USC Case 01: Pneumonia
Updated 5/22/2014
Mr. Regney is a 74 year-old black male who presents with a three-day history of fatigue,
myalgia, arthralgia, chills and a fever of 102 to 104. He denies sore throat or cough. His
appetite has been poor but he is forcing himself to eat a small amount of soup. He has a
history of chronic sinusitis and almost always has a yellowish nasal discharge. He denies
nausea or vomiting but had a loose stool this morning. He is noticing night sweats with
his fever. He lives with his wife who is well, but his granddaughter, who came to visit a
few days ago on Halloween, had a cold.
Given this history, what are your working diagnoses and why?
The working diagnoses should include:
1. Viral Illness/Influenza: With a history of exposure to a granddaughter with a
cold, one should consider viral illnesses. The fact that it is early November (after
Halloween), we need to be aware of the beginning season of influenza. Patient's
symptoms of myalgia, arthralgia and a fever of 102 to 104 degrees accompanied
with chills and sweats is highly suggestive of influenza.
2. Sinusitis: Patient has history of chronic sinus problems now with purulent nasal
discharge and a fever can be suggestive of a sinus infection.
3. Occult Infection: Pneumonia, UTI, or pyelonephritis can also cause the
symptoms that the patient has.
4. Tuberculosis: With the resurgence of TB, especially in the elderly population, it
needs to be included in the differential diagnosis. However, the acute onset of the
illness and high fever make TB less likely
What other history would be helpful to clarify our thinking?
What illness did the granddaughter have and how sick was she? Did she have a mild URI
or did she have influenza?
What is the health status of the patient? Are there other co-existing medical problems
which compromise the patient's immune status (such as COPD, diabetes, chronic renal
failure, congestive heart failure, chronic liver disease)?
Are the patient's immunizations up to date - specifically has he gotten his flu shots or
pneumococcal vaccine?
What is the patient's social history - specifically does he smoke, does he consume
alcohol, does he eat a balanced diet? All of these can contribute to how well he fights off
infection.
PAST MEDICAL HISTORY:
Hypertension: well controlled
Osteoarthritis: stable
Chronic Sinusitis: status post two sinus surgeries
Barrett's Esophagus: status post esophageal dilatation (1994)
PAST SURGICAL HISTORY:
Vein stripping in 1960
Right inguinal hernia repaired X2
Sinus surgery X2
MEDICATIONS:
Corgard 80mg 1 poq/day
Procardia XL 60mg 1 poq/day
SOCIAL HISTORY:
He is married, with two grown children. He is retired. Works as a bartender part-time.
Has 1-2 drinks a day for many years but does not smoke. The granddaughter who visited
had a mild URI.
What data would be important to gather in your physical exam?
1. The general appearance of the patient would be very important. Is he comfortable
and relaxed or does he look distressed and toxic in appearance?
2. Vital signs would be important, looking specifically at his temperature,
respiratory rate, blood pressure and pulse. Focus exams would include: HEENT,
neck, lungs, and cardiovascular system. Abdominal exam to look for any signs of
infectious processes in the abdomen. One should also check for CVA tenderness
(Lloyd’s punch) to test for pyelonephritis.
3. Osteopathic Structural findings
PHYSICAL EXAM:
On exam, patient is alert, appears pale, but is non-toxic in appearance. He is able to move
from the chair to the examining table with some assistance.
Vital signs show a T=99o, BP=122/72, P=72, RR=16. On HEENT: his eye exam is normal.
Ear: normal tympanic membrane with normal landmarks and reflexes. Nose: slight
congestion; nasal mucosa is somewhat boggy with a small amount of yellowish
discharge. Throat: normal. Examination of the facial bones was normal with no
tenderness. Neck: supple, with a few small cervical nodes. Lungs: clear to auscultation
and percussion. Cardiac exam: regular rhythm, normal S1-S2, no murmur or gallop noted.
Abdomen: soft, non-tender, liver and spleen are benign, normal bowel sounds. There is
no CVA tenderness noted. Extremities: no edema tenderness or cyanosis noted. There is
TART findings at T1-T5.
What is your most likely diagnosis at this time?
1. Viral Illness/Influenza: Giving the history and the benign exam, the most likely
diagnosis at this time are viral illness and possibly influenza. It is a bit early for
influenza given that this is only in the early part of November. *
2. Chronic Sinusitis: It is doubtful that this is contributing to the patient's acute
illness.
3. Thoracic Somatic Dysfunction
* Even though patient reports drinking 1-2 drinks a day, one needs to be aware of alcohol
abuse with his occupation as a bartender, as alcohol abuse impairs the immune system,
alcoholics are more at risk for serious illness.
What immunization history is important in this patient?
Patients in this age group are especially at risk for influenza and pneumococcal
pneumonia with high morbidity and mortality
CDC Guidelines: 2014 Updated
2013-14 CDC recommendations for Pneumococcal vaccines
Which children and adults need the PPSV23 vaccine?

