When Low-Risk Pneumonia Is Not Low Risk: A Case of Multisystem Complications in Community-Acquired Pneumonia
Main Article Content
Abstract
Background. Community-acquired pneumonia (CAP) is commonly stratified using severity scores such as the Pneumonia Severity Index (PSI), which guides clinical decision-making. However, low-risk classification does not always reflect the true clinical trajectory, particularly in elderly patients with frailty. We report a 70-year-old female initially classified as low-risk CAP (PSI score 80, Class II) who developed significant multisystem complications, including massive pleural effusion, suspected secondary to syndrome of inappropriate antidiuretic hormone secretion (SIADH) related to hyponatremia, and secondary cardiac dysfunction with reduced left ventricular ejection fraction.
Methods. This report uses a descriptive design in the form of a single case study. The patient in this case report was treated at Ibnu Sina Hospital, Makassar, with a diagnosis of CAP, PSI score 80, low risk class II, Coronary artery disease, Hypoglycemia, and Reactive thrombocytosis.
Result. This case highlights the pathophysiological cascade of CAP involving systemic inflammation (elevated cytokines such as IL-6), endothelial dysfunction leading to pleural fluid accumulation, neurohormonal dysregulation causing electrolyte imbalance, and myocardial stress contributing to cardiac impairment.
Conclusion. Low PSI scores should not lead to underestimation of disease severity. Hyponatremia may serve as an early red flag of systemic involvement, and massive pleural effusion should be considered a marker of disease progression.
Implication. Early multidisciplinary management and close monitoring are essential, particularly in elderly and frail patients.
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References
Al Zaman, K., Alhebsi, A. A., Almheiri, A., Alhosani, H., Alshehhi, N. T., & Alwheibi, E. S. (2025). Syndrome of Inappropriate Antidiuretic Hormone (SIADH) in Chronic Respiratory Diseases: A Comprehensive Review. Cureus. https://doi.org/10.7759/cureus.77407
Aldás, I., Menéndez, R., Méndez, R., España, P. P., Almirall, J., Borderías, L., Rajas, O., Zalacaín, R., Vendrell, M., Mir, I., & Torres, A. (2020). Early and late cardiovascular events in patients hospitalized for community-acquired pneumonia. Archives of Bronchoneumology (English Edition), 56(9), 551–558. https://doi.org/10.1016/j.arbr.2020.07.003
Alhariri, B. N., Ameen, A., & Nashwan, A. J. (2022). Community-Acquired Pneumonia with rapidly progressing pleural effusion within 24 hours: A case report. Journal of Emergency Medicine, Trauma and Acute Care, 2022(4). https://doi.org/10.5339/jemtac.2022.16
Alwesaibi, H. A., Albin Saad, A. H., Almulaify, M. S., & Alqatari, M. G. (2025). Bilateral Pleural Effusion in Cryptogenic Organizing Pneumonia: A Case Report and Review of Atypical Presentations. Cureus. https://doi.org/10.7759/cureus.84390
Aydin, A. E., Ates Bulut, E., Kocyigit, S. E., Dost, F. S., Mutlay, F., Altunkalem Seydi, K., Esenkaya, F., & Isik, A. T. (2025). An Instant Relationship Between Hyponatremia, Geriatric Syndromes, and Drugs in Older Adults: A Cross-Sectional Analysis from a Single Geriatric Clinic. Diagnostics, 15(6). https://doi.org/10.3390/diagnostics15060744
Barkas, G. I., Karakousis, N. D., Daniil, Z., Gourgoulianis, K. I., & Kotsiou, O. S. (2024). Sarcopenia and Pleural Effusions: Exploring a Potential Link. In Muscles (Vol. 3, Number 3, pp. 189–201). Multidisciplinary Digital Publishing Institute (MDPI). https://doi.org/10.3390/muscles3030017
Behera, S., Swain, B., Jena, P. K., & Murmu, M. C. (2022). Study of association and significance of hyponatremia in patients with lower respiratory tract infection (LRTI). International Journal of Health Sciences, 961–970. https://doi.org/10.53730/ijhs.v6ns4.5828
