SANJAY SINGHANIA
FEVER AND PRODUCTIVE
COUGH
CHIEF
COMPLAINT
GENERAL DATA
 Patient X is a 71-year-old female, retired corporate
attorney, currently residing in New Haven came to
Yale Emergency Department due to fever and
productive cough
HISTORY OF PRESENT ILLNESS
 4 days PTA patient noted the onset of cough. Initially
nonproductive, then became productive with yellowish sputum
and was associated with left sided chest pain.
 2 days PTA she noted feeling chills and had a temperature of
38.9°C. The fever, cough and chest pain continued over the
next 48 hrs. which prompt her to seek consult to Yale
Emergency Department.
 She denied hemoptysis, weight loss, sore throat, sinusitis,
back pain, diarrhea, rash, joint pain or headaches.
PAST MEDICAL HISTORY
 She has a history of congestive heart failure related
to ischemic heart disease that has been controlled
with Lasix, an ACE- inhibitor, and Lopressor.
PERSONAL SOCIAL HISTORY
 Patient X is a retired corporate attorney and lives
alone in New Haven. She is a former smoker but
quit 3 months ago when her husband died of lung
cancer. She denies alcohol use, recent travel,
domestic pets or any risk factors for HIV exposure.
PERTINENT FINDINGS
IN MEDICAL HISTORY
PERTINENT FINDINGS
PERTINENT (+)
71 years old
Female
38.9 C Fever
Productive cough
Yellow sputum
chills
Left sided chest pain
history of congestive heart failure
related to ischemic heart disease that
has been controlled with Lasix
Former smoker
Husband died of lung ca
PERTINENT (-)
 She denied hemoptysis, weight
loss, sore throat, sinusitis, back
pain, diarrhea, rash, joint pain or
headaches.
 She denies alcohol use, recent
travel, domestic pets or any risk
factors for HIV exposure
PHYSICAL
EXAMINATION
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
GENERAL SURVEY
VITAL SIGNS
SKIN
HEENT
PERTINENT POSITIVE (+)
PERTINENT NEGATIVE (-)
• Thin
• in mild respiratory distress
• Temperature: 38.9°C
• RR: 28 cycles per min
• PR: 120 beats per min.
• BP: 128/84 mmHg
• O2 saturation: is 89% on
room air
• Decrease turgor
• TMs mildly red
• oropharynx is mildly red
• sinuses nontender
• no middle ear fluid
• oropharynx no exudate.
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
CHEST AND LUNGS
PERTINENT POSITIVE (+)
PERTINENT NEGATIVE (-)
• remarkable for splinting to
• Right chest is clear
the left side on deep
inspiration
• dullness to percussion ≈ 1/4
way up on left side
• decreased breath sounds at
left base
• egophony and bronchial
breath sounds are evident as
one listens more superiorly
on the left side. The right
chest is clear. COR - RRR
without murmurs or rubs.
PHYSICAL EXAMINATION
PHYSICAL EXAMINATION
CARDIOVASCULAR
ABDOMEN
NEURO
PERTINENT POSITIVE (+)
PERTINENT NEGATIVE (-)
• COR - RRR without
murmurs or rubs.
