PMC3988709_01
(a) Chest X-ray on admission with diffuse bilateral infiltrates. (b) 2 weeks after admission, intubated, receiving TMP/SMZ plus broad-spectrum antibiotics, after a 5-day immunoglobulin infusion course. First appearance of ground glass opacification and cystic/bullous lesions. Pseudomonas aeruginosa isolated from blood cultures. (c) 3.5 weeks after admission, short term clinical improvement.
CRIM2014-801805.001.jpg
PMC3988709_01_CRIM2014-801805.001.jpg
fig1
The initial chest X-ray (CXR) showed bilateral diffuse infiltrates arising from the perihilar regions (Figure 1(a)). While the patient was receiving the above-described therapy and was showing minimal improvement, his CXR was evolving and showed ground-glass opacification and bullous-type lesions at the upper lung fields bilaterally (Figure 1(b)). The patient's clinical condition improved significantly almost 2 weeks after appropriate antimicrobial and adjunctive therapy (Figure 1(c)).
(a) 5 weeks after admission, new respiratory failure, bullous lesions, and dense infiltrates. (b) 7 weeks after admission, receiving again TMP-SMZ, now with clindamycin, and antipseudomonas antibiotics (colistin, ciprofloxacin, and imipenem), after the 2nd immunoglobulin infusion course. (c) 9 weeks after admission, radiologic deterioration of dense infiltrates. Pseudomonas aeruginosa still isolated from bronchial samples, no other pathogen identified. (d) 10 weeks after admission, significant clinical improvement. (e) 11 weeks after admission, before hospital discharge.
CRIM2014-801805.002.jpg
PMC3988709_01_CRIM2014-801805.002.jpg
fig2
New CXR and computed tomography (CT) scans revealed worsened dense infiltrates and bullous lesions (Figure 2(a)). Patient's CXR continued to evolve during therapy and P. aeruginosa was repeatedly isolated from bronchial secretions (Figures 2(b) and 2(c)). The patient responded clinically to his new regimen after 2-3 weeks and radiologically after almost 4-5 weeks (Figures 2(d) and 2(e)).