Resident Case Report

1
Resident Case Report

• Rohan Arya

2
History of Present Illness

• 45 year old male presents to E.R. with a
  complaints of frontal headaches x 5-7 Days.
  Other complaints included productive cough
  (white sputum), generalized body aches, and
  progressive fatigue. Initially symptoms began
  with mild headaches which then progressed to URI
  symptoms.

3
Case Report

• Patient also reports
• Photophobia
• Dizziness
• Nausea and vomiting
• Loose bowel movements
• Subjective fevers and chills
• Recent travel to New Hampshire

4

• Questions

5
Case Report

• Patient denies
• Neck stiffness
• Hemoptysis
• Shortness of breath
• Hematemesis / hematochzia / melena
• Rashes
• Focal Neurological deficits
• Weight loss / Night sweats
• Sick contacts

6

• Differential Diagnosis ?

7
Case Report

• PMHx
• HIV (last known CD4 count gt100, nadir unknown,
  h/o O/I unknown, on HAART)
• Hepatitis B (never treated)
• PSHx
• Appendectomy
• Allergies
• NKDA

8
Case Report

• Home Medicines
• Bactrim
• Viread
• Zithromax
• Norvir
• Epzicom
• Lexeva
• Effexor
• Seroquel

9
Case Report

• Social Hx
• No tobacco / ETOH / IVDA
• Sex w/ men only
• Recent travel to New Hampshire
• Family Hx
• Non Contributory

10
Case Report

• Review of systems
• As per HPI
• Physical Examination
• VITALS BP 92-119/66-84, HR 64-88, RR 18-20,
  SAT 92-95 RA, Tmax 99.6
• GEN NAD, AAOx3, fatigued.
• HEENT PERRLA, () photophobia, MMM, (-) LAD,
  oral lesions, focal neurological deficits or
  nuchal rigidity

11
Case Report

• PULM Equal air entry bilat, bilat lower and
  middle lung zone rhonchi and fine rales, no
  wheezes
• CVS Normal S1S2, Reg rate rhythm, no murmurs,
  rubs or thrills, non displaced PMI
• ABD Flat, soft, NT, ND, BS ()
• EXT Warm, no edema, bilat pedal pulses palpable

12
Case Report

• Labs
• 135 109 21 (7.3) 11.4
• (58) 1.8 (2.6) 100
• 3.6 23 (1.2) 2.8 34
• N 59 L 33 ANC (1.5)
• 7.5 2.5 UA protien-30
• 0.6 2.0 RPR (-)
• (517) (625) PCP (-) x2
• 89 Influenza A/B (-)

13
Case Report

• Labs Continued
• Serum crypto antigen (-)
• CSF WBC 8, RBC 2, L 98, M 2
• Glucose 53, Protein (68).
• CK 195, LDH (1784)
• ABG 7.39 / 39 / 73 / -1 / 23.9 / 96

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Case Report

• CXR

15
Case Report
16
Case Report

• CT Head Pan sinus mucosal disease with probable
  acute sinusitis
• DIFFERENTIAL DIAGNOSIS?

17
Case Report

• Differential Diagnosis of the Pneumonia
• PCP
• Bacterial atypical vs Pseudomonas vs CAP vs
  Listeria
• Fungal
• Viral RSV, Influenza A/B, H1N1
• Lymphoma
• Atypical MAC vs T.B

18
Case Report

• Initial Plan
• Meningitis - Less likely.
• - bactrim to cover MRSA, Cefipime, zithromax to
  cover gram (), gram (-) and Listeria.
• 2. PNA - Cefipime, zithromax, Tamiflu, bactrim
  to cover CAP, atypicals, influenza and MSA.
• - Respiratory isolation.
• - R/O T.B. with sputum x3.
• - R/O PCP with sputum x3.

19
Case Report

• CVS - IVF because increased losses secondary to
  fevers and decreased PO intake.
• HIV Continue HAART.
• GI Follow LFTs, maybe elevated because of Hep
  B.
• ID Antibiotics as above, Blood Cultures x2.

20
Case Report

• Day 2 Pulmonary consult called and bronchoscopy
  scheduled.
• - Recommended increase tamiflu to 150mg Q12.
• - Cont isolation and current antibiotics.
• Day 3 Patient had bronchoscopy and fluid sent
  for PCP, H1N1, Cultures, etc.

21
Case Report

• Patients hospital stay was fairly unremarkable
  with one episode of acute desaturation,
  hypotension, rigors and elevated temperature at
  which CCM was called to see patient. High flow
  oxygen via face mask and fluid boluses were
  given. Transfer to MICU not needed.
• Pt received 10 day course of the antibiotics and
  Tamiflu, improved and was discharged with
  Diagnosis of H1N1 Pneumonia.

22
Discussion

• The current outbreak of the pandemic swine-origin
  (H1N1) influenza virus (S-OIV) emerged in Mexico
  City in March 2009.
• First cases in the U.S.A were reported in
  California and then spread rapidly throughout the
  U.S.
• As of Mid August 2009, 182,166 cases and 1799
  deaths have occurred world wide.
• From the above numbers, 7983 cases and 522 deaths
  were in the U.S.A.

23
Epidemiology

• Swine Flu is a misnomer.
• It is a new strain of influenza A that is a
  quadruple reassortment of swine (x2), avian and
  human influenza strains, the largest proportion
  of the genes coming from the swine influenza
  viruses.
• Illness with influenza was first recognized
  during the influenza pandemic in 1918-1919.
• First Isolated from humans in 1974

24
Epidemiology

• In 1975 the swine influenza virus caused illness
  (1 fatality) among 16 soldiers at Fort Dix, NJ.
  Later studies showed that up to 230 soldiers were
  infected.
• Between 1958-2005 were reported in civilians. 6
  cases (17) were fatal. 44 of individuals had
  known exposure to pigs. The cases were reported
  in U.S.A, former Czechoslovakia, Holland,
  Switzerland, Russia and Hong Kong.

