Case Report: 51 year old man with worsening pneumonia while hospitalized

History

51 yo with increasing shortness of breath, cough and weakness over a period of a few weeks.

  • No previous significant past medical history
  • Low grade fever
  • Works as a custodian and was subjected to a lot of second-hand smoke

His initial CXR:

Initial CXR

Hospital Course

  • Initially placed on Rocephin, Levaquin and Doxycycline
  • Started on Solumedrol IV for several days.
  • Initial culture of sputum: Normal flora; Influenza culture: Negative
  • Had a bronchoscopy 5 days after admission for worsening respiratory distress: negative stains for Pneumocystis (PJP). Gram stain showed “few Gram positive cocci. Culture grew “yeast and normal respiratory flora”
Near completion of therapy inpatient
CXR after persistent worsening of his shortness of breath

On account of CXR findings, a CT scan was ordered:

CT pulmonary and parenchymal views (different levels)

Question 1: What process is likely being depicted in this CT scan?

  • The patient underwent a Video-Assisted Thoracoscopic surgery (VATS) with decortication on account of the findings)
  • Cardiothoracic (CT) surgery found an area of necrotic tissue in the setting of the Right lower lobe process and a thick pleural peel.

Pathology contacted the physician after their review:

H and E stain Pulmonary Parenchymal Tissue
Specialized stains: Lung tissue High Power

Question 2: What is the name of the specialized stain shown above? Why is it used?

Question 3: What is shown using this specialized stain?

Question 4: What do you suspect was the diagnosis and likely risk factors? Hint: Risk factors are from history, hospital course and discovered (at least 3).

Click for the answer to this week’s ID Case Report Challenge.

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