PNEUMONIA   10A

A 67-year-old man with a history of alcoholism presents with a 2-day history of fevers, chills, rigors, shortness of breath, and a cough productive of dark yellow sputum. He had a recent binge of alcohol use that ended 2 days before admission, and he woke up with these symptoms. On physical examination, his temperature is 39.5°C, his respiratory rate is 30 breaths/min, and he is in moderate respiratory distress. His lower right lung field has inspiratory crackles on auscultation. Laboratory testing reveals a white blood cell count of 16,000/mcL. A chest radiograph shows focal consolidation in the right middle and lower lobes.

What are the salient features of this patient’s problem? How do you think through his problem?

Salient features: Alcohol history predisposing to aspiration; fever and chills; rigors; shortness of breath; cough with purulent sputum; tachypnea; consolidation on examination and radiograph; leukocytosis

How to think through: Pneumonia is a clinical diagnosis in which symptoms, examination, white blood cell count, and chest radiograph are all considered. Although these all point to a diagnosis of pneumonia in this case, what other causes are plausible? (Aspiration pneumonitis, lung neoplasm, lung abscess, acute respiratory distress syndrome, bronchitis, tuberculosis, pulmonary embolism, congestive heart failure, atelectasis, drug reactions.) What are the next diagnostic steps? (Blood cultures; arterial blood gases.) Pathogens and outcomes vary with epidemiologic risk factors. This patient likely has community-acquired pneumonia (CAP), but recent exposure to health care settings and immune status (including HIV testing) should be assessed. His alcoholism may indicate other substance abuse, and both increase the risk of tuberculosis. What pathogens are most likely in this case? (The acuity of his illness is most consistent with “typical” bacterial pneumonia from Streptococcus pneumoniae, Haemophilus influenzae, and Klebsiella pneumoniae. “Atypical” pneumonia, e.g., Mycoplasma pneumoniae, is less likely in patients admitted to the hospital. But empiric antibiotic coverage for both types may be important. Although Staphylococcus aureus pneumonia is uncommon, it is associated with morbidity, so coverage for it may be appropriate with severe disease and for patients requiring intensive care.) If this patient responds to antibiotic treatment within the first 2 to 3 days, its duration should be 7 days for most pathogens.

PNEUMONIA   10B

What are the essentials of diagnosis and general considerations regarding pneumonia?

Essentials of Diagnosis

Fever or hypothermia, tachypnea, cough with or without sputum, dyspnea, chest discomfort, sweats or rigors (or both)

Bronchial breath sounds or inspiratory crackles on chest auscultation, opacity on chest radiograph

Leukocytosis

Purulent sputum

CAP occurs outside of the hospital; hospital-acquired pneumonia (HAP) occurs more than 48 hours after admission; ventilator-associated pneumonia (VAP) develops in a mechanically ventilated patient; health care–associated pneumonia (HCAP) occurs in community members with high health care facility exposures

General Considerations

May be bacterial (e.g., S. pneumoniae, M. pneumoniae, Chlamydophila pneumoniae, Neisseria meningitides, Moraxella catarrhalis, K. pneumoniae) or viral (e.g., influenza, respiratory syncytial virus, adenovirus)

HAP organisms may include S. aureus and Pseudomonas aeruginosa

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