Saturday clinical meeting :Saturday clinical meeting Medical Division CH (SC) 03 Oct 2009


Particulars :Particulars 47/M Serving JCO Resident of UP


Presenting complaints :Presenting complaints MH Ahmednagar 10/09/09 Fever X 7 days Sore throat Cough X 4 days Breathlessness X 2 days


H/o Presenting illness :H/o Presenting illness Fever X 7 days Low to moderate grade for first 2 days Afebrile X 2 days Recurrence Low – moderate grade Chills present , no rigors


H/o Presenting illness… :H/o Presenting illness… Cough X 4 days Dry initially After 2 days started having scanty mucoid expectoration No postural /diurnal variation /hemoptysis Breathlessness X 2 days Acute onset, progressive worsening Breathless while going to toilet and talking No h/o orthopnoea/ PND/ wheeze


H/o Presenting illness… :H/o Presenting illness… H/o sore throat, rhinorrhoea followed by nasal stuffiness X 6-7 days


No h/o :No h/o Pain chest/ palpitations Pain abdomen/ diarrhoea Headache/ altered sensorium/ seizures Bleeding from natural orifices Yellowish discoloration of eyes/ urine Decreased urine output Weight loss/ alopecia/ rash/ oral ulcers/ photosensitivity Other family members/ fellow workers having similar complaints


Past history :Past history No h/o similar complaints, hypertension, DM, CAD, Obstructive airway disease, TB H/o some skin rash for last 2 months – recovered fully


Personal history :Personal history Consumes vegetarian diet Chronic smoker – 30 pack yrs Social drinker Bladder and bowel habits – normal Sleep and appetite- normal No h/o high risk sexual behavior, IVDU, tattooing, needle prick injury, blood transfusion


Treatment history :Treatment history Patient on ?steroids for last 2 months for skin rash, stopped about 2 weeks prior to hospitalization


Summary :Summary 47 yrs old male, chronic smoker presented with one week history of fever with sore throat, followed by cough with mucoid expectoration and acute onset breathlessness


Possibilities? :Possibilities? Pneumonia Classical Atypical Structural heart disease RHD with FRA Infective endocarditis Epiglottitis Vasculitis ?


Difference between classical and atypical pneumonia? :Difference between classical and atypical pneumonia? Typical pneumonia Alveolar involvement with consolidation Signs more than symptoms Organisms - Streptococcus pneumoniae, Haemophilus influenzae, Staphylococcus aureus, Gram-negative bacilli Atypical pneumonia Interstitial involvement predominant, lobar or patchy congestion with no consolidation Symptoms more than signs Symptoms out of proportion with radiological findings Extra pulmonary features common Organisms – Chlamydia, Mycoplasma, Legionella, Rickettsia, Viruses (varicella, influenza, adenovirus)


O/E :O/E General Exam - Obese individual with moon facies P 108/min, regular BP 130/80 mm of Hg RR 26/min T 101 F Pallor + No clubbing, cyanosis, pedal edema, peripheral lymphadenopathy, JVP not raised Throat congestion +, no sinus tenderness, no post nasal drip No peripheral stigmata of IE/ FRA/ HIV


Peripheral stigmata of HIV? :Peripheral stigmata of HIV? Seborrheic dermatitis Oral candidiasis Temporal wasting Melanonychia Multidermatomal herpes zoster Condyloma accuminata Genital warts Kaposi’s sarcoma


S/E :S/E RS : B/l scattered wheeze present , B/L crackles infrascapular region P/A : soft, non tender, no organomegaly NS: oriented, conscious, alert, no focal deficit CVS: unremarkable


Summary :Summary 47 yrs old male, chronic smoker presented with short febrile illness with features of both upper and lower respiratory tract involvement


Possibilities ? :Possibilities ? Bronchopneumonia Staphylococcal Pneumococcal Interstitial pneumonia Atypical organisms Viral PCP AIP AEP Vasculitis


Inv (MH Ahmednagar) :Inv (MH Ahmednagar) Hb 13 gm% TLC 4100 DLC P54 L39 M02 E05 Urine R/E, M/E – turbid, Alb ++, 10-12 PC Urea/ Creat 43/1.3 mg/dL Bil 1.0 mg/dL OT/ PT 34/44 IU/L MP / Paracheck neg


CXR – 10/09/09 – possibilities? :CXR – 10/09/09 – possibilities?


