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Internal Medicine

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Patient Care

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Case Report

Abstract

Background: Aspiration pneumonitis, an acute chemical lung injury following the inhalation of gastric contents, is frequently misdiagnosed as bacterial pneumonia. Misclassification often leads to unnecessary antibiotic use. Early recognition and accurate diagnosis are critical to avoid overtreatment and associated risks.

Case Presentation: A 21-year-old male with a history of cerebral palsy with quadriplegia, epilepsy, oropharyngeal dysphagia (status post PEG tube), and bedbound status presented to the ED following a witnessed aspiration event. During oral pleasure feeding, he choked, became transiently cyanotic, and had a brief coughing episode after vomiting. Family also reported a one-week history of intermittent cough, subjective fevers, and chills, for which no prior medical care was sought.

On presentation, the patient was hemodynamically stable and afebrile, with an oxygen saturation of 98% on room air. He was alert and non-verbal, in no apparent distress. Pulmonary exam was unremarkable, without adventitious sounds or respiratory effort. Labs showed leukocytosis (WBC 14.7 x10⁹/L), normocytic anemia (Hgb 12.5 g/dL), and hyponatremia (Na 128 mmol/L). Renal, liver, and inflammatory markers were normal. Chest CT revealed a 2 cm pleural-based nodular density in the left mid-lung, with differential including round atelectasis versus aspiration-related changes. No consolidation, effusion, or lymphadenopathy was seen.

Initially treated for community-acquired aspiration pneumonia with ampicillin-sulbactam, antibiotics were discontinued the next day after reassessment showed no fever, stable oxygenation, absence of infiltrates, and clinical improvement. Aspiration pneumonitis was favored, and supportive care was continued. A modified barium swallow study showed moderate to severe oropharyngeal dysphagia with silent aspiration and absent mastication. The patient was advised to use nectar-thick liquids (no straws), with PEG tube as the primary route for nutrition and medications. He remained clinically stable and afebrile throughout hospitalization. No further interventions were needed. He was discharged in stable condition with family education on aspiration precautions and feeding strategies. Outpatient follow-up and surveillance imaging for the lung nodule were arranged.

Conclusion: Aspiration pneumonitis is often misdiagnosed as infectious pneumonia, particularly in high-risk patients such as those with neurological impairment and dysphagia. Differentiating between these conditions is critical, as accurate clinical assessment and recognition of the distinct clinical course and radiographic features of aspiration pneumonitis can help prevent unnecessary antibiotic use and support antimicrobial stewardship efforts.

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Aspiration Pneumonitis Mimicking Pneumonia: Diagnostic Reassessment and Antibiotic Stewardship in a Case of Cerebral Palsy-Associated Dysphagia

Background: Aspiration pneumonitis, an acute chemical lung injury following the inhalation of gastric contents, is frequently misdiagnosed as bacterial pneumonia. Misclassification often leads to unnecessary antibiotic use. Early recognition and accurate diagnosis are critical to avoid overtreatment and associated risks.

Case Presentation: A 21-year-old male with a history of cerebral palsy with quadriplegia, epilepsy, oropharyngeal dysphagia (status post PEG tube), and bedbound status presented to the ED following a witnessed aspiration event. During oral pleasure feeding, he choked, became transiently cyanotic, and had a brief coughing episode after vomiting. Family also reported a one-week history of intermittent cough, subjective fevers, and chills, for which no prior medical care was sought.

On presentation, the patient was hemodynamically stable and afebrile, with an oxygen saturation of 98% on room air. He was alert and non-verbal, in no apparent distress. Pulmonary exam was unremarkable, without adventitious sounds or respiratory effort. Labs showed leukocytosis (WBC 14.7 x10⁹/L), normocytic anemia (Hgb 12.5 g/dL), and hyponatremia (Na 128 mmol/L). Renal, liver, and inflammatory markers were normal. Chest CT revealed a 2 cm pleural-based nodular density in the left mid-lung, with differential including round atelectasis versus aspiration-related changes. No consolidation, effusion, or lymphadenopathy was seen.

Initially treated for community-acquired aspiration pneumonia with ampicillin-sulbactam, antibiotics were discontinued the next day after reassessment showed no fever, stable oxygenation, absence of infiltrates, and clinical improvement. Aspiration pneumonitis was favored, and supportive care was continued. A modified barium swallow study showed moderate to severe oropharyngeal dysphagia with silent aspiration and absent mastication. The patient was advised to use nectar-thick liquids (no straws), with PEG tube as the primary route for nutrition and medications. He remained clinically stable and afebrile throughout hospitalization. No further interventions were needed. He was discharged in stable condition with family education on aspiration precautions and feeding strategies. Outpatient follow-up and surveillance imaging for the lung nodule were arranged.

Conclusion: Aspiration pneumonitis is often misdiagnosed as infectious pneumonia, particularly in high-risk patients such as those with neurological impairment and dysphagia. Differentiating between these conditions is critical, as accurate clinical assessment and recognition of the distinct clinical course and radiographic features of aspiration pneumonitis can help prevent unnecessary antibiotic use and support antimicrobial stewardship efforts.

 

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