A 46-year-old married male farmer was admitted to our hospital on April 20, 2021, due to lower urinary tract symptoms and febrile sickness. He had experienced frequent micturition and urgency, painful urination, dysuria, and discomfort of perineal swelling for about a week before admission, but did not seek medical attention. The patient reported no other symptoms such as nausea, vomiting, cough, sputum expectoration, dyspnea, fever, chills, and other discomforts. As fever occurred with a temperature of 38.5 C and lasted for 1 day without any chills and cough, he presented to the fever clinic and was referred to the urology department. The patient had no history of major diseases or infectious diseases, except for an allergy to sulfonamides. He had a smoking history of 30 cigarettes per day for 25 years and drank alcohol occasionally. On admission, his vital signs included temperature (T) of 38.7 C, pulse (P) of 92 beats/min and respiration (R) of 20 times/min, and blood pressure (Bp) of 150/90 mmHg. Pulmonary auscultation suggested that rough breath sounds in both lungs, while rhonchi and crackles were not heard. The left renal area was tender to percussion, and a digital rectal examination revealed prostate tenderness. Other physical examination results were unremarkable. Chest computed tomography (CT) scan showed double pneumonia and bilateral localized thickening (Figure 1a). Laboratory examinations of blood, urine, and prostatic fluid were performed after admission, and the results are shown in Table 1. B-Scan ultrasonography of the urinary system showed multiple small calculi in both kidneys. Considering the medical history and current examination results, prostatitis, pneumonia, and kidney calculi were tentative diagnoses. The patient was administered piperacillin-tazobactam (4.5 mg, intravenous (IV) injection, quaque 8 hours) for anti-infective treatment and symptomatic treatment for spasmolysis and relaxation of urethral smooth muscle.
After initial treatment, the patient's fever did not abate. On April 22, 2021, a consultation with the department of Respiratory and Critical Care Medicine confirmed the diagnosis of CAP and considered the possibility of mycoplasma infection. Empirical treatment with antimicrobial moxifloxacin (0.4 g, IV, quaque die) and antiviral agent oseltamivir (75 mg, peros, bis in die) was initiated, which gradually alleviated the patient's symptoms of painful urination and dysuria, and brought his body temperature back to normal within 2 days. However, on April 28, 2021, the patient developed a fever again (T, 38.5 C) along with cough, mild chest tightness, and breathlessness. Re-examination of chest CT showed double pneumonia with localized thickening of bilateral pleura, with increased range of flocculent high-density shadow in lobes of bilateral pulmonary as compared to the initial examination (Figure 1b). After re-consultation, the patient was transferred to the department of Respiratory and Critical Care Medicine for further treatment.
After a detailed medical history investigation, the patient recalled having killed over 10 pigeons approximately 2 weeks before. Considering the possibility of C. psittaci pneumonia, electronic bronchoscopy was performed for etiological evidence, but no obvious abnormalities were noticed in the trachea and bronchus. Bronchoalveolar lavage (BAL) was performed, and bronchoalveolar lavage fluid (BALF) was collected for examination. Microbiological examination of BALF revealed a small number of Gram-positive cocci and Gram-negative bacilli. No fungi were found in BALF, while (1,3)-beta-d-glucan (BDG) test (G test) and galactomannan antigen test (GM test) were negative. Routine blood examination (Table 1) showed that procalcitonin was within normal range; plasma albumin value was below the normal range, but there were no abnormalities in blood potassium, blood sodium, blood chloride, liver function, and renal function. Antibodies of mycoplasma, chlamydia, EB virus, and blood tuberculosis were all negative. Two weeks later, the chlamydia antibody was positive, and its negative may be related to the short time. BALF analysis with mNGS (Simcere Diagnostic, Nanjing, China) reported sequence reads of Burkholderia contaminans complex (3488), Stenotrophomonas maltophilia (145), Pseudomonas aeruginosa (22), Candida albicans (441), Aspergillus flavus (4), and C. psittaci (13) (Figure 2). The number of C. psittaci sequences detected by mNGS in the patient's prostate fluid was 7. By joint consideration of the patient's history of close contact with pigeons and C. psittaci infection suggested by mNGS, the diagnosis of C. psittaci pneumonia was confirmed. On May 1, 2021, doxycycline (100 mg, IV, quaque 12 hours) was administered in combination with moxifloxacin, and the fever subsided the next day. After 5 days, a re-examination of chest CT revealed that lesions were mostly absorbed and pneumonia was significantly improved (Figure 1c). After doxycycline combined with moxifloxacin treatment, the fever did not recur, respiratory symptoms subsided, and the urinary system symptoms alleviated significantly. Due to improvement, the patient was discharged on May 10, 2021. Regarding bilateral kidney calculi, he was instructed to drink plenty of water and consulted the department of urology if necessary. With a follow-up for 1 month, the patient did not have any discomfort. The disease progression of the patient and treatment procedure are shown in Figure 3.