Dr. Vivek Chail
General Practitioner
The following is an actual conversation between an iCliniq user and a doctor that has been reviewed and published as a Premium Q&A.
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Patient's Query
Hello doctor,
My mother was admitted to hospital nine months back with a catheter-related UTI. She was also hypothermic. Tests revealed that the UTI had become urinary sepsis. She was given IV antibiotics for this. Her legs were swollen with edema, as was her lower abdomen, but her chest was clear. She had three chest X-rays taken while she was in the hospital. I have attached these radiographs for your analysis. She developed sudden hypoxemia (SpO2 dropped to 70) and was given supplemental oxygen to saturate her blood. A stethoscope detected bilateral crepitations in her lungs. She had no cough, no tachycardia and no fever (she remained hypothermic throughout her stay in the hospital). Her leg edema remained during her time in hospital. The comments that accompanied her radiographs consisted of just a few ambiguous words. They included question marks and failed to make definitive diagnoses. This is why I am sending the radiographs to you. I need to know specifically what was happening in her lungs.
Hi,
Welcome to icliniq.com.
The chest X-ray done shows mildly increased bilateral lung markings and a mildly enlarged cardiac shadow (attachment removed to protect patient identity). There are no serious concerns about this X-ray. In the chest X-ray done a few days later, there is a generalised haziness in the left lung in addition to the prominent lung markings and the mildly enlarged cardiac shadow. Depending on the clinical signs, the possibilities can be a unilateral pneumonia or pulmonary edema. However, in literature, pulmonary edema is usually unilateral on the right side and without cardiac enlargement. In the chest X-ray done four days later, there are randomly distributed peri hilar opacities in the bilateral lungs and on seeing carefully there are air bronchograms and this is likely a picture of disseminated pneumonia. The other possibility being a diffuse pulmonary edema.
Thank you.
Patient's Query
Hi doctor,
Thank you for the reply.
When you list diffuse pulmonary edema as the other possibility after disseminated pneumonia, do you mean the cardiogenic variety of pulmonary edema? I am guessing so (due to the diffuse infiltrates, enlarged heart, and air bronchograms).
Hi,
Welcome back to icliniq.com.
A cardiogenic pulmonary edema is a possibility only if she had features of mitral regurgitation, congestive heart failure or left heart failure. I am not sure if she had any of the above. Otherwise, it would be a differential diagnosis between non-cardiogenic pulmonary edema and disseminated pneumonia.
Thank you.
Patient's Query
Hi doctor,
Thank you for the reply,
She had some features of congestive heart failure (leg edema, hypoxemia, crackles breathing, hypothermia), and as you observed, enlarged heart shadow, as well as asthma, all of which made me wonder if the pulmonary edema you mentioned as a possibility might be cardiogenic. So the most likely diagnosis is disseminated pneumonia, with the other possibility diffuse pulmonary edema?
My mother had no history of aspiration, she could swallow well, and she had a functional gag reflex. There were no instances of her choking (or even coughing) while in the hospital. The radiographs details are not compatible with aspiration. Do you agree?
Hi,
Welcome back to icliniq.com.
I do not feel it can be from aspiration. To me, it looks like disseminated pneumonia which has evolved in about 10 to 12 days while in the hospital. This can, however, be linked to the urosepsis which is the most likely triggering factor in this situation. I am not aware of the bacteria isolated from urine and blood samples. Sometimes it can be the same bacteria in two organ systems and at times it can be a mixed infection. Pulmonary edema is a second possibility.
Thank you.
Patient's Query
Hi doctor,
Thanks for the reply,
Like you, I do not think my mum's chest radiographs show aspiration-related infection or aspiration-related injury. The opacity patterns are incompatible with an aspiration cause. Thank you for explaining that the radiographs show either disseminated pneumonia that evolved during my mum's stay in the hospital (the most likely diagnosis) or pulmonary edema (the other possible diagnosis). In your previous reply you said you do not feel the damage to my mum's lungs can be from aspiration. I agree with that. Am I correct in thinking that my mum's radiographs show no evidence of aspiration having occurred? And whether those radiographs show disseminated pneumonia or pulmonary edema, it was caused by something other than aspiration?
Thank you as always for your help and understanding.
Hi,
Welcome back to icliniq.com.
When studying radiographs like that of your mother, we surely would like to know about the white blood cell counts, and blood culture reports, and any persisting fever. Usually, pneumonia during hospital stays is bacterial and in most cases, there will be supporting findings like persisting fevers, high blood cell counts, and an occasional pathogen isolated from a blood culture. If the conditions favoring an infection are not satisfied then we think of pulmonary edema being the cause of the radiograph pattern. At times there can be a mixed picture in a patient with sepsis and it is difficult to single out an infection from pulmonary edema in severe cases.
Thank you.
Patient's Query
Hi doctor,
Thank you for the reply,
When I asked if the opacities in my mum’s radiographs might be the result of aspiration, you replied that you do not feel it could be from aspiration. This is agreed with what I already believed that my mum did not aspirate. So presumably the opacity patterns in radiographs that show aspiration pneumonia or aspiration-related pulmonary edema look different from the opacity patterns in my mum’s radiographs? In other words, the opacity patterns in my mum’s radiographs show no evidence that aspiration had occurred.
I did not think that my mum had aspirated. Your observations have backed up my opinion on that. Thanks to you, I know that my mum's radiographs show disseminated pneumonia or pulmonary edema, caused by something other than aspiration. I am interested in how the opacity patterns allowed you to determine this. As always, I appreciate your help and your patience.
Thank you again.
Hi,
Welcome back to icliniq.com.
Usually, we see opacities in a lobar or segmental distribution in aspiration pneumonia chest X-rays. In most cases, the opacities are in the lower lobes (right more than left) due to the position of the patient when aspiration might have taken place. Having said that, an atypical presentation of aspiration pneumonia is less likely but cannot be ruled out completely.
Thank you.
Patient's Query
Hi doctor,
Thank you for the reply,
Are my mum's radiographs typical of those showing pneumonia from inhaled bacteria or co-infection from blood sepsis? (You mentioned before that her urinary sepsis could have been a co-factor present in more than one body system.) Also, are her radiographs typical of those showing pulmonary edema?
Thank you in advance.
Hi,
Welcome back to icliniq.com.
In the hospital setting it can get difficult to tell isolated pulmonary edema from a co-existing bacterial infection if a patient is seriously ill. Often we match the clinical features and the X-ray images. Pulmonary edema adds to the burden of infection. Bacteria have many routes of entry and usually, the first manifestations of the disease are important to know the probable route of entry. Blood sepsis infection spreads more quickly than the inhaled route.
Therefore in the case of your mother, it will help to know the details of clinical findings and when she started worsening, and what were the first manifestations of serious disease.
Thank you.
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