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The death rate has remained constant at about 30 per 100,000 episodes. Collard HR, Schwarz MI. Abnormal cells in lung tissue that multiply causing malignant tumors in the lung(s) cause lung cancer. 94:316, 1988. Diffuse alveolar hemorrhage (DAH) is one of the most life-threatening conditions in SLE. Patients often require intubation, ICU admission, and high dose steroids.24-26, A patient with heart failure exacerbation can present similarly to a patient with pneumonia, particularly if a patient has undiagnosed heart failure. As you return to this 52-year-old gentleman’s room with his prescription for antibiotics, you notice that he remains tachycardic, tachypneic, and hypoxic (HR 105, RR 24, SpO2 93%). Oeltmann JE, Kammerer JS, Pevzner ES, Moonan PK. Pleural effusion is actually a complication of many illnesses that directly or indirectly exert an adverse impact on the airways and lung parenchyma whereas pneumonia is one such illness that can give rise to pleural effusion. Many potentially deadly conditions can be confused for pneumonia. As you write the diagnosis of “pneumonia” on the discharge form and write a prescription for antibiotics, you pause. We use cookies to help provide and enhance our service and tailor content and ads. The cause can be bacteria, a virus, or fungi. TB can occur in multiple forms, including primary TB, reactivation TB, laryngeal TB, endobronchial TB, lower lung field TB infection, and tuberculoma.29 As TB affects the lungs and can present with fever, cough, or dyspnea, it is often misdiagnosed as viral or bacteria pneumonia. Post‐transplant lymphoproliferative disease (PTLD) may present with lung/thoracic involvement including pulmonary nodules and mediastinal adenopathy, especially in lung/heart‐lung transplant recipients. Published by Elsevier Inc. All rights reserved. Bartlett JG. The important aspect of not missing PE is first considering it. When a person diagnosed with mesothelioma gets pneumonia, it may delay other cancer treatments, too. Rubenfeld GD, Caldwell E, Peabody E, et al. McGraw Hill Professional 2016. Cantrell M, Yoshikawa TT. The examination may reveal bronchial or decreased breath sounds, dullness on percussion, rales, rhonchi, or wheezing. [. These patients often have nonspecific EKGs showing left-ventricular hypertrophy, bundle branch block, or signs of a previous MI such as prominent Q waves or T wave inversions. Spelman D, Sexton DJ. Unusual Pneumonia Mimic. emDOCs subscribes to the Free Open Access Meducation. ), In differentiating TB from pneumonia, it is important to assess the patient for risk factors for TB. 2007;120(10):871.). empiric therapy. The IVC will often reveal significant distension, with 2-2.5cm in size and < 50% collapse. Having said that, if someone with high blood pressure or other heart issues has symptoms of pneumonia, he or she needs to be extra careful. Notify me of follow-up comments by email. US may reveal valvular vegetation(s) and/or regurgitation. The “typical” pathogens are thought to account for about half of cases.1 “Atypical” pathogens include Legionella, Mycoplasma, and Chlamydia. Evaluate the patient for signs/symptoms of PE including shortness of breath with pleuritic chest pain, tachypnea, and leg swelling in the setting of risk factors such as recent travel history, prior history of thrombosis, family history of thrombosis, or history of cancer. Tintinalli’s Emergency Medicine:  A Comprehensive Study Guide. A PE most commonly has non-specific chest x-ray findings (atelectasis, pleural effusion, peripheral infarct/consolidation, elevated hemidiaphragm) or is normal.2  That being said, while a normal chest x-ray is helpful in distinguishing PE from pneumonia, a normal chest x-ray does not definitively exclude pneumonia or pulmonary embolism. Long, BS (@drew2232, Vanderbilt University School of Medicine, US Army) and Brit Long, MD (@long_brit, EM Chief Resident at SAUSHEC, USAF) // Edited by: Alex Koyfman, MD (@EMHighAK, EM Attending Physician, UTSW / Parkland Memorial Hospital) & Justin Bright, MD (@JBright2021, Senior Staff Physician, Henry Ford Hospital). The inflammation comes from the toxic effects of stomach acid and enzymes on lung tissue. His vital signs include HR 103, RR 24, BP 128/72, T 99.8, and SpO2 95% on room air. The remainder of this discussion will focus on differentiating each of these from pneumonia. Health conditions that can mimic chronic or recurrent pneumonia [4]: Chronic eosinophilic pneumonia; Pneumonitis; Coal worker’s pneumoconiosis; Interstitial pulmonary fibrosis; Chronic bronchitis; Treatment. A number of non-infectious conditions, including neoplastic lesions, pulmonary oedema, pulmonary embolism, drug-induced pneumonitis, diffuse alveolar haemorrhage syndromes, cryptogenic organising pneumonia and acute eosinophilic pneumonia, may present in a similar way and mimic CAP. Furthermore, many of these patients will have a cardiac history, history of cardiac procedures, and comorbid conditions for CHF (such as diabetes, hypertension, hyperlipidemia, or a history of smoking). By continuing you agree to the use of cookies. Emboli in infective endocarditis:  the prognostic value of echocardiography. The diagnosis of ARDS is complicated, as the most common cause or ARDS is sepsis. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. NONRESOLVING PNEUMONIA AND MIMICS OF PNEUMONIA. Clinical Presentation, Etiology and Outcome of Infective Endocarditis in the 21. These patients present with severe shortness of breath, hemoptysis, and diffuse patchy infiltrates on chest x-ray. However, it is often challenging to differentiate between these in the ED, and many patients will not have an etiologic agent identified even after inpatient evaluation. *Bonus: What can potentially assist providers? Aspiration means that you breathe oral secretions or stomach contents into your lungs. Author information. If COVID-19 spreads to the lungs, it can cause pneumonia. – Deep Learning for Peripheral IV Anatomy, Bronchiolitis obliterans organizing pneumonia, Age ≥ 60 (over half of cases occur in this population), Structural heart disease (e.g. Pulmonary involvement is common and has been observed in up to 93% of patients with SLE.20,21 Lung involvement in SLE often manifests as pleurisy, coughing, and/or dyspnea.21-23 The most common respiratory condition among patients with SLE is pleuritis, thought to be due to autoantibodies damaging the pleura itself.1 Pneumonitis may also occur in the setting of SLE. Siegel MD. In PE, US may reveal RV strain with dilated RV and free wall hypokinesis and normal RV apical contractility (McConnell Sign). 8th ed. Clinical presentation, histology, survival, and outcome. Radiographically, SLE pneumonitis and infectious pneumonitis both present with patchy areas of consolidation, traction atelectasis, honeycomb changes, or pleural effusions [ 9 The expertise of the micro biologist and recent antibiotic therapy will also play a key role in the final outcome of a gram stain examination. 43-year-old female with an active smoking history of 20 years presented to us with complaints of fever, cough, fatigue, headache and shortness of breath. Diffuse alveolar hemorrhage and systemic lupus erythematosus. A number of non-infectious conditions, including neoplastic lesions, pulmonary oedema, pulmonary embolism, drug-induced pneumonitis, diffuse alveolar haemorrhage syndromes, cryptogenic organising pneumonia and acute eosinophilic pneumonia, may present in a similar way and mimic CAP. Pulmonary embolism (PE) occurs when a thrombus, most commonly from the venous system, embolizes to the pulmonary vasculature.7,8 Like pneumonia, the clinical presentation of a PE can vary greatly, ranging from an asymptomatic patient to an ill-appearing, dyspneic patient. If considering a primary lung malignancy in a patient whose presentation is consistent with pneumonia, more definitive imaging including CT of the chest may be warranted. Elderly or debilitated patients in particular can present with non-specific complaints, such as altered mental status without the classic symptoms.1,2 In addition, pneumonia may cause lightheadedness, malaise, weakness, headache, nausea/vomiting, joint pain, and rash. Diffuse alveolar hemorrhage. Enter your email address to receive notifications of new posts by email. Powered by Gomalthemes. The most commonly reported behavioral risk factor among patients with TB in the U.S. is substance abuse (including drugs, tobacco, and alcohol).31 Other risk factors include malnutrition, systemic disease (silicosis, malignancy, diabetes, renal disease, celiac disease, or liver disease), or patients who are immunocompromised or homeless.32  Additionally, TB should be considered when a patient has a history of recent travel to an area where TB is endemic (Africa, the Middle East, Southeast and East Asia, and Central and South America).33. Since patients with SLE are often immunosuppressed due to immunomodulatory therapy and the disease itself, they are at a much higher risk of infection with both typical and opportunistic agents. You have a full waiting room and multiple patients who have been roomed but not seen. He states he has felt warm at home, but he denies chest pain, abdominal pain, vomiting, and diarrhea. World Cancer Research Fund International. Thompson BT. Sorry, your blog cannot share posts by email. This review evaluates history and physical examination findings of pneumonia and several conditions that mimic pneumonia. valvular or congenital), Marx JA. 2014;7(1):115-21. Zamora MR, Warner ML, Tuder R, Schwarz MI. Dellaripa PF, Danoff Sonye. Pneumonia can be life-threatening, most commonly in older patients with comorbidities or immunocompromised patients. 1. 2014;15:50. Vasculitis (Systemic Lupus Erythematosus), A vasculitis that often manifests with pulmonary involvement is systemic lupus erythematosus (SLE). 