Non-resolving Pneumonia Research Articles

Successful Medical Treatment of Pulmonary Mucormycosis in Diabetic Patients

Pulmonary mucormycosis is a relatively uncommon infection that is mostly observed among diabetic patients. We present here three cases of pulmonary mucormycosis as the cause of non-resolving pneumonia in diabetic patients. The goals of our review are to better characterize the population at risk, presenting symptoms, radiological appearance, diagnostic methods and to demonstrate the efficacy of medical therapy.

Bronchial Wash Gene Xpert MTB/RIF in Lower Lung Field Tuberculosis: Sensitive, Superior, and Rapid in Comparison with Conventional Diagnostic Techniques.

Lower lung field tuberculosis (LLF TB) is an atypical presentation of tuberculosis (TB). LLF TB is common, and a proportionate number of non-resolving pneumonia cases are diagnosed to have pulmonary TB. The prospective observational study was conducted during June 2013 to December 2015 in the Department of Pulmonary Medicine, MIMSR Medical College, Latur, India; the objective of the study is clinical, microbiological, and radiological presentation of LLF TB and the comparison of yield of conventional diagnostic techniques and bronchoscopy-guided modalities in LLF TB. Additional important objective of the study is to find LLF TB in patients with nonresolving pneumonia (NRP). A total of 2,600 patients with pulmonary TB were included in the study after inclusion and exclusion criteria. Ethical clearance was taken from the ethical committee of the institutional review board. Consent was taken from the patients before inclusion in the study. Statistical analysis was done using chi-square test. In the present study, 300 (11.53%) cases of LLF TB of total 2600 pulmonary tuberculosis were included, females constitutes 66.66% (200/300) with mean age of 58.4 ± 11.8 years and males constitutes 33.34% (100/300) with mean age of 56.8 ± 10.6 years. Constitutional symptoms were observed as cough in 93% cases, fever in 83% cases, shortness of breath in 72% cases, anorexia in 91% cases, and weight loss in 84% cases. Radiological assessment of study cases documented the involvement of right lower zone in 84% cases and left lower zone in only 16% cases. In the studied LLF TB cases, 57 cases (20.66%) were diagnosed by routine sputum microscopic examination for acid fast bacilli (AFB) and 80 cases (28%) were diagnosed by induced sputum microscopic examination for AFB. In the study of 170 LLF TB cases, head-to-head comparison between conventional diagnostic techniques (sputum microscopy and Induced sputum microscopy for AFB) made diagnosis in 60 cases, while bronchoscopy-guided sampling techniques (BAL for AFB and BAL for Gene Xpert MTB/RIF) made diagnosis in 155 cases (91.17%) (P < 0.00001). Comorbid conditions such as human immunodeficiency virus (HIV) coinfection in 36 cases (12.00%), Diabetes mellitus in 64 cases (21.33%), and chronic kidney disease (CKD) in 22 cases (7.33%) were observed. Comorbidities were observed in 41.67% of the studied cases and found very significant assessment to have successful treatment outcome (P < 0.00001). In the study of 300 LLF TB cases, 60 cases were having NRP pattern. In LLF TB cases with NRP pattern, bronchoscopy-guided bronchial wash microscopy for AFB made diagnosis in 18 cases (42%), while bronchoscopy-guided BAL for Gene Xpert MTB/RIF made diagnosis in 58 cases (96.66%) (P < 0.00001). LLF TB is usually underdiagnosed because of diverse clinical and radiological presentation, less diagnostic yield of conventional diagnostic modalities, and these modalities used routinely and universally. Bronchoscopy-guided diagnostic techniques are superior, sensitive, and reliable to confirm LLF TB. Gene Xpert MTB/RIF in bronchial wash samples is found to be best diagnostic modality in evaluating LLF TB and should be used routinely to have successful treatment outcome. A proportionate number of NRP cases are having LLF TB and a high index of suspicion is a must while evaluating these cases.

Flexible Bronchoscopy in Non-resolving Pneumonia.

