When the Pneumonia Doesn’t Get Better

An Elderly Man with Non-Resolving Fever and a Pulmonary Infiltrate

A 62-year-old Pakistani man presented with fever and chest pain of five-day duration. He was non-smoker and he had no history of hemoptysis, wheezing, loss of weight or exposure to tuberculosis. Other history was unremarkable. Physical examination revealed a heart rate of 116 beats/min, BP of 121/ 58 mm Hg, temperature of 38.5°C, and a room air oxygen saturation of 92 %. There was no cervical, axillary, or inguinal lymphadenopathy. Chest examination revealed bronchial breath sounds in the right middle and lower zones. Cardiac examination revealed tachycardia with no gallops or murmurs. Abdomen was nontender without hepatosplenomegaly. Extremities were free of cyanosis, edema, and clubbing. There were no skin lesions

Imagerie moderne des pneumonies infectieuses aiguës

Les pneumonies infectieuses aiguës constituent un problème de santé publique important, car elles sont une cause majeure de morbidité et de mortalité chez l’adulte. Si les données cliniques et radiographiques permettent le plus souvent de faire le diagnostic de pneumonie infectieuse, le diagnostic étiologique est plus difficile. En effet, de nombreux agents pathogènes peuvent être responsables de pneumonie et la réaction du parenchyme pulmonaire est peu variée, d’où la faible spécificité des lésions radiologiques observées en dehors de quelques cas particuliers. C’est pourquoi la compréhension des mécanismes physiopathologiques permet d’expliquer certains aspects radiologiques. De même, la connaissance des bases anatomocliniques et radiologiques autorise la reconnaissance de trois aspects radiographiques principaux. Quant à l’appréciation des contextes épidémiologique et immunitaire, ils peuvent permettre également d’approcher le germe en cause.

The challenge of nonresolving pneumonia. Knowing the norms of radiographic resolution is key

Pneumonia that fails to resolve after 10 to 14 days of antibiotic therapy can lead physicians to call for consultation or unnecessary invasive diagnostic procedures. Understanding the infectious and noninfectious causes of pneumonia and their normal times to resolution is enormously helpful in the judicious evaluation of and timely intervention in this very challenging condition.

Slowly resolving and nonresolving pneumonia. Questions to ask when response is delayed

What is the proper course of action when pneumonia symptoms seem to linger? Is the disease running a typical course, or is further evaluation needed? Dr Johnson addresses these important questions with an outline of risk factors for delayed resolution and a detailed listing of diagnostic considerations. He also discusses reasonable timing of further studies and the usefulness of radiography and fiberoptic bronchoscopy.

Nonresolving or slowly resolving pneumonia

Given the variability in rate of radiographic resolution, it remains controversial to decide when to initiate an invasive diagnostic work-up for nonresolving or slowly resolving pulmonary infiltrates. In immunocompetent patients who present with classical features of CAP (i.e., fever, chills, productive cough, new pulmonary infiltrate), clinical response to therapy is the most important determinant for further diagnostic studies. Within the first few days, persistence or even progression of infiltrates on chest radiographs is not unusual. Defervescence, diminished symptoms, and resolution of leukocytosis strongly support a response to antibiotic therapy, even when chest radiographic abnormalities persist. In this context, observation alone is reasonable, and invasive procedures can be deferred. Serial radiographs and clinical examinations dictate subsequent evaluation. In contrast, when clinical improvement has not occurred and chest radiographs are unchanged or worse, a more aggressive approach is warranted. In this setting, we advise fiberoptic bronchoscopy with BAL and appropriate cultures for bacteria, legionella, fungi, and mycobacteria. When endobronchial anatomy is normal and there is no purulence to suggest infection, TBBs should be done to exclude noninfectious causes (discussed earlier) or infections attributable to mycobacteria or fungi. An aggressive approach is also warranted in patients who are clinically stable or improving when the rate of radiographic resolution is delayed. As discussed earlier, what constitutes excessive delay is controversial, and depends upon the acuity of illness, specific pathogen, extent of involvement (i.e., lobar versus multilobar), comorbidities, and diverse host factors. Stable infiltrates even 2 to 4 weeks after institution of antibiotic therapy does not mandate intervention provided patients are improving clinically. Invasive techniques can also be deferred when unequivocal, albeit incomplete, radiographic resolution can be demonstrated. Lack of at least partial radiographic resolution by 6 weeks, even in asymptomatic patients, however, deserves consideration of alternative causes (e.g., endobronchial obstructing lesions, or noninfectious causes). Fiberoptic bronchoscopy with BAL and TBBs has minimal morbidity and is the preferred initial invasive procedure for detecting endobronchial lesions or substantiating noninfectious causes. The yield of bronchoscopy depends on demographics, radiographic features, and pre-test likelihood. In the absence of specific risk factors, the incidence of obstructing lesions (e.g., bronchogenic carcinomas, bronchial adenomas, obstructive foreign body) is low. Bronchogenic carcinoma is rare in nonsmoking, young (< 50 years) patients but is a legitimate consideration in older patients with a history of tobacco abuse. Non-neoplastic causes (e.g., pulmonary vasculitis, hypersensitivity pneumonia, etc.) should be considered when specific features are present (e.g., hematuria, appropriate epidemiologic exposures). Ancillary serologic tests or biopsies of extrapulmonary sites are invaluable in some cases. In rare instances, surgical (open or VATS) biopsy is necessary to diagnose refractory or non-resolving "pneumonias."

