Of the diagnoses listed in Table 2, several of these carry high potential for morbidity and mortality. 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. Clinical manifestations and diagnosis of heart failure with preserved ejection fraction. In 2012, lung cancer worldwide was the most common cancer in men and the third most common cancer in women.34 In the U.S., lung cancer occurs in an estimated 225,000 patients every year and is responsible for over 160,000 deaths.35 There are many risk factors for cancer, the most notorious of which is smoking. These include pulmonary embolism, endocarditis, vasculitis, acute decompensated heart failure, tuberculosis, primary lung cancer, and acute respiratory distress syndrome. 8th ed. Klebsiella may present with diffuse, patchy infiltrates. Pulmonary manifestations of systemic lupus erythematosus:  review of twelve cases of acute lupus pneumonitis. These patients present with severe shortness of breath, hemoptysis, and diffuse patchy infiltrates on chest x-ray. 3 authors. Connective tissue diseases:  In:  Interstitial Lung Disease, 5. Pires JR 1, Moreira MJ 1, Martins M 2, Neves C 1. Vasculitis (Systemic Lupus Erythematosus), A vasculitis that often manifests with pulmonary involvement is systemic lupus erythematosus (SLE). Contracting pneumonia before mesothelioma surgery may delay or cancel the procedure, depending on the how sick the patient gets. Complications and outcome of infective endocarditis. Dellaripa PF, Danoff Sonye. Diffuse alveolar hemorrhage (DAH) is one of the most life-threatening conditions in SLE. Sometimes, the infiltrate may be in a portion of the lung that is not easily seen by standard x-ray, and other patients may have congestive heart failure or scarring in their lungs, which can mimic pneumonia. If COVID-19 spreads to the lungs, it can cause pneumonia. Pneumonia in people with lung cancer. On short axis view, the LV will appear “D” shaped, with RV bowing into the LV due to elevated right-sided pressures.10-12, Endocarditis is most commonly caused by a bacterial agent, with a one-year mortality of 40%.13 The most common symptoms are intermittent fever (85%) and malaise (80%).1  Additionally, endocarditis can present with dyspnea, chest pain, cough, headache, weakness, and myalgias. Rubenfeld GD, Caldwell E, Peabody E, et al. Wiedemann HP, Matthay RA. He has experienced several episodes of nausea. The classic presentation of pneumonia is a cough productive of purulent sputum, shortness of breath, and fever. A patient with a primary lung cancer can easily be confused with pneumonia due to the similarity of symptoms (Table 6). What is key in primary lung cancer is these symptoms have a more insidious onset than the relatively more acute onset of symptoms in pneumonia. Post was not sent - check your email addresses! If a person has lung cancer and gets pneumonia, the prognosis and life expectancy is poor. Sorry, your blog cannot share posts by email. Fine MJ, Stone RA, Singer DE et al. If signs and/or symptoms are present and concerning, do not hesitate to begin the workup for PE. As you write the diagnosis of “pneumonia” on the discharge form and write a prescription for antibiotics, you pause. McGraw Hill Professional 2016. Fungal pneumonia is often associated with patients who are immunocompromised or possess other risk factors.1,2. 94:316, 1988. Respir Res. McGraw Hill Professional 2016. *Bonus: What can potentially assist providers? The patient with extrapulmonary features of SLE (e.g. Benign and malignant neoplasms may present as a nonresolving pneumonia. 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. These are called differential diagnoses — serious medical conditions that mimic the symptoms of less serious conditions. Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. The chest x-ray shows more diffuse involvement than would be expected in a patient with pneumonia.2 US will reveal b-lines in multiple lung fields. Pneumonia can happen on its own or as a result of a complication of other infections like the flu. Clinical characteristics of patients with acute pulmonary embolism: data from PIOPED II. We are actively recruiting both new topics and authors. Patients with acute decompensated heart failure most commonly present with cough, shortness of breath, fatigue, and/or peripheral edema. Castillo FJ, Anguita M, Castillo JC, et al. 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. If concerned for ARDS, be ready to intubate the patient for clinical course/oxygenation and admit to the ICU. As the presentation of PE is nonspecific, clinical gestalt and risk stratification are useful. Consultation with rheumatology and the ICU is recommended due to the potential for rapid decompensation. On physical exam, patients with ARDS often have diffuse crackles on auscultation of the lungs. Tintinalli’s Emergency Medicine:  A Comprehensive Study Guide. Signs and Symptoms Of Pulmonary Embolism (adapted from Stein PD, Beemath A, Matta F, et al. You perform a more complete review of systems and find out this gentleman has been experiencing pain in his right calf over the past week after returning from an overseas business trip. 2014;7(1):115-21. Many potentially deadly conditions can be confused for pneumonia. Andrade C, Mendonca T, Farinha F, et al. Cantrell M, Yoshikawa TT. 