OBJECTIVE: To present a case of Pneumonia

GENERAL DATA: RS 90 years old female Married Roman Catholic From Paco Manila Informant: Relative Reliability: 80%

HISTORY OF PRESENT ILLNESS

5 days PTA (+) productive cough with whitish sputum (-) fever (-)eadache (-) nausea or vomiting

sought consult at her attending physician labs reqeusted- CBC, crea, sodium and chest xray

1 day PTA-

Acarbose 100 mg TID, spironolactone 25 mg+ Butizide 2.5 mg tab, moxifloxacin 400 mg tab OD, Endosteine 300 mg BID. advised for admission----refused

Few hours PTA

(+)persistence of productive cough associated with difficulty of breathing.

30 minutes PTA

(+)unresponsive, after coughing rushed immediately to the ER

ADMISSION

PAST MEDICAL ILLNESS

(+)Diabetes mellitue type 2=20 years
Glimepiride 4 mg tab OD - stopped
Metformin 500 mg tab BID - stopped Acarbose 50mg TID

(+)Hypertension stage 2 =20 years

Verapamil 40 mg tab BID Losartan 100 mg tab BID (-) asthma (-) PTB (-) allergy for food or drugs

FAMILY HISTORY

(+) Hypertension- children (+) Asthma- both maternal and maternal side (-) Diabetes (-) Kidney Disease (-) Tuberculosis (-) Stroke

PERSONAL AND SOCIAL HISTORY

(+) stopped smoking 30 years ago
(-)non-alcoholic beverage drinker -usual activity was walking 1 block away from their house and usually sleeps after resting for a couple of minutes

REVIEW OF SYSTEM
(-) weight loss, (-) loss of appetite (-) rashes, (-) erythema, (-) clubbing of nails, (-) headache, (-) injury (+) blurring of vision (-) tinnitus, (-) discharge (-) epistaxis, (-) sneezing, (-) allergies (+) 2 pillow orthopnea, (+) easy fatigability, (+) paroxysmal nocturnal dyspnea (-) bleeding gums, (-) hemoptysis (-) chest pain (-) diarrhea, (-)abdominal pain, (-) constipation
(+) nocturia, (+) urgency, (-) hematuria, (-) dysuria (-) edema, (-) joint swelling (+) loss of consciosness (+) dizziness

GENERAL SURVEY
Patient is unconscious, stretcher-borned, in cardio-respiratory arrest VITAL SIGNS BP: 0 wt: 54kg (estimated PR:0 ht: 160 (estimated) RR:0 BMI:22 T:36 C

PHYSICAL EXAMINATION
SKIN:

no active lesion good skin turgor no jaundice

Physical examination
HEENT: No facial asymmetry/ deformity Anicteric sclera, pink palpebral conjunctiva, (+) pupils dialted, not reactive to light 4-5 mm (-) nasal discharge (-) lymph node enlargement (+) firm, nodular well-circumscribed mass on the left side of the neck (+) dry oral mucosa

PHYSICAL EXAMINATION
Chest and Lung: Symmetrical chest expansion (-) deformities ,(-)scars (+) coarse crackles, bibasal (-) wheezes

Physical examination
Cardiovascular: Adynamic precordium no rate no rhythm (-) murmur

PHYSICAL EXAMINATION
Abdomen: Flabby Normoactive bowel sounds No scar, no striae Soft

Physical Examination
Extremities: (-) clubbing of nails No deformities (-) cyanosis (-) edema (-) pulses

INITIAL DIAGNOSIS
Acute respiratory failure secondary to aspiration pneumonia T2 Diabetes Mellitus HASCVD, CAD, CHF FC IV

LABORATORY EXAMS
CBG: 249 mg/dL CBC: 12,900/12.9/ 39/85/15/adequate BUN- 21 HI/ Crea-1.13 ABG: 7.46/35/202/24.9/100 12L ECG: sinus tachycardia, RAD, anterior septal wall ischemia, poor R wave prog, NSSTTWC

Chest x ray
pneumonia both lower lung intercurrent pleural effusion and not ruled out cardiomegaly, atherosclerotic aorta, osteoarthritis, right shoulder

MANAGEMENT
Diet: DM diet, low fat low salt IVF: PNSS IL x 16 Meds: Moxifloxacin 400 mg IV OD, Clindamycin 300 mg IV q8, Simvastatin 10 mg tab/NGT OD HS

FINAL DIAGNOSIS

Acute respiratory failure secondary to Aspiration Pneumonia HASCVD, CAD, CHF FC IV

T2 DM

SALIENT FEATURES
Subjective: 90 years old female Objective:
easy fatigability Noctura Urgency Coarse crackles

DIFFENTIAL DIAGNOSIS
DISEASE COPD RULE IN History of cigarette smoking. dyspnea RULE OUT decreased intensity of breath sounds, and prolonged expiration on physical examination, wheezing coughing up blood (classically seen as pink, frothy sputum), excessive sweating, anxiety, and pale skin

Pulmonary edema

shortness of breath or breathlessness Shortness of breath can manifest as orthopnea (inability to lie down flat due to breathlessness) and/or paroxysmal nocturnal dyspnea (episodes of severe sudden breathlessness at night)

Differential Diagnosis
Asthma chest tightness, shortness of breath, and coughing. Asthma affects people of all ages, but it most often starts during childhood. causes recurring periods of wheezing (a whistling sound when you breathe) The coughing often occurs at night or early in the morning.

