20

CASE 20


A 44-year-old white man presented with a 3-month history of intermittent fever, chills, and a cough production of green sputum. He also complained about weakness, weight loss, chest pain, and shortness of breath. He had been given several courses of antibiotics without significant improvement and had noted the presence of a headache for the past few weeks. He had a history of COPD and had been on chronic steroids for the past 6 months.



PHYSICAL EXAMINATION



VS: T 39°C, P 118/min, R 36/min, BP 148/90 mmHg

PE: The patient appeared ill. Decreased breath sounds in the right lung were heard. Slight weakness of the left upper extremity was also noted.


LABORATORY STUDIES



Blood



Hematocrit: 34%

WBC: 5800/μL

Differential: 63% PMNs, 5% bands, 32% lymphs

Blood gases: pO2 62 mmHg

Serum chemistries: Normal


Imaging


A chest x-ray revealed extensive nodular infiltrates in the right middle and upper lobes and cavitary disease (Fig. 20-1).


image

FIGURE 20-1 Admission chest film showing extensive nodular and cavitary disease in the right middle and upper lobes in this patient.


(Courtesy of Dr. Daniel Skiest, Department of Medicine, University of Texas Southwestern Medical Center, Dallas, TX.)



Diagnostic Work-Up


Table 20-1 lists the likely causes of illness (differential diagnosis). Investigational approach for the etiology of chronic pneumonia may include


• Gram and acid-fast stains of respiratory or biopsy specimens

• Cultures of sputum or biopsy specimens (prolonged incubation of routine blood agar cultures and mycobacterial cultures are required)

• In failed tests, fungal cultures and serology

TABLE 20-1 Differential Diagnosis and Rationale for Inclusion (consideration)






Actinomycosis

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Aug 25, 2016 | Posted by in MICROBIOLOGY | Comments Off on 20

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