cpc #2: fever, cough, dyspnea, and change in mental status barbara j. crain, m.d., ph.d. october 7,...
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CPC #2:Fever, cough, dyspnea,
and change in mental status
Barbara J. Crain, M.D., Ph.D.
October 7, 2008
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Heart
Borderline cardiomegalyHypertensive changes
Heart weight 460 gm for height: 229=399 gm for weight 241-481 gm
Occasional “boxcar nuclei”
Mild to moderate coronary atherosclerosis
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Kidney Nephrosclerosis Arteriolosclerosis Hypertensive changes
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Brain (striatum)
Dilated perivascular spaces Arteriolosclerosis Perivascular hemosiderin
Hypertensive changes in blood vessels
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Brain (deep cortical white matter)
Normal white matter (H&E) Normal astrocytes (GFAP) Reactive astrocytes (GFAP)
Focal pallor and reactive astrocytosis,most likely hypertensive in origin
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Liver
Mild acute congestion Mild macrosteatosis Mild nonspecific
inflammation of triads No evidence of fibrosis,
cirrhosis, or alcoholic hepatitis
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Lungs – gross examination
Small pleural effusions Markedly increased weight: 2,900 gm
(reference 685 – 1,050 gm) Firm, red parenchyma, most marked in right lung 2-cm cavitary lesion in right upper lobe Gross impression: severe bronchopneumonia with
abscess
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Lung abscesses
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Lung with congestion and hemorrhage
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Lung with hemorrhage, necrosis
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Lung with hemorrhage, necrosis
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Lung with hemorrhage, necrosis and bacteria: pneumonia in leukopenic patient
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Gram-positive cocci
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Gram-positive cocci
http://swampie.files.wordpress.com/2008/02/staphylococcus-aureus.jpg
http://images.encarta.msn.com/xrefmedia/sharemed/targets/images/pho/t028/T028362A.jpg
??
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Blood culture from night of admission ORG 1: METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS IN
ANAEROBIC BOTTLE
--------------------------------------------------------------
RESULT
ANTIBIOTIC MIC (mcg/ml) INTERPRETATION
Oxacillin ------------- >2 -------------- Resistant
Vancomycin ------------- 2 ------------ Susceptible
Staphylococcal isolates that are resistant to oxacillin (MRS) should
not be treated with penicillins, beta-lactam/beta-lactamase inhibitor
combinations, cephalosporins and carbapenems.
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Sputum culture
1. BACT MICRO EXAM
TYPE 2 - ADEQUATE SPECIMEN. MANY POLYMORPHONUCLEAR CELLS AND MANY SQUAMOUS EPITHELIAL CELLS. MANY NORMAL UPPER RESPIRATORY FLORA
2. BACTERIOLOGY CULTURE
MODERATE MIXED RESPIRATORY FLORA AT 1 DAY
POSITIVE AT 1 DAY
ORG 1: HEAVY METHICILLIN RESISTANT STAPHYLOCOCCUS AUREUS
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Major autopsy findings
Severe hemorrhagic and necrotizing bronchopneumonia with abscess formation, right > left
Culture-positive for MRSA Chronic changes associated with hypertension
Borderline cardiomegaly
Arteriolonephrosclerosis of kidneys
Hypertensive cerebral vascular disease
Focal chronic white matter damage
Mild to moderate coronary atherosclerosis
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Cause of death
Part Ia)Sepsis (due to or as a consequence of)
b)Acute MRSA bronchopneumonia with abscess formation
Part IIa)Atherosclerotic vascular diseaseb)Hypertensionc)Cardiomegalyd)History of smoking
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Hospital-acquired MRSA infections
First described in 1960, increasing problem in 1980’s MSSA vs. MRSA: includes a large genetic element ;
staphylococcal cassette chromosome mec (SCCmec) SCCmec carries the mec gene complex and various resistance
genes against non ß-lactam antibiotics Over half the Staph isolates in some hospitals are now MRSA Infections often in very ill patients, particularly in ICUs Bacteremia, pneumonia, endocarditis High morbidity and mortality
Clin Infect Dis 2008; 46:S344-49Brit J Anaesth 2004;92:121-130
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Community-acquired MRSA infections
More often children and young adults without underlying illnesses
Generally skin / soft tissue infections (cellulitis, abscess)
Emerging problems: necrotizing fasciitis, Waterhouse-Friedrichsen syndrome, empyema, necrotizing pneumonia
Person-to-person transmission Strains causing CA-MRSA going back into hospitals
http://www.jems.com/Images/mrsa_tcm16-33808.jpg
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Community-acquired MRSA pneumonia
Rapidly progressive necrotizing pneumonia Effusions, bacteremia common Primarily children, young adults High mortality rate
(>50% in some series) Median survival time 4-7 days Often preceded by viral-like illness
(particularly influenza A)
Emerg Infect Dis 2006;12:498-500MMWR 2007;5614):325-329Ann Clin Microb Antimicrob 2008;7:1
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Pathogenesis of CA-MRSA
Well characterized strains: USA300 most common in US
Basis for apparent increased virulenceIncreased fitness of bug?
Improved evasion of host immune system?
Unique toxin production?
Panton-Valentine leukocidin (PVL) gene: toxin with leukocytolytic and dermonecrotic activity
Clin Infect Dis 2008; 46:S350-5http://a.abcnews.com/images/Health/ld_mrsa_080425_mn.jpg9
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http://www.health.alberta.ca/influenza/SC_handwashing.jpg
Prevention of MRSA
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http://www.health.alberta.ca/influenza/SC_handwashing.jpg