Atypical Presentation of Pneumonia
Claire Head
Ama Basoah
Melanie Long
Hannah Bellsham-Revell
George Smith
Mr. P.R.
50 year oldMalePost office Counter Clerk
History PC:
Cough and SOB, 6/52, with lack of energy
HPC: Admitted on Good Friday after feeling generally ill for 2/52 previously. Cough: Frequently throughout the day.
Produced dark green sputum
Loss of appetite
Nausea and vomiting
Cough syrup for chesty cough made it slightly better but not effective for very long
Worse at night
History SOB: Constant for 4 weeks at rest (mainly noticed by wife) and on
exercise
Does not recall having any associated features
Does not recall anything which may have exacerbated it.
Dull achy pain radiating from Rt. axilla to Rt. chest when lying down propped on Rt. elbow.
Never had anything like this before.
PMH:Tonsillectomy
° MI, ° asthma, ° BP, ° DM, °Cholesterol, ° RF, ° Epilepsy, ° TB
(Note that he has NOT had the BCG vaccination).
History
FH: Mum died aged 61, colon ca. Dad died aged 68, lung ca Sister had MI 3/12 ago.
DH: None before hospital admission except for the occasional
vitamin tablet No allergies
History
SH: 1st floor flat with wife and cat (not allergic to it). Has no problems with walking up or down stairs. No contact with anyone with any infections. No recent travel Smoking: Ex-smoker (stopped 1 week prior to
admission) – 38 pack years Alcohol: ½ bottle of vodka and 2 pints of beer, a
day. Says he quit to help stop smoking.
Examination
S/E: Cardiovascular: ° Chest pain, ° palpitations Respiratory: Cough (as above), ° haemoptysis.
Sleeps with 2 foam pillows. ° PND. GI: Good appetite, but not a fan of hospital food.
Bowels open twice daily but of late has been loose. ° Pain on passing stool.
GU: ° Pain or stinging CNS: ° Loss of vision, ° headaches, blackouts or
faints
Examination
General:
°Jaundice.
Temp. 38.1°, RR 30/min, tachycardia 100bpm, BP 104/69
Cardiovascular:HS: I + П + 0 (quiet!)
JVP:
Examination Respiratory
Abdominal
PR – soft, brown stool, ° melaena, ° blood
2cm hepatomegalySoft, no masses, mild tendernessBS√
xxxx xxxxxxxxxxxx
Vocal resonanceCrackles Rt. mid/upper lobeDull percussion note air entryTrachea central
Investigations: 18/04/03
Na 134 K 3.5 Cl 95 Bic 22 Ur 30.4 Cre 149 Glu 5.7 Bil 15
Alt 166 AP 84 Alb 16 GT 31 Ca 1.94 Ps 1.33 Cac 2.42 CRP 527.3
Inv continued
Haematology results.Hb 15.3WCC 15.7Platelets 301MCV 107
Blood gases.pH 7.473pCO2 4.18
pO2 6.92Base Ex -0.5
CXR 18/04/03
Initial Diagnosis and Management Problems on admission 18/04/03 were:
Tachypnoeic (30) Hypotensive (104/69) Elevated urea (30.4) Hypoxic Low albumin (16)
Initial impression on admission from CXR appearance and clinical signs was of a right upper lobe pneumonia.
Differential diagnosis of cavitation in the right upper lobe: TB S. aureus Klebsiella anaerobes Other atypical organisms
19/04/03: IV Cefotaxime/PO Erythromyocin Saline nebs IV fluids Chest physio Pabrinex
If no improvement, consider CPAP and possible ITU admission.
19/04/03: (Admitted to ITU) Review antibiotics- IV only CPAP +5 NG tube Possible TB diagnosis? Add in anti-TB therapy (Rifampicin, Isonozid,
Pyrazidanimide, Ethambutol).
