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CPC # 2 Infectious Disease October 7, 2008

This case study presents a 58-year-old alcoholic man with acute pneumonia, hepatic encephalopathy, lactic acidosis, coagulopathy, and renal failure. The patient rapidly deteriorated and expired within 36 hours.

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CPC # 2 Infectious Disease October 7, 2008

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  1. CPC # 2Infectious DiseaseOctober 7, 2008 Lisa L. Maragakis, MD MPH

  2. Important Features of the Case • 58 yo man with a history of alcoholism, smoking, hypertension and chronic pain • Presents with 5 days of cough and fever with progressive dyspnea and “weakness” • Confusion and slurred speech is also reported by the patient’s wife • Other symtoms include: • headache • Pleuritic chest pain (R) • Urinary incontinence (new)

  3. Important Features of the Case • No recent medical care and not taking anti-hypertensive meds • Upon admission: • BP=133/94, P=125, RR=24, afebrile; • Moderate respiratory distress; 95% on 6L NC; wheezing and rhonchi • Alert, not oriented to date, slurred speech • WBC=1.1,  Hct (50%), ↓Plt (55k), ALT (141),  Tbili (2.1) ↓TP/alb,  PT/PTT,   lactate (12.6), BUN (48),  Cr (4.0), ammonia=33 • Imaging shows multi-lobar dense consolidation and cavitation of RUL, lymphadenopathy • Head CT essentially negative

  4. Summary of the Case • Alcoholic man presents with an acute illness characterized by multi-lobar pneumonia, hepatic encephalopathy, lactic acidosis, coagulopathy and renal failure • Rapidly developed hypotension, respiratory failure, and expired within 36 hours

  5. Possible Etiologies of the Elevated Ammonia level • Hepatic encephalopathy • Shock • ETOH • Renal disease • GI bleeding • Salicylate intoxication • Ethylene glycol

  6. Possible Etiologies of the Elevated Lactate level • Severe hypoxemia • Shock • Decrease in lactate utilization due to ETOH and liver disease

  7. Community-Acquired Pneumonia, Sepsis and Multi-organ Failure • Approximately 10% of CA pneumonia requires ICU care and mechanical ventilation • Risk factors • Advanced age • Comorbid disease • DM • ETOH

  8. Community-Acquired Pneumonia, Sepsis and Multi-organ Failure • Severe CAP defined by • RR>30, PaO2/FIO2<250, need for mechanical ventilation, multi-lobar pneumonia, increased size of infiltrate up to 50% in 48 hrs, BP<90/60, pressor requirement, acute renal failure • Mortality rates 20-53% (as opposed to 2-30% for “regular” CAP)

  9. Community-Acquired Pneumonia, Sepsis and Multi-organ Failure • S. pneumoniae and L. pneumophila are the most common etiologies • Gram negative bacilli, especially Klebsiella, occur in patients with DM, COPD, and ETOH abuse (this patient)

  10. Community-Acquired Pneumonia, Sepsis and Multi-organ Failure • Initial presentation of CAP in older adults can present as • Decline in functional status • Weakness • Mental status changes • Anorexia • Abdominal pain

  11. Differential Diagnosis of Community Acquired Pneumonia • S. pneumoniae accounts for 20-60% of cases • H. influenzae causes 7-11% • Older and debilitated patients more likely to have GNB colonizing oropharynx • Group A and B streptococci • M. cattarhalis • Legionella • Atypicals: M. pneumoniae, Clamydyia • Viral pneumonia: RSV, influenza, parainfluenza • Aspiration pneumonia

  12. Differential Diagnosis of Community Acquired Pneumonia • Aspiration • Silent vs witnessed • ETOH is a risk factor • Chemical pneumonitis • Mixed flora + anaerobes • Upper lobe atypical but not impossible

  13. Differential Diagnosis of Community Acquired Pneumonia • Atypical pneumonia syndromes • M. pneumoniae • C. pneumoniae • Legionella • Francisella tularensis • M. TB • Coxiella burnetii • Pneumocystis

  14. Differential Diagnosis of Community Acquired Pneumonia • S. aureus • Not on the traditional lists of CAP etiology • Seen increasingly as causing CAP • Can cause necrotizing, cavitary pneumonia with rapidly progressive sepsis as seen in this case

  15. Diagnosis • Send sputum and blood cultures BEFORE antimicrobials are started • Legionella urinary antigen (only detects serogroup 1) • Consider NP aspirate during flu season • Consider anthrax if widened mediastinum • Bronchoscopy, open lung biopsy

  16. Therapy for CAP • Not in the ICU • Ceftriaxone PLUS Azithromycin or • Moxifloxacin • In the ICU • Same as above or • Cover for Pseudomonas if at risk • Cefipime PLUS Azithromycin • Moxifloxacin PLUS Aztreonam

  17. Risks for Pseudomonas • Prolonged hospital or LTCF stay (>5d) • Structural lung disease • Steroid therapy • Broad-spectrum ABX in past month • AIDS • Neutropenia

  18. Therapy for CAP • Aspiration • Clindamycin can be added to cover anaerobes • CA-MRSA • Linezolid can be added to cover empirically while awaiting culture data

  19. Therapy for CAP • If you have the luxury of tailoring therapy • Base ABX treatment choice on organism that grows from sputum and/or blood

  20. In this case… • Treated with moxifloxacin (appropriate) • If I had to bet, I would say this patient had CA-MRSA necrotizing pneumonia and sepsis with multi-organ failure

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