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Pneumonia - Symptoms and causes Accessibility Pneumonia Stages, Their Symptoms, and Condition Management - Healthline When there is lung involvement, the choice of biopsy technique is based on the balance of the invasiveness of the procedure and the histological yield of the obtained specimen. Co-morbidities like COPD, diabetes, alcoholism, smoking and immunosuppression are significant factors causing nonresolution. Both, FOB (85.7%) and CT-guided FNAC (91.67%) were very useful for etiological diagnosis of non-resolving pneumonia. Frankel S.K., Cosgrove G.P., Fischer A., Meehan R.T., Brown K.K. CDC twenty four seven. Accessibility The patient's chest X-ray postero-anterior (PA) view at that time showed middle lobe consolidation [Figure 1a]. A slowly resolving or non-resolving pneumonia (NRP) is a common clinical dilemma, affecting 10-20% of patients hospitalised with community-acquired pneumonia. Twenty five patients (41.6%) were smoker, and smoking was distinctly more common in malignant etiology, compared to other groups (P = 0.006) [Table 1]; 8 patients (19%) were alcoholic. Treatment for pneumonia depends on the type of pneumonia, how sick the patient is, the patient's age, and if other underlying medical . Specific attention will be given to the natural history of commonly occurring pneumonias in this age group, related host defense impairments, unusual infectious causes of slowly resolving pneumonia, and noninfectious mimics of pneumonia. Non-resolving or slowly resolving pneumonia. [7] Non-resolving pneumonia was found to be responsible for 15% of inpatient pulmonary consultations and 8% of bronchoscopies. The differential diagnosis for the CT findings included an atypical pneumonia, possibly fungal in origin, malignancy, septic emboli, or vasculitis. With regard to the resolution of radiographic condensation, at 4 weeks up to 40% of the patients still present images [3]. Diagnostic yield of biopsy was 78%, 15 patients were diagnosed as malignancy, and 8 patients were diagnosed to have benign disease. Begamy T. Thoracic empyema. Epub 2015 Aug 7. PDF J.-L. Vincent (ed.), - Springer Non-infectious causes like tracheobronchomalacia and foreign body aspiration are other important etiologies to be looked for. HHS Vulnerability Disclosure, Help Gram-negative bacteria were found to be the predominant pathogens, accounting for approx. -, Walton E.W. She endorsed a unilateral pruritic red palmar rash. [15] In the present study also, right lung involvement was most common (65%), and right upper lobe was most commonly affected (25%). The image shows extensive mixed type necrosis with a focal rounded area of suppurative necrosis on the left side (dashed line) (H&E stain, 100). As the patient's condition deteriorated with documented weight loss of 5 Kg in 2 weeks, his father brought him to our hospital. Bacterial infections are the commonest etiology. found malignancy as a specific cause for non-resolving pneumonia in 11.4% cases in their series of 35 patients. 1958 Aug 2;2(5091):265270. A wide range of non-infectious disorders can masquerade as bacterial pneumonia, including pulmonary embolism, malignancy, interstitial lung diseases, alveolar haemorrhage, and vasculitis. Fiberoptic bronchoscopy (FOB) was planned next in all patients (4 patients did not give consent for FOB). National Library of Medicine Learn more below about the infections that commonly cause pneumonia. Histoplasmosis is caused by inhalation of the fungus Histoplama spp, and the degree of infection and clinical presentation are determined by the size of inoculum, immune status of the individual and presence of underlying lung disease. Slow or incomplete resolution of pneumonia despite treatment is a common clinical problem, estimated to be responsible for approximately 15 percent of inpatient pulmonary consultations and 8 percent of bronchoscopies [].There are a variety of reasons that a case of pneumonia might resolve slowly or incompletely, including those relating to the etiology of the pneumonia . Antimicrobial treatment failures in patients with community-acquired pneumonia: Causes and prognostic implications. Fine-needle aspiration biopsies are helpful in ruling out malignancy and