Case 14-2000

Abstract

A 60-year-old man was admitted to the hospital because of pneumonia.The patient had been well until 10 days earlier, when exertional dyspnea developed, with chills, fever, and night sweats. Two days later, his temperature rose to 40°C. Four days before being admitted to this hospital, he was admitted to another hospital, where a radiograph of the chest showed one area of consolidation in the left lower lobe, another area in the right upper lobe, and a small left pleural effusion. The white-cell count was 12,700 per cubic millimeter, with 60 percent neutrophils and 26 percent band forms. Specimens were obtained for culture. Cefuroxime therapy was begun, and cefuroxime was subsequently replaced by ceftriaxone, gentamicin, and erythromycin. The temperature rose to 40°C daily, and daily headache was reported. A sputum culture yielded gram-negative rods, which were suspected to be a species of haemophilus. By the fifth hospital day, the pleural effusion had enlarged. Microscopical examination of a sputum specimen revealed occasional gram-positive diplococci and a few gram-variable bacilli. The patient was transferred to this hospital.The patient worked on a farm on the island of Nantucket, Massachusetts, where he was exposed to chickens, turkeys, horses, sheep, and domestic rabbits; he was not aware of any exposure to wild rabbits or deer. Seven years before admission, he had been treated with an antibiotic for Lyme disease. He was allergic to amoxicillin. His father had died of psittacosis and cardiac disease, and his mother had died of sarcoidosis. There was no history of wheeze, productive cough, hemoptysis, pleuritic chest pain, nausea, vomiting, diarrhea, weight loss, recent trav-el, or exposure to persons with tuberculosis or other acute illnesses, and there were no risk factors for human immunodeficiency virus (HIV) infection.The temperature was 38.5°C, the pulse was 75, and the respirations were 22. The blood pressure was 100/80 mm Hg.On examination, the patient was slightly tachypneic. No skin lesions or enlarged lymph nodes were found. Dullness and crackles were present at the base of the left lung, with egobroncophony, and consolidation was detected at the apex of the right lung.Laboratory tests were performed (Tables 1 and 2).