Bravo Jover, R. M., Gil-Guillen, V. F., Pérez Barba, C., Quesada, J. A., García López, M., García Soriano, I., & Pascual Pérez, M. de los R. (2025). Factors Associated with Complicated Parapneumonic Pleural Effusion/Empyema in Patients with Community-Acquired Pneumonia: The EMPIR Study. Journal of Clinical Medicine, 14(5). https://doi.org/10.3390/jcm14051739
Broughton, N., Comer, K., Casey-Gillman, O., Moore, L., Antoniou, S., Patel, R., Fhadil, S., Wright, P., Ozkor, M., Guttmann, O., Baumbach, A., Wragg, A., Jain, A. J., Choudry, F., Mathur, A., Rathod, K. S., & Jones, D. A. (2023). An exploration of the early discharge approach for low-risk STEMI patients following primary percutaneous coronary intervention. In Am J Cardiovasc dis (vol. 13, number 2). www.AJCD.us/
Collet, J. P., Thiele, H., Barbato, E., Bauersachs, J., Dendale, P., Edvardsen, T., Gale, C. P., Jobs, A., Lambrinou, E., Mehilli, J., Merkely, B., Roffi, M., Sibbing, D., Kastrati, A., Mamas, M. A., Aboyans, V., Angiolillo, D. J., Bueno, H., Bugiardini, R., ... Siontis, G. C. M. (2021). 2020 ESC Guidelines for the management of acute coronary syndromes in patients presenting without persistent ST-segment elevation. In European Heart Journal (Vol. 42, Number 14, pp. 1289–1367). Oxford University Press. https://doi.org/10.1093/eurheartj/ehaa575
Desai, A., Aliberti, S., Amati, F., Stainer, A., & Voza, A. (2022). Cardiovascular Complications in Community-Acquired Pneumonia. In Microorganisms (Vol. 10, Number 11). MDPI. https://doi.org/10.3390/microorganisms10112177
Febriyenti, A., Yosmar, R., & Permatasari, D. (2025). Cardiovascular Drug-Drug Interactions (DDIs) in Coronary Heart Disease Patients with Hypertension. Journal of Pharmaceutical and Sciences (JPS), 8(4), 2711–2720. https://doi.org/10.36490/journal-jps.com
H. Ticona, J., M. Zaccone, V., & M. McFarlane, I. (2020). Community-Acquired Pneumonia: A Focused Review. American Journal of Medical Case Reports, 9(1), 45–52. https://doi.org/10.12691/ajmcr-9-1-12
Hakansson, A. P., Orihuela, C. J., & Bogaert, D. (2018). Bacterial-Host Interactions: Physiology and Pathophysiology of Respiratory Infection. Physiol Rev, 98, 781–811. https://doi.org/10.1152/physrev.00040.2016.-It
Imbriano, L. J., Grant, C., & Scott, N. (2025). The Different Paths That Lead to Hypotonic Hyponatremia, and a Safe Approach to Treatment. In Journal of Clinical Medicine (Vol. 14, Number 1). Multidisciplinary Digital Publishing Institute (MDPI). https://doi.org/10.3390/jcm14010092
Israelsen, S. B., Fally, M., Nielsen, P. B., Kolte, L., Iversen, K. K., Ravn, P., & Benfield, T. (2024). Reassessing Halm's clinical stability criteria in community-acquired pneumonia management. European Respiratory Journal, 64(5). https://doi.org/10.1183/13993003.00054-2024
Li, T., Chen, S., Shen, Y., Li, Z., Han, S., Yuan, Y., Zhang, Y., Feng, D., Jin, Z., Jin, Y., & Wang, F. (2025). Epidemiology and co-infection patterns of community-acquired pneumonia among children from 2015 to 2023 in Henan Province, China: longitudinal surveillance study. Scientific Reports, 15(1). https://doi.org/10.1038/s41598-025-14685-7
Liu, W. C., Li, S. B., Zhang, C. F., & Cui, X. H. (2022). Severe pneumonia and acute myocardial infarction complicated with pericarditis after percutaneous coronary intervention: A case report. World Journal of Clinical Cases, 10(10), 3222–3231. https://doi.org/10.12998/wjcc.v10.i10.3222
Martin, N. D., Codner, P., Greene, W., Brasel, K., & Michetti, C. (2020). Contemporary hemodynamic monitoring, fluid responsiveness, volume optimization, and endpoints of resuscitation: An AAST critical care committee clinical consensus. Trauma Surgery and Acute Care Open, 5(1). https://doi.org/10.1136/tsaco-2019-000411
