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Community Acquired
Pneumonia in a Young
Diabetic
June 21, 2006
John N Landis, MD
Chief, Pulmonary Medicine
Baystate Medical Center
Springfield, MA
A
23 year old female with
diabetes presented to the
emergency department on
1/01/05 with a cough, fever and
3 weeks of pleuritic chest pain.
 The
ED physician interpreted the
chest x-ray as bilateral
infiltrates and diagnosed
community acquired pneumonia.
 Patient
was discharged from the
ED on azithromycin.
1/1/05
2
days later the patient returned
to the hospital ED and a left
PNTX was noted on CXR with
progression of pneumonia.
 ON 1/3/05 the patient was
admitted and left chest tube was
placed.
 The week following, the patient
had left chest tube removed but
developed worsening pulmonary
infiltrates and respiratory
distress.
1/3/05
 ID
consultant noted on 1/07/05
– Failure to respond to “standard
antibiotics”
– Persistent fever but no leukocytosis
– Negative sputum and blood cultures
– Therefore unusual organism
suspected
– Vacomycin, zosyn, and azithromycin
initiated
– Plans to obtain bronchoscopic
washings if no improvement
1/10/05
A
pulmonary consult was called
on 1/10/05.
 The patient was transferred to the
ICU, intubated and
bronchoscoped.
 A PPD was placed on 1/9/05 and
was 5mm.
 Bronchoscopy revealed 4+ AFB
 Patient was placed on INH, RIF,
PZA, and SM. Due to the extent of
the disease Levaquin was added
and steroids were withheld.
1/10/05
 On
1/19/05 the patient
developed a 50% R PNTX and a
right chest tube was placed.
 The PNTX did not resolve.
 IR placed an additional catheter
in right chest on 1/20/05 and a
2nd catheter in right apex on
1/21/05.
1/10/05
1/19/05
1/19/05
1/20/05
1/20/05
1.21.05
1/22/05
 The
PNTX began to resolve, the
right chest tube was removed on
1/22/05 and pigtail catheter was
removed on 1/31/05.
 On 1/24/05 tracheostomy was
performed and the patient was
continued on mechanical
ventilation.
1/20/05
1/31/05
1/31/05
2/15/05
2/15/05
3/2/05
 The
patient’s tracheostomy tube
was decannulated and PICC line
removed on 3/21/05.
 5 TB drugs were continued
through 2/25/05 when SM
stopped.
 4 drugs converted to PO route.
 Levaquin was discontinued on
3/11/05.
 Patient was discharged on
3/21/05 with Rifamate, PZA and
B6 and nasal O2 continued.
First TB Clinic Visit- 4/12/05
Class III TB
 CXR slightly improved- extensive
fibrotic change
 SPO2- 91%
 PZA discontinued
 3-4 drugs had been continued for 3
months: INH, RIF, SM and PZA.
 Cultures reviewed
 all
cultures negative since 2/10/05
 all smears negative since 2/18/05
3/2/05
4/12/05
Second TB Clinic Visit- 5/17/05
 Sputums
obtained from 3/27/05,
4/4/05, and 4/9/05- negative
on smear and culture.
 Sputum from 5/19/05- negative
on smear.
 Continue Rifamate and B6
 O2 discontinued
4/12/05
5/17/05
Third TB Clinic Visit- 7/19/05
 Continuing
Rifamate and B6
 CT Scan requested due to
increased cough with rhonchi on
auscultation
of chest.
 Bronchiectasis suggested on CT
scan of 8/8/05.
5/17/05
7/19/05
8/8/05
Fourth TB Clinic Visit- 9/27/05
 Continues
Rifamate.
 CT Scan- chronic scarring
 Definite bronchiectasis LLL and
no cavities
Fifth TB Clinic Visit- 1/3/06
 Continues
Rifamate (all TB
medications discontinued on
1/17/06)
 Asymptomatic
9/2/03
1/17/06
Sixth TB Clinic Visit- 5/9/06
L
chest pain
 PFTS 3/16/06- moderate
restrictive disease 60%
predicted.
 CT Scan 3/20/06- fibrosis of
RUL, RML, RLL, and LLL,
pneumatocoel RUL/LLL,
bronchiectasis, LLL, RML.
Pulmonary Function Laboratory
Report 3/16/06
Spirometry
FVC L
FEV1 L
FEV1/FVC
Observed Pre
2.19
2.03
92
% Pred Pre
55
60
106
Lung Volumes
TLC
Observed Pre
3.38
% Pred Pre
63
Diffusion
DLCO corr
Observed Pre
17.60
% Pred Pre
59
3/20/06
Summary

This 25 year old female, presented with
signs and symptoms of CAP- was treated
with ceftriaxone and azithromycin for 10
days until florid necrotizing TB diagnosed
on 1/10/05 from bronchoscopic washings.
Treatment included ventilatory support, 5
drug TB chemotherapy and nutritional
support. Initially 3 of the 5 TB drugs were
given parenterally : RIF, Levaquin
intravenously +SM-SC subcutaneously.

PZA/INH were given via GT. No index
case was ever confirmed and no
intrahospital transmission occurred. With
regards to household contacts, all were
negative, except a nephew and her
boyfriend. Extensive hospital contact
review showed no conversions of PPD.
The patient sustained moderate RLD
from acute lung injury but has recovered
fully and has returned to work full time.
Probable factors leading to severity of her
disease: Diabetes and possibly poor diet.
 Rare
cases of fulminating necrotizing
pneumonia caused by TB have been
reported. Fortunately this organism
was pan-sensitive and responded to
administered anti-microbials. The
patient although near death from
ARDS survived a 2 ½ month
hospitalization to fully return to an
active life. Amazingly, few if any
contacts were infected by her.