To study the utility of diagnostic flexible bronchoscopy and bronchoalveolar lavage (BAL) in children with non-resolving pneumonia. This was a cross-sectional study conducted in a tertiary care hospital from July 2015 through June 2016. Fifty-two consecutive children of both genders from 1 mo to 14 y of age with a diagnosis of non-resolving pneumonia were included. Flexible bronchoscopy was done in all patients with or without bronchoalveolar lavage (BAL). BAL was sent for gram staining, culture, gene expert™ and lipid laden macrophages examination. Main outcome measures were to find any morphological abnormality in the tracheobronchial tree and organism profile of a positive BAL culture. During the period of 12 mo, 52 consecutive patients of non-resolving pneumonia were enrolled. Median (IQR) age of the study population was 12 (68.8) mo. Mean±SD duration of illness was 22.7±5.6 d. Flexible bronchoscopy was found to be very safe and effective tool that directly led to definitive diagnosis in 30.7% of cases. It was positive for different organisms in 22 (52.3%) children. Neglected foreign body was seen in five patients. Non-resolving pneumonia is often an area of clinical dilemma. Bacterial infections are the commonest etiology. Non-infectious causes like tracheobronchomalacia and foreign body aspiration are other important etiologies to be looked for. Early bronchoscopy and bronchoalveolar lavage analysis can play a crucial role in the evaluation of these patients and may provide an important clue or strongly supportthe specific diagnosis.

Imaging of Pneumonia: An Overview

Pneumonia is one of the common causes of morbidity and mortality in general population. Imaging plays an important role in the management of pneumonia. In the current era, there has been an increase in the patients with extremes of age, immunocompromised status, underlying lung pathology, post-transplant status, and atypical infections. It is necessary to use cross-sectional imaging modalities like computed tomography (CT) due to atypical or non-specific chest radiograph findings in such cases. CT narrows down the differential diagnosis, for etiological agent. It helps in the evaluation of the causes of non-resolving pneumonia, pulmonary, and non-pulmonary complications of pneumonia. Pneumonia is classified into three main types as community-acquired pneumonia, hospital-acquired pneumonia, and aspiration pneumonia. It is important to differentiate these three types, since host factors and etiological organisms differ, thus changing the course and management in these patients. Knowing the clinical background and correlation with imaging findings may help in the early detection of pathogen and direct the physician toward appropriate management. Imaging also helps in follow-up of patients to look for response to therapy. Cross-sectional imaging can help in ruling out diseases mimicking pneumonia.

Severe GERD with Non Resolving Pneumonia Requiring Surgical Intervention for Survival

Infant reflux becomes evident in the first few months of life, peaks at 4 months and resolves in up to 88% by 12 months and in nearly all by 24 months. Infantile reflux manifests more often with regurgitation, signs of esophagitis and resulting failure to thrive. We report the case of two months old male child with GERD with non-resolving pneumonia only relieved after surgical intervention.

Pulmonary actinomycosis in a postlobectomy patient—rare sequelae

Nonresolving pneumonia has a varied etiology and sometimes may pose a diagnostic challenge. We report a case of a pulmonary actinomycosis presenting as a nonresolving pneumonia. This was associated with the presence of an infected endobronchial suture material 16 years after lobectomy. Prompt introduction of specific treatment and removal of endobronchial suture material led to the excellent recovery of the patient.

“Non-resolving pneumonia”: A case of cryptogenic organizing pneumonia

“Non-resolving pneumonia”: A case of cryptogenic organizing pneumonia

Uncommon Diagnosis: Pulmonary B Cell Lymphoma Presenting as Non-Resolving Pneumonia

