70 Year Old Man with Respiratory Failure

1
70 Year Old Man with Respiratory Failure

• Andrea Glassberg
• Pulmonary Case Conference
• April 8, 2003

2
Clinical Presentation

• A 70 yo man presented to the hospital complaining
  of one week of subjective fevers, progressive
  shortness of breath, and dry cough.
• He reported several weeks of myalgias, but denied
  any chest pain, abdominal pain, nausea, rash,
  joint pain, headaches, confusion.

3
Clinical Presentation

• The patient had been hospitalized for three
  weeks, three months prior to this admission for
  an illness characterized by respiratory failure
  and ARDS, presumed to be secondary to pneumonia.
  He recovered completely and was at home for two
  months before his current symptoms developed.

4
(No Transcript)
5
Past Medical History

• Hypertension
• Type II Diabetes
• Gout
• Obesity
• ARDS
• Psychiatric (Paranoid Delusions)

6
Social History

• Quit tobacco 10y ago
• No ETOH
• No recent travel, wife returned from Europe one
  week before the patient was admitted.

7
Medications

• NKDA
• HCTZ
• Fosinopril
• ASA
• Resperidone
• Rosiglitazone
• Allopurinol

• Rabeprazole
• Isordil
• Furosemide
• Docusate
• Atenolol
• Amlodipine

8
Exam

• Uncomfortable appearing obese elderly man in
  respiratory distress.
• T 100.8
• BP 170/70
• HR 99
• RR 38
• O2 sat 78 on RA

9
Exam

• CV no JVD, RRR, nl S1, S2, S4
• Lungs coarse crackles bilaterally
• Abd Benign
• Ext no C/C/E
• Skin no rashes or lesions

10
Labs

• WBC 13.4
• HCT 40
• Platelets 200
• Lytes normal
• Creatinine 1.4
• Glucose 250

• LFTs normal
• Coags normal
• CPK 113
• ABG 7.53/33/35
• ESR 99
• UA negative

11
(No Transcript)
12
Additional Information?
13
(No Transcript)
14
(No Transcript)
15
(No Transcript)
16
(No Transcript)
17
(No Transcript)
18
(No Transcript)
19
(No Transcript)
20
(No Transcript)
21
Differential Diagnosis?
22
Additional Data

• Viral DFA negative
• Blood, urine, sputum cultures negative
• BAL all cultures negative
• PCP negative
• No evidence for DAH
• ANA, RF, pANCA, cANCA, anti GBM negative

23
What would you do now?
24
Does this patient have SARS?

• Andrea Glassberg
• Pulmonary Case Conference
• April 8, 2003

25
SARS Severe Acute Respiratory Syndrome

• The WHO issued a worldwide alert on 3/15/03 for a
  mysterious respiratory illness that presents as
  an atypical pneumonia and is characterized by
  fever with cough or breathing problems and
  appears to spread easily among close contacts.

26
Suspected Case

• A person presenting after 1 November 2002 with
  history of
• high fever (gt38 C), and
• cough or breathing difficulty, and
• One or more of the following exposures during the
  10 days prior to onset of symptoms
• close contact with a person who is a suspect or
  probable case of SARS
• history of travel, to an affected area
• residing in an affected area

27
Characteristics

• Previously healthy adults age 25-70
• Incubation 2-7 days
• Radiographic abnormalities need not be present
• 10-20 require intubation
• 3 case fatality rate
• Leukopenia
• Thrombocytopenia
• Elevated CPK
• Elevated transaminases (2-6 times normal)

28
SARS CT
29
Etiology/Detection

• A new coronavirus (SARS-virus) which is unlike
  any other known members of the genus Coronavirus
• Cytopathogenic effect (CPE) in VERO cells and
  FRhk-4 cells, which can be inhibited with serum
  from SARS convalescent patients.
• Electron microscopic pictures from cell-culture
  and respiratory specimens from SARS patients show
  coronavirus-like particles.
• Immunofluorescence assays (IFA) with serum from
  convalescent patients detect cells infected with
  the virus in cell-culture.
• Reactivity with SARS-virus could not be detected
  in serum from several hundreds of non-SARS
  individuals in the U.S.A., Canada and Hong Kong.
• Generic coronavirus primers detect SARS virus RNA
  in cell-culture and in specimens from SARS
  patients. Specific primers have been developed in
  several laboratories and are currently been
  compared for sensitivity.

30
Diagnostic Testing

• The ELISA detects antibodies reliably but only
  from about day 20 after the onset of clinical
  symptoms.
• An immunofluorescence assay (IFA), detects
  antibodies reliably as of day 10 of infection,
  but is a demanding and comparatively slow test
  that requires the growth of virus in cell
  culture.
• PCR for detection of SARS virus genetic material
  is useful in the early stages of infection but
  produces many false-negatives.

31
Cases and Countries 4/08/03

• 2671 cases
• 103 deaths
• 17 countries

32
(No Transcript)
33
(No Transcript)
34
Management

• Isolate
• Take samples to exclude standard causes of
  pneumonia (including atypical causes)
• Take samples for SARS investigation including
  White blood cell count, platelet count, creatine
  phosphokinase, liver function tests, urea and
  electrolytes and C reactive protein
• Antibiotics to cover CAP and atypical pneumonia
• Avoidance of activities that may cause
  aerolization.
• Currently no role for ribavirin or steroids

35
References

• www.cdc.gov
• www.who.org
• www.nytimes.com