1. Morning Report Team A2
Hassan G. Mohamed, Abdelrahman Ahmed, Adam and Rynita
Harper University Hospital

2. Chief Complaint
A 52-year-old man presented to the emergency room with shortness of breath for 10 days

3. 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

4. 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

5. 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

6. Physical Examination

7. Vital Signs Temperature = 38.0 Heart rate = 127bpm
Respiratory rate = 28
Blood Pressure= 78/54
SaO2= 83% on room air

8. 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.

9. Illness Script?
Add illness script

10. Differential Diagnosis/ Questions?
Non-resolving bacterial pneumonia (non-adherance to therapy)
Viral pneumonia TB PE
Legionella

11. Investigations? I II
III IV

12. Complete Blood Count WBCs 7.1 Hb 10.2 Platelets 376
Differential: Neutrophils abs 5.1 (71%)
- Lymphocytes 1.2 (16%)
Return

13. Na 131 Cl 100 BUN 21 K 4.3 HCO3 19 Cr 1.26 Basic Metabolic Panel
AG = 12
Calcium 9.4
Return

14. Arterial Blood Gas
pH=
PaCO2= 25.6
PaO2 = 62.2
HCO3= 17
Return

15. Return

16. What is the most likely diagnosis?

17. 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

18. 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

19. 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

20. 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 

21. 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

22. Clinical Features Fever Dry Cough Dyspnea on exertion
Subacute course ( 3 weeks on average)

23. 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

24. 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

25. 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 )

26. 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

27. 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%.

29. LDH 311
B glucan was >500
BAL PCP PCR was positive

30. 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

31. LDH 132
B D Glucan >500

33. Thank
You!