What is your diagnosis? | Figure 1

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Anesthesiology Resident

A 60 year old man presents with fever and chills, productive cough with rusty sputum, pleuritic pain, and shortness of breath for the past several days. A complete blood count reveals neutrophilia. A chest radiograph reveals consolidation involving the entire left lower lobe.

Diagnosis Questions

a. What is your diagnosis?

b. What is the organisms usually involved?

c. What is the morphological stage of this disease?

The patient’s CT reveals multiple ground-glass opacities, most of them with reticulation, and some associated with small foci of consolidation with air bronchograms involving all pulmonary lobes. The distribution is predominantly in the posterior and peripheral parts of the lungs, mainly in the lower lobes, where there is more extensive involvement of the parenchyma.

With thanks to Wenzhou Medical University, China for sharing this case, and to Dr. Rodrigo Caruso Chate, a chest radiologist in Brazil, for the CT interpretation.

Case provided by Raioss, a Brazilian startup that works with AI in radiology and PACS that developed Coronacases.org - a platform that allows HCPs worldwide to see and learn from coronavirus cases as if they were seeing an imaging test of their own patient.

Posted by Figure 1 on April 9, 2020.

A 61 year old patient with longstanding hypertension, managed with a diuretic, calcium channel blocker, and beta blocker, had struggled with medication adherence and poor blood pressure control. Over several weeks, the patient noticed increasing shortness of breath with exertion, orthopnea, and fatigue, initially thought to be related to uncontrolled hypertension. When the symptoms progressed to shortness of breath at rest, the patient presented to the emergency department.

On arrival, the blood pressure was significantly elevated, and lung exam revealed bibasilar crackles. Chest X ray showed a dense opacity in the right lower lobe along with blunting of the right costophrenic angle. Labs demonstrated leukocytosis and elevated inflammatory markers, and sputum cultures grew Streptococcus pneumoniae, suggesting community-acquired pneumonia.

Taken together, the findings were consistent with acute decompensated heart failure on the background of poorly controlled hypertension, complicated by superimposed pneumonia. The patient was admitted for treatment of hypertensive urgency, intravenous antibiotics, diuretics, and supportive measures, with particular attention to medication counseling and strategies to improve long-term adherence in order to lower the risk of future cardiovascular and pulmonary complications.

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Examination reveals normal blood pressure and high random blood sugar. She obtains her feeding only from milk and does not take any oral medications for diabetes.

What is your suggestion? I told her family she must go to the hospital but they refuse... I asked for CBC, ECG, cardiac enzymes, HbA1c, pelvic-abdominal ultrasound, urine analysis, and stool analysis.

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