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Medical Grand Rounds A perplexing pneumonia

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Worked as a cleaner in a hotel and caravan park. Married with 1 son. ... 2 dogs. No overseas or Australian travel. No risk factors for blood-borne viruses ... – PowerPoint PPT presentation

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Title: Medical Grand Rounds A perplexing pneumonia


1
Medical Grand Rounds A perplexing pneumonia
  • Infectious Diseases Team
  • John Hunter Hospital
  • August 2005

2
JA 54 yo female
  • PHx
  • One episode pneumonia responded to usual AB Tx in
    2003
  • Ex smoker. Ceased 2/12 ago. 35 pack year history
  • Mild asthma prn ventolin only
  • Hysterectomy

3
History
  • Presented to Belmont Hospital with a 6 week
    history of fever, shortness of breath and a
    productive cough (dark green sputum)
  • Weight loss 6kg despite good appetite
  • Drenching night sweats
  • No antibiotic treatment prior to presentation

4
Psychosocial History
  • Worked as a cleaner in a hotel and caravan park
  • Married with 1 son.
  • Lives with husband and son - Both well
  • 2 birds
  • 2 dogs
  • No overseas or Australian travel
  • No risk factors for blood-borne viruses

5
Examination on presentation to BDH
  • Fever 39.4 degrees
  • Mild tachypnoea 20 bpm
  • Cachectic
  • LLL dull percussion
  • LLL bronchial BS
  • PaO2 55mmHg room air. CO2 33mmHg

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7
Treatment
  • IV Ceftriaxone, Azithromycin 5/7
  • Ongoing high swinging fevers, cough
  • IV Timentin, Azithromycin 5/7
  • No response at all
  • David Arnold consulted

8
Further Investigations
  • ANA/ENA/ANCA - negative
  • Cultures blood and sputum negative
  • Bronchoscopy 15/02/05 NAD, Nocardia and
    Actinomycosis cultures sent. AFB smear negative
  • Trans bronchial biopsy inflamed and necrotic
    lung well demarcated from normal lung. No
    malignancy

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10
JHH transfer
  • 9/3/05 VAT and open lung biopsy LLL
  • IV Cephalothin, oral ciprofloxacin
    post-operatively
  • Ongoing fevers despite this
  • 11/3/5 Histology…….

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Diagnostic possibilities? . .
  • Granulomatous chronic pneumonia

21
  • Granulomatous chronic pneumonia
  • Diagnostic possibilities? . . .
  • Mantoux negative (useless)
  • ZN smear for AFBs negative
  • Serology for Q-fever, histoplasma negative
  • Special stains for fungi, histiocytosis X
    negative
  • PCR on tissue for MAC and MTb negative

22
Cultures
  • 14/3/5 - LLL biopsy on 9/3/5 POSITIVE for
    Burkholderia cepacia
  • Commenced IV ceftazidime and ciprofloxacin
  • In retrospect, one of the sputum cultures from
    the previous week also grew B.cepacia

23
Progress
  • 16/3/5 L thoracotomy and lower lobectomy
  • To debulk woody and destroyed L lower lobe
    (suggested by cardiothoracic surgeon)

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25
Progress
  • Day 3 post op developed LUL collapse
  • Physio, intermittent CPAP
  • LUL did not reinflate
  • 20/3/5 Bronchoscopy and washout
  • Saw moderate purulent secretions in L main
    bronchus
  • Improved clinically. Continued Ceftazidime plus
    ciprofloxacin

26
Progress
  • 1 week later
  • 27/3/5 febrile increasing CRP (435) , CXR changes

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28
Progress
  • Recrudescent B.cepacia due to spillage of pus
    into RUL
  • IV ceftazidime, tobramycin, meropenem,
    ciprofloxacin
  • Moderately lymphopaenic throughout admission
    (0.3-0.6x 109/L)
  • Further negative tests
  • Neutrophil function test
  • Lupus anticoagulant
  • Cardiolipin Ab
  • HIV serology
  • IgG subsets normal

29
Discharge
  • Out About service- Ceftazidime, ciprofloxacin
    6 weeks IV ceftazidime in total
  • Followed by a further 3/12 of oral high dose
    Bactrim and ciprofloxacin
  • July 05 Well. Regained 8kg. CRP4.
    Lymphocytes0.9
  • Repeat CT 27/7 - fluffy nodules still present
    continue oral antibiotics for further 3/12

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