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Fever, cough, dyspnea, and change in mental status.
History of Present IllnessThe patient is a 58-year-old African American man who presented to The Johns Hopkins Hospital Emergency department with a 5-day history of subjective fever, productive cough, progressive weakness and severe dyspnea. His wife also noted a change in mental status, with confusion and slurred speech. The patient had a history significant for hypertension and alcoholism. Review of systems was notable for headache, right-sided pleuritic pain, and new urinary incontinence. He had been in his usual state of health prior to this illness and denied any recent hospitalizations, visits to the Emergency Room, loss of consciousness, seizures, or episodes of alcohol withdrawal. Prior to this illness he had no fevers, night sweats, or weight loss.
Past Medical History
Hypertension
Alcoholism
Chronic arm and back pain
The patient's family history is significant for "renal disease". Father died in his 50s of renal disease, mother died in her 30s of unknown cause.
Social HistoryThe patient is a former roofer who is on disability due to chronic pain of the back and right arm. He is married and lives with his wife. He has a 20-pack-year smoking history and currently drinks 1 pint of vodka 2 to 3 days/week. No history of withdrawal hospitalizations, IV drug abuse. He does not have a primary care physician and goes to the Emergency Room as needed for medication refills.
Medications
Unknown antihypertensive agent, not taken for the past 3 weeks.
Motrin 600 mg daily
No known drug allergies.
Review of SystemsNo history of diplopia, photophobia, neck pain, or abdominal complaints.
Physical Exam on Admission
- T: 99.5 BP: 133/94 P: 125 RR: 24 SaO2: 95% on 6L nc
- General: African-American male in moderate respiratory distress
- HEENT: Very poor dentition. Sclera anicteric. Extraocular movements intact.
- CV: Tachycardia with no murmurs appreciated.
- Lungs: Tachypnea. Bilateral, anterior and posterior wheezing and rhonchi. No friction rub
- Abdomen: No tenderness to palpation. Normal bowel sounds.
- Lymph Node Exam: No lymphadenopathy.
- Extremities: No cyanosis, clubbing, or edema.
- Neuro: Alert and oriented to person and place, but not date. Speech slightly slurred.
- Na 140; K 4.6; Cl 101; BUN 48; Cr 4.0; Glucose 104; Calcium 11.0; TP 3.7;
- Albumin 2.1; TBili 2.2; AST 32; ALT 141; Alk Phos 45
- WBC 1,100; RBC 4.16; Hemoglobin 13.0; Hct 50%; MCV 89.4; Platelet 55,000
- PT 14.3; PTT 50.6
- Ammonia 33; Lactic acid 12.6
- Chest X-ray: Right upper lobe and right lower lobe infiltrate.
- Chest CT: Multilobar pneumonia with dense consolidation. Cavitation right upper lobe. Pretracheal lymphadenopathy (largest 1.3 cm) as well as possible hilar adenopathy and subcentimeter mediastinal adenopathy.
- Head CT: Age-appropriate involutional changes with mild chronic microvascular ischemic disease. Age indeterminate lacunar infarcts in the corona radiata and centrum semiovale bilaterally.
The patient was given moxafloxacin, supplemental oxygen, atrovent, and albuterol in the Emergency Department and admitted to the Medicine service. Sputum and blood cultures were obtained. Over the next few hours, the patient's oxygen saturation decreased requiring an increasing inspired oxygen concentration and he became hypotensive. Despite treatment with fluids, he developed progressive hypotension and respiratory failure requiring transfer to the medical intensive care unit, where he was intubated and started on vasopressors. Despite aggressive care, he developed multiorgan failure, refractory hypotension, and suffered several cardiac arrests. Discussions were held with his family and they agreed to withdraw care to comfort measures and he expired within 36 hours of admission.
Images of Serial Radiologic Studies:
Images 1-3: The initial plain film, frontal and lateral, shows
a dense consolidative pattern in the RUL, especially the anterior segment.
Image 4: CT shows consolidation with adjacent ground glass
opacity in the RUL. There is early peripheral cavitation likely.
Images 5-6: Follow-up portable AP chest film shows increased
severe consolidative pattern in right lung with hyperexpansion of the involved lung.
What organism(s) is most likely the cause of the patient's pneumonia, sepsis,
and multiorgan failure?
What is the most likely source of this infection?
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