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What Causes Deteriorated Breathing Despite Treatment For Pneumonia Klebsella?

Posted on Sat, 5 Apr 2014

Question: Dear XXXXXXX XXXXXXX This is regarding my dads diagnosis and treatment.We di CT scan and TB test as we waited for 6 weeks culture he got This scan was Oct by Nov end he contracted pneumonia klebsella. Post which he was treated in hospital but the lung retained a slight haze. Bronchoscopy was also done but didnt show any major issues. My question is: was cancer the only other test which we needed to do? His breathing deteriorated on 25th dec and he had to be put on ventilator on 26th he passed away.We have not been able to get closure and wonder what the reason was and a month back he seemed totally ok In this period of 1.5 months......did the Ct indicate pnemonia or is that something else he contracted. Should he have been on bed rest and not gone out at all in this period..........since Tb was negative we assumed its not so serious in that phase. Plus if u say cancer then .........if it was done earlier would cancer have been cured/controlled. In ICU the infection was controlled and wbc came down to 10 and later 6 he was going to be shifted to the ward when last 2 days he suddenly could not breathe properly and was going to be intubated when he passed away due to sudden dip in bp and cardiac arrest

Answered by Dr. Gyanshankar Mishra (6 hours later)

Brief Answer: Histological diagnosis might have been required. Detailed Answer: Hi, Thanks for posting the query on HCM. Since the query has been forwared to me, I would like to comment the following: 1. Its dishearting to know that you lost your dad to a lung disease. 2. The CT scans uploaded by you lead to various possibilities - COPD, ILD,Malignancy,Collagen vascular disease,other Benign lung disease - complicated by secondary infection / septicemia / aspiration / Thromboembolic phenomenon - leading to respiratory failure - cardiac arrest as end result. Any of the previous is a possibility based on your history. Considering his age, the recovery from such lung involvement is practically very difficult for the patient. 3. Some of the issues that can shed some light here are: a. was any cardiac involvement detected - investigations: ECG/ 2D Echo. b. Histological diagnosis could have helped - eg: FNAC from mediastinal lymph nodes, Pleural biopsy. But such an investigation is not without risks. c. Other blood investigations to rule out other diseases like collagen vasular disease/ sarcoidosis / TB, etc. d. Had he ever smoked in life? What was his occupation in his active years? Did he have any other disease in the past? 4. During the one month period , it all depended on his clinical condition whether rest was required or not. However rest does help in recovery and rest would have helped him since both CT scans show lung involvement. 5. Considering the differential diagnosis of cancer - If it was cancer then both the scans will be considered as advanced stage cancer as lung, pleura and mediastinal lymph nodes were involved. Maybe if the patient had consulted at an earlier time with suggestive symptoms then there is a possibility but that is totally hypothetical since the diagnosis of cancer itself is not confirmed. Plus if it was cancer, It would have been very difficult form him to tolerated the chemoradiotherapy regimes considering his age. 6. As pointed out above there are various possibilities of diagnoses in the absence of histopathological diagnosis. I am sure the patient was being worked up in the hospital till the last but such cases do happen as science of Medicine is not 100% predictable. Also it needs to be considered as to what level of invasive investigations can the patient tolerate in such cases. I hope I have answered your query. I will be glad to answer follow up queries if any. Please accept my answer if you have no follow up queries. Regards Dr. Gyanshankar Mishra MBBS MD DNB Consultant Pulmonologist

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Gyanshankar Mishra (4 hours later)

First - there is Ct scan in Oct -what did that indicate ? what was wrong then with his lungs -what treatment shoud he have started immediately.? We were awaiting bronchoscopy and biopsy post this.Did the delay worsen his condition or was he deterioating in OCT itself? We waited for TB results by which time he got worse.The deterioration in his lung if it was COPD -would it have got worse over time as before this he had not taken an xray and was on broncho dilators and mucolite 2) He smoked many years back -echo was normal.He had a bypass after which he never smoked in his 60s.Blood test for TB was awaited.What is the blood test for sarcodiosis and collagen? 3) How does one get klebsiella pneumonia. 4) How 3)

Answered by Dr. Gyanshankar Mishra (10 hours later)

