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