Case Reports

Special Operations Training: An Atypical Presentation of Aspiration Pneumonia

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A peripherally inserted central catheter line was placed for daily IV ceftriaxone infusions to be continued with oral clindamycin for the subsequent 4 weeks. A CT scan of the chest at 8 weeks posthospitalization revealed minimal postoperative scarring, and pulmonary function tests showed normal flow volume loop and maximum voluntary ventilation (Figure 4). The patient reported full recovery and was returned to full activity, including further Special Operations training.


Pulmonary infections associated with near-drowning events are caused by a host of organisms that must be considered in the differential diagnosis. The most common include Aeromonas species, Burkholderia pseudomallei, Pseudallescheria boydii, Streptococcus pneumoniae, and Pseudomonas aeruginosa.2 However, the causative organism in this case was endogenous. Streptococcus intermedius is an anaerobic, Gram-positive cocci, a member of the Streptococcus milleri group, and is considered normal flora of the oral mucosa, upper respiratory tract, vagina, and gastrointestinal tract.3,4 This organism is innocuous in its normal habitat but may result in considerable mortality and morbidity if spread to alternative sites due to its ability to form abscesses and cause systemic infections.5

Although uncommon, respiratory infections caused by S intermedius typically result from aspiration of gastric or oral contents and may lead to pulmonary abscesses or empyema.1,6,7 It may present as a primary empyema.8 Current literature suggests a mortality rate between 2% and 14% with higher rates in older populations.9 A retrospective study looking at 72 cases of Streptococci viridans pulmonary infection from 1984 to 1996 found only 2 documented cases where S intermedius was identified as the cause of concomitant empyema and lung abscesses. This study also indicated a strong male predominance with only 7% of lung abscesses occurring in females.10,11

This patient developed a pulmonary abscess and empyema as a probable consequence of aspiration during underwater training exercises. The diagnosis was complicated, because the patient did not initially disclose the pertinent history, and he ignored his symptoms so that he could continue training. His actions delayed aggressive antibiotic therapy and likely led to the rapid progression of pneumonia and his complicated clinical course, because S intermedius has shown intermediate susceptibility or resistance to fluoroquinolone monotherapy.12

This case was also unusual given the subacute presentation and 3-month history of hemoptysis. On review of the available medical literature, hemoptysis is an unusual symptom of pulmonary infections caused by S intermedius but can likely be attributed to necrosis of the pulmonary tissue.8,13

Most patients with S intermedius pulmonary infection rapidly progress due to the virulence of this organism and predisposing comorbidities.14,15 However, this patient had a relatively indolent progression for 3 months, which speaks to the increased respiratory reserve of a healthy, young male in excellent cardiovascular condition.


This case highlights the potential for normal oral flora to cause advanced pulmonary disease in patients with no significant comorbidities. Streptococcus intermedius infections can be subacute in presentation but may rapidly progress to severe disease once seeded in the pleural cavity. Whereas early pleural space drainage remains fundamental, urgent surgical intervention may be required for loculated disease. Although infections with this organism may lead to irreversible pulmonary complications, complete resolution with full recovery is possible in young, healthy patients.

Primary care physicians must take a careful history to ensure optimal patient outcomes. This concept is particularly important to consider in aviators and Special Operations personnel who may be reluctant to seek medical care. Establishing a sense of trust among active-duty military is essential for mission accomplishment.

Author disclosures
The authors report no actual or potential conflicts of interest with regard to this article.

The opinions expressed herein are those of the authors and do not necessarily reflect those of Federal Practitioner, Frontline Medical Communications Inc., the U.S. Government, or any of its agencies. This article may discuss unlabeled or investigational use of certain drugs. Please review complete prescribing information for specific drugs or drug combinations—including indications, contraindications, warnings, and adverse effects—before administering pharmacologic therapy to patients.

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