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What Pneumonia Experts Say About Clinton’s Case

If Hillary Clinton brushed aside medical advice to rest after getting a diagnosis of mild pneumonia, she was risking developing a more serious case, medical experts said Monday.
Pneumonia — which leads to infiltration of fluid into the lungs, leaving a patient short of breath and often feverish but still able to function — can become serious or even fatal if it is not properly treated, doctors said.
The illness can be caused by viruses, bacteria or, less often, fungi or damage from toxic fumes. Without extensive testing, which is not normally needed, it is impossible to know what caused Mrs. Clinton’s case.
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Mrs. Clinton’s doctor released a statement saying that the illness was diagnosed on Friday morning and that she was advised to “rest and modify her schedule.” Her team has released very little information about her condition: exactly how it was diagnosed; what antibiotics she is taking; the results of any blood work, chest X-ray or other diagnostic tests that may have been performed; or whether she has any underlying condition that made her vulnerable to the illness. On Monday, a campaign spokesman said that more medical information would be released this week and that those records would show she had “no other undisclosed condition.”
As a result, doctors asked about her case said they could only speculate.
“Hillary is sick, but she had two days of activities after she was diagnosed, so she’s not that sick,” said Dr. Paul A. Offit, the chief of infectious diseases at Children’s Hospital of Philadelphia. He said he doubted she was infected with “the really serious bacteria that put you in a hospital.”
It is not uncommon for a doctor to diagnose pneumonia merely after listening to a patient’s chest through a stethoscope and hearing “rales,” which sound like tissue paper being crinkled, said Dr. William Schaffner, the chairman of preventive medicine at Vanderbilt University Medical School.
A doctor can also order a chest X-ray, a sputum sample and blood tests, “but she could be getting perfectly good medical care even if these things were not done,” Dr. Schaffner said.
Normally, patients are started on antibiotics immediately, and the test of whether the diagnosis and treatment were right is whether they quickly improve.
Elevated white blood cell counts could indicate a bacterial infection, and a sputum sample and nasal swab can be taken to see what bacteria are present.
But growing bacteria in culture can take days, “and in half of all pneumonia cases, even with tests, we aren’t able to identify the cause,” said Dr. Charles S. Dela Cruz, a lung specialist at Yale medical school.
If a patient does not get better after taking antibiotics, more testing should begin, Dr. Schaffner said. Only then do doctors begin to worry about a more serious underlying cause, such as leukemia.
Several doctors said they did not think Mrs. Clinton posed any infection risk to others.
Adults “are very, very rarely carriers of bacterial pneumonia,” Dr. Schaffner said. Adult-driven outbreaks in rare cases occur in close quarters like submarines and prisons, but adults do not normally carry pneumonia bacteria in their noses and throats as children do.
“That’s why patients admitted to hospitals with community-acquired pneumonia aren’t put in isolation,” he said. “There’s no need.”
Dr. James M. Musser, the head of pathology at the Houston Methodist Medical System, said, “Most people are not infectious if they have pneumonia, and being on antibiotics makes them even less infectious.”
Dr. Dela Cruz differed, saying he felt patients should limit contact with others the first few days of treatment when the source of a pneumonia is unknown.
Dehydration, which Mrs. Clinton’s team blamed for her apparent collapse at Sunday’s memorial service, could be caused by a combination of standing outdoors on a hot, humid day and any fever she might have had, Dr. Schaffner said. Like sweating during exercise, fever causes the body to lose moisture, which can lower blood pressure and cause fainting.
Mrs. Clinton’s normal blood pressure is 100/65, according to a description of her health released July 28, 2015, by Dr. Lisa R. Bardack, her internist. That is on the low side of a normal range, and could contribute to a tendency to faint, Dr. Schaffner noted.
Allergies, which typically cause sneezing, not coughing, rarely trigger pneumonia, experts said.
“In retrospect, that coughing episode looks more like a possible viral infection,” Dr. Schaffner said, noting that on the campaign trail, Mrs. Clinton has come close to many people and has shaken many hands. The Centers for Disease Control and Prevention just warned doctors that flu season appeared to be starting unusually early this year, he added.
Since both are over age 65, Mrs. Clinton and Donald J. Trump, the Republican presidential candidate, should be getting annual flu shots and should also have had two shots against pneumococcal pneumonia, experts said. Although “pneumo shots” protect against several bacterial strains that are the most common causes of pneumonia, they do not protect against all of them.

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