EpistemisChocolate sputum of pulmonary origin
Specialty: Respiratory.
Why it occurs
- Amebic liver abscess fistulized to the lung through the diaphragm (caused by Entamoeba histolytica; the chocolate-brown necrotic liver material passes through the pleura and enters the bronchi)
- Lung abscess due to anaerobic germs with extensive tissue necrosis and degraded intraalveolar hemorrhage
- Aspergillus mycetoma or fungal ball (aspergilloma) colonizing a pre-existing tuberculous cavern with chronic low-grade bleeding
- Pneumonitis due to severe aspiration of old gastric contents with degraded food debris
- Advanced pulmonary paragonimiasis with suppurative fibrous cysts
Initial workup
Hepatobiliary ultrasound (search for liver abscess with elevation of the right hemidiaphragm); Contrast-enhanced computed tomography (CT) of the chest and upper abdomen; Fresh examination of sputum to look for Entamoeba histolytica trophozoites; Serology for amebiasis (ELISA); Diagnostic bronchoscopy to rule out active hepatobronchial fistula.
red flags
Sudden onset dyspnea at rest, acute pain in the right upper quadrant radiating to the ipsilateral shoulder (sign of phrenic irritation due to liver abscess), hectic fever, chills, or signs of sepsis/septic shock with hemodynamic instability.
Standard management
- Metronidazole — 500-750 mg intravenously or orally every 8 hours for 10-14 days as the antiparasitic regimen of choice against amoebas
- Tinidazole — 2 g orally once a day for 5 days as an alternative to metronidazole
- Piperacillin/Tazobactam (4.5 g intravenously every 6 hours in case of bacterial superinfection of the lung abscess or associated empyema).
Educational guidance for study. It is NOT a prescription recommendation. The actual choice depends on the cause, the patient, and current guidelines.
- Area
- Respiratory
- Listed causes
- 5
- Treatment options
- 3