Farmer in rural area in France suffering from pneumonia and atelectasis treated by prolonged antibiotic therapy: clinical case report

Early Abstract:

Context: Community-acquired pneumonia are frequent and sometimes fatal. Prompt biological recognition of pathogen is rarely possible, and recommendations are to use clinical presentation to determine the need for hospitalization and the choice of antibiotic. While pulmonary radiography should be performed for every clinical suspicion of community acquired pneumonia, CT is recommended in case of severe presentation, difficult diagnosis or suspicion of complications or cancer. However, during the first wave of Covid-19, CT were widely used for early triage of patients allowing discovery of atypical pneumonia aspects. 
Issues: A 62-year-old Caucasian farmer, living a remote area of France, went to the emergency department of a small town of rural Auvergne, for cough, chest pain and fatigue, during COVID containment. He had undergone septoplasty with turbinoplasty and uvulectomy six weeks earlier. He had also used several weedkillers the weeks before symptoms appeared. The chest scan performed revealed localized condensation, obstructive atelectasis, air bronchogram disappearance, bulging of adjacent fissure and some necrosis. Causative organism wasn’t identified. As it was associated with biological inflammation, oral amoxicillin was prescribed for two weeks. One week after he stopped the treatment, symptoms worsened, as did biological inflammation. Decision was made to put him back on antibiotics, same molecule but higher dose with 6 g per day instead of 3 g per day during four additional weeks. Another chest scan was needed because cough, chest pain and fatigue came back a few weeks later. Aspect was reassuring, so was the PET scan carried out three months after and the lung function tests. However, fatigue lasted one year. 
Lessons learned: This case report documents a pulmonary infection whose first scan aspect was strikingly suggestive of cancer and for which the usual empirical antibiotic therapy was insufficient. 
This case highlights the importance of regular clinical reevaluation and thus the significant role of GP, especially in rural and remote areas. The relevant elements we notice in this atypical case are as follows: the distance between the patient and the nearest hospital and the weeks he waited before consulting a doctor, the septoplasty he underwent, his professional exposure particularly to weedkillers. Our research found no description of a similar case in literature. 
Keywords: agrochemicals, farmers, pneumonia, primary care, tomography.