Differential Diagnosis of Nonresolving Pneumonia

1. 67 year old male was admitted to OSH on 6/30/05 with L-sided chest pain, shortness of breath, and hypoxia after 2 weeks of coughing up yellow sputum. CT at OSH showed L pleural effusion, L hilar fullness, and a 2x3 cm mediastinal LN. Thoracentesis on 7/1 showed exudative fluid without evidence for malignancy and no growth. The patient was started on moxifloxacin, and BAL washings on 7/5 grew MSSA. As of 7/13, patient’s condition had not improved, and he was transferred to UVA still feeling ill, nauseated, and dyspneic. PMHx: diabetes mellitus, HTN, chronic kidney disease, R tib/fib fx 8 months ago. SHx: quit smoking in 1982 after 30+ pk yrs. Allergic to augmentin. History otherwise noncontributory. On exam, patient was afebrile, O2 sat 94% on 2LNC, and his breath sounds were decreased over entire L lobe. WBC was 13.2.

2. Differential Diagnosis of Nonresolving Pneumonia • Inappropriate treatment of pathogen • Misdiagnosis of nonbacterial pathogens: mycobacteria, fungi, Nocardia, and Actinomyces • Resistant bacterial pathogens • Development of complications: empyema, lung abscess • Neoplastic disorders: brochogenic ca, bronchoalveolar cell ca, lymphoma • Immunologic disorders: vasculitis, BOOP, Eosinophilic pneumonia syndromes, AIP, pulmonary alveolar proteinosis, sarcoidosis, SLE • Drug toxicity • Pulmonary vascular abnormalities: CHF, PE

3. L pleural effusion and L-sided air space disease. Minimal layering of left pleural effusion. Possibly partially loculated left effusion and/or airspace disease L base.

4. Pleural thickening along the posterior aspect of the right lung base and marked left-sided pleural thickening that includes costal, paravertebral, and mediastinal pleural surfaces. Circumferential pleural thickening within the left hemithorax may be either infection or malignancy.

5. There is a fluid collection with sporadic pockets of gas that appears to be trapped in the posterior pleural space. This may represent an empyema.

6. 18 mm short axis prevascular lymph node. L hilar mass 27 x 34 mm may represent an enlarged lymph node or primary malignancy.

7. Hospital Course • Patient placed on vancomycin and clindamycin. • Thoracentesis on 7/14. 40 cc fluid with glucose < 2 (<40-30), LDH 5275 (>1000), pH 7.4 (<7.20), 3+PMNs, no bacteria. • Bronchoscopy on 7/14 with biopsy and BAL showed no evidence of malignancy. Negative for legionella, AFB, viruses, PCP, fungi. BAL positive for gm+ cocci. • On 7/20, patient went to TCV for drainage of empyema and L visceral and parietal decortication. As the pleural rind was elevated, they entered a L apical segment lower lobe abscess. This was drained. Chest tube was placed. Pathology consistent with empyema and abscess. No evidence of malignancy. • On 7/25, chest tube removed. • On 7/27, patient was discharged. He was maintaining O2 sat of 96% on 1-2L at rest and ambulating with 3LNC. CXR at time of discharge showed haziness secondary to decortication but resolving effusion. • Final diagnosis: MSSA lung abscess and empyema

8. Student Teaching File CaseAmy OylerUVA SOM 06Period #2: July 23- August 20, 2005 References • Ost, David, Alan Fein, Steven Feinsilver, Rakesh Shah, “Nonresolving pneumonia.” UptoDate. • Strange, Charlie, “Pathogenesis and management of parapneumonic effusions and empyema in adults.” UptoDate.