The atypical pneumonias: The South African context

Introduction Lower respiratory tract infections are a common problem in general practice. Since its isolation more than 120 years ago, Streptococcus pneumoniae has remained the most common organism responsible for community-acquired pneumonia (CAP). Historically, S. pneumoniae pneumonia was considered to have a “typical” clinical presentation, with the patient experiencing chills, rigors, cough product ive of sputum containing Gram-positive cocci, and segmental or lobar consolidation on chest X-ray. Prior to antibiotics, infection resulted in death or resolution by crisis (hectic fevers and delirium) or lysis (gradual decrease in fever). In the late 1930s, cases of pneumonia, which were different to ‘typical’ pneumococcal pneumonia, appeared in the medical literature. These pneumonias often occurred as outbreaks, were associated with an insidious onset and a prodrome of a low-grade fever, photophobia and headache, with a worsening cough. Sputum Gram’s stain failed to demonstrate pneumococci, and the chest X-ray showed a bronchopneumonia rather than a lobar or segmental consolidation. These pneumonias were designated as Case Study A 26 year-old male presents with a generalised rash. He gives a history of having ‘flu’ for the past week with a fever and headache; he has also developed a dry cough, which has worsened over the past few days. Other than paracetamol he has taken no other medication. He is allergic to penicillin. His six-year-old daughter had the ‘flu’ a month ago and is now well. Examination reveals a healthy-looking male with a generalised rash involving the palms of the hands and the soles of the feet (Figure A and B). There is no mucosal involvement. He has a temperature of 37.9C, no lymphadenopathy and minimal crackles over the left lower zone of his chest. His chest X-ray is shown in Figure C. He has a normal full blood count.