Medical Grand Rounds A perplexing pneumonia

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Medical Grand RoundsA perplexing pneumonia

• Infectious Diseases Team
• John Hunter Hospital
• August 2005

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JA 54 yo female

• PHx
• One episode pneumonia responded to usual AB Tx in
  2003
• Ex smoker. Ceased 2/12 ago. 35 pack year history
• Mild asthma prn ventolin only
• Hysterectomy

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History

• Presented to Belmont Hospital with a 6 week
  history of fever, shortness of breath and a
  productive cough (dark green sputum)
• Weight loss 6kg despite good appetite
• Drenching night sweats
• No antibiotic treatment prior to presentation

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Psychosocial History

• Worked as a cleaner in a hotel and caravan park
• Married with 1 son.
• Lives with husband and son - Both well
• 2 birds
• 2 dogs
• No overseas or Australian travel
• No risk factors for blood-borne viruses

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Examination on presentation to BDH

• Fever 39.4 degrees
• Mild tachypnoea 20 bpm
• Cachectic
• LLL dull percussion
• LLL bronchial BS
• PaO2 55mmHg room air. CO2 33mmHg

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Treatment

• IV Ceftriaxone, Azithromycin 5/7
• Ongoing high swinging fevers, cough
• IV Timentin, Azithromycin 5/7
• No response at all
• David Arnold consulted

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Further Investigations

• ANA/ENA/ANCA - negative
• Cultures blood and sputum negative
• Bronchoscopy 15/02/05 NAD, Nocardia and
  Actinomycosis cultures sent. AFB smear negative
• Trans bronchial biopsy inflamed and necrotic
  lung well demarcated from normal lung. No
  malignancy

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JHH transfer

• 9/3/05 VAT and open lung biopsy LLL
• IV Cephalothin, oral ciprofloxacin
  post-operatively
• Ongoing fevers despite this
• 11/3/5 Histology.

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Diagnostic possibilities? . .

• Granulomatous chronic pneumonia

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• Granulomatous chronic pneumonia
• Diagnostic possibilities? . . .
• Mantoux negative (useless)
• ZN smear for AFBs negative
• Serology for Q-fever, histoplasma negative
• Special stains for fungi, histiocytosis X
  negative
• PCR on tissue for MAC and MTb negative

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Cultures

• 14/3/5 - LLL biopsy on 9/3/5 POSITIVE for
  Burkholderia cepacia
• Commenced IV ceftazidime and ciprofloxacin
• In retrospect, one of the sputum cultures from
  the previous week also grew B.cepacia

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Progress

• 16/3/5 L thoracotomy and lower lobectomy
• To debulk woody and destroyed L lower lobe
  (suggested by cardiothoracic surgeon)

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Progress

• Day 3 post op developed LUL collapse
• Physio, intermittent CPAP
• LUL did not reinflate
• 20/3/5 Bronchoscopy and washout
• Saw moderate purulent secretions in L main
  bronchus
• Improved clinically. Continued Ceftazidime plus
  ciprofloxacin

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Progress

• 1 week later
• 27/3/5 febrile increasing CRP (435) , CXR changes

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Progress

• Recrudescent B.cepacia due to spillage of pus
  into RUL
• IV ceftazidime, tobramycin, meropenem,
  ciprofloxacin
• Moderately lymphopaenic throughout admission
  (0.3-0.6x 109/L)
• Further negative tests
• Neutrophil function test
• Lupus anticoagulant
• Cardiolipin Ab
• HIV serology
• IgG subsets normal

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Discharge

• Out About service- Ceftazidime, ciprofloxacin
  6 weeks IV ceftazidime in total
• Followed by a further 3/12 of oral high dose
  Bactrim and ciprofloxacin
• July 05 Well. Regained 8kg. CRP4.
  Lymphocytes0.9
• Repeat CT 27/7 - fluffy nodules still present
  continue oral antibiotics for further 3/12

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