A 63-year-old female presented to her primary care physician with a 6-day history of fever, cough, and dyspnea. Her cough was productive of green sputum that was occasionally streaked with blood. She had mild chest discomfort but no chest pain or pleurisy at that time. Review of systems was otherwise unremarkable. Her medical history was significant for obstructive lung disease (COPD), hypothyroidism (well controlled), hypertension, and a long history of smoking (60 pack years). Two years ago, she had computed tomography (CT) scanning of the chest which showed emphysematous changes but no cavities. Despite having severe COPD, she continued to smoke daily and consume alcohol (80 units weekly). She used home nebulization for her COPD, generally utilizing sterile water, but occasionally tap water. There was no illicit drug use. She did not have any history of recent hospitalization within the preceding 90 days.
On examination, the patient was not in any distress and auscultation revealed mild wheezing. She did not want to receive any further testing at that time and was prescribed a 5-day course of levofloxacin 750 mg daily. Two weeks later, the patient presented for follow-up with worsening cough, increasing hemoptysis, and respiratory distress. On examination, she was in moderate respiratory distress with an oxygen saturation by pulse oximetry of 92% on room air, but not febrile or tachycardic, with a blood pressure of 167/97 mmHg.
Chest X-ray was done revealing right upper lobe opacification with a large air-fluid level suggestive of cavitating pneumonia (Figure 1). On admission then, leukocyte count was normal at 7.8 x 103/mL with no left shift; procalcitonin (PCT) was 0.12 ng/mL and C-reactive protein (CRP) was elevated at 143.8 mg/L. Testing for renal, thyroid, and hepatic function and cardiac enzymes was within normal. Autoimmune panel was unremarkable. Testing for human immunodeficiency virus (HIV), bacterial and fungal urine, and serum antigens was all negative. CT scanning confirmed extensive opacification nearly completely filling the right upper lobe (Figure 2). Also new were associated cavitary regions within the right upper lobe. The largest area of cavitation measured 5.1 x 4.2 cm.
Two sputum cultures were collected separately and Gram stain revealed no squamous epithelial cells, few neutrophils, and Gram-negative rods. Within one day, both samples grew Pseudomonas aeruginosa, which was resistant to levofloxacin and ciprofloxacin. The patient was started on ceftazidime, as the isolate tested susceptible to cefepime, ceftazidime, gentamicin, piperacillin/tazobactam, and tobramycin. Two days into inpatient stay, the patient developed a leukocytosis of 13.1 x 103/mL with left shift. By that time, tuberculosis had been excluded with negative sputum for acid fast bacilli, along with a negative interferon-gamma release assay. Five days into admission, with no improvement, the patient underwent bronchoalveolar lavage and culture again grew P. aeruginosa with negative tuberculosis testing. Quantitative microbiologic analysis of the bronchoalveolar lavage was reported at 20,000 colonies/mL. The pattern of antibacterial susceptibility was exactly the same as that reported on the sputum cultures. One week into admission, the patient developed respiratory failure requiring intubation and was admitted to intensive care. Despite prolonged treatment, the patient died from progressive respiratory and multiorgan failure two weeks from admission.