CASE PRESENTATION

Presenter: Dr Amanda Lundah

Date: 15/4/20
 HISTORY

History of presenting complaints

• Male,27 • Patient was in usual state of health until 5 days
• Complaints – hemoptysis ( 5/7) ago when he presented with productive cough
with bloody sputum associated with difficulty
night sweats ( 5/7) breathing, left sided sharp chest pain and night
weight loss (5/7) sweats . He also noted some weight loss and
watery non bloody diarrhea of 4 days duration.
diarrhea (4/7) No history of travel outside country , no leg pain
of swelling prior to symptoms ,no vomiting
,headache ,dysuria or hematuria.
 HISTORY

• PMH – RVD R on TLE for last 2 years, said to be General examination

compliant. Vitals
• Unknown CD4,VL • Temperature – 37.3

• PDH – Atripla • BP – 118/79

• Social history – welder by profession • SPO2 – 85% on room air

• PR – 112 beats/min
• drinks alcohol occasionally ( lagers on weekends)
• RR – 34 cycles/breath
• Smokes cigarettes occasionally – 3 sticks a day
for last 7 years ( 1.05 pack years)
 EXAMINATION CONTINUED

• GC – ill looking
• In moderate respiratory distress on 02 via nasal prongs
• Not pale, jaundiced or cyanosed , fully conscious
• Afebrile to touch but diaphoretic
• Blood stains on shirt
• No cervical lymphadenopathy
• Chest – bilateral crepitations with bronchial breath sounds in right upper chest and left lower chest
• CVS – S1,S2 tachycardic
• PA – mild hepatomegaly
Generalized abdominal tenderness with mild guarding
• MSS – no pedal edema
 ASSESSMENT

• 27 year old RVD R welder on Atripla for last 2 years presented with a 5 day history of hemoptysis, pleuritic chest pain, night sweats and
bronchial breath sounds with generalized abdominal tenderness on physical examination.
• DDX: Severe CAP most likely pneumococcal with bacteremia
• Atypical pneumonia
• Disseminated TB
• PCP
• Pulmonary embolism
• Aspergillosis
• Lung cancer
• pneumosiderosis
 PLAN

• FBC, U/Es, Cr, LFTS

• CXR
• Sputum for MCS, gram stain, AFB microscopy and culture, gene xpert
• Blood culture
• CD4,VL
• 100% 02 on non rebreather mask
• Ceftriaxone 2g OD and Azithromycin 500mg STAT then 250 mg 0D
• Penicillin G 4MU 4 hourly IV was given as Ceftriaxone was unavailable at the time
• Septrin 960mg OD
• Transfer to ICU for impending respiratory failure
INVESTIGATIONS

CXR – homogenous opacity in right middle lobe and left lower lobe.
FBC – WBC – 9.91
HB 13.2
PLT- 139
Neutrophils – 79%
Basophils 2.3%
Liver enzymes - AST 91
ALT 66.6
Total protein 63.8
Albumin 25.7
Urea – 3.69
Creatinine – 64.7
 INVESTIGATIONS

Sputum
• Gene x pert – No MTB detected
• AFB – no AFB seen
• Gram stain – gram positive diplococci
• Sputum culture – not done by lab due to low Bartlett score

Diagnosis: Suspected Invasive pneumococcal disease in a Welder

1) DEFINITION INVASIVE PNEUMOCOCCAL
DISEASE

2) PATHOPHYSIOLOGY OF PNEUMOCOCCAL
PNEUMONIA IN WELDERS

3) TREATMENT OF PNEUMOCOCCAL
DISEASE
 INVASIVE PNEUMOCOCCAL DISEASE (IPD)

• Streptococcus pneumonia has 90 serotypes based on polysaccharide composition of capsule.

• It can cause both non invasive and invasive disease
• Invasive pneumococcal disease (IPD) refers to disease in which the bacterium enters a sterile site
such as blood, cerebrospinal fluid (CSF), pleural fluid, joint fluid ,peritoneal fluid, pericardial
fluid and not sputum.
• Non-invasive disease includes pneumonia, otitis media, sinusitis and bronchitis. 
 RISK FACTORS FOR IPD

• Extremes of age • Alcohol abuse

• Anatomic or functional asplenia • Cigarette smoking
• Cochlear implants • Chronic pulmonary disease (COPD, asthma )
• CSF leaks • Chronic liver disease
• Immunosuppressive states (congenital
• Renal failure or nephrotic syndrome
immunodeficiency ,malignancy, b cell defects
HIV,DM,steroids,chemotherapy) • Welders

• Solid organ or hematopoietic cell transplantation • Male sex

 WHY ARE WELDERS PREDISPOSED TO IPD

PAFR hypothesis Oxidative stress hypothesis

• welding fumes upregulate PAFR in nasal and • Inhalation of metal fumes increases free iron
respiratory cells
• The free iron can act as a growth medium for
• Strep pneumonia has phosphorylcholine in its bacteria or cause free radical injury.
cell wall which has similar molecular structure
to human PAF
• It adheres to the cell via molecular mimicry
and infects cells when the receptor is
internalized
 EPIDEMIOLOGY OF IPD

• Retrospective chart review done in

Alberta , Canada
• Conducted from 2000 – 2004
• Welders were found to have an attack
rate of 22.7 cases per 100,000
population/year (95% CI 12.23-33.23)
• General population had an attack rate
of 8.7 cases per 100 000
population/year (95% CI 8.10 -9.26)
• Conclusion – welders particularly
those that smoke are at increased risk
of IPD and should be considered for
routine administration of PPV.

