From the Guidelines
For a 68-year-old patient with recurrent pneumonia, a comprehensive workup is essential to identify underlying causes, and I strongly recommend starting with a thorough history, complete blood count, comprehensive metabolic panel, chest X-ray, and high-resolution CT scan of the chest. This approach is crucial given the patient's history of severe episodes occurring in two waves without hospitalization, which may indicate an underlying condition such as immunodeficiency, anatomical abnormality, or chronic aspiration 1.
The patient's presentation of recurrent pneumonia in "two waves" suggests the possibility of unusual pathogens, including tuberculosis, endemic fungal pneumonia, or P. carinii pneumonia, which should be considered in the differential diagnosis 1. A careful repeat of the history is essential to identify epidemiological clues related to animal exposures and travel that may suggest specific pathogens.
Key components of the workup should include:
- Pulmonary function testing to assess for obstructive or restrictive lung disease
- Sputum cultures during active infections to identify pathogens and guide antibiotic therapy
- Consideration of bronchoscopy with bronchoalveolar lavage to evaluate for anatomical abnormalities and collect samples for microbiological analysis
- Immunological testing, including immunoglobulin levels (IgG, IgA, IgM) and antibody response to pneumococcal vaccination, to assess immune function
- Evaluation for gastroesophageal reflux disease and aspiration risk with a swallowing study
- HIV testing given the recurrent infections
Given the complexity of the case and the potential for underlying conditions, a comprehensive and multidisciplinary approach is necessary to prevent future episodes and improve the patient's quality of life. The pattern of recurrence in two waves suggests possible seasonal influences or intermittent exposures that should be explored through detailed history, and consideration of unusual pathogens as outlined in the guidelines for the management of adults with community-acquired pneumonia 1.
From the FDA Drug Label
The FDA drug label does not answer the question.
From the Research
Recommended Workup for Recurrent Pneumonia
The workup for a 68-year-old patient with recurrent pneumonia, currently stable without known infection, and a history of severe episodes occurring in two waves without hospitalization, should include:
- Identification of underlying etiologies, such as structural abnormalities, underlying medical conditions, and immunological abnormalities, including infection by the human immunodeficiency virus (HIV) 2
- Evaluation for chronic obstructive lung disease, bronchial obstruction, specific malignancies, hypogammaglobulinemia, alcoholism, neurologic diseases, and esophageal abnormalities, which are common predisposing conditions in older adults 3
- Consideration of primary immunodeficiency diseases, such as IgA deficiency, X-linked agammaglobulinemia, common variable immunodeficiency, hyper IgM syndrome, and Wiskott-Aldrich syndrome, which can present with recurrent pneumonia 4
- Assessment for other underlying illnesses, including oropharyngeal incoordination with aspiration syndrome, immune disorder, congenital cardiac defects, asthma, pulmonary anomalies, gastroesophageal reflux, and sickle cell anemia, which are common in patients with recurrent pneumonia 5
Diagnostic Approach
The diagnostic approach should be staged and systematic, using available diagnostic tools to establish an etiologic diagnosis 6. This may involve:
- Clinical evaluation, including history and physical examination
- Laboratory tests, such as complete blood count, blood cultures, and serological tests
- Imaging studies, such as chest radiographs and computed tomography scans
- Pulmonary function tests, such as spirometry and diffusion capacity
- Consultation with a specialist, such as a pulmonologist or immunologist, may be necessary to help with difficult or confusing cases 6