Photo Quiz

Multifocal Pneumonia: Fever, Cough, and Dyspnea


Am Fam Physician. 2021 Apr 15;103(8):503-504.

An 80-year-old patient presented to the emergency department in October 2020 with several days of increasing shortness of breath. Three days before that, the patient went to urgent care because of intermittent fevers up to 103°F (39.4°C) and a dry cough. The patient went to the emergency department after the symptoms continued to worsen. The medical history included atrial fibrillation, hypertension, and hyperlipidemia. The patient lived independently at home and had never smoked cigarettes.

On examination, the patient's vital signs included a pulse rate of 113 beats per minute, respiratory rate of 26 breaths per minute, and temperature of 100.8°F (38.2°C). The patient required 5 L of oxygen via nasal cannula to maintain an oxygen saturation of 96%. Lung auscultation revealed diffuse rales bilaterally.

Relevant laboratory results included a white blood cell count of 13,000 per μL (13.0 × 109 per L) with 48% lymphocytes. A chest radiograph demonstrated moderate multifocal, bilateral, patchy airspace and interstitial opacities (Figure 1).




Based on the patient's history, physical examination, laboratory, and imaging findings, which one of the following is the most likely diagnosis?

  • A. Aspiration pneumonia.

  • B. Congestive heart failure.

  • C. COVID-19 interstitial pneumonia.

  • D. Mycoplasma pneumonia.


The answer is C: COVID-19 interstitial pneumonia, a novel acute respiratory illness caused by SARS-CoV-2 infection. Many patients with acute COVID-19 present with respiratory symptoms, including dry cough, shortness of breath, tachypnea, and hypoxemia. Pneumonia and acute respiratory failure can develop in the 5% to 10% of patients with severe disease.1 Patients with COVID-19 typically follow a biphasic disease course, with a milder initial presentation that is followed by clinical deterioration about seven to 10 days after the onset of symptoms.1 Imaging findings include bilateral ground-glass opacities, and subsegmental and lobar areas of consolidation.2

The patient's nasal swab test was positive for COVID-19 at the urgent care clinic three days before the patient presented to the emergency department. Polymerase chain reaction testing is most useful for

Address correspondence to Josh Mugele, MD, at Reprints are not available from the authors.

Author disclosure: No relevant financial affiliations.


show all references

1. Raghu G, Wilson KC. COVID-19 interstitial pneumonia: monitoring the clinical course in survivors. Lancet Respir Med. 2020;8(9):839–842....

2. Huang C, Wang Y, Li X, et al. Clinical features of patients infected with 2019 novel coronavirus in Wuhan, China [published correction appears in Lancet. 2020;395(10223):496]. Lancet. 2020;395(10223):497–506.

3. Black CC, Richards R, Czum JM. Educational case: aspiration pneumonia. Acad Pathol. 2019;6:2374289519893082.

4. King M, Kingery J, Casey B. Diagnosis and evaluation of heart failure. Am Fam Physician. 2012;85(12):1161–1168. Accessed February 24, 2021.

5. Reittner P, Müller NL, Heyneman L, et al. Mycoplasma pneumoniae pneumonia: radiographic and high-resolution CT features in 28 patients. AJR Am J Roentgenol. 2000;174(1):37–41.

This series is coordinated by John E. Delzell Jr., MD, MSPH, associate medical editor.

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