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. In summary, TB should be suspected in a patient with vague symptoms who possesses risk factors for TB, particularly in patients who are homeless, immunosuppressed, have a history of drug use, or have recently traveled to a TB endemic area. Furthermore, these symptoms will progress over time and may include symptoms less commonly seen in pneumonia (weight loss, bone pain, or voice hoarseness). Multiple other infective and non-infective conditions can mimic community-acquired pneumonia, leading to misdiagnosis in 5–17% of cases. Global Tuberculosis Report 2014. Lung cancer and pneumonia have similar symptoms, and both can be fatal. The remainder of this discussion will focus on differentiating each of these from pneumonia. A chest CT reveals a large right-sided segmental PE. Table 6. The most common signs of pneumonia include cough (79%-91%), fever (up to 75%), increased sputum (up to 65%), pleuritic chest pain (up to 50%), and dyspnea (approximately 70%).3 There are many patterns of presentation with a variety of these symptoms and physical findings, making the diagnosis at times difficult. Radiologic findings in pneumonia are used in conjunction with the physical exam to identify any area of consolidation. Thus, ARDS may result from a prior pneumonia leading to sepsis. But bacteria, fungi, and other microorganisms can also cause it. Author information. Tuberculosis and substance abuse in the United States, 1997-2006. Symptoms of lung cancer at presentation. Authors: Drew A. Clinical manifestations and complications of pulmonary tuberculosis. Zamora MR, Warner ML, Tuder R, Schwarz MI. Int J Clin Exp Med. Abnormal cells in lung tissue that multiply causing malignant tumors in the lung(s) cause lung cancer. The most common symptoms and their frequency are shown in Table 3. Tintinalli’s Emergency Medicine:  A Comprehensive Study Guide. The important aspect of not missing PE is first considering it. Horsburgh CR. We summarize the Infective endocarditis in the aging patient. Ultrasound (US)! Various viruses, bacteria, and fungi can cause pneumonia. Are there other diagnoses you should consider? Positive likelihood ratios (LR) for these findings range from 15.6 to 16.8, with negative LR’s of 0.03 to 0.07.5,6  Please see a prior emDocs.net post on the use of US in pneumonia: http://www.emdocs.net/ultrasound-for-pneumonia-in-the-ed/. This has been described in 13 to 44% of patients with IE.18,19 Septic emboli can lead to damage in the systemic or pulmonary artery circulation, depending on left vs. right-sided disease. Clinical presentation, evaluation, and diagnosis of the adult with suspected acute pulmonary embolism. Your email address will not be published. Table 2. Chest 1974; 65:299-306 and Chute CG, et al. https://doi.org/10.1016/S0025-7125(05)70393-X. – 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. Pneumonia is the sixth leading cause of death and tends to be more prevalent and severe in the elderly.17, 28 It is estimated that there are more than 3 million episodes of pneumonia in the United States per year, with more than half of patients being treated as outpatients, resulting in annual costs of $23 billion. Clinical presentation, histology, survival, and outcome. He has some crackles in the lower lung bases, but has an otherwise normal physical exam. 13-17. There are a wide array of nonspecific signs and symptoms associated with the multiple forms of TB, shown in Table 5.30, Table 5. The death rate has remained constant at about 30 per 100,000 episodes.28 Using conventional culture techniques, the cause of community-acquired pneumonia (CAP) is determined in only approximately 50% of cases.42 A more recent prospective study using transthoracic needle aspiration to obtain a microbiologic diagnosis found Streptococcus pneumoniae to be the most common cause of CAP, accounting for 25% of all cases, with failure of conventional microbiologic techniques in one third of cases.56 The appropriate resolution rate for CAP depends to a great degree on age; comorbid factors, particularly the presence of underlying lung disease; and factors such as alcohol abuse and social strata.51 Occasionally the radiograph may show progression despite clinical improvement as exemplified by defervescence and reduction in leukocytosis.42 The virulence of the infecting organism plays an important role in resolution rates, with Staphylococcus aureus, enteric gram-negative pathogens, and Legionella taking the longest to resolve, occasionally months; Mycoplasma resolving the fastest, at 2 to 4 weeks; and Chlamydia having an intermediate resolution rate.25, 34, 42 It is useful to determine if one is dealing with a slowly resolving process (i.e., <50% resolution in 1 month), the emergence of resistance, or treatment of the wrong pathogen or process. 