From: https://www.ncbi.nlm.nih.gov/pubmed/20637673
 TREATMENT OF PNEUMOCOCCAL PNEUMONIA
(PENICILLIN SUSCEPTIBLE STRAINS)
Antibiotic Dosing (IV)

Penicillin G 2-3 million units 4 hourly

Ampicillin 2 g every 6 hours

Ampicillin – Sulbactam 1.5 – 3 g every 6 hours

Ceftriaxone 1-2 g every 24 hours

Cefotaxime 1-2 g every 8 hours

Data from: Mandell LA, Wunderink RG, Anzueto A, et al. Infectious Diseases Society of
America/American Thoracic Society consensus guidelines on the management of community-acquired
pneumonia in adults. Clin Infect Dis 2007; 44 Suppl 2:S27.
 THERAPY FOR BACTEREMIC PNEUMONIA

• Due to poor outcome in critically ill patients, combination therapy has been recommended:
Beta lactam plus macrolide or fluoroquinolone with excellent activity against streptococcus
pneumoniae i.e.
• Ceftriaxone /cefotaxime plus azithromycin or levofloxacin/moxifloxacin
• high dose penicillin G (4 MU 4 hourly IV) plus azithromycin or levofloxacin/moxifloxacin
 MONOTHERAPY VS COMBINATION THERAPY PRIOR TO THE
AVAILABILITY OF IN VITRO SUSCEPTIBILITY RESULTS

• A retrospective study was conducted in

Alberta from 2000 – 2004.
• The study recruited 1154 patients with IPD,
most of whom had bacteraemia.
• It found that the use of two antimicrobial
agents concurrently was independently
associated with decreased 30-day mortality
(hazard ratio 0.54, 95% CI 0.34-0.84).

From: https://www.ncbi.nlm.nih.gov/pubmed?term=21512414
 PNEUMOCOCCAL PNEUMONIAE AND
CONCOMITANT MENINGITIS
Empiric antibiotic treatment - Because concurrent meningitis can often not be definitively
excluded at the time of presentation and because mortality is notoriously high during the first 72
hours of treatment, recommendation for adults includes:
• vancomycin ( 15 to 20 mg/kg IV every 8 to 12 hours if renal function is normal ) plus
ceftriaxone(2g IV 12 hourly) or cefotaxime (2g 4 to 6 hourly IV) Serum trough concentrations of
vancomycin should range from 15 to 20 mcg/mL.
 TARGETED ANTIBIOTIC TREATMENT

• Empiric therapy should be altered once the laboratory has ascertained susceptibility of the
organism.
Vancomycin should be continued if:
• concern for meningitis still exists
• documentation of high-level penicillin resistance
• infecting strain has a MIC >1 mcg/mL to third-generation cephalosporins
 TARGETED THERAPY

• Following the return of in vitro susceptibility testing, it is reasonable to simplify therapy to

penicillin if the isolate is susceptible.
for patients with meningitis:
• penicillin MIC ≤0.06 mcg/mL, and for patients without meningitis: penicillin MIC ≤2 mcg/mL).
•  Penicillin G (4 million units IV every four hours) can be used instead of a third-generation
cephalosporin, although it is also reasonable to continue therapy with a third-generation
cephalosporin given the excellent efficacy, convenient dosing, and affordability of these agents.
 TARGETED THERAPY

• Combination therapy should normally not exceed three to four days; monotherapy can usually be
used after antimicrobial susceptibility results are available.
• When using monotherapy to treat invasive pneumococcal disease, we select one of the following
agents in adults:
• Ceftriaxone (2 g IV every 12 hours) or cefotaxime(2 g IV every 4 to 6 hours)
• Vancomycin (15 to 20 mg/kg IV every 8 to 12 hours) adjusted for renal function
 PENICILLIN ALLERGIC PATIENTS

• Patients that have severe allergy to penicillin or third generation cephalosporins can be treated
with respiratory fluoroquinolones.
• Alternatives include clindamycin, linezolid or vancomycin.
 DURATION OF THERAPY

There have been no controlled trials on the optimal duration of antibiotics for the treatment of invasive pneumococcal infection.
Several factors should be considered when planning a treatment course:
• Location of primary infection
• Immune status of the host
• The presence or absence of suppurative complications
• The response of the patient to therapy
In general, uncomplicated bacteraemia should be treated with a 10- to 14-day course of appropriate antibiotics.
Completion of therapy with an oral antibiotic is acceptable if the susceptibility pattern allows. The course of therapy will need to be adjusted
if the patient has concurrent invasive pneumococcal infection (e.g., endocarditis, septic arthritis, brain abscess) or fails to respond to therapy.
 PATIENT UPDATE

• Patient did not go to ICU due to lack of space

• His condition improved based on increased saturations to 90% on 5l/02 and improved respiratory
rate
• He was started empirically on ATT and high dose Septrin
THE END
 REFERENCES

• https://europepmc.org/article/pmc/pmc4747856
• Turett GS, Blum S, Fazal BA, et al. Penicillin resistance and other predictors of mortality in
pneumococcal bacteremia in a population with high human immunodeficiency virus
seroprevalence. Clin Infect Dis 1999; 29:321
• https://www.cdc.gov/pneumococcal/clinicians/diagnosis-medical-mgmt.html
• https://www.atsjournals.org/doi/full/10.1164/rccm.201908-1581ST