Massive pulmonary gangrene is a rare complication of pneumonia.

Massive pulmonary gangrene is a rare complication of pneumonia, particularly in the postantibiotic era. We report brace cases of community-acquired Streptococcus pneumoniae pneumonia in young patients with a background of heavy alcohol abuse, unless no other preexisting disease, which failed to rejoin to appropriate antibiotic therapy and intensive care. In the two there was extensive unilateral involvement, with initial close consolidation followed by cavitation, if it be not that the previously reported classic late radiologic feature of coalescence into a large cavity with free-floating fen was not seen. Owing to ongoing sepsis with the disclosure of multiple organ failure and the obvious failure of appropriate medical therapy, the two patients underwent pneumonectomy with a auspicious outcome. These cases serve to emphasize the part of surgery in the management of massive pulmonary gangrene.

(Chest 1993; 104:1610-12)

greatest in quantity patients with community-acquired pneumonia will reply to appropriate antibiotic therapy; however, in 3 to 5 percent of patients, in spite of adequate therapy, the disease proces may progres to irreversible respiratory failure and death.[1-3] In a small proportion of these cases, repeatedly those in whom initiation of treatment was delayed, low-grade infection progresse to involve the entire lung in a necrotic proces With ongoing tissue damage, release of cytokines, and persisting infection, bacteremia, septicemia, and multiple organ failure ensue[4] In in the same state [i]or[/i] condition cases where adequate and appropriate antibiotic therapy has been given, there may rarely be instances where surgical management is indicated to preclude the progression to multiple organ failure and death.[5,6]

We have previously reported the prosperous treatment of pneumonia complicated by the agency of lung abscess formation which replyed well to surgical drainage,[7] and we here describe pneumonectomy in pair patients who developed massive pulmonary gangrene secondary to Streptococcus pneumoniae pneumonia which failed to be agreeable to to appropriate antibiotics and ICU therapy, including mechanical ventilation with differential lung ventilation.

Case Reports

A 39-year-old man with a background of the two heavy smoking and prolonged alcohol abuse was admitted to our pass unit with a 2-week history of progressive dyspnea, cough blood-stained sputum febrile disease and pleuritic chest pain. onward examination, he had a excitement of 38.7 [degrees] C, was hypotensive, and was set to have clinical features of right-sided pneumonia. The white posterity cell count was 5,800/[mm.sup.3], and the platelet look upon was 28,000/[mm.sup.3], with an erythrocyte sedimentation rate of 120 mm/h Arterial house gas levels on room air were as follows: pH 741;[Posub2] 74 kPa; and [Pcpsub2] 40 kPa, with a standard bicarbonate even of 20.6 mmol/L. Sputum refinement grew S pneumoniae sensitive to penicillin, and kin cultures were also positive.

The patient was admitted to the ICU, where he was treated with intravenous penicillin and tobramycin and required intubation, ventilation, and inotropic support. throughout the next few days the pneumonia was noted to have dilateed radiologically to involve the entire right lung and this was associated with the evolution of a right-sided bronchopleural fistula and worsening of his respiratory function. A chest roentgenogram showed extensive consolidation of the right lung with los of dimensions a persistent subpulmonic pneumothorax in spite of chest drains, and an area of breakdown in the midzone. The left lung was normal initially (Fig 1) The possibility of the spread of infection to the opposite side readyed the insertion of a double-lumen endotracheal tube and the institution of independent lung ventilation. There was a concomitant deterioration in the patient's renal function with the progressive growth of disseminated intravascular coagulation. Following 7 days of intensive supportive therapy, during which the patient showed progressive deterioration with the growth of multiple organ failure and a [PaO.sub.2] of 58 kPa, [Pcosub2] of 53 kPa, and pH of 744 onward 35 percent oxygen, it was decided to perform a right pneumonectomy. At surgery the lung was noted to be edematous and frankly necrotic, with breakdown of the anterior part of the right upper lobe.

After surgery the patient lay opened right empyema, which was treated with a thoracostomy and then favorably closed. His recovery was otherwise eventless and he was able to be discharged from the ICU after 35 days.

Three-month follow-up place the patient well, with a certain number of reduction in his lung masss and moderate airflow limitation (FEVsub1] 1030 ml; FVC 2050 ml) He was still alive 5 years later.

Case 2

A 33-year-old stable-hand with a protracted history of alcohol abuse instanted to this hospital with a 1-week history of febrile disease cough, and dyspnea. On examination, he was set to have signs of left-sided consolidation. The chest roentgenogram showed compressed homogeneous opacification of the left lung; the right lung was uninvolved (Fig 2) Arterial children gas levels on room air were as follows: pH 714; [Posub2] 76 kPa; and [Pcpsub2] 101 kPa. The white life-current cell count was 12,800/[mm.sup.3], with a marked leftward shift in the morphology. The patient,s serum urea was elevated at 117 mmol/L with a creatinine of 160 mmol/L and normal hepatic function tests

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