obtaining tissue for culture, but cannot confirm the diagnosis of GPA [9]. The investigations and interventions required are determined on a case-by-case basis. the contents by NLM or the National Institutes of Health. Fayez K, Tamim H, Walid K, Shadi L. Nonresolving pneumonia. Tayside Respiratory Research Group, University of Dundee and Ninewells Hospital and Medical School, Dundee, Scotland Fein AM. Careers, Unable to load your collection due to an error. In this article, noninfectious causes of pulmonary infiltrates mimicking community-acquired pneumonia are discussed. P value was calculated using Fisher's exact test, and P value < 0.05 was considered to be significant. Accessibility Careers, Unable to load your collection due to an error. sharing sensitive information, make sure youre on a federal Profile of repeat fiberoptic bronchoscopy. . FOB is an extremely useful investigation; CT-guided FNAC also gives good yield when properly selected. (B) Chest computed tomography in axial plane, in lung window, confirms presence of right middle lobe mass (white arrow), with well defined borders, lobulated outline and cavitation (black arrow). Pneumonia may affect one or both lungs, and can cause serious illness in young children, people over age 65, and people with other health problems.. Introduction. Mean age was 51.33 1.71 years with male to female ratio 2:1. Histoplasmosis was once thought to be a nonentity in India. The time to clinical stability varies substantially between patients, being longer in older patients, patients with comorbidities, and patients with a higher severity of pneumonia. Following a negative tuberculin skin test and normal hepatitis serology, she was started on high dose prednisone (1mg/kg), and Methotrexate (15mg/week). Signs and symptoms of chronic pneumonitis include: Shortness of breath. Rome L, Murali G, Lippmann M. Nonresolving pneumonia and mimics of pneumonia. Kauffman CA. 1). HHS Vulnerability Disclosure, Help CT scan of chest showing worsening consolidation. Fibre-optic bronchoscopy revealed pus coming from the right main bronchus and a gelatinous mass in the posterior wall of trachea and a widened carina with constricted right main bronchus [Figure 2]. Sputum cultures were non-diagnostic on all occasions. Sixty consecutive cases of non-resolving or slowly resolving pneumonia of both genders, attending the department of pulmonary medicine during the study period, were selected by adhering to the inclusion and exclusion criteria. An important cause of non-resolving pneumonia - PMC National Library of Medicine This review article gives an overall view about different . Organising pneumonia may be classified into three categories according to its cause: organising pneumonia of determined cause; organising pneumonia of undetermined cause but occurring in a specific and relevant context; and cryptogenic (idiopathic) organising pneumonia. Pneumonia: Causes, Symptoms, Diagnosis & Treatment The approach to nonresolving pneumonia Bethesda, MD 20894, Web Policies Non-resolving pneumonia: A rare presentation of progressive An important cause of non-resolving pneumonia Clipboard, Search History, and several other advanced features are temporarily unavailable. In this study, although the yield of CT-guided FNAC (91%) was slightly better compared to yield of FOB (85.7%), it has to be kept in mind that CT-guided FNAC was done only in select cases and FOB should always be the first investigation of choice before CT-guided FNAC in evaluating non-resolving pneumonia No diagnostic procedure is absolutely sensitive for evaluation of non-resolving or slowly resolving pneumonia. The term non-resolving pneumonia has been variably defined by investigators and early descriptions were based principally on clinical examination findings. Gastric presentation (vasculitis) mimics a gastric cancer as initial symptom in granulomatosis with polyangiitis: a case report and review of the literature. On examination, the patient was very toxic with blood pressure 90/60 mmHg, pulse rate 130/min regular, respiratory rate 32/min with moderate pallor. Flexible Bronchoscopy in Non-resolving Pneumonia 2017 Jun;242(2):109-114. doi: 10.1620/tjem.242.109. and transmitted securely. Csernok E., Trabandt A., Mller