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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3063_Библиотеки_им_академика_М_И_Перельмана
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Admission criteria for pneumonia are based on the severity of the illness, not the x-ray
findings. Culture results will not be given at the time you must make this triage
decision.
Pneumococcal pneumonia is still the most common cause of hospitalization for community-
acquired pneumonia. The history of cough and pleuritic chest pain with purulent sputum that
grows streptococcal pneumonia is confirmatory.
In this patient with a specific organism seen on the Gram stain and the results of culture known,
treatment with penicillin alone is sufficient if the culture indicates that the pneumococcus is
sensitive. This patient should be admitted for IV medications because of increased WBC count,
hypoxia, fever, older age, and chills.
For patients admitted with this presentation in whom a specific organism is not identified,
penicillin alone is too narrow an agent. Second-generation cephalosporins (e.g., cefuroxime)
or a third-generation cephalosporin (e.g., ceftriaxone) in combination with a macrolide could
be used. Ticarcillin/clavulanate or ampicillin/sulbactam are good choices as well and should
be combined with a macrolide or doxycycline to cover Mycoplasma, Chlamydia, and
Legionella.
CCS NOTE
The regular hospital ward is the location for most pneumonia patients who are
admitted. The ICU should be chosen only in the persistently hypoxic or hypotensive.
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In patients with community-acquired pneumonia, the CURB-65 score is used as a mortality
clinical prediction tool. It assigns 1 point for each positive indicator:
A score of 0–1 indicates consideration for outpatient management, while ≥2 indicates the
need for hospitalization.
If the patient has heart disease and a prolonged QT interval on EKG, use doxycycline. Avoid
macrolides and fluoroquinolones.
All older patients (age >70) with serious co-morbid conditions such as cancer, CHF, or
liver/renal disease should be strongly considered for admission to the hospital. The main
criteria for hospitalization are:
Final Diagnosis
Community-acquired pneumonia
Confusion
Blood urea nitrogen level >19.6 mg/dL (7.0 mmol/L)
RR ≥30/min
Systolic BP <90 mm Hg or diastolic BP ≤60 mm Hg
Age ≥65
Older age
Tachycardia
Hypoxia
High fever
Leukocytosis
Inability to take oral medications
Hypotension
Confusion
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CLINICAL PEARL
Make sure you know what covers Pseudomonas and when you need to cover it:
Beta-lactams that cover Pseudomonas include:
Hot tub folliculitis
Malignant otitis externa in diabetics
Septicemia
Burn victims
Cystic fibrosis
Severely neutropenic patients (<500 neutrophils/mm
3
) presenting with fever, usually
those on chemotherapy
Ventilator-associated pneumonia
Cefepime
Ceftazidime
Piperacillin/tazobactam
Ticarcillin/clavulanate
Imipenem/meropenem (not ertapenem)
Aztreonam (no Gram-positive coverage)
Non-beta-lactam include aminoglycosides and ciprofloxacin
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Case 10
Chief Complaint
Fever and increasing headache for 1 week
History and Physical Examination
A 38-year-old man with AIDS comes to your office with a week of fever, ranging from
38.6–38.8 C (101.4–101.8 F) and an increasing headache. He also complains of sunlight
hurting his eyes, nausea, and weakness. His past medical history is significant for
Pneumocystis pneumonia and total CD4 count 89 cells/μL. He was just started on
trimethoprim/sulfamethoxazole, tenofovir, emtricitabine, and efavirenz.
Vital signs are T 39 C (102.2 F), BP 110/70 mm Hg, pulse 95/min. Physical examination
shows photophobia and slight nuchal rigidity. The rest of the examination is normal.
Differential Diagnosis
Initial Management
Setting: emergency department
Cryptococcal meningitis
1.
Bacterial meningitis
2.
Viral meningitis
3.
Toxoplasmosis
4.
Lymphoma
5.
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Diagnostic/Therapeutic Plan
Test Results
Discussion
Cryptococcus is spread via soil and pigeon droppings via a respiratory route. Most patients
will have mild or no respiratory symptoms. Mucicarmine staining will show round budding
yeast with peripheral clearings or halos which are thick polysaccharide capsules. Initiation of
treatment with conventional amphotericin B plus flucytosine must start immediately.
Flucytosine may act synergistically with the amphotericin. Flucytosine must never be given
alone because of the likelihood of the development of resistance.
CLINICAL PEARL
An important element of CCS is the sequence and timing of when to do things. The
results of either the antigen test or the culture at the point of initial triage will not be
presented. Treatment in infectious diseases is started empirically and modified later.
In addition to an elevated opening pressure, other factors associated with a worse prognosis in
cryptococcal meningitis are low WBC count in CSF, low glucose level in CSF, positive India
Lumbar puncture
Serum and CSF cryptococcal antigen
Lumbar puncture: 4 WBCs, opening pressure 32 cm H
2
O (normal: <20 cm H
2
O), India ink
positive, VDRL tests negative
Serum titer 1:1,024; CSF titer 1:512; CSF fungal culture grows cryptococcus
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ink, and high cryptococcal antigen titer. Titers >1:8 or 1:16 are generally considered positive.
