Chest Case #3

67 yr old male with pmhx notable for dm/htn presents with 2 days subjective f/c, malaise, increasing dyspnea with exertion and abdominal pain. He endorses an occasional dry cough and decrease appetite without chest pain/diaphoresis, his course has been progressive with no alleviating factors. He denies past similar episodes and was in his usual state of health until 2 days ago.

History and PhysicalT 102.8 P 125 BP

150/90 O2 92% RR 20

Gen: ill-appearingCV: Tachycardic,

RRythm; ext. warm with good cap refill/ pulses appropriate.

Pulm: diffuse rhonchi with moderate air mvmt.

Abd: s/nt/nd – normal bowel sounds, heme neg. stool.

Chest X-Ray

Diagnosis: Atypical Pneumonia

1. Note patchy infiltrates with peri-hilar prominence (adenopathy) 2. No evidence of isolated consolidation – diffuse process

OxygenIV FluidsAntibiotics

Unresponsive to B-lactam abxUse macrolide or resp. fluoroquinolone

Admit Location based on acuity/clinical

picture/comorbidities

ED Management

Presentation“Atypical” pneumonia can present with generalized complaints

without specific respiratory symptoms usually associated with pneumonia (cough/congestion/chest pain).

CXR

Based on atypical pattern on chest x-ray, abx selection should be directed at an atypical infection.

ABXOrganisms responsible for atypical pneumonia include Legionella,

Chlamydophila, Mycoplasma, and viruses (including influenza)

Pearls

PopulationsAtypical pneumonia is most commonly found in older children,

young adults, and the elderly – in addition to those populations at higher risk for a respiratory infection (underlying lung disease, immunocompromised).

Organism specificRemember summer prevalence and GI complaints with Legionella

presentations (nausea/vomiting, diarrhea, abdominal pain) Mycoplasma infections are sometimes associated with bullous

myringitis in addition to other extra-pulmonary findings (rash, arthritis/arthralgias, ).

Pearls cont'd

Additional Images: Atypical PNA