21/04/03: Discharged ITU
23/04/03-03/05/03: Admitted to ITU. Worsening respiratory distress:
Blood gases on 10L O2 (23/04/03):
PH 7.509
PCO23.69
PO2 9.9
Bic 25.7
Sats 95.4% Bi Pap NG tube
29/04/03: BAL:
• C&S: Coliform ++• Candida spores and hyphae seen• ZN -ve
02/05/03: BAL:
• Coliform scanty• Coagulase negative Staph scanty• AFBs not seen• Yeasts, fungi and legionella not isolated
06/05/03: Continue high dose antibiotics Stop TB therapy X-ray, CT
05/05/0318/04/03
21/05/03: 3/52 ‘echos’ in ears, maybe since on
holiday in Alps Audiometry testing:
• Dip 2000-8000Hz, lowest 6000Hz• Typical of Gentamicin Ototoxicity
Gentamicin Levels:
0
0.5
1
1.5
2
2.5
3
Date:
Con
cent
rati
on:
White Cells:
0
2
4
6
8
10
12
14
16
18
20
18/0
4/03
20/0
4/03
22/0
4/03
24/0
4/03
26/0
4/03
28/0
4/03
30/0
4/03
02/0
5/03
04/0
5/03
06/0
5/03
08/0
5/03
10/0
5/03
12/0
5/03
14/0
5/03
16/0
5/03
18/0
5/03
20/0
5/03
Date:
Va
lue
:
WCC:
Neutrophils:
Epidemiology
Incidence: 5-11/ 1000 adult populationCAP accounts for 5-12% of all LRTIs22-42% adults with CAP, admitted to
hospital 5-10% of these, managed on ITU
Epidemiology cont’d.
Extremes of age most at riskUK mortality rates :
Mx in community <1% Mx in hospital 5.7 - 12% Mx in ITU >50%
Costs per episode of CAP: Mx in community £100 Mx in hospital £1700- 5100
Classification of Pneumonia
Community acquired
1o infection2o to concomitant
diseaseMostly Gram +ve
Hospital acquired (nosocomial)
>48 hours post admission
2o to underlying disease
Mostly Gram -ve
Aetiology
Typ ica lo rg an ism s
A typ ica lo rg an ism s
C om m u n ity acq u ired
Typ ica l o rg an ism s
A typ ica l o rg an ism s
H osp ita l acq u ired
P n eu m on ia
Community acquired pneumonia: aetiology
Typical bacteriaS. pneumoniaeH. influenzaeS. aureusAll virusesInfluenza A & B
Community acquired pneumonia: aetiology
Atypical organisms
M. pneumoniaeM. catarrhalisLegionella spp.C. pneumoniae C. psittaci C. burnetii
Causes in infants RSV Adenovirus
Immunocompromised
Pneumocystis CMV, HSV, Adenovirus M. tuberculosis
Hospital acquired pneumonia: aetiology
Gram -ve bacteria Anaerobes Klebsiella Pseudomonas
Gram +ve bacteria S. aureus
BTS Guidelines
All patients referred to hospital with CAP: CXR Oxygenation assessed by pulse oximetry. SaO2 <92% should have arterial blood gas
measurements, as should all patients with features of severe pneumonia
Assessed for volume depletion and may require intravenous fluids.
Oxygen therapy Indicated for:
PaO2 <8 kPa Hypotension (systolic <100 mmHg) metabolic acidosis (bicarbonate <18 mmol/l) Respiratory distress (resp. rate of >24 bpm)
The aim of oxygen therapy should be to maintain PaO2 at >8 kPa or SaO2 >92
35% O2 concentration if no contraindications low concentrations (24–28%) if preexisting COPD If very severe:
• non-invasive ventilation • respiratory stimulants • transfer to a high dependency unit or ICU
Monitoring the patient Normally twice daily. Severe pneumonia or continuous oxygen or
cardiovascular support should be monitored more frequently. Pulse, blood pressure, respiratory rate, temperature oxygen saturation
with a recording of the inspired oxygen concentration mental status
The acute phase reactant CRP is a sensitive marker of progress in pneumonia
CRP drop of 50% over 4 days is consistent with a good clinical response
A fall in the level of CRP of less than 50% or a persistently high or rising white cell count suggests failure of antibiotic treatment
Persisting hypoxia with PaO2 <8 kPa despite maximal oxygen administration, progressive hypercapnia, severe acidosis (pH <7.26), shock, or depressed consciousness are indications for transfer to the ICU
TreatmentFew pneumonias are defined microbiologically
hence most prescribing is empirical.Consideration of common pathogens
SGH protocol is Cefotaxime and Erythromycin Legionella suspected = addition of oral rifampicin
Parenteral treatment * ** severe pneumonia impaired consciousness loss of swallowing reflex functional or anatomical reasons for malabsorption
*Chan et al, BMJ 1995;310:1360-1362 **Siegel et al CHEST 1996;110:965-971
Treatment The aim of antibiotic treatment is to ensure elimination of
the target pathogen in the shortest time.
