Dr. Hussam
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A 65-year-old male presents with a 3 day history of cough productive of green sputum with right sided chest pain on deep inspiration. He also reports high fever, rigors and a 5 pound weight loss in the past month. On physical exam he is noted to have a temperature of 38.5°C, RR 26, BP 120/80, HR=100 regular, poor dentition, injected pharynx, 0.5cm non-tender lymph nodes in anterior cervical area and decreased breath sounds at the right base, dullness to percussion at right base and course bronchi and rales at the right lower lobe. Sputum examination reveals ,10 epithelial cells, >25 WBC/LPF with numerous gram negative bacilli. Lab revealed a WBC of 13,400 with 60 segs, 14% bands, 30% lymphs and a serum Cr of 1.8. CXR shows a right lower lobe infiltrate with blunted costrophrenic angle. Based on the clinical presentation and the Gram stain the most likely diagnosis is:
A Klebsiella pneumoniae
B Mycobacterium tuberculosis
C Mycoplasma pneumoniae
D Pneumocystis carinii
E Staphylococcus aureus
F Streptococcus pneumoniae
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| milu
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A? they are gram (-) bacilli :|
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| bactitech
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The answer is (A). Kleb. pneumoniae is an enteric gram negative rod. M. tuberculosis won't stain on a gram stain. Neither will Mycoplasma or Pneumocystis. Staph. aureus presents on a gram as gram positive cocci in clusters, and S. pneumoniae are gram positive cocci in pairs and, if you're lucky, they will be textbook picture lancet shaped.
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| Dr. Hussam
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well i don't know the answer of this question, but i think its a tricky one, it should be mycobaterium, cuz all the clinical signs go with it, klebsiella doesn't make green sputum, its usually bloody or red currant jelly, besides there's a history of weight loss and enlarged lymph node, mycobacterium doesn't show with gram stain, so t hese gram -ve should be contamination, any ideas?
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| bactitech
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http://www.pulmonologychannel.com/tuberculosis/sy...
http://www.emedicinehealth.com/articles/17621-3.a...
Obviously I don't see the whole clinical picture down in the lab. What I DO see, and have seen over the course of a 30 year lab stint, 25 of which have been in microbiology, is LOTS and LOTS of specimens. I have seen every type and appearance of sputum known to man over the course of my career. I think characterizing sputum by color may be helpful, but you can't cash in all your chips with appearances. One of the sites above said that TB can present with bloody sputum also. A coworker became very ill with pneumonia about 15 years ago. He had been home sick. I was working alone in the evening when he came in looking extremely ill, disheveled, and diaphoresing. He gave me a sputum specimen (in a container :-)) and asked me to gram stain it right away and he left. It was yellow green in appearance. They had had him on two antibiotics that didn't do anything for him. I made the smear and looked at it immediately. It was absolutely loaded with pleomorphic gram negative rods = Hemophilus influenzae. I called his physician immediately and they put him in the hospital. This was in the days before Azithromycin and Biaxin. They had had him on erythro which didn't touch it, and possibly ampicillin, which is not a good bet nowadays and back then more amp resistant strains were showing up. Case in point - does H. influenzae ALWAYS make sputum look like that? It was certainly yellowish green. I actually used to play a game at night to see if I could "guess the pathogen" by the appearance of the specimen. The answer - not very often. Most sputum specimens are badly collected and very unreliable. Because of rejection criteria, a good percentage are discarded because they contain too much saliva (>25 epis/LPF).
So.....what I think is that this question just proves how difficult it is to diagnose pneumonia. What's to say that this patient couldn't have TB with a superimposed Kleb infection???? I obviously honed in on the gram stain because that's what I do for a living, but the doc has access to xrays, patient history, etc. which of course will help him make the decision to turf this to infectious disease :-).
I personally thought TB didn't necessarily present so quickly, i.e. three days. If the patient has COPD this obviously complicates matters, and if he's HIV or alcoholic, etc. then anything could be possible.
I would guess that the appearance of the xray might help correlate the lab results. He's obviously got somewhat of a left shift going on in his differential but his total WBC isn't that horrendously elevated. Serum creatinine of 1.8 is just a touch elevated but that could be a red herring. I don't know enough about xrays to totally understand what's up.
Diagnosis: ambiguous question.
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| bactitech
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Duplicate post removed.
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Clinical Microbiology since 1974
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| bactitech
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Duplicate post removed.
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| merrk
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Thanks, very interesting and practical info bacitech!
Dr. Hussum, the LN are not enlarged. Numerous GN bacilli are unlikely to be contaminants (though the numbers are not mentioned.
why does he have kidney failure? Is that connected?
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