Interesting case of pneumonia Blog Space/ interesting case of pneumonia

An immunocompetent hypertensive gentleman in fifties was shifted to Zydus Hospital, Ahmedabad for

evaluation of Non-Covid pneumonia. The radiology was showing dense peripheral air space

consolidation of left lower lobe with mild (Non-tappable) ipsilateral sympneumonic pleural effusion. His

history was favoring acute onset illness with 7 days of duration & hospitalization elsewhere for one day

to ascertain covid status.

His examination on the day of admission revealed SpO2 of 95% on room air & tubular type of bronchial

breath sounds over left infra-scapular & infra-axillary region with no crepitations. He was started on

empirical BL +BLI & macrolide antibiotics with supportive care.

His etiological evaluation revealed Klebsiella Pneumonie in respiratory panel. Although the antimicrobial

coverage was good, clinically he was not responding - indicated by need of supplemental oxygen,

presence of sputum purulence as well as development of fever spike (up to 99.6'F) after 48 hours of

initial treatment. The antibiotic regimen was changed to Carbapenem, Fluoroquinolone & Linezolid

suspecting drug resistant pathogen. He produced very little purulent sputum on that day. which was

sent for culture & sensitivity.

His clinical condition remained status quo after 48 hours of upgraded regimen with no further fever

spikes, but he developed new finding - crepitations over right infraclavicular & infrascapular region - a

progression on right side confirmed with X-ray chest on same day. Anticipating further clinical

deterioration, he was shifted to ICU - with culture confirming growth of GNB. He threw another fever

spike on that day - indicating partial effect of regimen. After thorough discussion, acting patiently, we

waited for drug sensitivity - which confirmed carbapenem resistance. The carba-R assay detected NDM

& OXA-48 and the antibiotic regimen was tailored accordingly. After 48 hours of the regimen, the

patient shown clinical-lab-radiological improvement after which he was shifted to ward & finally

discharged with parenteral antibiotics.

His follow up after 14 days course of antibiotic regimen revealed near complete resolution in X-ray chest

& normal breath sounds.

The most important aspect in the care of patient

suffering from pneumonia is robust observation & close monitoring to suspect drug resistance at the

earliest. Failing to detect it not only leads to progression of disease requiring intensive care with invasive

or non-invasive ventilation but also to significant mental, social & financial disruption.

Community transmission of drug resistant pathogens is not commonly suspected, however we did

witnessed koch's postulate in the gentleman's case. Due to timely & coordinated efforts - he was saved

from prolonged hospitalization & advanced respiratory supports for which this pathogen is infamous.

Dr. Jaykumar Mehta

MBBS (Gold Medalist)

MD, DNB, MNAMS, PD Fellow (Pulmonology)

Consultant Interventional Pulmonologist (Zydus Hospital, Ahmedabad)