A 67-year-old man comes to the emergency department due to 3 days of fever and cough productive of yellowish sputum. He has had no hemoptysis, weight loss, night sweats, or anorexia. He has not traveled recently and has not had exposure to anyone with similar symptoms. The patient was discharged from the hospital 3 weeks ago after an episode of community-acquired pneumonia involving the left lower lobe. He is a chronic smoker with a 45-pack-year smoking history. He drinks alcohol occasionally. Temperature is 38.1 C (100.6 F), blood pressure is 112/52 mm Hg, pulse is 98/min, and respirations are 22/min. Oxygen saturation is 90% on room air. Physical examination reveals decreased breath sounds and crackles over the left lower lobe. Chest x-ray is consistent with consolidation of the left lower lung zone. What is the most appropriate next step in management of this patient?

Question

A 67-year-old man comes to the emergency department due to 3 days of fever and cough productive of yellowish sputum.  He has had no hemoptysis, weight loss, night sweats, or anorexia.  He has not traveled recently and has not had exposure to anyone with similar symptoms.  The patient was discharged from the hospital 3 weeks ago after an episode of community-acquired pneumonia involving the left lower lobe.  He is a chronic smoker with a 45-pack-year smoking history.  He drinks alcohol occasionally.  Temperature is 38.1 C (100.6 F), blood pressure is 112/52 mm Hg, pulse is 98/min, and respirations are 22/min.  Oxygen saturation is 90% on room air.  Physical examination reveals decreased breath sounds and crackles over the left lower lobe.  Chest x-ray is consistent with consolidation of the left lower lung zone.  What is the most appropriate next step in management of this patient?

Quizplus · Accepted Answer

Explanation: This patient's fever, productive cough, tachypnea, hypoxia, and left lower lobe crackles are all likely due to a left lower lobe pneumonia as demonstrated by the area of consolidation on the chest radiograph. The complicating factor is that the patient had a pneumonia in the same location only 3 weeks ago. The most appropriate next test in the workup is further chest imaging with a CT scan. Given his extensive smoking history, the most concerning possibility is the presence of an obstructing endobronchial neoplasm leading to a nonresolving pneumonia. Such masses can be difficult to detect amidst the area of consolidation on chest radiographs, but chest CT can be helpful in making the diagnosis. Chest CT would also show a lung abscess or empyema, which could also be contributing to the failure of this patient's symptoms to resolve. Other possible causes of treatment-resistant pneumonia include bacterial resistance, other pathogens such as tuberculosis or fungus, immune dysfunction, or noninfectious neoplastic or inflammatory conditions mimicking pneumonia. If the chest CT is not helpful, bronchoscopy may be needed. Open lung biopsy would only be considered if both chest CT and bronchoscopy were nondiagnostic (Choice D). (Choice B) Although an immune deficiency can result in a nonresolving pneumonia, the patient's advanced age makes congenital causes unlikely. Furthermore, this patient has no clear risk factors for HIV. Chest CT would be a much better test at the current time. (Choice C) Lack of night sweats, weight loss, and hemoptysis makes tuberculosis less likely. Obtaining material for mycobacterial cultures, possibly by bronchoscopy, could be considered if CT supports the possibility of mycobacterial infection. (Choice E) Chronic obstructive pulmonary disease from smoking could be a factor in delayed resolution of pneumonia in this patient, but the greater concern is the presence of an obstructing malignancy. As such chest CT would be the most appropriate next test. Educational objective: An obstructing endobronchial malignancy should be suspected in patients with an extensive smoking history who have nonresolution of a pneumonia. A chest CT can help to diagnose such a malignancy as well as other causes of a nonresolving pneumonia such as an abscess or empyema.

A 67-Year-Old Man Comes to the Emergency Department Due to 3