A 35 year-old with hypertension presents to the emergency department with 4 days of fevers, productive cough, and dyspnea in mid-July. Associated symptoms include diffuse abdominal pain, watery diarrhea, and headache. She lives alone in Chicago and is without recent travel history or healthcare exposures.
On exam she is febrile, HR 90, RR > 30, hypotensive but responded to aggressive volume resuscitation and hypoxic requiring high flow nasal cannula. Labs are notable for hyponatremia and mildly elevated serum creatinine and AST/ALT. NP swab for COVID-19 is negative, Chest x-ray is shown.
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Correct Answer: Obtaining Legionella Urine Antigen
This case describes a severe community-acquired pneumonia (CAP), meeting 3 minor criteria by 2019 ATS/ IDSA guidelines – respiratory rate, hypoxia, and fluid responsive hypotension. The new guidelines suggest considering legionella urinary antigen for any severe CAP Although limited data behind this recommendation, in this case there are several features concerning for legionella that warrant the investigation.
- Prominent extra pulmonary symptoms (diarrhea, headache)
- Relative bradycardia in the setting of fever, characteristic feature in legionella also seen in infections by other intracellular gram-negatives – specifically (typhoid)
- Mild hyponatremia and mild elevation of transaminases
- Timing during summer where there is increased incidence due to humidity.
- Xray findings are varied but often demonstrates a lobar consolidation, as shown
- More severe illness in a young and healthy person
Distractor answer choices
- The beta-lactam and macrolide are sufficient, given no history of hospital exposures, prior respiratory culture data, or chronic lung disease to prompt broadening antibiotics
- Oseltamivir would be reasonable if Influenza were suspected, but this is unlikely at this time of year.
- Procalcitonin should not be used to initiate therapy in this person who is clearly critically ill from respiratory pathogen.
- Steroids should not be routinely used, in this case shock was rapidly fluid responsive
Link: https://pubmed.ncbi.nlm.nih.gov/31573350/
Author: Mauricio Kahn at UAB
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This question was uploaded on 2/29/22