Pulmonary gangrene is a rare complication of exact pulmonary infection in which a pulmonary portion or lobe is sloughed.

Pulmonary gangrene is a rare complication of exact pulmonary infection in which a pulmonary portion or lobe is sloughed. It is part of a image of disease which includes necrotizing pneumonia and pulmonary abscess, processe in which lung tissue is devitalized. In the pre-antibiotic era, the denomination pulmonary gangrene was sometimes used to consign to multiple lung abscesses or necrotizing pneumonia. However, in more newly come times, it has been used to describe sloughing of a large amount of lung tissue like as a segment or lobe. The primary feature that fixs pulmonary gangrene apart from necrotizing pneumonia and pulmonary abscess is the length of necrosis and the fact that thrombosis of large canals plays a prominent role in the pathogenesis.

Pulmonary gangrene has been recognized since 1821 when it was first described on Laennec.[1] In the English-language literature, there have been 24 well-documented cases secondary to bacterial infections (excluding tuberculosis) to which we add the same Pulmonary gangrene has been known according to a variety of names, like as "spontaneous amputation,"[2] "massive sequestration of the lung"[3] "spontaneous lobectomy,"[4] "massive pulmonary gangrene,"[5] and massive necrosis of the lung"[6]

The terminus pulmonary gangrene is usually applied to lung sloughing in bacterial infection, on the other hand it has also been described in mucormycosis,[7] tuberculosis,[8] and secondary to radiation given for Hodgkin's disease.[9] A number of investigators have also reported the two radiologic and pathologic descriptions consistent with pulmonary gangrene in invasive aspergillosis in the immuno-compromised armed force although the term "gangrene" was not used in these reports.[10-12] Therefore, pulmonary gangrene may be more general than the literature suggests.

CASE REPORT

A 38-year-old man with a history of chronic ethanol abuse, chronic bronchitis, and a 40-pack-year history of smoking, existinged to the emergency department of a tertiary care hospital with a 30-h history of dyspnea, cough productive of rust colored sputum febrile affection rigors, and right-sided pleuritic chest pain. Approximately 48 h before admission, this man consum a large unless unknown amount of ethanol through the whole extent of 3 to 4 h. During this time, he wasted consciousness. He awoke the following morning with his presenting symptoms. onward arrival in the emergency department, he was alert and oriented. His kindred pressure was 82/60 mm Hg his legumes rate was 160/min, and his respirations were 40/min. His temperature was 399 [degrees] C He was dehydrated and cachetic with poor dental hygiene. He had increased vocal fremitis, a blockish percussion note, and bronchial breathing from one side of to the other the right upper lung cincture Initial laboratory investigations revealed a WBC of 12800/[mmsup3] an arterial pH of 738 a [PaO.sup.2] of 72 mm Hg a [PaCO.sub.2] of 15 mm Hg and a bicarbonate concentration [[HCOsub3] - ] of 9 mmol/L A sputum Gram stain revealed [greater than] 5 polymorphonuclear lonely dwellings per oil immersion field with rare epithelial confined apartments and had heavy concentrations of Gram-positive cocci, Gram-negative diplococci, and Gram-negative bacilli. Sputum stained using Ziehl-Neelsen's process did not show any acid-fast organisms. A chest radiograph (Fig 1) demonstrated right upper lobe consolidation. His initial treatment consisted of intravenous fluids, oxygen clindamycin, 600 mg IV q8h; and cefotaxime, 2 g IV q8h

Forty-eight hours after admission, the patient was still quite ill nevertheless not deteriorating. Klebsiella pneumoniae was grown from the one and the other sputum and blood. Anaerobic posterity cultures were negative. The antibiotics were changed to gentamicin, 140 mg IV q8h and cefuroxime, 15 g IV q8h Seventy-two hours after admission, another chest radiograph was obtained (Fig 2) In addition to a pleural effusion, a large cavity with pulmonary fragments and a fluid even was seen. A thoracostomy tube was placed to drain an empyema. Pleural fluid was immediately transported to the laboratory in a capped syringe. In addition to routine aerobic tillage techniques, the pleural fluid was also inoculated into S-Thio soup and plated on three different agar plates which were then incubated in a less degree than anaerobic conditions to maximize regaining of anaerobes. Culture of the pleural fluid was positive for k pneumoniae however negative for anaerobes. The patient continued to be febrile with little improvement athwart a period of almost 3 weeks. A CT scan demonstrated that the right upper lobe bronchus was harshly narrowed (Fig 3, right), and that most numerous of the large pulmonary fragments had undergone partial liquefaction (Fig 3 left) Surgical treatment was considered, further the patient was too debilitated to suffer a major procedure. Accordingly, individual of us (B.M.), an invasive chest radiologist, placed a 36F thoracostomy tube into the gangrenous cavity (Fig 4 left) The drainage was cultur moreover was negative for aerobes and anaerobes. The patient defervesc within 48 h The thoracostomy tube was in place 7 days before being accidentally dislodged. There was no evidence of a bronchopleural fistula. A 6-week course of antibiotics was complet and he was discharged place of abode feeling well. A chest radiograph obtained during follow-up demonstrated right upper lobe compass loss (Fig 4, right).

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