A 73-year-old man comes to the emergency department with fever and chest discomfort. He was hospitalized with right lower-lobe pneumonia 3 months ago and improved with antibiotics. He has since had an intermittent cough and a 4.5-kg (10-lb) weight loss. The patient is a life-long nonsmoker. He has a long history of Parkinson's disease with gait instability along with hypertension and acid-reflux disease. His temperature is 38.3 C (101 F), blood pressure is 122/70 mm Hg, heart rate is 105/min, and respirations are 24/min. Examination shows upper-extremity rigidity, resting tremor, mild dysarthria, and frequent drooling. Lung examination shows crackles and dullness at the right base. Extremities are warm to the touch. The white blood cell count is 13,500/µL. Chest x-ray shows a right middle-lobe infiltrate. Intravenous antibiotics are started. Which of the following tests is most helpful in evaluating this patient?

Question

A 73-year-old man comes to the emergency department with fever and chest discomfort.  He was hospitalized with right lower-lobe pneumonia 3 months ago and improved with antibiotics.  He has since had an intermittent cough and a 4.5-kg (10-lb) weight loss.  The patient is a life-long nonsmoker.  He has a long history of Parkinson's disease with gait instability along with hypertension and acid-reflux disease.  His temperature is 38.3 C (101 F), blood pressure is 122/70 mm Hg, heart rate is 105/min, and respirations are 24/min.  Examination shows upper-extremity rigidity, resting tremor, mild dysarthria, and frequent drooling.  Lung examination shows crackles and dullness at the right base.  Extremities are warm to the touch.  The white blood cell count is 13,500/µL.  Chest x-ray shows a right middle-lobe infiltrate.  Intravenous antibiotics are started.  Which of the following tests is most helpful in evaluating this patient?

Quizplus · Accepted Answer

Explanation: 11ec2b69_c073_39b5_8f63_edd630dd8ac6_MD0005_00 This patient with underlying Parkinson's disease, oropharyngeal symptoms (dysarthria and drooling), and recurrent right-sided pneumonia has typical features of chronic aspiration. Nearly 90% of individuals with Parkinson's disease suffer from dysphagia during the course of the disease, and the resulting aspiration pneumonia is a leading cause of death. Aspiration pneumonia generally requires more aggressive intervention than typical community-acquired pneumonia. Aspiration often involves polymicrobial and anaerobic organisms, and patients with aspiration pneumonia often have poor underlying functional and nutritional status. Initial management includes blood and sputum cultures with initiation of broad-spectrum antibiotics with anaerobic coverage (eg, clindamycin). Once the patient has been stabilized, a bedside swallowing assessment may be helpful. Definitive diagnosis is made with a videofluoroscopic swallowing study. Based on results, a multidisciplinary dysphagia rehabilitation program can be initiated, usually with input from the dietary service, nursing, and speech therapy. Specific interventions typically include thickened liquids and modified swallowing techniques. (Choice A) Bronchoscopy can be useful in patients with recurrent pneumonia to rule out (and biopsy) endobronchial obstruction. This is especially helpful in patients with known or suspected malignancy. However, this patient shows features of aspiration. Although bronchogenic carcinoma may develop in nonsmokers, it is less likely. (Choice B) Computed tomography (CT) scan is frequently performed in patients with recurrent pneumonia to identify a mass lesion in the lung or airway. It can also help identify atypical infections as well as noninfectious pulmonary disorders. However, a CT scan would be unlikely to provide additional useful information in cases of suspected aspiration. (Choice C) Patients with hypogammaglobulinemia are at risk of recurrent infections due to encapsulated bacteria (eg, Streptococcus pneumoniae). Elderly patients with impaired nutrition may develop a secondary hypogammaglobulinemia, but this patient's pattern of right mid- and lower-lobe infections is more typical for aspiration. (Choice D) Pulmonary tuberculosis is a potential cause of persistent/recurrent lung infections in the elderly. In the majority of cases (>80%), however, tuberculosis will involve the upper/apical lung regions rather than the mid and lower lobes. Educational objective: A frequent complication of Parkinson's disease is the development of dysphagia and aspiration, which may be silent. Undetected dysphagia may lead to weight loss and frequent aspiration pneumonia. The diagnosis is confirmed with a videofluoroscopic swallowing study. A multidisciplinary intervention is required to address nutrition and reduce the risk of recurrent aspiration pneumonia.

A 73-Year-Old Man Comes to the Emergency Department with Fever