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A Case of Pneumonia and Enteritis

A Case of Pneumonia and Enteritis. Case and discussion by Adam Simons R2 Boise VAMC. Case Presentation. 79yo man presented to the VA ER with fever and diarrhea x 3 days. Diagnosed with gastroenteritis and discharged after supportive care.

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A Case of Pneumonia and Enteritis

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  1. A Case of Pneumonia and Enteritis Case and discussion by Adam Simons R2 Boise VAMC

  2. Case Presentation 79yo man presented to the VA ER with fever and diarrhea x 3 days. Diagnosed with gastroenteritis and discharged after supportive care. Symptoms persisted x 1 week, now with worsening dyspnea. Found by his S/O shivering and obtunded on edge of his bed. It is summertime

  3. Case Presentation DM since 1997: A1c = 7.9 CKD: Recent BUN = 35, Cr = 1.89 HTN, HLD Hypothyroid Chronic hip pain BPH: HCV: negative Abd u/s: 2.3cm AAA only Pneumovax 3 years PTA

  4. Case Presentation Smoker @ 3-4 PPD x 30 years q. 1999 Retired glaser No recent travel, lives in a modern apartment, no pets. No sick contacts Drinks well water Yard work with pesticides

  5. Case Presentation Initial oxygen sat. 70% on room air T 100.3 P 78 BP 123/73 RR 35 Sat 95% NRB Somnolent, oriented to self. General: Diaphoretic, short sentences. Weak cough. Resp: Diffuse ronchi, decreased BS on left Remainder of exam normal

  6. Case Presentation ABG 7.49/27/78 (15L NRB) WBC 10.4, Hct 30.7 Na 133, Co2 23, BUN 43, Cr. 2.5 Alb 2.6, Bili 1.4, AlkP 39, AST 415, ALT 265 Lactate 2.2 BNP 594 (0-99) CPK 1159, Myo 778, Trop 0.08 (0.09) UA: clean Sputum: Mixed.

  7. Case Presentation • Abdominal U/S • Cholelithiasis. • 1.9 cm hyperechoic lesion in the right lobe of the liver posteriorly. This may represent a hemangioma. Solitary hyperechoic metastasis cannot be absolutely ruled out. No biliary dilatation. • Ill-defined linear area of decreased density in the pancreas. Exact etiology is unclear. This may represent a mildly dilated pancreatic duct with debris. • Minimal ascites.

  8. Case Presentation Thoughts?

  9. Community Acquired Pneumonia Streptococcus pneumoniae Haemophilus influenzae Moraxella catarrhalis Chlamydophila pneumoniae Legionella species Mycoplasma pneumoniae viruses: influenza, RSV, parainfluenza, adenovirus 14

  10. Case Presentation Pt was intubated for impending respiratory failure Treated with fluids, vancomycin, ceftriaxone, azithromycin and bronchodilator therapy. Morning after admission, urine was found to be positive for Legionella pneumophila antigen

  11. Legionnaires' Disease Legionnaires’ disease is a pulmonary infection caused by various species of Legionella, water borne bacteria. With the advent of more sensitive assays, legionella is increasingly recognized as a common cause of both community-acquired and health-care associated pneumonia.

  12. Classic Clinical Manifestations • Diarrhea • Fever > 39°C • Hyponatremia • Neurologic findings including confusion • Hepatic dysfunction • Hematuria

  13. Cunha 2010

  14. A new Pathogen Convention of the American Legion, Philadelphia 1976 221 treated, 34 deaths Swine flu? Bacterial pathogen IDJanuary 18 1977

  15. Legionnaires’ Epidemics England 1985: Stafford District Hospital Water Tower: 28 deaths. Netherlands 1999: Flower Exhibition Humidifier: 32 deaths. Australia 2000: Aquarium Cooling Tower: 4 deaths Spain 2001: Hospital cooling tower: 6 deaths UK 2002: Arts center cooling tower: 7 d.

  16. Pontiac Fever

  17. Legionella Species

  18. The Boise VA Experience 2005-2011: 783 tests sent. 7 positive. (1%)

  19. CDC Statistics Neil et al 2008 23,076 cases reported to CDC 1990-2005 3,181 cases reported in 2008.

  20. CDC Statistics Neil et al 2008

  21. In perspective Marston et al 1997 Cohort study: Ohio1991 data CAP requiring hospitalization 267/100K Extrapolation: 485,000 yearly nationwide Cohort-wide culture/serology Extrapolated legionellosis rate: 8,000-18,000 Compared with <4,000 cases reported Mycoplasma pneumoniae (18,700-108,000), Chlamydia pneumoniae (5890-49,700).

  22. Why diagnose? • Ensure appropriate treatment. • Increased surveillance early action • 20% of cases are travel associated • Hotels • Cruise ships • Dispersed cases (long incubation)

  23. Diagnostic options

  24. Treatment Options • Levofloxacin, moxifloxacin 7-10d • Azithromycin, erythromycin 7-10d • Adjunct Rifampin (severe illness)

  25. Case Presentation Antibiotics were narrowed to azithromycin and ceftriaxone. He was extubated on hospital day 5, given 14 day course of oral azithromycin monotherapy. His diarrhea also resolved

  26. Case Presentation After extubation, further conversation with the patient revealed that he was an avid gardener, and had constructed a system for misting his garden out of PVC pipe.

  27. Questions? Sources: 1. Mulazimoglu L, Yu VL. Can Legionnaires disease be diagnosed by clinical criteria? A critical review. Chest. 2001;120(4):1049-1053.   2. Marston BJ, Plouffe JF, File TM, et al. Incidence of community-acquired pneumonia requiring hospitalization. Results of a population-based active surveillance Study in Ohio. The Community-Based Pneumonia Incidence Study Group. Arch. Intern. Med. 1997;157(15):1709-1718.   3. Neil K, Berkelman R. Increasing incidence of legionellosis in the United States, 1990-2005: changing epidemiologic trends. Clin. Infect. Dis. 2008;47(5):591-599.   4. Stout JE, Yu VL. Legionellosis. N. Engl. J. Med. 1997;337(10):682-687.   5. Ng V, Tang P, Fisman DN. Our evolving understanding of legionellosis epidemiology: learning to count. Clin. Infect. Dis. 2008;47(5):600-602.   6. Cunha BA, Mickail N, Syed U, Strollo S, Laguerre M. Rapid clinical diagnosis of Legionnaires' disease during the "herald wave" of the swine influenza (H1N1) pandemic: The Legionnaires' disease triad. Heart & Lung: The Journal of Acute and Critical Care. 39(3):249-259.   7. Shimada T, Noguchi Y, Jackson JL, et al. Systematic review and metaanalysis: urinary antigen tests for Legionellosis. Chest. 2009;136(6):1576-1585.  

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