Brief Answer: Based on CT no specific treatment could be started Detailed Answer: Hi, Thanks for the follow up. After going through the follow up query, I would like to comment the following: 1. October CT scan is suggestive of ILD changes with bronchiectasis with secondary respiratory infection. At that point the patient needed further evaluation - bronchoscopy, FNAC could be planned depending on risk evaluation profile, other blood investigations, etc.Medications like Antibiotics and bronchodilators would have been started at that stage. Since there was no specific etiological diagnosis at that stage, starting a specific treatment was not possible till further work up of the patient was done. 2. Being an ex smoker , he was at risk of underlying COPD. The previous bronchodilators would have been providing relief to his underlying COPD symptoms however at the time of presentation , the secondary infection would have led to its deterioration. COPD as a disease only progresses with time. 3. Investigations: Serum ACE levels and Mantoux test for sarcoid, Collagen vascular diseases- extractable nuclear antigen profile, ANA, etc. 4. Kleibsella pneumonia is contracted by inhalation route. I hope I have answered your query. I will be glad to answer follow up queries if any. Please accept my answer if you have no follow up queries. Regards Dr. Gyanshankar Mishra MBBS MD DNB Consultant Pulmonologist

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar

Follow up: Dr. Gyanshankar Mishra (5 hours later)

1) Dr what could have been the secondary infection in Oct? 2) Could he have contracted klebsiella in hopsital? 3) Why didnt it go inspite of treatment 4) Why did he get well and then go breathless after 10days when everone felt he was ok. (WBC 6 eyc) 5) The CT was done in OCt -did we delay his treatment by waiting for brochoscopy after 4 weeks waiting for TB result. 6) he ahda consolidation in his right lung which they never could find what itwas - so theye gave TB medication too -could that have beend etrimental. 7) They ddid serum ACE and Broncho later from ICU which showed nothing wrong. So what else could it have been Dr - if we know what caused his death and if it could have been prevented will help.Was his lung really bad if he didnt contract klebsiella would he have lived for long?

Answered by Dr. Gyanshankar Mishra (2 hours later)

Brief Answer: Answers are listed below. Detailed Answer: Hi, Thanks for posting the query on HCM. Since the query has been forwared to me, I would like to comment the following: 1) Dr what could have been the secondary infection in Oct? Ans: In absence of a culture dst report, it is difficult to predict the exact organism but gram negatives and anaerobes could have been the culprit. 2) Could he have contracted klebsiella in hopsital? Ans: He could have contracted it anywhere, considering his age and already diseased lung. Bronchiectasis can represent old healed sequelea of infection (any respiratory infection in the past). Any previous Xray / CT scan can help. 3) Why didnt it go inspite of treatment Ans: The infection could have been due to a drug resistant strain. 4) Why did he get well and then go breathless after 10days when everone felt he was ok. (WBC 6 eyc) Ans: His underlying lung was never normal after his diagnosis in OCT 2013. A control of infection could have led to symptomatic improvement however, a repeat infection could have led to re appearance of symptoms. (Risk factors: old age, Diseased lungs). 5) The CT was done in OCt -did we delay his treatment by waiting for brochoscopy after 4 weeks waiting for TB result. Ans: The treatment and management protocol is best assessed by the doctor who has clinically assesses the patient. Bronchoscopy being an invasive procedure and not without its risk in old aged patients could have been planned by the managing doctor at a later stage due to the patient’s clinical status plus the doctor might have wanted to check the TB results first which if positive could have avoided bronchoscopy. 6) he ahda consolidation in his right lung which they never could find what itwas - so theye gave TB medication too -could that have beend etrimental. Ans: Empirical anti tb drugs is justified in such cases where there is a possibility of TB and cannot be 100% ruled out. If the patient is under regular medical follow up then such medications should not be detrimental. 7) They ddid serum ACE and Broncho later from ICU which showed nothing wrong.: Ans: did the XXXXXXX report show any infection? So what else could it have been Dr - if we know what caused his death and if it could have been prevented will help.Was his lung really bad if he didnt contract klebsiella would he have lived for long? Ans: Retrospectively its very difficult to point that something went wrong as sometimes inspite of everything being done medically correct, its difficult to change the end result.As pointed in my previous posts any of the conditions could have been responsible for the adverse outcome: “COPD, ILD,Malignancy,Collagen vascular disease,other Benign lung disease - complicated by secondary infection / septicemia / aspiration / Thromboembolic phenomenon - leading to respiratory failure - cardiac arrest as end result.” I am sure work up was going on till the very end. I hope I have answered your query. I will be glad to answer follow up queries if any. Please accept my answer if you have no follow up queries. Regards Dr. Gyanshankar Mishra MBBS MD DNB Consultant Pulmonologist

Above answer was peer-reviewed by : Dr. Chakravarthy Mazumdar