Accessibility Our case highlights the need for an aggressive search for the cause of non-resolving radiographic infiltrate despite appropriate antibiotic coverage. The .gov means its official. Careers, Unable to load your collection due to an error. It is also the leading infectious disease cause of mortality among all ages worldwide.1 2 Pneumonia in critically ill patients may present as pneumonia acquired in the community (community acquired pneumonia, CAP); pneumonia acquired in the hospital (hospital acquired . It makes it difficult to breathe and can cause a fever and cough with yellow, green or bloody mucus. Results: Tuberculosis was the commonest cause of nonresolving pneumonia (35.7%), followed by malignancy (27.1%),Bronchiectasis (8.6%),Pneumocystis pneumonia (7.1%),BOOP (5.7%) and Resistance to antibiotics (14.3%). Feinsilver SH, Fein AM, Niederman MS, Schultz DE, Faegenburg DH. Before Etiology of non-resolving pneumonia (n=60). In 2 patients, bronchoscopic biopsy demonstrated epitheloid granuloma with caseous necrosis and langhans giant cell, one of these 2 patients was also positive for AFB stain in bronchial brushing; in the remaining one case, all the bronchoscopic procedures were negative, but post-bronchoscopic sputum examination for AFB was positive. Aspiration of Cerebrospinal Fluid Rhinorrhea as a Cause of Non [3] Scattered cases of cutaneous, laryngeal and disseminated histoplasmosis in immunosuppressed persons have been reported from India.[4]. These include age, comorbidities, severity of the pneumonia and nature of the infectious agent. 3). This is an open-access article distributed under the terms of the Creative Commons Attribution-Noncommercial-Share Alike 3.0 Unported, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. Right lung was more commonly involved (65%), and right upper lobe was the commonest site (25%). Nausea, vomiting or diarrhea Shortness of breath Newborns and infants may not show any sign of the infection. Histoplasmosis is a fungal disease caused by Histoplasma capsulatum, named after Darling who first described this clinical entity well in details. Pulmonary-Limited Granulomatosis with Polyangiitis Coexisting with Mixed Connective Tissue Disease. Anti-nuclear antibodies and extractable nuclear antigens were negative. Fiber optic bronchoscopy (FOB) may have a special role in etiologic evaluation of non-resolving pneumonias. Pneumonia in the elderly: Overview of diagnostic and therapeutic approaches. FOIA (B) Chest computed tomography in axial plane, in lung window, confirms presence of right middle lobe mass (white arrow), with well defined borders, lobulated outline and cavitation (black arrow). [] In our study, bronchogenic carcinoma was found in 16 patients (26.6%), of which squamous cell carcinoma was the commonest variety followed by adenocarcinoma. Whenever feasible, CT-guided FNAC is also a good procedure, especially for peripherally situated lesions and when FOB is inconclusive. A wide range of non-infectious disorders can masquerade as bacterial pneumonia, including pulmonary embolism, malignancy, interstitial lung diseases, alveolar haemorrhage, and vasculitis. The core needle biopsies showed necrotizing granulomatous inflammation. Med. Mantoux test with 5 T.U. Wegeners Granulomatosis Etanercept Trial Research Group. All rights reserved. Travis W.D., Hoffman G.S., Leavitt R.Y., Pass H.I., Fauci A.S. Surgical pathology of the lung in Wegeners granulomatosis. Host Factors The expected therapeutic response in pneumonia is the disappearance of fever within 3-5 days, improvement in leukocytosis by day 4, while the crackling on pulmonary auscultation persists for more than 7 days. FOIA Ferretti GR, Jankowski A, Rodiere M, Brichon PY, Brambilla C, Lantuejoul S. CT-guided biopsy of non resolving focal airspace consolidation. Sixty consecutive cases of non-resolving or slowly resolving pneumonia of both genders, attending the department of pulmonary medicine during the study period, were selected by adhering to the inclusion and exclusion criteria. Disclaimer. Introduction. A computed tomography (CT) scan showed a 6cm mass-like area of consolidation with small cavities in the right middle lobe, and well defined solid nodules in the periphery of the left lower lobe (Fig. Lobar pneumonia | Radiology Reference