Community-acquired pneumonia. The tyranny of a term.

Picture this. It’s a true story. A twenty-nine-year-old woman enters a hospital emergency room with complaints of fever and cough. In the emergency room her fever is confirmed, she has a cursory exam and is sent for a chest X-ray that shows a left mid-lung infiltrate (see the X-ray above). A diagnosis of community-acquired pneumonia (CAP) is made, and the patient is discharged on azithromycin. She faithfully takes the antibiotic, but after a week is no better and returns to the emergency room. This time the chest X-ray shows expansion of the left mid-lung infiltrate and a new right upper lobe infiltrate. She is admitted to the hospital. What is the admission diagnosis? It’s community-acquired pneumonia. After all, she has evidence of pneumonia, and it occurred outside of a health care setting, so it is, in fact, a community-acquired pneumonia. This time she is treated with moxifloxacin, and, after four days, she is stable and discharged to complete her antibiotic course. Two weeks later her fever and cough have not subsided so she returns to the emergency room. The infectious diseases consultation service is called to see her. They take a history! Among the information that is quickly obtained with just a few questions is the following: Her cough and fever had been present for almost two months before she made her first trip to the emergency room; she had lost nine pounds since the illness began; she had night sweats almost daily; and she resided in a recovery home for former drug users where another resident has had a bad cough for a few months. What is the diagnosis? Tuberculosis seems very likely. She is hospitalized, isolated, and a sputum sample has acid-fast bacilli and later grows Mycobacterium tuberculosis. What should we make of this story? If one were to present the case of a patient with two months of cough, fever, night sweats, weight loss and a pulmonary infiltrate, any third-year medical student would consider the diagnosis of tuberculosis. Yet fully trained physicians missed the diagnostic boat on three occasions. Why? We believe it is the tyranny of the term “community-acquired pneumonia.” All one needs is a cough, fever, and an abnormal chest X-ray and no further information is required. We have a diagnosis and a course of treatment. What could be simpler? Yet the hazards of this approach are obvious. Language matters. The way we frame an issue, and the words we use to indicate it or describe it can dictate the way in which it is handled. The term CAP has eliminated thoughtful Community-acquired pneumonia