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CASE PRESENTATION

General Data
J.S., a 26 year old male, single, Filipino, Catholic, residing at Bulacan, Bulacan was admitted for the first time in our institution.

Chief Complaint
Difficulty of Breathing

History of Present Illness


Patient is apparently well until.. One week prior to admission, patient developed productive cough with yellowish to greenish phlegm. No associated signs and symptoms noted like fever, colds, difficulty of breathing, nausea, vomiting, diarrhea, body malaise, and chest pain. No medications taken. No consultation was done. One hour prior to admission, patient complained of difficulty of breathing associated with undocumented fever, left sided chest pain, pleuritic in character, and left arm numbness. Due to persistence of the signs and symptoms patient sought consult hence admission.

Past Medical History


(+) Allergy seafoods (+) Bronchial Asthma since childhood; last attack: June 29, 2010 (-) PTB (-) Hepatitis (-) Hypertension (-) DM (-) No previous Hospitalization

Personal/Social History
(+) smokes 2 pack years (+) alcoholic beverage drinker works as a Technical Support Analyst in Teletech Customer Care Management, Robinsons Mall Novaliches

Family History
(+) Heart Disease: Paternal Side (+) Hypertension: Paternal side

Review of System
General: (-) chills (-) weight loss Skin: (-) rashes, (-) easily brusing, (-) pruritus, (-) jaundice Head: (-) headache, (-)dizziness Eyes: (-) blurring of vision Ears: (-) hearing loss, (-) pain, (-) tinnitus Nose: (-) epistaxis Respiratory: (-) hemoptysis, Cardiovascular: (-) Orthopnea, (-) palpitation, (+) shortness of breath Gastrointestinal: (-) abdominal pain, (-) change in bowel habits Genitourinary: (-) urgency, (-) frequency, (-) dysuria Endocrine: (-) polydipsia, (-) polyuria Musculoskeletal: (-) limitation of movement, (-) joint pain, (-) muscle weakness

Physical Examination
Vital Signs: Blood Pressure: 120/70mmHg Heart Rate: 118bpm Respiratory Rate: 28bpm Temp: 38.5 C General: Conscious, weak looking, in mild cardiorespiratory distress Skin: (+) flushed skin, (-) pallor, (-) jaundice HEENT: (+) pink palpebral conjunctiva, (+) anicteric sclerae, (+) palpable nontender lymph node in left upper cervical region, (-) TPC, (-) Exudates Chest/ Lungs: Symmetrical chest expansion, (-) retraction (+) tachypnea, (+) increased tactile fremitus, (+) dull to precussion, (+) rhonchi, Heart: (+) Adynamic precordium, (+) tachycardic, (+) regular rhythm, (-) heart murmurs Abdomen: flat, no scars, soft, tympanitic, normoactive bowel sounds, nontender Extremity: (-) edema, (+) full equal pulses

Neurological Exam: unremarkable


CN I: N/A CN II: Pupils: 2 3mm equally reactive to light CN III, IV, VI: EOM is intact CN V: (+) corneal reflex CN VII: (-) facial asymmetry CN VIII: (+) good grossly hearing CN IX and X: (+) gag reflex CN XI: Good shoulder shrug CN XII: Midline tongue

Lab. Exams

Chest X- Ray Result:


Consolidation areas seen in anterior and posterior basal segments of the left lower lobe Heart is not enlarged Diaphragm and sulci are unremarkable Visualized bones are intact

Impression: Pneumonia, Left ECG Interpretation: Sinus Tachycardia

Course in the Ward


Upon admission: venoclysis was started using PNSS 1L x 10. Diet: hypoallergenic diet Diagnostic tests: CBG, CBC, Sodium, Potassium, Creatinine, O2 Sat, Urinalysis, 12 Lead ECG, and Chest X-ray PA Medications: Cefuroxime 750 mg IV q8 ANS Azithromycin 500mg/tab once a day Paracetamol 500mg/tab 1 tab q4 PRN for T 37.5 C Paracetamol 300mg/tab 1 tab q4 IV PRN forr T 38.5C Duavent Nebulization 1 dose q8 PRN N-acetylcystein (Fluimucil) 600mg/tab 1 tab dissolved in glass of water once a day Dolcet 1 tab q8 PRN for pleuritic chest pain.