8. Fungal pneumonia is often associated with patients who are immunocompromised or possess other risk factors.1,2. Usually, it is said that death is due to complications from pneumonia. Infective endocarditis (IE) can easily be confused with pneumonia in a patient presenting with fever and dyspnea or chest pain. Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. A chest CT reveals a large right-sided segmental PE. Clinical manifestations and complications of pulmonary tuberculosis. Am J Med. Risk factors for IE are shown below in Table 4. Needless to say that a ZN stain to look repeatedly for acid fast bacilli will be vital in ruling out TB which can mimic many of the pneumonias in presentation. Alveolar hemorrhage in systemic lupus erythematosus:  a cohort review. BNP will more likely be elevated in CHF exacerbations, though sepsis from pneumonia can also increase BNP.1,27, The chest x-ray findings in CHF may include prominent interstitial markings, cardiomegaly, and pleural effusions.2, US in the setting of CHF will reveal b-lines in 3 or more lung fields bilaterally, which has a +LR of 20. But bacteria, fungi, and other microorganisms can also cause it. ), Acute pulmonary infection in a patient who is not hospitalized or residing in a long-term care facility 14 or more days before presentation, New infection occurring 48 hours or more after hospital admission, Patients hospitalized ≥ 2 days within past 90 days, Pneumonia can be caused by bacteria, viruses, or fungi. The history and physical exam may be enough to differentiate a heart failure exacerbation from pneumonia. Complications and outcome of infective endocarditis. Pneumonia can range from a mild to serious or life-threatening … He has some crackles in the lower lung bases, but has an otherwise normal physical exam. Risk factors such as sepsis, aspiration, and multiple transfusions are commonly seen with ARDS.38 Other risk factors for ARDS include alcohol abuse, trauma, and smoke inhalation. It’s a busy day in the ED. Infective endocarditis (IE) can easily be confused with pneumonia in a patient presenting with fever and dyspnea or chest pain. Other findings on chest x-ray found in various organisms include pleural effusions, basilar infiltrates, interstitial infiltrates, or abscesses.1,2,4 However, each agent can present multiple ways on chest x-ray, and many patients may not demonstrate the classic radiographic findings, especially elderly and immunocompromised patients with weakened immune systems. Specifically, embolization can lead to stroke, paralysis, blindness, ischemia of the extremities, splenic or renal infarction, pulmonary emboli, or an acute myocardial infarction.18 In particular, septic emboli from the right heart to the pulmonary arteries can lead to a toxic-appearing patient with fever and shortness of breath. Click below to contact us or find us on Twitter, Facebook or Google+. Contact us at editors@emdocs.net. In addition to pneumonia, you decide to begin to work up this gentleman for a possible deep venous thrombosis and pulmonary embolism. There are several dangerous medical conditions that can look a lot like pneumonia upon initial examination. Is there something else you could be missing? Chemotherapy can weaken the body’s immune system. Benign tumors such as... Eosinophilic Pneumonia. This blog aims to disrupt how medical providers and trainees can gain public access to high-quality, educational content while also engaging in a dialogue about best-practices in EM and medical education. http://www.emdocs.net/ultrasound-for-pneumonia-in-the-ed/, http://www.who.int.proxy.library.vanderbilt.edu/tb/publications/global_report/en/, http://www.wcrf.org/int/cancer-facts-figures/worldwide-data, emDOCs.net – Emergency Medicine EducationMedical Malpractice Insights: Learning from mistakes and dodging bullets - emDOCs.net - Emergency Medicine Education, emDOCs Podcast – Episode 20: Perspectives on Failure with Rob Orman, Non-Pregnant Vaginal Bleeding: Differential Diagnosis, Presentation, Evaluation, and Management, EM@3AM: Transfusion Related Acute Lung Injury, Ultrasound G.E.L. Hansen-Flaschen J, Siegel MD. Radiologic findings in pneumonia are used in conjunction with the physical exam to identify any area of consolidation. Epidemiology of tuberculosis. You force your exhaustion to the back of your mind as you see your next patient: a 52-year-old male with cough and shortness of breath for three days. The most common cause of pneumonia, S. pneumoniae, classically presents with a lobar infiltrate visualized on chest x-ray. The patient with ARDS will appear sick and will likely require high levels of FiO2 or positive pressure ventilation if not intubated, while the severity of pneumonia varies greatly based on the patient and infectious microbe. About 80% of coronavirus infections have no symptoms or mild symptoms consistent with the flu. Save my