A 60-year-old Caucasian man is admitted to the hospital with an episode of bacterial pneumonia. Upon review of his past medical history, you notice that he has had three recent admissions within the past seven months for bacterial pneumonia. All the episodes were successfully treated with intravenous antibiotics. Previous chest x-ray comparisons reveal that the infiltrate always occurs at the right middle lobe and leaves a persistent scar. The scar was not noted on the chest x-ray prior to the episodes of pneumonia. He has a 50-pack year history of smoking. He quit smoking 10 years ago.
Which of the following is the most likely cause of the patient's recurrent pneumonia?

Question

A 60-year-old Caucasian man is admitted to the hospital with an episode of bacterial pneumonia.  Upon review of his past medical history, you notice that he has had three recent admissions within the past seven months for bacterial pneumonia.  All the episodes were successfully treated with intravenous antibiotics.  Previous chest x-ray comparisons reveal that the infiltrate always occurs at the right middle lobe and leaves a persistent scar.  The scar was not noted on the chest x-ray prior to the episodes of pneumonia.  He has a 50-pack year history of smoking.  He quit smoking 10 years ago.
Which of the following is the most likely cause of the patient's recurrent pneumonia?

Quizplus · Accepted Answer

Explanation: The patient in the above vignette has multiple/recurrent episodes of bacterial pneumonia, which respond to antibiotics. This is most likely due to a partial obstruction of the bronchus or a branch of the bronchus supplying the right middle lobe. The most likely cause of endobronchial obstruction in this elderly male with an extensive smoking history is bronchogenic carcinoma. A carcinoid tumor is another cause of endobronchial obstruction, especially in younger and non-smoking patients. Endobronchial lesions cause compression of the airway lumen and prevent adequate clearance of secretions. This causes stasis of secretions and recurrent pneumonias, even after successful treatment of previous episodes. Other causes of nonresolving pneumonia or pulmonary infiltrates are bronchoalveolar cell carcinoma, lymphoma, eosinophilic pneumonia, bronchiolitis obliterans organizing pneumonia (BOOP), systemic vasculitis, pulmonary alveolar proteinosis, and drugs (amiodarone). (Choice A) Patients with tuberculosis usually do not respond to antibiotic therapy, unless there is a superimposed bacterial infection. They also present with symptoms of chronic tubercular infections, such as a chronic cough, weight loss and night sweats. (Choice B) Patients with recurrent alveolar hemorrhage usually present with recurrent episodes of hemoptysis. These episodes do not respond to antibiotic therapy. (Choice D)Acquired immunodeficiency (AIDS) is a possibility. It is unusual for a congenital immunodeficiency to present at this age. (Choice E) Recurrent pulmonary embolism can rarely present as nonresolving pneumonia. Patients classically have symptoms of pleuritic chest pain with hypoxia and do not respond to antibiotics. Educational Objective: Recurrent pneumonia in an elderly smoker may be the first manifestation of bronchogenic carcinoma.

A 60-Year-Old Caucasian Man Is Admitted to the Hospital with an Episode