Two patients with fever and cough Viktor Kotarski MD ID specialist University Hospital for Infectious Diseases Zagreb Case 1 54 yearold male patient ID: 935170
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Slide1
CLINICAL PROBLEM SOLVING
Two patients with fever and cough Viktor Kotarski, MD ID specialist University Hospital for Infectious Diseases, Zagreb
Slide2Case 154-year-old male patienthistory of diabetes type II and hypertensionpresents with a 3-day history of fever (up to
38.9 °C), cough, fatique and shortness of breaththe patient had had a cold for 3-4 prior to the onset of fever (nasal congestion, runny nose, sore throat)The next step:
Detailed history and clinical exam, basic lab
Detailed history and clinical exam, basic lab
, chest X-ray
Detailed history and clinical exam, basic lab
,
chest CT scan
Slide3The next step:
Detailed history and clinical exam, basic lab Detailed history and clinical exam, basic lab, chest X-ray
Detailed history and clinical exam, basic lab
,
chest CT scan
Slide4Case 1Detailed history and clinical exam:Temp. 39.2 °CBP 130/80 mmHg
Pulse 92/minRF 22/minSpO2 94%Awake, alert, orientedRales on auscultation on the right lung in the parascapular areaChest X-ray:Basic lab:
L 16.5 x 10
9
/cmm
CRP 208 g/L
Slide5Case 1The next step:treat in an outpatient settingadmit to the hospitaladmit to the ICU
Slide6Slide7Case 1The next step:treat in an outpatient settingadmit to the hospitaladmit to the ICU
Slide8Case 1Treatment :beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin)macrolide (azythromycin)respiratory fluoroquinolone (moxifloxacin)
beta-lactam plus macrolidebeta-lactam plus fluoroquinolone
Slide9Case 1Treatment :beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin)macrolide (azythromycin)respiratory fluoroquinolone (moxifloxacin)
beta-lactam plus macrolidebeta-lactam plus fluoroquinolone
Slide10Case 1In reality…The patient received azithromycin 1 x 500mg p.o. for 3 daysAfter completion of treatment he didn’t feel better and went to the ER
Slide11Case 1Detailed history and clinical exam:Temp. 38.5 °C BP 100/75 mmHgPulse 100/min
RF 30/minSpO2 92%Awake, alert, orientedCrackles in the right lung in the parascapular areaBasic lab:L 15.8 x 109/cmm
CRP 255 g/L
Chest X-ray:
No significant change in comparison to the last exam
Slide12Case 1The next step:treat in an outpatient settingadmit to the hospitaladmit to the ICU
Slide13Case 1Treatment:beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin)macrolide (azythromycin)respiratory fluoroquinolone (moxifloxacin)
beta-lactam plus macrolidebeta-lactam plus fluoroquinolone
Slide14Case 1 - outcomeThe patient became afebrile 2 days after ceftriaxone was added to the treatment regimenVital signs stable and within normal limitsDischarged after 3 days
Slide15Case 248-year-old male patientpreviously healthypresents with a 4-day history of fever (up to 39.5 °C)
with rigors, chills and malaiseon the 4th day he started to cough
Slide16Case 2Detailed history and clinical exam:Temp. 39.2 °CBP 130/80 mmHgPulse 92/min
RF 22/minSpO2 94%Awake, alert, orientedRales on auscultation on the right lung in the parascapular areaChest X-ray:Basic lab:L 16.5 x 10
9/cmm
CRP 208 g/L
Slide17Case 2The patient was sent home with a prescription for amoxicillin 1 x 1000 mg p.o. for 10 daysAfter 4 days of treatment he didn’t feel better and came to the ER
Slide18Case 2Detailed history and clinical exam:Temp. 38.5 °CBP 130/75 mmHgPulse 100/min
RF 28/minSpO2 92%Awake, alert, orientedRales on auscultation on the right lung in the parascapular areaBasic lab:L 15.8 x 109/cmm
CRP 350 g/L
Chest X-ray:
Slide19Case 2The next step:treat in an outpatient settingadmit to the hospitaladmit to the ICU
Slide20Case 2The next step:treat in an outpatient settingadmit to the hospitaladmit to the ICU
Slide21Case 2The most probable cause of treatment failure:pleural effusion (empyema) or abscessresistant strain of S. pneumoniaeother pathogens (viruses,
S.aureus, Legionnaires disease, tuberculosis…)ARDSmalignancyother causes
Slide22Case 2Additional workup:chest CT scanbronchoscopymicrobiological tests
serology
Slide23Case 2Microbiological tests:blood culturesputum culturebronchoscopy + culture
tuberculosis culture, PCR, microscopy, QuantiFERON testrespiratory pathogens PCRlegionella antigen in urine
Slide24Case 2Treatment:beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin)macrolide (azythromycin)respiratory fluoroquinolone (moxifloxacin)
beta-lactam plus macrolidebeta-lactam plus fluoroquinolone
Slide25Case 2Treatment:beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin)macrolide (azythromycin)respiratory fluoroquinolone (moxifloxacin)
beta-lactam plus macrolidebeta-lactam plus fluoroquinolone
Slide26Case 2 - outcomeLegionnaire’s disease was diagnosed by positive Legionella urinary antigen testTreatment with moxifloxacin 1 x 400mg i.v. was initiatedInitially the patient required aditional oxygen (6L/min by face mask)He became afebrile after 3 days of therapy with moxifloxacin, vital signs stable and within normal limitsDischarged after 4 days to continue treatment with oral moxifloxacin for a total of 10 days
Slide27Treatment of CAP simplifiedVital signs!! Respiratory rate!!Outpatient setting: start with amoxicillin 3 x 500-1000 mg p.o. (watch for allergies!)Patients who require hospitalization: treat with combination therapy (beta-lactam plus macrolide) or respiratory fluoroquinolone (in case of allergies)Re-evaluate the patient after 3-4 days
If they are not getting better:maybe it’s not S. pneumoniae (consider Legionella, Mycoplasma, S.aureus, viruses, tuberculosis…) look for complications (pleural effusion, sepsis, ARDS)