1. CPC # 2 Infectious Disease October 7, 2008 Lisa L. Maragakis, MD MPH

2. Important Features of the Case 58 yo man with a history of alcoholism, smoking, hypertension and chronic pain Presents with 5 days of cough and fever with progressive dyspnea and “weakness” Confusion and slurred speech is also reported by the patient’s wife Other symtoms include: –headache –Pleuritic chest pain (R) –Urinary incontinence (new)

3. Important Features of the Case No recent medical care and not taking anti- hypertensive meds Upon admission: –BP=133/94, P=125, RR=24, afebrile; –Moderate respiratory distress; 95% on 6L NC; wheezing and rhonchi –Alert, not oriented to date, slurred speech WBC=1.1,  Hct (50%), ↓Plt (55k),  ALT (141),  Tbili (2.1) ↓TP/alb,  PT/PTT,   lactate (12.6),  BUN (48),  Cr (4.0), ammonia=33 Imaging shows multi-lobar dense consolidation and cavitation of RUL, lymphadenopathy Head CT essentially negative

4. Summary of the Case Alcoholic man presents with an acute illness characterized by multi-lobar pneumonia, hepatic encephalopathy, lactic acidosis, coagulopathy and renal failure Rapidly developed hypotension, respiratory failure, and expired within 36 hours

5. Possible Etiologies of the Elevated Ammonia level Hepatic encephalopathy Shock ETOH Renal disease GI bleeding Salicylate intoxication Ethylene glycol

6. Possible Etiologies of the Elevated Lactate level Severe hypoxemia Shock Decrease in lactate utilization due to ETOH and liver disease

7. Community-Acquired Pneumonia, Sepsis and Multi-organ Failure Approximately 10% of CA pneumonia requires ICU care and mechanical ventilation Risk factors –Advanced age –Comorbid disease –DM –ETOH

8. Community-Acquired Pneumonia, Sepsis and Multi-organ Failure –Severe CAP defined by RR>30, PaO2/FIO2<250, need for mechanical ventilation, multi-lobar pneumonia, increased size of infiltrate up to 50% in 48 hrs, BP<90/60, pressor requirement, acute renal failure –Mortality rates 20-53% (as opposed to 2-30% for “regular” CAP)

9. Community-Acquired Pneumonia, Sepsis and Multi-organ Failure –S. pneumoniae and L. pneumophila are the most common etiologies –Gram negative bacilli, especially Klebsiella, occur in patients with DM, COPD, and ETOH abuse (this patient)

10. Community-Acquired Pneumonia, Sepsis and Multi-organ Failure –Initial presentation of CAP in older adults can present as Decline in functional status Weakness Mental status changes Anorexia Abdominal pain

11. Differential Diagnosis of Community Acquired Pneumonia S. pneumoniae accounts for 20-60% of cases H. influenzae causes 7-11% Older and debilitated patients more likely to have GNB colonizing oropharynx Group A and B streptococci M. cattarhalis Legionella Atypicals: M. pneumoniae, Clamydyia Viral pneumonia: RSV, influenza, parainfluenza Aspiration pneumonia

12. Differential Diagnosis of Community Acquired Pneumonia Aspiration –Silent vs witnessed –ETOH is a risk factor –Chemical pneumonitis –Mixed flora + anaerobes –Upper lobe atypical but not impossible

13. Differential Diagnosis of Community Acquired Pneumonia Atypical pneumonia syndromes –M. pneumoniae –C. pneumoniae –Legionella –Francisella tularensis –M. TB –Coxiella burnetii –Pneumocystis

14. Differential Diagnosis of Community Acquired Pneumonia S. aureus Not on the traditional lists of CAP etiology Seen increasingly as causing CAP Can cause necrotizing, cavitary pneumonia with rapidly progressive sepsis as seen in this case

15. Diagnosis Send sputum and blood cultures BEFORE antimicrobials are started Legionella urinary antigen (only detects serogroup 1) Consider NP aspirate during flu season Consider anthrax if widened mediastinum Bronchoscopy, open lung biopsy

16. Therapy for CAP Not in the ICU –Ceftriaxone PLUS Azithromycin or –Moxifloxacin In the ICU –Same as above or –Cover for Pseudomonas if at risk Cefipime PLUS Azithromycin Moxifloxacin PLUS Aztreonam

17. Risks for Pseudomonas Prolonged hospital or LTCF stay (>5d) Structural lung disease Steroid therapy Broad-spectrum ABX in past month AIDS Neutropenia

18. Therapy for CAP Aspiration –Clindamycin can be added to cover anaerobes CA-MRSA –Linezolid can be added to cover empirically while awaiting culture data

19. Therapy for CAP If you have the luxury of tailoring therapy –Base ABX treatment choice on organism that grows from sputum and/or blood

20. In this case… Treated with moxifloxacin (appropriate) If I had to bet, I would say this patient had CA-MRSA necrotizing pneumonia and sepsis with multi-organ failure