• soft, nontender without
hepatosplenomegaly
• nonfocal
PERTINENT FINDINGS
PERTINENT (+)
• HCO3: 29 (NV: 22 to 28 mEq/L)
• Glu: 150 (NV:70 to 99 mg/dL)
• WBC:18.0 (NV:(4.5 to 11.0 ×
109/L)
• 41 lymphs (NV: 20-40%)
• Sputum Gram’s stain: a few
PMN, many epithelial cells, and
scattered Gram positive and
Gram negative cocci and rods
are seen
• size/left lower lobe infiltrate is
present that obscures the left
heart border
PERTINENT (-)
•
•
•
•
•
•
•
•
•
Na: 143(NV:135-145 mEq/L)
K: 4.2 (NV:3.6-5.2 mmol/L)
Cl: 100 (NV: 96-106 mEq/L)
Cr: 1.0 (NV: 0.59 to 1.04 mg/dL)
Hb: 13.8(NV:12.1 to 15.1 g/dL)
Hct :39.8(NV:36% to 48%)
54 segmenters (NV:40-60%)
5 bands (NV:0-5%)
platelets 255K (NV:150,000 to
450,000)
• EKG: NSR/normal rate, intervals
and no ischemic changes
• CXR: Normal heart size
• UA: clear/1.020/1+ protein/no cells
or casts
Differential Diagnosis
01
Lobar Pneumonia
02
03
Acute Bronchitis
03
Pulmonary Edema Secondary
to CHF
04
Pulmonary Tuberculosis
Comparison of Signs and Symptoms
Disease
Productive
cough
Fever and
Chills
Yellow
sputum
Tachypnea
Tachycardia
Peripheral O2
desaturation
Lobar Pneumonia
+
+
+ (early
stage)
+
+
+
Acute Bronchitis
+
+
+
+
+
+
Pulmonary Edema
Secondary to CHF
+
+
+
+
+
+
Pulmonary
Tuberculosis
+
+
+
+
+
+
Comparison of Signs and Symptoms
Disease
Chest
Pain
Dullness to
percussion
Decreased
skin turgor
Splinting to the left
side on deep
inspiration
Decreased
breath sound
at left base
Lobar Pneumonia
+
+
+
+
+
Acute Bronchitis
+
-
+
+
+
Pulmonary Edema
Secondary to CHF
+
+
+
+
+
Pulmonary
Tuberculosis
+
+
+
+
+
P R I M A RY
I M P R E S S I O N
TYPICALCOMMUNITY
ACQUIRED PNEUMONIA
SECONDARY TO
CONGESTIVE HEART
FAILURE
HOW WE ARRIVED
IN OUR DIAGNOSIS
HOW WE ARRIVED IN OUR PRIMARY IMPRESSION?
1. Patient experienced the following signs and symptoms:
•
•
•
•
•
•
•
•
Fever
chills
Yellow sputum
Productive cough
Tachypnea with pleuritic chest pain
remarkable for splinting to the left side on deep inspiration
Dullness on percussion
Decreased breath sounds
*Reference:
Htun, T. P., Sun, Y., Chua, H. L., & Pang, J. (2019). Clinical features for diagnosis of
pneumonia among adults in primary care setting: A systematic and meta-review. Scientific
reports, 9(1), 7600. https://doi.org/10.1038/s41598-019-44145-y
HOW WE ARRIVED IN OUR PRIMARY IMPRESSION?
2. Patient X has a History of Congestive Heart failure
 Chronic heart failure patients has an increased risk of pneumonia due
to alveoli flooding and reduced microbial clearance. A study by Mor
and Thompson suggest that patients with chronic heart failure, in
particular those using loop diuretics, have markedly increased risk of
hospitalization with pneumonia.
*Reference:
Mor A, Thomsen RW, Ulrichsen SP, Sørensen HT. Chronic heart failure and risk of
hospitalization with pneumonia: a population-based study. Eur J Intern Med. 2013
Jun;24(4):349-53. doi: 10.1016/j.ejim.2013.02.013. Epub 2013 Mar 17. PMID: 23510659
RISK FACTORS
RISK FACTORS
• Patient X is a former smoker
 The risk of ex-smokers was similar to current smokers, about 2.14 to
1. According to the study of American College of Chest Physician-The
number of cigarettes smoked per day and the life-time pack-years showed a
positive dose-response relationship, with a significant trend in pneumonia.
*Reference:
Mor A, Thomsen RW, Ulrichsen SP, Sørensen HT. Chronic heart failure and risk of
hospitalization with pneumonia: a population-based study. Eur J Intern Med. 2013
Jun;24(4):349-53. doi: 10.1016/j.ejim.2013.02.013. Epub 2013 Mar 17. PMID: 23510659
RISK FACTORS
• Patient X is 71 years old
 Age is one of the primary risk factors for pneumococcal pneumonia, and even
healthy adults 65 years or older are at increased risk for pneumococcal disease.
