Working Diagnosis:
Necrotizing Pneumonia, etiology unknown; gram negative rod versus Staphylococcus aureus. Also with viral URI secondary to parainfluenza.

Treatment:
The patient was treated with 48 hours of IV Vancomycin and Piperacillin-tazobactam. After stabilization and 24 hours without fever, she was discharged on a 7-day course of amoxicillin/clavulanate and ciprofloxacin.

Outcome:
The patient followed up 12 days after finishing antibiotics with a repeat chest x-ray Case Photo #2 showing "...improved right upper lobe pneumonia with apparent complete resolution of previous areas of cavitation..." Athlete was able to return to sport shortly after finishing antibiotics with a total of 16 days missed and 7 days of modified participation until full return.

Author's Comments:
Pneumonia accounts for nearly 10 million physician visits annually. [1] Community acquired pneumonia is often due to Streptococcus pneumonia, though other bacterial sources should be considered. In cases of necrotizing pneumonia, gram negative rods and Staphylococcus aureus strains that produce Panton-Valentine leukocidin are highly suspected. [2] Early identification of pneumonia and proper treatment are vital to prevent additional morbidity.

Editor's Comments:
Teaching points:
1. Diagnosis of necrotizing pneumonia:
- series of chest radiography every every 3–4 days to determine if antiobiotic therapy is effective [2]
- immediately obtain chest CT if:
a. pneumonia progresses on chest radiographs
b. pleural effusion or hydropneumothorax are present
c. respiratory distress, hemoptysis, or septic shock despite appropriate antiobiotic therapy [2]
2. Treatment of necrotizing pneumonia:
- broad-spectrum IV antibiotics targeting common pathogens (K. pneumoniae, S. aureus, streptococci) [2]

References:
1. Bartlett, JG et al. “Community-Acquired pneumonia in adults: Guidelines for management.� Clinical Infectious Disease. 1998 26(4): 811-838.
2. Tsai, YF et al. “Necrotizing pneumonia: a rare complication of pneumonia requiring special consideration. Current Opinion Pulmonary Medicine. 2012 18(3): 246-52.

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