853

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Case Report

Occult Pneumonia Associated with Dehydration: Myth or

Reality
Ferns M. Hall1 and Morris Simon

The concept that a febrile, dehydrated patient with a normal Blood cultures drawn at the time of hospital admission, with results
chest radiograph nevertheless may have pneumonia is wide- not available until after the second radiographic examination, grew
spread among clinicians. A presumed diminution in exudative Streptococcus pneumoniae (Pneumococcus). The patient was treated
with antibiotics, and follow-up chest radiographs showed gradual
response to the infection is thought to account for the lack of
clearing, with complete resolution after 8 days.
radiologic and, frequently, auscultatory findings. In our expe-
rience, the possibility of dehydration-related occult pneumonia
has been used to justify obtaining a modest number of chest Discussion
radiographs at repeated short intervals, particularly in hospi-
talized geriatric patients. However, examples of this entity are Bacterial pneumonia is presumed to start as a small focus
largely anecdotal, and no case reports could be found in the of infection in the lung parenchyma that spreads by direct
literature. Indeed, in the clinical setting, proof of its existence extension through the alveolar spaces and pores of Kohn.
probably is not possible. We present a case in which dehy- Connective tissue and pleura act as relative barriers to this
dration appeared to delay the radiographic findings of pneu- spread. Dehydration decreases blood volume and vascular
monia. hydrostatic pressures and thereby might diminish the normal
exudative responses of vasodilation and increased leakage
Case Report of plasma across capillary walls. However, laboratory studies
and clinical experience have shown that the rate of extension
An 84-year-old woman was admitted to the hospital because of
of pneumonia is quite variable, and the presumptions that
general malaise and fever of 2-day duration. She was alert with no
dyspnea or cough. Her medical history included hypertension and dehydration either prolongs the lag period or diminishes the
chronic renal failure. She was considerably dehydrated, but the magnitude of the exudative response are difficult to prove
findings on physical examination, including auscultation of the chest, clinically.
were otherwise normal. Her temperature in the emergency room was We have had a long-term interest in the concept of occult
1 03.8#{176}F
(39.8#{176}C)rectally. The WBC count was 1 6,2O0/zl, with 85% dehydration pneumonia, and the findings of the case pre-
polymorphonuclear cells and 15% band forms. sented were as suggestive of this entity as any we have seen.
The patient was admitted with the presumptive diagnosis of infec- The patient was alert, and aspiration was not a clinical con-
tion. The chest radiograph obtained at admission (Fig. 1 A) was sideration, as it frequently is in persons who are dehydrated.
reported as normal, with no consolidation identified. Despite the lack
The positive blood cultures were obtained on admission,
of clinical or radiologic evidence of pneumonia, her physicians consid-
ered this diagnosis because of the findings of dehydration. Therefore,
before the normal chest radiograph, and the organism re-
after judicious treatment with IV fluids only (1400 ml normal saline in covered is the most common cause of bacterial pneumonia.
24 hr) and encouragement to drink fluids, a second chest radiograph The dehydration required administration of IV fluids, but the
was obtained 30 hr after the first examination (Fig. 1 B). This showed patient was not overhydrated clinically, and focal pulmonary
an extensive right upper lobe consolidation involving all segments. edema was not a differential consideration on the second

Received November 11, 1986; accepted after revision December 16, 1986.
‘Both authors: Department of Radiology, Beth Israel Hospital and Harvard Medical School, Boston, MA. Address reprint requests to F. M. Hail, Department of
Radiology, Beth Israel Hospital, 330 Brookline Aye, Boston, MA 02215.
AJR 148:853-854, May 1987 0361 -803X/87/1485-C)853 © American Roentgen Ray Society
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Fig. 1.-A, Pneumonia in a dehydrated patient Radiograph taken at time of admission was interpreted as normal. Retrospectively, it shows an equivocal
apical subsegmental paramediastinal opacity in right upper lobe.
B, Radiograph obtained 30 hr later shows lobar consolidation in right upper lobe. Right mediastinal profile is slightly more prominent than in A, a finding
consistent with patient’s improved state of hydration.

chest radiograph. Finally, with fluid replacement only, devel- no clinical data to support the existence of occult pneumonia
opment of a lobar consolidation was rapid. If the request for related to dehydration. However, a single experimental animal
repeat films had been reviewed by a staff radiologist, it is study by Caldwell et al. [2] addressed this question directly
most likely that such a short interval between radiographs and found no evidence to support the concept. Bacteria were
would have been discouraged. introduced intrabronchially into four normally hydrated and
Retrospectively, the findings on the first radiograph (Fig. four dehydrated dogs. Subsequently, chest radiographs were
1 A) might be interpreted as a subtle apical subsegmental obtained, and the dogs were sacrificed at various intervals
consolidation of the right upper lobe. However, this does not between 2 and 24 hr. In this canine model, dehydration had
alter the rapid radiologic progression to a lobar pneumonia. no effect on the chronologic, radiologic, or histologic features
Rapid spread of nonaspiration pneumonia is rare, but it can of pneumonia. These authors also noted that in each of 20
happen. If the patient in this report had not been dehydrated, patients hospitalized with the diagnosis of both dehydration
the rapid appearance of the consolidation still would be sur- and pneumonia, radiologic evidence of consolidation was
pnsing. Therein lies the dilemma of documenting occult de- always present on the initial radiograph.
hydration pneumonia, and, in the final analysis, it must remain Our case report lends some support to the idea that de-
an anecdotal impression. hydration may suppress the radiologic and auscultatory find-
Chest radiographs may also appear normal in other in- ings of pneumonia. Obviously, this does not prove the exist-
stances of documented pulmonary infection. Pneumocystis ence of occult pneumonia associated with dehydration. An
carinll pneumonia occurs in patients with AIDS who have alternative explanation, the rapid extension of a small focus
normal chest radiographs but positive findings on gallium of infection by contiguity, is equally valid. Indeed, despite the
scans [1]. At this early stage of infection, organisms and acceptance of this entity by many chest clinicians and radiol-
associated inflammatory changes are present without air- ogists, there is no clinical scenario that can prove its exist-
space consolidation. However, dehydration is rarely an etio- ence, and animal work specifically suggests that it does not
logic factor in these patients, who are usually young and occur.
otherwise healthy.
In an informal inquiry of five chest clinicians, three believed
that radiologically and clinically occult pneumonia related to
REFERENCES
dehydration was a real entity, albeit unusual. In a telephone
survey of 10 academic chest radiologists, five believed the 1. Barron TF, Bimbaum NS, Shane LB, Goldsmith SJ, Rosen MJ. Pneumo-
entity exists; two of these thought it was considerably more cystis carinll pneumonia studied by gallium-67 scanning. Radiology
1985;154:791-793
common than generally recognized. The remaining five ex-
2. CaIdwell A, Glauser FL Smith WA, Hoshiko M, Morton ME. The effects of
pressed various degrees of skepticism. dehydration on the radiologic and pathologic appearance of experimental
We could find no reports of cases similar to our own and canine segmental pneumonia. Am Rev Respir Dis 1975;1 12:651 -656