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Necrotizing pneumonia

Necrotizing pneumonia (NP), also known as cavitary pneumonia or cavitatory necrosis, is a rare but severe complication of lung parenchymal infection. In necrotizing pneumonia, there is a substantial liquefaction following death of the lung tissue, which may lead to gangrene formation in the lung. In most cases patients with NP have fever, cough and bad breath, 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 pneumoniae, Staphylococcus aureus, and Klebsiella pneumoniae. Diagnosis is usually done by chest imaging, e.g. chest X-ray or CT scan. Among these, a CT scan is the most sensitive test, which shows loss of lung architecture and multiple small thin walled cavities. Often cultures from bronchoalveolar lavage and blood may be done for identification of the causative organism(s). It is primarily managed by supportive care along with appropriate antibiotics. However, if a patient develops severe complications like sepsis 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. Its clinical features were presumably first outlined by Hippocrates. 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==
Causative organisms
The most common pathogens responsible for NP are Streptococcus pneumoniae, Staphylococcus aureus and Klebsiella pneumoniae. Consequently, non-PCV7 serotypes like 3, 5, 7F 19A emerged as new threats. Of this, serotypes 3 and 19A were particularly associated with NP. These PVL-producing strains are frequently methicillin-resistant (MRSA). In developing countries with high rates of HIV infection, Mycobacterium tuberculosis is the common cause of NP in children. Adults Adults are more commonly affected by community-acquired Staphylococcus aureus, Streptococcus pneumoniae and K. pneumoniae. Gram-negative organisms like K. pneumoniae and P. aeruginosa are usually associated with pulmonary gangrene. ==Predisposing risk factors==
Predisposing risk factors
Adults Necrotizing pneumonia typically occurs in adult males who have coexisting health problems like diabetes mellitus, alcohol use disorder, and corticosteroid therapy. ==Additional imaging==
Additional imaging
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. This requires further clarification. ==See also==
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