On the 1st hospital day


IVF to follow: PNSS IL x10 Cont. medications

On the 2nd hospital day,


continued venoclysis using PNSS IL x10. Ff. up Chest X-ray and ECG results Shifted Cefuroxime IV to Cefuroxime 500mg TID PO. Azithromycin was given.

On the 3rd hospital day,


Lactulose 30 cc may be given if with no bowel movemen Patient may go home anytime. Home medications include Cefuroxime 500mg/tab 1 tab TID and N-Acetylcystein 600 mg/tab.

Salient Features
(+) productive cough with yellowish to greenish phlegm (+) difficulty of breathing (+) undocumented fever (+) left sided pleuritic chest pain (+) left arm numbness (+) palpable cervicolymphadenopathy (+) tachypnea (+) increased tactile fremitus (+) dull to percussion (+) rhonchi (+) tachycardic Labs: WBC: 12.0 Increased Segmenters: 0.80 Increased

Diagnosis
Community Acquired Pneumonia, Low Risk Bronchial Asthma, Controlled Costochondritis, Left

Differential Diagnosis
acute bronchitis acute exacerbations of chronic bronchitis heart failure pulmonary embolism radiation pneumonitis

COMMUNITY ACQUIRED PNEUMONIA

Pneumonia
is an abnormal inflammatory condition of the lung. Classification: Community- acquired Pneumonia(CAP) Health careassociated Pneumonia (HCAP)
Hospital-Acquired Pneumonia (HAP) Ventilator-Associated pneumonia (VAP)

HCAP is associated with hospitalization for 48 h, hospitalization for 2 days in the prior 3 months, nursing home or extended-care facility residence, antibiotic therapy in the preceding 3 months, chronic dialysis, home infusion therapy, home wound care, and contact with a family member who has a multidrug-resistant (MDR) infection.

Community Acquired Pneumonia


an infection of the alveoli, distal airways, and interstitium of the lungs that occurs outside the hospital setting. Characterized clinically by: Fever, chills, cough, pleuritic chest pain, sputum production At least one opacity on chest radiography

Manifests as four general patterns

o Lobar pneumonia: involvement of an entire lung lobe


o Bronchopneumonia: patchy consolidation in one or several lobes, usually in dependent lower or posterior portions centered around bronchi and bronchioles

o Interstitial pneumonia: inflammation of the interstitium, including the alveolar walls and connective tissue around the bronchovascular tree o Miliary pneumonia: numerous discrete lesions due to hematogenous spread

EPIDEMIOLOGY
Incidence: U.S. o 8001500 cases per 100,000 persons annually o Affects 4 million adults per year
20% require hospitalization.

Age o Incidence highest at extremes of age Sex o Rate higher among men than among women Race o More common among African Americans than among whites

ETIOLOGY
Typical bacterial pathogens:
S. pneumoniae, Haemophilus influenzae, Staphylococcus aureus [including community-acquired methicillin-resistant S. aureus (CA-MRSA)], gram-negative bacteria such as Klebsiella pneumoniae and Pseudomonas aeruginosa

Atypical organisms:
Mycoplasma pneumoniae, Chlamydophila pneumoniae, Legionella spp., respiratory viruses (e.g., influenza viruses)

Anaerobes play a significant role in CAP only when aspiration occurs days to weeks before presentation.

