Fever Productive cough Shortness of breath 副标题
Fever Productive cough Shortness of breath 副标题
History of present illness 25-year-old male Chief complaints Productive cough and shortness of breath on exertion for 2 weeks, with fever and chill System review: Unremarkable Personal history Intravenous drug abuse in the past Work in basements that were damp and moldy Azithromycin for 5 days failed
History of present illness • 25-year-old male • Chief complaints : • Productive cough and shortness of breath on exertion for 2 weeks, with fever and chills. • System review: Unremarkable • Personal history: • Intravenous drug abuse in the past • Work in basements that were damp and moldy. • Azithromycin for 5 days failed
On presentation T:38.33℃C(101°F),P:124bpm,R:18/min,BP:108/58mmHg Oxygen saturation was 84%on room air. Auscultation. Lung: bibasilar crackles Heart: normal WBC:17.1×109/L( normal4-11×109/L) Neutrophil:15.6×109/L(91.2%) CT scan: multiple cavitary and pre-cavitary lesions in both lung fields measuring 1-3 cm
On presentation • T: 38.33 ℃ (101 ℉), P：124 bpm, R: 18/min, BP:108/58 mmHg • Oxygen saturation was 84% on room air. • Auscultation: • Lung: bibasilar crackles • Heart: normal • WBC：17.1×109/L (normal 4 –11×109/L) • Neutrophil：15.6×109/L (91.2%) • CT scan: multiple cavitary and pre-cavitary lesions in both lung fields measuring 1–3 cm
(a (b)
Differential diagnoses Clues. Fever, chill, high WBC and N% Cough, short of breath on exertion poor oxygenation Multiple cavitary and pre-cavitary lesions Intravenous drug abuse in the past Work in basements that were damp and moldy. Azithromycin treatment failure Differential diagnoses: Lung infection Tuberculosis, fungal Blood stream infection: endocarditis Non-infection disease: Wegener granulomatosis
Differential diagnoses ? • Clues: • Fever, chill, high WBC and N% • Cough, short of breath on exertion, poor oxygenation • Multiple cavitary and pre-cavitary lesions • Intravenous drug abuse in the past • Work in basements that were damp and moldy. • Azithromycin treatment failure • Differential diagnoses： • Lung infection: Tuberculosis, fungal • Blood stream infection: endocarditis • Non-infection disease: Wegener granulomatosis
Treatment Further exam Empirical treatment: vancomycin and cefepime Initial blood cultures: MSSA Sputum Acid-Fast Bacilli: Negative Serum cryptococcal antigens histoplasma antigen: Negative Switched to intravenous oxacillin Echocardiogram: large-sized, freely mobile vegetation on the pulmonic valve with moderate pulmonic insufficiency Completely recover without surgery
Treatment & Further exam • Empirical treatment: vancomycin and cefepime • Initial blood cultures : MSSA • Sputum Acid-Fast Bacilli: Negative • Serum cryptococcal antigens & histoplasma antigen: Negative • Switched to intravenous oxacillin • Echocardiogram: large-sized, freely mobile vegetation on the pulmonic valve with moderate pulmonic insufficiency • Completely recover without surgery