Rizwan Qureshi, Joe Rahmim.
Gangrene of the lung: A Surgical Challenge.
J Coll Physicians Surg Pak Jan ;11(9):577-9.

A 58 years old Caucasian gentleman was transferred to Regional Thoracic Surgical Unit from another institution with cough, sputum, fever, chills and right sided pleuritic pain. About 13 months ago, he had total laryngectomy, permanent tracheostomy and left sided radical block neck dissection for supraglottic squamous cell carcinoma with subsequent radical radiotherapy (64 gy 32 fraction 6 and half week).

On arrival, he was dehydrated and cachetic with poor dental hygiene. His blood pressure was 82/60 mmHg, pulse rate 160/min and respiration 40/min. Temperature was 39.4 degree centigrade. Clinical assessment revealed decreased air entry, dull percussion note and patch of bronchial breathing in right upper zone.

Initial laboratory investigations revealed a WBC count of 12,800/mm3, an arterial pH of 7.38, a Pao2 of 72 mmHg, a Paco2 of 15 mmHg and a bicarbonate concentration of 9 mmol/l.

Sputum gram staining revealed heavy concentration of gram-positive cocci, gram negative diplococci, and gram-negative bacilli. Sputum stained using Ziehl-Neelsen`s method did not show any acid-fast organisms.

The chest radiograph and CT scans were suggestive of right upper lobe consolidation with air bronchogram mainly occupied by multiple cavities and sloughed lung parenchyma. The initial treatment consisted of intravenous fluids, oxygen, clindamycin, 600 mg I/V given 8 hourly, and cefotaxime 2g I/V, 8h.

Forty-eight hours after admission, the patient was still quite ill. Klebsiella pneumoniae was isolated from both sputum and blood. Anaerobic blood cultures were negative. The antibiotics were changed to gentamycin, 140 mg I/V, 8h, and cefuroxime, 1.5 g I/V, 8h. Seventy-two hours after admission, the radiographic picture was unchanged and the patient appeared to be in septic condition with white blood cell count of 24,000 mm3

At this stage, bronchoscopic examination revealed only frothy, white, non-purulent material issuing from the right upper lobe orifice; the examination was otherwise normal.

Right sided video assisted thoracoscopy (VATS) was carried out as a diagnostic as well as therapeutic measure. It surprisingly revealed, necrotic right lung accompanied with empyema. About 600 ml of pus was evacuated. Empyema cavity was debrided and chest tubes were placed under vision. Culture of the pleural fluid was positive for Klebsiella pneumoniae but negative for anaerobes.

Serial pleural washouts were carried out every 24 hours with normal saline and the pleural fluid was sent for culture every alternative day. Within 7 days, the pleural cavity became clean and his clinical status improved. Right explorative thoracotomy was undertaken which proceeded to right upper and middle bilobectomies.

Pathology results were consistent with lung necrosis associated with superimposed polymicrobial infection. There was preservation of alveolar architecture with evidence of thrombotic occlusion of the terminal pulmonary vasculature. The patient had an uneventful recovery and discharged on the tenth postoperative day.

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