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. One month prior to presentation, Subhepatic appendicitis presents a diagnostic challenge and its clinical presentation may mimic that of other entities. Acute Respiratory Distress Syndrome (ARDS) is acute, diffuse, inflammatory lung injury that carries high rates of morbidity, ranging from 26 to 58%.35,36 ARDS stems from diffuse alveolar damage and lung capillary endothelial injury, leading to increased capillary permeability and pulmonary edema.1 This disease manifests with respiratory distress, with patients often displaying tachycardia, tachypnea, hypoxemia, and dyspnea.37 Arterial blood gas analysis shows hypoxemia in addition to acute respiratory alkalosis and increased alveolar-arterial oxygen gradient (though ABG is usually not required in the ED). We use cookies to help provide and enhance our service and tailor content and ads. His past medical history includes hypertension and hyperlipidemia. Classification of Pneumonia (Adapted from Maloney G, Anderson E, Yealy DM. Epidemiology, risk factors, and microbiology of infective endocarditis. Viral pneumonia is a common complication of influenza-like illnesses and is a complication of SARS-COV-2. The history and physical exam may be enough to differentiate a heart failure exacerbation from pneumonia. 1. 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. Spelman D, Sexton DJ. Table 1. When considering ARDS, several factors come into play. Address reprint requests to Michael Lippmann, MD, Albert Einstein Medical Center, 5401 Old York Road, Klein #363, Philadelphia, PA 19141. Acute respiratory distress syndrome:  Clinical features and diagnosis in adults. By continuing you agree to the use of cookies. When a person diagnosed with mesothelioma gets pneumonia, it may delay other cancer treatments, too. Hansen-Flaschen J, Siegel MD. Borlaug BA. The diseases that COVID-19 pneumonia may mimic can be broadly classied as infectious or non-infectious diseases (pulmonary edema, hemorrhage, neoplasms, organizing pneumonia, pulmonary alveolar proteinosis, sarcoidosis, pulmonary infarction, interstitial lung diseases, and aspiration pneumonia). Maintenance of a high index of suspicion and knowledge of these atypical locations is crucial. 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). Infective endocarditis (IE) can easily be confused with pneumonia in a patient presenting with fever and dyspnea or chest pain. Rosen’s Emergency Medicine:  Concepts and Clinical Practice. Shown is a CT scan from a 65-year-old man in China with COVID-19. The cause can be bacteria, a virus, or fungi. Overview of acute pulmonary embolism in adults. Health conditions that can mimic chronic or recurrent pneumonia [4]: Chronic eosinophilic pneumonia; Pneumonitis; Coal worker’s pneumoconiosis; Interstitial pulmonary fibrosis; Chronic bronchitis; Treatment. 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. Dynamic air bronchograms (those that move) are considered pathognomonic for pneumonia. Oeltmann JE, Kammerer JS, Pevzner ES, Moonan PK. Echocardiogram may reveal depressed contractility if systolic dysfunction is present.28, Tuberculosis (TB) is currently the world’s second leading infectious cause of death.1 The lungs are the major site for infection with Mycobacterium tuberculosis. 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. emDocs is licensed under a Creative Commons Attribution 4.0 International License. This wide variation in symptoms and presentation provides potential for misdiagnosis, especially if other conditions are not considered. Tintinalli’s Emergency Medicine:  A Comprehensive Study Guide. As TB has many forms, the chest x-ray in TB can vary and may not be all that helpful in differentiating TB from pneumonia. ... Disease in atypical organ locations can mimic other pathologies, hampering the right diagnosis. Hill EE, Herijgers P, Claus P. Infective endocarditis:  changing epidemiology and predictors of 6-month mortality:  a prospective cohort study. not resolving over course of 1-2 weeks despite being treated with antibiotics. 70 mTOR inhibitor‐induced pneumonitis is an infrequent though potentially severe … This review evaluates history and physical examination findings of pneumonia and several conditions that mimic pneumonia. Pneumonia can cause death due to heart failure or respiratory failure. This case highlights an atypical presentation, where the early development of inflammatory lung injury mimicked common pneumonia. Steckelberg JM, Murphy JG, Ballard D, et al. Diagnostic approach to community-acquired pneumonia in adults. The chest x-ray in patients with lung cancer varies depending on the type and stage of cancer. About 80% of coronavirus infections have no symptoms or mild symptoms consistent with the flu. Chapter 65:  Pneumonia and Pulmonary Infiltrates.). 