Course in MH Ahmednagar :Course in MH Ahmednagar Diagnosis – B/L pneumonitis Inj Ceftriaxone 2 gm iv 12 hrly Inj Amikacin 400 mg iv BD Nebulization


11/09/09 :11/09/09 Patient continued to be breathless P 116, RR 28-30 SpO2 78 – 80 % - 80% on O2 Peripheral cyanosis + Chest – B/l scattered ronchi +, crepts +


Course in hospital… :Course in hospital… 100 % O2 Inj Ceftriaxone 2gm 12 hrly Tab Azithromycin Tab Levofloxacin Nebulization with Salbutamol


Course in hospital… :Course in hospital… Put on Non invasive ventilation No improvement Transferred to CH ( SC)


At CH (SC) 11/09/09 :At CH (SC) 11/09/09 General Examination PR 96/min, normal volume BP 110/70 mm Hg RR 42/min SpO2 70 % room air With 5 L O2 by face mask 76% Temp 100F Throat congestion ++ No pallor, icterus, cyanosis, pedal edema, peripheral LNE


S/E :S/E RS: B/L bronchial breath sounds infrascapular region, B/l inspiratory crackles present up to spine of scapula CVS P/A NAD NS


CXR – 11/09/09 :CXR – 11/09/09 CXR 10/09/09


Possibilities ? :Possibilities ? ARDS secondary to Pneumonia (bacterial pneumonia/ atypical organisms/ S-OIV) Pneumocystiis jirovecii Acute interstitial pneumonia Acute eosinophilic pneumonia


How do you diagnose S-OIV ? :How do you diagnose S-OIV ? Real Time Reverse Transcriptase PCR Viral culture Four-fold rise in swine influenza A (H1N1) virus specific neutralizing antibodies


What is ARDS ? :What is ARDS ?


Etiology of ARDS :Etiology of ARDS


How to manage ARDS? :How to manage ARDS?


Management :Management O2 + NIV ( SpO2 90 – 91 %) Inj. Ceftriaxone Inj. Levofloxacin Inj. Linezolid Tab Oseltamivir 75 mg BD Zanamivir respules 5 mg 2BD Inj. Hydrocortisone 50 mg 6 hrly


Course in hospital…(12/09/09) :Course in hospital…(12/09/09) ABG PaO2 35 mmHg Mechanical ventilation PEEP 14 cm H2O SpO2 92% ( fiO2 100%) 12/09/09 – 2315 h rRT-PCR S-OIV positive ARI - CAT C


How do you categorize ARI? :How do you categorize ARI? Category A Patients with mild fever plus cough/sore throat with or without body ache, headache, diarrhoea and vomiting Category B (i) Category A plus high grade fever and severe sore throat (ii)Presence of certain high risk conditions


ARI categorization… :ARI categorization… Cat C Cat B + Breathlessness, chest pain, drowsiness, fall in blood pressure, sputum mixed with blood, bluish discolouration of nails Irritability among small children, refusal to accept feed  Worsening of underlying chronic conditions


What are high risk conditions? :What are high risk conditions? Children under five Pregnant women Patients lung diseases, heart disease, liver disease, kidney disease, blood disorders, diabetes, neurological disorders, cancer and HIV/AIDS Patients on long term cortisone therapy Age >65 years,


Clinical significance of these categories? :Clinical significance of these categories? Cat- A : No antivirals , no testing Cat B: Antivirals , no testing Cat C : Antivirals and testing for S-OIV