Our immune systems naturally weaken with age, it's harder for our bodies to fight
off infections and diseases like pneumococcal pneumonia — even for healthy
adults.
*Reference:
Stupka, J. E., Mortensen, E. M., Anzueto, A., & Restrepo, M. I. (2009). Communityacquired pneumonia in elderly patients. Aging health, 5(6), 763–774.
https://doi.org/10.2217/ahe.09.74
RISK FACTORS
• Patient X has a History of Congestive Heart failure
 Chronic heart failure patients has an increased of pneumonia due to alveoli
flooding and reduced microbial clearance. A study by Mor and Thompson
suggest that patients with chronic heart failure, in particular those using loop
diuretics, have markedly increased risk of hospitalization with pneumonia.
*Reference:
Mor A, Thomsen RW, Ulrichsen SP, Sørensen HT. Chronic heart failure and risk of
hospitalization with pneumonia: a population-based study. Eur J Intern Med. 2013
Jun;24(4):349-53. doi: 10.1016/j.ejim.2013.02.013. Epub 2013 Mar 17. PMID: 23510659
WHAT IS THE
ETIOLOGIC
AGENT?
Streptococcus pneumoniae
Streptococcus pneumoniae
•
•
•
•
•
•
Gram-positive
α-hemolytic
Lancet-shaped diplococcus
Bile soluble
Optochin sensitive
Catalase-negative but produces hydrogen
peroxide.
• Can cause a range of different illnesses
including sinusitis, otitis media, pneumonia,
bacteraemia, osteomyelitis, septic arthritis
and meningitis
• frequent colonizer of the human
nasopharynx with a colonization rate of
27–65%
• Most common etiologic agent on Typical
Community Acquired cough
Figure 1. Shows Streptococcus pneumoniae under the
microscope
27
OTHER ETIOLOGIC AGENTS
EPIDEMIOLOGY
PNEUMONIA IS COMMON AND SERIOUS
• 150.7 million new cases worldwide in 2020
• 2nd leading cause of hospitalization worldwide
~20% of patients with pneumonia require hospitalization
• 6th leading cause of death in the world
~10% of patients with pneumonia die
Variations in rates of disease:
•
•
More common in men
More common in African Americans
compared to Caucasians and Asians
•
More common in children and older
adults
(overall rate for 18-49 yo is ~5 per 1000
overall rate for >65 yo is 75 per 1000 )
Figure 2. Worldwide disability adjusted life year (DALY) of pneumococcal pneumonia. Global distribution of
pneumococcal pneumonia on a log10 scale of the 2016 DALY per 100,000 pneumococcal pneumonia data
obtained from Institute for Health Metrics and Evaluation
Figure 3. Global distribution of lower respiratory infections over time. This figure depicts how the burden for
four major lower respiratory infections changes over time in response to the introduction of antibiotic
treatments and vaccine implementation. Disability adjusted life year (DALY) data obtained from Institute for
Health Metrics and Evaluation
EPIDEMIOLOGY
• Spread via air-borne droplets from a cough or sneeze.
• Outbreaks usually occur in close communities
• Incubation period: 1-3 days
• Susceptibility of population: immunity after infection is short
and unsteady, no cross-immune
PATHOGENESIS
CLEARANCE vs. COLONIZATION
Microbes constantly enter airways
but many factors prevent
colonization:
• mucous entrapment
• ciliary clearance
• immune surveillance
• intact epithelial barrier
• secreted factors such as:
‒ secretory IgA
‒ surfactant proteins (SP-a, SP-d)
‒ defensins
Disrupting or overwhelming these defense mechanisms can allow microbes to
colonize the lungs, resulting in PNEUMONIA
Effects and patterns of microbial colonization:
where and how inflammati o n appe ars can be informativ e
Alveolar
Interstitial
• In alveolar lumen
• Purulent exudate of
RBCs and PMNs
• Mostly in alveolar wall
• Mononuclear WBCs
• Fibrinous exudate
Lobar pneumonia
• lobar distribution
• “typical” CAP
• S. pneumo, H. flu.
