Pneumonia Mimics Final - Handout.ppt - ccme.osu.edu - Pneumonia Mimics Final - 4... · Stool O&P...
Transcript of Pneumonia Mimics Final - Handout.ppt - ccme.osu.edu - Pneumonia Mimics Final - 4... · Stool O&P...
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Pneumonia MimicsPneumonia MimicsPneumonia MimicsPneumonia Mimics
Jim Allen, MD,Professor of Internal Medicine
Division of Pulmonary & Critical Care MedicineOhio State University Medical Center
Causes of Community-Acquired Pneumonia in Outpatients
Causes of Community-Acquired Pneumonia in Outpatients
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JulyJuly87 year old woman with community-acquired
Case #1
acqu edpneumoniaImproves partially with empiric antibiotics
AugustAugustRe-admitted with recurrent pneumonia
Case #1
pneumoniaImproves partially with empiric antibiotics
OctoberOctoberRe-admitted with recurrent pneumoniaN i t
Case #1
No improvement with empiric antibioticsUndergoes BAL; cultures all negative
OctoberOctoberAfter 4 admissions to th h it l
Case #1
the hospital, transferred for long-term antibiotics
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NovemberNovemberAfter 3 weeks, BAL now growing acid fast bacteria
Case #1
bacteriaAfter 4 weeks, identified as M. tuberculosisInfection control nightmare begins
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Tuberculosis in 2011
Tuberculosis in 2011
“Shoot first, ask questions later”RespiratorRespiratory isolation when TB suspected4 drug treatmentAlways check drug sensitivities
The moral of the story:Don’t get bit by red snappers
The moral of the story:Don’t get bit by red snappers
HistoryHistory80 year old man admitted with hypoglycemia and status epilepticus
Case #2
status epilepticusPersistent anoxic encephalopathy and respiratory failureTransferred for ventilator weaning after 6 days in ICU
After 4 weeks:Still ventilator dependentDaily fevers to 102
Case #2
yF despite 1 week of empiric antibioticsBlood eosinophil count 570BAL: 11% eosinophils; no pathogens
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Diagnosis: phenytoin-induced lung diseaseDiagnosis: phenytoin-induced lung diseaseAntibiotics stoppedPnenytoin stopped
Case #2
Pnenytoin stoppedShort course corticosteroidsFever & pulmonary infiltrates resolvedRespiratory failure resolved and weaned off of the ventilator
Can be very easy to missClues:
Peripheral pulmonary
Drug-induced lung disease:Drug-induced lung disease:
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pulmonary infiltratesBlood eosinophilia (>350/cmm)BAL eosinophiliaSkin rash
Diagnosis of exclusion
Common Drugs:Common Drugs:
PhenytoinMacrodantin
SulfasalazineCocaine
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AmiodaroneMinocyclineMethotrexateBleomycin
ACE inhibitors (cough)Sulfa-containing antibiotics
Mesalamine (Asacol)Mesalamine (Asacol)
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Macrobid(macrodantin)
Macrobid(macrodantin)
Drug-induced lung disease may be very difficult to confirmRe-challenge is riskywww.pneumotox.com is a great resourceD t di th
The morals of the story:The morals of the story:
Doctors cause more disease than we realize
79 year old manCough and dyspnea onset in November 2009
Case #3
Hospitalized with pneumonia in February 2010 and treated with empiric antbioticsImproved but not back to normal when seen in April 2010
Former smokerLandscaperExam: crackles in the lower left lung
Case #3
gLabs: eosinophil count = 460Not taking any candidate drugs for drug-induced lung disease
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Case #3
Case #3
Anti-strongyloides antibody positiveAnti-strongyloides antibody positive
Case #3
Case #3After treatment with After treatment with ivermectinivermectin
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StrongyloidesStrongyloidesLives in the intestineOnce infected, always infectedCorticosteroids are wormCorticosteroids are worm fertilizerSerology is the best diagnostic test
Strongyloides is sneaky
