Necrotizing pneumonia

Last revised by Liz Silverstone on 24 Dec 2022

Necrotizing pneumonia refers to pneumonia characterized by the development of necrosis within infected lung tissue.

While the term has been used synonymously with cavitating pneumonia in some publications 1, not all necrotizing pulmonary infections may be complicated by cavitation.

Necrotizing changes may be seen in ~7% of those with bacterial pneumonia 2. It can affect patients of any age and is increasingly being reported in the pediatric population 3.

Progression to necrotizing pneumonia can occur from either virulence factors 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 4
    • this ability to cause lung necrosis appears to be intimately related to the secretion of the Panton-Valentine Leukocidin (PVL); a pore-forming cytotoxin present in the majority of Methicillin-resistant Staphylococcus aureus isolates, which assembles as a ring pore in the membrane of the host leukocytes, leading to leakage of cell contents and ultimately leukocyte necrosis and a superantigen effect 5
  • Klebsiella pneumoniae (Klebsiella pneumonia) 6
  • Enterobacter spp.
  • Nocardia spp. (pulmonary Nocardia infection)
  • Actinomyces spp. (thoracic actinomyces infection)
  • Pseudomonas spp. (Pseudomonas aeruginosa pneumonia)
  • Pneumococcus spp.: especially type III Pneumococcal sp. 2
  • Haemophilus influenzae (pulmonary Haemophilus influenzae infection) 7

If a necrotizing 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 necrotic portions.

CT imaging may show distinct areas of low attenuation with decreased parenchymal enhancement (representing liquefaction 8) in all or parts of the affected area of infection (consolidation). 

Normal pulmonary parenchymal architecture within the necrotic segment is often lost 1

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 necrotizing pneumococcal pneumonia contrary to what is seen in adults 8

As opposed to a formed lung abscess, interventional procedures (e.g. drainage) may be counterproductive in cases of necrotizing pneumonia due to the likelihood of creating a bronchopleural fistula 9. In some centers, pulmonary resection has been carried out as a surgical option 10,11.

For a lesion with large areas of low intrinsic low attenuation, consider:

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Cases and figures

  • Case 1: with bronchopleural fistula and empyema
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  • Case 2: pediatric
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  • Case 3: pediatric
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  • Case 4: with pneumothorax
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  • Case 5: tuberculosis
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