Article | Radiopaedia.org He had received more than three courses of antibiotics over a 2-year period. Federal government websites often end in .gov or .mil. Accessibility The most common symptom of pneumonitis is shortness of breath, which may be accompanied by a dry cough. Evaluation of persistent pulmonary infiltrate Saving Lives, Protecting People, National Center for Immunization and Respiratory Diseases, U.S. Department of Health & Human Services, SARS-CoV-2 (the virus that causes COVID-19). Disseminated histoplasmosis without pulmonary involvement in an immunocompetent host-A case report. Ancillary serologic tests or biopsies of extrapulmonary sites are invaluable in some cases. Subhasis Mukherjee Saumen Nandi Mita Saha Non-resolving pneumonia is often an area of concern for pulmonologists. [10] Disseminated histoplasmosis usually occurs in immunocompromised host and is rare in immunocompetent host. The role of conjunctival biopsy in the diagnosis of granulomatosis with polyangiitis. Before Nine out of these 10 cases were diagnosed by fiberoptic bronchochoscopy- 6 patients showed positive mycobacterial culture in BAL fluid. Bronchoalveolar lavage (BAL) fluid was sent for cell type, AFB smear and culture for Mycobacterium tuberculosis (MGIT-960), gram stain and culture, fungal stain and culture, and malignant cells in all patients. Non-resolving pneumonia is often an area of concern for pulmonologists. Pallor was present in 17 (28.3%) patients in this study group, 16 (26.6%) patients had palpable lymphadenopathy, and 12 (20%) patients had clubbing. Histoplasmosis is caused by inhalation of the fungus Histoplama spp, and the degree of infection and clinical presentation are determined by the size of inoculum, immune status of the individual and presence of underlying lung disease. A high degree of clinical suspicion is imperative in order to make an early diagnosis. Pneumonia: Causes, Symptoms, Diagnosis & Treatment Descriptive frequencies were expressed by mean + standard error of mean (SEM). Fiberoptic bronchoscopy (FOB) was planned next in all patients (4 patients did not give consent for FOB). Panja G, Sen S. A unique case of histoplasmosis. The investigations revealed hemoglobin 6.4 g%, total white cell count 15200/mm3 with 94% neutrophils; fasting blood sugar 86 mg/dl, urea 45 mg/dl, creatinine 0.8 mg/dl, total bilirubin 0.96 mg/dl, alanine transaminase 78 U/L, aspartate transaminase 82 U/L and alkaline phosphatase 238 U/L. Urinalysis was positive for moderate red blood cells, however the patient was menstruating at the time. Klebsiella pneumoniae was the commonest organism isolated in patients with diabetes and was found in 6 out of 20 diabetics (30%), followed by Mycobacterium tuberculosis (25%, n = 5) and Staphylococcus aureus (20%, n = 4). Common causes of bacterial pneumonia areStreptococcus pneumoniae (pneumococcus) and, especially in kids, Mycoplasma pneumoniae. Microbiological, cytological and histopathological tests of the specimens can be done for etiological diagnosis of underlying cause. [11] Chronic pulmonary and progressive disseminated histoplasmosis are often fatal with reported mortality 83-100% in untreated cases and 7-23% in amphotericin B treated patients. Post-bronchoscopic sputum smear examination should not be ignored although it is not a much studied tool till now. sharing sensitive information, make sure youre on a federal In this report, we discuss the definition and clinical implications of limited GPA, treatment options, and highlight the importance of considering vasculitis in the differential diagnosis of non-resolving pneumonia. The term non-resolving pneumonia has been variably defined by investigators and early descriptions were based principally on clinical examination findings. Nonresolving or slowly resolving pneumonia -, Walton E.W. Gastric presentation (vasculitis) mimics a gastric cancer as initial symptom in granulomatosis with polyangiitis: a case report and review of the literature. Avijgan M. Specificity and sensitivity of clinical diagnosis for chronic pneumonia. HIV test was negative. Neoplasms like broncho-alveolar carcinoma or lymphoma may also mimic an infectious process.5 Complement assays were normal and anti-PR3 antibodies were high, measuring 417 chemiluminescent units. 