RISK CATEGORIES
Low risk CAP Moderate risk CAP High risk CAP

LOW RISK CAP


Stable vital signs
RR < 30/min PR < 125/min SBP > 90, DBP > 60 mmHg Temp. < 40 C

No or stable co-morbid conditions - DM, neoplastic disease, neurologic

disease, CHF Class I,

CAD,

immunosuppresive therapy (Grade A) - Renal insufficiency (Grade B) - COPD, chronic liver disease, or chronic alcohol abuse (Grade C)

MODERATE RISK CAP


Vital Signs: any one of the following - RR > 30/min - PR > 125/min - Temp. > 40 C X-ray findings of: - Multi-lobar involvement - Progression of lesion to 50% within 24 hours - Abscess - Pleural effusion Those with suspected aspiration Those with extra-pulmonary findings of sepsis: hepatic, hematologic, gastrointestinal, endocrine Unstable comorbid condition: uncontrolled DM, active malignacies, neurologic disease in evolution, CHF Class II-IV, unstable CAD, renal failure on dialysis, uncompensated COPD, decompensated liver disease

HIGH RISK CAP


All criteria under moderate risk plus Impending or frank respiratory failure - Hypoxemia with PaO2 < 60 mmHg - Acute hypercapnia with PaCO2 > 50 mmHg Hemodynamic alterations and hypoperfusion: - SBP < 90mmHg, DBP < 60mmHg - Urine output < 30cc/hour - Altered mental state

RISK FACTORS
Alcoholism Asthma Immunosuppression Age > 70 years Dementia Seizure disorders Tobacco smoking Chronic obstructive pulmonary disease (COPD)

SIGNS AND SYMPTOMS


History
Most typical signs/symptoms

Fever Cough (nonproductive or productive of purulent sputum) Pleuritic chest pain Chills and/or rigors Dyspnea
Headache Nausea Vomiting Diarrhea Fatigue Arthralgia/myalgia Falls and new-onset or worsening confusion (in elderly patients)

Frequent signs/symptoms

Physical

findings o Fever o Tachypnea o Tachycardia o Chest examination Dullness to percussion Increased tactile and vocal fremitus Egophony Whispering pectoriloquy Crackles Pleural friction rub

Pathogenesis
Inhalation, aspiration and hematogenous spread are the 3 main mechanisms by which bacteria reaches the lungs Primary inhalation: when organisms bypass normal respiratory defense mechanisms or when the patient inhales aerobic Gram negative organisms that colonize the upper respiratory tract or respiratory support equipment

Aspiration: occurs when the patient aspirates colonized upper respiratory tract secretions Hematogenous: originate from a distant source and reach the lungs via the blood stream.

DIAGNOSTIC APPROACH
Assess pneumonia severity.
Pay attention to vital signs, including oxygen saturation. Always count the respiratory rate yourself for 1 min.
The single most useful clinical sign of severity is a respiratory rate of >30/min in a person without underlying lung disease.

Ensure adequate oxygenation and support of circulation during the evaluation.

Consider possible etiologies.


Carefully collect information on:
Travel Occupational and other exposures Underlying illnesses Prior infections

Never forget tuberculosis and Pneumocystis infection as possible etiologies. Consider pulmonary embolus in all patients with pleuritic chest pain.

Perform etiologic workup.


Chest x-ray Sputum stains and cultures Blood cultures, if bacteremia is likely Urine antigen tests for S. pneumoniae and Legionella pneumophila type 1 can be helpful. Serology can be helpful in identifying certain pathogens.

LABORATORY TESTS
Nonspecific studies
Assessment of the severity of pneumonia and coexisting disease Arterial blood gas Complete blood count Serum electrolyte and glucose measurements Blood urea nitrogen (BUN) and creatinine measurements

Sputum stains and culture Grams stain


Useful in screening a sputum sample for suitability for culture and in making a presumptive etiologic diagnosis
A sputum sample with >25 white blood cells (WBCs) and <10 squamous epithelial cells per low-power field is suitable for culture. Significant interobserver variability exists in the interpretation of gram-stained sputum smears.

