Case history
Case history #1
A 64-year-old man presents with fever, cough productive of copious sputum with a putrid odour, and malaise. He is unable to assign the exact onset of his symptoms but claims they have developed over at least 1 month. He lives alone and is a long-time smoker with a history of chronic alcohol misuse. He also reports the occasional use of illicit drugs. Over the past year he has been admitted twice to the local emergency department after being found unconscious due to alcohol intoxication. On physical examination he looks profoundly malnourished and his dental hygiene is very poor. Auscultation of the chest reveals fixed amphoric breath sounds over the right hemi-thorax. A sputum culture grows a mixed microbial population of aerobes and anaerobes.
Case history #2
A 75-year-old woman with a long history of poorly controlled diabetes mellitus presents with fever, non-productive cough, and malaise. Her symptoms began acutely 48 hours earlier, and she self-medicated with a macrolide antibiotic. Physical and radiological examinations confirm the diagnosis of left upper lobe pneumonia. She is admitted to hospital and an aminopenicillin is added to her treatment. Although she initially shows a marginal clinical improvement (but never complete apyrexia), over the next few days her fever gradually worsens, the cough becomes productive, and her lung function deteriorates. Chest CT scan reveals spread of the existing pneumonia and development of multiple cavitating lesions with air-fluid levels. A bronchoscopy is performed, and the culture of the obtained bronchoalveolar lavage fluid grows Klebsiella pneumoniae.
Other presentations
Clinical manifestations may occasionally be subtle. In patients with diabetes mellitus, lung abscess due to K pneumoniae presents with acute symptoms, often with concomitant bacteraemia, non-putrid sputum, delayed resolution of fever, and multiple cavities visible radiographically.[5]
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