SESSION TITLE: Student/Resident Case Report Poster - Lung Pathology II SESSION TYPE: Student/Resident Case Report Poster PRESENTED ON: Tuesday, October 25, 2016 at 01:30 PM - 02:30 PM INTRODUCTION: Persistent symptomatology or incomplete resolution of pneumonia despite treatment is a common clinical problem. Up to 20 percent of nonresponding community-acquired pneumonia may be due to noninfectious causes. Delay in diagnosis may lead to progression of disease and unnecessary antibiotics. We describe a case of diffuse large B cell lymphoma presenting as a non-resolving pneumonia. CASE PRESENTATION: A 62 year old man with a remote smoking history presented with 2 weeks of cough. A chest x-ray revealed lingular and left lower lobe opacities, and the patient was given Levaquin 750mg for 5 days. The patient initially showed clinical improvement but then presented with worsening of his cough. He was prescribed doxycycline 100mg bid for 10 days. A chest CT revealed extensive infiltrate in the left lower lobe with persistent symptoms despite treatment prompting hospitalization. Although he was afebrile with a WBC only mildly elevated at 11.8 K/UL, his ESR and CRP were significantly elevated at 94 mm/hr and 2.30 mg/dl, respectively. Sputum cultures grew normal oropharyngeal flora. A repeat chest CT scan after 10 days revealed extensive abnormalities in the left lower lobe with ground glass opacity in the Left upper lobe without pathologically enlarged lymph nodes (Image1). Due to the non-resolving nature of his symptoms and radiographic findings, the patient underwent bronchoscopy, which revealed marked mucosal abnormalities (Image 2). An endobronchial biopsy was obtained, which was positive for diffuse large B cell lymphoma. Pet scan shows hypermetabolism in the LLL, left infrahilar area and left hilum. He then consulted with his outside cancer institute for further management. DISCUSSION: Although non-resolving pneumonia is common, primary pulmonary lymphoma is rare. Less than 5 percent of non-Hodgkin lymphomas present with an alveolar infiltrate. Furthermore, it is often difficult to diagnose with standard fiberoptic bronchoscopy sampling techniques. However, given that resistant bacteria as well as less common infections such as, fungi, Nocardia, and Actinomyces are in the differential diagnosis, maintaining a broad differential and consideration of bronchoscopy is an important step in the approach to these patients, particularly since bronchoscopy is generally well-tolerated. CONCLUSIONS: Lack of at least partial radiographic resolution of pulmonary infiltrates by six weeks warrants consideration of alternative causes such as obstructing endobronchial lesions, resistant or atypical infection, or noninfectious causes. Reference #1: Lung India. 2013 Jan;30(1):27-32. doi: 10.4103/0970-2113.106130. A study on non-resolving pneumonia with special reference to role of fiberoptic bronchoscopy. Chaudhuri AD1, Mukherjee S, Nandi S, Bhuniya S, Tapadar SR, Saha M Reference #2: J Bronchology Interv Pulmonol. 2015 Oct 22. Pulmonary Parenchymal Lymphoma Diagnosed by Bronchoscopic Cryoprobe Lung Biopsy. Schiavo D1, Batzlaff C, Maldonado DISCLOSURE: The following authors have nothing to disclose: Zainab Mirza, Violet Kramer, Sharon Weiner No Product/Research Disclosure Information

An Esophago-Pleural Fistula in a Case of Non-Resolving Pneumonia in a Patient With a History of Lung Cancer

An Esophago-Pleural Fistula in a Case of Non-Resolving Pneumonia in a Patient With a History of Lung Cancer

Usefulness of Fiber-optic Bronchoscopy in the Diagnosis of Pulmonary Diseases in Diabetic Patients: Experience in a Tertiary Care Hospital

Background: Fiber-optic bronchoscopy (FOB) is an invasive procedure performed to identify possible endobronchial lesions. Diabetic patients often present with non-resolving pneumonia and collapse, many of whom are elderly and smoker; thus always giving rise to the suspicion of malignancy.Methods: This observational study was performed from March 2009 to August 2013 in the Department of Internal Medicine and Pulmonology of BIRDEM General Hospital, Dhaka, Bangladesh; a 500 bedded tertiary care hospital dealing mostly with diabetic patients.Results: Out of 160 diabetic patients 126 (78.7%) were male, 34 (21.3%) were female. Mean age of the patients was – 57.2 ±10.8 years. The indications of bronchoscopy were collapse (38, 23.8%), non-resolving consolidation (55, 34.4%), mass lesion (38, 23.8%), hemoptysis (10, 6.2%) and others (19, 11.8%). Findings in the bronchoscopy were mitotic lesion (56, 35.0%), inflammatory lesion (50, 31.3%) and normal finding (54, 33.8%). Among 56 cases of mitotic lesion, bronchial biopsy was taken in 48 (85.7%) cases. Histopathology reports of bronchial biopsy were squamous cell carcinoma (18, 37.5%), large cell carcinoma (11, 22.9%), adenocarcinoma (7, 14.6%), small cell carcinoma (5, 10.4%), inflammatory lesion (4, 8.3%) and normal finding (3, 6.3%). Among 38 cases of collapse, mitotic lesion was found in 24 (63.2%) cases. Among 55 (100%) cases of non-resolving consolidation, mitotic lesion was found in 18 (32.5%), inflammation in 23 (41.8%) and normal findings in 14 (25.5%) cases.Conclusion: Bronchoscopy is an useful method to detect any endobronchial lesion in suspected cases of collapse or non-resolving pneumonia in diabetic patients and it can be the choice of investigation in non-resolving pneumonia.Birdem Med J 2016; 6(1): 18-21

Primary Lung Lymphoma

Primary lung lymphoma (PLL) is a rare entity. It is difficult to diagnose, with a nonspecific clinical and radiological presentation. It may masquerade as pneumonia and lung tumors, and this disease should be kept in mind especially in the differential diagnosis of nonresolving pneumonias. This report describes a PLL case.

