Assessing Severity by liaoqinmei

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									Atypical Presentation
of Pneumonia
           Claire Head
          Ama Basoah
          Melanie Long
      Hannah Bellsham-Revell
          George Smith
Mr. P.R.

 50 year old
 Male
 Post office Counter Clerk
History
 PC:
     Cough and SOB, 6/52, with lack of energy


 HPC:
     Admitted on Good Friday after feeling generally ill for 2/52
      previously.
     Cough:     Frequently throughout the day.
                 Produced dark green sputum
                 Loss of appetite
                 Nausea and vomiting
                 Cough syrup for chesty cough made it slightly better but
                 not effective for very long
                 Worse at night
 History
 SOB: Constant for 4 weeks at rest (mainly noticed by wife) and on
     exercise
     Does not recall having any associated features
     Does not recall anything which may have exacerbated it.
     Dull achy pain radiating from Rt. axilla to Rt. chest when lying
     down propped on Rt. elbow.
     Never had anything like this before.


 PMH:
   Tonsillectomy
   ° MI, ° asthma, ° BP, ° DM, °Cholesterol, ° RF, ° Epilepsy, ° TB

(Note that he has NOT had the BCG vaccination).
History
 FH:
     Mum died aged 61, colon ca.
     Dad died aged 68, lung ca
     Sister had MI 3/12 ago.


 DH:
     None before hospital admission except for the occasional
      vitamin tablet
     No allergies
History
 SH:
     1st floor flat with wife and cat (not allergic to it).
     Has no problems with walking up or down stairs.
     No contact with anyone with any infections.
     No recent travel
     Smoking: Ex-smoker (stopped 1 week prior to
      admission) – 38 pack years
     Alcohol: ½ bottle of vodka and 2 pints of beer, a
      day. Says he quit to help stop smoking.
Examination

 S/E:
     Cardiovascular: ° Chest pain, ° palpitations
     Respiratory: Cough (as above), ° haemoptysis.
      Sleeps with 2 foam pillows. ° PND.
     GI: Good appetite, but not a fan of hospital food.
      Bowels open twice daily but of late has been
      loose. ° Pain on passing stool.
     GU: ° Pain or stinging
     CNS: ° Loss of vision, ° headaches, blackouts or
      faints
Examination
 General:
  °Jaundice.
  Temp. 38.1°, RR 30/min, tachycardia 100bpm, BP
  104/69


 Cardiovascular:
  HS:        I + П + 0 (quiet!)
  JVP:       
Examination
   Respiratory
                  xxxx           Vocal resonance
                  xxxx          Crackles Rt. mid/upper
                  xxxx          lobe
                  xxxx          Dull percussion note
                                  air entry
                                Trachea central




   Abdominal                   2cm hepatomegaly
                                Soft, no masses, mild
                                tenderness
                                BS√




