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Wednesday, 27 November 2013

Lower respiratory tract infection - Pneumonia – The Misdiagnosis

Lower respiratory tract infection
The lower respiratory tract infection are the infection consisting of the trachea (wind pipe), bronchial tubes, the bronchioles, and the lungs, including the bronchitis and pneumonia. According to  The World Health Report 2004 – Changing History(1), in 2002 lower respiratory track infection were still the leading cause of deaths among all infectious diseases, and accounted for 3.9 million deaths worldwide and 6.9% of all deaths that year.
Pneumonia is defined as a condition of the inflammation of the lung as a result of infection, caused by bacteria, such as bacteria Streptococcus pneumoniae or influenza viruses in most cases. Fungi, such as Pneumocystis jiroveci, certain medication such as PPI Stomach Acid Drugs and other conditions such as impaired immune systems.
B.1. Misdiagnosis
In a study of a total of 518 patients, more patients in 2005 had a hospital admission diagnosis of community-acquired pneumonia (CAP) without radiographic abnormalities compared to 2003 (2005, 91 patients [28.5%]; 2003, 41 patients [20.6%]; p = 0.04), and more patients received antibiotics within 4 h of triage (2005, 210 patients [65.8%]; 2003, 107 patients [53.8%]; p = 0.007). Blood cultures prior to antibiotic administration increased (2005, 220 patients [69.6%]; 2003, 93 patients [46.7%]; p < 0.001). However, the final diagnosis of CAP dropped to 58.9% in 2005 from 75.9% in 2003 (p < 0.001). The mean (+/- SD) antibiotic utilization per patient increased to 1.66 +/- 0.54 in 2005 compared to 1.39 +/- 0.58 in 2003 (p < 0.001). There were no significant differences in PSI or CURB-65 scores, or mortality, according to St. John Hospital and Medical Center, linking antibiotic administration within 4 h of hospital admission (as a quality indicator) to financial compensation may result in an inaccurate diagnosis of CAP, inappropriate utilization of antibiotics, and thus less than optimal care(35).
According to medical malpractic help.com, the misdiagnosis of pneumonia include Influenza, or the flu, Chronic obstructive pulmonary disease, or COPD, Acute bronchiti(36).
1. Coccidioides
There is a report of a case of a 66-year-old man who was status-post bone marrow transplantation for chronic myelogenous leukemia was hospitalized with new onset rash, nausea, and vomiting and subsequently expired. A sputum culture collected on the day of death revealed heavy growth of C. recurvatus 6 days after collection. At autopsy, microscopic examination of the lungs revealed numerous thick-walled, nonbudding spherules ranging in size from 40 to 80 µm. Initial immunohistochemical staining of the formalin-fixed lung tissue was positive for Coccidioides(37).
2. Swine flu
There is a report of a 59-year-old man presented with a severe flu-like illness and widespread pulmonary infiltrates on chest x-ray. A rapid influenza direct test was positive and the patient was nursed in isolation. On subsequent review, a diagnosis of probable atypical pneumonia was made, which was confirmed with positive urinary serology for Legionella pneumophila and treatment with appropriate antibiotics was started(38). Another report of a case of Pneumocystis jiroveci pneumonia (PCP) in a renal transplant patient which was initially misdiagnosed as pandemic influenza H1N1(38a).
3. Tuberculosis
There is a report of a case of misdiagnosis of tuberculosis in a patient with pulmonary lymphogranulomatosis and destructive pneumonia in the presence of AIDS(39).
4. Adult-onset Still disease (AOSD)
Adult-onset Still disease (AOSD) is an uncommon inflammatory condition of unknown origin and pathogenesis. Pulmonary involvement is rare and includes pleuritis and transient radiological infiltrations. There is a report of two cases of AOSD characterized by lung involvement at presentation. Both were misdiagnosed as pneumonia with para-pneumo­nic effusion. We also discuss the difficulties in diag­nosis of AOSD with pulmonary infiltration(40).
4. Etc. 

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Sources 
(1) http://www.who.int/whr/2004/en/
(34) http://www.ncbi.nlm.nih.gov/pubmed/21848975
(35) http://www.ncbi.nlm.nih.gov/pubmed/12802780
(36) http://www.medicalmalpracticehelp.com/misdiagnosis/respiratory/pneumonia
(37) http://www.ncbi.nlm.nih.gov/pubmed/19147507
(38) http://www.ncbi.nlm.nih.gov/pubmed/22767692
(38a) http://www.ncbi.nlm.nih.gov/pubmed/22037439
(39) http://www.ncbi.nlm.nih.gov/pubmed/16279522
(40) http://www.ncbi.nlm.nih.gov/pubmed/22472935