Pulmonary actinomycosis presenting as post-obstructive pneumonia

Actinomycosis is a chronic suppurative infection caused by filamentous Gram-positive bacilli,leading to a purulent discharge due to sulfur granule formation. Thoracic actinomycosis represents around 20% of Actinomyces infections, with endobronchial involvement being fairly uncommon. Pulmonary actinomycosis should be considered in the differential diagnosis of non-resolving lobar pneumonia or a lobar mass suspicious for malignancy on endobronchial biopsy. A case of endobronchial actinomycosis presenting as post-obstructive pneumonia and mimicking right upper lobe endobronchial carcinoma, which was associated with foreign body aspiration, is reported here.

Role of fiberoptic bronchoscopy and BAL in assessment of the patients with non-responding pneumonia

BackgroundNon-responding pneumonia is usually a topic of interest for pulmonologists. Fiberoptic bronchoscopy (FOB) and bronchoalveolar lavage (BAL) may be an important tool in assessment of non-responding pneumonia. There is paucity of recent studies in this area. AimThis study aimed to assess the impact of early bronchoscopy and BAL in etiological diagnosis of the patients with non-responding pneumonia with special emphasis on efficacy of FOB and BAL in diagnosis. Settings and designA prospective, observational study was conducted in chest and medical microbiology and immunology departments, Zagazig University Hospitals. Patients and methodsThere were total 135 patients included in our study after fulfilling the criteria of non-responding pneumonia by clinical and laboratory parameters, patients were subjected to FOB and BALF microbiological, cytological, histopathological investigations. ResultsThe patients were 90 males and 45 females with a mean age of 47.6±12.2years. Unilateral lung involvement was seen in 108 (80%) patients, whereas bilateral involvement in 27 (20%) patients. Right upper lobe was the most commonly involved site (25.9%). In this study, bacterial pneumonia 83.71% was found to be the commonest etiology of non-resolving pneumonia, followed by bronchogenic carcinoma 13.3% and tuberculosis 2.96%. FOB was done for all patients. BAL fluid results were 88 positive, gram stain samples (65.1%), 4 BAL ZN stain and mycobacterial culture positive cases (2.96%), pyogenic organisms were isolated in 113 patients 83.71% by BAL fluid culture. Bronchoscopic biopsies were also performed in 18 cases. BAL fluid cytology was positive in 6 cases (33.3%), transbronchial forceps biopsy positive results were found in 10 cases (55.55%) and bronchial brushing showed positive results in 3 cases (16.66%). ConclusionsNRP is common and represents a difficult clinical problem as the cause may vary from a benign delay in recovery to life-threatening progressive pneumonia. A systematic approach to investigation and management is recommended with consideration of both infectious and non-infectious causes.

Pulmonary Leukocytoclastic Vasculitis as an Initial Presentation of Myelodysplastic Syndrome.

Systemic vasculitis involving the lung is a rare manifestation of myelodysplastic syndrome (MDS), and secondary vasculitis is considered to have poor prognosis. A 44-year-old man presented with fever and dyspnea of 1 month duration. A chest radiograph revealed bilateral multiple wedge shaped consolidations. In addition, the results of a percutaneous needle biopsy for non-resolving pneumonia were compatible with pulmonary vasculitis. Bone marrow biopsy was performed due to the persistence of unexplained anemia and the patient was diagnosed with MDS. We reported a case of secondary vasculitis presenting as non-resolving pneumonia, later diagnosed as paraneoplastic syndrome of undiagnosed MDS. The cytopenia and vasculitis improved after a short course of glucocorticoid treatment, and there was no recurrence despite the progression of underlying MDS.

A Curious Case of Acute Respiratory Failure: Is It Antisynthetase Syndrome?

Antisynthetase (AS) syndrome is a major subgroup of inflammatory myopathies seen in a minority of patients with dermatomyositis and polymyositis. Although it is usually associated with elevated creatine phosphokinase level, some patients may have amyopathic dermatomyositis (ADM) like presentation with predominant skin involvement. Interstitial lung disease (ILD) is the main pulmonary manifestation and may be severe thereby determining the prognosis. It may rarely present with a very aggressive course resulting in acute respiratory distress syndrome (ARDS). We report a case of a 43-year-old male who presented with nonresolving pneumonia who was eventually diagnosed to have ADM through a skin biopsy without any muscle weakness. ADM may be associated with rapidly progressive course of interstitial lung disease (ADM-ILD) which is associated with high mortality. Differentiation between ADM-ILD and AS syndrome may be difficult in the absence of positive serology and clinical presentation may help in clinching the diagnosis.

