Pneumonia gone bad

aka Pulmonary Puzzler 004

Consider a 56 year old male with no past medical history presenting with 10 days of fevers, chills, myalgias and cough followed by worsening breathlessness over the past 4 days.

His admission chest X-ray is shown below:


Q1.  Describe the chest X-ray findings

Answer and interpretation

The chest X-ray demonstrates a dense alveolar infiltrate involving the lateral aspect of the left mid-zone.

The patient rapidly deteriorated with fulminant shock, multi-organ failure and worsening oxygenation. The following chest ray is taken shortly after ICU admission:

Q2. What devices are present on the chest X-ray?

Answer and interpretation


  • right IJ central line
  • left IJ vascath (dialysis catheter)
  • nasogastric tube
  • endotracheal tube

Q3. Which device is in the wrong place and where should it be?

Answer and interpretation

The left IJ vascath is in too far.

Central lines and vascaths should not be inserted beyond the superior extent of the pericardial reflection (which corresponds to the take off of the right main bronchus) because beyond this point they can erode through the superior vena cava or the right atrium / ventricle leading to pericardial tamponade and death.

A subsequent chest X-ray is as follows:

Q4. What has happened since the previous chest x-ray?

Answer and interpretation

A chest drain has been inserted draining the left pleural effusion and the vascath has been pulled back to an appropriate position.

The following microbiology is obtained:

Q5.  What is the diagnosis?

Answer and interpretation

The overwhelming evidence here points to a diagnosis of Streptococcus pyogenes pneumonia, bacteraemia and empyema!

The clinical history suggests the possibility of a bacterial infection complicating influenza and, indeed, this turned out to be the case

Influenza may predispose to invasive group A Strep disease (at least it does in mice)

Q6.  What is the prognosis?

Answer and interpretation

In a series of 2079 cases of invasive group A Strep infection, the case fatality rate was 38% for pneumonia, compared with 26% for patients with necrotizing fasciitis.


Pulmonary Puzzler-LITFL 700


Pulmonary Puzzler

Intensivist in Wellington, New Zealand. Started out in ED, but now feels physically ill whenever he steps foot on the front line. Clinical researcher, kite-surfer  | @DogICUma |

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