Bronchopneumonia
Atypical pneumonia
• patchy distribution
• aspiration, intubation,
bronchiectasis
• Staph, enterics,
Pseudomonas
• diffuse infiltrate w/ perihilar concentration
• Mycoplasma, Chlamydophila, Legionella
• Respiratory viruses, e.g. influenza
35
COMMUNITY ACQUIRED PNEUMONIA
• Infection of the pulmonary parenchyma acquired from
exposure in the community
• Classically divided into “typical” and “atypical” syndromes:
I.
“Typical” CAP:
• presents with “typical” severe, acute infection
• infectious agent (usually S. pneumo or H. flu) is culturable/ identifiable
• responsive to cell-wall active antibiotics
II. “Atypical” CAP:
• presentation is usually sub-acute
• causative pathogens are difficult to culture/identify by standard methods
• not responsive to penicillins
CLINICAL
MANIFESTATION
Describe the physical findings in the
chest and what they indicate?
• Splinting to the left side on deep inspiration: Splinting is a reduce in inspiratory effort
through shallow breathing to lessen the sharp pain felt with inspiration
• Dullness to percussion indicates denser tissue, such as zones of effusion or consolidation.
Once an abnormality is detected, percussion can be used around the area of interest to define
the extent of the abnormality. Normal areas of dullness are those overlying the liver and spleen
at the anterior bases of the lungs
• Decrease breath sounds at left base or decreased sounds can mean: Air or fluid in or around
the lungs (such as pneumonia, heart failure, and pleural effusion) Increased thickness of the
chest wall. Over-inflation of a part of the lungs
Describe the physical findings in the
chest and what they indicate?
• Egophony is increased resonance of voice sounds heard when auscultating
the lungs. When spoken voices are auscultated over the chest, a nasal quality
is imparted to the sound which resembles the bleating of a goat.
• Bronchial breath sounds are tubular, hollow sounds which are heard when
auscultating over the large airways (e.g. second and third intercostal spaces).
They will be louder and higher-pitched than vesicular breath sounds
42
TYPICAL CAP PRESENTATION
History
• sudden onset of fever and cough
Physical signs and symptoms
•
•
•
•
•
•
fever
tachycardia
tachypnea
productive cough with purulent sputum and possible hemoptysis
pallor and cyanosis
localized:
− dullness to percussion
− decreased breath sounds
− crackles
, ronchi
, egophony (“E”
-to-”A”
change)
Investigations
•
•
•
CXR showing lobar consolidation
CBC showing leukocytosis w/ left shift
Sputum sample contains neutrophils, RBCs; Gram stain may be
positive depending on organism
COMPLICATIONS
COMPLICATIONS
Don’t SLAP HER:
• Septicemia
• Lung abscess
• ARDS
• Para-pneumonic effusion
• Hypotension
• Empyema
• Respiratory failure/Renal failure
WORK UP/LABS
46
ROUTINE LABORATORY TEST
The following laboratory tests may not be useful for diagnostic purposes
but are useful for classifying illness severity and site-of-care/admission
decisions:
• Serum electrolyte panel (sodium, potassium, bicarbonate, blood urea nitrogen [BUN], creatinine,
glucose)
• Arterial blood gas (ABG) determination (serum pH, arterial oxygen saturation, arterial partial
pressure of oxygen and carbon dioxide) – Hypoxia and respiratory acidosis may be present.
• Venous blood gas determination (central venous oxygen saturation)
• Complete blood cell (CBC) count with differential
• Serum free cortisol value
• Serum lactate level
47
BLOOD CULTURE
• Blood cultures should be
obtained before the
administration of antibiotics.
These cultures require 24
hours (minimum) to
incubate. When blood
cultures are positive, they
correlate well with the
microbiologic agent causing
the pneumonia.
Figure 4.S. pneumoniae colonies with a surrounding
green zone of alpha-hemolysis (black arrow) on a
BAP
48
LABORATORY TECHNIQUES
• Flow chart for
identification and
characterization of
a S.pneumoniae isola
te
49
SPUTUM EVALUATION
• Sputum Gram stain and
culture should be performed
before initiating antibiotic
therapy (if a good-quality,
contaminant-sparse specimen
containing < 10 squamous
epithelial cells per low-power
field can be obtained). The
white blood cell (WBC) count
should be more than 25 per
low-power field in nonimmunosuppressed patients.