Strongyloides is sneaky
87 year old mother of OSU physicianRecurrent “colitis”, eosinopilia pulmonaryeosinopilia, pulmonary infiltrates and cough for 20 yearsPositive anti-strongyloides antibodySymptoms resolved with ivermectin
35 YO CM with tuberous sclerosis and severe mental retardationR t f &
You’ll miss it if you only order the regular stool
O&P examYou’ll miss it if you only order the regular stool
O&P exam
Recurrent fevers & pseudomonas pneumoniaPersistent fevers and blood eosinophilia (up to 2,700/mcL)Stool O&P negative (antigenic)
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Worms are everywhereNon-resolving pneumonia + peripheral eosinophilia = order a strongyloides antibody titer
The morals of the story:The morals of the story:
y
HistoryHistory64 yr old man exposed to black dust in ceiling tiles during remodeling Feb, 2004Diagnosed with RLL pneumonia by CXR
Case #4
Diagnosed with RLL pneumonia by CXR and symptoms improved with ATBSubsequent CXRs and CTs showed progression of infiltrates
History (cont)History (cont)
PMH – no illnessesSx – architectural designer; 100 PY
Case #4
smoker; son is a radiology residentROS – all negativeMoist crackles RLL posterior; no egophony
Labs (Dec, 2004)Labs (Dec, 2004)Fungal serologies, urine histo antigen all negBAL – 52% MP, 27% N, 15% L, 6% E;
Case #4
negative AFB, fungal cultures; cytology negativeTransbronchial biopsy – calcified granuloma with histo organisms seenBrushings – negative cytology
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May, 2005May, 2005Repeat BAL: negative cultures, negative cytology
Case #4
Surgical lung biopsy: possible cryptogenic organizing pneumonia
Clinical Course (con’t)Clinical Course (con’t)Trial of prednisone 40 mg/day – no subjective improvementRepeat BAL Dec 2005: 71% MP 18% N
Case #4
Repeat BAL Dec, 2005: 71% MP, 18% N, 10% L, 1% E; negative cultures and cytologyTransbronchial biopsy = no cancer
February, 2006February, 2006Severe hypoxemiaAdmitted to ICU and subsequently has 6 week hospitalization for
Case #4
week hospitalization for antibiotics & steroidsDeclined 2nd surgical lung biopsyEventually discharged home with hospiceDied January, 2007
Case #4
Autopsy slides
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Bronchoalveolarcarcinoma
Bronchoalveolarcarcinoma
The great impersonatorOften hard to
Radiographic presentations:
Lobar consolidation
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Often hard to diagnose in life even with surgical biopsy
Solitary pulmonary noduleDiffuse patchy infiltratesMultiple pulmonary nodules
Non-small cell lung cancers
Non-small cell lung cancers
AdenocarcinomaSquamous cell carcinomaLarge cell undifferentiated carcinomaBronchoalveolar carcinoma
The moral of the story:Non-resolving pneumonia is usually not pneumonia
The moral of the story:Non-resolving pneumonia is usually not pneumonia
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69 year old woman admitted with cough in November 2009Improved transiently with cefpodoxime but relapsed after 2 weeks
Case #5
but relapsed after 2 weeksRe-admitted in February 2010 and improved again with levafloxacin; BAL bacterial, fungal, AFB cultures negative
Normal IgGNegative anti-CCPNegative ANA
Normal fungal titersNormal hypersensitivity
Case #5
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gNormal QuantiferonNormal alpha-1-antitrypsin
panelNormal serum protein electrophoresisNormal CBC
Case #5
Sent home and told to not take antibioticsReturned for bronchoscopy when antibiotic-free
Case #5
antibiotic freeBAL:
34% macrophages54% neutrophils11% lymphocytes1% eosinophils
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Bronchial washings and BAL = Mycobacterium avium complex
Case #5
Mycobacterium avium complex
Case #5
After initiation of 3-drug treatment3-drug treatment
M. avium complexM. avium complexOccurs in:
Naturally occurring water sourcesAnimalsHeated waterHeated water systems
Incidence probably underestimatedJust growing it doesn’t mean you’ve got it!
