Imaging Case of the Week 3

A 50 year old male patient presents with high fever, cough and dyspnoea. He has a history of type II diabetes and alcohol abuse. The chest xray obtained is shown. What is your diagnosis and what antibiotics would you use to treat this patient?

[peekaboo_link name=”Answer”]Answer[/peekaboo_link] [peekaboo_content name=”Answer”]

The chest xray shows pneumonic consolidation in the right upper lobe. There is an old left clavicular fracture with screw in situ. But there are two additional features on the xray which are concerning. You probably have already noticed a cavity with fluid level within the consolidated area. There is also a `bulging fissure sign` which is essentially sagging of the horizontal fissure.

In an immuno-compromised patient or a patient with history of chronic alcoholism or diabetes with pneumonia, one should keep in mind the possibility of infection with unusual organisms especially gram negative organisms such as Klebsiella. The bulging of the horizontal fissure is due to heavy exudative process which can be seen in infections due to Klebsiella, Streptococcus pneumoniae, Staphylococcus aureus and occasionally Legionella. Cavitation with bulging horizontal fissure strongly supports Klebsiella aetiology (also known as Friedlander`s pneumonia). There is a predilection for upper lobe.

It is important to initiate gram negative antimicrobial cover for these patients. Therapeutic guidelines suggests ceftriaxone or gentamicin or tazocin cover if Klebsiella is suspected as the cause.