McDonagh, T. A., Metra, M., Adamo, M., Baumbach, A., Böhm, M., Burri, H., Čelutkiene, J., Chioncel, O., Cleland, J. G. F., Coats, A. J. S., Crespo-Leiro, M. G., Farmakis, D., Gardner, R. S., Gilard, M., Heymans, S., Hoes, A. W., Jaarsma, T., Jankowska, E. A., Lainscak, M., ... Koskinas, K. C. (2021). 2021 ESC Guidelines for the diagnosis and treatment of acute and chronic heart failure. In European Heart Journal (Vol. 42, Number 36, pp. 3599–3726). Oxford University Press. https://doi.org/10.1093/eurheartj/ehab368
Moïsi, L., Mino, J. C., Guidet, B., & Vallet, H. (2024). Frailty assessment in critically ill older adults: a narrative review. In Annals of Intensive Care (Vol. 14, Number 1). Springer Science and Business Media Deutschland GmbH. https://doi.org/10.1186/s13613-024-01315-0
Putot, A., Garin, N., Rello, J., & Prendki, V. (2025). Comprehensive management of pneumonia in older patients. In European Journal of Internal Medicine (Vol. 135, pp. 14–24). Elsevier B.V. https://doi.org/10.1016/j.ejim.2025.02.025
Putra, T. R. I., Maya, P., Hasan, M., Pranata, A., Salsabila, S., & Sariningrum, H. A. (2022). Characteristics of Non-Malignant Pleural Effusion Patients at Dr. Zainoel Abidin Hospital in 2019. Indonesian Journal of Internal Medicine, 9(1), 15. https://doi.org/10.7454/jpdi.v9i1.696
Salman Khan, Abdur Rehman, Muhammad Zubair, Moeen ul Haq, & Nisar Khan. (2022). Frequency of hyponatraemia in patients admitted with community acquired pneumonia in medical unit of teaching hospital. Pakistan Journal of Chest Medicine, 28(3), 297–301. https://doi.org/https://doi.org/10.1996/pjcm.v28i3.807
Sherlyn, and Grace. (2024). Prevalence and Treatment of Community-Acquired Pneumonia. The Indonesian Journal of General Medicine, 2(6).
Sheth, H. J., Sood, S. V., Patel, R. P., & Malhotra, S. D. (2017). A case report on angioedema induced by levofloxacin: an unexpected occurrence. International Journal of Basic & Clinical Pharmacology, 6(11), 2749. https://doi.org/10.18203/2319-2003.ijbcp20174800
Stotts, C., Corrales-Medina, V. F., & Rayner, K. J. (2023). Pneumonia-Induced Inflammation, Resolution and Cardiovascular Disease: Causes, Consequences and Clinical Opportunities. In Circulation Research (Vol. 132, Number 6, pp. 751–774). Lippincott Williams and Wilkins. https://doi.org/10.1161/CIRCRESAHA.122.321636
Tieu, S., Charchoglyan, A., Paulsen, L., Wagter-Lesperance, L. C., Shandilya, U. K., Bridle, B. W., Mallard, B. A., & Karrow, N. A. (2023). N-Acetylcysteine and Its Immunomodulatory Properties in Humans and Domesticated Animals. In Antioxidants (Vol. 12, Number 10). Multidisciplinary Digital Publishing Institute (MDPI). https://doi.org/10.3390/antiox12101867
Velat, I., Bušić, Ž., Jurić Paić, M., & Čulić, V. (2020). Furosemide and spironolactone doses and hyponatremia in patients with heart failure. BMC Pharmacology and Toxicology, 21(1). https://doi.org/10.1186/s40360-020-00431-4
Wang, C.-Y., Tiong, T.-Y., Chen, Y., Lin, Y.-H., Yadav, V. K., Changchien, C.-Y., Chian, C.-F., & Tsai, C.-L. (2026). Heart Failure Pleural Fluid Impairs Endothelial Barrier through miR 501-3p Mediated ZO 1 Remodeling. IScience, 115549. https://doi.org/10.1016/j.isci.2026.115549
Wang, X., Hu, J., & Wu, D. (2022). Risk factors for frailty in older adults. In Medicine (United States) (Vol. 101, Number 34, p. E30169). Lippincott Williams and Wilkins. https://doi.org/10.1097/MD.0000000000030169
Yasir, M., & Mechanic, O. J. (2023). Syndrome of Inappropriate Antidiuretic Hormone Secretion Continuing Education Activity. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing. https://www.ncbi.nlm.nih.gov/books/NBK507777/