1. NYU Medical Grand Rounds Clinical Vignette Verity Schaye, MD PGY-3 September 15, 2010 U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

2. The patient is a 66 year old female who presented with malaise, chills, muscle aches, productive cough, shortness of breath and wheezing for one week. Chief Complaint U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

3. The patient’s past medical history includes moderate persistent asthma, poorly controlled, but without recent hospitalizations. Notably, the patient was not up to date on her vaccinations, including influenza. She was in her usual state of health until one week prior to admission with the above complaints, and was treated for a presumed asthma exacerbation with a high dose steroid taper. A chest x-ray obtained at that time was within normal limits. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

4. The patient’s symptoms did not improve after one week of therapy, at which time she was directly admitted from the outpatient clinic for treatment with intravenous steroids. History of Present Illness U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

5. Additional History Past Medical History: Hypertension Hyperlipidemia Type II Diabetes diagnosed 2004 Past Surgical History: None Social History: No history of tobacco, alcohol or drug use Family History: noncontributory Allergies: No Known Drug Allergies U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

6. Additional History Medications: Albuterol inhaler as needed Theophylline 300mg twice a day Fluticasone 500mcg and Salmeterol 50mcg inhalation powder twice a day Metformin 500mg twice a day Simvastatin 40mg nightly Omeprazole 20mg daily Prednisone taper U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

7. Physical Examination General: well developed, well nourished, elderly female, in mild respiratory distress Vital Signs: T: 97.6 BP:146/88 HR:96 RR:26 and O2 saturation:95% on 3 liters nasal cannula Diffuse inspiratory and expiratory wheezes, egophony at right lung base The remainder of Physical Exam was normal U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

8. Laboratory Findings CBC: white blood cell count 8.8, 85.7% neutrophils Remainder of CBC was within normal limits Basic Metabolic panel: glucose 316 Remainder of basic was within normal limits Hepatic panel: within normal limits Arterial Blood Gas: 7.42/38/70.5/93% Influenza swab: negative U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

9. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Admission Chest X-Ray

10. The patient was initially admitted for a presumed asthma exacerbation. Working or Differential Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

11. Hospital Day 1: –The patient was placed on high dose intravenous steroids and initially improved. Hospital Day 2: –The patient continued to improve and a steroid taper was begun. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

12. Hospital Day 3: –The patient was febrile to 102. –The patient was pan-cultured and a chest x- ray was repeated which showed new bibasilar opacities. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

13. U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS Chest X-Ray Hospital Day 3

14. Hospital Day 3: –Laboratory work was significant for an increasing white blood cell count to 12.3, with 51% neutrophils, 29% bands. –Sputum Cultures and Blood cultures were positive for Methicillin-resistant Staphylococcus aureus. –The patient was placed on Vancomycin and Piperacillin/Tazobactam with clinical improvement. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

15. Hospital Day 7: –The patient was discharged with a course of oral linezolid for the treatment of Methicillin- resistant Staphylococcus aureus pneumonia. Hospital Course U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS

16. Influenza complicated by Methicillin- resistant Staphylococcus aureus pneumonia super-infection Final Diagnosis U NITED S TATES D EPARTMENT OF V ETERANS A FFAIRS