Senior Report 8.23

seniorreport

Case Presentation by Aditee Jodhani, MD

 

History of Present Illness:

A 45 year old female presents to the ED with shortness of breath worsening for the past 2 weeks. She states for the last several days she has also been experiencing fatigue, subjective fever, and chills. The patient denies any productive cough, hemoptysis or chest pain. She does have a history of HIV and intermittently follows up with a physician for treatment. She denies any current or past tobacco use. The patient has been living at a homeless shelter for the past 2-3 months and doesn’t know if she’s had contact with sick individuals.

 

Physical Exam:

Vital Signs:

BP 112/76, HR 102, RR 22, T 37.7, pulse ox 91% on RA

General: mildly uncomfortable, sitting upright

HEENT: no pharyngeal erythema, no palpable cervical lymphadenopathy

Cardiovascular: RRR, normal S1 and S2, no murmurs

Respiratory: Clear breath sounds bilaterally, mildly tachypneic speaking in short sentences, no wheezing or rales

GI: abdomen soft, nontender, +BS

Neurological: Alert and oriented x3, moving all four extremities spontaneously.

 

A chest xray and ABG was obtained. ABG: pH 7.46, C02 28, p02 68

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Questions:

1. Based on the information given above what is the most likely cause for the patient’s presentation?

A. bacterial pneumonia

B. COPD exacerbation

C. Pneumocystis jiroveci pneumonia

D. Pneumothorax

 

2. What is the most appropriate treatment for this patient?

A. Nebulized beta agonists with oral steroids

B. Ceftriaxone and doxycycline

C. Trimethoprim-sulfa

D. Trimethoprim-sulfa and corticosteroids

 

3. The patient states she has an allergy Bactrim, what other medications can be used to treat the patient’s condition?

A. Dapsone and trimethoprim

B. Clindamycin and primaquine

C. Lower dose Bactrim 10mg/kg daily

D. Caspofungin aerosolized pentamidine

 

Answers:

1. C
2. D
3. B

 

Explanation:

1. The best answer is C, Pneumocystis jiroveci pneumonia. The patient is immunocompromised with unknown CD4 count and should be treated as Pneumocystis jiroveci pneumonia until further workup (bronchoscopy) can prove otherwise. The chest xray represents early Pneumocystis jiroveci pneumonia, which can look normal instead of the classical diffuse bilateral infiltrates seen in image 1:

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Based on the patient’s symptoms, vital signs and ABG, treatment should not be postponed. Pneumocystis jiroveci pneumonia is an opportunistic infection seen mostly in immunocompromised patients. HIV patients not on antiretroviral treatment have a 75-90% risk of developing Pneumocystis jiroveci pneumonia, mostly when CD4 counts fall below 200. Patients begin prophylaxis either when CD4 counts fall below 200 or when an AIDS defining illness like oral-pharyngeal candidiasis occurs.

The patient has a normal respiratory physical exam, no significant history of tobacco use or risk factors such as trauma to indicate pneumothorax or COPD as a possible diagnosis. Although bacterial pneumonia is a possibility the patient’s personal medical history and mild hypoxia are concerning and more consistent with Pneumocystis jiroveci pneumonia. Increased morbidity and mortality due to infection require emergent treatment until the diagnosis can be confirmed. Mortality rates ranged between 20-40% but have since gone down to 10-20% with appropriate treatment survival rates are as high as 60-90%.

 

2. The answer is D. The ABG results show the patient requires treatment with antibiotics and steroids. Although Pneumocystis jiroveciis classified as both protozoan and fungal first line treatment is trimethoprim-sulfa. Dosage is 15-20mg/kg daily.

Steroid treatment has been shown to decrease alveolar exudates and inflammation, reduce intubation by 50% and proven beneficial in HIV patients with Pneumocystis jiroveci pneumonia. Use of steroids has not been proven effective in immunocompromised patients with Pneumocystis jiroveci pneumonia. Steroid therapy is initiated when 1 of 2 criteria are met with a high suspicion of Pneumocystis jiroveci pneumonia. 1.) Arterial pO2 < 70 mmHg or 2.) A-a gradient >35mmHg on room air. Some studies indicate that steroid therapy should be started within 72 hours of antibiotic therapy. Steroids help decrease the toxins responsible for worsening pulmonary inflammation after antibiotic therapy is initiated. However for severe disease starting steroid therapy after 72 hours has not shown a clear benefit in many studies.

 

3. The correct answer is B. The patient has moderate to severe disease which can be treated with clindamycin and primaquine. IV pentamidine can also be used for severe disease however is considered less effective and more toxic. Mild to moderate disease can be treated with dapsone and trimethoprim for patients requiring alternate therapy, however this patient is characterized as having severe disease.

Severe disease is characterized by use of steroids in conjunction with antibiotics. Aerosolized pentamidine is considered an ineffective treatment associated with frequent relapses and is not used as a second line agent for Pneumocystis jiroveci pneumonia. Lower dose Bactrim at 10mg/kg has shown efficacy, Thomas et al, and is associated with fewer side effects however at this time is not currently recommended by the CDC or for patients with intolerance to bactrim.

