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

2. Case 1 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)
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 2

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 Chest X-ray: Basic lab: L 16.5 x 109/cmm CRP 208 g/L
Detailed history and clinical exam:
Temp °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 °C
Basic lab:
L 16.5 x 109/cmm
CRP 208 g/L 4

5. Case 1 The next step: treat in an outpatient setting
admit to the hospital
admit to the ICU
Ovdje negdje ili na idućem slidu stavi CURB score i CRB score da pojasniš kako će odlučiti o načinu i mjestu liječenja 5

7. Case 1 The next step: treat in an outpatient setting
admit to the hospital
admit to the ICU 7

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

9. Case 1
Treatment :
beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin)
macrolide (azythromycin)
respiratory fluoroquinolone (moxifloxacin)
beta-lactam plus macrolide
beta-lactam plus fluoroquinolone
Odgovor na zasebni slide, poboldan. 9

10. 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

11. Case 1
Detailed history and clinical exam:
Temp °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
Chest X-ray:
No significant change in comparison to the last exam
Basic lab:
L 15.8 x 109/cmm
CRP 255 g/L

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

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

14. 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

15. 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
Dosadan sam s ovim °C 15

16. Case 2 Chest X-ray: Basic lab: L 16.5 x 109/cmm CRP 208 g/L
Detailed history and clinical exam:
Temp °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
Basic lab:
L 16.5 x 109/cmm
CRP 208 g/L

17. 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

18. Case 2 Chest X-ray: Basic lab: L 15.8 x 109/cmm CRP 350 g/L
Detailed history and clinical exam:
Temp °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
Chest X-ray:
Basic lab:
L 15.8 x 109/cmm
CRP 350 g/L

19. Case 2 The next step: treat in an outpatient setting
admit to the hospital
admit to the ICU
I vdje negdje ubaciti CURB i CRB kako bi znali da to treba uvijek koristiti pri odlučivanju o načinu liječenja 19

20. Case 2 The next step: treat in an outpatient setting
admit to the hospital
admit to the ICU
I vdje negdje ubaciti CURB i CRB kako bi znali da to treba uvijek koristiti pri odlučivanju o načinu liječenja 20

21. 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

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

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

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
Treatment:
beta-lactam antibiotic (penicillin, amoxicillin, cephalosporin)
macrolide (azythromycin)
respiratory fluoroquinolone (moxifloxacin)
beta-lactam plus macrolide
beta-lactam plus fluoroquinolone

26. 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

27. Treatment of CAP simplified
Vital signs!! Respiratory rate!!
Outpatient setting: start with amoxicillin 3 x 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)