A 75-year-old female presented to the hospital ER with shortness of breath, fatigue, a purulent cough, chest pain and (subjective) fever. In the emergency department, the patient was found to be hypoxic with an oxygen

PHRD 531 Infection and Immunity - Spring 2024

Graded Case # 2

Drs. Drew, Thompson, Wilson, Adams, & Pulga

Chief complaint: shortness of breath and cough x 5 days

History of Present Illness: A 75-year-old female presented to the hospital ER with shortness of breath, fatigue, a purulent cough, chest pain and (subjective) fever. In the emergency department, the patient was found to be hypoxic with an oxygen saturation of 88% (on room air) and respiratory rate of 22. A chest x-ray, sputum culture, respiratory viral panel testing (influenza, RSV, Basic Respiratory Viral Panel) and SARS-CoV-2 (COVID-19) tests were obtained. The patient was admitted to the general medicine unit. 

Past Medical History:

Hypothyroidism

Osteoporosis

T2DM

HTN

Gastric reflux disease

Social History:

Non-smoker, ETOH occasionally, currently retired (former teacher)

Family History:

Mother – deceased, no significant medical history

Father – deceased, history of T2DM and MI

Allergies:

PCN –rash when she was a child (has tolerated cephalosporins in the past)

Home Medications:

Levothyroxine 100mcg PO daily

Fosamax 70mg PO weekly

Metformin 500mg PO BID

Lisinopril 10 mg PO daily

Calcium carbonate (Tums) 1-4 tablets PO daily PRN acid reflux

Physical Exam:

General: underweight, slightly ill-appearing female

Height: 65 inches

Weight: 47.7 kg

Vitals: BP - 141/91; HR – 110.; Temp – 101.8 F; RR – 22; O2 sat 88% on room air

HEENT: normal

Cardiac: mild tachycardia, regular rate and rhythm

Resp: wheezes and crackles, purulent cough

Abdomen: soft, positive bowel sounds, no flank pain

Neuro: awake, oriented to person, place and time

Genitourinary: no dysuria or increased frequency

Extremities: normal

Labs:

Comprehensive Metabolic Panel:

CBC:

WBC differentials (normal range) Result

Neutrophils     (40-60%)          80%

Lymphocytes    (20-40%)          16%

Monocytes       (2-8%)              2%

Eosinophils      (1-4%)              1.5%

Basophils         (0.5-1%)           <0.5%

ESR (normal range is 0-22 mm/hr) 32mm/hr 

CRP (normal <1.0 mg/dL) 18.2 mg/dL

Procalcitonin (normal < 0.1 ng/mL) 0.8 ng/mL

Fourth Generation HIV1/2 Immunoassay: negative

ECG: QTc prolonged, 498 ms (normal <460 ms)

Imaging:

Chest x-ray: bilateral pulmonary infiltrates suggestive of pneumonia

Microbiology:

SARS-CoV-2 PCR – negative

Respiratory viral panel (basic)-negative

MRSA nasal swab-negative

Sputum gram stain: Gram-positive cocci in pairs and chains

Sputum culture: Streptococcus pneumoniae

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The patient is diagnosed with a community-acquired pneumonia (CAP). Please answer the following questions pertaining to this case in Blackboard.

1.      What laboratory and/or clinical findings in this patient are consistent with the diagnosis of an infection?

2.      After reviewing the workup of the patient, what specific findings may affect the antimicrobial agent you choose? List at least 5.

3.      The microbiology lab reports that this isolate of S. pneumoniae is resistant to penicillin.  What is the mechanism of resistance of S. pneumoniae to penicillin?

4.      The attending physician wants to treat the pneumonia with IV levofloxacin. Do you have any concerns with the use of levofloxacin in this patient?

5. Based on your assessment of the patient, how would you initially manage the patient’s pneumonia? Include drug, dose, duration, pertinent monitoring/follow-up and patient counseling.