   PR – soft, brown stool, ° melaena, ° blood
Investigations: 18/04/03
   Na    134       Alt   166
   K     3.5       AP    84
   Cl    95        Alb   16
   Bic   22        GT    31
   Ur    30.4      Ca    1.94
   Cre   149       Ps    1.33
   Glu   5.7       Cac   2.42
   Bil   15        CRP   527.3
Inv continued
 Haematology results.       Blood gases.
 Hb        15.3           pH      7.473
 WCC       15.7           pCO2    4.18
 Platelets 301            pO2     6.92
 MCV       107            Base Ex -0.5
CXR 18/04/03
Initial Diagnosis and
Management
 Problems on admission 18/04/03 were:
       Tachypnoeic (30)
       Hypotensive (104/69)
       Elevated urea (30.4)
       Hypoxic
       Low albumin (16)
 Initial impression on admission from CXR appearance and
  clinical signs was of a right upper lobe pneumonia.
 Differential diagnosis of cavitation in the right upper lobe:
       TB
       S. aureus
       Klebsiella
       anaerobes
       Other atypical organisms
 19/04/03:
      IV Cefotaxime/PO Erythromyocin
      Saline nebs
      IV fluids
      Chest physio
      Pabrinex
If no improvement, consider CPAP and possible ITU
    admission.
 19/04/03: (Admitted to ITU)
      Review antibiotics- IV only
      CPAP +5
      NG tube
      Possible TB diagnosis?
      Add in anti-TB therapy (Rifampicin, Isonozid,
       Pyrazidanimide, Ethambutol).
 21/04/03:
     Discharged ITU
 23/04/03-03/05/03: Admitted to ITU.
     Worsening respiratory distress:
       Blood gases on 10L O2 (23/04/03):
       PH    7.509
       PCO23.69
       PO2 9.9
       Bic   25.7
       Sats 95.4%
     Bi Pap
     NG tube
 29/04/03:
     BAL:
       • C&S: Coliform ++
       • Candida spores and hyphae seen
       • ZN -ve
 02/05/03:
     BAL:
       •   Coliform scanty
       •   Coagulase negative Staph scanty
       •   AFBs not seen
       •   Yeasts, fungi and legionella not isolated
 06/05/03:
     Continue high dose antibiotics
     Stop TB therapy
     X-ray, CT
18/04/03   05/05/03
 21/05/03:
     3/52 ‘echos’ in ears, maybe since on
      holiday in Alps
     Audiometry testing:
       • Dip 2000-8000Hz, lowest 6000Hz
       • Typical of Gentamicin Ototoxicity
Epidemiology
 Incidence: 5-11/ 1000 adult population
 CAP accounts for 5-12% of all LRTIs
 22-42% adults with CAP, admitted to
  hospital
     5-10% of these, managed on ITU
Epidemiology cont’d.
 Extremes of age most at risk
 UK mortality rates :
     Mx in community <1%
     Mx in hospital 5.7 - 12%
     Mx in ITU >50%
 Costs per episode of CAP:
     Mx in community £100
     Mx in hospital £1700- 5100
Classification of Pneumonia
Community acquired      Hospital acquired
                            (nosocomial)
 1o infection         >48 hours post
 2o to concomitant     admission
  disease              2o to underlying
 Mostly Gram +ve       disease
                       Mostly Gram -ve
Aetiology
Community acquired
pneumonia: aetiology
Typical bacteria
 S. pneumoniae
 H. influenzae
 S. aureus
 All viruses
 Influenza A & B
Community acquired
pneumonia: aetiology
Atypical organisms     Causes in infants
 M. pneumoniae       RSV
 M. catarrhalis      Adenovirus

 Legionella spp.
 C. pneumoniae      Immunocompromise
                             d
 C. psittaci
                      Pneumocystis
 C. burnetii         CMV, HSV, Adenovirus
                      M. tuberculosis
Hospital acquired
pneumonia: aetiology
 Gram -ve bacteria
     Anaerobes
     Klebsiella
     Pseudomonas
 Gram +ve bacteria
     S. aureus
BTS Guidelines
 All patients referred to hospital with
  CAP:
     CXR
     Oxygenation assessed by pulse oximetry.
     SaO2 <92% should have arterial blood gas
      measurements, as should all patients with
      features of severe pneumonia
     Assessed for volume depletion and may
      require intravenous fluids.
  Oxygen therapy
 Indicated for:
      PaO2 <8 kPa
      Hypotension (systolic <100 mmHg)
      metabolic acidosis (bicarbonate <18 mmol/l)
      Respiratory distress (resp. rate of >24 bpm)
 The aim of oxygen therapy should be to
  maintain PaO2 at >8 kPa or SaO2 >92
      35% O2 concentration if no contraindications
      low concentrations (24–28%) if preexisting COPD
       If very severe:
        • non-invasive ventilation
        • respiratory stimulants
        • transfer to a high dependency unit or ICU
 Monitoring the patient
 Normally twice daily. Severe pneumonia or continuous oxygen or
  cardiovascular support should be monitored more frequently.
      Pulse, blood pressure, respiratory rate, temperature oxygen saturation
       with a recording of the inspired oxygen concentration
      mental status

 The acute phase reactant CRP is a sensitive marker of progress in
  pneumonia
      CRP drop of 50% over 4 days is consistent with a good clinical
       response
      A fall in the level of CRP of less than 50% or a persistently high or rising
       white cell count suggests failure of antibiotic treatment

 Persisting hypoxia with PaO2 <8 kPa despite maximal oxygen
  administration, progressive hypercapnia, severe acidosis (pH
  <7.26), shock, or depressed consciousness are indications for
  transfer to the ICU
    Treatment
     Few pneumonias are defined
      microbiologically hence most prescribing is
      empirical.
     Consideration of common pathogens
            SGH protocol is Cefotaxime and Erythromycin
            Legionella suspected = addition of oral rifampicin
     Parenteral treatment * **
            severe pneumonia
            impaired consciousness
            loss of swallowing reflex
            functional or anatomical reasons for malabsorption
*Chan et al, BMJ 1995;310:1360-1362        **Siegel et al CHEST
1996;110:965-971
 Treatment
 The aim of antibiotic treatment is to ensure elimination of
  the target pathogen in the shortest time.