PNEUMONIA
Pneumonia is an infection of the parenchyma. Categorized as:
Community-acquired pneumonia (CAP) Health careassociated pneumonia (HCAP)
Hospital-acquired pneumonia (HAP) Ventilator-associated pneumonia (VAP)

PNEUMONIA
No. 1 cause of mortality- 924/100,000 (2004) No. 1 cause of morbidity- 861/100,000 (2003) The incidence rates are highest at the extremes of age.

COMMUNITY ACQUIRED PNEUMONIA

Evidence of systemic illness (temperature >38C and/or the symptom complex of sweating, fevers, shivers, aches and pains). vary from indolent to fulminant in presentation and from mild to fatal in severity. Most common pathogen = S. pneumo

Health careassociated pneumonia (HCAP)

Hospital Acquired Pneumonia - refers to pneumonia that arises more than 4872 hours after endotracheal intubation Ventilator Associated Pneumonia - defined as pneumonia that occurs 48 hours or more after admission, which was not incubating at the time of admission

Physiology
Defences of the pulmonary system Mechanical factors Hairs and turbinates of the nares catch larger inhaled particles before they reach the lower respiratory tract Branching architecture of the tracheobronchial tree traps particles on the airway lining Mucociliary clearance and local antibacterial factors either clear or kill the potential pathogen Gag reflex and the cough mechanism offer critical protection from aspiration. The normal flora adhering to mucosal cells of the oropharynx prevents pathogenic bacteria from binding and thereby decreases the risk of pneumonia caused by these more virulent bacteria

Pathogenesis
3 main mechanisms by which bacteria reaches the lungs 1.) Primary inhalation:
organisms bypass normal respiratory defense mechanisms inhales aerobic GN organisms that colonize the upper respiratory tract or respiratory support equipment

2.)Aspiration
occurs when the Pt aspirates colonized upper respiratory tract secretions Stomach: reservoir of GNR that can ascend, colonizing the respiratory tract

3.) Hematogenous
originate from a distant source and reach the lungs via the blood stream.

Pathogens
CAP usually caused by a single organism Even with extensive diagnostic testing, most investigators cannot identify a specific etiology for CAP in 50% of patients. In those identified, S. pneumo is causative pathogen 60-70% of the time

Streptococcus pneumonia
Most common cause of CAP Gram positive diplococci Typical symptoms (e.g. malaise, shaking chills, fever, rusty sputum, pleuritic hest pain, cough) Lobar infiltrate on CXR Suppressed host 25% bacteremic

Atypical Pneumonia
#2 cause (especially in younger population) Commonly associated with milder Sxs: subacute onset, non-productive cough, no focal infiltrate on CXR Mycoplasma: younger Pts, extra-pulm Sxs (anemia, rashes), headache, sore throat Chlamydia: year round, URI Sx, sore throat Legionella: higher mortality rate, water-borne outbreaks, hyponatremia, diarrhea

Viral Pneumonia
More common cause in children
RSV, influenza, parainfluenza

Influenza most important viral cause in adults, especially during winter months Post-influenza pneumonia (secondary bacterial infection)
S. pneumo, Staph aureus

Other bacteria
Anaerobes
Aspiration-prone Pt, putrid sputum, dental disease

Gram negative
Klebsiella - alcoholics Branhamella catarrhalis - sinus disease, otitis, COPD H. influenza

Staphylococcus aureus
IVDU, skin disease, foreign bodies (catheters, prosthetic joints) prior viral pneumonia

CLINICAL DIAGNOSIS
Value of the chest radiograph in the diagnosis of CAP-- For diagnostic certainty in the management of a patient with suspected pneumonia, chest radiography should be performed. Chest x-ray is also essential in assessing severity of disease & in prognostication. It may suggest possible etiology & help differentiate pneumonia from other conditions.