Nonresolving pneumonia in steroid-treated patients with obstructive lung disease

PURPOSE

To review autopsy-proven cases of opportunistic pneumonia and determine how many of these patients had received corticosteroid therapy for obstructive lung disease in order to define whether this therapy was the major risk factor predisposing to infection.

PATIENTS AND METHODS

All autopsies performed at Winthrop-University Hospital over a 5-year period were reviewed, and 30 cases of opportunistic pneumonia were identified. In eight of 30 cases, corticosteroid therapy for chronic obstructive pulmonary disease (COPD) was the only identifiable risk factor for opportunistic infection. The other 22 patients had other well-defined risk factors for infection. Chart review of the eight patients with COPD was undertaken to define the clinical features of their infections.

RESULTS

All eight patients had a progressive multilobar pneumonia that failed to resolve, either clinically or radiographically, despite the use of multiple broad-spectrum antibiotics. In four cases, the infection was community-acquired, while in the other four cases, it was nosocomial in origin. Despite the presence of a nonresolving pneumonia, opportunistic infection was generally not considered as a diagnostic possibility, with only one case being correctly diagnosed antemortem. Autopsy examination documented Aspergillus species as being responsible for six episodes of pneumonia, Candida albicans accounting for one episode, and cytomegalovirus accounting for one episode.

CONCLUSION

Based on this experience, it is clear that corticosteroid therapy of COPD can lead to opportunistic pulmonary infection, in or out of the hospital. This diagnosis should be considered when patients receiving this therapy develop a pneumonia that fails to respond to broad-spectrum antibiotics.

Utility of fiberoptic bronchoscopy in nonresolving pneumonia

Although fiberoptic bronchoscopy (FOB) has been traditionally used to evaluate nonresolving pneumonia, its efficacy is unknown. We, therefore, reviewed FOB in 35 consecutive patients who had (1) a roentgenographic infiltrate, (2) cough, (3) either temperature greater than 38.1 degrees C, leukocytosis, sputum production, (4) symptoms present for at least ten days, and antibiotic therapy for at least one week. Known lung cancer and AIDS were excluded. Fiberoptic bronchoscopy was diagnostic in 86 percent (12/14) in whom a specific cause was found. No patient had endobronchial cancer. Two patients with nondiagnostic FOB and persistent systemic symptoms had open lung biopsy specimens showing Wegener's granulomatosis and bronchiolitis obliterans with organizing pneumonia (BOOP). Twenty-one patients with nondiagnostic FOB had no final diagnoses other than community-acquired pneumonia. We conclude that FOB is extremely useful in finding a specific diagnosis for a nonresolving pneumonia when a specific diagnosis can be made. Fiberoptic bronchoscopy was most likely to yield a specific diagnosis in nonsmoking patients with multilobar infiltrates of long duration and could have been avoided in older, smoking, or otherwise compromised patients with lobar or segmental infiltrates with no decrease in diagnostic yield in our series.