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

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Presentation on theme: "CPC #2: Fever, cough, dyspnea, and change in mental status Barbara J. Crain, M.D., Ph.D. October 7, 2008."— Presentation transcript:

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 gm Occasional “boxcar nuclei”  Mild to moderate coronary atherosclerosis

3 Kidney  Nephrosclerosis  Arteriolosclerosis  Hypertensive changes

4 Brain (striatum) Dilated perivascular spacesArteriolosclerosisPerivascular hemosiderin Hypertensive changes in blood vessels

5 Brain (deep cortical white matter) Normal white matter (H&E)Normal astrocytes (GFAP)Reactive astrocytes (GFAP) Focal pallor and reactive astrocytosis, most likely hypertensive in origin

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

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

13 Gram-positive cocci

14 ??

15 Blood culture from night of admission ORG 1: METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS IN ANAEROBIC BOTTLE RESULT ANTIBIOTIC MIC (mcg/ml) INTERPRETATION Oxacillin > Resistant Vancomycin Susceptible Staphylococcal isolates that are resistant to oxacillin (MRS) should not be treated with penicillins, beta-lactam/beta-lactamase inhibitor combinations, cephalosporins and carbapenems.

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 Part I a)Sepsis (due to or as a consequence of) b)Acute MRSA bronchopneumonia with abscess formation Part II a)Atherosclerotic vascular disease b)Hypertension c)Cardiomegaly d)History of smoking

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 Clin Infect Dis 2008; 46:S Brit J Anaesth 2004;92:

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

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) Emerg Infect Dis 2006;12: MMWR 2007;56  14): Ann Clin Microb Antimicrob 2008;7:1

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 Clin Infect Dis 2008; 46:S350-5

23 Prevention of MRSA

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