doc_clotaire
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A 76-year-old man who was a smoker for the past 30 years with a history of chronic obstructive pulmonary disease (COPD) presents to the emergency department with a low-grade fever and increasing cough for the past three days. He also complains of shortness of breath for the past 48 hours. He worked as a nurse for 30 years and had a chronic hepatitis B infection for which he received interferon-2-alpha for 16 weeks and tolerated it well. During the physical examination, he has a large loose stool and appears acutely ill and confused. His temperature is 101 F, respirations are 24/min, pulse is 100/min, and blood pressure is 130/80 mm Hg. He has diffuse coarse expiratory rhonchi in both lungs. Laboratory studies show: hematocrit 33%, white cell count 16,000/mm3, platelets 150,000/mm3, sodium 128 mEq/L, bicarbonate 24 mEq/L, BUN 24 mg/dL, creatinine 1.2 mg/dL, and glucose 140 mg/dL. The chest x-ray shows hazy interstitial infiltrates. Sputum Gram stain shows only white cells. What should be the next step in the management of this patient?
(A) Transtracheal aspirates for Gram stain and culture
(B) Oral antibiotics
(C) Admit to hospital and start intravenous azithromycin and ceftriaxone
(D) Do blood cultures and start on intravenous cefuroxime
(E) Admit to hospital and start with intravenous ceftriaxone
(F) Admit to hospital and start with intravenous cefuroxime
(E) Bronchoscopy
What is your diagnosis ? Please explain !
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| Justice
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Atypical pneumonia most likely
Pt has comorbid status
I woul go with (C) Admit to hospital and start intravenous azithromycin and ceftriaxone
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| vradojc1
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As Justice says, atypical pneumonia. Admit due to the presentation and Cef i.v. + zythro.
However, I haven't heard of parenteral formulation of zythromax.
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| vradojc1
Forum Elite
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Well, there is. Checked on Pfizer's website.
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| sprint123
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I go with C....Legionella Pneumonia
High fever,rr-24,High WBC count,Hypntremia and increased BUN warrants hospitalisation rather than startinf on oral azithromycin...
Whys hould we give ceftriaxone along with azithro,if it is legionella??
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| sachida
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In agreement with Sprint 123, lagionella pneumonia
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| r_albayunen
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maybe to cover for hemophilus influenzae ..
the clue for legionella "confusion" treated with macrolides: azitro, erytro ..
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| sridevibandaru24
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Leigionella-----Pneumonia+Hyponatremia+non bloody Diarrhea
confusion may also be present. Treatment is Azithromycin/Erythromycin
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| doc_clotaire
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(C) Admit to hospital and start intravenous azithromycin and ceftriaxone
Explanation:
The presentation with a history of diarrhea, hyponatremia, hazy interstitial infiltrates, and nondiagnostic Gram stain is consistent with Legionella pneumonia. Legionella should respond well to macrolides, particularly erythromycin, as well as fluoroquinolones or doxycycline. The sensitivity of a transtracheal aspirate is 90%, but the specificity is low. The major advantage of this method is that material obtained by transtracheal aspirate is not contaminated by upper respiratory organisms.
It is incorrect to treat this patient as an outpatient because patients who fall into risk class IV of the pneumonia severity index need hospitalization, perhaps even in the intensive care unit, and intravenous antibiotics. It is incorrect to treat community-acquired pneumonia with a penicillin or cephalosporin alone. Many of the causative organisms, such as Chlamydia, Legionella, and Mycoplasma do not respond to cefuroxime.
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In this case, an age above 70 (70 points), the presence of liver disease (20), mental status changes (20), and sodium level below 130 (20) gives a total of 130 points. This patient should definitely be hospitalized.
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| ram3
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I agree big time (C) Admit to hospital and start intravenous azithromycin and ceftriaxone over age sixty five and hyponatreamia are criteria for admission to hospital
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