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Emergency Case: 78-Year-Old Man with Respiratory Distress After Air Travel

A 78-year-old male presents with severe difficulty in breathing following a recent flight from India. His medical history includes asthma and coronary artery disease. The patient exhibits severe respiratory distress, hypoxia, and signs of potential candidal infection. Laboratory findings indicate leukocytosis, metabolic acidosis, and elevated lactate. Considerations include pneumonia, malignancy, and sepsis. Immediate steps include fluid resuscitation, initiating IV antibiotics, and further testing for HIV and infections. The case highlights the complexities of treating respiratory distress in the context of travel and underlying health issues.

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Emergency Case: 78-Year-Old Man with Respiratory Distress After Air Travel

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  1. The Case of the Elderly Man with Difficulty in Breathing on a Plane Kristen Owen, DO MSUCOM October 12, 2014

  2. Pertinent Positives • 78 y.o. male presents with severe DIB • Recent plane trip from India • History of asthma • History of CAD w/ coronary stents

  3. ROS • Associated symptoms: • Fatigue • Diarrhea • Sweating • Lethargy • Wheezing

  4. Physical Exam • Vital Signs reveal a normal HR, increased RR, normal BP and a normal temp. • O2 saturation is 100% on Bipap • HEENT: dry mucous membranes, bilateral pharynx swelling, anterior cervical lymphadenopathy • Respiratory: severe resp. distress, bilateral diminished, severe, substernal retractions

  5. Pertinent Labs • CBC revealed a leukocytosis, neutrophilia, and increased bands. • Hypermagnesemia • Elevated Lactate • Elevated Alkaline phosphatase • ABG revealed a metabolic acidosis

  6. CXR

  7. CT Chest

  8. CT Chest

  9. CT Soft Tissue Neck

  10. CT Soft Tissue Neck

  11. Video of Oropharynx • Diffuse erythema with white exudate • Likely consistent with a candidal infection • Pt is likely immunocompromised-HIV, malignancy, infection, recent course of steroids, chemotherapy or radiation.

  12. What We Know • Pt has: • Respiratory Failure • Metabolic Acidosis • Sepsis (by definition) • Multilobar Pneumonia (by CT scan) • Diarrhea

  13. DDX for Respiratory Distress • PE • Asthma • Pneumonia • Pneumothorax • CHF • Mucous Plugging • Tuberculosis • SARS • Altitude Sickness

  14. DDX for Pneumonia • S. pneumonia • S. aureus • Legionella • Pneumocystis carinii • Pseudomonas • Influenza • Pertussis • H. influenza • RSV • Mycoplasma pneumonia • Chlamydia pneumonia • Moraxella catarrhalis • Gram negative enterics

  15. Diseases Common to India • HIV/AIDS • Tuberculosis • Pneumonia • Malaria • Food Borne Pathogens

  16. DDX for Diarrhea • Bacterial- E. coli, Campylobacter, Salmonella, Shigella, Clostridium dificile, Vibrio, Aeromonas, Pleisiomonas, Yersinia • Parasites- Giardia, Cryptosporidium, Cyclospora, Microsporidia, Isospora, Entameobahistolytica • Viral causes- Hepatitis A and E, Rotavirus, Adenovirus

  17. DDX for Malignancy Lung Cancer • Small Cell Carcinoma • Non-Small Cell Carcinoma Adenocarcinoma Squamous cell carcinoma Large cell carcinoma Lymphoma Non-Hodgkins Lymphoma Hodgkins Lymphoma

  18. Things that we Need to Do • Establish 2 large bore IV’s and fluid resuscitate (sepsis protocal) • Check a core temp. • Start IV antibiotics-Zosyn, Levaquin, and Vancomycin. • Order Rapid HIV, Interferon Gold, and Influenza tests. • Stool studies-FOB, fecal lactoferrin

  19. My Best Guess • Candida from being immune compromised • Malignancy-Hodgkins lymphoma • Pneumonia-H. influenza • Diarrhea-Adenovirus

  20. Hodgkin’s Lymphoma Bimodal age distribution • One peak in the 20s-30s • Second peak over age 50 Usually people present with an asymptomatic enlarged lymph node or a mass on CXR Symptoms usually occur over several months-”B” symptoms-fever, night sweats, weight loss

  21. Diagnosis of Hodgkin’s Lymphoma • Biopsy of a Lymph Node • Confirmed by the presence of Reed-Sternberg cells.

  22. H. influenza • Second most common cause for pneumonia. • Transmitted person to person by droplets • Vaccinations in children have helped with decreasing infections • In adults, chronic pulmonary disease, smoking, HIV, alcoholism, pregnancy, malignancy, and older age can predispose patient to infection.

  23. H. influenza • Treatment • Rocephin , Zithromax, or Levaquin

  24. Resources • http://www.cdc.gov/globalhealth/countries/india/ • http://www.uptodate.com/contents/treatment-of-community-acquired-pneumonia-in-adults-in-the-outpatient-setting?source=preview&search=pneumonia&selectedTitle=1%7E150&language=en-US&anchor=H468093943#H468093943 • http://www.uptodate.com/contents/clinical-presentation-and-patterns-of-disease-distribution-in-classical-hodgkin-lymphoma-in-adults?source=see_link • http://www.uptodate.com/contents/microbiology-epidemiology-and-treatment-of-haemophilus-influenzae?source=machineLearning&search=h.+influenza&selectedTitle=1%7E150&sectionRank=1&anchor=H13#H13

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