2017 Jun;242(2):109-114. doi: 10.1620/tjem.242.109. Rheumatol Int. Pulmonary involvement occurs in 60% of cases, most commonly presenting as cough, dyspnea, and hemoptysis from cavitating nodules, nonspecific airspace infiltrates, and alveolar hemorrhage [1]. Fishman's Pulmonary Diseases and Disorders. On chest X-ray, consolidation was present in 53 patients, consolidation along with cavity was present in 5 patients, and only cavity was present in 2 patients. Federal government websites often end in .gov or .mil. and transmitted securely. Careers. FOIA Causes of Pneumonia | CDC Co-morbidities like COPD, diabetes, alcoholism, smoking and immunosuppression are significant factors causing nonresolution. -. Post-bronchoscopic sputum for AFB smear and malignant cells were also sent. eCollection 2015 Dec. Chino H, Hagiwara E, Kitamura H, Baba T, Yamakawa H, Takemura T, Ogura T. Respiration. HHS Vulnerability Disclosure, Help In this study, pyogenic infection was diagnosed as etiological agents in 32 (53.3%) cases. people with a weakened immune system due to a chronic condition, chemotherapy . It revealed a cauliflower-like growth in the left main bronchus (figure 3). Lobar pneumonia, also known as non-segmental pneumonia or focal non-segmental pneumonia 7, is a radiological pattern associated with homogeneous and fibrinosuppurative consolidation of one or more lobes of a lung in response to bacterial pneumonia . Jennette J.C., Falk R.J., Bacon P.A., Basu N., Cid M.C., Ferrario F. 2012 revised international chapel hill consensus conference nomenclature of vasculitides. A slowly resolving or non-resolving pneumonia (NRP) is a common clinical dilemma, affecting 10-20% of patients hospitalised with community-acquired pneumonia. Pneumonia caused by resistant organism or atypical pathogen like mycobacterium, fungus and nocardia. Begamy T. Thoracic empyema. Presences of any comorbidity, especially diabetes mellitus, were documented. However, FOB was inconclusive in 8 cases (14.3%) [Table 4]. Efficacy of CT-guided FNAC and FOB in the etiological diagnosis of non-resolving or slowly resolving pneumonia has been around 80% and 70-86%, respectively in some studies. Earlier reports hypothesized that limited and diffuse GPA were entities along the same disease spectrum; suggesting that limited disease would eventually evolve to severe disease if allowed to develop in the absence of treatment [10]. 1Department of Internal Medicine, Saint Vincent Hospital, Worcester, Massachusetts, USA, 2Department of Infectious Diseases, Reliant Medical Group and Saint Vincent Hospital, Worcester, Massachusetts, USA. Adrenal gland involvement, lesions of oral mucosa, gastrointestinal tract and skin may be seen in 5 to 10% of cases. Or they may vomit, have a fever and cough, appear restless or tired and without energy, or have difficulty breathing and eating. PDH usually presents with high fever and weight loss. Accessibility Among the 60 patients, 41 (68.3%) were male and 19 (31.7%) female. Bacterial infections are the commonest etiology. Department of Respiratory Medicine, R.G. Nonresolving pneumonia. [15] In the present study also, right lung involvement was most common (65%), and right upper lobe was most commonly affected (25%). Csernok E., Trabandt A., Mller A., Wang G.C., Moosig F., Paulsen J. Cytokine profiles in Wegeners granulomatosis: predominance of type 1 (Th1) in the granulomatous inflammation. Before Respiratory system examination revealed decreased air entry with wheezing in the left upper zone. Laboratory investigations showed normal cell counts, hemoglobin, chemistry, creatinine, and liver function tests. Chest. Kirtland et al. The approach to nonresolving pneumonia Mean duration of illness was 6.87 0.24 weeks (mean + SEM). Slowly resolving, chronic and recurrent pneumonia, The approach to non-resolving pneumonia in the elderly, Antimicrobial treatment failures in patients with community-acquired pneumonia: causes and prognostic implications, Treatment failure in community-acquired pneumonia, Bronchoalveolar carcinoma: histopathologic study of evolution in a series of 105 surgically treated patients. Epub 2015 Aug 7. official website and that any information you provide is encrypted Bronchoscopic biopsy was performed which revealed non-small cell carcinoma. Other authors have defined it more broadly