Journal of Global Infectious Diseases

LETTER TO EDITOR
Year
: 2015  |  Volume : 7  |  Issue : 3  |  Page : 119--120

A red flag for community-acquired pneumonia in the elderly


Tanmay S Panchabhai1, Debabrata Bandyopadhyay1, Valeria Arrossi2, Kyle D Brizendine3, Muzaffar Ahmad1,  
1 Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland, Ohio, USA
2 Pathology and Laboratory Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA
3 Department of Infectious Disease, Medicine Institute, Cleveland Clinic, Cleveland, Ohio, USA

Correspondence Address:
Tanmay S Panchabhai
Department of Pulmonary, Allergy and Critical Care Medicine, Respiratory Institute, Cleveland, Ohio
USA




How to cite this article:
Panchabhai TS, Bandyopadhyay D, Arrossi V, Brizendine KD, Ahmad M. A red flag for community-acquired pneumonia in the elderly.J Global Infect Dis 2015;7:119-120


How to cite this URL:
Panchabhai TS, Bandyopadhyay D, Arrossi V, Brizendine KD, Ahmad M. A red flag for community-acquired pneumonia in the elderly. J Global Infect Dis [serial online] 2015 [cited 2020 Jul 9 ];7:119-120
Available from: http://www.jgid.org/text.asp?2015/7/3/119/146383


Full Text

Sir,

Advanced age is associated with defects in innate and adaptive immunity, called immunosenescence. [1] As a result, apparently immunocompetent patients become susceptible to many opportunistic infections. [2] The clinical features of sepsis are distinct in elderly individuals. We describe an elderly female patient who presented with community-acquired pneumonia, which posed a considerable diagnostic challenge, leading to significant delay in appropriate intervention.

An 84-year-old Caucasian female presented with nonproductive cough, decreased appetite, and malaise of 2 months' duration. She was initially diagnosed as right middle lobe pneumonia and had received three courses of antibiotics. However, her symptoms continued to worsen and she required 5 liters oxygen via nasal cannula. She had no history of fevers, chills, night sweats, weight loss, or skin rash. She had past history of hypertension, hyperlipidemia, and chronic atrial fibrillation.

Initial laboratory data demonstrated elevated calcium with 1,25-dihydroxyvitamin D 3 , parathyroid hormone, parathyroid-related peptide, serum M-protein, and angiotensin-converting enzyme level. All primary relevant microbiology evaluations were normal. A computerized tomography (CT) scan of the chest showed partial collapse and consolidation of the right middle lobe, and a 15-mm cavitary lesion situated inferiorly [Figure 1]. {Figure 1}

The patient underwent bronchoscopy with normal airway examination, and bronchoalveolar lavage (BAL) and transbronchial biopsies (TBBx) were performed from the right middle and lower lobes, respectively. The BAL cultures were negative. The TBBx demonstrated interstitial pneumonitis with histiocytic infiltrates and vaguely formed non-necrotizing granulomas [Figure 2]a and b. The hematoxylin-andeosin (H&E) and Gomori's methenamine-silver (GMS) stains showed several yeasts morphologically consistent with Histoplasma species within the cytoplasm of the infiltrating histiocytes [Figure 3]a and b. The patient's serum fungal battery for histoplasma antibody and urinary histoplasma antigen were later reported as positive. Therapy with intraconazole was initiated for the diagnosis of acute diffuse histoplasmosis. Her symptoms improved remarkably, and her oxygen was weaned down. A follow-up chest X-ray at 8 weeks showed complete resolution of the lesion.{Figure 2}{Figure 3}

Histoplasma capsulatum is the most common endemic mycosis in the US. [3] The lungs provide a portal of entry for this fungus. Acute histoplasmosis is often self-limited, and the symptoms are usually mild in immunocompetent hosts. Ledke et al. noted certain age-related differences in the characteristics of histoplasmosis. [4] The asymptomatic presentation, acute histoplasmosis, chronic cavitary lesion similar to mycobacterial tuberculosis, and absence of hilar lymphadenopathy are more common in the elderly population. [4] Chronic progressive histoplasmosis, also commonly described in the elderly population, manifests with minimal symptoms but electrolyte abnormalities. Histoplasmosis characteristically causes necrotizing granulomatous inflammation, leading to hypercalcemia, which is less likely to occur in immunocompromised individuals.

Treatment is indicated in the elderly with acute pulmonary histoplasmosis if symptoms persist for longer than a month or in case of a severe disease burden. [5] This infection is commonly treated with itraconazole in the elderly and not amphotericin, given the risk of nephrotoxicity. [4],[5] Chronic progressive pulmonary histoplasmosis should be treated, even if it is minimally symptomatic.

The clinical outcome of fungal infections is also likely to be worse in elderly patients because they are less able to cope with the burden of endemic mycosis, owing to age-related changes in innate and adaptive immunity. A high index of suspicion should be harbored for acute pulmonary histoplasmosis in elderly patients presenting with atypical features of community-acquired pneumonia.

References

1Grubeck-Loebenstein B, Wick G. The aging of the immune system. Adv Immunol 2002;80:243-84.
2Kauffman CA. Endemic mycoses in older adults. Infect Dis Clin Pract 1995;4:41-5.
3Kauffman CA. Endemic mycoses: Blastomycosis, histoplasmosis, and sporotrichosis. Infect Dis Clin North Am 2006;20:645-62.
4Ledtke C, Tomford JW, Jain A, Isada CM, van Duin D. Clinical presentation and management of histoplasmosis in older adults. J Am Geriatr Soc 2012;60:265-70.
5Kennedy CC, Limper AH. Redefining the clinical spectrum of chronic pulmonary histoplasmosis: A retrospective case series of 46 patients. Medicine (Baltimore) 2007;86:252-8.