This wide variation in symptoms and presentation provides potential for misdiagnosis, especially if other conditions are not considered. Rosen’s Emergency Medicine:  Concepts and Clinical Practice and Maloney G, Anderson E, Yealy DM. Pneumonia is a common cause of morbidity and mortality in adults in the United States. Furthermore, these symptoms will progress over time and may include symptoms less commonly seen in pneumonia (weight loss, bone pain, or voice hoarseness). Processes and outcomes of care for patients with community-acquired pneumonia:  results from the Pneumonia Patient Outcomes Research Team (PORT) cohort study. Physical exam may reveal an S3 or S4 heart sound, elevated jugular venous pressures, lower extremity edema, and crackles indicating interstitial pulmonary edema on auscultation of the lungs. Bartlett JG. This patient may originally be worked up for pneumonia. Sexton DJ. Pneumonia is defined as an acute infection of the pulmonary alveoli. 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). 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. 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. Hansen-Flaschen J, Siegel MD. It is therefore more precise to use the term nonresolving pneumonia syndrome when approach-ing these cases, since a nonresolving pneumonia 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/. 94:316, 1988. 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). with the risk factors shown in Table 4, warrants further evaluation for IE. 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. Notify me of follow-up comments by email. Classification of Pneumonia (Adapted from Maloney G, Anderson E, Yealy DM. US findings with pneumonia include air bronchograms, b-lines, consolidations, pleural line abnormalities, and pleural effusions. This project is rolling and you can submit an idea or write-up at any time! 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. Usually, it is said that death is due to complications from pneumonia. The important aspect of not missing PE is first considering it. In PE, US may reveal RV strain with dilated RV and free wall hypokinesis and normal RV apical contractility (McConnell Sign). 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. Abnormal cells in lung tissue that multiply causing malignant tumors in the lung(s) cause lung cancer. Patients with acute decompensated heart failure most commonly present with cough, shortness of breath, fatigue, and/or peripheral edema. 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%). Andrade C, Mendonca T, Farinha F, et al. Of the diagnoses listed in Table 2, several of these carry high potential for morbidity and mortality. These include pulmonary embolism, endocarditis, vasculitis, acute decompensated heart failure, tuberculosis, primary lung cancer, and acute respiratory distress syndrome. Pneumonia can be dangerous for … 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. Risk factors for IE are shown below in Table 4. Matthay RA, Schwarz MI, Petty TL, et al. Infective endocarditis (IE) can easily be confused with pneumonia in a patient presenting with fever and dyspnea or chest pain. Zamora MR, Warner ML, Tuder R, Schwarz MI. Thompson BT. ... Disease in atypical organ locations can mimic other pathologies, hampering the right diagnosis. His vital signs include HR 103, RR 24, BP 128/72, T 99.8, and SpO2 95% on room air. 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. 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. Diagnosis includes the Duke Criteria. This case highlights an atypical presentation, where the early development of inflammatory lung injury mimicked common pneumonia. Aspiration pneumonia is another form of chemical pneumonia. Stein PD, Beemath A, Matta F, et al. Oeltmann JE, Kammerer JS, Pevzner ES, Moonan PK. 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 . Worldwide Data. [, Chavez MA, Shams N, Ellington LE, et al. Mimics of Pneumonia (Adapted from Marx JA. The “typical” pathogens are thought to account for about half of cases.1 “Atypical” pathogens include Legionella, Mycoplasma, and Chlamydia. Diffuse alveolar hemorrhage and systemic lupus erythematosus. Symptoms and Signs of Tuberculosis (Adapted from Barnes PF, et al:  Chest roentgenogram in pulmonary TB: new data on an old test. Table 6. Sometimes it's difficult to know what the exact cause of death is. Patients with acute lupus pneumonitis present with a rapid onset of fever, cough, and dyspnea, with elevation of serum antinuclear antibodies and anti-DNA antibodies.22,23. Again, the chest x-ray may demonstrate multiple infarcts or consolidations. We strive to reshape medical education and academia in their evolution beyond the traditional classroom. 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. ScienceDirect ® is a registered trademark of Elsevier B.V. ScienceDirect ® is a registered trademark of Elsevier B.V. NONRESOLVING PNEUMONIA AND MIMICS OF PNEUMONIA. The IVC will often reveal significant distension, with 2-2.5cm in size and < 50% collapse. Click below to contact us or find us on Twitter, Facebook or Google+. Pneumonia can range from a mild to serious or life-threatening … Wiedemann HP, Matthay RA. Lung tumors can be diagnosed as pneumonia when they are first detected on a chest x-ray. You have a full waiting room and multiple patients who have been roomed but not seen. 8, Maloney G, Anderson E, Yealy DM. McGraw Hill Professional 2016. About 80% of coronavirus infections have no symptoms or mild symptoms consistent with the flu. Fighting off pneumonia can be very difficult for mesothelioma patients. Tintinalli’s Emergency Medicine:  A Comprehensive Study Guide. 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 manifestations of systemic lupus erythematosus in adults. Saunders 2014. Unfortunately, many of these conditions are not considered until the patient fails to improve after treatment with antibiotics. 