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CLINICAL PROBLEM SOLVING

CLINICAL PROBLEM SOLVING. Two patients with fever and cough Viktor Kotarski , MD ID specialist University Hospital for Infectious Diseases, Zagreb. Case 1. The next step: Detailed history and clinical exam, basic lab

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CLINICAL PROBLEM SOLVING

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  1. CLINICAL PROBLEM SOLVING Two patients with fever and cough Viktor Kotarski, MD ID specialist University Hospital for Infectious Diseases, Zagreb

  2. Case 1 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 • 54-year-old male patient • history of diabetes type II and hypertension • presents with a 3-day history of fever (up to 38.9 °C), cough, fatique and shortness of breath • the patient had had a cold for 3-4 prior to the onset of fever (nasal congestion, runny nose, sore throat)

  3. 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

  4. Case 1 Detailed history and clinical exam: Temp. 39.2 °C BP 130/80 mmHg Pulse 92/min RF 22/min SpO2 94% Awake, alert, oriented Rales on auscultation on the right lung in the parascapular area Chest X-ray: Basic lab: • L 16.5 x 109/cmm • CRP 208 g/L

  5. Case 1 The next step: • treat in an outpatient setting • admit to the hospital • admit to the ICU

  6. Case 1 The next step: • treat in an outpatient setting • admit to the hospital • admit to the ICU

  7. Case 1 Treatment : • beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin) • macrolide (azythromycin) • respiratory fluoroquinolone (moxifloxacin) • beta-lactam plus macrolide • beta-lactam plus fluoroquinolone

  8. Case 1 Treatment : • beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin) • macrolide (azythromycin) • respiratory fluoroquinolone (moxifloxacin) • beta-lactam plus macrolide • beta-lactam plus fluoroquinolone

  9. Case 1 In reality… The patient received azithromycin 1 x 500mg p.o. for 3 days After completion of treatment he didn’t feel better and went to the ER

  10. Case 1 Chest X-ray: No significant change in comparison to the last exam Detailed history and clinical exam: Temp. 38.5 °C BP 100/75 mmHg Pulse 100/min RF 30/min SpO2 92% Awake, alert, oriented Crackles in the right lung in the parascapular area Basic lab: • L 15.8 x 109/cmm • CRP 255 g/L

  11. Case 1 The next step: • treat in an outpatient setting • admit to the hospital • admit to the ICU

  12. Case 1 Treatment: • beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin) • macrolide (azythromycin) • respiratory fluoroquinolone (moxifloxacin) • beta-lactam plus macrolide • beta-lactam plus fluoroquinolone

  13. Case 1 - outcome • The patient became afebrile 2 days after ceftriaxone was added to the treatment regimen • Vital signs stable and within normal limits • Discharged after 3 days

  14. Case 2 • 48-year-old male patient • previously healthy • presents with a 4-day history of fever (up to 39.5 °C) with rigors, chills and malaise • on the 4th day he started to cough

  15. Case 2 Detailed history and clinical exam: Temp. 39.2 °C BP 130/80 mmHg Pulse 92/min RF 22/min SpO2 94% Awake, alert, oriented Rales on auscultation on the right lung in the parascapular area Chest X-ray: Basic lab: • L 16.5 x 109/cmm • CRP 208 g/L

  16. Case 2 The patient was sent home with a prescription for amoxicillin 1 x 1000 mg p.o. for 10 days After 4 days of treatment he didn’t feel better and came to the ER

  17. Case 2 Chest X-ray: Detailed history and clinical exam: Temp. 38.5 °C BP 130/75 mmHg Pulse 100/min RF 28/min SpO2 92% Awake, alert, oriented Rales on auscultation on the right lung in the parascapular area Basic lab: • L 15.8 x 109/cmm • CRP 350 g/L

  18. Case 2 The next step: • treat in an outpatient setting • admit to the hospital • admit to the ICU

  19. Case 2 The next step: • treat in an outpatient setting • admit to the hospital • admit to the ICU

  20. Case 2 The most probable cause of treatment failure: • pleural effusion (empyema) or abscess • resistant strain of S. pneumoniae • other pathogens (viruses, S.aureus, Legionnaires disease, tuberculosis…) • ARDS • malignancy • other causes

  21. Case 2 Additional workup: • chest CT scan • bronchoscopy • microbiological tests • serology

  22. Case 2 Microbiological tests: • blood culture • sputum culture • bronchoscopy + culture • tuberculosis culture, PCR, microscopy, QuantiFERON test • respiratory pathogens PCR • legionella antigen in urine

  23. Case 2 Treatment: • beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin) • macrolide (azythromycin) • respiratory fluoroquinolone (moxifloxacin) • beta-lactam plus macrolide • beta-lactam plus fluoroquinolone

  24. Case 2 Treatment: • beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin) • macrolide (azythromycin) • respiratory fluoroquinolone (moxifloxacin) • beta-lactam plus macrolide • beta-lactam plus fluoroquinolone

  25. Case 2 - outcome • Legionnaire’s disease was diagnosed by positive Legionella urinary antigen test • Treatment with moxifloxacin 1 x 400mg i.v. was initiated • Initially 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 limits • Discharged after 4 days to continue treatment with oral moxifloxacin for a total of 10 days

  26. Treatment of CAP simplified • Vital 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)

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