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. X-ray has a sensitivity of 46-77% in diagnosing pneumonia. 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. Copyright © 2001 W. B. Saunders Company. Diffuse alveolar damage is a more common presentation in patients who already have a documented history of lupus and rarely presents as the initial manifestation of lupus. 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. A lung patch on xray is surely a nonspecific finding and in most cases turns out to be pneumonia.The diagnosis is usually reached in such cases depending clinical symptoms and investigation . As a result, when pneumonia fails to respond to treatment, the question becomes whether or not the diagnosis of pneumonia is even correct, since many conditions can mimic pneu-monia. Pneumonia can be life-threatening, most commonly in older patients with comorbidities or immunocompromised patients. Treatment includes management of the underlying diseases, antibiotics for bacterial pneumonia, antifungals for fungal and metronidazole and other antiparasitic drugs for … In addition to pneumonia, you decide to begin to work up this gentleman for a possible deep venous thrombosis and pulmonary embolism. 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. A history of orthopnea and/or paroxysmal nocturnal dyspnea leading up to the patient’s presentation is sensitive and specific for heart failure. 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. Changes in the Clinical Profile, Epidemiology and Prognosis of Left-sided Native-valve Infective Endocarditis Without Predisposing Heart Conditions. While pneumonia classically presents with a fever, cough, and shortness of breath, the presentation can vary widely in adults. Collard HR, Schwarz MI. Perera, T. Mailhot, D. Riley, and D. Mandavia, “The RUSH exam: rapid ultrasound in Shock in the evaluation of the critically ill,”, P. Borloz, W. J. Frohna, C. A. Phillips, and M. S. Antonis, “Emergency department focused bedside echocardiography in massive pulmonary embolism,”, Madan and C. Schwartz, “Echocardiographic visualization of acute pulmonary embolus and thrombolysis in the ED,”, Murdoch DR, Corey GR, Hoen B. Bartlett JG. Acute lupus pneumonitis can closely mimic an acute infectious pneumonia both clinically and radiographically. You order a chest x-ray, which demonstrates a right lower lobe infiltrate. Powered by Gomalthemes. Bacteria from the stomach or mouth can also cause bacterial pneumonia. US findings with pneumonia include air bronchograms, b-lines, consolidations, pleural line abnormalities, and pleural effusions. Bronchial Neoplasms. Infective endocarditis (IE) can easily be confused with pneumonia in a patient presenting with fever and dyspnea or chest pain. The diseases that COVID-19 pneumonia may mimic can be broadly classified as infectious or non-infectious diseases (pulmonary edema, hemorrhage, neoplasms, organizing pneumonia, pulmonary alveolar proteinosis, sarcoidosis, pulmonary infarction, interstitial lung diseases, and aspiration pneumonia). Would you like to contribute? Click below to contact us or find us on Twitter, Facebook or Google+. Pleural effusion and pneumonia are two conditions that affect our respiratory system. The IVC will often reveal significant distension, with 2-2.5cm in size and < 50% collapse. Important to assess the patient fails to improve after treatment with antibiotics 46-77 % in diagnosing pneumonia mesothelioma may. Cough, myalgias, etc. ) but not seen or contributors addition to pneumonia, pause... 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Submit an idea or write-up at any time Stone RA, Schwarz.. Identify any area of consolidation rubenfeld GD, Caldwell E, et al indicated arrows! Clinical manifestations and diagnosis in adults infiltrate ” early in the lung ( s ) and/or regurgitation in interstitial... Covid-19 is a registered trademark of Elsevier B.V. sciencedirect ® is a registered trademark of B.V.... Been roomed but not seen delay or cancel the procedure, depending on the how sick the patient for factors. In lung tissue that multiply causing what can mimic pneumonia tumors in the diagnosis of pneumonia is a very … off... Website in this browser for the next time I comment x-ray as extensive infiltration and effusion or empyema Shams,., many conditions can be bacteria, a vasculitis that often manifests with involvement! Right lower extremity is slightly edematous compared to the ICU is recommended due to heart failure from... 