Role of virtual and flexible bronchoscopy in the management of a case of unnoticed foreign body aspiration presented as nonresolving pneumonia in an adult female.

It is not so common to aspirate foreign body in normal adults without any predisposing factors as compared to children and those with the altered neurological state. Endobronchial foreign bodies are one of the causes of obstructive pneumonia and difficult to diagnose as signs and symptoms are often nonspecific. However, once they are diagnosed, they can generally be removed, leading to rapid and drastic resolution of symptoms. Bronchoscopy is the gold standard in the identification and localization of an airway foreign body and also for better management of the ailment. However with the help of virtual bronchoscopy one can decide the location of the foreign body before any invasive intervention and being noninvasive it can be performed in follow-up easily to check the patency of airways. It is not possible to detect the exact size of foreign body with the virtual bronchoscopy. In this article, we report a case of unnoticed foreign body aspiration in a 49-year-old female patient who was initially treated for pneumonia. However, due to nonresolution of opacity contrast enhanced computed tomography thorax with virtual and flexible bronchoscopy were performed, which revealed a foreign body in the right lower lobe bronchus that was removed with biopsy forceps in piecemeal. In her follow-up visit, she underwent virtual broncoscopy that revealed clear airways. Thus, detailed history and high index of suspicion is required for nonresolving pneumonias that may occur due to unnoticed foreign body/ies in an adult.

A case of disseminated bronchus-associated lymphoid tissue lymphoma masquerading as nonresolving pneumonia.

A case of disseminated bronchus-associated lymphoid tissue lymphoma masquerading as nonresolving pneumonia.

Endobronchial pulmonary mucormycosis diagnosed by fiberoptic bronchoscope: A rare case report

Pulmonary mucormycosis is relatively uncommon, but a life-threatening infection affecting mostly individuals with diabetes mellitus, hematological malignancies, chronic renal failure, posttransplantation and other immunocompromised states. Mucormycosis of the lung has a wide range of clinical and radiological manifestations. Very few cases of pulmonary mucormycosis presenting as a fungal ball, cavity resembling tuberculosis, nonresolving, and recurrent pneumonia in patients with diabetes mellitus or other immunosuppressive conditions, were reported from India. We report a case of pulmonary mucormycosis in an adult male patient with uncontrolled diabetes.

Adenoid cystic carcinoma of lung: a very unusual presentation

&lt;p class="abstract"&gt;&lt;span lang="EN-US"&gt;Adenoid Cystic Carcinoma (ACC) is a rare malignancy of the lung arising from the main bronchial division, sub mucosal glands of large airways. Initially it was suspected as a non-resolving pneumonia, which did not respond to empirical antibiotics. Contrast Enhanced Computer Tomography (CECT) of thorax was suggestive of malignancy, bronchoscopic biopsy was suggestive of adenoid cystic carcinoma. The mainstay of treatment is surgical resection (lobectomy, pneumonectomy). As the tumor is radiosensitive, radiotherapy can be used following surgery in the treatment.&lt;/span&gt;&lt;/p&gt;

English

INTRODUCTION: Progressive primary pulmonary tuberculosis is rare in infancy and may often be confused with bacterial pneumonia or congenital anomalies. However it may be an important cause of morbidity and mortality in a highly endemic country like India. CASE REPORT: A 3 month old female child presented with fever, cough and respiratory distress for past 1 month. She was treated for Pneumonia with antibiotics for 15 days by a local practitioner, with no improvement and so was referred to our Centre. She was BCG vaccinated and there was no history of contact with tuberculosis patient. Chest X-Ray PA view revealed bilateral extensive infiltrates suggestive of Bronchopneumonia. AFB staining of gastric lavage was positive. CSF analysis and USG abdomen were within normal limits. A provisional diagnosis of progressive primary pulmonary tuberculosis was made and she was started on anti-tuberculosis treatment, to which she responded dramatically and repeat AFB stain of gastric lavage was negative. CONCLUSION: A diagnosis of Pulmonary TB should be suspected in infants with non-resolving pneumonia, even in BCG vaccinated infants and without