Nuts & bolts of the situation: chronic productive cough, green sputum
occasionally hemoptysis, SOB, chills & night sweats - all indicating
an infection but is afebrile with only slight increased RR and elevated WBC.
CT shows Right sided emboli but also shows
changes in the Left lung consistent with chronic bronchial and alveolar
disease (bronchial wall thickening, mucus plugging and bronchial
secretions on the L side + patchy bibasilar atelectasis).
Treated for emboli with ongoing cough, pleurisy,
sputum and intermittent Sob, wheeze. Mounts a fever 102 on Day #2 with
negative CXR, but WBC increases over following days with CXR showing
haziness in left lower lung Day #5. Procalcitonin
is negative as are blood cultures. Started on Levaquin and
The chronic green sputum, cough
and chills are not explained by acute PE. The abn CT lung is not
Conclusion: Most likely this is acute PE with
chronic bronchiectasis and acute infective bronchitis. This is a
hospital complication definitely but doubt that it is a pneumonia.
The discussion continued to include:
- the inciting reasons for the 3rd chest x-ray
were fatigue/tachycardia which are very nonspecific
- So if a patient comes in with infective bacterial bronchitis which
progresses to PNA during hospital admission, is that a hospital acquired
PNA? I guess technically it is but the wording does not reflect the
situation as it implies the patient picked up the infection in the hospital
which this patient likely did not.
- how long does it take from onset of symptoms to imaging findings in pneumonia typically on CXR? How soon does a PNA show on
a CT scan vs CXR? : a Pulmonologist joins in with: CXR can lag by as much as 5 days depending on the fluid status and the
technique (portable versus proper position versus penetration). The CT
scan shows abn earlier but there hasn’t been a specific study of time
course as far as I
know. CT PE is not the best for PNA, and “ground glass” may be an
alveolitis versus bronchiolitis versus early pneumonitis.
- "This is a
hospital complication definitely "...Is it? It was POA!
Clearly there is an infection from the start (be it viral or bacterial).
line question: how do we code the presumed bacterial PNA that was
treated after day 5? It clearly was in evolution since before