Recurrent Episode of SOB
We discussed a 47 year old M with history of morbid obesity, non-ischemic CMY (EF 60%), pulmonary HTN, PE/DVTs, OSA on CPAP who presented with a 2 day history of shortness of breath. He reports chills, associated pleuritic chest pain as well as a productive cough of brownish sputum. Of note, one week prior to admission, he was hospitalized for similar symptoms for which he was diuresed and given antibiotics. Further questioning reveals non-adherence to his outpatient antibiotic regimen which led him to return back to the hospital. However, despite being placed on broad spectrum antibiotics initially, his leukocytosis worsens and he becomes febrile. Imaging shows interval worsening of RLL and RML infiltrates with a new pleural effusion and concerns from the team to pursue ultrasound guided thoracentesis. Further observation on IV antibiotics resolved the effusion and ultimately led to clinical improvement.
Even with the common diagnosis of community acquired pneumonia (CAP), it is still imperative to explore other alternatives contributing to the symptoms, given this patient profile. Highlights of the discussion included:
* Review of the revised W.H.O. classification of pulmonary hypertension from the Journal of American College of Cardiology in 2009
* The use of CURB-65 as a diagnostic tool for triaging patients with CAP
*Case studies and new guidelines from the American Thoracic Society and Infectious Diseases Society of America regarding management of CAP.