Pneumonia

Greeting

Good day, dear Professor Doctor …,

I would now like to present the patient Mrs. Ida Heinze to you.

She is 43 years old, one meter seventy tall and weighs about 75 kg. The body mass index (BMI) is 25.9 kg/m² and therefore falls in the overweight range.

Present history

The patient presented to our emergency department with a productive cough for three days and fever .
An assessment of the sputum was not possible because the patient regularly swallows it.
The axillary body temperature measured 38.9 °C.
In addition she complained of rigors, hyperhidrosis, headaches, myalgias as well as asthenia.

The patient also complained of thoracic pain resulting from repeated coughing or with deep inspiration.
The pain occasionally radiates to the left shoulder and the back.

The following symptoms were denied: dyspnea, tachycardia, rhinoconjunctivitis, oral coatings, odynophagia, cervical lymphadenopathy, gastrointestinal complaints and rash.

According to her report, paracetamol and aspirin 500 mg led to a temporary improvement of the complaints.

She stated that about twelve days ago she had a mild cold with a dry cough.

She did not see her general practitioner because the GP is currently attending a course.

She has not traveled recently.

Autonomic history

The autonomic history is unremarkable, apart from insomnia due to the cough in recent days and inappetence. In addition she has recently followed a Mediterranean diet, which led to a weight loss of about 4 kg.

Past medical history

The following past medical history is reported:

For three years there has been a known arterial hypertension and a diabetes mellitus type 2.
Both conditions are currently well controlled.
No complications have occurred so far.

Five years ago a mammary carcinoma of the right breast was diagnosed. At that time a complete mastectomy and adjuvant chemotherapy were performed. Three years ago radiotherapy was additionally carried out.

For about eight years she has had low back pain with radiculopathy due to a diagnosed disc prolapse.

Previous operations

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Gynecology

Her last menstruation occurred six days ago; there are no gynecological complaints.

Medications

Currently the patient is taking the following medications as prescribed:

metformin 500 mg 1-0-1
ramipril 5 mg 1-0-½
ibuprofen 400 mg as needed

She reported that she is vaccinated against COVID-19 and has also received an influenza vaccination this year.

Note: When a statement can be objectively confirmed by a medical observation – for example by a prescription – the indicative is appropriate.

Allergies

During a tonsillitis, administration of penicillin led to dyspnea and urticaria, presumably as part of an anaphylactic reaction.

Noxae

She is a non-smoker, drinks occasionally one to two glasses of sparkling wine on special occasions and reports no drug use.

Social history

She is an architect and lives in a patchwork family with her husband’s two children. The younger child had a head lice infestation.

Family history

The patient reported that her mother died at the age of 64 from a pancreatic carcinoma .
Her father is 73 years old and lives in a nursing home. About two months ago he fell down the stairs and fractured his femur , which was surgically treated.

Suspected and differential diagnosis

In my opinion the history – particularly the productive cough and the constitutional symptoms – points to pneumonia.

The most likely is a pneumonia caused by Streptococcus pneumoniae. However, laboratory investigations are required to confirm the diagnosis.

Differentially, other bacterial (e.g., Haemophilus influenzae, Staphylococcus aureus) as well as viral pathogens (e.g., influenza virus, respiratory syncytial virus) are possible.

In immunosuppressed patients atypical pathogens must also be considered.

Bronchiolitis mainly affects infants and young children.
The course does not correspond to COPD, and high fever is typically absent.
In tuberculosis, on the other hand, a chronic course with a corresponding exposure history is to be expected.
ACE inhibitors or AT1 receptor blockers (ARBs) can cause a dry cough as a side effect.
A cardiac cause does not fit the clinical picture or the history in this case.

Diagnostic workup

Because the underlying diseases are currently under control and there are no signs of sepsis such as hypotension, tachycardia or altered consciousness, the patient can be treated outpatient. Nevertheless, high-risk patients require close monitoring or good access to medical care.

physical examination

First the vital signs are recorded, including heart rate, blood pressure, respiratory rate, oxygen saturation and Body temperature.
This is followed by a targeted physical examination, beginning with inspection.

A tachypnea/dyspnea or breathing using accessory respiratory muscles may be noticeable.

In viral pneumonias, rhinoconjunctivitis, oral abnormalities, cervical lymphadenopathy or an exanthem may be observed.
In Streptococcus pneumoniae pneumonia, rust-brown discolored, purulent sputum is typically seen.
In Mycoplasma pneumoniae infection, erythema multiforme, aseptic meningitis, urticaria or erythema nodosum can occur as extrapulmonary manifestations.

On examination, the percussion note over the affected area is often dull.
Vocal fremitus is increased in pneumonia and decreased or absent in pleural effusion.
If the diaphragm moves scarcely with breathing, this also suggests a pleural effusion.