A., Wang G.C., Moosig F., Paulsen J. Cytokine profiles in Wegeners granulomatosis: predominance of type 1 (Th1) in the granulomatous inflammation. Hepatosplenomegaly, lymphadenopathy, anemia and leukopenia are the usual clinical findings. Schnabel A., Holl-Ulrich K., Dalhoff K., Reuter M., Gross W.L. We describe the case of a young patient with a history of non-resolving pneumonia. Among these patients, malignancy was found in 8 cases (66.7%). Core needle biopsy (for pathology and culture analysis) is a legitimate means to confirm the diagnosis when there is lung involvement, and can be performed in a minimally-invasive fashion. Feinsilver SH, Fein AM, Niederman MS, Schultz DE, Faegenburg DH. The present article reviews the causes, investigation, and management of NRP, and presents an algorithm for identification and management of these patients. Congestion. The https:// ensures that you are connecting to the Wheat LJ, Goldman M, Knox K. Cryptococcosis and the Endemic Mycoses. Early recognition, diagnosis, and treatment of GPA is imperative, as the mortality rate is >80% if left untreated [1], [2]. Other authors have defined it more broadly as radiographic infiltrate that is slow to resolve after optimal antibiotic therapy given for at least 10days.2 Approximately 20% of presumed non-resolving community-acquired pneumonia is due to non-infectious causes.3 Aetiologies like inflammatory, drug-induced and vascular disorders, as well as neoplasm can mimic pneumonia. Walton E.W. Noninfectious pneumonitis after everolimus therapy for advanced renal cell carcinoma. Lehtomki K. Clinical diagnosis of pneumococcal, adenoviral, mycoplasmal and mixed pneumonias in young men. Evaluation of nonresolving and progressive pneumonia. Overall, core needle biopsies are superior to fine needle aspiration for non-neoplastic inflammatory lung conditions [9]. Multiple procedures may be used in a rational approach to reach the definitive diagnosis [Figure 1]. Slow or non-resolving pneumonia may be caused by multiple factors acting singly or in combination. official website and that any information you provide is encrypted Infectious Diseases Society of America/American thoracic Society Consensus Guidelines on the management of community-acquired pneumonia in adults, Acute parenchymal lung disease in immunocompetent patients: diagnostic accuracy of high resolution CT. (A) Chest radiograph (posteroanterior view), (A) Chest radiograph (posteroanterior view) reveals right mid lung zone mass (arrow) and, The image shows extensive mixed type necrosis with a focal rounded area of, Follow up chest radiograph (posteroanterior, Follow up chest radiograph (posteroanterior view) performed following treatment, demonstrates significant decrease in, MeSH Lack of response to antibiotics prompted invasive testing with bronchoscopy which revealed a growth in the left main bronchus. In one case series, the reported sensitivity in differentiating infectious from non-infectious causes of parenchymal lung disease was as high as 90%.8 However, in our case, two CT scans done as an outpatient failed to reveal the underlying tumour, probably because the mass was endobronchial in location rather than involving the lung parenchyma. -, Jennette J.C., Falk R.J., Bacon P.A., Basu N., Cid M.C., Ferrario F. 2012 revised international chapel hill consensus conference nomenclature of vasculitides. We treated the case as non-resolving pneumonia and did antibiotics adjustment with the intravenous cefoperazone-sulbactam (1.5 g) 8 hourly and oral clarithromycin (500 mg) twice daily along with the other supporting treatment. official website and that any information you provide is encrypted Diabetes was significantly more associated with infective etiology, compared to malignancy (P = 0.023) [Table 1]. and transmitted securely. Macroscopic appearance of bronchial tree during FOB (intraluminal growth, presence of secretions/pus, appearance of bronchial mucosa, etc.) Macroscopic findings during bronchoscopy (n=56), Comparative yield of FOB versus CT-guided FNAC. Careers. PDF Etiology and Clinical Outcome of Non-Resolving Pneumonia in a Tertiary Harnalikar M, Kharkar V, Khopkar U. Disseminated cutaneous histoplasmosis in an immunocompetent adult. 