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Morning Report Team A2 Hassan G. Mohamed, Abdelrahman Ahmed, Adam and Rynita Harper University Hospital
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Chief Complaint A 52-year-old man presented to the emergency room with shortness of breath for 10 days
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History of Present Illness
Dyspnea on minimal exertion that has limited his activity level Dry cough that has improved Fever and chills for one day Shortness of Breath
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Review of the Systems Constitutional: Fatigue, weight loss ( 20 lbs in the last month) HEENT: Headache, sore throat CVS: No chest pain or palpitations Renal: urine has become darker in color Hematology/Lymphatics: Negative. Neurologic: Dizziness, No syncope
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Histories PMHx: recent and brief hospital stay for 1 day during which he was diagnosed with pneumonia and was discharged on 7 days of moxifloxacin PSHx: no previous surgical history SHx: Denies smoking, alcohol use, or drug abuse. FHx: Mother: PVD, Father: DM. Medications: none other than recent Moxifloxacin use
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Physical Examination
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Vital Signs Temperature = 38.0 Heart rate = 127bpm
Respiratory rate = 28 Blood Pressure= 78/54 SaO2= 83% on room air
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General: Alert and oriented x3, looks ill, Labored breathing
HEENT: Dry oral mucosa, No oral thrush or lymphadenopathy Respiratory: 4L nasal canula, b/l crackles at the base of the lungs on auscultation, No wheezing Cardiovascular: Tachycardic, Regular rhythm, S1 auscultated, S2 auscultated, No click, rub, murmur or gallop. No LE edema. Gastrointestinal: Soft, Non-tender, Non-distended, Normal bowel sounds, No organomegaly. Genitourinary: WNL Musculoskeletal: Normal range of motion, Normal strength, No tenderness, No swelling. Integumentary: Warm. Dry, flaky facial skin Neurologic: Alert, Oriented, Normal sensory Psychiatric: Cooperative, Appropriate mood & affect.
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Illness Script? Add illness script
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Differential Diagnosis/ Questions?
Non-resolving bacterial pneumonia (non-adherance to therapy) Viral pneumonia TB PE Legionella
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Investigations? I II III IV
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Complete Blood Count WBCs 7.1 Hb 10.2 Platelets 376
Differential: Neutrophils abs 5.1 (71%) - Lymphocytes 1.2 (16%) Return
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Na 131 Cl 100 BUN 21 K 4.3 HCO3 19 Cr 1.26 Basic Metabolic Panel
AG = 12 Calcium 9.4 Return
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Arterial Blood Gas pH= PaCO2= 25.6 PaO2 = 62.2 HCO3= 17 Return
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Return
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What is the most likely diagnosis?
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Hospital Course #Severe sepsis likely due to Pneumonia: SIRS 3/4
Vitals improved with 3 L boluses of IV fluids, fever improved with Tylenol, placed on 4 L NC was given cefepime & Vanco in ED Etiology CAP vs atypicals vs PCP vs other causes in immunocompromised PLAN - Switched to ceftriaxone and azithromycin urine strep/legionella Ag's Resp & blood cultures LDH, B glucan, and pneumocystis stain (induced sputum) CD 4 consults: ID & Pulm
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Hospital Course #Nonionic gap Metabolic Acidosis:
- most likely due to diarrhea - order albumin for more accurate assessment of the AG #HIV positive: - T cell subsets (CD4/CD8) Viral load
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LDH = 816 B glucan >500 Induced sputum for pneumocystis was negative Started empiric treatment for PCP with Bactrim CD=7 BAL confirmed the diagnosis 2 days later
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Pneumocystis Jirovecii
Fungus Formerly Carinii Most common opportunistic infection in patients with HIV United States: there was a decrease in PCP incidence in HIV patients from 29.9 per 1000 person years between 1994 to to 3.9 per 1000 person years between 2003 to 2007
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Usually occurs when CD4 count is < 200 cells/μL or CD4 < 14%
Hematopoietic and solid organ transplant recipients during immunosuppression Any patient taking equivalent of ≥ 20 mg Prednisone/day for more than 1 month
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Clinical Features Fever Dry Cough Dyspnea on exertion
Subacute course ( 3 weeks on average)
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Diagnosis Beta-D-Glucan LDH Imaging
Cell wall polysaccharide of Pneumocystis and other fungi sensitivity/specificity of 95%/86%. Negative predictive value of over 95 Beta-D-Glucan present in 90 percent of HIV-infected patients with PCP and had some prognostic significance. In HIV-positive patients sensitivity was 100% LDH Chest X-ray: normal Interstitial infiltrates, alveolar CT chest: ground-glass appearance Imaging Clinic Micro Infect 19:39 ,2013 Swiss Med Weekly 2011 Apr 29;141:w13184
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Detecting the organism = definitive diagnosis
Induced Sputum: Sensitivity is highly variable, between 50 to 90 % BAL: sensitivity of BAL from 90 to 98 percent PCR of respiratory fluid: Active area of research, not yet useful
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Treatment TMP-SMX: DS 2 tabs TID for 21 days
If PaO2<70 or A-a >35 Prednisone ( 40 mg BID for 5 days then 40 mg daily for 5 days the 20 mg daily for 11 days )
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Take Home Message Suspect PCP in patients with symptoms of pneumonia but for a duration more than 3 days with significant SOB Keep it in the differential if patient has HIV or transplant on immunosuppression ASK ABOUT HIV. CHECK FOR HIV Screen with LDH and glucan ( HIGH Sensitivity) Confirm with induced sputum, BAL, Stains/PCR
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69-year-old female with history of end-stage renal disease status post renal transplant in presenting with fever and dry cough for 1 week in addition to dyspnea on exertion. Her temperature was 39 C and physical examination revealed bibasilar crackles. She is requiring 4 L of Oxygen to maintain a saturation of 94%.
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LDH 311 B glucan was >500 BAL PCP PCR was positive
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60-year-old male with history of right renal transplant in 2008, chronic generalized edema presents with shortness of breath which started 3 days prior to admission with cough productive of yellow sputum for 1 week. He was hypoxic on arrival to the ED and needed BiPAP with 4 L oxygen via nasal cannula. Physical examination revealed bibasilar crackles and developed a temperature of C 3 days after admission
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LDH 132 B D Glucan >500
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Thank You!
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