Radiological opacities in S-OIV infection? :Radiological opacities in S-OIV infection? Normal radiograph B/l patchy alveolar opacities predominantly basal affecting 3 – 4 lung segments Interstitial opacities- reticular, linear, nodular Multilobar infiltrates Unilobar infiltrates


How do you treat S-OIV infection :How do you treat S-OIV infection Antivirals Neuraminidase inhibitors Oseltamivir - oral Zanamivir - respules/ IV Adamantanes - Amantidine, Rimantidine – XX Resistant


16/09/09 :16/09/09 T – 103 F P 108/min, BP 112/72 mm of Hg No fresh findings Cultures sent Antibiotics – Piptaz + Amikacin


Slide 43:QBC/ Paracheck – negative PBS : no toxic granules, shift to left present USG abdomen: hepato-splenomegaly


18/09/09 :18/09/09 Fever persisted Improvement clinically/ radiologically 20/09/09 Persistent fever Inj Clindamycin and Fluconazole added


ABG… :ABG…


Slide 47:CXR 12/09/09 CXR 14/09/09


CXR – 22/09/09 :CXR – 22/09/09


22/09/09 :22/09/09 Improvement in chest findings & PaO2 Weaned off ventilator Fever persisted ( Max T 108 F) Culture 16/09 – Candida cruzii : Urinary catheter tip CVC (BACTEC) 19/09 – 21/09 : no growth : 4 cultures


22/09/09 :22/09/09 Antifungals modified Fluconazole Caspofungin Piptaz, Amikacin & Linezolid were discontinued Meropenem started Central line and Foley’s catheter removed


Present status :Present status Continues to have occasional low grade fever spike Ambulant within ward Desaturates on room air – needs supplemental O2 intermittently Why??


Course of ARDS :Course of ARDS


HRCT Chest :HRCT Chest


How do health care workers protect themselves? :How do health care workers protect themselves? PPE Gloves Face shield or goggles Gown Mask or respirator Centers for Disease and Prevention, (May 20, 2004). Guidance for the Selection and Use of Personal Protective Equipment (PPE) in Healthcare Settings. Retrieved May 1, 2009 from http://www.cdc.gov/ncidod/dhqp/ppe.html


What is the role of prophylactic medication for contacts? :What is the role of prophylactic medication for contacts?


What is the new development? :What is the new development? IV Zanamivir: A therapy for patients hospitalized with severe influenza and for those in whom neither oral nor inhaled routes are an option Peramivir: An as-yet-unlicensed neuraminidase inhibitor (iv/im) Fludase (DAS181): A sialidase fusion construct that cleaves the sialic acid receptors that influenza viruses use for attachment, removing influenza receptors from the airway epithelium and preventing infection of lung cells Cyanovirin-N: A hemagglutinin inhibitor that may block viral entry Short interfering RNAs: A therapy that may hold promise for influenza T-705: A substituted pyrazine compound that is active against neuraminidase-inhibitor–resistant and amantadine-resistant viruses and that probably inhibits the RNA polymerase Long-acting inhaled neuraminidase inhibitors enhanced potency of dimeric derivatives of zanamivir


Vaccines… :Vaccines… Injectible vaccines CSL Ltd Novartis Diagnostics Sanofi Pasteur Intranasal Medimmune


What is the target population for vaccination? :What is the target population for vaccination? Initial target groups -- Pregnant women Household contacts and caregivers for children younger than 6 months of age Healthcare and emergency medical services personnel All people from 6 months through 24 years of age Persons aged 25 through 64 years who have health conditions associated with higher risk of medical complications from influenza GENEVA -- On 7 July 2009, the Strategic Advisory Group of Experts (SAGE) on Immunization


Is our patient non infectious now ? :Is our patient non infectious now ?


Acknowledgements :Acknowledgements Anaesthesia Lt Col Shivender Singh Sqn Ldr G Basra Maj Alok Jaiswal Dermatology Col R S Grewal, VSM & his team