Community-acquired Pneumonia Failure Research Articles

A CHALLENGING CASE OF DYSPNEA: ACUTE EXOGENOUS LIPID PNEUMONIA

SESSION TITLE: Wednesday Fellows Case Report Posters SESSION TYPE: Fellow Case Report Posters PRESENTED ON: 10/23/2019 09:45 AM - 10:45 AM INTRODUCTION: Dyspnea is a common symptom that generally occurs during exertion and is considered pathological when it occurs at rest. Approximately, 90% of dyspnea is caused by pulmonary diseases making it immensely important that dyspnea be thoroughly evaluated as it can be fatal. And even after thorough evaluation, a clear answer for the etiology of patient’s dyspnea is not quite apparent. We report one such challenging case that after a meticulous collaboration from radiologist, pathologist and pulmonologist, and detailed history taking followed by a detailed work-up to rule out more common fatal causes of shortness of breath patient’s etiology of dyspnea was revealed to be acute exogenous lipid pneumonia (ELP) caused by lipid-based vapor rub (LBVR). CASE PRESENTATION: A 67 year old Japanese male with past medical history of hypertension presented to the hospital with worsening non-productive cough and dyspnea at rest for the past two weeks. He has never had such symptoms in the past. He had also started to self-medicate with a LBVR over the past 2 weeks with minimal relief. He denied smoking tobacco and using recreational drugs. He worked in maintaining air conditioners and heat furnaces for the past 40 years. He did not have birds at home. He denied any sick contacts. He has been up-to-date on his vaccinations. During the hospital stay, he was started on community acquired pneumonia (CAP) treatment and was also diuresed daily after chest x-ray revealed non-specific interstitial and alveolar prominence in both lung bases. Despite CAP and heart failure treatment for 3 days, patient continued to require supplemental oxygen (FiO2 of 40%) to maintain oxygen saturation (SpO2) of 92%. He then underwent computed tomography (CT) of chest which showed multi-focal patchy and confluent ground-glass airspace opacities with interstitial thickening in the lower lobes. Due to these findings on CT and no improvement in oxygen requirements, a bronchoscopy was performed with transbronchial biopsy which showed alveoli filled with lipid laden macrophages consistent with lipid pneumonia. Inspection of airway during bronchoscopy revealed tracheobronchopathia osteochondroplastica. He was discharged home with supplemental oxygen and was asked to cease using the LBVR. Patient followed up out-patient and he no longer had dyspnea at rest. His SpO2 had improved to 96% on room air. DISCUSSION: Chronic ELP usually occurs when lipid-based products are aspirated, or inhaled over an extended period. Acute ELP from inhaling LBVR has never been reported. LBVR products are commonly used to help with cough and congestion, however, it can lead to acute ELP as reported in this case. CONCLUSIONS: The usage of LBVR is often overlooked when acquiring history. This case uniquely sheds light on the tendency of over the counter LBVR to acutely cause exogenous lipid pneumonia making it very important for clinicians to inquire about LBVR usage. Reference #1: Betancourt, SL; Martinez-Jimenez, S; Rossi, SE; Truong, MT; Carrillo, J; Erasmus, JJ (January 2010). "Lipoid pneumonia: spectrum of clinical and radiologic manifestations.". AJR. American journal of roentgenology. 194 (1): 103–9. Reference #2: Kim JY, Jung JW, Choi JC, Shin JW, Park IW, Choi BW (February 2014). "Recurrent lipoid pneumonia associated with oil pulling". The International Journal of Tuberculosis and Lung Disease. 18 (2): 251–2 Reference #3: Moe Bell, Marvin (2015). "Lipoid pneumonia: An unusual and preventable illness in elderly patients“. Canadian Family Physician. 61 (9): 775–777. DISCLOSURES: No relevant relationships by Jalal Damani, source=Web Response

Predicting treatment failure in patients with community acquired pneumonia: a case-control study.

IntroductionTreatment failure in community-acquired-pneumonia (CAP) patients is associated with a high mortality rate, and therefore are a matter of great concern in clinical management. Those patients have increased mortality and are a target population for randomized clinical trials.MethodsA case–control study was performed in patients with CAP (non-failure cases vs. failure cases, discriminating by late and early failure). CRP, PCT, interleukin 1, 6, 8 and 10 and TNF were determined at days 1 and 3 of hospitalization.ResultsA total of 253 patients were included in this study where 83 patients presented treatment failure. Of these, 40 (48.2%) had early failure. A discriminative effect was found for a higher CURB-65 score among late failure patients (p = 0.004). A significant increase on day 1 of hospitalization in CRP (p < 0.001), PCT (p = 0.004), IL-6 (p < 0.001) and IL-8 (p = 0.02), and a decrease in IL-1 (p = 0.06) in patients with failure was observed compared with patients without failure. On day 3, only the increase in CRP (p < 0.001), PCT (p = 0.007) and IL-6 (p < 0.001) remained significant. Independent predictors for early failure were higher IL-6 levels on day 1 (OR = 1.78, IC = 1.2-2.6) and pleural effusion (OR = 2.25, IC = 1.0-5.3), and for late failure, higher PCT levels on day 3 (OR = 1.60, IC = 1.0-2.5), CURB-65 score ≥ 3 (OR = 1.43, IC = 1.0-2.0), and multilobar involvement (OR = 4.50, IC = 2.1-9.9).ConclusionsThere was a good correlation of IL-6 levels and CAP failure and IL-6 & PCT with late CAP failure. Pleural effusion and multilobar involvement were simple clinical predictors of early and late failure, respectively.Trial registrationIRB Register: http://2009/5451.

