1. A CASE OF NON RESOLVING PNEUMONIA
Dr. RAMADOSS.R
SENIOR RESIDENT
DEPT. OF MEDICINE
PGIMER & Dr. RML HOSPITAL

2. HISTORY 68 years old woman, House wife. Chief complaints of-
Fever - 2 months
Cough with expectoration -15 days
Breathlessness-10 days

3. HISTORY
Fever- 2 months, insidious in onset, documented (104°F), continuous, associated with chills.
No burning micturition /pain abdomen/ loose stools/
pus discharge from any site/Discharge PV/ altered sensorium

4. HISTORY Cough - 15 days, no diurnal or postural variation
with yellowish sputum -Not foul smelling/ blood streaked.
Breathlessness days, insidious in onset, progressive, present even at rest.
No orthopnea/PND

5. PAST HISTORY Tuberculosis- 40 yrs ago, treatment completed.
Hypertensive- 8 years, on medications.
Rheumatoid Arthritis - 8 years - details of diagnosis not known – On Methotrexate 7.5mg weekly, Hydroxychloroquine 200 mg HS since 2007, Methyl prednisolone 16 mg once a week since 2013.
No other co-morbidities.
Non-alcoholic, non-smoker

6. COMMUNITY ACQUIRED PNEUMONIA
TREATMENT HISTORY
Patient was admitted to a private hospital with a provisional diagnosis of
COMMUNITY ACQUIRED PNEUMONIA
Methotrexate and methyl prednisolone was stopped, hydoxychloroquine was continued.
She was treated with oxygen, nebulized bronchodilator & empirical antibiotics and was investigated for the etiology of pneumonia

7. INVESTIGATIONS (OUTSIDE)Hb
11.2
TLC
19,100
Polymorphs 96
lymphocytes 4
ESR 62
Platelets
2.6 L
PCV
33.2
MCV
81 (83-101)
MCH
27.3(27-32)
MCHC
33.7 ( )
Urea
28 (15-44)
Creatinine
1.2( )
Uric Acid
3.7( 2.6-6)
Na/K
128/ 4.3
Bilirubin-T/D/I
0.4/0.2/0.2
SGOT/SGPT
16/17
Total protein
7.0
Albumin
3.4
Globulin
3.6
Urine R/M
normal
ABG
Type I respiratory failure

8. CHEST X-RAY

9. CECT CHEST

10. CECT CHEST
Consolidation: Right Upper lobe, Right middle lobe lateral segment, Left lower lobe
Peripheral based wedge shaped area with lack of air bronchogram in superior segment of left lower lobe ??Consolidation ??malignancy
Minimal B/L pleural effusion
Multiple enlarged mediastinal LNs: Right paratracheal, AP Window, Pre carinal,Subcarinal and Right hilar (Largest measuring 2x1.5 cms)

11. INVESTIGATIONS (OUTSIDE)
Sputum examination –Gram stain, Z/N stain for AFB- Negative, Culture- Sterile
Bronchoscopy- Inflammation of right upper lobe and left lingula
Bronchial secretion Cytology- Smears showed scattered superficial squamous cells, columnar and numerous polymorphs against mucoproteinaceous background. No malignant cells seen in smear.

12. INVESTIGATIONS (OUTSIDE)
Serum IgE- WNL
p-ANCA, c-ANCA- negative
HIV- Negative
Throat swab for H1N1 - Negative
Urine c/s, blood c/s- sterile
CRP (N<6.0)
TRANSBRONCHIAL LUNG BIOPSY & TRUECUT LUNG BIOPSY
s/o acute pyogenic inflammation(Pneumonitis)

13. 23rd Feb – 3rd March 2016
Received Clarithromycin, Moxifloxacin, Piperacillin Tazobactum, Teicoplanin, Meropenem,Oseltamavir, Hydrocortisone in 10 days
In view of no improvement in symptoms, patient was brought to Dr.RML Hospital

14. EXAMINATION Conscious, alert and oriented Tachypneic Pallor present
No clubbing/ cyanosis/pedal edema/JVP- Not raised
BMI-22.7

15. EXAMINATION VITALS Pulse Rate-100/min, regular
Respiratory rate- 30/min, using accessory muscles
BP-110/80 mm Hg
Temperature-103° F
Saturation- 86% on room air

16. SYSTEMIC EXAMINATION Respiratory system: Trachea central
Bronchial breath sounds & coarse crepitations- right infra- axillary, right inter-scapular, left inter-scapular
CVS, CNS, P/A – WNL
Musculoskeletal system:
Bony hard nodules present in PIP of bilateral 5th fingers & right middle finger DIP joint- non tender and non mobile.
No other swollen or tender joint/ deformity.