Infiltrate Patterns

ETIOLOGIC DIAGNOSIS
Gram's Stain and Culture of Sputum The main purpose of the sputum Gram's stain is to ensure that a sample is suitable for culture Gram's staining may also help to identify certain pathogens (e.g., S. pneumoniae, S. aureus, and gram-negative bacteria) by their characteristic appearance To be adequate for culture, a sputum sample must have >25 neutrophils and <10 squamous epithelial cells per low-power field Low sensitivity but specific

 Blood Cultures Certain high-risk patientsincluding those with neutropenia secondary to pneumonia, asplenia, or complement deficiencies; chronic liver disease; or severe CAPshould have blood cultured Antigen Tests Pneumococcal and certain Legionella antigens in urine The sensitivity and specificity of the Legionella urine antigen test are as high as 90% and 99%, respectively The pneumococcal urine antigen test is also quite sensitive and specific (80% and >90%, respectively)

 Polymerase Chain Reaction Available for a number of pathogens, including L. pneumophila and mycobacteria A multiplex PCR can detect the nucleic acid of Legionella spp., M. pneumoniae, and C.

pneumoniae
use of these PCR assays is generally limited to research studies Serology Recently have fallen out of favor because of the time required to obtain a final result for the convalescentphase sample

SITE OF CARE
Low Risk CAP - stable vital signs: RR <30 breaths/min temp>36C or <40 C PR <125 beats/min DPB >60 mmHg No altered mental state of acute onset No suspected aspiration No or stable co-morbid conditions Chest xray: localized infiltrates and no evidence of pleural effusion nor abscess

MODERATE RISK CAP

Unstable vital signs
RR 30 breaths/min

SBP <90 mmHg,DBP < 60 Temp 36C or 40C RR 125 beats/min

uncontrolloed DM, acitvemalignancies, neurologic disease in evolution, CHF, class I-IV, unstable CAD, renal failure dialysis, uncompensated COPD, decompensated liver disease

Altered mental state of acute onset Suspected aspiration

CHEST XRAY
MULTILOBAR INFILTRATES PLEURAL EFFUSION OR ABSCESS

HIGH RISK CAP

ANY OF THE CLINICAL FEATURE OF MODERATE RISK CAP PLUS ANY OF THE FOLLOWI NG SEVERE SEPSIS AND SEPTIC SHOCK NEED FOR MECHANICAL VENTILATION

Site of Care

Treatment
Empiric antibiotic treatment should be initiated within 4 hours of diagnosis of CAP Directed against most likely pathogen Rapidly shifted to narrower spectrum antibiotics

once sensitivity patterns are known

Switch to Oral Therapy

Four criteria:
Improvement in cough and dyspnea Afebrile on two occasions 8 h apart WBC decreasing Functioning GI tract with adequate oral intake

If overall clinical picture is otherwise favorable, can can switch to oral therapy while still febrile

Complications
Respiratory failure Shock Multiorgan failure Bleeding diatheses Exacerbation of comorbid illnesses

 Metastatic infection, E.g., brain abscess or endocarditis Lung abscess Lung abscess may occur in association with aspiration or with infection caused by a single CAP pathogen, such CA-MRSA, P. aeruginosa, or (rarely) S. pneumoniae Aspiration pneumonia is typically a mixed polymicrobial infection involving both aerobes and anaerobes

 Complicated pleural effusion. A significant pleural effusion should be tapped for both diagnostic and therapeutic purposes If the fluid has a pH of <7, a glucose level of <2.2 mmol/L, and a lactate dehydrogenase concentration of >1000 U/L or if bacteria are seen or cultured, then the fluid should be drained; a chest tube is usually required

PROGNOSIS
Prognosis of CAP depends on the patient's age, comorbidities, and the site of treatment (inpatient or outpatient) Young patients without comorbidity do well and usually recover fully after ~2 weeks Older patients and those with comorbid conditions can take several weeks longer to recover fully

Prevention
Smoking cessation Vaccination recommendations
Influenza
Inactivated vaccine for people >50 yo, those at risk for influenza compolications, household contacts of high-risk persons and healthcare workers Intranasal live, attenuated vaccine: 5-49yo without chronic underlying dz

Pneumococcal
Immunocompetent 65 yo, chronic illness and immunocompromised 64 yo

Pneumonia in the Elderly

Prevention important Presentation can be subtle Antibiotic choice in CAP is same as other adults Healthcare associated pneumonia
Consider S. aureus (skin wounds) and GN bacteria (aspiration)
Pneumonia in Older Residents of Long-term Care Facilities. AFP 2004; 70: 1495-1500.

Pneumonia in Immunocompromised Pts

Smokers, alcoholics, bedridden, immunocompromised, elderly Common still common
S. pneumo Mycoplasma

Pneumocystis Carinii Pneumonia

P. jirovecii Fever, dyspnea, non-prod cough (triad 50%), insidious onset in AIDS, acute in other immunocompromised Pts CXR: bilateral interstitial infiltrates Steroids for hypoxia TMP-SMZ still first line

chest xray

What is your presumptive diagnosis?