Therefore, although a normal WBC count in CSF is <5, this patient’s count of 4 indicates a
worse prognosis rather than a better one.
Amphotericin is given in any life-threatening fungal illness, such as cryptococcal meningitis.
Although some patients will be successfully treated from the beginning with fluconazole alone,
an unacceptably high percentage will fail treatment. Despite the factors listed above that are
associated with poor prognosis, it is difficult to reliably predict who has mild enough disease
to be treated with fluconazole alone. Hence, all patients should be started initially on
amphotericin. After the acute treatment with amphotericin is complete, fluconazole must be
continued orally lifelong in the AIDS patient if the CD4 cells do not increase. Discontinuation
of fluconazole may be considered in some patients who have had an excellent response to
HAART (highly active antiretroviral therapy), as defined as sustained increase in CD4 cells to
>100/µl for more than 6-12 mos and who are asymptomatic.
In patients who have an elevated opening CSF pressure on initial LP (>20 cm H
2
O), daily
repeat lumbar puncture to lower the CSF pressure is an important adjunctive treatment that
substantially lowers the morbidity and mortality associated with this disease. Elevated CSF
pressure is not appreciably lowered by medical therapy or corticosteroids.
Immune reconstitution inflammatory syndrome (IRIS) refers to a spectrum of inflammatory
disorders that develops in patients with AIDS upon initiation of antiretroviral therapy. There is
a paradoxical worsening of underlying opportunistic infections, undiagnosed or treated earlier,
related to rapid restoration of immune function after commencement of HAART. IRIS typically
develops within the first 3 mos after starting HAART, though it may occur much later. It occurs
more often in patients with a low pretreatment CD4 count (usually <100/µl) and those who
have a rapid improvement in CD4 counts and suppression of viral load.
For example, a patient with AIDS in whom HAART is initiated may have undiagnosed
underlying cryptococcal meningitis. The patient may have no symptoms of the disease
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(headache, fever) in the absence of any immune cells. Once HAART is initiated, and if there is
a rapid recovery of CD4 cells, the patient’s immune cells are able to mount an immunologic
response against cryptococcus and the patient will present with worsening headaches and fever
and other symptoms consistent with an inflammatory response.
IRIS can be seen with most opportunistic infections, including pulmonary tuberculosis. In most
cases, unless the illness is life-threatening, HAART may be continued and the patient can be
symptomatically treated with NSAIDS or corticosteroids. If a known opportunistic illness (OI)
exists prior to starting HAART and CD4 count is very low, it is suggested to start treating the
infection and begin HAART 2-4 wks later.
CLINICAL PEARL
If a ring-enhancing lesion is seen on CT in an HIV patient with CD4 <100, presume
toxoplasmosis and start pyrimethamine with sulfadiazine. Repeat the CT in 2 wks to
confirm that there is improvement.
Further Management Plan
IV amphotericin followed by oral fluconazole
Final Diagnosis
Cryptococcal meningitis
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Case 11
Chief Complaint
“I have a burning sensation in my penis when I urinate.”
History and Physical Examination
A 28-year-old man comes to your office with several days of burning on urination and a
yellowish penile discharge. He reports a history of a similar illness a year ago for which
he received some medication but cannot describe. He is otherwise healthy and uses no
medications. He is sexually active but denies HIV risk factors. He is adamant that all of
his sexual partners have been completely healthy because he hates using condoms and
makes sure his partners have no symptoms.
He is afebrile, and there is no adenopathy. Except for a yellow discharge coming from the
urethra, the remainder of the examination is normal.
Differential Diagnosis
Initial Management
Setting: outpatient
Gonococcal urethritis1.
Nongonococcal urethritis (chlamydia, herpes, Mycoplasma hominis, Ureaplasma)2.
Trichomoniasis3.
Reiter syndrome4.
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Diagnostic/Therapeutic Plan
Test Results
Assessment
A sexually active person with urethral discharge is most consistent with a sexually transmitted
urethritis. A urethral swab can frequently identify intracellular gram-negative diplococci,
which are consistent with gonococcus. Their absence on Gram stain does not exclude the
diagnosis. Although visualization of intracellular gram-negative diplococci on a cervical or
urethral smear has a high specificity for N. gonorrhoeae, the absence of this finding is not
sensitive enough to exclude infection. Nucleic acid amplification urine tests therefore are
preferred. If gram-negative cocci are visible, culture is not necessary.
The swab should be inserted 1.5–2 cm into the urethra and rotated. The insistence by the
patient that his partners have been asymptomatic does not exclude gonorrhea. In fact, the major
source of infection seems to be from asymptomatic people who are colonized with the
organism. The endocervix is the most common site of asymptomatic colonization.
Further Management Plan/Results
Positive for N. gonorrhoeae
Positive for gonorrhea
Urethral swab with Gram stain and wet mount
Urethral swab: negative for organism
Culture of urethral swab on Thayer-Martin
medium
1.
DNA probe for both chlamydia and
gonorrhea
2.
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