On auscultation, crackles and diminished breath sounds are frequently heard in pneumonia.

In a pleural effusion, breath sounds over the affected area are markedly diminished or absent.

A diabetic examination is required in this patient, including foot examination and ophthalmoscopy.

Laboratory tests

Laboratory tests include a differential blood count, inflammation markers (CRP, procalcitonin) and renal function values (urea, creatinine). Additionally — if indicated — β-HCG determination and an arterial blood gas analysis are performed.

For microbiological diagnostics, a Gram stain and bacterial cultures are prepared.

Sputum consists of exudate with plasma, leukocytes and bacteria and usually contains an admixture of saliva. Therefore, a mixed microbial flora is often found, which makes a clear assignment of the pathogen difficult.

PCR testing of a nasopharyngeal swab is a highly sensitive method for detecting potentially infectious pathogens, especially in atypical or viral pneumonias.

Chest X-ray

A pneumonia is diagnosed by detection of an infiltrate on chest imaging and can be largely ruled out if no infiltrate is present.

A subsegmental or patchy pneumonia can be caused by bacteria, viruses, Mycoplasma pneumoniae or Chlamydia pneumoniae.

A hematogenously disseminated Staphylococcus aureus pneumonia typically shows 1–3 cm round lesions that frequently cavitate.

A cavitating lesion in the upper lobe without an air-fluid level, especially in the posterior segment, suggests tuberculosis, nontuberculous mycobacteria or nocardiosis.

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Chest CT

A chest CT is performed in pneumonia mainly when the X-ray findings are unclear or the therapy is not effective. Common indications are suspicion of complications such as abscess, empyema or pleural effusion, as well as evaluation of atypical or recurrent pneumonias. CT also serves to precisely assess the extent and to exclude other causes such as pulmonary embolism or tumor obstruction.

Computed tomography (CT) is an imaging method that uses X-rays to create detailed cross-sectional images of internal organs. The patient is moved into a tubular scanner and must lie still during the examination. Sometimes contrast agent is administered to allow a more precise depiction. The examination is painless and lasts only a few minutes. Before contrast-enhanced examination it is important that you drink sufficient fluids. We should also determine kidney function. Certain medications like metformin should be paused beforehand — we will clarify that with you. In rare cases an allergic reaction to the contrast agent may occur, but do not worry: we are prepared and have all necessary medications and measures on site.

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Consultations

Internal medicine, pulmonology, infectious diseases

Treatment

It is important to ask about recent antibiotic intake, as this influences the pathogen situation and the choice of empirical antibiotic.

Outpatient treatment of community-acquired pneumonia (CAP)

In uncomplicated pneumonia, clinical improvement is expected within 48 to 72 hours.

Adults:

• Amoxicillin/clavulanic acid (Augmentan®, Amoclav®)

• Tablets 875/125 mg, 1–0–1 for 5–7 days

• if Legionella, Mycoplasma, Chlamydia are suspected

• + Azithromycin (Zithromax®, Azithromycin AL®) – tablets 500 mg, once daily for 3 days,

• Or levofloxacin (Tavanic®) – tablets 750 mg, once daily for 5 days, for β-lactam allergy or atypical pathogens

Children:
Children under 5 years are treated with ampicillin or amoxicillin.
From 5 years of age an additional macrolide (e.g., azithromycin) is added to cover atypical pathogens.

• Amoxicillin (e.g., InfectoMox®, AmoxiHEXAL®)

• Suspension

• Concentration: 125 mg/5 ml, 250 mg/5 ml, 500 mg/5 ml

• Azithromycin (e.g., Zithromax®)

• Dosage: 10 mg/kg body weight/day once daily for 3 days

• Concentration: 100 mg/5 ml, 200 mg/5 ml

Inpatient initial therapy (empirical):

Combination of a β-lactam antibiotic (e.g., ceftriaxone; Rocephin® 1 g i.v. once daily) and a macrolide (e.g., azithromycin 500 mg i.v. or p.o. once daily).

In a viral pneumonia, symptomatic and supportive treatment is central, i.e., antipyresis, adequate fluid intake, oxygen administration for hypoxia and physical rest.
Antiviral therapy is used only for certain pathogens (e.g., influenza or SARS-CoV-2).

Complications

Sepsis occurs when a local infection, such as pneumonia, spreads via the bloodstream throughout the body and triggers a systemic inflammatory response. It can lead to organ dysfunction, circulatory instability and, in the worst case, septic shock and represents a life-threatening emergency.

A pneumothorax occurs when air enters the pleural space causing partial or complete lung collapse; it can occur as a complication of pneumonia or due to rupture of an emphysematous bleb.

An empyema refers to an accumulation of purulent fluid in the pleural space, usually due to a contiguous bacterial infection, which requires drainage.