Frequency of non-tuberculousmycobacterial infections
Frequency of non-tuberculousmycobacterial infections
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M. avium complex: four main clinical syndromes
M. avium complex: four main clinical syndromes
1. HIV-associated2. Cavitary lung disease
MalePre-existing lung di
3. Cystic fibrosis-associated
4. Mid-lung diseaseOtherwise healthy women
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diseaseAgeAlcoholism Upper lobe infiltrates or cavities
womenOver age 50 yrsLingular or RML nodular diseasePresent with cough and no systemic symptoms“Lady Windermere Syndrome”
Lady Windermere’s Fan (1892) Lady Windermere’s Fan (1892)
Reich JM & Johnson RE. Mycobacterium avium complex pulmonary disease presenting as p gisolated lingular or middle lobe pattern: The Lady Windermere Syndrome. Chest 1992; 101:1605
Oscar Wilde
M. avium complex: other pulmonary syndromes
M. avium complex: other pulmonary syndromes
Infection associated with pectus excavatumSolitary pulmonary noduleHypersensitivity pneumonitis (“hot tub lung”)
44 year old woman with:44 year old woman with:
Lichen planus treated with a TNF inhibitor Lymphoma treated with rituxamabRecurrent pneumoniaRespiratory failure requiring transfer to LTACH for ventilator weanBAL = Mycobacterium abscessus
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45 year old man with ‘refractory pneumonia’45 year old man with
‘refractory pneumonia’
51 year old woman withchronic lymphocytic
leukemia
51 year old woman withchronic lymphocytic
leukemiaRecurrent bronchitis & pneumoniaTransiently improves with antibioticsBAL = M. avium complex
Mycobacterium AviumComplex: Treatment
Mycobacterium AviumComplex: Treatment
Clarithromycin (1,000mg) or azithromycin (500mg) three times a week Rifampin (600 mg) or rifabutin (300 mg) three times a weekEthambutol (25mg/kg) three times a weekStreptomycin two to three times per week should be considered for the first eight weeks as toleratedTreat for a long, long, long time
ATS/IDSA Statement: Diagnosis, Treatment, and Prevention of Disease Caused by Nontuberculous Mycobacteria. Am J Respir Crit Care Med2007: 175: 367-416
Bronchiectasis + Nodules = MACBronchiectasis + Nodules = MAC
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58 year old woman with recurrent pneumonia and
cough
58 year old woman with recurrent pneumonia and
cough
BronchiectasisBronchiectasis Nodules
The moral of the story:A high-resolution chest CT sometimes paints a picture
worth a thousand chest x-rays
The moral of the story:A high-resolution chest CT sometimes paints a picture
worth a thousand chest x-rays
19 yr old OSU undergraduate student3 days of increasing:
Case #6
3 days of increasing:DyspneaPleuritic chest painFeverMyalgias
Physical exam:Tachypneic with labored respirations
Laboratory studies:
WBC = 15,000O2 46
Case #6
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respirationsTemperature = 101 FLungs = scant bi-basilar crackles
pO2 = 46 (room air)
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Intubated on presentationBAL:
Case #6
60% eosinophils20% macrophages15% lymphocytes5% neutrophils
All cultures negative
Acute Eosinophilicpneumonia
Acute Eosinophilicpneumonia
Presentation:Average symptoms 4 daysAverage age 29
Exam:Average temperature 101 degrees F
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yrsSymptoms:
Cough 100%Dyspnea 95%Chest pain 73%Myalgias 50%
>40% “beginner” smokers
gAverage respiratory rate 32/minCrackles in 80%
Acute Eosinophilic pneumoniaAcute Eosinophilic pneumoniaChest X-ray:
Kerley B linesInterstitial infiltratesAlveolar infiltrates
Lab:Average WBC 17,000
Blood eosinophils not usually elevated
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Pleural effusionselevated
Average pO2 57 mmIgE sometimes elevatedPFTs:
RestrictionLow diffusing capacity
Acute Acute EosinophilicEosinophilic Pneumonia Day #1Pneumonia Day #1
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Acute Acute EosinophilicEosinophilic Pneumonia Day #2Pneumonia Day #2
Acute Acute EosinophilicEosinophilic Pneumonia Day #3Pneumonia Day #3
Acute Acute EosinophilicEosinophilic Pneumonia Day #7Pneumonia Day #7
Acute EosinophilicPneumonia
Acute EosinophilicPneumonia
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Acute Eosinophilicpneumonia
Acute Eosinophilicpneumonia
