lower lobe bronchus by a yellowish-white foreign body that looked like worn out popcorn when removed. Further history reveals that the patient likes to eat popcorn leaning towards her left side on her couch while watching television. Pathologic evaluation of the foreign body reveals vegetable matter. Gram stain of the biopsy specimen obtained during bronchoscopy reveals filamentous elements of gram-positive rods that are negative by acid-fast and partially acid-fast techniques (Figure 2). Aerobic culture shows no growth of microorganisms.

 

3. Which organism is most likely the cause of this patient’s disease?
  1. Actinomyces species
  2. Clostridium species
  3. Klebsiella pneumoniae
  4. Nocardia species
  5. Streptococcus pneumoniae
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4. What is the most appropriate initial step in this patient’s management?

  1. Ciprofloxacin
  2. Ciprofloxacin and surgical drainage
  3. Penicillin
  4. Penicillin and surgical drainage
  5. Tetracycline
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5. A 68-year-old man who recovered from the flu 2 weeks ago presents to the ED with progressive shortness of breath and pleuritic chest pain on the right side. He was released from prison 3 months ago. The patient reports having a productive cough, fever up to 104°F, chills, and night sweats for the last 4 days. He attempted to alleviate his symptoms with over-the-counter medications, but symptoms persisted. Lung examination is significant for dullness to percussion and absent breath sounds in the right lower lobe. A chest radiograph shows a large free-flowing right-sided pleural effusion. Thoracentesis reveals a pleural fluid with a pH of 7.1, glucose level of 36 mg/dL, and lactate dehydrogenase level of 800 U/L. Gram stain of the pleural fluid shows numerous polymorphonuclear leukocytes with intracellular gram-positive cocci in groups. What is the next best step in the management of this patient?

  1. Chest tube placement and intravenous (IV) ampicillin/sulbactam
  2. Chest tube placement and IV vancomycin
  3. IV vancomycin
  4. Surgical decortication
  5. Surgical decortication and IV vancomycin
Click here to compare your answer.


 

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