1. PNEUMONIA and CNS INFECTIONS 3 rd Year Medicine Clerkship Core Series John Lynch, MD, MPH jblynch@uw.edu

2. PNEUMONIA

3. Case 1 47 y man with alcoholism presents with 1 days of fever, productive cough with yellow sputum. Smokes 1 PPD and recently was hospitalized for a neck fracture.

5. Case 1 47 y man with alcoholism presents with 1 days of fever, productive cough with yellow sputum. Smokes 1 PPD and recently was hospitalized for a neck fracture. –What are the most likely organisms causing his pneumonia? –What physical findings provide clues to the specific etiology of his pneumonia? –What are the appropriate treatment choices in this clinical setting and with these findings?

7. Case 2 35 y woman with 1 week of HA, myalgias, sore throat, fever, and mild productive cough. She is febrile and diminished breath sounds over the RLL. Works in daycare, no travel.

9. Case 2 35 y woman with 1 week of HA, myalgias, sore throat, fever, and mild productive cough. She is febrile and diminished breath sounds over the RLL. Works in daycare, no travel. –What are the most likely organisms causing her pneumonia? –What laboratory tests are available for diagnosing atypical pneumonia? –What are the appropriate treatment choices in this clinical setting and with these findings?

11. Case 3 22y man with HIV (CD4 430) and IVDU seen in the ER with fever, non-productive cough, pleuritic CP x 3 days.

13. Case 3 22y man with HIV (CD4 430) and IVDU seen in the ER with fever, non-productive cough, pleuritic CP x 3 days. –What is the differential diagnosis? –How do you make the diagnosis? –What are the most frequently implicated organisms? –What are the empiric treatment options?

14. Case 4 36 yo homeless man with 1 month of fevers, cough and 10 lb weight loss.

16. Case 4 36 yo homeless man with 1 month of fevers, cough and 10 lb weight loss. –What is the differential diagnosis? –What laboratory tests would you order? –How would you treat this patient?

18. Case 5 54 y man s/p liver transplant 3 months ago with fever, cough and pleuritic SP x 1 week. Had HCV cirrhosis. Currently on prednisone, tacrolimus and azathioprine.

20. Case 5 54 y man s/p liver transplant 3 months ago with fever, cough and pleuritic SP x 1 week. Had HCV cirrhosis. Currently on prednisone, tacrolimus and azathioprine. –What is the differential diagnosis? –What is the diagnostic approach?

21. Case 6 33 y woman 12 days into hospitalization following an MVC. She is intubated in the TICU and has a new fever of 39.1 and thick ET suction.

23. Case 6 33 y woman 12 days into hospitalization following an MVC. She is intubated in the TICU and has a new fever of 39.1 and thick ET suction. –What is the diagnostic approach? –What is a reasonable empiric treatment regimen?

25. Alphabet Soup of Terms CAP: Community-acquired pneumonia –Outside of hospital or extended-care facility HCAP: Healthcare-associated pneumonia –Long-term care facility (NH), hemodialysis, outpatient chemo, wound care, etc. HAP: Hospital-acquired pneumonia –≥ 48 h from admission VAP: Ventilator-associated pneumonia –≥ 48 h from hospital admission + endotracheal intubation

26. CNS INFECTIONS

27. Case 1 15 y male, sexually active and recent IVDU, in the ER with 2 days of fever and HA. He has photophobia, T 38.2, mild meningismus and a normal neurological exam. –What CNS infectious syndromes are most likely? –What are the most common etiologies for his CNS infection syndrome? –What diagnostic test(s) would you perform?

29. Case 2 40 y man with URI symptoms (sore throat, myalgias) x 2 days followed by severe chills and diffuse purplish spots. Wife thinks he is groggy. This morning unable to arouse so called 911. He is febrile, hypotensive and reacts only to painful stimuli. He has marked meningismus, L pupil is minimally responsive and he has a non-blanching, blotchy purple rash. –What CNS infectious syndrome(s) is/are likely? –What would be your approach in evaluating this patient in the ER? –Empiric therapy? –Would you do anything for his close contacts?

31. Case 3 24 y man with IVDU, recently HIV-negative in the ER with HA and LLE weakness x 2-3 days. Low-grade temperature, cellulitis on the L forearm and LLE weakness. Head CT shows a ring-enhancing lesion in R prefrontal area, no sinusitis. –What are the clinical settings in which brain abscess develop? –How would you make a diagnosis? Would you perform a lumbar puncture? –What are the appropriate empiric antibiotics for treatment of brain abscess?

32. Case 4 527 y female OB resident with 6 days of fevers, forgetfulness and malaise. She has a frontal headache and episodic vomiting. She is confused, T 38.2, P 100, BP 104/60, minimal neck stiffness. Decreased arm strength in left arm and she has mild ataxia. Memory for remote and recent events is impaired. –What’s on the differential? –What is the diagnostic approach? –Empiric therapy?