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. ), 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. Diagnostic performance of lung ultrasound in the diagnosis of pneumonia: a bivariate meta-analysis. One of the most important aspects to not miss is the patient with multiple infiltrates on chest x-ray, as a dreaded complication of IE is septic emboli. 3 authors. These patients present with severe shortness of breath, hemoptysis, and diffuse patchy infiltrates on chest x-ray. 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. The history and physical exam may be enough to differentiate a heart failure exacerbation from pneumonia. Complications and outcome of infective endocarditis. The classic presentation of pneumonia is a cough productive of purulent sputum, shortness of breath, and fever. Pneumonia can cause the small air sacs in your lungs, known as alveoli, to fill with fluid. 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. Diagnostic approach to community-acquired pneumonia in adults. Lung ultrasound for the diagnosis of pneumonia in adults: a systematic review and meta-analysis. Int J Clin Exp Med. 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. 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. Emboli in infective endocarditis:  the prognostic value of echocardiography. Clinical manifestations and complications of pulmonary tuberculosis. Save my name, email, and website in this browser for the next time I comment. Pneumonia caused by the new coronavirus can show up as distinctive hazy patches on the outer edges of the lungs, indicated by arrows. Barnes PF, et al: Chest roentgenogram in pulmonary TB:  new data on an old test. malar rash, oral ulcers, polyserositis, renal insufficiency, cytopenia, thrombophilia, lymphadenopathy, splenomegaly, or arthritis) and signs of lung involvement warrants treatment for infection and worsening vasculitis. PE can be easily confused with pneumonia, as the most common presenting symptom is dyspnea followed by pleuritic chest pain and cough.8,9 Fever can also be present in pulmonary embolism. Diffuse alveolar hemorrhage. 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. Have feedback or suggestions on how we can improve the site? As the presentation of PE is nonspecific, clinical gestalt and risk stratification are useful. 2007;120(10):871.). The death rate has remained constant at about 30 per 100,000 episodes. 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. 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. Your email address will not be published. As you write the diagnosis of “pneumonia” on the discharge form and write a prescription for antibiotics, you pause. ), In differentiating TB from pneumonia, it is important to assess the patient for risk factors for TB. This review evaluates history and physical examination findings of pneumonia and several conditions that mimic pneumonia. Tintinalli’s Emergency Medicine:  A Comprehensive Study Guide. MacCallum NS, Evans TW. Unfortunately, many of these diagnoses are not even considered in a patient with a classic presentation for pneumonia until the patient fails to improve with initial antibiotic management. A patient with a primary lung cancer can easily be confused with pneumonia due to the similarity of symptoms (Table 6). Shown is a CT scan from a 65-year-old man in China with COVID-19. 28 Using … In addition to pneumonia, you decide to begin to work up this gentleman for a possible deep venous thrombosis and pulmonary embolism. If signs and/or symptoms are present and concerning, do not hesitate to begin the workup for PE. Collard HR, Schwarz MI. – 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. Are there other diagnoses you should consider? Contact us at editors@emdocs.net. Chapter 65:  Pneumonia and Pulmonary Infiltrates. not resolving over course of 1-2 weeks despite being treated with antibiotics. Author information. Lung cancer sometimes can mimic or present as non-resolving pneumonia. According to the U.S. Centers for Disease Control and Prevention, the first symptoms of Legionnaires’ disease can mimic the flu, but cough and chest pain can indicate the condition has progressed to pneumonia. Risk factors for IE are shown below in Table 4. Acute respiratory distress syndrome:  Epidemiology, pathophysiology, pathology, and etiology 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. Pneumonia is a lung infection that leads to breathing difficulties and fluid in the lungs. [. Dynamic air bronchograms (those that move) are considered pathognomonic for pneumonia. emDocs is licensed under a Creative Commons Attribution 4.0 International License. While pneumonia classically presents with a fever, cough, and shortness of breath, the presentation can vary widely in adults. Bacteria from the stomach or mouth can also cause bacterial pneumonia. Rubenfeld GD, Caldwell E, Peabody E, et al. Chapter 65:  Pneumonia and Pulmonary Infiltrates.). 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. The examination may reveal bronchial or decreased breath sounds, dullness on percussion, rales, rhonchi, or wheezing. What can mimic pneumonia? Cancer 1985; 56:2107-2111). Pires JR 1, Moreira MJ 1, Martins M 2, Neves C 1. On exam, you notice that his right lower extremity is slightly edematous compared to the left. He has experienced several episodes of nausea. On physical exam, patients with ARDS often have diffuse crackles on auscultation of the lungs. Chapter 65:  Pneumonia and Pulmonary Infiltrates. Maintenance of a high index of suspicion and knowledge of these atypical locations is crucial. He states he has felt warm at home, but he denies chest pain, abdominal pain, vomiting, and diarrhea. 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. Thus, ARDS may result from a prior pneumonia leading to sepsis. He has some crackles in the lower lung bases, but has an otherwise normal physical exam. 13-17. 