<![CDATA[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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