CLINICAL PROBLEM SOLVING Two patients with fever and cough Viktor Kotarski, MD ID specialist University Hospital for Infectious Diseases, Zagreb

Case 1 54-year-old male patient history of diabetes type II and hypertension presents with a 3-day history of fever (up to 38.9 °C), cough, fatique and shortness of breath the patient had had a cold for 3-4 prior to the onset of fever (nasal congestion, runny nose, sore throat) The next step: Detailed history and clinical exam, basic lab Detailed history and clinical exam, basic lab, chest X-ray Detailed history and clinical exam, basic lab, chest CT scan 2

The next step: Detailed history and clinical exam, basic lab Detailed history and clinical exam, basic lab, chest X- ray Detailed history and clinical exam, basic lab, chest CT scan

Case 1 Chest X-ray: Basic lab: L 16.5 x 109/cmm CRP 208 g/L Detailed history and clinical exam: Temp. 39.2 °C BP 130/80 mmHg Pulse 92/min RF 22/min SpO2 94% Awake, alert, oriented Rales on auscultation on the right lung in the parascapular area °C Basic lab: L 16.5 x 109/cmm CRP 208 g/L 4

Case 1 The next step: treat in an outpatient setting admit to the hospital admit to the ICU Ovdje negdje ili na idućem slidu stavi CURB score i CRB score da pojasniš kako će odlučiti o načinu i mjestu liječenja 5

Case 1 The next step: treat in an outpatient setting admit to the hospital admit to the ICU 7

Case 1 Treatment : beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin) macrolide (azythromycin) respiratory fluoroquinolone (moxifloxacin) beta-lactam plus macrolide beta-lactam plus fluoroquinolone 8

Case 1 Treatment : beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin) macrolide (azythromycin) respiratory fluoroquinolone (moxifloxacin) beta-lactam plus macrolide beta-lactam plus fluoroquinolone Odgovor na zasebni slide, poboldan. 9

Case 1 In reality… The patient received azithromycin 1 x 500mg p.o. for 3 days After completion of treatment he didn’t feel better and went to the ER

Case 1 Detailed history and clinical exam: Temp. 38.5 °C BP 100/75 mmHg Pulse 100/min RF 30/min SpO2 92% Awake, alert, oriented Crackles in the right lung in the parascapular area Chest X-ray: No significant change in comparison to the last exam Basic lab: L 15.8 x 109/cmm CRP 255 g/L

Case 1 The next step: treat in an outpatient setting admit to the hospital admit to the ICU

Case 1 Treatment: beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin) macrolide (azythromycin) respiratory fluoroquinolone (moxifloxacin) beta-lactam plus macrolide beta-lactam plus fluoroquinolone

Case 1 - outcome The patient became afebrile 2 days after ceftriaxone was added to the treatment regimen Vital signs stable and within normal limits Discharged after 3 days 14

Case 2 48-year-old male patient previously healthy presents with a 4-day history of fever (up to 39.5 °C) with rigors, chills and malaise on the 4th day he started to cough Dosadan sam s ovim °C 15

Case 2 Chest X-ray: Basic lab: L 16.5 x 109/cmm CRP 208 g/L Detailed history and clinical exam: Temp. 39.2 °C BP 130/80 mmHg Pulse 92/min RF 22/min SpO2 94% Awake, alert, oriented Rales on auscultation on the right lung in the parascapular area Basic lab: L 16.5 x 109/cmm CRP 208 g/L

Case 2 The patient was sent home with a prescription for amoxicillin 1 x 1000 mg p.o. for 10 days After 4 days of treatment he didn’t feel better and came to the ER

Case 2 Chest X-ray: Basic lab: L 15.8 x 109/cmm CRP 350 g/L Detailed history and clinical exam: Temp. 38.5 °C BP 130/75 mmHg Pulse 100/min RF 28/min SpO2 92% Awake, alert, oriented Rales on auscultation on the right lung in the parascapular area Chest X-ray: Basic lab: L 15.8 x 109/cmm CRP 350 g/L

Case 2 The next step: treat in an outpatient setting admit to the hospital admit to the ICU I vdje negdje ubaciti CURB i CRB kako bi znali da to treba uvijek koristiti pri odlučivanju o načinu liječenja 19

Case 2 The next step: treat in an outpatient setting admit to the hospital admit to the ICU I vdje negdje ubaciti CURB i CRB kako bi znali da to treba uvijek koristiti pri odlučivanju o načinu liječenja 20

Case 2 The most probable cause of treatment failure: pleural effusion (empyema) or abscess resistant strain of S. pneumoniae other pathogens (viruses, S.aureus, Legionnaires disease, tuberculosis…) ARDS malignancy other causes

Case 2 Additional workup: chest CT scan bronchoscopy microbiological tests serology

Case 2 Microbiological tests: blood culture sputum culture bronchoscopy + culture tuberculosis culture, PCR, microscopy, QuantiFERON test respiratory pathogens PCR legionella antigen in urine

Case 2 Treatment: beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin) macrolide (azythromycin) respiratory fluoroquinolone (moxifloxacin) beta-lactam plus macrolide beta-lactam plus fluoroquinolone

Case 2 Treatment: beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin) macrolide (azythromycin) respiratory fluoroquinolone (moxifloxacin) beta-lactam plus macrolide beta-lactam plus fluoroquinolone

Case 2 - outcome Legionnaire’s disease was diagnosed by positive Legionella urinary antigen test Treatment with moxifloxacin 1 x 400mg i.v. was initiated Initially the patient required aditional oxygen (6L/min by face mask) He became afebrile after 3 days of therapy with moxifloxacin, vital signs stable and within normal limits Discharged after 4 days to continue treatment with oral moxifloxacin for a total of 10 days

Treatment of CAP simplified Vital signs!! Respiratory rate!! Outpatient setting: start with amoxicillin 3 x 500-1000 mg p.o. (watch for allergies!) Patients who require hospitalization: treat with combination therapy (beta-lactam plus macrolide) or respiratory fluoroquinolone (in case of allergies) Re-evaluate the patient after 3-4 days If they are not getting better: maybe it’s not S. pneumoniae (consider Legionella, Mycoplasma, S.aureus, viruses, tuberculosis…) look for complications (pleural effusion, sepsis, ARDS)