Recurrent Pneumonia

[SisterConcern]

My brother has had pneumonia 3 times in the past 6 months (October, November, & February). In October, his symptoms began with what doctors thought was pericarditis, which I'm assuming lead to pneumonia, respitory failure, septic shock, and kidney damage. He was hospitalized at the time for a total of 8 days most of which were spent in the ICU. In November, he was again admitted with similar symptoms, which did develop into pneumonia, although this time he was not intubated and his lung continued to function on its own. Less than 2 weeks ago (Feb. 22), he was again admitted for with the same initial symptoms (pericarditis) which developed with greater complications: pericarditis with fluid build-up around the heart, aspiration pneumonia, septic shock, and kidney failure. He is currently still in the hospital, and this time he was intubated for 8 days and spent 10 days in ICU. What could be the cause of these recurrent infections? Needless to say, he has come close to death in all three cases. Other pertinent info about his condition: He is 22 year old. He has congenital absence of the right pulmonary artery (He was diagnosed at age 12 with this congenital condition, but prior to October 2008, he was never hospitalized nor suffered any extreme adverse affects from this condition.) His case has the doctors stumped. What could be the cause? How could the infections be prevented? Is this related to the congenital condition?

[SisterConcern]

Thanks so much for your response to my question!
After the last hospital stay mentioned in my question, my brother returned home on Saturday, March 7th, with the final word from his doctors being that they were unsure of what was causing the recurrent infections and pericarditis. After being home for 3 days, my brother returned to the hospital on Wednesday, March 11th after a follow-up appointment with his primary care physician. At this appointment he again exhibited signs of pericarditis (tachycardia and shortness of breath). When he arrived through the ER, doctors ran extensive tests including ekg, ct scan, blood cultures, etc. to determine what was going on again. He was kept overnight for observation, and the following day on Thursday his heart rate continued to increase and his breaths per minute we up as well. At that point, doctors returned him to the ICU for further observation and tests. The ICU team further decided to check for autoimmune and inflamatory diseases and called a team from rheumatoid dept. They further checked all of his cultures which have all been negative. All of the tests conducted by rheumatoid service turned up negative results as well. Cardiology also came to visit my brother in ICU and determined that he had never been fully treated for the pericarditis due to the complications that always followed from the pneumonia, septic shock, and kidney damage. (Also during the last hospital stay, a full immune deficiency work-up was conducted with all of the regular checks turning up negative.) Today, Saturday, March 14th, he has been moved back to Family Medicine Service and is being treated with ibuprophren and a medicine for pericarditis (I don't know the name), as well as fentanyl. He is no longer on antibiotics due to the fact that all of his blood cultures have turned up negative. Right now, we think that the doctors have determined to treat the pericarditis agressively in order to prevent the build up of fluid around the heart as well as head off the development of pneumonia. We are in the wait and see period, but we are hopeful that the underlying cause of the last 6 months of stress and trauma for our family will finally come to conclusion based upon the treatment prescribed by the doctors.

[National Jewish Health]

This must be terrible for all of you.  What you describe is very worrisome and suggests infection with an atypical, unusual or opportunistic bacterium or other infectious agent, at least partially resistant to the antibiotics your brother has received.  Such infections can occur with a normal immune system or with an acquired immunodeficiency disorder, of which there are a number, including human immune virus/acquired immunodeficiency syndrome (HIV/AIDS).  They can also occur with exotic diseases from other continents, in which case your brother’s recent travel history would be very important.

Pericarditis and pneumonia can be caused by bacteria, viruses, fungi and mycobacterial disease, both classic tuberculosis (TB) and nontuberculosis mycobacteria (NTM).  You might want to ask your brother’s doctors if cultures of his sputum, blood, pleural or pericardial fluid have been cultured for the previously listed organisms and, if so, have any infectious organisms been identified?  If not, consideration should be given to performing these special cultures.

Pericarditis is frequently associated with immunodeficiency states, caused by any of the listed organisms, including less frequent causes such as Actinomycosis, Nocardiosis, Cryptococcus Neoformans, cytomegalovirus and mycobacterium avium complex (MAC).

The congenital absence of the right pulmonary artery is, in all likelihood, unrelated to his past 6 months illness.  In some instances of cardiovascular malformations or incomplete vessel development, there are other congenital cardiac abnormalities, some of which may be silent and go unnoticed, yet predispose an individual to heart valve infection, called acute or sub-acute bacterial endocarditis.

I assume that an infectious disease specialist is a member of the team trying to save your brother’s life, but if not, you should definitely make that request.

Good luck to you, your brother and your family.

Please give us a follow-up to let us know how your brother is doing.