Transcript CPC#2 October 6, 2009 Infectious Diseases

Clinico-Pathological Conference #2
October 6, 2009
The Patient
• 52 yr old female with SLE – scleroderma overlap
– Inflammatory polyarthritis
– Sclerodermatous skin changes with Raynauds
– Extensive GI dysmotility- TPN
– Glomerulonephritis
– Restrictive lung disease
– Hypocomplementemia
– Inflammatory myositis / myocarditis
SLE-scleroderma
• 2006– Polyarthritis
– Weakness with myositis
• 2/2008
– Esophageal dysmotility
• TPN + IV methylprednisolone (30 mg/day)
HPI
• 1 month PTA- volume overload, cardiac
dysfunction
– R / L cardiac cath: no pulmonary arterial
hypertension or coronary artery disease
– Endomyocardial biopsy: inflammatory cells,
scaring: mycophenolate, methylpred (60mg/dy)
Medications
Lasix 20 mg daily
Hydrochlorquine 200 mg twice daily
Lisinopril 5 mg daily
Metoprolol 25 mg twice daily
Prednisolone 60 mg intravenously in the morning
Reglan 10 mg four times daily
Myfortic 180 mg twice daily
Dilaudid 2mg as needed
Dapsone 100 mg every Monday-Wednesday-Friday
Flagyl 500 mg every 8 hours for bacterial overgrowth
Protonix 40 mg twice daily
Ambien 10 mg as needed
Ergocalciferol 1000 International Units daily
Course
• 3 weeks later– OSH: SOB, fever, chills,
rigors, cough
– Bilateral infiltrates
– Rapid decline with
sepsis, multi-organ
failure despite
• Vancomycin, pip/tazo,
oral flagyl, caspofungin
•
T: 38.5, HR: 108, BP:92/62 on vasopressors, SaO2: 91% on FiO2=0.5
General: intubated, sedated, acutely ill, appears somnolent but is arousable.
HEENT: clear oropharynx, no thrush, no ulceration.
Lungs: coarse breath sounds throughout.
CV: rapid and regular heart sounds.
Abdomen: Soft, infrequent bowel sounds.
Extremities: marked violaceous discoloration of fingers and toes, diffusely and bilaterally; no
acute digital infarcts.
Skin: Thickening in the trunk and extremities, sclerodactyly.
Neuro: moves all four extremities on command, Intact bilateral dorsiflexion and plantar flexion.
•
Laboratory Values on Transfer Na 127, K 3.7, Cl 87, bicarbonate 23, BUN 74, creatinine 2.6.
Calcium 8.5, protein 5.2, albumin 2.8
AST 2859, ALT 1416, alkaline phosphatase 1154, total bilirubin 5.3, ammonia 57,
CPK 179.0, troponin 1.96, CK-MB 2%, lactic acid 2.7 LDH 3610
WBC 23,110, hemoglobin 7.8, hematocrit 26.2, platelet 221,000, polymorphonuclear cells 91%
PT 16.1, INR 1.6, aPTT 31.6
Urinalysis: 2 WBC/PHF, 65 RBCs/PHF
Cultures- Blood cultures negative, Sputum culture positive for yeast, urine culture negative, CSF
cultures negative
Legionella DFA-negative, Urine Strep antigen-negative, Serum galactomannan- 0.5
Course
• Bronchosopy:
– Ulcerations with vesicular appearance throughout
the main airways
– Purulence RLL bronchus
• Dies 7 days later despite “broad spectrum
antibiotic” therapy, aggressive supportive care
– 13 days after presentation to hospital
– 4 weeks after initiation of current symptoms
Summary
Moderately immunocompromised patient
with ‘gradual’ respiratory decline, fever (4
week) bilateral pneumonia with acute
sepsis – multi-organ dysfunction
Ulcerative lesions in airway
Chronic severe paralytic ileus
Important Issues Contributing to
Differential
• Degree of immunocompromise
– Chronic steroids + pulse, MMF
• Duration of illness
– “sub-acute” progression of pneumonia with sepsis
• Appearance of infiltrates
– Nodules, ground glass, focal lobar infiltrates
•
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Time of year: Feb – March
Previous smoker
Chronic GI dysmotility: aspiration
Where is she from? Other risks for infection?
Questions posed
• What are the risk factors for pneumonia in this
patient?
– Corticosteroid exposure (+MMF?)
• Other prior therapies (TNF-a inhibitors, rituxan?)
– Hypocomplementemia
– Underlying airway disease – smoking (ulcerations?)
– Underlying structural lung disease – disruption of alveoli
(alveolar hemorrhage / pneumonitis)
– GI dysmotility – aspiration
– Time of year / antecedent respiratory virus ?
• Myocarditis / myositis 1 month PTA
Differential
Non-infectious
• Osler (1904)
suggested that
pulmonary
involvement as
part of SLE
– Alveolar hemorrhage /
damage
– Lupus pneumonitis /
progressive interstitial lung
disease
– Progressive pulmonary
hypertension
– Pulmonary embolism
– Malignancy
Differential
Infectious (syndrome)
• Community-acquired pneumonia
• Progressive hospital-acquired pneumonia
• Aspiration pneumonia
• Multiple / sequential infections
– Respiratory virus followed by bacterial pneumonia
• Influenza – S. pneumonia / S. aureus
• Respiratory virus – fungal pneumonia
• Disseminated viral infection
– Influenza
– Herpes virus (HSV, VZV)
– Adenovirus
Infectious Differential
• Bacterial
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• Viral
common
S. pneumoniae
H. influenzae
common
S. aureus
Rapidly progressive, necrotizing
Group A / B Streptococcus
•
Mixed anaerobes (aspiration)
Enterobacteriaceae
Increased colonization
Other organ involvement? Liver / myocarditis?
– Disseminated Herpes virus
– “Respiratory virus” (RSV, influenza,
para-influenza, adenovirus, HMPV,
coxsackievirus)
Fungal
– Aspergillosis (airway to invasive)
– Cryptococcosis
• E. coli (ESBL?)
Airway lesions + GM
Prior hospitalization
• K. pneumonia (ESBL?)
– Misc. filamentous fungus Suboptimal therapy
Endemicity (?)
Underlying disease
(e.g. Zygomycetes)
P. aeruginosa (MDR)
common
– Endemic fungus (Histoplasma,
Legionella spp.
Coccidiomycosis, Blastomyces)
Multiple other atypicals:
Tm / slf - dapsone? – Pneumocystis
M. pneumoniae, Chlamydia
Nocardia spp.
Tm / slf - dapsone?
• Parasitic
Tm / slf - dapsone?– Toxoplasma gondii
Mycobacteria
– Strongyloides stercoralis
Deductive reasoning
• Moderately immunosuppressed, sub-acute
pneumonia + gram stain / AFB stain negative, with
ulcerative airway lesions, + galactomannan
– Assumptions:
• Other organ dysfunction (liver, heart) really as described
• Omission of sputum / BAL Afb and gram stain not purposeful
(high burden of disease for stain-negative bacterial process)
• “Yeast” in sputum = Candida, not from endemic region
Tracheobronchial + invasive aspergillosis
Rapidity of death / sepsis: likely a secondary bacterial pneumonia