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Resident Case Report

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  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 >100, 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%

  14. 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 LFT’s, 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.

  32. 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, PFT’s show mod obstrucive disease and decreased diffusion capacity. Sputum is positive for mycobacteria.

  42. 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