All adults 65 years of age and older

Anyone 2 through 64 years of age who has a long-term health problem such as:
heart disease, lung disease, sickle cell disease, diabetes, alcoholism, cirrhosis, leaks
of cerebrospinal fluid or cochlear implant.

Anyone 2 through 64 years of age who has a disease or condition that lowers the
body’s resistance to infection, such as: Hodgkin’s disease; lymphoma or leukemia;
kidney failure; multiple myeloma; nephrotic syndrome; HIV infection or AIDS;
damaged spleen, or no spleen; organ transplant.

Anyone 2 through 64 years of age who is taking a drug or treatment that lowers
the body’s resistance to infection, such as: long-term steroids, certain cancer drugs,
radiation therapy.

Any adult 19 through 64 years of age who is a smoker or has asthma.

Residents of nursing homes or long-term care facilities.
PPSV may be less effective for some people, especially those with lower resistance to
infection.
But these people should still be vaccinated, because they are more likely to have serious
complications if they get pneumococcal disease.
Children who often get ear infections, sinus infections, or other upper respiratory
diseases, but who are otherwise healthy, do not need to get PPSV because it is not
effective against those conditions.
For additional details, consult the PPSV Vaccine Information Statement, the Adult
Immunization Schedule, and the ACIP Recommendations for Use of Pneumococcal
Vaccines, Sept 2010.
Which adults need the PCV13 vaccine?

Adults 19 years of age or older with certain medical conditions, and who have not
previously received PCV13. Medical conditions include:
o
Cerebrospinal fluid (CSF) leaks
o
Cochlear implant(s)
o
Sickle cell disease and other hemaglobinopathies
o
Functional or anatomic asplenia
o
Congenital or acquired immunodeficiencies
o
HIV infection
o
Chronic renal failure
o
Nephrotic syndrome
o
Leukemia
o
Hodgkin disease
o
Generalized malignancy
o
Long-term immunosuppressive therapy
o
Solid organ transplant
o
Multiple myeloma

Adults with one of the above listed conditions who have not received any
pneumococcal vaccine, should get a dose of PCV13 first and should also continue
to receive the recommended doses of PPSV23. Ask your healthcare provider for
details.