The presence of any gram-positive diplococci has a sensitivity of 100% but a specificity of 0 for a diagnosis of pneumococcal infection.
The presence of >10 gram-positive diplococci per oilimmersion field has a sensitivity of 55% and a specificity of 85% for this diagnosis.

Other sputum stains that may be helpful in some patients o Stains for Acid-fast bacilli Pneumocystis Fungi Cytology o Rapid antigen testing for viral pathogens (e.g., influenza)
Culture o Results should always be correlated with those of Gram staining. If an organism is isolated from sputum and its morphologic correlate is not seen on Gram staining, the isolate may be colonizing the upper airway. o Certain microorganisms, if isolated from sputum, should always be considered pathogens. These include: M. tuberculosis Legionella spp. Blastomyces dermatitidis Histoplasma capsulatum Coccidioides immitis

Only about one-third of elderly patients admitted with CAP produce sputum suitable for culture.
One-third of these specimens fail to yield a pathogen.

Blood culture Blood should be obtained for culture from patients to be treated on an ambulatory basis if they have been receiving antibiotic therapy and have presented because of any of the following:
o Hyperthermia (body temperature >38.5C) o Hypothermia (body temperature <36C) o Homelessness o Alcohol abuse

All patients admitted to the hospital for CAP should have 2 sets of blood cultures done before initiation of antibiotic therapy (positivity rate: 620%). The most common isolates, in descending order, are S. pneumoniae (~60%), S. aureus, and Escherichia coli .

Serology
Detection of IgM antibody or demonstration of a 4-fold rise in titer of antibody to a particular agent between acute- and convalescent-phase serum samples generally is considered good evidence that this agent is the cause of CAP. The following etiologic agents often are diagnosed serologically:
o M. pneumoniae o C. pneumoniae o Chlamydia psittaci o Legionella spp. o Coxiella burnetii o Adenovirus o Parainfluenza viruses o Influenza virus A

serologic tests include complement fixation, indirect immunofluorescence, and ELISA. Separate IgM and IgG antibody detection tests can be performed with the latter 2 assays.

One difficulty in relying on serology is that a polyclonal antibody response to one agent may result in a 4-fold rise in antibody titer to others. o Thus, results may be nonspecific.
Serologic testing is not recommended for routine use. o If agents such as C. burnetii are suspected, serologic testing is necessary. o Serology is a useful part of the workup of outbreaks of pneumonia associated with negative blood and sputum cultures.

Polymerase chain reaction (PCR) Amplification of the DNA or RNA of microorganisms that are not part of the pharyngeal flora (from microbial cells collected by throat swab) has been used to infer that the implicated microorganism is the cause of pneumonia. A multiplex PCR allows detection of DNA of Legionella spp., M. pneumoniae, and C. pneumoniae. This test is expensive and is not routinely available.

Imaging
Chest x-ray
o Diagnostic test of choice for pneumonia o May show lobar consolidation, interstitial infiltrates, cavitation, associated pleural fluid, etc. o Occasionally, an etiologic diagnosis is suggested by chest radiography findings.
A cavitating upper-lobe lesion raises the likelihood of tuberculosis. Pneumatoceles suggest S. aureus pneumonia. An air-fluid level suggests a pulmonary abscess, which often is polymicrobial. In the immunocompromised host, a crescent (meniscus) sign suggests aspergillosis.

o In most instances, no etiologic inference can be made from radiographic abnormalities, despite the traditional teaching that a lobar vs. interstitial appearance may be more suggestive of "typical" bacterial vs. "atypical" bacterial or nonbacterial etiologies.

o If pneumonia is strongly suspected on clinical grounds and no opacity is seen on the initial chest radiograph, it is useful to repeat the radiograph in 2448 hours or to perform CT.
Correction of dehydration may lead to development of chest film infiltrates. o Opacity visible on the chest radiograph may not be due to pneumonia; many other disease processes can result in opacities (see Differential Diagnosis).

