A 54-year-old male nonsmoker is seen with complaints of a flulike illness. Initial symptomatic treatment is provided. Two days later, he returns, as he is still not feeling well. His primary physician prescribes a macrolide along with the symptomatic treatment. After 5 days of this treatment, the patient says he is running a fever and has increasing fatigue, weakness, and cough. He also complains of pain in the right wrist with some difficulty in motion. He has left groin pain and is unable to walk more than a few steps. On physical exam, vital signs are: pulse 110 bpm; temperature 102degF; respirations 24/min; blood pressure 10/68 mm Hg. He looks weak and says he has lost about 8 lb in the last 10 days. Peinent findings: lung exam reveals area of egophony, and E to A changes in the left anterior and posterior lung field. The patient has swelling with some areas of skin sloughing in the right wrist and tenderness with limitation of movement in the left groin area. Laboratory data: Hb 11 g/dL; Hct 33%; WBCs 16.0/uL; differential 90% segmented neutrophils; BUN 42 mg/dL; creatinine 1.1 mg/dL; sodium 142 mEq/L; potassium 3.4 mEq/L. ABGs on room air: pH 7.45, PCO2 34 mm Hg; PO2 65 mm Hg. CXR is shown.Associated findings may include all of the following except?
This x-ray shows a nonhomogeneous airspace density in the left middle and lower zones with areas of incomplete consolidation and evolving pneumatocele formation. The left diaphragm is raised and the trachea appears shifted to the left, suggesting loss of volume of the left lung. There is minimal blunting of the left costophrenic angle, suggesting a left pleural effu-sion. This CXR is consistent with the left lower lobe necrotizing pneumonia with loss of volume, which can be seen in staphylococcal pneumonia. The prodrome of a flulike illness and the development of pneumonia along with multisystem involvement suggest a bacteremic process. Both staphylococcal and pneumococcal pneumonia can produce this picture. However, the signs of the loss of volume in the left lung along with the necrotizing airspace disease or pneumatoceles suggest that this is more likely staphylococcal pneumonia. Associated conditions include septic ahritis, endocarditis, and brain abscess. Reye syndrome is unlikely in an adult and is not an applicable choice here.
Septic ahritis
Endocarditis
Brain abscess
Reye syndrome
Respiratory system