24

CASE 24


A 62-year-old white man was admitted to the hospital in the month of January with fever, shortness of breath, productive cough, and chest pain. He also complained of a thick, yellowish discharge in his eyes that prevented him from opening his eyes in the morning.


He was a chain smoker (three packs per day), did not drink alcohol, and had no chronic underlying diseases. The patient had not received the current flu vaccine, and 10 days prior to admission, the patient experienced sudden onset of fever, chills, sore throat, and arthralgias. His symptoms had gradually resolved over the following week, before the development of his current symptoms.



PHYSICAL EXAMINATION



VS: T 39.4°C, P 120/min, R 30/min, BP 140/80 mmHg.

PE: The ill-appearing man was in mild respiratory distress. On chest examination, decreased breath sounds and rales were heard at the left base. Unilateral erythematous palpebral conjunctiva, watery eye, and purulent exudate (Fig. 24-1) were also noted.

image

FIGURE 24-1 Erythematous palpebral conjunctiva, hyperemia, and purulent discharge in this patient.


(Courtesy of Dr. Paul Southern, Departments of Pathology and Medicine, University of Texas Southwestern Medical Center, Dallas, TX.)



LABORATORY STUDIES



Blood



Hematocrit: 42%

WBC: 16,700 /μL

Differential: 55% PMNs, 16% bands, 22% lymphs

Blood gases: pO2 64 mmHg on room air

Serum chemistries: Normal


Imaging


A chest x-ray revealed an alveolar infiltrate in the posterior segment of the left lower lobe.



Diagnostic Work-Up


Table 24-1 lists the likely causes of illness (differential diagnosis). Viral serology (to retrospectively confirm influenza) may be undertaken, and additional tests to define the etiology of pneumonia and purulent conjunctivitis may include


• Blood cultures

• Gram stain and cultures of sputum and conjunctival swab

• In a negative Gram stain of conjunctival swab, direct antigen (ELISA) for Chlamydia trachomatis

TABLE 24-1 Differential Diagnosis and Rationale for Inclusion (consideration)






Atypical pneumonia due to intracellular pathogens (e.g., Legionella spp.)

Chlamydia trachomatis

Haemophilus influenzae

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Aug 25, 2016 | Posted by in MICROBIOLOGY | Comments Off on 24

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