“Smoke on the water”: a challenging case of pneumonia

Excerpt

On May 2019, a 21-year-old man was admitted to Emergency Room of Careggi University Hospital in Florence (Italy), for acute dyspnea associated with high-grade fever (38 °C) and two episodes of mild hemoptysis (blood-tinged sputum). At initial evaluation, he appeared alert and agitated, tachypneic (30 breaths per minute), without sensory-motor deficits. O₂ saturation in room air was 83% and arterial blood gas analysis showed severe hypoxemic respiratory failure (PaO₂/FiO₂ 120 mmHg). He was hemodynamically stable (blood pressure 150/85 mmHg), with sinus tachycardia (110 beats per minute). High flow oxygen (FiO₂ 60%) was administered by Venturi mask with only partial improvement of hypoxemia and dyspnea. Initial blood exams are reported in Table 1. Chest X-ray and CT scan with contrast dye showed confluent lobular ground-glass opacities in a diffuse pattern, predominantly on the upper lobes, with partial sparing of basal and peripheral lungs’ fields (Fig. 1a, b); neither signs of pulmonary embolism, lymphadenopathy, nor pleural or pericardial effusions were detected. Molecular testing of nasopharyngeal swabs for adenovirus, influenza A and B viruses was negative. Empirical antibiotic therapy with piperacillin/tazobactam, azithromycin, and trimethoprim/sulfamethoxazole was initiated; thereafter the patient was transferred to the Intermediate Care unit for continuing care.

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