8600 Rockville Pike BMC Pulm Med. 3 A causal pathogen is often not identified. It makes it difficult to breathe and can cause a fever and cough with yellow, green or bloody mucus. Potential causes are many and include . We herewith report, from eastern part of India, a geographically rare and unexpected case of progressive disseminated histoplasmosis (PDH) in a 17-year-old immunocompetent male patient that presented as non-resolving pneumonia. Like other vasculitides, the clinical presentation of GPA is diverse and can involve any organ system. Pneumonia is a type of lung infection that causes cough, fever, and difficulty breathing. The site is secure. PMC Bronchoscopic biopsy from the mass showed inflammatory granulation tissue with proliferation of capillaries and infiltration of a large number of inflammatory cells. Bronchoscopy with biopsy will lead to accurate diagnosis. Among the 60 patients, 41 (68.3%) were male and 19 (31.7%) female. and transmitted securely. Before However, pathological patterns have emerged illustrating that the presence of vasculitis may characterize more diffuse disease, while granulomatous inflammation is more prevalent in the limited subset [1]. Histoplasmosis is a fungal disease caused by Histoplasma capsulatum, named after Darling who first described this clinical entity well in details. She was diagnosed with a limited form of Granulomatosis with Polyangiitis (GPA), by percutaneous core needle lung biopsy. In Indian literature first case of histoplasmosis was reported by Panja and Sen in 1954. and transmitted securely. Fig. Bethesda, MD 20894, Web Policies Blood cultures were negative and sputum cultures revealed mixed respiratory flora. Surgical lung biopsy has an established high diagnostic yield, but has appreciable associated morbidity, including pain and prolonged recovery times [3], [5], [6]. Bronchoscopic biopsy was also performed in all the 56 cases. The https:// ensures that you are connecting to the Results: Tuberculosis was the commonest cause of nonresolving pneumonia (35.7%), followed by malignancy (27.1%),Bronchiectasis (8.6%),Pneumocystis pneumonia (7.1%),BOOP (5.7%) and Resistance to antibiotics (14.3%). In: Fishman AP, editor. Bronchial brushing showed positive results in 4 cases- 3 cases showed positive cytology for squamous cell cancer, and 1 case was positive for Z-N stain. Copyright 2023 European Medical Group LTD trading as European Medical Journal. Consolidation limited to a single lobe was the commonest radiological finding (93.75%) in cases of bacterial pneumonia. Blood for complete hemogram, blood glucose, urea, creatinine, liver function test, chest X-rays (posteroanterior and lateral view), sputum culture for Mycobacterium tuberculosis in mycobacterial growth indicator tube (MGIT 960) and sputum for malignant cells were sent in all patients. A wide range of non-infectious disorders can masquerade as bacterial pneumonia, including pulmonary embolism, malignancy, interstitial lung diseases, alveolar haemorrhage, and vasculitis. Core needle biopsy, such as the one used in our case, has been shown to provide a definitive diagnosis in a proportion of cases, but the data regarding the yield of the procedure is limited and not specific for limited pulmonary vasculitis [8]. Organising pneumonia | Thorax Carruthers D.M., Connor S., Howie A.J., Exley A.R., Raza K., Bacon P.A. A Case of Non-resolving Pneumonia Non - resolving pneumonia is defined as pneumonia with a slow or partial resolution of symptoms or radiological abnormalities in spite of adequate antibiotic therapy. Nausea, vomiting or diarrhea Shortness of breath Newborns and infants may not show any sign of the infection. [1] Non-resolving pneumonia is defined as pneumonia with a slow resolution of radiologic infiltrates or clinical symptoms despite adequate antibiotic therapy. was negative. This website uses cookies to improve your experience. Recurrent pneumonias - Cancer Therapy Advisor You must accept all conditions before being able to view the post. Physical examination revealed a temperature of 100.1F, pulse was 116/min, respiratory rate was 24/min, blood pressure 136/84mmHg and oxygen saturation was 95% on room air. Brief Clinical Review: Non-Responding Pneumonia | Request PDF A 48 year-old woman presented to