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Hospital de Zumárraga Guipúzcoa, Spain
Correspondence to: Enrique Antón, MD, PhD, Department of Internal Medicine, Hospital de Zumárraga, 20700-Zumárraga, Guipúzcoa, Spain; e-mail: hzeanton{at}hzum.osakidetza.net
To the Editor:
I have read with great interest the article by Durning et al (July 2003).1 Our experience with round pneumonia2 and Q fever3 has permitted to us detect various methodologic errors that make some comments and conclusions in this report questionable.
First, the microbiologic study did not include agents of atypical pneumonia (Q fever, Mycoplasma pneumoniae, Chlamydia pneumoniae, Legionella pneumophila). Serologic tests such as seroconversion, elevated IgM in acute stage, or urinary antigens were absent; perhaps this explains why the etiologic organism was not identified.
Second, the authors performed a MEDLINE search that was restricted to the English language. This leads to a serious self-limitation. In the world’s first medical database there are, as well as the English-language articles, the abstracts and the medical subject headings that offer essential information about the published reports in non–English-language journals.23
Third, in Table 1, which reviews 18 case reports of round pneumonia in adults, 14 cases are shown without etiology (75%). The search for agents of atypical pneumonia appears in none of them.
Fourth, neither were the most relevant articles in English-language journals about etiology of round pneumonia browsed. Round pneumonia constitutes an atypical radiologic presentation of pulmonary infections and is very rare in adults. Q fever is a world zoonosis caused by Coxiella burnetii (Rickettsiae) that was first described by Derrick in 1937 in Australia.4 Its usual clinical presentation is as pneumonia,3 and so should be included in the diagnostic work of pneumonia. Various authors567 have studied the radiologic presentation of Q fever pneumonia in adults, all of them in the English language. Pickworth et al5 noticed, in a series of 21 cases, that sometimes (4 cases, 19%) the lesion became rounded (2 to 7 cm in diameter) during resolution, and concluded that the appearance of round pneumonia should alert to possible Q fever. Gordon et al6 assessed, retrospectively, chest radiographs of 25 patients with epidemic and sporadic Q fever pneumonia and demonstrated multiple round pneumonia in 14% of sporadic cases and in 45% of epidemic. Millar et al7 reviewed the chest radiographs on hospital admission of 32 cases of Q fever serologically confirmed, and the more frequent lung changes encountered (78%) were multiple round segmental consolidations (from one to seven), 5 to 10 cm in diameter, and usually situated in the lower lobes. Some lesions became round during resolution. They concluded that the finding of a single or multiple round pneumonia was found to be good evidence that the patient had "Q fever."
Q fever is, probably, the first cause of round pneumonia in adults. However, in the 21st century, some authors continue to think that round pneumonia is most often caused by Streptococcus pneumoniae without reference to Q fever.89 The diagnostic work in round pneumonia should include agents of atypical pneumonia, especially Q fever.
Durning et al1 state that the "treatment of adults with round pneumonia is not similar to that of individuals with lobar pneumonia." "Therapy with antibiotics in these cases should be effective against the common pathogens causing lobar pneumonia"1 but also against Q fever: old and new macrolides (erythromycin and clarithromycin) and new quinolones (levofloxacin) are curative and prevent chronic Q fever.
References
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