Case

1
Case 1

• Anitra S. Graves, MD
• Pulmonary Fellow
• PGY-4

2
Case History

• Chief Complaints Fever and Weight Loss

3
History of Present Illness

• 55 y/o Caucasian man with known chronic
  obstructive pulmonary disease who reported a 5
  month history of persistent, cough productive of
  green sputum despite multiple antibiotic
  regimens. Intermittent low grade fevers and 20
  lbs weight loss.

4
History of Present Illness

• Previous antibiotic regimens include
• Biaxin, 10 days (discontinued for GI upset)
• Azithromycin, 21 days
• Levoquin, 21 days
• Minocycline/Flagyl, 10 days

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Past Medical History

• Bullous Emphysema, FEV1 0.8 (25)
• Spontaneous Pneumothorax
• Iron Deficiency Anemia
• Corticosteroid-induced DM
• Up to date with immunizations

6
Social History

• 30-40 pack year tobacco abuse, quit several years
  ago
• Lives in South Carolina, no recent travel
• Architect
• Allergies Sulfa

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Current Medications

• Caspofungin, Day 13
• Cefipime, Day 6
• Seravent MDI 2 puffs BID
• Combivent 2 puffs QID
• Humibid LA 1.2 grams BID
• FeSO4 325mg BID
• Pepcid 20 mg BID

8
Physical Exam

• BP 110/70, P 100, RR 24, Pox 95 (1 liter)
• General Cachectic thin male in no acute distress
• HEENT Poor oral dentition/hygiene, no cervical
  LAD
• CV RR, tachycardic distant hear sounds

9
Physical Exam

• RESP Poor air movement otherwise clear, no
  dullness, increased fremitus LUL,
• ABD Soft, normal bowel sounds
• EXTREM No cyanosis, clubbing

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RADIOGRAPHY
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Laboratories

• WBC 11.5, Hb 9.2, Plts 580
• Chemistries unremarkable
• Cultures
• CT guided needle biopsy specimens, typical
  aerobic respiratory flora
• AFB cultures negative
• Sputum culture 06.10.02 (outside hosp.) 1
  Aspergillus

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Assessment

• Differential Diagnosis
• Infected Bullae
• Lung Abscesses
• Necrotizing Pneumonia
• Pulmonary Gangrene

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Assessment

• Suspected Organisms
• TB
• Nocardiosis
• Aspergillus
• Gram Negative Rods/Anaerobes
• Staphylococcus species
• Polymicrobial

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Plan

• Management Options
• Bullectomy
• CT guided drainage
• IV Antibiotics

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Plan

• Bullectomy
• Most common indication is severe dyspnea in the
  setting of a large bulla occupying at least 30
  of hemithorax.
• Second most common indication is history of
  pnumothorax

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Plan

• Surgical risk unacceptably high in this patient
• FEV1 less than 40 of predicted
• Presence of infection
• Diminished diffusing capacity

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Plan

• CT guided drainage not pursued
• Effective drain placement improbable
• High risk of iatrogenic pneumothorax
• Previously attempted twice and failed

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Plan

• IV Anitbiotics
• Cefipime, Caspofungin continued
• Antibiotics were recommended to continue for 6
  more weeks, with follow-up imaging to immediately
  follow

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References

• Andriole, VT. Aspergillus infections Problems in
  diagnosis and treatment. Infect Agents Dis 1996
  547
• Bartlett, JG. Lung abscess and necrotizing
  pneumonia. In Infectious Diseases. Gorbach, SL,
  Bartlett, JG, Blacklow, NR (Eds) WB Saunders,
  Philadelphia 1992
• Ingenito, EP, Loring, SH, Moy, ML, et al.
  Comparison of physiological and radiological
  screening for lung volume reduction surgery. Am J
  Respir Crit Care Med 2001 1631068
• Kinnear, WJ, Tattersfield, AE. Emphysematous
  bullae. BMJ 1990 300208

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References

• Patterson, TF, Kirkpatrick, WR, White, M, et al.
  Invasive aspergillosis. Disease spectrum,
  treatment practices, and outcomes. I3 Aspergillus
  Study Group In Process Citation. Medicine
  (Baltimore) 2000 79250
• Patients at high risk of death after
  lung-volume-reduction surgery. N Engl J Med 2001
  3451075
• Rationale and design of the National Emphysema
  Treatment Trial (NETT) A prospective randomized
  trial of lung volume reduction surgery. J Thorac
  Cardiovasc Surg 1999 118518
• Shah, SS, Goldstraw, P. Surgical treatment of
  bullous emphysema Experience with the Brompton
  technique. Ann Thorac Surg 1994 581452