Adults who have previously received one or more doses of PPSV23, and have one
of the above listed conditions should also receive a dose of PCV13 and should
continue to receive the remaining recommended doses of PPSV. Ask you
healthcare provider for details.
Indications for Influenza Vaccine: Updated 5/2014 per the CDC
Who should get the influenza vaccine?
CDC: 2013-2014
Routine annual influenza vaccination is recommended for all persons aged ≥6 months
who do not have contraindications. Recommendations pertaining to the use of specific
vaccines and populations are summarized below.
TABLE 2. Contraindications and precautions to the use of influenza vaccines — United States, 2013–14 influenza season*
Vaccine
IIV (includes IIV3, II4, and ccIIV)
RIV
LAIV
Contraindications
History of severe allergic reaction to any component of the
vaccine, including egg protein, or after previous dose of any
influenza vaccine.
History of severe allergic reaction to any component of the
vaccine
History of severe allergic reaction to any component of the
vaccine, including egg protein, gentamicin, gelatin, and
arginine, or after a previous dose of any influenza vaccine;
Concomitant Aspirin therapy in children and adolescents.
In addition, ACIP recommends against use in the following:
Children aged <2 years
Precautions
Moderate to severe illness with or without fever
History of Guillain-Barré syndrome within 6
weeks of receipt of influenza vaccine.
Moderate to severe illness with or without feve
History of Guillain-Barré syndrome within 6
weeks of receipt of influenza vaccine.
Moderate to severe illness with or without feve
History of Guillain-Barré syndrome within 6
weeks of receipt of influenza vaccine.
adults aged ≥50 years
children aged 2 through 4 years whose parents or
caregivers report that a health-care provider has told them
during the preceding 12 months that their child had wheezing
or asthma or whose medical record indicates a wheezing
episode has occurred during the preceding 12 months (see
screening guidance, footnote in Table 1);
persons with asthma;
children and adults who have chronic pulmonary,
cardiovascular (except isolated hypertension), renal, hepatic,
neurologic/neuromuscular, hematologic, or metabolic
disorders;
children and adults who have immunosuppression
(including immunosuppression caused by medications or by
HIV);
persons with egg allergy;
close contacts and caregivers of severely
immunosuppressed persons who require a protected
environment; pregnant women
Abbreviations: IIV = inactivated influenza vaccine; IIV3 = inactivated influenza vaccine,
trivalent; LAIV = Live activated influenza vaccine
You decided that the most likely diagnosis for this patient is viral illness and advised the
patient to rest and take Tylenol as needed for the fever. He was advised to call you if his
symptoms are not better in a couple of days. You also performed OMT to his Thoracic
spine using muscle energy technique.
Three days later, patient's wife called to report that Mr. Regney is not better and
continues to have a temperature of 102 to 104. He had lost 10 pounds in one week
because of his anorexia and mild nausea. You advised the patient to be seen the same day.
In your office, Mrs. Regney reported that he still has the same symptoms of myalgia,
arthralgia, fever, chills and anorexia. Since yesterday he has been very fatigued and
spends most of the day in bed. He is taking Tylenol alternating with Advil for his fever.
Since his last visit he developed a slight cough which is productive of yellowish sputum.
He denies vomiting, abdominal pain, or dysuria. He has no back pain or chest pain. He
denies exposure to tuberculosis.
On exam, he is alert and appears weak, but is in no acute distress. Vital signs are a T=
98.8, BP=110/60, P=85 and a RR=16. His HEENT exam is unremarkable except that his lip
is somewhat bluish in color. Neck: supple without masses. Lungs: clear to auscultation.
Cardiac exam: regular rhythm, normal S1-S2, no murmur or gallop. Abdomen: soft and
non-tender, liver and spleen are benign. Extremities: no edema, tenderness or cyanosis.
TART findings have returned at T1-T5 levels.
What are your working diagnoses now?
1. Influenza: patient's symptoms and persisting fever is still consistent of influenza.
2. Pneumonia: viral pneumonia is certainly can be a complication of influenzae or
other viral illness. Bacterial pneumonia is also a high possibility in that a
secondary bacterial infection is common after a viral illness. Even though the
patient's lung exam has been clear, he may well have pneumonia since the elderly
patients may often have atypical presentation of pneumonia and may not have
rhonchus or crepitus in their lung exam.
3. Sinusitis: is lower in the differential at this time.
4. Bacterial Endocarditis: without a history of precipitating events such as dental
work or abnormal valvular disease, this differential is less likely.
5. Somatic Dysfunction: the patient continues to present with TART findings
suggestive of viscerosomatic reflex from his infection.
Diagnostic Work-up
Select from the following menu the diagnostic test(s) you think are appropriate.
Calculate the cost of your workup.
(You should order these diagnostic studies necessary to evaluate your working
diagnosis/diagnoses. Each test should be ordered with a specific question in mind. [i.e.
avoid a "shotgun" approach].)
Lab Test
Acid phosphatase
Amylase
Blood Culture
BUN and Creatinine
CBC w/ Differential
Chest X-ray PA & Lateral
Unenhanced CT of the Chest
Enhanced CT of the Chest
EKG
Sed Rate
Fasting Glucose
GGT
TB Skin Test
Liver panel
Lumbar plain film series (AP/Lateral/Oblique)
Platelet Count
PSA
Psychiatric Consult
Renal Ultrasound
Serum Calcium and Phosphates
Serum Electrolytes
Serum Protein Electrophoresis
Serum Total Protein and Albumin
Serum Uric Acid
Sinus X-ray
Sputum C&S
Thyroid Profile (T3)
TSH
U/S of abdomen
Urinalysis (dipstick and micro)
Cost
27.00
13.00
56.00
39.00
47.00
143.00
753.00
679.00
40.00
25.00
19.00
11.00
15.00
57.00
200.00
20.00
49.00
150.00
451.00
38.00
68.00
59.00
36.00
19.00
170.00
41.00
29.00
39.00
413.00
32.00
What are your working diagnoses now?
Pneumonia
What are the common pathogens causing community- acquired pneumonia?
Table C: Common Pathogens causing Pneumonia in Adults
Community-Acquired
Streptococcus Pneumoniae *
Mycoplasma pneumoniae *
Group A beta-hemolytic Streptococcus
Haemophilus influenzae*
Hospital-Acquired
Klebsiella pneumoniae *
Pseudomonas aeruginosa *
Other gram-negative aerobes *
Staphylococcus aureus *
Staphylococcus aureus *
Moraxella catarrhalis @
Klebsiella pneumonia *
Pseudomonas aeruginosa *
Mixed Anaerobes (aspiration) *
Legionella pneumophila
Pneumocystis carinii
Chlamydia psittaci
Chlamydia pneumoniae *
Viral agents*
Influenza A virus*
* Most common
Streptococcus pneumoniae
Anaerobes
Legionella pneumophila
Fungus (Aspergillus)
@= Uncommon
What features are important to keep in mind when considering pneumonia in the
elderly?
Table D: Features to consider in Elderly Patients with Pneumonia
Organisms




