Name:
A 65-Year-Old with Fever and Cough
Description:
A 65-Year-Old with Fever and Cough
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Duration:
T00H07M12S
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Upload Date:
2022-02-28T00:00:00.0000000
Transcript:
Language: EN.
Segment:0 .
[intro music]
DR. HANDY: Hi, welcome to Harrison's Podclass where we discuss important concepts in internal medicine. I'm Cathy Handy.
DR. WIENER: And I'm Charlie Wiener and we're coming to you from the Johns Hopkins School of Medicine.
DR. HANDY: Welcome to episode 59, a 65-year-old with fever and cough.
DR. WIENER: Okay Cathy, here we go. A 65-year-old woman is admitted to the hospital in the United States in January with a two-day history of fevers, myalgias, headache and cough. She has a history of stage 3 kidney disease, diabetes mellitus and hypertension. Upon admission her blood pressure is 138 over 65, her heart rate is 122, her temperature is 39.4, her respiratory rate is 24 per minute with a resting room air oxygen saturation at 85%.
DR. WIENER: On physical examination you notice diffuse crackles in both lungs and a chest radiograph confirms the presence of bilateral lung infiltrates concerning for pneumonia. So what are your initial thoughts?
DR. HANDY: Well, this woman likely has pneumonia with the fever, diffuse crackles, hypoxemia on room air and the radiographic abnormalities. I'm going to assume also that her white blood cell count is elevated even though you haven't given us labs yet. I would like to know what she is coughing up, but in any event I'm worried because she has multiple risk factors for severe bacterial pneumonia, plus you specified January and that's right in the middle of flu season in the United States.
DR. WIENER: You mentioned risk factors, what got your attention there?
DR. HANDY: Well, we know that patients with renal disease and diabetes are at risk for a host of infections, including pneumonia, plus her age is another risk factor. I'm hoping she's been diligent with her pneumonia vaccines. She should have received pneumococcal vaccination as well as the annual flu vaccine by now. But we know that the seasonal flu vaccine is typically about 50-75% effective at preventing seasonal infection, but even when not fully protective it may ameliorate the severity of infection when acquired.
DR. WIENER: Okay, we don't know about her vaccination status but the question asks, all of the following could be included in the initial management of this patient, except? A. amantadine; B. oseltamivir; C. droplet precautions; D. nasal zanamivir; or E. peramivir.
DR. HANDY: Well first off, absolutely she should be placed under droplet precautions. This is flu season and any patient with suspected pneumonia should be on droplet precautions. In the COVID era we've actually upped the precautions for patients like this to aerosol precautions. So in the coming years that recommendation will be dependent on the prevalence of COVID-19 or other emerging viral diseases. But if you're thinking influenza or the common bacterial pneumonia then droplet precautions are the least to impose, and she needs oxygen immediately in attention to her volume status, I suspect she's dry given her acute illness even with her kidney disease.
DR. WIENER: Okay well, the other options mentioned were medications, which of those is not recommended for initial management?
DR. HANDY: So of the choices you mentioned, the answer is A. amantadine, that is not recommended anymore.
DR. WIENER: Why? I thought it was an influenza medication?
DR. HANDY: Amantadine and its cousin rimantadine are M2 blockers that have activity against influenza A but not B. If we were discussing this patient some years ago it may have been an okay answer. However, widespread resistance has currently relegated these compounds to historical interest only.
DR. WIENER: Okay, what about the others?
DR. HANDY: In general, in patients with influenza treatment with antiviral medications has been demonstrated to decrease the duration of symptoms by one to one and a half days when initiated within the first 48 hours after the onset of symptoms. Most currently available drugs for treatment of influenza A and B viruses are neuraminidase inhibitors. The use of these is recommended for complicated influenza infections in hospitalized patients in the absence of formal proof of efficacy and when diagnosis may have been delayed.
DR. HANDY: They define risk groups of who can benefit from neuraminidase inhibitors to include children less than two years of age, adults over age 65, patients with chronic conditions, immunosuppressed individuals, pregnant women or women who have delivered infants within two weeks, and patients who are younger than 19-years-old who are receiving long-term asthma treatment. Also included are native Americans, including Alaska natives, morbidly obese individuals and residents of nursing homes or chronic care facilities.
DR. WIENER: Wow, so it sounds like a lot of people are eligible for these medications in patients with suspected influenza. In that case, why don't you tell me more about the neuraminidase inhibitors?
DR. HANDY: As their name implies, these drugs act by inhibiting the influenza neuraminidase and thus limiting the egress of influenza virus from an infected cell. They are most effective in patients whose influenza illness is recognized early and confirmed by rapid antigen detection or on the basis of clinical and epidemiologic evidence.
DR. WIENER: So the neuraminidase inhibitors work against influenza A and influenza B. I know that influenza A is more common during this flu season, but I know every year at Hopkins we get notable numbers of influenza B.
DR. HANDY: Right, and you could use these with both.
DR. WIENER: What are the common neuraminidase inhibitors?
DR. HANDY: So the ones that are available are oral oseltamivir, nasal spray zanamivir and intravenous peramivir and zanamivir. Oseltamivir, which is most widely used, is an orally absorbed drug that is converted to its active component, oseltamivir carboxylate in the liver. Gastrointestinal symptoms, especially nausea may accompany the administration of oseltamivir. Because zanamivir is not orally bioavailable, it's given as an inhaled dry powder disperse through a descaler device.
DR. WIENER: Yeah, and I've not heard of baloxavir.
DR. HANDY: Baloxavir is a newly approved selective inhibitor of influenza cap-dependent endonuclease for treatment of acute uncomplicated flu within two days of illness onset in people 12 years and older who are otherwise healthy or at high risk of developing flu related complications. The CDC does not recommend use of baloxavir in pregnant women, breastfeeding mothers, outpatients with complicated or progressive illness, severely immunocompromised people or hospitalized patients because of the lack of information on use of baloxavir for these groups to date.
DR. WIENER: Okay, so the teaching points in this case are that patients with suspected influenza based on seasonality, presentation and risks should be started on a neuraminidase inhibitor as soon as possible. These agents will cover both seasonal influenza A and influenza B. Amantadine and rimantadine are no longer first-line therapies. And remember, the patients who did receive the seasonal flu vaccine remain at risk for developing disease.
DR. HANDY: And to read more about this, you can check out the Harrison's chapter on influenza but I'll also refer you to the CDC website on just influenza generally, but then they also have a webpage on baloxavir. That general webpage is www.cdc.gov/flu That general webpage is www.cdc.gov/flu [Mr. Shanahan] This is Jim Shanahan, publisher at McGraw Hill. Harrison's Podclass is brought to you by McGraw Hill's Access Medicine, the online medical resource that delivers the latest trusted content from the best minds in medicine.
DR. HANDY: Go to accessmedicine.com to learn more.