17. PHOTOGRAPH OF HANDS

18. SUMMARY
68/F- k/c/o HTN, RA, previously treated for pulmonary TB presented with high grade continuous fever for 2months, cough with expectoration and breathlessness for 15 days, not responding to empirical antibiotics
O/E- febrile, tachypneic, tachycardia with RS examination s/o consolidation
Musculoskeletal examination s/o Osteoarthritis

19. NON RESOLVING PNEUMONIA
SUMMARY
Patient was admitted with provisional diagnosis of
NON RESOLVING PNEUMONIA
Patient was started on oxygen, empirical antibiotics-- Piperacillin-Tazobactum, Vancomycin & Levofloxacin

20. CAUSES OF NON RESOLVING PNEUMONIA
Inappropriate antimicrobial therapy
Presence of resistant or unusual organisms
Defects in defense
Drugs (Methotrexate here)
Complications of initial pneumonia
Delayed radiological recovery
Diseases mimicking pneumonia-malignancy, vasculitis

21. NON RESOLVING PNEUMONIA
Unusual organisms
-Fungal- Aspergillosis, Histoplasmosis, Cryptococcosis, Mucormycosis
-Atypical bacteria- Nocardiosis, Actinomycosis, MOTT

22. CHEST X RAY COMPARISON

23. INVESTIGATIONS- Dr. RMLH
ESR 39 HB
8.7
TLC
14,400
Polymorphs 88
Lymphocytes 10
eosinophils 2
Platelets
3.5L
PCV
29.4
MCV
81.9
MCHC
29.6
RBS
107
Urea 15
Creatinine
0.8
Total bilirubin
0.6
Direct bilirubin
0.2
Indirect bilirubin
0.4
SGOT/SGPT
24/18
ALP
162
Tot Protein
5.5
Albumin/globulin
3.3/2.2
Na/K
132/3.9
Ca/PO4
8.5/3.4

24. RADIOGRAPH OF HANDS

25. RADIOGRAPH OF KNEE JOINTS

26. INVESTIGATIONS CECT THORAX REVIEW
Consolidation in right upper lobe, right middle lobe, left lower lobe
Dense consolidation with foci of cavitation
Multiple nodular lesions with irregular margin
HALO sign (defined as a nodule surrounded by a zone of ground glass attenuation).

27. CECT THORAX

28. INVESTIGATIONS
CECT Chest findings in background of immunosuppression made us to look for unusual organisms causing pneumonia.
Serum for galactomannan, sputum for gram stain, modified ZN stain & culture (bacterial and LJ medium) was sent.
RF/ Anti-CCP/ ANA – Negative.

29. INVESTIGATIONS
Gram stained smear showed presence of slender, weakly gram-positive, branching filamentous bacilli.
Suspicion of Nocardia infection occurred and modified Ziehl- Neelsen staining (1% H 2 SO 4 ) was done which showed numerous acid fast branching filamentous organisms morphologically resembling Nocardia spp
Sputum KOH failed to demonstrate any fungal hyphae
Cultures- sterile

30. Nocardia in modified ZN stain

31. FINAL DIAGNOSIS PULMONARY NOCARDIOSIS
Treatment started with imepenem, ampicillin and cotrimoxazole (trimethoprim 480mg/sulphamethoxazole 2400mg) in three divided doses

32. TREATMENT
After 1week of giving combination therapy patient improved symptomatically.
Patient developed adverse reactions to TMP-SMX, linezolid but later tolerated after desensitization.

33. FOLLOW UP CHEST X-RAYS

34. SIMILAR CASE REPORTS

36. NOCARDIA CLINICAL MANIFESTATIONS
Majority of cases occurs in patients with host defense defects
CLINICAL MANIFESTATIONS
Pulmonary- nodules, lobar infiltrates, cavitations- 39 %
Cutaneous- abcesses,myecetoma- 8 %
CNS- brain abcess, cerebritis, meningitis- 9 %
Disseminated-CNS, skin, eye, heart, bone, joint, kidney- 32 %

37. NOCARDIA
Microscopy and culture are not difficult however, because of the slow growth of the organisms, cultures should be kept for at least 30 days.
Nocardia spp are not normally found in the respiratory tract; as a result, isolation of Nocardia from the sputum is almost always indicative of infection.

38. TREATMENT
Mild to moderate cases- drugs known to be effective against most isolates is usually effective
Sulphonamides are drugs of choice
Divided doses of 5 to 10 mg/kg per day of the trimeth-o-prim component (or 25 to 50 mg/kg per day of sulfamethoxazole) are recommended

39. TREATMENT
Alternative antimicrobial agents with activity against Nocardia include amikacin, imipenem, meropenem, ceftriaxone, cefotaxime, minocycline, moxifloxacin, levofloxacin, linezolid, tigecycline, and amoxicillin+clavulanic acid
After definite clinical improvement therapy can be continued with a single oral drug usually TMP-SMX.

40. TREATMENT

41. TAKE HOME MESSAGE
Diseases need immunosuppressive therapy should be diagnosed carefully.
All the patients with the risk factors like COPD, bronchiectasis, cystic fibrosis and immunocompromised state with nonresponsive pneumonia must be evaluated for rare infections like nocardia.
Delay in diagnosis and treatment can be life threatening.
Mortality rate of % in severe immune compromised status.

42. THANK YOU