Community acquired pneumonia in a young diabetic june 21 2006
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Community Acquired Pneumonia in a Young Diabetic June 21, 2006. John N Landis, MD Chief, Pulmonary Medicine Baystate Medical Center Springfield, MA. A 23 year old female with diabetes presented to the emergency department on 1/01/05 with a cough, fever and 3 weeks of pleuritic chest pain.

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Community acquired pneumonia in a young diabetic june 21 2006

Community Acquired Pneumonia in a Young DiabeticJune 21, 2006

John N Landis, MD

Chief, Pulmonary Medicine

Baystate Medical Center

Springfield, MA


  • A 23 year old female with diabetes presented to the emergency department on 1/01/05 with a cough, fever and 3 weeks of pleuritic chest pain.

  • The ED physician interpreted the chest x-ray as bilateral infiltrates and diagnosed community acquired pneumonia.

  • Patient was discharged from the ED on azithromycin.


1/1/05 emergency department on 1/01/05 with a cough, fever and 3 weeks of pleuritic chest pain.


  • 2 days later the patient returned to the hospital ED and a left PNTX was noted on CXR with progression of pneumonia.

  • ON 1/3/05 the patient was admitted and left chest tube was placed.

  • The week following, the patient had left chest tube removed but developed worsening pulmonary infiltrates and respiratory distress.


1/3/05 left PNTX was noted on CXR with progression of pneumonia.


  • ID consultant noted on 1/07/05 left PNTX was noted on CXR with progression of pneumonia.

    • Failure to respond to “standard antibiotics”

    • Persistent fever but no leukocytosis

    • Negative sputum and blood cultures

    • Therefore unusual organism suspected

    • Vacomycin, zosyn, and azithromycin initiated

    • Plans to obtain bronchoscopic washings if no improvement


1/10/05 left PNTX was noted on CXR with progression of pneumonia.


  • A pulmonary consult was called on 1/10/05. left PNTX was noted on CXR with progression of pneumonia.

  • The patient was transferred to the ICU, intubated and bronchoscoped.

  • A PPD was placed on 1/9/05 and was 5mm.

  • Bronchoscopy revealed 4+ AFB

  • Patient was placed on INH, RIF, PZA, and SM. Due to the extent of the disease Levaquin was added and steroids were withheld.


1/10/05 left PNTX was noted on CXR with progression of pneumonia.



1/10/05 chest tube was placed.

1/19/05


1/19/05 chest tube was placed.

1/20/05


1/20/05 chest tube was placed.


1.21.05 chest tube was placed.

1/22/05



1/20/05 on 1/22/05 and pigtail catheter was removed on 1/31/05.

1/31/05


2/15/05 on 1/22/05 and pigtail catheter was removed on 1/31/05.

1/31/05


2/15/05 on 1/22/05 and pigtail catheter was removed on 1/31/05.

3/2/05


  • The patient’s tracheostomy tube was decannulated and PICC line removed on 3/21/05.

  • 5 TB drugs were continued through 2/25/05 when SM stopped.

  • 4 drugs converted to PO route.

  • Levaquin was discontinued on 3/11/05.

  • Patient was discharged on 3/21/05 with Rifamate, PZA and B6 and nasal O2 continued.


First tb clinic visit 4 12 05
First TB Clinic Visit- 4/12/05 line removed on 3/21/05.

  • Class III TB

  • CXR slightly improved- extensive fibrotic change

  • SPO2- 91%

  • PZA discontinued

  • 3-4 drugs had been continued for 3 months: INH, RIF, SM and PZA.

  • Cultures reviewed-

    • all cultures negative since 2/10/05

    • all smears negative since 2/18/05


4/12/05 line removed on 3/21/05.

3/2/05


Second tb clinic visit 5 17 05
Second TB Clinic Visit- 5/17/05 line removed on 3/21/05.

  • Sputums obtained from 3/27/05, 4/4/05, and 4/9/05- negative on smear and culture.

  • Sputum from 5/19/05- negative on smear.

  • Continue Rifamate and B6

  • O2 discontinued


5/17/05 line removed on 3/21/05.

4/12/05


Third tb clinic visit 7 19 05
Third TB Clinic Visit- 7/19/05 line removed on 3/21/05.

  • Continuing Rifamate and B6

  • CT Scan requested due to increased cough with rhonchi on auscultation of chest.

  • Bronchiectasis suggested on CT scan of 8/8/05.


5/17/05 line removed on 3/21/05.

7/19/05


8/8/05 line removed on 3/21/05.


Fourth tb clinic visit 9 27 05
Fourth TB Clinic Visit- 9/27/05 line removed on 3/21/05.

  • Continues Rifamate.

  • CT Scan- chronic scarring

  • Definite bronchiectasis LLL and no cavities


Fifth tb clinic visit 1 3 06
Fifth TB Clinic Visit- 1/3/06 line removed on 3/21/05.

  • Continues Rifamate (all TB medications discontinued on 1/17/06)

  • Asymptomatic


9/2/03 line removed on 3/21/05.

1/17/06


Sixth tb clinic visit 5 9 06
Sixth TB Clinic Visit- 5/9/06 line removed on 3/21/05.

  • L chest pain

  • PFTS 3/16/06- moderate restrictive disease 60% predicted.

  • CT Scan 3/20/06- fibrosis of RUL, RML, RLL, and LLL, pneumatocoel RUL/LLL, bronchiectasis, LLL, RML.


Pulmonary function laboratory report 3 16 06
Pulmonary Function Laboratory Report 3/16/06 line removed on 3/21/05.

SpirometryObserved Pre% Pred Pre

FVC L 2.19 55

FEV1 L 2.03 60

FEV1/FVC 92 106

Lung VolumesObserved Pre% Pred Pre

TLC 3.38 63

DiffusionObserved Pre% Pred Pre

DLCO corr 17.60 59


3/20/06 line removed on 3/21/05.


Summary
Summary line removed on 3/21/05.

  • This 25 year old female, presented with signs and symptoms of CAP- was treated with ceftriaxone and azithromycin for 10 days until florid necrotizing TB diagnosed on 1/10/05 from bronchoscopic washings. Treatment included ventilatory support, 5 drug TB chemotherapy and nutritional support. Initially 3 of the 5 TB drugs were given parenterally : RIF, Levaquin intravenously +SM-SC subcutaneously.


  • PZA/INH were given via GT. No index case was ever confirmed and no intrahospital transmission occurred. With regards to household contacts, all were negative, except a nephew and her boyfriend. Extensive hospital contact review showed no conversions of PPD.

    The patient sustained moderate RLD from acute lung injury but has recovered fully and has returned to work full time. Probable factors leading to severity of her disease: Diabetes and possibly poor diet.


  • Rare cases of fulminating necrotizing pneumonia caused by TB have been reported. Fortunately this organism was pan-sensitive and responded to administered anti-microbials. The patient although near death from ARDS survived a 2 ½ month hospitalization to fully return to an active life. Amazingly, few if any contacts were infected by her.


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