Resistant Pneumonia Case Shakes Up Diagnostic Rules
A chest x-ray showed an infiltrate in the right lower lobe of the lung, which was confirmed by CT. However, antibiotics did not improve the condition.
This rare case report by Ahmad B. Al-Zughoul, MD, a resident doctor of internal medicine, Saint Agnes Medical Center, Fresno, California, describes simultaneous bacterial ( Mycoplasma pneumoniae ), viral (coronavirus NL63), and fungal ( Coccidioides spp.) pneumonia in an immunocompetent adult.
The Patient and His History
The patient with no past medical history presented to the emergency department with a week-long history of skin rash, fever, and shortness of breath. The patient denied any preexisting medical conditions.
On admission, the patient was febrile, with a body temperature of 38.8 °C. His heart rate was tachycardic at 115 beats/min. His respiratory rate was normal. Blood pressure and oxygen saturation in room air were within their respective normal ranges.
Findings and Diagnosis
Physical examination showed mild pharyngeal erythema, few coarse crackles at the lung bases, and a maculopapular rash on the trunk, shoulders, and upper thighs.
Laboratory findings showed leukocytes with 15.0 × 103/μL (reference range, 4.5-11.0 × 103/μL), neutrophilia of 12.22 × 103/μL (reference range, 2.6-8.2 × 103/μL), and mild eosinophilia of 0.36 × 103/μL (reference range, 0.00-0.35 × 103/μL).
A multiplex polymerase chain reaction respiratory panel called BioFire, which screens for both common viral and bacterial pathogens, was performed on a nasopharyngeal swab sample, and it was positive for M pneumoniae and coronavirus. Initial immunoglobulin M (IgM) and immunoglobulin G (IgG) enzyme immunoassays for Coccidioides spp. were negative, despite the patient's residence in an endemic area.
A chest x-ray revealed a right lower lung infiltrate, which was confirmed by chest as well, which did not reveal pleural effusion or lymphadenopathy.
Suspecting community-acquired pneumonia, clinicians initiated 500 mg intravenous (IV) daily and ceftriaxone 1 g IV daily. After 48 hours of IV antibiotics, the patient remained symptomatic with cough and fever, and leucocytosis persisted, although the skin rash was improving. He was started on levofloxacin 750 mg IV daily to cover the possibility of macrolide-resistant M pneumoniae . The patient was still having a cough and fever 5 days into admission, with a high total white blood cell count of 17.5 × 103/μL and an increased eosinophil count of 1.08 × 103/μL.
Repeat Coccidioides IgM and IgG assays then returned positive. Following the infectious disease consultation, oral fluconazole (200 mg daily) was prescribed. The patient's symptoms and blood cell counts normalised rapidly with this regimen.
Discussion
'This case report sheds light on how the presence of multiple respiratory pathogens can potentially complicate the clinical course and management of pneumonia in such patients. Clinicians should be aware of the sensitivity and specificity of microbiological tests used to diagnose specific respiratory pathogens in their institution to make informed management decisions for their patients. Consultation with infectious disease specialists can be very helpful as well in complicated or difficult cases or cases not responding to appropriate management,' the study authors wrote.
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