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CPC 2: Fever, cough, dyspnea, and change in mental status

Heart. Borderline cardiomegalyHypertensive changesHeart weight 460 gm for height: 229=399 gm for weight 241-481 gmOccasional

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CPC 2: Fever, cough, dyspnea, and change in mental status

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    1. CPC #2: Fever, cough, dyspnea, and change in mental status Barbara J. Crain, M.D., Ph.D. October 7, 2008

    2. Heart Borderline cardiomegaly Hypertensive changes Heart weight 460 gm for height: 229=399 gm for weight 241-481 gm Occasional “boxcar nuclei” Mild to moderate coronary atherosclerosis

    3. Kidney Nephrosclerosis Arteriolosclerosis Hypertensive changes

    4. Brain (striatum)

    5. Brain (deep cortical white matter)

    6. Liver Mild acute congestion Mild macrosteatosis Mild nonspecific inflammation of triads No evidence of fibrosis, cirrhosis, or alcoholic hepatitis

    7. Lungs – gross examination Small pleural effusions Markedly increased weight: 2,900 gm (reference 685 – 1,050 gm) Firm, red parenchyma, most marked in right lung 2-cm cavitary lesion in right upper lobe Gross impression: severe bronchopneumonia with abscess

    8. Lung abscesses

    9. Lung with congestion and hemorrhage

    10. Lung with hemorrhage, necrosis

    11. Lung with hemorrhage, necrosis

    12. Lung with hemorrhage, necrosis and bacteria: pneumonia in leukopenic patient

    13. Gram-positive cocci Strep in chains or Staph in grape-like clusters?Strep in chains or Staph in grape-like clusters?

    14. Gram-positive cocci Strep in chains or Staph in grape-like clusters?Strep in chains or Staph in grape-like clusters?

    15. Blood culture from night of admission ORG 1: METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS IN ANAEROBIC BOTTLE -------------------------------------------------------------- RESULT ANTIBIOTIC MIC (mcg/ml) INTERPRETATION Oxacillin ------------- >2 -------------- Resistant Vancomycin ------------- 2 ------------ Susceptible Staphylococcal isolates that are resistant to oxacillin (MRS) should not be treated with penicillins, beta-lactam/beta-lactamase inhibitor combinations, cephalosporins and carbapenems. Was telephoned to unit as Critical Action Value 35 hours later; Shortly thereafter, the aerobic bottle grew out MRSA, as did a subsequent sputum cultureWas telephoned to unit as Critical Action Value 35 hours later; Shortly thereafter, the aerobic bottle grew out MRSA, as did a subsequent sputum culture

    16. Sputum culture 1. BACT MICRO EXAM TYPE 2 - ADEQUATE SPECIMEN. MANY POLYMORPHONUCLEAR CELLS AND MANY SQUAMOUS EPITHELIAL CELLS. MANY NORMAL UPPER RESPIRATORY FLORA 2. BACTERIOLOGY CULTURE MODERATE MIXED RESPIRATORY FLORA AT 1 DAY POSITIVE AT 1 DAY ORG 1: HEAVY METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS

    17. Major autopsy findings Severe hemorrhagic and necrotizing bronchopneumonia with abscess formation, right > left Culture-positive for MRSA Chronic changes associated with hypertension Borderline cardiomegaly Arteriolonephrosclerosis of kidneys Hypertensive cerebral vascular disease Focal chronic white matter damage Mild to moderate coronary atherosclerosis

    18. Cause of death

    19. Hospital-acquired MRSA infections First described in 1960, increasing problem in 1980’s MSSA vs. MRSA: includes a large genetic element ; staphylococcal cassette chromosome mec (SCCmec) SCCmec carries the mec gene complex and various resistance genes against non ß-lactam antibiotics Over half the Staph isolates in some hospitals are now MRSA Infections often in very ill patients, particularly in ICUs Bacteremia, pneumonia, endocarditis High morbidity and mortality MRSA first noted in 1960, started becoming a problem in hospitals in 1980’sMRSA first noted in 1960, started becoming a problem in hospitals in 1980’s

    20. Community-acquired MRSA infections More often children and young adults without underlying illnesses Generally skin / soft tissue infections (cellulitis, abscess) Emerging problems: necrotizing fasciitis, Waterhouse-Friedrichsen syndrome, empyema, necrotizing pneumonia Person-to-person transmission Strains causing CA-MRSA going back into hospitals Community-acquired started in mid to late 1990’s, problem is worsening, particularly in last 5 yearsCommunity-acquired started in mid to late 1990’s, problem is worsening, particularly in last 5 years

    21. Community-acquired MRSA pneumonia Rapidly progressive necrotizing pneumonia Effusions, bacteremia common Primarily children, young adults High mortality rate (>50% in some series) Median survival time 4-7 days Often preceded by viral-like illness (particularly influenza A)

    22. Pathogenesis of CA-MRSA Well characterized strains: USA300 most common in US Basis for apparent increased virulence Increased fitness of bug? Improved evasion of host immune system? Unique toxin production? Panton-Valentine leukocidin (PVL) gene: toxin with leukocytolytic and dermonecrotic activity

    23. Prevention of MRSA

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