Time to Intubation Is Associated with Outcome in Patients with Community-Acquired Pneumonia

IntroductionIt has been suggested that delayed intensive care unit (ICU) transfer is associated with increased mortality for patients with community-acquired pneumonia (CAP). However, ICU admission policies and patient epidemiology vary widely across the world depending on local hospital practices and organizational constraints. We hypothesized that the time from the onset of CAP symptoms to invasive mechanical ventilation could be a relevant prognostic factor.MethodsOne hundred patients with a CAP and necessitating invasive mechanical ventilation were included. Prospectively collected data were retrospectively analysed. Two study groups were identified based on the time of the initiation of invasive mechanical ventilation (rapid respiratory failure requiring mechanical ventilation within 72 h of the onset of CAP and progressive respiratory failure requiring invasive mechanical ventilation 4 or more days after the onset of CAP).ResultsExcepting more COPD patients in the rapid respiratory failure group and more patients with diabetes in the progressive respiratory failure group, these patients had similar characteristics. The overall in-hospital mortality rate was 28% in the rapid respiratory failure group and 51% in the progressive respiratory failure group (P = 0.03). The ICU and the day 30 mortality rates were higher in the progressive respiratory failure group (47% vs. 23%, P = 0.02; and 37.7% vs. 21.3%, P = 0.03; respectively). After adjusting for the propensity score and other potential confounding factors, progressive respiratory failure remained associated with hospital mortality only after 12 days of invasive mechanical ventilation.ConclusionsThis study suggested that the duration or delay in the time to intubation from the onset of CAP symptoms was associated with the outcomes in those patients who ultimately required invasive mechanical ventilation.

Community-acquired pneumonia

Community-acquired pneumonia (CAP) is a major cause of morbidity, mortality and expenditure of resources. When followed, guidelines for CAP management have been demonstrated to improve clinical outcomes; however, several issues are still open. This review summarizes the recent advances in this field and the priority needs for future research. Recently identified clinical and biochemical tools promise to improve the assessment of CAP severity; however, definition of the most accurate and feasible rule(s) for clinical practice is now necessary. Some empirical antimicrobial regimens are still being debated, such as the need for atypical pathogen coverage in home-treated and nonsevere hospitalized patients and the inclusion of respiratory fluoroquinolones among first-choice molecules. New drugs such as tigecycline and cethromycin appear promising. Pharmacokinetically enhanced amoxicillin/clavulanate is highly effective, even for treating CAP caused by multiple-drug-resistant Streptococcus pneumoniae. Other aspects recently clarified include the inappropriateness of rigid time-to-first-antibiotic-dose rules, the advantages of shorter antibiotic treatments for nonsevere patients and the need of special clinical attention for acute myocardial infarction among patients with severe CAP or clinical failure. Recent developments have significantly contributed to refine the management of CAP patients. However, various hot topics remain undefined as yet and urgently require ad-hoc research in order to optimize the outcomes and the costs of this highly social-impacting disease.

Outcomes and Prognostic Factors for Severe Community-Acquired Pneumonia that Requires Mechanical Ventilation

BackgroundCommunity-acquired pneumonia (CAP) remains a common and serious condition worldwide. The mortality from severe CAP remains high, and this has reached 50% in some series. This study was conducted to determine the mortality and predictors that contribute to in-hospital mortality for patients who exhibit CAP and acute respiratory failure that requires mechanical ventilation.MethodsWe retrospectively reviewed the medical records of 85 patients with severe CAP as a primary cause of acute respiratory failure, and this required mechanical ventilation in a setting of the medical intensive care unit (ICU) of a tertiary university hospital between 2000 and 2003.ResultsThe overall in-hospital mortality was 56% (48/85). A Cox-proportional hazard model revealed that the independent predictive factors of in-hospital mortality included a PaCO2 of less than 45 mmHg (p<0.001, relative risk [RR]: 4.73; 95% confidence interval [CI]: 2.16-10.33), a first 24-hour urine output of less than 1.5 L (p=0.006, RR: 2.46, 95% CI: 1.29-4.66) and a high APACHE II score (p=0.004, RR: 1.09, 95% CI: 1.03-1.16).ConclusionsAcute respiratory failure caused by severe CAP and that necessitates mechanical ventilation is associated with a high mortality rate. Initial hypercapnia and a large urine output favored survival, whereas a high APACHE II score predicted mortality.

Non-infectious and unusual infectious mimics of community-acquired pneumonia

Noninfectious or unusual infectious diseases may present with clinical, radiological and laboratorial characteristics of community-acquired pneumonia (CAP). Usually their presence is only suspected after treatment failure, leading to inappropriate interventions, unnecessary costs and risks related to the untreated potentially life-threatening disease. The present study aimed to assess the noninfectious or unusual infectious diseases that may be misdiagnosed as CAP that progresses with treatment failure. Sixteen hospitalized patients with presumptive diagnosis of CAP and treatment failure were described. The most prevalent symptoms were fever and cough. Radiological pattern of air-space disease was observed in 10 (62%) patients. The diagnosis was established by autopsy (12%) or invasive procedures (88%), as follows: open lung biopsy (nine), flexible fiberoptic bronchoscopy (two), transthoracic fine needle aspiration (two) and bone marrow aspiration (one). Eight patients had noninfectious diseases: pulmonary embolism, cryptogenic organizing pneumonia, Wegener's granulomatosis, hypersensitivity pneumonitis, bronchocentric granulomatosis, neoplastic disease and acute leukemia. The unusual infectious diseases were: tuberculosis, cryptococcosis, actinomycosis, histoplasmosis and paracoccidioidomycosis. Patients with noninfectious or unusual infectious diseases may present with symptoms and radiological findings that mimic CAP. These diseases should always be suspected in patients who do not respond to initial empirical antimicrobial treatment, especially young patients or those without comorbidity.