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Procalcitonin vs Clinical and Chest Film Findings to Diagnose Community-Acquired Pneumonia in Patients With Acute Asthma or Acute Exacerbations of Chronic BronchitisProcalcitonin Levels vs Chest Film Findings FREE TO VIEW

Burke A. Cunha, MD
Author and Funding Information

From the Infectious Disease Division, Winthrop-University Hospital, and State University of New York School of Medicine.

Correspondence to: Burke A. Cunha, MD, Infectious Disease Division, Winthrop-University Hospital, 259 First St, Mineola, NY 11501

Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Financial/nonfinancial disclosures: The author has reported to CHEST that no potential conflicts of interest exist with any companies/organizations whose products or services may be discussed in this article.

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).

Reproduction of this article is prohibited without written permission from the American College of Chest Physicians (http://www.chestpubs.org/site/misc/reprints.xhtml).


Chest. 2011;140(6):1667-1668. doi:10.1378/chest.11-1705
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To the Editor:

I read with interest the article by Dr Bafadhel et al1 in a recent issue of CHEST (June 2011) on using procalcitonin levels to diagnose community-acquired pneumonia (CAP) in adults with acute exacerbations of chronic bronchitis (AECB) or asthma. The diagnostic significance of procalcitonin depends on the clinical context.2 However, the use of procalcitonin levels in diagnosing CAP in adults with acute asthma or AECB seems to be unnecessary.

Patients with asthma exacerbations who are ill enough to be seen in the ED have well-known clinical features. Patients presenting with asthma are afebrile with a chest radiograph showing hyperinflation but no pulmonary infiltrates. Patients with AECB presenting to the ED are afebrile and have changes in their sputum (ie, volume, color, and tenacity). Unlike those with asthma, patients with AECB are prone to bacterial CAP. However, the chest radiograph readily differentiates AECB from CAP by the presence or absence of focal/segmental infiltrates. In AECB, chest radiographic findings are limited to peribronchial cuffing, but the radiographs are usually unremarkable. The diagnosis of bacterial CAP is based on the presence of fever, pulmonary symptoms, and a focal/segmental infiltrate on chest radiograph. Viral CAPs on chest radiograph are clear or may show an accentuation of lung markings or bilateral patchy interstitial infiltrates. Therefore, diagnosis of bacterial CAP in adults with acute asthma or AECB rests primarily on the presence of fever and chest radiograph infiltrates compatible with bacterial CAP.3,4

Patients with AECB are predisposed to develop Streptococcus pneumoniae, Haemophilus influenzae, and, particularly, Moraxella catarrhalis CAP. In contrast to AECB, bacterial CAP is a rare complication of an acute asthma exacerbation. Respiratory viruses are frequent triggers of acute asthma whereas Mycoplasma pneumoniae and Chlamydophila pneumoniae may trigger, exacerbate, or cause asthma. Procalcitonin levels are unelevated or mildly or moderately elevated with viral and atypical CAPs. With bacterial CAPs, procalcitonin levels are more highly elevated with bacteremic and lobar CAP.3,4

In an era dominated by technologically driven diagnoses, we should not forget that the traditional clinical approach to diagnosing CAP still rests on history, physical examination, and chest radiographic findings. This time-tested approach has not lost its clinical usefulness or accuracy. It has been said, and I agree, “All biomarkers have their weaknesses and strengths. None should be used alone; and none is anything more than an aid in the exercise of clinical judgement.”5 Procalcitonin levels add nothing except additional cost and possibly diagnostic confusion to the relatively straightforward clinical diagnosis of CAP and acute asthma and AECB.

Bafadhel M, Clark TW, Reid C, et al. Procalcitonin and C-reactive protein in hospitalized adult patients with community-acquired pneumonia or exacerbation of asthma or COPD. Chest. 2011;1396:1410-1418 [CrossRef] [PubMed]
 
Cunha BA. Empiric antimicrobial therapy of community-acquired pneumonia: clinical diagnosis versus procalcitonin levels. Scand J Infect Dis. 2009;4110:782-784 [CrossRef] [PubMed]
 
Cunha BA. Pneumonia Essentials. 2010;3rd ed Sudbury, MA Jones & Bartlett
 
Marrie TJ. Community-Acquired Pneumonia. 2001; New York, NY Kluwer Academic/Plenum Publishers
 
Christ-Crain M, Opal SM. Clinical review: the role of biomarkers in the diagnosis and management of community-acquired pneumonia. Crit Care. 2010;141:203 [CrossRef] [PubMed]
 

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References

Bafadhel M, Clark TW, Reid C, et al. Procalcitonin and C-reactive protein in hospitalized adult patients with community-acquired pneumonia or exacerbation of asthma or COPD. Chest. 2011;1396:1410-1418 [CrossRef] [PubMed]
 
Cunha BA. Empiric antimicrobial therapy of community-acquired pneumonia: clinical diagnosis versus procalcitonin levels. Scand J Infect Dis. 2009;4110:782-784 [CrossRef] [PubMed]
 
Cunha BA. Pneumonia Essentials. 2010;3rd ed Sudbury, MA Jones & Bartlett
 
Marrie TJ. Community-Acquired Pneumonia. 2001; New York, NY Kluwer Academic/Plenum Publishers
 
Christ-Crain M, Opal SM. Clinical review: the role of biomarkers in the diagnosis and management of community-acquired pneumonia. Crit Care. 2010;141:203 [CrossRef] [PubMed]
 
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