Failure to Respond

A CLINICAL PROBLEM-SOLVING article by Michael Ezzie from Ohio State University, Columbus.
A 52-year-old man presented to his primary care physician with dyspnea and cough. For the past 15 years, he had recurrent episodes of cough that were relieved only by intermittent courses of oral corticosteroids. He had been treated on three occasions during the past year with 20 mg of prednisone daily for 2 weeks. In the previous 3 weeks, his cough had increased in frequency, and severe dyspnea had developed. This time, 2 weeks of prednisone had not provided relief. He had occasional chills but no fever. His cough was productive of yellow sputum.
The patient's medical history included complete resection of a thymoma 5 years earlier.
The patient was admitted to the hospital. Chest X ray showed bilateral alveolar infiltrates.
The patient was started on moxifloxacin for community-acquired pneumonia. Gram's staining of a sputum specimen showed gram-positive diplococci with many leukocytes; two blood cultures grew penicillin-sensitive Streptococcus pneumoniae. The patient was switched to intravenous penicillin G but continued to be hypoxemic. Chest X ray showed no improvement after 5 days of therapy.
Clinical improvement with pneumococcal pneumonia is generally observed within 3 days after the initiation of appropriate therapy, and the limited improvement in the patient's condition was a concern.
When a patient's condition does not improve despite appropriate therapy, the clinician must reconsider the course of action. This requires critical appraisal of the original diagnosis and a thorough investigation of possible causes of treatment failure.