an outpatient clinic with a two-week history of non-productive cough and general malaise. Ten patients (62.5%) were smokers among the patients with malignancy. It revealed a cauliflower-like growth in the left main bronchus (figure 3). Feinsilver SH, Fein AM, Niederman MS, Schult DE, Faegenburg DH. Further, the sensitivity of ANCA testing lacks in limited disease compared to diffuse disease (67% vs 91%) [1]. official website and that any information you provide is encrypted Utility of firberoptic bronchoscopy in non resolving pneumonia. On repeat chest radiograph four weeks after treatment, there was interval improvement in the airspace disease density (Fig. Balamugesh T, Aggarwal AN, Gupta D, Behera D, Jindal SK. In a recent study from south India tuberculosis (TB) was the cause of non-resolving pneumonia in 35.7% cases and malignancies were responsible for another 27% cases,[8] whereas Western literature has showed malignancies being responsible for up to 11% cases of non-resolving pneumonia.[5]. Non-resolving pneumonia may be the first manifestation of lung malignancy and should be considered early in patients with a history of smoking. Ventilator-associated pneumoniais when someone gets pneumonia after being on a ventilator, a machine that supports breathing. The granulomas consisted mainly of giant cells and epithelioid histiocytes surrounding areas of suppurative basophilic necrosis and embedded in a polymorphous inflammatory infiltrate. She was diagnosed with a limited form of Granulomatosis with Polyangiitis (GPA), by percutaneous core needle lung biopsy. The special stains as well as tissue cultures for fungi and mycobacteria were negative. Histopathology revealed squamous cell carcinoma. Silver . Mean duration of illness was 6.87 0.24 weeks (mean + SEM). Recognizing the difference between limited and diffuse disease is important, as this affects the type of treatment, prognosis, and relapse rate. Eschericia coli and Acinetobacter spp were found in 3 cases each [Table 2]. Lung India : Official Organ of Indian Chest Society. Pneumonia is inflammation and fluid in your lungs caused by a bacterial, viral or fungal infection. Rates of pulmonary involvement are equivalent between limited and diffuse disease, however limited disease does not present with alveolar hemorrhage [1]. Respiratory syncytial virus (RSV) SARS-CoV-2 (the virus that causes COVID-19) Common causes of bacterial pneumonia are Streptococcus pneumoniae (pneumococcus) and, especially in kids, Mycoplasma pneumoniae. Anti-cytoplasmic nuclear antibodies were positive with c-ANCA at a concentration of 8 AI units. Follow up chest radiograph (posteroanterior view) performed following treatment, demonstrates significant decrease in size of largest lesion in mid lung zone (white arrow). government site. Exclusion of an alternate diagnosis like tuberculosis, malignancies, pneumonia mimics etc., should be the first step in the approach to this problem. [16], In the present study, CT-guided FNAC was done in 12 patients, and etiological diagnosis was established in 11 cases (diagnostic yield being 93.7%). A ten-day course of moxifloxacin was prescribed for treatment of pneumonia. Aspiration of Cerebrospinal Fluid Rhinorrhea as a Cause of Non 2018 Nov 29;18(1):181. doi: 10.1186/s12890-018-0733-2. Nine out of these 10 cases were diagnosed by fiberoptic bronchochoscopy- 6 patients showed positive mycobacterial culture in BAL fluid. Kar Medical College and Hospital, Kolkata, India. Wegeners granulomatosis. Summary Persistent pulmonary infiltrate results when a substance denser than air (e.g., pus, edema, blood, surfactant, protein, or cells) lingers within the lung parenchyma. [16] Balamugesh et al. The rate of disease relapse occurs in 18%40% within 24 months, and occurs more often in patients with limited disease [1], [12]. Further investigation with bloodwork, urinalysis, and nasal examination showed no evidence of multi- organ involvement. Antimicrobial treatment failures in patients with community-acquired pneumonia: Causes and prognostic implications. In either limited or diffuse disease, clinical remission is usually achieved within three to six months after induction treatment, and patients can be transitioned to maintenance therapy regimens [12]. The investigations revealed hemoglobin 6.4 g%, total white cell count 15200/mm3 with 94% neutrophils; fasting blood sugar 86 mg/dl, urea 45 mg/dl, creatinine 0.8 mg/dl, total bilirubin 0.96 mg/dl, alanine transaminase 78 U/L, aspartate transaminase 82 U/L and alkaline phosphatase 238 U/L. In our case the diagnosis of histoplasmosis was established by histopathological examination of tracheal lesion, BAL fluid and TBNA results, positive culture from sputum and therapeutic response to anti-fungal treatment. On initial presentation, her vital signs were stable and the physical examination was unremarkable. National Library of Medicine As in case 1, antibiotics help if symptoms of infection are pre-sent, but only temporarily. Bethesda, MD 20894, Web Policies Cordier J.F., Valeyre D., Guillevin L., Loire R., Brechot J.M. (A) Chest radiograph (posteroanterior view) reveals right mid lung zone mass (arrow) and multiple pulmonary nodules (arrows) in left lung. The case represents a unique example of progressive disseminated histoplasmosis in an immunocompetent individual in India. [11] Chronic pulmonary and progressive disseminated histoplasmosis are often fatal with reported mortality 83-100% in untreated cases and 7-23% in amphotericin B treated patients. Histoplasmosis, a fungal disease caused by Histoplasma capsulatum, is endemic in North and South America. *Correspondence to [emailprotected]. Chest. Viruses, bacteria, and fungi can all cause pneumonia. Blood for rheumatoid factor, anti-nuclear antibody (hep-2 method), C-ANCA and p-ANCA, serum angiotensine converting enzyme (SACE) were done additionally in selected patients, wherever found relevant. In the United States, common causes of viral pneumonia are. Adrenal gland involvement, lesions of oral mucosa, gastrointestinal tract and skin may be seen in 5 to 10% of cases. Before Enzyme-linked immunosorbent assay (ELISA) for HIV 1 and 2 was non-reactive. Inadequate knowledge regarding the expected clinical course and outcome of a community-acquired or nosocomial pneumonia is a common reason for pulmonary consultation; selection of patients and appropriate timing of further evaluation can be challenging. 8600 Rockville Pike Seven out of 10 patients (70%) of squamous cell carcinoma were diagnosed by bronchoscopic procedures with bronchoscopic biopsy, showing positive histopathology in all the 7 cases and in addition, BAL fluid and bronchial brushings also showed positive result in 3 of these 7 cases; in the remaining 3 cases, diagnosis was established by CT-guided FNAC. [12] Klebsiella pneumoniae and Mycobacterium tuberculosis were the two most common etiologies in diabetic patients and were found in 33.3% and 25% cases, respectively. Isolated lung involvement is rare, and it is important to search for other systemic manifestations of GPA at the time of diagnosis, and during follow up. Is its microbiology changing? We present a patient treated for recurrent pneumonia despite persistence on imaging for 6 years before being diagnosed with lung adenocarcinoma. In this study, FOB was done in 56 patients (4 patients did not give consent for bronchoscopy). Pulmonary involvement occurs in 60% of cases, most commonly presenting as cough, dyspnea, and hemoptysis from cavitating nodules, nonspecific airspace infiltrates, and alveolar hemorrhage [1]. Mandell LA, Wunderink RG, Anzeuto A, et al. Follow up chest radiograph (posteroanterior view) performed following treatment, demonstrates significant decrease in size of largest lesion in mid lung zone (white arrow). [11] Diabetes mellitus was found to be the commonest comorbidity in this study and was present in 33.3% cases. On chest X-ray, consolidation was present in 53 patients, consolidation along with cavity was present in 5 patients, and only cavity was present in 2 patients. Healthcare-associated pneumoniais when someone develops pneumonia during or following a stay in a healthcare setting. Nonresolving pneumonia, chronic pneumonia and slowly resolving pneumonia are related entities to recurrent pneumonia and have been used in the literature interchangeably to refer to pneumonia with . At least two phenotypes can be distinguished in GPA; limited disease (less severe), and diffuse disease (more severe) [1].