 The resolution of pneumonia
      elimination of the invading pathogen and its products
      subsidence of the host inflammatory response

 There is presently no evidence that systemic
  corticosteroids are of benefit.

 The duration of treatment remains subject to clinical
  judgment and will vary with the individual patient and
  disease severity
No Response to Empirical
Treatment
 Consider
     Correct diagnosis (radiological review)
     complications
       • pleural effusion or empyema
       • lung abscess or worsening pneumonic shadowing
     Adequate absorption of an oral regimen
     Microbiological reviewed to exclude less common
      pathogens
       • S. aureus, atypical pathogens, Legionella species,
       • viruses, and Mycobacteria species.
     Mixed infections can arise in approximately 10%
      of patients admitted to hospital with CAP
Specific Pathogen Directed
Antibiotic treatment
 In routine clinical practice only about one third to one quarter of
  patients with CAP admitted to hospital will be defined
  microbiologically.
       Mycoplasma and chlamydial infection will be diagnosed late in the
        illness reducing the opportunity for early targeted treatment.
 The choice of agent may be modified following the availability of
  sensitivity testing or following consultation with a specialist in
  microbiology or infectious disease.
 S. pneumoniae highly resistant to penicillin is currently
  uncommon in the UK.
 S. aureus is an uncommon cause of CAP in the UK.
       Most community isolates are sensitive to methicillin,
       recent increase in MRSA in hospitalised patients may result in
        subsequent readmission with an MRSA infection which may include
        CAP
       methicillin sensitive and resistant infections imply parenteral
        treatment in view of the serious nature of staphylococcal
        pneumonia.
 Assessing Severity

 Confusion
 Urea               >7mmol/l
 Respiratory Rate   >30/min
 Blood pressure     <60mmHg
Assessing Severity
   Age                      >60 years
   Atrial Fibrillation
   Multilobar involvement
   Albumin                  <35g/l
   Hypoxia                  <8kPa
   WCC                      <4x109/l
   Leucocytosis             >20x109/l
   Bacteraemia
Complications
 Respiratory Failure:
       Type 1 commonly - high flow (60%) O2
       Be ready to intubate or ventilate if increasing pCO2 or worsening
        acidosis
 Hypotension:
       Dehydration, -vasodilatation due to sepsis.
       Fluid therapy, central line, inpotropes, ITU
 Atrial Fibrillation:
       Quite common, particularly in the elderly.
       Usually resolves with the treatment of the pneumonia, Digoxin may
        be used in the short term to control rate
 Pleural Effusion:
       Inflammation of the pleura - fluid exudate
       Small - may resolve, larger, symptomatic or infected - may need
        drainage
 Empyema:
      Pus in the Pleural Space - resolving pneumonia + recurrent fever
      Clinical features and CXR - pleural effusion: fluid turbid, yellow, pH
       ,7, low glucose, high LDH
      Drained - radiological guidance
      Loculated - Streptokinase to break down the adhesions
 Lung Abscess:
      Cavitating area of localized supparative infection within the lung
      Swinging fever, cough, purulent, foul smelling sputum, pleuritic
       chest pain, haemoptysis, malaise, weight loss, clubbing, anaemia,
       crepitations
      Antibiotics, postural drainage, aspiration, antibiotic instillation,
       surgical excision
 Septicaemia:
      May cause metastatic infection, IBE, meningitis
      IV antibiotics
 Pericarditis, Myocarditis.
 Jaundice:
      Cholestatic - sepsis, 2o to antibiotic therapy
Conclusion
 No causative organism was found
 The presentation was atypical:
     Slow onset (normally acute presentation)
 When a cavitating lesion is found, think
  TB
 Watch Gentamicin levels carefully in
  those with renal impairment

								
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