Figure.S. pneumoniae in sputum specimens
50
CHEST RADIOGRAPH
• Chest radiography is
considered the standard
method for diagnosing the
presence of pneumonia, that
is, the presence of an infiltrate
is required for the diagnosis.
However, it must be noted that
the accuracy of plain chest
radiography for detecting
pneumonia decreases
depending on the setting of
infection
Figure. A chest X-ray of a patient who have bacterial
pneumonia
51
CHEST ULTRASONOGRAPHY
• Ultrasonography (US) is useful
in evaluating suspected
parapneumonic effusions. US
can identify septations within
the fluid collection that may
not be visible on CT scans. US
also has great utility for
directing needle placement for
pleural fluid aspiration
(throacentesis) at the patient's
bedside.
Figure. Chest Ultrasonography showing lung
consolidation of a patient who have pneumonia
MANAGEMENT
APPROACH TO
PATIENT X
Figure 5. A concept map showing the approach to
a 71 year old female who came in due to fever and
productive cough
Should the patient be hospitalized or
could she be treated as an outpatient?
• Yes, the patient should be hospitalized and monitored since
patient is categorized under moderate-risk community
acquired pneumonia until signs of improvement is
manifested.
When should antibiotics be initiated for
the empiric treatment of communityacquired pneumonia (CAP)?
• Antibiotics, the mainstay for the treatment of pneumonia,
should be initiated as soon as a diagnosis of CAP is made.
Patient X is under moderate-risk
community acquired pneumonia
• Clinical Features of
patients with CAP
according to risk
categories
EMPIRIC THERAPY B:
For patients with
moderate risk CAP
What initial antibiotics
are recommended for
the empiric treatment
of moderate-risk
community-acquired
pneumonia?
• For moderate-risk CAP, a
combination of an IV
nonantipseudomonal β-lactam
(BLIC, cephalosporin) with either
an extended macrolide or a
respiratory fluoroquinolone is
recommended as initial
antimicrobial treatment.
When should de-escalation of empiric
antibiotic therapy be done?
• De-escalation of initial empiric broad-spectrum antibiotic or
combination parenteral therapy to a single narrow spectrum
parenteral or oral agent based on available laboratory data is
recommended once the patient is clinically improving, is
hemodynamically stable and has a functioning gastrointestinal tract.
SIGNS OF IMPROVEMENT
• In the absence of any unstable coexisting illness or other life
threatening complication, the patient may be discharged once
clinically stable and oral therapy is initiated
• A repeat chest radiograph prior to hospital discharge is not needed
in a patient who is clinically improving
• A repeat chest radiograph is recommended during a follow-up visit,
approximately 4 to 6 weeks after hospital discharge to establish a
new radiographic baseline and to exclude the possibility of
malignancy associated with CAP, particularly in older smokers
REASONS ON LACK OF RESPONSE OF
PATIENTS TO EMPIRIC THERAPY
• The following are the reasons
why patients have lack of
response to empiric therapy
Recommended Hospital discharge criteria
PREVENTION
PREVENTION
• Get the flu vaccine each year. People can develop bacterial
pneumonia after a case of the flu. You can reduce this risk by getting
the yearly flu shot.
• Get the pneumococcal vaccine. This helps prevent pneumonia
caused by pneumococcal bacteria.
• Practice good hygiene. Wash your hands frequently with soap and
water or an alcohol-based hand sanitizer.
• Don’t smoke. Smoking damages your lungs and makes it harder for
your body to defend itself from germs and disease. If you smoke, talk
to your family doctor about quitting as soon as possible.
• Practice a healthy lifestyle. Eat a balanced diet full of fruits and
vegetables. Exercise regularly. Get plenty of sleep. These things help
your immune system stay strong.
• Avoid sick people. Being around people who are sick increases your
risk of catching what they have.
Thank You
Stay safe and God speed DOC!
SANJAY SINGHANIA