 

References:

Thomas M, Rupali P, Woodhouse A, Ellis-Pegler R. Good outcome with trimethoprim 10 mg/kg/day-sulfamethoxazole 50 mg/kg/day for Pneumocystis jirovecii pneumonia in HIV infected patients. Scand J Infect Dis. Aug 17 2009;1-7. [Medline].

[Guideline] Siberry GK, Abzug MJ, Nachman S, Brady MT, Dominguez KL, Handelsman E, et al. Guidelines for the prevention and treatment of opportunistic infections in HIV-exposed and HIV-infected children: recommendations from the National Institutes of Health, Centers for Disease Control and Prevention, the HIV Medicine Association of the Infectious Diseases Society of America, the Pediatric Infectious Diseases Society, and the American Academy of Pediatrics. Pediatr Infect Dis J. Nov 2013;32 Suppl 2:i-KK4.

Spach, David MD. OIs: Treatment: A 40 year old with fever and Respiratory Symptoms. HIV web study. http://www.hivwebstudy.org/cases/ois-treatment/40-year-old-fever-and-respiratory-symptoms. March 2015.

Nicholas John Bennett, MBBCh, PhD, MA(Cantab), FAAP; Chief Editor: Michael Stuart Bronze, MD. Pneumocystis jiroveci Pneumonia Overview of Pneumocystis jiroveci Pneumonia. Medscape. http://emedicine.medscape.com/article/225976-overview#aw2aab6c17. Sept 2014.

Constance A. Benson, M.D., Jonathan E. Kaplan M.D., Henry Masur, M.D. Treating Opportunistic Infections Among HIV-Infected Adults and Adolescents. Recommendations from CDC, the National Institutes of Health, and the HIV Medicine Association/Infectious Diseases Society of America. MMWR. December 17, 2004 / 53(RR15);1-112.

Cindy Meng Hou, DO, MBA and Sindy Paul, MD, MPH, FACPM. PREVENTING AND TREATING PCP AND MAC: A CONTINUING CHALLENGE IN HIV/AIDS CARE (11HC08). Rutgers, Center for continuing outreach and education. http://ccoe.rbhs.rutgers.edu/online/ARCHIVE/11HC08/article2.htm. 2015.

Guidelines for the prevention and treatment of opportunistic infections in HIV-infected adults and adolescents. http://www.aidsinfo.nih.gov. 2015

got public health?

No Love in the Time of Cholera

I was raised on drinking tap water. To this day, I still don’t understand why my California relatives are willing to spend money to drink bottled water. Evidently, they are not alone…..grocery stores and filled with complete aisles of multiple brands of bottled water, and now flavored water. However, the current cholera epidemic plaguing Zimbabwe has never made me so appreciative of our easy access to (clean) tap OR bottled water.

At present, there are a greater than 15,000 people affected, with a reported 775 people that have died from cholera. As Zimbabweans are fleeing the country to seek clean water and medical treatment in neighboring countries, the disease has the potential to spread throughout Africa. Due to breaking down of the government and health care system, and lack of access to clean water, Zimbabwe has had multiple outbreaks of cholera throughout the decade, but none this large or devastating.

Caused by the bacteria Vibrio cholerae, disease is transmitted through contaminated food or water, even shellfish. The enterotoxin that is produced invades the mucosal epithelium of thevc small intestine, leading to profound diarrhea. The severe dehydration the develops is considered a medical emergency, and may lead to shock and death in a rapid fashion.

Treatment is simple: aggressive oral rehydration therapy with a prepackaged mixture of sugar and salts which is mixed with water.IV rehydration is also acceptable, yet oral rehydration methods are more readily available, inexpensive and works well (if accesssible). Antibiotics are also available, but the key is rehydration. An oral vaccine has been developed, however it is currently not recommended by the World Health Organization (WHO) or Centers for Disease Control (CDC) once an outbreak has started or to travelers. Also chemoprophylaxis is also discouraged since it may not prevent disease and may facilitate antimicrobial resistance.

Some killer facts (courtesy of CNN):

  • A healthy adult can be killed in hours (unique among diarrheal illnesses)
  • Very short incubation period (2 hours to 5 days)
  • 75% do not exhibit any symptoms (that is, until the runs hit)
  • A total of 236 896 cases were reported in 2006, which is an increase of 79% compared with the number of cases reported in 2005
  • HIV and malnourished individuals are more severely affected and more likely to die—-considering the high prevalence of HIV and malnourishment in Africa, this is a devastating problem.
  • If left untreated, one out of two people may die

For more info:
WHO: World Health Organization
CDC: Centers for Disease Control

Here is an audio clip worth listening to.
cholera1
It’s hard to write this and not feel helpless….the solution is clear, but what can be done on our end to help? It’s not only the issue of access to clean water and oral rehydration solutions, but getting them to the people who need it most. Can the Gatorade company or the electrolyte/vitamin fortified water manufacturers help out? Surely their products contain most of what is needed, and they have the financial means to do so.

So the next time you see a bag of normal saline or stop by the water machine, be thankful for what we take for granted.

Thanks for reading.

Your comments and thoughts are much appreciated!

Dr. Marjan Siadat is a second-year Emergency Medicine resident at Detroit Receiving Hospital, Wayne State University. She is the editor of the public health section for Receiving.