A lung abscess is an encapsulated, purulent tissue necrosis in the lung parenchyma with typical cavity formation and air-fluid level, usually due to a bacterial infection or aspiration.

General information about pneumonia

Pneumonia:

Infection of the lung parenchyma → causes lower respiratory tract symptoms

Classification by site of infection / acquisition:

1. HAP criteria:

Onset ≥ 48 h after hospital admission

No infection or incubation on admission

Or shortly after discharge from the hospital

2. CAP criteria:

All other pneumonias that arise outside the hospital

Significance: Differentiation important for pathogen spectrum and choice of therapy

Predisposing factors for pneumonia:

Chronic lung diseases:

COPD, cystic fibrosis, bronchiectasis or other structural lung damage
→ Increased risk for bacterial pneumonia, especially with concurrent corticosteroid therapy

Alcohol consumption:

Excessive alcohol consumption → suppresses the cough reflex
Impairs leukocyte function and migration
→ Increased risk for aspiration pneumonia

General immunodeficiency:
Chemotherapy or radiotherapy for cancer, organ transplantation with immunosuppressive medication, or hematologic diseases (e.g. leukemia, lymphoma) can weaken immune defense.
This leads to more severe courses in RSV, influenza and parainfluenza virus infections.

Pregnancy:

Predisposes especially to severe influenza pneumonias

Immunosuppression / HIV/AIDS:

In young adults with AIDS there is an approximately hundredfold increased risk of developing bacterial pneumonia.

Extra

Names:

Petra Knöterich, Marina Mayer, Sabine Ritter, Karl Lauterbach, Petra Schneider

Details:
She is a former smoker. She previously smoked about one pack per day for 15 years and started at the age of 16.
She stated that her father was a heavy smoker and died of lung cancer, which is why she quit smoking.
The patient has been in menopause for one year. Cesarean section

Teacher, social worker, orchestra employee, she plays trombone.

Past medical history:

Gouty arthritis for eight years.
Burnout syndrome in the history.
Bilateral varicose vein surgery one and a half years ago, uncomplicated course.
Diabetes mellitus type 1
Epilepsy (seizure-free for 20 years)
Removal of a basal cell carcinoma
Prostate carcinoma, diagnosed one year ago and treated with radiotherapy.

Family history:
The father died at age 52 of bronchial carcinoma.
Stroke in the father
Breast cancer and dementia in the mother.

Medications:
Zyloric® 300 mg (allopurinol) – 1-0-0-0
Terbinafine 250 mg – 1-0-0-0
Omeprazole 20 mg – 1-0-0-0
Insulin
L-thyroxine 50 mg

Allergy:
An allergy to pollen is present, which manifests as rhinorrhea.
Allergy to seafood with rash and erythema as reaction signs.

Questions

1. What is meant by chronic bronchitis?

Chronic bronchitis is a productive cough illness where cough and sputum persist for at least three months per year for two consecutive years.
The most common cause is smoking, less commonly inhalation of irritants or dust.

2. Is the radiation exposure from a CT scan too high?

Radiation exposure from a CT scan is significantly higher than from a standard X-ray, but it is considered medically justified if the examination is necessary.
Thanks to modern equipment and low-dose techniques, the radiation dose is kept as low as possible.

3. What would you do if a diabetic has renal insufficiency and takes metformin?

In renal insufficiency metformin must be reviewed or discontinued because it can accumulate in the body and there is a risk of lactic acidosis.
eGFR < 45 ml/min: dose reduction and close monitoring
eGFR < 30 ml/min: discontinue metformin

4. What is a swab?

A swab is a diagnostic sample collection of cells, secretions or mucus from a body surface or mucosa (e.g. throat, nose, vagina, wound).
The material is taken with a sterile swab and then examined microscopically, by culture or molecularly (e.g. PCR) to detect pathogens such as bacteria, viruses or fungi.

5. Which chronic wounds do you know?

Chronic wounds: do not heal within longer than 8 weeks, e.g.

Venous/arterial leg ulcer (ulcus cruris)
Pressure ulcer (decubitus)
Diabetic foot ulcer (ulcus diabeticorum)

6. How do we differentiate an erosion from an ulcer?

An erosion is a superficial tissue defect that affects only the epidermis (for skin) or the mucosa (for mucous membrane) and heals without scarring.
An ulcer is a deeper tissue defect that extends into the submucosa or deeper layers and usually heals with scarring.

7. How can we treat varicose veins?

Varicose veins are treated conservatively with compression, exercise and leg elevation.
With more severe symptoms sclerotherapy, laser therapy or surgical removal (stripping) of the affected vein can be performed.

8. What is the medical name of the big toe metatarsophalangeal joint?

The big toe metatarsophalangeal joint is called Articulatio metatarsophalangea I or briefly MTP-I joint.
It connects the first metatarsal bone with the proximal phalanx of the big toe.

9. How do you examine the lungs?