High-resolution CT
Occasionally detects pulmonary opacities in patients with symptoms and signs suggestive of pneumonia and negative chest x-ray More likely than chest radiography to show bilateral involvement, pleural fluid/empyema, adenopathy, etc.

DIAGNOSTIC PROCEDURES
Thoracentesis o If a pleural effusion of >1 cm is detected on lateral decubitus chest x-ray, the fluid should be sampled for studies including Grams stain, culture, cell counts, and measurements of protein, lactate dehydrogenase (LDH), glucose, and pH. Bronchoscopy/bronchoalveolar lavage/lung biopsy: o May be required to obtain material for further studies when the diagnosis defies other diagnostic efforts and the patient does not improve despite empirical therapy

COMMUNITY ACQUIRED PNEUMONIA

Algorithm: Management-Oriented Risk Stratification of Community-Acquired Pneumonia In Immunocompetent Adults

Any of the ff: 1. RR > 30/min 2. PR > 125/min 3. T > 40C or < 35C 4. Extrapulmonary evidence of sepsis 5. Suspected aspiration 6. Unstable comorbid conditions

YES

7. CXR: multilobar, pleural effusion, abscess, progression to >50% within 24 hrs NO LOW RISK CAP

Any of the ff: 1. Shock or signs of hypoperfusion: YES - Hypotension -Altered mental state HIGH RISK CAP -urine output <30ml/hr 2. PaO2 < 60mmHg acute hypocapnea ICU Admission PaCO2>50mmHg

NO MODERATE RISK CAP

Outpatient

Ward Admission

EMPIRICAL ANTIBIOTIC TREATMENT


Outpatients Previously healthy and no antibiotics in past 3 months A macrolide [clarithromycin (500 mg PO bid) or azithromycin (500 mg PO once, then 250 mg od)] or Doxycycline (100 mg PO bid) Comorbidities or antibiotics in past 3 months: select an alternative from a different class A respiratory fluoroquinolone [moxifloxacin (400 mg PO od), gemifloxacin (320 mg PO od), levofloxacin (750 mg PO od)] or A -lactam [preferred: highdose amoxicillin (1 g tid) or amoxicillin/clavulanate (2 g bid); alternatives: ceftriaxone (12 g IV od), cefpodoxime (200 mg PO bid), cefuroxime (500 mg PO bid)] plus a macrolidea In regions with a high rate of high-level pneumococcal macrolide resistance, consider alternatives listed above for pts with comorbidities.

Inpatients, non-ICU A respiratory fluoroquinolone [moxifloxacin (400 mg PO or IV od), gemifloxacin (320 mg PO od), levofloxacin (750 mg PO or IV od)] A -lactamc [cefotaxime (12 g IV q8h), ceftriaxone (12 g IV od), ampicillin (12 g IV q46h), ertapenem (1 g IV od in selected pts)] plus a macrolided [oral clarithromycin or azithromycin (as listed above for previously healthy patients) or IV azithromycin (1 g once, then 500 mg od)] Inpatients, ICU A -lactame [cefotaxime (12 g IV q8h), ceftriaxone (2 g IV od), ampicillinsulbactam (2 g IV q8h)] plus Azithromycin or a fluoroquinolone (as listed above for inpatients, non-ICU)

EMPIRICAL ANTIBIOTIC TREATMENT


LOW RISK CAP Previously healthy and no antibiotics in past 3 months - A macrolide (Clarithromycin 500mg BID or Azithromycin 500mg OD or - Doxycycline 100mg BID Comorbidities or antibiotics in past 3 months: select an alternative from a different class -A respiratory fluoroquinolone (Moxifloxacin 400mg OD, Gemifloxacin 320mg OD, Levofloxacin 750mg OD) or -A beta-lactam (Amoxicillin 1gm TID, Amoxicillin/Clavulanate 2gm BID, Cefpodoxime 200mg BID, Cefuroxime 500mg BID) plus macrolide