Similar to those in younger adults
Gram-negative aerobes and Staphylococcus aureus more prevalent
May have mixed causes
At risk for influenza
Onset: Often insidious
Presentation





Often lack of cough, sputum production and fever
Change in mental status common (new or worsening confusion)
General decline in functional status
Deterioration of previously stable condition (e.g., diabetes mellitus out of control,
relapse of congestive heart failure)
Gait disturbance and falls
Examination






Often lack fever
Increased respiratory rate (may be early clue)
Tachycardia
Auscultation unremarkable (i.e., normal) or not helpful (i.e., rales present in
premorbid state for other reasons
Dehydration common
White blood cell count and chest x-ray initially normal
Difficult differential diagnoses





Congestive heart failure
Atelectasis
Pulmonary embolus
Pneumonia
Chemical pneumonitis (gastric aspiration)
Treatment: Sanford is the most up to date and comprehensive reference.
Always check the most up to date and local resistance is important:
Out patient vs. inpatient. Comorbidities vs. None. Don’t forget Allergies.






Community Acquired Out Patient: No comorbidities: zithromax, biaxin, or
doxyxcycline.
o If out patient with comorbidites: oral ciprofloxacin (Cipro), Levaquin,
amoxicillin-clavulanate potassium (Augmentin), or cefuroxime (Ceftin)
are possible alternatives
Remember to discuss black box warning of quinolones.
Empiric therapy for community-acquired pneumonia: Hospitalized- parenteral
second-or third- generation cephalosporin or quinolones
Empiric therapy for hospital-acquired pneumonia-parenteral Anti-Pseudomonas
penicillin and an aminoglycoside: depends on local resistance also.
Antibiotic dosage usually lowered
Drug interactions and polypharmacy to be considered
Prevention




Pneumococcal vaccination
Annual influenza vaccination
Limit use of drugs that impair swallowing
Regular dental care

If Staphylococcus aureus is suspected, nafcillin (Nafcil, Unipen) should be used;
cefazolin (Ancef, Kefzol) and vancomycin (Vancocin) are alternatives. If
Legionella pneumophila is suspected, erythromycin should be added.
Elderly patients often present with pneumonia in an atypical fashion. Often there is lack
of cough and sputum production. They may not even have a fever. Your first clue may be
mental status changes or just a general decline in their functional status. As in Mr.
Regney's case, lung exam may not reveal rales and crackles and CBC may not show
leukocytosis. However, the morbidity and mortality rate of elderly with pneumonia is
much higher than the younger population. Hence, high index of suspicion and
prevention is the best treatment. Table D delineates this in more detail:
Does Mr. Regney need hospitalization? What factors influence the decision to
hospitalize the patient?
There are no firm guidelines for when to hospitalize a patient. Ultimately, it will be the
individual physician's decision with input from the patient and family. There are a
number of risk factors which have been associated with complication and mortality in
patient with community acquired pneumonia. When multiple risk factors are present,
hospitalization should be considered. Advanced age and co morbid conditions are the
two most important factors that predict a complicated course of the disease.
Table E: Risk Factors that Increase Mortality and Complications
Age > 65 Years
Presence of coexisting illness





Chronic obstructive airway disease
Diabetes mellitus
Chronic liver disease of any etiology
Chronic renal failure
Congestive heart failure
Other findings





Hospitalization within the last year
Suspicion of aspiration (gastric or Oropharyngeal secretions)
Chronic alcohol abuse or malnutrion
Altered mental status
Postsplenectomy state
Table F: Physical Findings Predictive of a Complicated Course

Respiratory rate above 30 breaths per minute




Diastolic blood pressure less than or equal 60 mm Hg or systolic blood pressure
less than or equal to 90 mm Hg
Fever greater than 101 º F
Evidence of confusion
Signs of extra pulmonary dissemination of infection
Table G: Laboratory Findings Predictive of a Complicated Course






PaO2 less than 60 mm Hg or PaCO2 of greater than 50 mm Hg on room air
White blood cell count less than 4 x 10 º /L or greater than 30 x 10 º /L
Abnormal renal function with BUN greater than 20 mg/dL
Need for mechanical ventilation
Rapidly progressive chest radiographic abnormalities
Sepsis or sepsis syndrome
(Adapted from the American Thoracic Society)
Mrs. Regney requests that the patient be hospitalized. His age of 74, significant fatigue,
weight loss of 10 pounds, and high fever all support significant illness. With the
suggestion of cyanosis of his lip, O2 saturation should be checked as the patient may
need O2 supplementation. Mr. Regney was admitted to the hospital for further
evaluation and treatment.