A 55-year-old man comes to the emergency department due to 2 days of fever, chills, and productive cough. Over the past 4 months, he has had 2 episodes of pneumonia, both of which resolved completely with antibiotics. He smoked a pack of cigarettes per day for 30 years but quit following the second bout of pneumonia. The patient's only other medical problem is hypertension. Temperature is 38.9 C (102 F), blood pressure is 130/86 mm Hg, pulse is 98/min, and respirations are 18/min. Oxygen saturation is 94% on room air. Crackles and increased breath sounds are present over the right lower lung field. Leukocyte count is 14,200/mm³ and blood urea nitrogen is 12 mg/dL. Chest x-ray reveals right lower lobe consolidation. Antibiotics are administered. On follow-up 5 days later, the patient describes improvement in his cough and fever. Crackles are still present at the right lung base. Review of chest x-rays obtained during the previous episodes of pneumonia reveals a consolidation in the right lower lung segment, same as found in the current episode. Which of the following is the most appropriate next step in management of this patient?

Question

Quizplus · Accepted Answer

Explanation: 11ec25c8_d4ac_6f11_bc81_2f0808c13cee_MD0003_00 This patient with recent fever, chills, productive cough, and leukocytosis has had his third episode of right lower lobe pneumonia in the past several months. Recurrent pneumonia occurring in the same anatomic location of the lung raises suspicion for localized airway obstruction, which, if present, can lead to impaired bacterial clearance and predisposition to infection (eg, postobstructive pneumonia). Potential causes of localized airway obstruction include: External bronchial compression due to lymphadenopathy, expanding neoplasm, or vascular anomaly Internal bronchial obstruction due to a foreign body, bronchiectasis, bronchial stenosis, or, rarely, endobronchial carcinoid Smoking is the strongest risk factor for the development of primary lung malignancy. In this patient age >50 with a significant smoking history (30 pack-years) and evidence of localized airway obstruction, it is essential to evaluate for lung malignancy using a CT scan of the chest. (Choice A) A barium swallow study may be used to evaluate for gastroesophageal reflux disease or dysphagia leading to chronic aspiration, which is a potential cause of recurrent pneumonia. However, CT scan of the chest is the most appropriate next step in this patient with a suspected lung mass. (Choice B) CT scan of the chest typically precedes bronchoscopy in patients with a suspected lung mass. Bronchoscopy is often used to obtain a tissue biopsy when a centrally located lung mass is identified on CT scan. (Choice D) In patients age >50, repeat chest x-ray to assess for malignancy is generally recommended between 6 and 12 weeks following treatment of a single episode of pneumonia. However, this patient with a significant smoking history and evidence of localized airway obstruction (eg, recurrent pneumonia) warrants more immediate evaluation. CT scan of the chest has better sensitivity than chest x-ray for detecting lung malignancy, especially in the presence of alveolar infiltrate. (Choice E) Serum quantitative immunoglobulin levels are needed to diagnose common variable immunodeficiency (CVID), which typically presents in adulthood with recurrent infections of the lung and upper respiratory tract (eg, sinusitis, otitis media). However, immunodeficiency (eg, CVID) would be expected to cause recurrent pneumonia in different regions of the lung rather than in the same region. Educational objective: Lung malignancy is a potential cause of localized airway obstruction and may present with episodes of recurrent pneumonia. CT scan of the chest should be used to evaluate patients in whom there is suspicion for lung malignancy. References: The microbiology of postobstructive pneumonia in lung cancer patients. (http://www.ncbi.nlm.nih.gov/pubmed/23857204)

A 55-Year-Old Man Comes to the Emergency Department Due to 2