Necrotising pneumonia refers to pneumonia characterised by the development of the necrosis within infected lung tissue.
While the term has sometimes been used synonymously with cavitating pneumonia in some publications 2, not all necrotising pulmonary infections may be complicated by cavitation.
Necrotising changes may be seen in up to around 7% of those with bacterial pneumonia 3. It can affect patients of any age and is increasingly being reported in the paediatric population.
Progression to necrotising pneumonia can occur from either virulences factor of the microorganism, predisposing factors of the host or both.
It can result from a large number of pathogens, which include:
- Staphylococcus aureus: particularly in young immunocompetent patients
- Klebsiella pneumoniae 6 (Klebsiella pneumonia)
- Enterobacter spp.
- Nocardia spp. (pulmonary Nocardia infection)
- Actinomyces spp. (thoracic actinomyces infection)
- Pseudomonas spp. (Pseudomonas aeruginosa pneumonia)
- Pneumococcus spp.: especially type III Pneumococcal sp. 3
- Haemophilus influenzae (pulmonary Haemophilus influenzae infection) 8
If a necrotising infection is suspected and CT evaluation is required, it may be better to give contrast as it allows appreciation of low attenuation and non-enhancement within the necrosed portions.
CT imaging may show distinct areas of low attenuation with decreased parenchymal enhancement (representing liquefaction 4) in all or parts of the affected area of infection (consolidation).
Normal pulmonary parenchymal architecture within the necrosed segment is often lost 2.
Treatment and prognosis
Treatment depends on the underlying agent while prognosis depends on the severity of the pathogen as well as the susceptibility of the host. In general, complete recovery can be anticipated in children with bacteremic necrotising pneumococcal pneumonia contrary to what is seen in adults 4.
As opposed to a formed lung abscess, interventional procedures (e.g. drainage) may be counterproductive in cases of necrotising pneumonia 10. In some centres, pulmonary resection has been carried out as a surgical option 12-13.
For a lesion with large areas of low intrinsic low attenuation, consider:
- lung abscess: more well-defined with little surrounding consolidation
- necrotising pulmonary malignancy 7
- 1. Tsai YF, Ku YH. Necrotizing pneumonia: a rare complication of pneumonia requiring special consideration. Curr Opin Pulm Med. 2012;18 (3): 246-52. doi:10.1097/MCP.0b013e3283521022 - Pubmed citation
- 2. Sawicki GS, Lu FL, Valim C et-al. Necrotising pneumonia is an increasingly detected complication of pneumonia in children. Eur. Respir. J. 2008;31 (6): 1285-91. Eur. Respir. J. (full text) - doi:10.1183/09031936.00099807 - Pubmed citation
- 3. Pande A, Nasir S, Rueda AM et-al. The incidence of necrotizing changes in adults with pneumococcal pneumonia. Clin. Infect. Dis. 2012;54 (1): 10-6. Clin. Infect. Dis. (full text) - doi:10.1093/cid/cir749 - Pubmed citation
- 4. Kerem E, Bar Ziv Y, Rudenski B et-al. Bacteremic necrotizing pneumococcal pneumonia in children. Am. J. Respir. Crit. Care Med. 1994;149 (1): 242-4. doi:10.1164/ajrccm.149.1.8111589 - Pubmed citation
- 5. Seo H, Cha SI, Shin KM et-al. Focal necrotizing pneumonia is a distinct entity from lung abscess. Respirology. 2013;18 (7): 1095-100. doi:10.1111/resp.12124 - Pubmed citation
- 6. Moon WK, Im JG, Yeon KM et-al. Complications of Klebsiella pneumonia: CT evaluation. J Comput Assist Tomogr. 1995;19 (2): 176-81. Pubmed citation
- 7. Jung JI, Kim H, Park SH et-al. CT differentiation of pneumonic-type bronchioloalveolar cell carcinoma and infectious pneumonia. Br J Radiol. 2001;74 (882): 490-4. Br J Radiol (full text) - Pubmed citation
- 8. Wong KS, Chiu CH, Yeow KM et-al. Necrotising pneumonitis in children. Eur. J. Pediatr. 2001;159 (9): 684-8. Pubmed citation
- 9. Hsieh YC, Hsiao CH, Tsao PN et-al. Necrotizing pneumococcal pneumonia in children: the role of pulmonary gangrene. Pediatr. Pulmonol. 2006;41 (7): 623-9. doi:10.1002/ppul.20411 - Pubmed citation
- 10. Hoffer FA, Bloom DA, Colin AA et-al. Lung abscess versus necrotizing pneumonia: implications for interventional therapy. Pediatr Radiol. 1999;29 (2): 87-91. Pubmed citation
- 11. Alifano M, Lorut C, Lefebvre A et-al. Necrotizing pneumonia in adults: multidisciplinary management. Intensive Care Med. 2011;37 (11): 1888-9. doi:10.1007/s00134-011-2328-8 - Pubmed citation
- 12. Reimel BA, Krishnadasen B, Cuschieri J et-al. Surgical management of acute necrotizing lung infections. Can. Respir. J. 2007;13 (7): 369-73. Free text at pubmed - Pubmed citation
- 13. Tsai YF, Tsai YT, Ku YH. Surgical treatment of 26 patients with necrotizing pneumonia. Eur Surg Res. 2011;47 (1): 13-8. doi:10.1159/000327684 - Pubmed citation