In a 46‑year‑old woman with hypertension (atenolol), hyperlipidemia (atorvastatin), prior gestational asthma, who has had six days of nasal congestion, frontal/ethmoid sinus pressure, sore throat and low‑grade fever relieved by paracetamol, now presenting with thick yellow sputum, pleuritic chest pain on coughing, left posterior coarse crackles and a swollen non‑erythematous left nasal turbinate, what is the most likely diagnosis and what are the appropriate next steps in management?

Diagnosis: Acute Bacterial Rhinosinusitis with Possible Lower Respiratory Tract Involvement

This patient has acute bacterial rhinosinusitis (ABRS) based on persistent purulent symptoms beyond 10 days, and the left posterior lung crackles raise concern for concurrent lower respiratory tract infection requiring chest radiography and possible antibiotic therapy. 1, 2

Clinical Reasoning for ABRS Diagnosis

The diagnosis of ABRS is established when symptoms persist ≥10 days without improvement or when there is "double worsening" (initial improvement followed by worsening within 10 days). 1, 2 This patient meets the first criterion with 6 days of symptoms that have persisted and evolved:

• Persistent purulent nasal discharge (thick yellowish phlegm) beyond the typical 5-7 day viral URI course 1, 3
• Frontal and ethmoid sinus pain/pressure that has persisted throughout the illness 1
• Unilateral findings (left swollen turbinate) which increase the likelihood of bacterial infection 1, 3
• Lack of improvement despite 3 days of symptomatic treatment 1

The initial viral URI has likely progressed to bacterial superinfection, a common pattern where purulent discharge that persists beyond 10 days indicates bacterial involvement rather than the normal progression of viral illness. 1, 3

Critical Red Flag: Pulmonary Findings

The left posterior coarse crackles are concerning and require immediate evaluation with chest radiography to exclude pneumonia. 1 This is particularly important because:

• The patient has prior gestational asthma and a strong family history of COPD, placing her at higher risk for lower respiratory complications 1
• Pleuritic chest pain (pain only when coughing) suggests possible pleural involvement 1
• Acute sinusitis can trigger or worsen bronchial hyperresponsiveness in patients with underlying reactive airway disease 1

Immediate Next Steps

1. Obtain Chest Radiograph (Urgent)

Order a chest X-ray immediately to evaluate the left posterior lung field crackles and rule out pneumonia, given the combination of productive cough, pleuritic chest pain, and abnormal lung examination. 1, 2

2. Initiate Antibiotic Therapy for ABRS

Prescribe high-dose amoxicillin-clavulanate (2000 mg amoxicillin/125 mg clavulanate twice daily) for 10-14 days as first-line therapy for ABRS in this patient. 1, 2

The rationale for amoxicillin-clavulanate over plain amoxicillin includes:

• Prior antibiotic exposure within the past week (she was already on symptomatic treatment, though not antibiotics) 4
• Moderate-to-severe disease evidenced by persistent symptoms, sinus pain, and pulmonary involvement 4, 2
• Coverage for β-lactamase-producing Haemophilus influenzae and Moraxella catarrhalis, which are common in adults with ABRS 5, 3, 4

3. Reassess Antibiotic Choice Based on Chest X-ray

• If pneumonia is confirmed: Consider upgrading to a respiratory fluoroquinolone (moxifloxacin 400 mg daily or levofloxacin 750 mg daily) to cover both ABRS and community-acquired pneumonia with a single agent 4, 2
• If chest X-ray is clear: Continue with high-dose amoxicillin-clavulanate for ABRS alone 1, 2

4. Optimize Adjunctive Therapy

Continue and optimize the current symptomatic regimen:

• NAC 600 mg effervescent tablet daily for mucolytic effect—continue this 6
• Intranasal corticosteroid (add fluticasone or mometasone 2 sprays per nostril daily) to reduce sinus mucosal inflammation and improve ostial drainage 1
• Nasal saline irrigation (high-volume, 240 mL per nostril twice daily) to mechanically clear purulent secretions 6, 7
• Discontinue levocetrizine/montelukast combination as second-generation antihistamines and leukotriene antagonists have minimal benefit in acute bacterial sinusitis 6, 7
• Continue benzydamine HCl throat spray for symptomatic sore throat relief 6

5. Address Medication Interactions and Comorbidities

Critical consideration for atenolol: Beta-blockers can occasionally worsen rhinitis symptoms through unclear mechanisms. 1 However, do not discontinue atenolol for hypertension management without cardiology consultation, as the cardiovascular risk outweighs the minor rhinitis contribution. 1

Avoid oral decongestants (pseudoephedrine, phenylephrine) entirely in this patient due to her hypertension and atenolol use, as these agents can cause elevated blood pressure, palpitations, and interact with beta-blockers. 7, 8

Follow-Up and Reassessment Plan

Schedule follow-up in 3-5 days to assess response to antibiotic therapy. 1 At that visit:

• If improving: Continue antibiotics for full 10-14 day course until symptoms resolve plus 7 additional days 1
• If not improving or worsening: Switch to respiratory fluoroquinolone (moxifloxacin 400 mg daily or levofloxacin 750 mg daily) and consider CT sinuses to evaluate for complications 1, 4, 2
• If chest symptoms persist: Repeat chest examination and consider pulmonary function testing given her asthma history 1

Warning Signs Requiring Urgent Re-evaluation

Instruct the patient to return immediately if she develops any of the following complications: 1

• Orbital signs: Periorbital swelling, erythema, visual changes, diplopia, or proptosis
• Intracranial signs: Severe headache, altered mental status, focal neurologic deficits, or neck stiffness
• Facial swelling or erythema over the sinuses
• High fever (>39°C/102.2°F) or rigors
• Worsening dyspnea or chest pain at rest

Common Pitfalls to Avoid

• Do not rely on plain sinus radiographs for diagnosis—the clinical criteria alone are sufficient for ABRS diagnosis, and imaging is reserved for suspected complications or treatment failure 1, 2
• Do not prescribe oral corticosteroids routinely for acute sinusitis; reserve them only for severe nasal polyposis or marked mucosal edema unresponsive to intranasal steroids 1, 7
• Do not use topical nasal decongestants (oxymetazoline) for more than 3 days, as this causes rhinitis medicamentosa (rebound congestion) 6, 7, 9
• Do not ignore the pulmonary findings—coarse crackles in a patient with asthma history and productive cough mandate chest imaging 1