Typical BAL:37% eosinophils20% lymphocytes15% neutrophils28% macrophages
Lung biopsy:Intra-alveolar eosinophils
Acute EosinophilicPneumonia Treatment:
Acute EosinophilicPneumonia Treatment:Methylprednisolone 125 mg/6 hours until respiratory failure resolvesPrednisone 60 mg/d - taper over a monthRelapses do not occur
Acute Eosinophilic Pneumonia: Causes/MimicsAcute Eosinophilic Pneumonia: Causes/Mimics
IdiopathicCigarette smokingPrescription drugsStreet drugsOrganic dust inhalationParasites
Acute eosinophilic pneumonia among US Military personnel
deployed in or near IraqShorr, et al. JAMA 2004: 292:2997-3005
Acute eosinophilic pneumonia among US Military personnel
deployed in or near IraqShorr, et al. JAMA 2004: 292:2997-3005
18 cases out of 183,000 deployed military78% recently beginning to smokeBAL = 40% eosinophils2/3 required mechanical ventilation2 diedSurvivors recovered completely
Acute eosinophilic pneumonia among US Military personnel deployed in or near Iraq. Shorr AF, Scoville SL, Cersovsky SB, et al. JAMA. 2004;292(24):2997-3005
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Why eosinophils and football don’t mix
Why eosinophils and football don’t mix
September 30, 1995
The moral of the story:A bronchoscopy can be a
powerful thing
The moral of the story:A bronchoscopy can be a
powerful thing
51 year old man with cough and dyspnea for 3 weeks. No improvement after a course of azithromycin and albuterolNon-smoker who works in sales. He has a hot tub
Case #7
Exam: dry crackles on the rightPFTs: restriction with low diffusing capacityLab: autoimmune serologies, fungal serologies, hypersensitivity serologies all negative
Case #7
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Case #7
Case #7
Cryptogenic organizing pneumonia
Cryptogenic Organizing Pneumonia
Cryptogenic Organizing Pneumonia
Clinical presentation:40-60 years oldSymptoms less than 2 months
C t i diti dCauses: autoimmune conditions, drugs, idiopathicLung biopsy required for confident diagnosisTreatment:
Prednisone (2/3 patients respond)Duration = >6 months
Cryptogenic organizing pneumonia (aka “BOOP”: Bronchiolitis Obliterans
Organizing Pneumonia)(aka crytogenic organizing pneumonia)
Cryptogenic organizing pneumonia (aka “BOOP”: Bronchiolitis Obliterans
Organizing Pneumonia)(aka crytogenic organizing pneumonia)
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Sub-pleural clearing in BOOPSub-pleural clearing in BOOP
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The moral of the story:A non-resolving pulmonary infiltrate and a non-diagnostic bronchoscopyis an invitation to a surgical biopsy
The moral of the story:A non-resolving pulmonary infiltrate and a non-diagnostic bronchoscopyis an invitation to a surgical biopsy
HistoryHistory66 yr old with severe emphysemaHome O2 for 4 yearsMeds: inhaled steroid tiotropium
Case #8
Meds: inhaled steroid, tiotropium, PRN albuterolFormer banker; quit smoking 8 years ago
History leading to admission
History leading to admission
October - COPD exacerbation treated with steroids & doxycycline
Case #8
with steroids & doxycyclineNovember - admitted with RUL pneumonia treated with moxifloxacinMarch - RUL pneumonia treated with moxifloxacinApril – still had RUL infiltrate
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Case #8
BronchoscopyBronchoscopyRight upper lobe occluded by an endobronchial mass
C l i
Case #8
Cultures negativeCytology and endobronchial biopsy negative
Repeat BronchoscopyRepeat BronchoscopyWashings/brushings negativeBiopsy - respiratory epithelium with moderate mixed acute and chronic i fl ti f t f f i
Case #8
inflammation; fragment of foreign material consistent with vegetable materialFollowing the bronchoscopy, he expectorated a mummified kernel of corn
Bronchoalveolar lavageBronchoalveolar lavageCell differential = 84% neutrophilsGram positive cocci, Gram positive rods Gram positive
Case #8
positive rods, Gram positive beaded bacilliRe-review of BAL and both biopsies by GMS stain indicate branching filamentous bacteria consistent with actinomyces
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Pulmonary ActinomycesPulmonary ActinomycesAll ages - peak age = 4th & 5th decadesMale:female = 2:1 to 4:1Risk factors: poor dental hygieneRisk factors: poor dental hygiene, emphysma, chronic bronchitis, alcoholism, bronchiectasisUsual presentation = abnormal x-rayNot usually associated with immunosuppression
