Case 22 Severe Pneumonia

See Case 1. The CXR shows opacities with air bronchograms involving both lung fields. This is typical of severe pneumonia as evidenced by multilobar involvement. Typical organisms include Streptococcus pneumoniae, Legionella, and gram negatives like Klebsiella and Pseudomonas aeroginosa. In South-East Asia, another possible etiologic agent is Burholderia pseudomallei (Meliodosis). Treatment will require combination parenteral antibiotics, usually beta lactams plus macrolide or fluoroquinolone. The prognosis is dependent not just upon the severity of presentation but also underlying age and co-morbidities, e.g. cancer, heart, liver, or renal disease, and stroke. This patient's pneumonia was confirmed to be due to severe Legionellosis.

Severe Case Pneumonia
Fig. 23.1

Case 23. A 30-year-old male presented with cough, shortness of breath and loss of weight over four months. This was his CXR (Fig. 23.1). What is the most likely diagnosis? What physical sign would be useful?


The CXR shows bilateral infiltrates and air bronchograms with a perihilar distribution. The heart size is normal. There are no Kerley B lines or evidence of upper lobe venous diversion. All these are typical features of PCP PCP is the most common life-threatening opportunistic infection in HIV disease. Generally, the most common opportunistic infection in HIV is oral candidiasis. Oral candidiasis should be looked for in any young patient with pneumonia as it may be a sign of T-cell immune deficiency. PCP can be diagnosed by sputum induction or bronchoalveo-lar lavage. Note that 10% of PCP patients could have a normal CXR.

Pcp Diagnosis Sputum

Case 24. This middle-aged female non-smoker was recently diagnosed and treated as for asthma with little response. This was her CXR (Fig. 24.1). What is the diagnosis?

Pleural Fluid Case Study

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