Original case provided by Lauren Brown, MD.
Edits, graphics and teaching points by Yilin Zhang, MD.
- Evaluation of a patient with nonresolving pulmonary infiltrate
For the case version (~10-15 min) of this clinical image, click here.
A 40 yo M presents with a 5 month history of nonproductive cough. He reports chest congestion and the feeling of a “rattling” in his chest. He reports a possible aspiration episode at the start of his symptoms. He denies any fevers, chills, night sweats or weight loss. He has no other PMH and takes no medications. He was never a smoker, works in a lab working with microbiology plates. He grew up in the Pacific Northwest and has traveled to ID. He denies any international travel.
On exam, his vital signs are normal, SaO2 99% on RA. Lungs are clear to auscultation.
His CXR shows:
He was treated with a 5 day course of azithromycin for presumed pneumonia. He had minimal change in his symptoms after antibiotics. Repeat CXR was obtained 4 weeks later:
Interval improvement but persistent consolidation of the RUL.
He subsequently underwent a chest CT:
FINAL DIAGNOSIS AND OUTCOME:
He underwent bronchoscopy which revealed normal airways, negative bacterial, fungal cultures, Aspergillus PCR, Nocardia PCR and AFB cultures. Biopsy results did show at least adenocarcinoma in situ with possible invasive features.
He was referred to Oncology for further staging and subsequently underwent RUL lobectomy with resection of a well differentiated, 4 x 3.5 x 3.5 cm adenocarcinoma with negative margins and negative lymph node.
TAKE HOME POINTS:
- Patients without radiographic resolution of “pneumonia” 4-8 weeks after treatment should undergo CT imaging and consideration of bronchoscopy to further evaluate for noninfectious or atypical infectious causes.
- Low, DE, Mazzulli, T & Marrie, T. Progressive and nonresolving pneumonia. Current Opinion in Pulmonary Medicine. 2005; 11: 247-252.
- Lim, WS, et al. British Thoracic Society guidelines for the management of community acquired pneumonia in adults: update 2009. Thorax. 2009; 64(Suppl III): iii1-iii55.
- Johnson, JL. Slowly resolving and nonresolving pneumonia: Questions to ask when response is delayed. Postgraduate Medicine. 2000. 108(6): 115-122.