The resolution of pneumonia elimination of the invading pathogen and its products subsidence of the host inflammatory response
There is presently no evidence that systemic corticosteroids are of benefit.
The duration of treatment remains subject to clinical judgment and will vary with the individual patient and disease severity
No Response to Empirical TreatmentConsider
Correct diagnosis (radiological review) complications
• pleural effusion or empyema
• lung abscess or worsening pneumonic shadowing Adequate absorption of an oral regimen Microbiological reviewed to exclude less common
pathogens • S. aureus, atypical pathogens, Legionella species,
• viruses, and Mycobacteria species. Mixed infections can arise in approximately 10% of patients
admitted to hospital with CAP
Specific Pathogen Directed Antibiotic treatment
In routine clinical practice only about one third to one quarter of patients with CAP admitted to hospital will be defined microbiologically.
Mycoplasma and chlamydial infection will be diagnosed late in the illness reducing the opportunity for early targeted treatment.
The choice of agent may be modified following the availability of sensitivity testing or following consultation with a specialist in microbiology or infectious disease.
S. pneumoniae highly resistant to penicillin is currently uncommon in the UK.
S. aureus is an uncommon cause of CAP in the UK. Most community isolates are sensitive to methicillin, recent increase in MRSA in hospitalised patients may result in
subsequent readmission with an MRSA infection which may include CAP
methicillin sensitive and resistant infections imply parenteral treatment in view of the serious nature of staphylococcal pneumonia.
Assessing Severity
ConfusionUrea >7mmol/lRespiratory Rate >30/minBlood pressure <60mmHg
Assessing SeverityAge >60 yearsAtrial FibrillationMultilobar involvementAlbumin <35g/lHypoxia <8kPaWCC <4x109/lLeucocytosis >20x109/lBacteraemia
Complications Respiratory Failure:
Type 1 commonly - high flow (60%) O2
Be ready to intubate or ventilate if increasing pCO2 or worsening acidosis
Hypotension: Dehydration, -vasodilatation due to sepsis. Fluid therapy, central line, inpotropes, ITU
Atrial Fibrillation: Quite common, particularly in the elderly. Usually resolves with the treatment of the pneumonia, Digoxin may be
used in the short term to control rate
Pleural Effusion: Inflammation of the pleura - fluid exudate Small - may resolve, larger, symptomatic or infected - may need drainage
Empyema: Pus in the Pleural Space - resolving pneumonia + recurrent fever Clinical features and CXR - pleural effusion: fluid turbid, yellow, pH ,7, low glucose,
high LDH Drained - radiological guidance Loculated - Streptokinase to break down the adhesions
Lung Abscess: Cavitating area of localized supparative infection within the lung Swinging fever, cough, purulent, foul smelling sputum, pleuritic chest pain,
haemoptysis, malaise, weight loss, clubbing, anaemia, crepitations Antibiotics, postural drainage, aspiration, antibiotic instillation, surgical excision
Septicaemia: May cause metastatic infection, IBE, meningitis IV antibiotics
Pericarditis, Myocarditis. Jaundice:
Cholestatic - sepsis, 2o to antibiotic therapy
Conclusion
No causative organism was foundThe presentation was atypical:
Slow onset (normally acute presentation)
When a cavitating lesion is found, think TB
Watch Gentamicin levels carefully in those with renal impairment