25
Epidemiology

• Rates on infection in the United States were
  highest among individuals 24 years of age.
• Highest for ages 4-24.
• Second highest group being 4.

26
Classification

• WHO guidelines suggest that influenza viruses be
  named after the
• Viral type (A, B, C or D)
• Host
• Place of isolation
• Year of isolation
• The appropriate name for the virus is influenza
  A/ California/ 04/ 2009.

27
Pathology

• Autopsies showed both upper and lower respiratory
  tract abnormalities.
• Among 21 confirmed H1N1 deaths, 20 showed diffuse
  alveolar damage. Of the 20
• 6 had necrotizing bronchiolitis.
• 5 had extensive pulmonary hemorrhages.
• Other Findings include
• Cypathic effects in bronchiol and alveolar cell
  and necrosis.
• Epithelial hyperplasia.
• Squamous metaplasia of large airways.

28
Transmission

• The influenza virus is found in respiratory
  secretions of infected individuals. As a result
  transmission is by coughing and sneezing via
  large particle droplet.
• Transmission by contaminated surfaces may occur
  but this mode of transmission is not proven.
• Other bodily fluids (stool) should be considered
  potentially infectious, but again, has not been
  proven.

29
Signs and Symptoms

• Typical flu-like symptoms
• Cough
• Sore throat
• Fevers
• Malaise
• Headaches
• Vomitting and diarrhoea
• Other chills, myalgias, arthralgias, shortness of
  breath and rhadbomyolysis.

30
Signs and Symptoms

• Most patients report a relatively mild illness
  with full recovery.

31
Radiographic Findings

• In 66 of confirmed H1N1 cases, infiltrates
  showed evidence of pneumonia or acute respiratory
  distress syndrome.
• Most common findings on CXR were
• Patchy consolidation in lower and central lung
  zones (71).
• Ground glass infiltrates with or without
  consolidation (25).
• In those patients who had CT scans done, either
  showed ground glass and consolidation vs nodular
  infiltrative pattern.

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Radiographic Findings
33
Radiographic Findings
34
Laboratory Findings

• State public health laboratories can perform PCR
  and subtype testing on samples.
• Local Laboratories can perform rapid IF or enzyme
  immunoassays to differentiate between influenza A
  and B types (limited sensitivity 60)
• Other laboratory findings
• Elevated ALT AST (45, 44)
• Anemia (37)
• Leukopenia (20)
• Leucocytosis (18)

35
Laboratory Findings

• Thrombocytopenia (14)
• Thrombocytosis (9)
• Elevated total bilirubin (5)
• Elevated CK
• Elevated LDH

36
Treatment

• All confirmed samples have shown sensitivity to
  neuraminidases (oseltamivir and zanamivir).
• Usual resistance to adamantanes (amantadine and
  rimantadine).
• Supportive care.
• Respiratory isolation for 7 days from onset of
  symptoms or until resolution of symptoms, which
  ever is longer.

37
Prevention

• Polyvalent vaccine
• Standard vaccine
• Patients should be considered infectious 1 day
  before to 7 days post illness onset.
• Children may be infectious up to 10 days.
• Hospitalized patients should be isolated in
  individual rooms with standard contact and eye
  precautions.
• Strict hand hygiene.

38
Prevention

• Post exposure prophylaxis should be considered
  for
• Close contacts who at high risk for influenza
  complications
• Healthcare personnel
• Public health workers
• First responders
• No documented indications for travel
  restrictions, culling of animals or wide spread
  school closures.
• Eating pork does not transmit the virus.

39
Questions

• 45 year old man is evaluated for malaise,
  myalgias, coryza and a cough. The patient takes
  ACEI, inhaled bronchodilator and low dose ASA. He
  has not had the influenza vaccine, and no recent
  travel. On exam he appears ill, is febrile and
  other wise the exam is unremarkable. Which of the
  following agents is most appropriate?
• Zanamivir
• Amantadine
• Oseltamivir
• Rimantadine

40

• Zanamivir
• Amantadine
• Oseltamivir
• Rimantadine

41

• 2. A 52 y.o. woman with a 2 month hx of SOB, and
  1 month hx of nonproductive cough. Both symptoms
  are worsening. Pt has no allergies, or exposure
  to pulmonary contaminants. No sig pmhx and only
  takes H2 antagonist. On exams she is dyspneic.
  Normal CXR, PFTs show mod obstrucive disease and
  decreased diffusion capacity. Sputum is positive
  for mycobacteria.

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• Which most likely explains the patients positive
  culture?
• MAC hypersensitive pneumonitis
• T.B.
• Norcardia pneumonia
• Rhodococcus pneumonia
• Contaminant

43

• MAC hypersensitive pneumonitis
• T.B.
• Norcardia pneumonia
• Rhodococcus pneumonia
• Contaminant

44

• 3. 62 y.o. man come to ED b/c of 3 day hx of
  fever, cough and yellow green sputum production.
  Pt had severe pna at age 40 and since had daily
  cough productive of white-yellow sputum. He
  typically receives 1-2 courses of abx yearly when
  sputum production increases. He never smoked. On
  exam RLL crackles are heard and is febrile. Labs
  show elevated WBC and CXR shows RLL infiltrate.

45

• Antibiotic coverage should include?
• M.tuberculosis
• RSV
• Norcardia brasiliensis
• Pseumonas aeroginosa
• Chlamydophila pneumoniae

46

• Antibiotic coverage should include?
• M.tuberculosis
• RSV
• Norcardia brasiliensis
• Pseumonas aeroginosa
• Chlamydophila pneumoniae