Worsening Aspiration Pneumonia in a Patient with Gastroparesis and Complex Comorbidities

Case at a Glance

A 38-year-old female with a complex medical history including gastroparesis and several psychiatric conditions presents with worsening symptoms of aspiration pneumonia despite four days of antibiotic therapy. Her deteriorating condition, marked by severe dyspnea, fatigue, and chest pain, suggests treatment failure and necessitates urgent re-evaluation.

Patient's Story

The patient is a 38-year-old female who was recently diagnosed with aspiration pneumonia, believed to be secondary to her known gastroparesis. Four days into her antibiotic course, she reports a significant decline in her condition. She experiences severe shortness of breath with minimal exertion, such as walking across a room. The fatigue is debilitating, making activities of daily living like preparing food extremely difficult. She describes a constant burning sensation in her chest, dizziness with movement, and tingling in her extremities upon exertion. Eating has become painful, even while adhering to a prescribed soft/liquid, low-fiber diet.

Initial Assessment

The patient is a 38-year-old female with a BMI of approximately 30 kg/m². Her past medical history is notable for bipolar II disorder, anxiety, ADD, chronic migraines, and Irritable Bowel Syndrome (IBS). A key comorbidity is gastroparesis, identified as the likely cause of the aspiration event. She is a non-smoker. Her current medication regimen is extensive and includes buspirone, Adderall XR, duloxetine (Cymbalta), ajovy, gabapentin, lumateperone (Caplyta), propranolol, spironolactone, and trazodone. The patient reports she is also awaiting genetic testing results from a full connective tissue panel due to a suspicion of vascular Ehlers-Danlos syndrome (vEDS).

The Diagnostic Journey

The initial diagnosis was aspiration pneumonia. However, the patient's failure to improve after four days of antibiotic treatment prompted concern for a more complex or severe process. Her worsening dyspnea, chest pain, and systemic symptoms like fatigue and dizziness indicated that the initial outpatient treatment was insufficient. The underlying gastroparesis is a significant factor, predisposing her to recurrent aspiration. The pending investigation into a possible connective tissue disorder, such as vEDS, is a critical piece of the diagnostic puzzle, as such disorders can be associated with gastrointestinal dysmotility and other systemic issues that could complicate her recovery.

Final Diagnosis

Aspiration pneumonia with clinical deterioration, suggestive of treatment failure or a complicated infection (e.g., empyema, abscess, or infection with a resistant pathogen), secondary to severe gastroparesis. The etiology of the gastroparesis remains under investigation, with a suspected underlying connective tissue disorder.

Treatment Plan

Given the patient's worsening symptoms, the initial outpatient antibiotic regimen was deemed inadequate. The recommended course of action is immediate hospital admission for further management. The plan includes:

1. Initiation of intravenous (IV) broad-spectrum antibiotics, with subsequent tailoring based on culture results.
2. Supportive care, including supplemental oxygen to manage dyspnea and hypoxemia, as well as IV fluids for hydration.
3. Further imaging, such as a chest CT scan, to evaluate for complications of pneumonia.
4. Consultation with Gastroenterology for aggressive management of gastroparesis to prevent further aspiration events.
5. Consultation with Pulmonology for management of the complicated pneumonia.

Outcome and Follow-up

The immediate outcome depends on the response to inpatient therapy. Long-term follow-up is critical and should be multi-faceted. This includes completing the diagnostic evaluation for the suspected connective tissue disorder, as a definitive diagnosis would guide future management across multiple organ systems. A thorough review and optimization of her complex medication regimen is warranted. The patient will require a coordinated, multidisciplinary care team involving her primary care physician, pulmonologist, gastroenterologist, and potentially a rheumatologist or geneticist to manage her complex health needs and prevent future episodes of aspiration pneumonia.