Complex Consolidation: the importance of the white cell differential

Abstract

A 38-year old male international pilot presented
to accident and emergency with an eight-week
history of dry cough, breathlessness, fevers,
weight loss and night sweats. His only medical
history was a diagnosis of asthma three years
previously for which he took a regular fluticasone
inhaler and salbutamol as required. Optimisation
of inhaled therapy by his general practitioner had
not provided any symptomatic relief. He was a
non-smoker and denied previous exposure to
tuberculosis (TB). On examination, he was febrile
at 37.5°, tachycardic at 110 and desaturating to
93% on air. Chest auscultation revealed right
lower and mid zone inspiratory crepitations.
Admission blood tests demonstrated a raised
white cell count (WCC) of 12.0 x 109/L (n=4.0-
11.0), an eosinophilia of 3.8 x 109/L (n=<0.4), a
C-reactive protein (CRP) of 114.5 mg/L (n=<3.0)
and platelet count of 426 x 109/L (n=150-400). A
chest X-ray revealed bilateral, multi-lobar, patchy
consolidation (Figure 1). Empirical intravenous
antibiotic therapy with benzylpenicillin and
clarithromycin was started to treat communityacquired
pneumonia. Additional laboratory
testing was negative for HIV, atypical pneumonia
antigens, autoimmune disease and viral infection.