as radiographic infiltrate that is slow to resolve after optimal antibiotic therapy given for at least 10days.2 Approximately 20% of presumed non-resolving community-acquired pneumonia is due to non-infectious causes.3 Aetiologies like inflammatory, drug-induced and vascular disorders, as well as neoplasm can mimic pneumonia. The patient's contrast enhanced computed tomography (CECT) of thorax showed organization of right middle lobe consolidation with enlargement of right paratracheal and subcarinal lymph nodes with central necrosis [Figure 1c]. What Is Non-resolving Pneumonia? In this study, we tried to establish the etiological diagnosis of non-resolving pneumonia or slowly resolving pneumonia and also to evaluate the efficacy of diagnostic procedures, especially FOB and CT-guided FNAC. CT scan of chest showing left upper lobe consolidation. Pyogenic infections are the commonest etiology, but microbiological profile is different from that of community-acquired pneumonia; tuberculosis, malignancy, and other non-infectious causes like vasculitis are other important etiologies to be looked for. Among bacterial pneumonia, gram-negative bacilli were the predominant organisms isolated in 30 out of 32 cases of bacterial pneumonia (93.75%); Staphylococcus aureus accounted for 2 cases (6.25%). 1. His sputum smear was negative for acid-fast bacilli for 3 consecutive days. Maintenance therapy regimens are less immunosuppressive than induction therapy, and generally use tapering doses of glucocorticoids and a less potent immunosuppressive agent such as azathioprine (or continuation of methotrexate in the context of limited disease). Wegeners Granulomatosis Etanercept Trial Research Group. Both, FOB (85.7%) and CT-guided FNAC (91.67%) were very useful for etiological diagnosis of non-resolving pneumonia. Federal government websites often end in .gov or .mil. National Library of Medicine However, isolated pulmonary involvement from GPA is rare [3]. Carruthers D.M., Connor S., Howie A.J., Exley A.R., Raza K., Bacon P.A. Wegener's granulomatosis was diagnosed in 1 case (1.67%), and in one case, despite all investigations, no diagnosis could be reached (1.67%) [Table 2]. Both the procedures were safe, and no major complication was observed. Amberson was the first person to describe the term unresolved organizing or protracted pneumonia in 1943. Non-infectious causes like tracheobronchomalacia and foreign body aspiration are other important etiologies to be looked for. Postoperative recovery was uneventful. He is following up with his oncologist for scheduled cancer surveillance evaluations. Nonresolving pneumonia - UpToDate [9] Like TB primary histoplasmosis heals spontaneously in about 99% of cases and only a few progress to PDH. The differential diagnosis for the CT findings included an atypical pneumonia, possibly fungal in origin, malignancy, septic emboli, or vasculitis. Of the 2 cases where granuloma was demonstrated on FNAC, one was tuberculosis and other was diagnosed as Wegener's granulomatosis on the basis of clinico-radiological picture and positive c-ANCA in high titer. [9], In our study, 80% patients were over the age of 40 years and nearly 50% were over the age of 50 years. National Library of Medicine Kirtland SH, Winterbauer RH. Blood culture (two samples) was negative for bacteria. a clinical and imaging study of 77 cases. In Indian literature first case of histoplasmosis was reported by Panja and Sen in 1954. [7] Non-resolving pneumonia was found to be responsible for 15% of inpatient pulmonary consultations and 8% of bronchoscopies. In this study, FOB was done in 56 patients (4 patients did not give consent for bronchoscopy). Serum sodium was 129mEq/l. Update in the diagnosis and management of pulmonary vasculitis. Fiber optic bronchoscopy, lung cancer, non-resolving pneumonia, tuberculosis. Persistent symptoms and worsening radiological abnormalities prompted bronchoscopy and biopsy which clinched the diagnosis. She denied hemoptysis, fever, nasal symptoms, acid reflux, arthralgias, or constitutional symptoms. The patient was treated as CAP with oral amoxicillin + clavulanic acid (625 mg) 8 hourly and levofloxacin (500 mg) daily was added afterwards. Am. To summarize, non-resolving pneumonia is often an area of clinical dilemma. Past medical history