A 72-year-old man is brought to the office due to 4 weeks of worsening productive cough. The patient has also had malaise and night sweats and has lost 3 kg (6.6 lb) during this period. His wife states that he has had occasional nonproductive cough in the past, particularly while eating, but it is now persistent and productive of abundant yellow sputum. The patient has a history of hypertension and Parkinson disease. He has a remote 5-pack-year history but does not use alcohol. He is a retired schoolteacher, lives in Ohio, and has not traveled or been exposed to sick contacts recently. Temperature is 38.3 C (100.9 F), blood pressure is 126/68 mm Hg, pulse is 88/min, and respirations are 14/min. Pulse oximetry is 96% on room air. On examination, the patient appears frail with resting tremor of both hands. Lung auscultation reveals scattered rhonchi but no wheezing. Heart sounds are normal. Laboratory results are as follows: Chest x-ray reveals a density with cavitation in the right lower lobe. Which of the following is the most likely cause of this patient's current condition?

Question

A 72-year-old man is brought to the office due to 4 weeks of worsening productive cough.  The patient has also had malaise and night sweats and has lost 3 kg (6.6 lb) during this period.  His wife states that he has had occasional nonproductive cough in the past, particularly while eating, but it is now persistent and productive of abundant yellow sputum.  The patient has a history of hypertension and Parkinson disease.  He has a remote 5-pack-year history but does not use alcohol.  He is a retired schoolteacher, lives in Ohio, and has not traveled or been exposed to sick contacts recently.  Temperature is 38.3 C (100.9 F), blood pressure is 126/68 mm Hg, pulse is 88/min, and respirations are 14/min.  Pulse oximetry is 96% on room air.  On examination, the patient appears frail with resting tremor of both hands.  Lung auscultation reveals scattered rhonchi but no wheezing.  Heart sounds are normal.  Laboratory results are as follows:  Chest x-ray reveals a density with cavitation in the right lower lobe.  Which of the following is the most likely cause of this patient's current condition?

Quizplus · Accepted Answer

11ec25c8_d88c_414c_bc81_6786ceb6317b_MD0003_00 This patient's long-standing productive cough, systemic symptoms (eg, weight loss, malaise, night sweats), leukocytosis, and right lower lobe cavitary lesion likely indicate lung abscess. Most cases are caused by the aspiration of oropharyngeal anaerobic bacteria into dependent portions of the lung due to periods of impaired consciousness (eg, alcohol/drug abuse, seizure disorder) or swallowing dysfunction. Patients with Parkinson disease lose dopaminergic neurons that control the striated muscles in the oral cavity, pharynx, and esophagus, which causes progressive swallowing dysfunction and significantly increases the risk of aspiration. Coughing during eating is often an important clue. Lung abscess generally presents with indolent fever and cough productive of foul-smelling sputum. Systemic manifestations such as night sweats, weight loss, and malaise are often present, and laboratory evaluation frequently reveals leukocytosis and signs of chronic inflammation (eg, anemia of chronic disease, thrombocytosis). The diagnosis is generally confirmed when chest imaging reveals a cavitary infiltrate in a dependent portion of the lung (eg, superior segment of a lower lobe, posterior segment of an upper lobe). cavitary infiltrate (Choice A) Histoplasma capsulatum is endemic to the Ohio and Mississippi River valleys. It is a common cause of community-acquired pneumonia in these regions and frequently presents with subacute cough and systemic symptoms. However, most cases are marked by lobar pulmonary infiltrate and hilar/mediastinal lymphadenopathy; cavitation very rarely occurs. (Choice B) Granulomatosis with polyangiitis is a necrotizing vasculitis that frequently presents in older adults with subacute systemic manifestations and dyspnea from trachea or lung involvement. However, productive cough is uncommon, and chest x-ray usually reveals nodular infiltrates, not cavitary disease. (Choice C) Lung cancer can cause subacute weight loss, malaise, (usually dry) cough, anemia, thrombocytosis, and a cavitary infiltrate (in the setting of squamous cell carcinoma). However, the presence of swallowing dysfunction with fever, leukocytosis, and productive yellow sputum make lung abscess more likely in this case. (Choice E) Tuberculosis reactivation can lead to a cavitary lung lesion, subacute systemic symptoms, and leukocytosis. However, this patient with a cavitary lesion in the lower lobe in the setting of swallowing dysfunction is more likely to have aspiration pneumonia with subsequent lung abscess. Educational objective: Lung abscess is common in patients with periods of impaired consciousness (eg, alcohol/drug abuse, seizure disorder) or swallowing dysfunction (eg, Parkinson disease). It usually presents with indolent systemic symptoms and cough productive of foul-smelling sputum. Chest x-ray usually reveals a cavitary infiltrate in a dependent portion of the lung.

A 72-Year-Old Man Is Brought to the Office Due to 4