EMPIRICAL ANTIBIOTIC TREATMENT

MODERATE RISK CAP - A fluoroquinolone (Moxifloxacin 400mg PO or IV OD, Gemifloxacin 320mg PO OD, Levofloxacin 750mg PO or IV OD) - A beta-lactam (Cefotaxime 1-2gm IV q8h, Ceftriaxone 1-2gm IV OD, Ampicillin 1-2gm IV q4-q6) plus a macrolide

EMPIRICAL ANTIBIOTIC TREATMENT

HIGH RISK CAP (no risk for Pseudomonas) - A beta-lactam (Cefotaxime 1-2gm IV q8h, Ceftriaxone 2gm IV OD, Ampicillin-Sulbactam 2gm IV q8) plus - Azithromycin or a fluoroquinolone

EMPIRICAL ANTIBIOTIC TREATMENT


SPECIAL CONCERNS If Pseudomonas is a consideration - An antipseudomonal, antipneumococcal beta-lactam (Piperacillin/Tazobactam 4.5 gm IV q4-q6, Cefepime 1-2gm IV q12, Imipinem 500mg IV q6, Meropenem 1 g IV q8)plus either Ciprofloxacin 400mg IV q12 or Levofloxacin 750mg IV OD - The above beta-lactams plus an aminoglycoside (Amikacin 15mg/kg OD or Tobramycin 1.7 mg/kd OD) and Azithromycin -The above beta-lactams plus an aminoglycoside plus an antipneumococcal fluoroquinolone If CA-MRSA is a consideration - Add Linezolid 600mg IV q12 or Vancomycin 1gm IV q12

COMPLICATIONS
Respiratory failure Shock; Multiorgan failure Bleeding diathesis Exacerbation of comorbid illnesses Metastatic infections - Brain abscess; Endocarditis Lung abscess - usually occurs in the setting of aspiration - should be drained Pleural effusion - should be tapped for diagnostic and therapeutic purposes

Prognosis
Outpatients
o Young, otherwise healthy adults
Those treated as outpatients usually feel well enough to return to work in 4 or 5 days; almost all recover in 2 weeks. Those with relatively severe symptoms may require longer to recover.

o ~24% of those treated as outpatients experience a progression of symptoms and require hospital admission.

Inpatients
Patients generally stabilize within 37 days. The in-hospital mortality rate from pneumonia is ~8%.
The most common immediate causes of death are respiratory failure, heart disease, and sepsis. ~50% of deaths are related to pneumonia and ~50% to comorbid illnesses. Pneumonia-related deaths are much more likely to occur during the first week of hospitalization. Increasing age and evidence of aspiration independently predict both pneumonia-related and comorbidity-related mortality.

Immunosuppression Active cancer Male gender Multilobar pulmonary infiltrates

Mortality is related to the specific etiology.


Rates are highest (>50%) for P. aeruginosa, followed by Klebsiella spp., E. coli, S. aureus, and Acinetobacter spp. (all 3035%).

Early, appropriate antibiotic therapy is associated with decreased mortality rates.

Prevention
Influenza and pneumococcal vaccination status should be ascertained and vaccines offered when appropriate. All patients with pneumonia who are tobacco smokers should be encouraged to join smoking cessation programs. When a patient is prone to aspiration, preventive measures should be taken, including attention to oral hygiene. Only sterile water should be used in humidifiers in longterm-care facilities. Antimicrobial prophylaxis should be given in special situationsfor example:
o Latent tuberculosis prophylaxis o Pneumocystis prophylaxis for selected immunocompromised patients

IMMUNIZATION
PNEUMOCOCCAL VACCINE
> 60 yrs old Chronic illness: cardiovascular disease, lung disease, DM, alcohol abuse, chronic liver disease, asplenia Immune system disorder: HIV, malignancy

INFLUENZA VACCINE
> 50 yrs old Chronic illness Immune system disorder Residents of nursing homes Health care workers Persons in contact with high risk patients

THANK YOU!