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:
Sodium (134-145 mmol/L) 134
Potassium (3.5-5.2 mmol/L) 3.5
Chloride 96-106 mmol/L) 100
CO2 (20-29 mmol/L) 28
Glucose (65-99 mg/dL) 198
BUN (9-20 mg/dL) 10
Creatinine (0.76-1.27 mg/dL) 1.6
Calcium ((8.7-10.2 mg/dL) 9.1
Alkaline Phosphatase 62
ALT (0-44 IU/L) 30
AST (0-40 IU/L) 32
CBC:
WBC (3.4-10.83 µL) 19.1
Hemoglobin (13.0-17.7 g/dL) 12.8
Hematocrit (37.5-51.0%) 38.9
Platelet Count (150-4503 µL) 251
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
Streptococcus pneumoniae Susceptibility
MIC (mcg/mL Interpretation
Penicillin 0.12 Resistant
Ceftriaxone ≤1 Susceptible
Doxycycline ≤0.25 Susceptible
Erythromycin ≥8 Resistant
Levofloxacin ≥4 Resistant
Trimethoprim + Sulfamethoxazole ≥56 Resistant
Vancomycin ≤0.5 Susceptible
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.