A Tale of TWO PNEUMONIAS

1. A Tale of TWO PNEUMONIAS Kamal Singh, MD, D(ABMM) 7 May 2014

2. Diagnosis?

3. Diagnosis?

5. Recommendations for diagnostic testing remain controversial. • The overall low yield and infrequent positive impact on clinical care argue against the routine use of common tests such as blood and sputum cultures.

6. Here’s the problem……. • Blood cultures: Pretreatment blood cultures yielded positiveresults for a probable pathogen in 5%–14% in large series of nonselected patients hospitalized with CAP • The most common blood culture isolate in all CAP studies is S. pneumoniae • The yield for positive blood culture results is halved by prior antibiotic therapy • Respiratory tract Gram stain and culture : The yield of sputum bacterial cultures is variable and strongly influenced by the quality of the entire process, including specimen collection, transport, rapid processing, satisfactory use of cytologic criteria, absence of prior antibiotic therapy, and skill in interpretation • The yield of S. pneumoniae, is only 40%–50% from sputum cultures from patients with bacteremic pneumococcal pneumonia

7. When to order tests:

8. WHO GIVES A S___!

9. Some good news for Patient & Lab • Over the last two decades: • CAP epidemiology changed due to expanded antimicrobial use, and pneumococcal, Hib, and influenza vaccine coverage • Fortunately, improved molecular diagnostic methods have now become available

10. A microbial etiology could be identified for 67% of the patients (n=124). • The most frequently detected pathogens were S. pneumoniae (70 patients [38%]) and respiratory virus (53 patients [29%]). • Two or more pathogens were present in 43 (35%) of 124 cases with a determined etiology. • For patients with complete sampling, a microbiological agent was identified for 89% of the cases. • Sputum/Nasopharyngeal secretions: Analyzed by real-time quantitative PCR for Streptococcus pneumoniae, Haemophilusinfluenzae, Moraxellacatarrhalis and common respiratory viruses • Serological testing for Mycoplasmapneumoniae, Chlamydophilapneumoniae, • Urine antigen assays for detection of pneumococcal and Legionellapneumophila antigens

11. Case 1: 57 yo male with fevers for 2 days • Patient states he developed diffuse myalgias/arthralgias & headache after awakening and later that evening also had rigors and fevers as high as 104.6F that responded to Advil. • He went to the ED the next day but was found to be afebrile with a negative work-up and discharged home. • He re-presented in the afternoon with fevers and in the ED vitals were P 107, BP 144/75, Temp 101.6F, R 20, and SpO2 95%. • He had a CXR that showed LLL consolidation and was started on Vancomycin and Cefepime (changed to Zosyn 1 day later) and Oseltamivir • Past Medical History: Diffuse large B cell lymphoma in remission (completed 6 cycles of chemotherapy 2/2013) and Chronic Hep C

12. CXR

13. Background History • Denies any TB contacts. • Rents a few homes to newly arrived immigrants • Lawyer but also has a part-time home construction company. • No travels recently within USA or outside USA • 1 dog. Traps wild animals at his home – mainly possums • Had a sinus infection 2 weeks prior to presentation for which he was prescribed Augmentin which was later changed to Amoxicillin.

14. Labs

15. Hospital course • After admission he developed worsening SOB with desaturations down to SpO2: 87% now requiring O2 at 5L/min via nasal canula. • Patient states he only developed cough and SOB when in hospital but cough is essentially nonproductive. • Also reports 1-2 day history of pleuritic L-sided chest pain that is improved.

17. CT Chest- 4 days later

18. Preliminary Tests results: • Blood cultures 10/20 & 10/22: Negative X4 • Urine Culture 10/20: Negative • Respiratory Virus PCR 10/20: Negative • Urine Legionella Antigen: Negative • CMV PCR: Negative

19. Repeat CXR – 7 days later

20. Hospital Course cont. • Because of persistent fevers he underwent bronchoscopy: • PJP, AFB, Bacterial smear & cultures: Negative. • Voriconazole was added briefly – but stopped because of visual hallucinations. • He was switched to Meropenem (in case of drug fever), Vancomycin was continued • Repeat CT Chest was performed and ID was consulted

21. CT Chest – Day 8

24. Repeat Labs

25. A Therapeutic Intervention is Performed…

26. Growth reported on 10/30

27. Repeat Urine Legionella Antigen:

30. Case 2: 57 yo male with HIV & active heroin use • Patient was seen at RUMC ER for a fall and found to have L-arm fracture. • He had a CXR done with incidental finding of bilateral opacities on CXR and so was admitted • He reported cough with "yellow/green" sputum as well as 15-20 lb weight loss in past year. • Occasional night sweats. • Denies hemoptysis, SOB, fevers, chills. • The patient was hospitalized 1 month earlier at OSH with MRSA bacteremia and septic arthritis of L-elbow treated with Vancomycin until the patient left AMA. • Past Medical History: • HIV diagnosed 2002 non-adherent to HAART [CD4: 4 (1%) on current admission] • Chronic anemia • Hepatitis C Ab positive • Chronic LE ulcers

31. Physical Exam • VITALS: • BP: 110/62 mmHg, • Pulse: 80, • Temp: 100 °F (37.8 °C), • Resp: 20, SpO2: 95 % • CONSTITUTIONAL: Awake, reluctant to talk or be examined • ENT: Oral thrush • LUNGS: Chest clear • Heart: Normal • MUSCULOSKELETAL: L-arm in splint • Lower Leg: Shallow ulcer 6x3cm with purulent drainage • SKIN: track marks on bilateral arms

32. Lab results • WBC : 8.57 • N: 81%, M: L: 6.8%, M: 9.5%, E:0.8% • HGB: 6.5 • HCT : 20.6 • PLT: 127 • MCV: 95.8 • MCH: 30.2 NA 133 K 3.7 CL 109 CO2 19 BUN 13 CREAT 0.75 GLU 128 PROT 8.6 ALB 1.7 CA 7.0 TBIL 1.2 AP 163 SGOT 23 SGPT 10

34. CT Chest

39. Sputum Result

43. Hospital course • Patient non-cooperative • TTE: Limited & difficult study but no obvious vegetations • CT Head: Patient refused • Patient requested to leave AMA • Discharged on treatment doses of Levofloxacin for pneumonia and TMP/SMX (Bactrim) for Nocardia • Fluconazole for oral thrush

44. Re-admitted 3 weeks later • Brought to ED by family for weakness – family left without talking to doctors and patient provided little history due to altered mental status • Urine toxicology screen Positive for Opiates • Patient was noted to be hypotensive and started on broad-spectrum antibiotics with Vancomycin and Piperacillin-Tazobactam (Zosyn) and admitted to the MICU

46. Repeat Sputum Culture

47. Blood cultures X4 sets

48. Final Identification • Nocardiaabscessus complex/Nocardiaexalbida

49. Case 3: 48 yo female with pneumonia and altered mental status • Presents with a dry cough Feb 19 that became progressively worse prompting a visit to her GP on the 25th where she was noted to have lymphadenopathy and CXR showed a pneumonia. • She was started on amoxicillin on the 28th but returned to her GP on 4th March because of worsening cough & rash. She was then switched to Levofloxacin. • On March 5 she noted to have a temperature to 102.2F. • On March 7 she started to complain of a skewed diplopia, progressive decline in her mental status and acrocyanosis • She was hospitalized & started on Moxifloxacin, Vancomycin and Ceftriaxone. Lumbar Puncture was performed • Past Medical History: Hypertension and Asthma

50. Lumbar puncture results