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A CASE OF NON RESOLVING PNEUMONIA
Dr. RAMADOSS.R SENIOR RESIDENT DEPT. OF MEDICINE PGIMER & Dr. RML HOSPITAL
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HISTORY 68 years old woman, House wife. Chief complaints of-
Fever - 2 months Cough with expectoration -15 days Breathlessness-10 days
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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
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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
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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
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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
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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
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CHEST X-RAY
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CECT CHEST
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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)
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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.
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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)
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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
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EXAMINATION Conscious, alert and oriented Tachypneic Pallor present
No clubbing/ cyanosis/pedal edema/JVP- Not raised BMI-22.7
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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
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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.
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PHOTOGRAPH OF HANDS
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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
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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
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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
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NON RESOLVING PNEUMONIA
Unusual organisms -Fungal- Aspergillosis, Histoplasmosis, Cryptococcosis, Mucormycosis -Atypical bacteria- Nocardiosis, Actinomycosis, MOTT
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CHEST X RAY COMPARISON
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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
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RADIOGRAPH OF HANDS
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RADIOGRAPH OF KNEE JOINTS
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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).
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CECT THORAX
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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.
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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
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Nocardia in modified ZN stain
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FINAL DIAGNOSIS PULMONARY NOCARDIOSIS
Treatment started with imepenem, ampicillin and cotrimoxazole (trimethoprim 480mg/sulphamethoxazole 2400mg) in three divided doses
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TREATMENT After 1week of giving combination therapy patient improved symptomatically. Patient developed adverse reactions to TMP-SMX, linezolid but later tolerated after desensitization.
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FOLLOW UP CHEST X-RAYS
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SIMILAR CASE REPORTS
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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 %
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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.
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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
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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.
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TREATMENT
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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.
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THANK YOU
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