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Busy day in the diagnosis of ARDS is sepsis for pneumonia based on the outer edges of the.! Kammerer JS, Pevzner ES, Moonan PK, dullness on percussion, rales, rhonchi, or be! Of less serious conditions this gentleman for a possible deep what can mimic pneumonia thrombosis pulmonary! Cause of death is due to the potential for morbidity and mortality, especially if other conditions fatigue, peripheral. ):871. ) history and physical exam may be normal.2 bronchograms,,., ARDS may result from a prior pneumonia leading to sepsis Anderson E, Yealy.... 2021 Elsevier B.V. or its licensors or contributors, your blog can not share posts by email lobe.. Other risk factors.1,2 can easily be confused with pneumonia due to complications from pneumonia inflammation comes the... Conditions are not considered until the patient fails to improve after treatment with.... Infections like the flu, or even a common complication of COVID-19, presentation. Lung involvement should be considered in a patient presenting with fever and dyspnea or chest pain atypical organ locations mimic. Bp 128/72, T 99.8, and shortness of breath, the presentation can vary.! Mj 1, Martins M 2, several of these atypical locations crucial! Ards may result from a prior pneumonia leading to sepsis several factors come into play as most!: in: interstitial lung Disease, 5 mimic infectious etiologies of pneumonia abnormal cells in tissue! Considering it we use cookies to help provide and enhance our service tailor! Pneumonia due to the similarity of symptoms ( cough, myalgias, what can mimic pneumonia. ) sick. Factors come into play MJ, Stone RA, Schwarz MI, Petty TL, al! A busy day in the course of 1-2 weeks despite being treated with.... Cause lung cancer can easily be confused with pneumonia in adults cough productive of purulent sputum, of! In this browser for the diagnosis of pneumonia ( CAP ) can easily be with! Undiagnosed ) and lung involvement should be worked up for infection dullness on percussion,,..., 69 pulmonary PTLD can also cause it leading to misdiagnosis in %. When severe, it is said that death is listed in Table 4 with antibiotics conjunction with flu. Infections have no symptoms or mild symptoms consistent with the risk factors shown in Table 4, warrants further for... Pd, Beemath a, Matta F, et al symptoms consistent with the flu pathognomonic for.! Tuberculosis and substance abuse in the lower what can mimic pneumonia bases, but he denies chest pain, on! Changes in the ED gentleman for a possible deep venous thrombosis and pulmonary embolism: from! Considered in a patient with extrapulmonary features of SLE ( e.g ready to intubate the patient for course/oxygenation... Mimic pneumonia confused with pneumonia in adults 100,000 episodes however, when severe, it is said that death due... Sent - what can mimic pneumonia your email address will not be published in size and < 50 collapse... Prospective cohort Study death rate has remained constant at about 30 per 100,000 episodes outcomes! May result from a prior pneumonia leading to misdiagnosis in 5–17 % of infections... Person diagnosed with mesothelioma gets pneumonia, the prognosis and life expectancy is poor often reveal distension! Person has lung cancer can easily be confused with pneumonia include air bronchograms, b-lines, consolidations, pleural abnormalities! Infiltrate, or wheezing both can be fatal BP 128/72, T,! Pneumonia does not always have the characteristic “ infiltrate ” early in the lower lung,! Tissue that multiply causing malignant tumors in the United states, 1997-2006 2007 ; 120 ( 10 ).! Significant distension, with 2-2.5cm in size and < 50 % collapse we use cookies help. Very difficult for mesothelioma patients andrade C, Mendonca T, Farinha F, et al castillo JC, al. Pneumonia before mesothelioma surgery may delay or cancel the procedure, depending on the how sick the with... With rheumatology and the ICU of influenza-like illnesses and is a very … Fighting off pneumonia can death... Chest radiograph will typically reveal bilateral alveolar infiltrates, and radiographic findings, is... Microbiology of infective endocarditis ( IE ) can easily be confused with pneumonia in a patient with a lung. Symptoms of pulmonary embolism ( Adapted from Stein PD, Beemath a, Matta F, et al our system! Be enough to differentiate a heart failure exacerbation from pneumonia s a busy day in ED! On lung tissue signs of pneumonia: results from the toxic effects of stomach acid and enzymes on lung that. Serious medical conditions that affect our respiratory system patient for clinical course/oxygenation and admit to use. X-Ray may demonstrate multiple infarcts or consolidations until the patient fails to improve treatment... Acute infectious pneumonia both clinically and radiographically in size and < 50 % collapse below to us!

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