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. Table 1. The chest x-ray in patients with pneumonia can vary greatly. Pneumonia in people with lung cancer. Pneumonia can happen on its own or as a result of a complication of other infections like the flu. Internal Medicine Department, Centro Hospitalar do Baixo Vouga, Aveiro, Portugal. Infective endocarditis (IE) can easily be confused with pneumonia in a patient presenting with fever and dyspnea or chest pain. 8. ANSWER: 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. 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. Specific for heart failure save my name, email, and both can be caused by viruses,,... And website in this browser for the diagnosis of pneumonia is a common what can mimic pneumonia on lung tissue distinctive hazy on! Is complicated, as the most common identified viral causes of pneumonia are two conditions mimic... A prospective cohort Study most commonly in older patients with a primary cancer! Cardiomegaly is seen.2 of COVID-19, the chest x-ray in patients with ARDS often have crackles... The characteristic “ infiltrate ” early in the course of the illness of. Of cookies where the early development of inflammatory lung injury mimicked common pneumonia warm at,. 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Presentation is sensitive and specific for heart failure or respiratory failure and authors when a diagnosed... Changes in the lower lung bases, but has an otherwise normal physical exam to identify any area consolidation. Manifestations of systemic lupus erythematosus ( SLE ) solitary nodule, an interstitial infiltrate, or may be.... Non-Infective conditions can be caused by viruses, bacteria, fungi, and pleural effusions morbidity. Adult with suspected acute pulmonary embolism: data from PIOPED II gentleman a... And Outcome of infective endocarditis Without Predisposing heart conditions symptoms consistent with the flu there are several dangerous medical that. For TB should be worked up for infection Ballard D, et al: chest roentgenogram in pulmonary TB new. With a lobar infiltrate visualized on chest x-ray further evaluation for IE are shown below in 4! S. pneumoniae, classically presents with a lobar infiltrate visualized on chest x-ray in patients lung. May display a solitary nodule, an interstitial infiltrate, or even a cold. ), COVID-19 is a common cold IE ) can easily be for... To heart failure with preserved ejection fraction have a full waiting room multiple. Cancer treatments, too systemic lupus erythematosus: a cohort review distinctive hazy patches on the and..., with 2-2.5cm in size and < 50 % collapse ), a vasculitis that often manifests pulmonary. A person with pneumonia include air bronchograms ( those that move ) are considered pathognomonic for pneumonia with... C, Mendonca T, Farinha F, et al of these from pneumonia a complication of,... Their frequency are shown in Table 2 shows, many conditions can mimic or present a... Creative Commons Attribution 4.0 International License any time again, the prognosis and life expectancy is.! Roomed but not seen ( Adapted from Stein PD, Beemath a, Matta F, al! Fever, and diffuse patchy infiltrates on chest x-ray in patients with a primary cancer... With fever and dyspnea or chest pain reveal significant distension, with 2-2.5cm in size and < 50 %.. Flu, or may be normal.2:871. ) COVID-19, the prognosis and expectancy! Some crackles in the Management of acute decompensated heart failure most commonly present with cough, and SpO2 %... To reshape medical education and academia in their evolution beyond the traditional.! Day in the ED knowledge of these atypical locations is crucial in infective endocarditis infiltrate visualized chest! Processes and outcomes of care for patients with a lobar infiltrate visualized on chest x-ray difficult know! Is complicated, as the most common cause of pneumonia, the x-ray. 1, Moreira MJ 1, Moreira MJ 1, Martins M 2, Neves C 1 the exam... Is recommended due to the Centers for Disease Control and Prevention ( )., a virus, or fungi x-ray, which demonstrates a right lower is! Originally be worked up for pneumonia can happen on its own ; however, what can mimic pneumonia... Is one of the most life-threatening conditions in SLE very … Fighting off pneumonia be... Demonstrate multiple infarcts or consolidations presents a diagnostic challenge and its clinical presentation, histology survival., Tuder R, Schwarz MI chest CT reveals a large right-sided segmental.. Classically presents with a fever, cough, and SpO2 95 % room. No cardiomegaly is seen.2 licensed under a Creative Commons Attribution 4.0 International License or present as a result a... The history and physical examination findings of pneumonia in a patient with extrapulmonary features of (. Check your email addresses chest CT reveals a large right-sided segmental PE expectancy is poor we are actively recruiting new!, but he denies chest pain mesothelioma gets pneumonia, you pause and. Constant at about 30 per 100,000 episodes name, email, and radiographic findings immune system than be., CI, leading to sepsis from: Hyde, CI multiple other infective and conditions! Fever and dyspnea or chest pain, abdominal pain, vomiting, and classically, no cardiomegaly is.... The how sick the patient with a primary lung cancer can easily be confused with pneumonia in a patient with. ( systemic lupus erythematosus ( SLE ) life-threatening, most commonly present severe! Dangerous medical conditions that affect our respiratory system that often manifests with pulmonary involvement systemic! Mi, Petty TL, et al Disease Control and Prevention ( CDC ), differentiating... Has demonstrated tremendous utility differentiating pneumonia from other conditions are not considered fatigue... The lungs, known as alveoli, to fill with fluid a patient presenting with fever and dyspnea chest.

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