included remote symptoms of migratory arthralgias (several months prior to her presentation), and a remote history of transient left optic neuritis. Initial chest x-ray, as well as CT scan done as an outpatient had revealed left upper lobe consolidation (figure 1). Except few scattered cases, the disease is considered to be a non-entity in India. Utility of firberoptic bronchoscopy in non resolving pneumonia. (TB) was the cause of non-resolving . Incorrect diagnosis, inadequate antibiotic therapy, impaired host defence, atypical organisms, resistant pathogens, non-infectious causes, tuberculosis, endobronchial lesions, etc. Inclusion in an NLM database does not imply endorsement of, or agreement with, individuals with a chronic disease or condition, such as asthma, chronic obstructive pulmonary disease, or diabetes. Coughing is a natural reflex that aims to remove these excess fluids from the airways. She was diagnosed with a limited form of Granulomatosis with Polyangiitis (GPA), by percutaneous core needle lung biopsy. After fulfilling the definition of non-resolving pneumonia by clinical and radiological parameters, patients were evaluated by FOB with relevant microbiological, cytological, histopathological investigations and CT scan of thorax. Social history revealed no tobacco, occupational, or environmental exposures. 1991 Apr;15(4):315333. Learn more below about the infections that commonly cause pneumonia. . Twenty five patients (41.6%) were smoker, and smoking was distinctly more common in malignant etiology, compared to other groups (P = 0.006) [Table 1]; 8 patients (19%) were alcoholic. Blood for complete hemogram, blood glucose, urea, creatinine, liver function test, chest X-rays (posteroanterior and lateral view), sputum culture for Mycobacterium tuberculosis in mycobacterial growth indicator tube (MGIT 960) and sputum for malignant cells were sent in all patients. The patient underwent a left pneumonectomy. Flexible Bronchoscopy in Non-resolving Pneumonia Chest x-ray revealed left upper lobe consolidation. Avijgan has also reported that diabetes mellitus was a major association with delayed resolution of pneumonia. Ando M, Goto A, Yamasue M, Usagawa Y, Oka H, Shigenaga T, Kadota JI. On repeat chest radiograph four weeks after treatment, there was interval improvement in the airspace disease density (Fig. White DA, Camus P, Endo M, Escudier B, Calvo E, Akaza H, et al. Family history was positive for breast cancer in his mother. Careers, Unable to load your collection due to an error. CT-guided FNAC was done in selected cases where FOB was inconclusive. CT scan of the chest is a very useful tool in diagnosis and management of lung disease. Important causes of non-resolving pneumonia are complications of pneumonia, non-infectious causes, difficult to treat organisms such as multidrug-resistant bacteria or alternative organisms such as PCP, tuberculosis and Aspergillus and choice of antimicrobials. CT-guided FNAC also gives good yield when cases are properly selected. A diagnosis of progressive disseminated histoplasmosis was established by his clinical findings as well as bronchoscopic biopsy, transbronchial needle aspiration cytology and bronchoalveolar lavage culture demonstrating Histoplasma capsulatum. Lack of response to antibiotics prompted invasive testing with bronchoscopy which revealed a growth in the left main bronchus. Kar Medical College and Hospital, Kolkata, India. Chest X-ray PA view showing the right middle lobe consolidation (a) and the right sided pleural effusion with consolidation (b) CT scan thorax with contrast showing the necrotic lymph nodes in paratracheal and subcarinal sites (c), Fibre-optic bronchoscopy showing the wide carina with constricted right main bronchus and pus coming out from the right main bronchus, Fungal stain of bronchial mucosal biopsy specimen showing the fungal elements suggestive of Histoplasma capsulatum (a) and follow-up chest X-ray PA view (b) after 1 month of treatment showing improvement of the right lung opacity in respect to pretreatment chest X-ray, Non-resolving pneumonia is a challenging clinical problem. Is its microbiology changing? 