ActinomycosisActinomycosisAnaerobic (often won’t grow)Tends to cross thoracic boundariesOften has “companion bacteria”Th t tiThree presentations:
CervicofacialAbdominopelvicThoracic
RadiologyRadiology
Pneumonia - like patternTends to cross fissuresCan invade adjacent tissuesCan invade adjacent tissues
CT:Airspace consolidationMassPleural effusions (small)Mediastinal adenopathy
Upper lobe consolidationUpper lobe consolidation
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Right middle lobe consolidation
Right middle lobe consolidation
Pulmonary nodulePulmonary nodule
Mass-like with erosion into chest wall and ribsMass-like with erosion into chest wall and ribs
Actinomycosis: TreatmentActinomycosis: Treatment
PenicillinDrainage when possibleg pAlternative antibiotics:
DoxycyclineErythromycinClindamycin
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The morals of the story:1. The gram stain report may have more information than the culture report2. Corn does not belong in the airway
The morals of the story:1. The gram stain report may have more information than the culture report2. Corn does not belong in the airway
HistoryHistory48 year old man with pneumonia and anemia Progressive dyspnea for 2 months
Case #9
for 2 monthsBlood and bronchoalveolar lavage cultures all negativeReferred for antibiotics & pulmonary rehabilitation
Fails to improve despite 3 weeks of antibioticsSed rate 120
Case #9
Sed rate 120 secondsReferred for surgical lung biopsy
Case #9
Image of lung in at the time of VATS
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Wegener’s granulomatosisWegener’s granulomatosisCase #9
Wegener’s granulomatosisWegener’s granulomatosisCase #9
Wegener’s with cavityWegener’s with cavity
Wegener’s granulomatosisWegener’s granulomatosisConsider in:
Alveolar hemorrhageLung cavitiesPulmonary infiltrate + hematuria
Elevated cANCA highly suggestive (but not diagnostic)Diagnosis requires biopsyTreatment = steroids plus cyclophosphamide
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The moral of the story:Maintain a healthy sense of skepticism about referral diagnoses that don’t make sense
The moral of the story:Maintain a healthy sense of skepticism about referral diagnoses that don’t make sense
41 year old woman with dyspnea and cough for 2 months. No improvement after a course of azithromycinPMH: hypertension and hypothyroidism
Case #10
SH: non-smoker; teacher’s aid for MRDD pre-school childrenExam: basilar right-sided crackles
Sent for evaluation for possible surgical lung biopsy
Case #10
And then she said…And then she said…“And oh by the way, did I tell you that we raise goats and donkeys in the barn in our back yard?”“And oh by the way, did I tell you we have
Case #10
y y, ya Quaker Parrot? And Cockatiels? And Parakeets?”“And oh by the way, did I tell you we have birds living in our attic and there’s a hole in my closet ceiling so that my clothes are covered with bird feathers and bird poop?”
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Antibody Normal Value Patient
Canary Feathers <17 34 (H)
Finch Feathers <12 59 (H)
Case #10
Parrott Droppings <14 91 (H)
Parrott Proteins <12 50 (H)
Pigeon Droppings <70 78 (H)
Pigeon Feathers <22 60 (H)
Hypersensitivity PneumonitisHypersensitivity PneumonitisEtiology often hard to identify
BirdsHot tubsOccupation
Treatment:Remove offending antigenPrednisone
Outcome:
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OccupationDrug
T-suppressor cell alveolitis
Outcome:Complete resolutionChronic fibrosis
Hot TubHypersensitivity
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Drug-inducedHypersensitivity
Feather pillowHypersensitivity
The moral of the story:
The moral of the story:
Birds are badFeather pillows are just as badHot tubs are worse
Clinical approach to non-resolving infiltrates
Clinical approach to non-resolving infiltrates
Take a history!Never, ever, ever, ever miss tuberculosistuberculosisChest CT scanBronchoscopySurgical lung biopsy if all else fails
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The moral of the The moral of the story:story:
Sometimes nonSometimes non--l il i
The moral of the The moral of the story:story:
Sometimes nonSometimes non--l il iresolving resolving
pneumonia is just pneumonia is just pneumoniapneumoniaresolving resolving
pneumonia is just pneumonia is just pneumoniapneumonia