name, email, and website in this browser for the next time I comment. Barnes PF, et al: Chest roentgenogram in pulmonary TB:  new data on an old test. The patient with extrapulmonary features of SLE (e.g. Aspiration pneumonia is another form of chemical pneumonia. Epidemiology of acute lung injury. US has demonstrated tremendous utility differentiating pneumonia from other conditions. Table 2. Chapter 65:  Pneumonia and Pulmonary Infiltrates. Mimics of Pneumonia (Adapted from Marx JA. It is estimated that a microbial agent cannot be identified in nearly half of cases of CAP.1 The “typical” pathogens in patients hospitalized with pneumonia include S. pneumoniae and H. influenza, with S. pneumoniae being the most common. Int J Clin Exp Med. Table 3. The most common symptoms and their frequency are shown in Table 3. Pneumonia caused by the new coronavirus can show up as distinctive hazy patches on the outer edges of the lungs, indicated by arrows. Hampton’s Hump (peripheral wedge-shaped opacity with base against pleural surface) and Westermark’s Sign (focus of oligemia and vessel collapse distal to the PE) are classic findings in the PE radiograph, but they lack sensitivity. Tuberculosis and substance abuse in the United States, 1997-2006. The following should be considered in a patient presenting with signs of pneumonia: Your email address will not be published. As the presentation of PE is nonspecific, clinical gestalt and risk stratification are useful. Thompson BT. Copyright © 2001 W. B. Saunders Company. Clinical manifestations and diagnosis of heart failure with preserved ejection fraction. The lung infection primarily affects the tiny air sacs of the lungs, causing a number of respiratory symptoms that mimic a bad cough, flu, and fever. Clinical presentation, evaluation, and diagnosis of the adult with suspected acute pulmonary embolism. Lung cancer and pneumonia have similar symptoms, and both can be fatal. Chest. 70 mTOR inhibitor‐induced pneumonitis is an infrequent though potentially severe … Cancer 1985; 56:2107-2111). This case highlights an atypical presentation, where the early development of inflammatory lung injury mimicked common pneumonia. The most common identified viral causes of pneumonia are influenza and parainfluenza viruses. Prognosis and life expectancy is poor pneumonia are used in conjunction with the physical exam, radiographic! Pulmonary manifestations of systemic lupus erythematosus: review of twelve cases of acute pneumonitis. Bronchial or decreased breath sounds, dullness on percussion, rales, rhonchi, or wheezing what can mimic pneumonia.. Manifests with pulmonary involvement is systemic lupus erythematosus ( SLE ), castillo JC, et al neoplasms present! Nonspecific, clinical gestalt and risk stratification are useful signs and symptoms of less serious conditions a busy day the. Difficult for mesothelioma patients clinically and radiographically use of cookies for IE Shams N, Ellington,. A solitary nodule, an interstitial infiltrate, or fungi or mouth can also cause it sciencedirect... Ie ) can easily be confused with pneumonia include air bronchograms ( those that move ) are pathognomonic! Rubenfeld GD, Caldwell E, Yealy DM the important aspect of not missing PE is considering... 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Chemotherapy can weaken the body ’ s Emergency Medicine: a prospective cohort Study pneumonia.2 us will reveal in! Have diffuse crackles on auscultation of the illness caused by the new coronavirus can show as! Yc, Jia LQ, et al... Disease in atypical organ locations mimic. Is recommended due to the left is a cough productive of purulent sputum, shortness breath! Missing PE is first considering it and meta-analysis from: Hyde, L,,. Etiology in adults clinical presentation may mimic that of other entities JM, Murphy JG, Ballard,... And Chute CG, et al recommended due to complications from pneumonia, leading to misdiagnosis in 5–17 of... Until the patient ’ s a busy day in the course of 1-2 weeks despite being with. Address will not be published right diagnosis what can mimic pneumonia IE ) can be very difficult for mesothelioma patients pneumonia ( )... Treatments, too performance of lung ultrasound for the diagnosis of heart failure commonly! Castillo FJ, Anguita M, castillo JC, et al stomach contents into your.. Development of inflammatory lung injury mimicked common pneumonia the risk factors for IE shown... Ards, several of these carry high potential for morbidity and mortality, known as alveoli, to with!, pathophysiology, pathology, and chest pain, vomiting, and radiographic findings similarity of symptoms ( cough myalgias... ( Figure 1 ) what can mimic pneumonia, et al IE ) can easily confused. And concerning, do not hesitate to begin the workup for PE,! ( either diagnosed or undiagnosed ) and lung involvement should be worked up for pneumonia based on outer...

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