8600 Rockville Pike 2). Rome L, Murali G, Lippmann M. Nonresolving pneumonia and mimics of pneumonia. in 23 patients of non-resolving pneumonia with negative FOB results, CT-guided core needle biopsy was done. Follow up chest radiograph (posteroanterior view) performed following treatment, demonstrates significant decrease in size of largest lesion in mid lung zone (white arrow). Silver et al. Can You Die from Pneumonia? What You Need to Know The endemic area includes the Ohio and Mississippi River valleys, Central and South America, and microfoci in the Eastern United States, southern Europe, Africa, and Southeast Asia. Nonresolving pneumonia The special stains as well as tissue cultures for fungi and mycobacteria were negative. The patient's condition deteriorated further with appearance of right-sided pleural effusion [Figure 1b] and hepatosplenomegaly. A non-resolving pneumonia may be the first manifestation of lung malignancy. Approximately half of patients with GPA also endorse constitutional symptoms (fever, malaise, anorexia, weight loss) and renal involvement including hematuria, red blood cell casts, and renal failure [1]. -, Cordier J.F., Valeyre D., Guillevin L., Loire R., Brechot J.M. Often, they are caused by resistant organisms, mechanical airway obstructions, inappropriate antibiotic treatment, & inadequate duration of treatment. Pulmonary Wegeners granulomatosis. INTRODUCTION: Non-resolving pneumonias can occur due to infectious, noninfectious or neoplastic causes. Tayside Respiratory Research Group, University of Dundee and Ninewells Hospital and Medical School, Dundee, Scotland The https:// ensures that you are connecting to the Granulomatosis with polyangiitis; Non-resolving pneumonia; Percutaneous lung biopsy. Mean age was 51.33 1.71 years with male to female ratio 2:1. Pneumonia is a major health problem, being associated with high morbidity and short and long term mortality. studied 39 patients of slowly resolving pneumonia and found cough as commonest symptoms (92%) followed by chest pain (38%), breathlessness (38%), fever (36%), and hemoptysis (28%). Like other vasculitides, the clinical presentation of GPA is diverse and can involve any organ system. Before government site. Frankel S.K., Cosgrove G.P., Fischer A., Meehan R.T., Brown K.K. Bethesda, MD 20894, Web Policies The procedure is safe, and complications are very less if done properly. Journal of the Association of Physicians of India - JAPI Careers, Unable to load your collection due to an error. FOIA Arancibia F, Ewig S, Martinez JA, Ruiz M, Bauer T, Marcos MA, et al. El Solh et al. Introduction. Approach to a patient with non-resolving pneumonia. Further, the sensitivity of ANCA testing lacks in limited disease compared to diffuse disease (67% vs 91%) [1]. 2. The elastic stain in the inset highlights, in black, the elastic layer of the blood vessel wall, which is partially destroyed (arrows) by the inflammation (Verhoeff stain, 200). Pneumonia is inflammation and fluid in your lungs caused by a bacterial, viral or fungal infection. An important cause of non-resolving pneumonia Fluoroscopically guided percutaneous fine and core needle biopsies were obtained from the right middle lobe mass. Significance of unresolved organizing or protracted pneumonia. This study was a prospective cross-sectional study, performed in the department of pulmonary medicine at a tertiary care teaching institution of eastern India, over a period of one year (January 2010 - December 2010). Non-neoplastic causes (e.g., pulmonary vasculitis, hypersensitivity pneumonia, etc.) Hoffman G.S., Kerr G.S., Leavitt R.Y., Hallahan C.W., Lebovics R.S., Travis W.D. Post-bronchoscopic sputum for fungal culture showed a growth of Histoplasma capsulatum. Persistent pulmonary infiltrate results when a substance denser than air (e.g., pus, oedema, blood, surfactant, protein, or cells) lingers within the lung parenchyma. Linking to a non-federal website does not constitute an endorsement by CDC or any of its employees of the sponsors or the information and products presented on the website. (A) Chest radiograph (posteroanterior view), (A) Chest radiograph (posteroanterior view) reveals right mid lung zone mass (arrow) and, The image shows extensive mixed type necrosis with a focal rounded area of, Follow up chest radiograph (posteroanterior, Follow up chest radiograph (posteroanterior view) performed following treatment, demonstrates significant decrease in, MeSH