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. 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. The ED physician interpreted the chest x-ray as bilateral infiltrates and diagnosed community acquired pneumonia. Patient was discharged from the ED on azithromycin. Patient was discharged from the ED on azithromycin.

1/1/05

2 days later the patient returned to the hospital ED and a left PNTX was noted on CXR with progression of pneumonia. 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. 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. The week following, the patient had left chest tube removed but developed worsening pulmonary infiltrates and respiratory distress.

1/3/05

ID consultant noted on 1/07/05 ID consultant noted on 1/07/05 –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

A pulmonary consult was called on 1/10/05. A pulmonary consult was called on 1/10/05. The patient was transferred to the ICU, intubated and bronchoscoped. The patient was transferred to the ICU, intubated and bronchoscoped. A PPD was placed on 1/9/05 and was 5mm. A PPD was placed on 1/9/05 and was 5mm. Bronchoscopy revealed 4+ AFB 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. 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

On 1/19/05 the patient developed a 50% R PNTX and a right chest tube was placed. On 1/19/05 the patient developed a 50% R PNTX and a right chest tube was placed. The PNTX did not resolve. The PNTX did not resolve. IR placed an additional catheter in right chest on 1/20/05 and a 2 nd catheter in right apex on 1/21/05. IR placed an additional catheter in right chest on 1/20/05 and a 2 nd catheter in right apex on 1/21/05.

1/10/051/19/05

1/20/05

/22/05

The PNTX began to resolve, the right chest tube was removed on 1/22/05 and pigtail catheter was removed on 1/31/05. The PNTX began to resolve, the right chest tube was removed on 1/22/05 and pigtail catheter was removed on 1/31/05. On 1/24/05 tracheostomy was performed and the patient was continued on mechanical ventilation. On 1/24/05 tracheostomy was performed and the patient was continued on mechanical ventilation.

1/31/05 1/20/05

1/31/05 2/15/05

3/2/05

The patients tracheostomy tube was decannulated and PICC line removed on 3/21/05. The patients tracheostomy tube was decannulated and PICC line removed on 3/21/05. 5 TB drugs were continued through 2/25/05 when SM stopped. 5 TB drugs were continued through 2/25/05 when SM stopped. 4 drugs converted to PO route. 4 drugs converted to PO route. Levaquin was discontinued on 3/11/05. Levaquin was discontinued on 3/11/05. Patient was discharged on 3/21/05 with Rifamate, PZA and B6 and nasal O2 continued. Patient was discharged on 3/21/05 with Rifamate, PZA and B6 and nasal O2 continued.

First TB Clinic Visit- 4/12/05 Class III TB Class III TB CXR slightly improved- extensive fibrotic change CXR slightly improved- extensive fibrotic change SPO2- 91% SPO2- 91% PZA discontinued PZA discontinued 3-4 drugs had been continued for 3 months: INH, RIF, SM and PZA. 3-4 drugs had been continued for 3 months: INH, RIF, SM and PZA. Cultures reviewed- Cultures reviewed- all cultures negative since 2/10/05 all cultures negative since 2/10/05 all smears negative since 2/18/05 all smears negative since 2/18/05

3/2/05 4/12/05

Second TB Clinic Visit- 5/17/05 Sputums obtained from 3/27/05, 4/4/05, and 4/9/05- negative on smear and culture. 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. Sputum from 5/19/05- negative on smear. Continue Rifamate and B6 Continue Rifamate and B6 O2 discontinued O2 discontinued

4/12/05 5/17/05

Third TB Clinic Visit- 7/19/05 Continuing Rifamate and B6 Continuing Rifamate and B6 CT Scan requested due to increased cough with rhonchi on auscultation of chest. CT Scan requested due to increased cough with rhonchi on auscultation of chest. Bronchiectasis suggested on CT scan of 8/8/05. Bronchiectasis suggested on CT scan of 8/8/05.

7/19/055/17/05

8/8/05

Fourth TB Clinic Visit- 9/27/05 Continues Rifamate. Continues Rifamate. CT Scan- chronic scarring CT Scan- chronic scarring Definite bronchiectasis LLL and no cavities Definite bronchiectasis LLL and no cavities

Fifth TB Clinic Visit- 1/3/06 Continues Rifamate (all TB medications discontinued on 1/17/06) Continues Rifamate (all TB medications discontinued on 1/17/06) Asymptomatic Asymptomatic

1/17/069/2/03

Sixth TB Clinic Visit- 5/9/06 L chest pain L chest pain PFTS 3/16/06- moderate restrictive disease 60% predicted. 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. 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 SpirometryObserved Pre % Pred Pre FVC L FEV1L FEV1/FVC92106 Lung VolumesObserved Pre% Pred Pre TLC DiffusionObserved Pre% Pred Pre DLCO corr

3/20/06

Summary 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. 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. 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. 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.