Influenza With Superimposed Pneumonia: A Case Analysis

Patient Information

The patient is a sixty-seven-year-old African American male who presented to the emergency department with shortness of breath. On admission his height was 167 cm (5’5”) and his weight was recorded as 97.8 kg (216 lbs). This morning he came into the emergency department with breathing trouble. He told the nurse that he has a “new headache” and that he normally takes Lortab to treat his headaches and bone pain. He has had continued shortness of breath along with a productive cough. The patient also reported having a fever, chills, and generally feeling unwell.

Upon a brief assessment in the emergency department the patient was found to be tachypneic and was put on oxygen. Patient denied any previous history of COPD or asthma and does not require oxygen therapy at home. Results had come back from CT, and showed airspace disease within the right upper lobe, suspected for infiltration as well as reticular changes in the medial upper lobes. These signs revealed that the patient had pneumonia. He was given an influenza test afterwards which came back positive. He was given Tamiflu, an antiviral drug that treats the flu, and given broad spectrum antibiotics for his pneumonia. The patient was then completely admitted into the hospital.

The patient has a social history of tobacco use, along with a family history of hypertension and stroke. His medical history alone includes chronic kidney disease, and multiple myeloma that was diagnosed in 2016. Multiple myeloma is the cancer of a person’s plasma cells. These cells are found in our bone marrow, and when they become cancerous, they overgrow. Hence the “multiple” in the name. There was no advance directive that directly came from the patient, but he was considered a Full Code in the system and he is reportedly allergic to Ciprofloxacin. This specific antibiotic is from a fluoroquinolone drug class that stops the growth of bacteria. 

Review of Systems

Patient denies any recent weight loss, loss of appetite. Reports two-week history of bilateral eye pain and blurring of vision. Denies change in hearing, rhinorrhea, congestion or sore throat. Patient denies cranial pressure, palpitations, or swelling of extremities. Reports shortness of breath, a productive cough, and a history of smoking. Patient denies any new skin lesions or muscle aches. Reports weakness to the point of being unable to walk. Denies any new onset of tremors or paresthesia’s.

Physical Examination

Upon physically evaluating the patient, their vital signs showed a Temperature of 37.9 C (100.2 F), BP 151/100, HR 80, RR 26, SpO2 96%. The patient appeared well-developed, well-nourished, uncomfortable appearing and shivering. HEENT showed his pupils were 3 mm in size, not reactive to light and had accommodation. Extraocular movements intact, and anicteric sclerae. Maxillary and frontal sinuses nontender to palpation. Nares patent. Moist mucous membranes, white plaques present on tongue that are not able to be scraped off.

Regular rate and rhythm, no murmurs, rubs, or gallops noted. 2+ pulses in the radial and dorsalis pedis arteries bilaterally. Extremities non-edematous. Increased work of breathing with diffuse expiratory wheezes and decreased breath sounds in the right upper lobe. Normoactive bowel sounds, resonant to percussion. Right upper quadrant of the abdomen is tender to palpation and appears distended. No rashes or lesions noted on the skin. Full range of motion of joints. Symmetric facies, cranial nerves II through XII intact. Appropriate mood and affect.

Assessment/Treatment Plan

Multiple tests and imaging studies were taken on the patient and verified certain diagnoses. A complete blood count determined that the patient had thrombocytopenia with a low platelet count of ninety. Neutropenia was also shown which is an abnormally low count of white blood cells. This was a major concern for the patients flu associated pneumonia because a very low white blood cell count contributes heavily to a person getting infections. The patient does have multiple myeloma so this likely is contributing to the neutropenia. Unfortunately, later the patient was diagnosed with severe sepsis without septic shock and was given more antibiotics. Severe sepsis when it can affect your body’s organs. Septic shock can cause your organs to fail. 

For his pneumonia, he was given DuoNeb every six hours along with antibiotics. Other tests for streptococcus and legionella came back negative. His room was marked as “droplet precautions” for anyone who wanted or needed to enter the room. His physician said, that he had acute hypoxemia respiratory failure and was on 6L of oxygen by face mask, but his saturations were not staying where they should. The patient was attempted to switch over to high-flow oxygen but was not able to tolerate. The patient’s oxygen saturation dropped into the forties. The patient was then placed on BiPAP with a FiO2 of 100%.

Afterwards, the patient was still not having good saturations and continued to be tachypneic on BiPAP. He was then transferred to the ICU where he was put on a ventilator with a set rate of 18, PEEP of 13 and initially on 60% FiO2 but was taken down to 50% and put on Flolan to treat the patient’s pulmonary hypertension. I had never heard of this drug before, but I learned that this medication is a vasodilator that widens blood vessels in the lungs and body that have become narrow. It can be administered intravenously short-term or through a central venous catheter long-term. The drug is not stable at room temperature and must be kept ice cold while it is being infused through the patient.

The hypertension that the patient had became well controlled due to multiple medications given. His chronic kidney disease is being monitored daily, and nephron toxic medications are being limited. Another chest x-ray was taken and showed scattered infiltrates more peripheral than expected with pulmonary edema. There was also some atelectasis present. The patients anchor fast was changed, and upon removal a large amount of dead skin from the patient was attached to the adhesive side of the device. The respiratory therapist who was changing the device did not know how long the patient’s skin had been that way and reported it. The patient was prescribed ointment for this.

Medications

The patient is being given an extensive list of medications. Amlodipine (Norvasc) a calcium channel blocker, is being given to treat high blood pressure and angina. Carvedilol (Coreg) is a beta blocker that is treating the patients high blood pressure as well. It can help with heart failure and lessen the risk of death after a heart attack. Cefepime (Maxipime), an antibiotic, has been prescribed to help with the patients’ bacterial infections.

Chlorhexidine, a topical antiseptic is being used for mouthcare of the patient’s mucous membranes. Epoprostenol (Flolan) is a vasodilator that is treating his pulmonary hypertension. Insulin lispro (Humalog), controls his blood glucose due to his diabetes. Sodium Polystyrene Sulfonate, this medication removes excess potassium in the body. Nozin, an ethanol topical medication is being given nasally. It can reduce the risk of nasal pathogen transmission of bacteria. (Medscape, n.d.) Mupirocin (Bactroban Nasal) is also being given nasally for bacterial infections. Pantoprazole (Protonix) is treating stomach acid due to the patient’s Gastroesophageal reflux disease. Meropenem (Merrem) is an antibiotic that is being used to treat an infection. Azithromycin (Zithromax) another antibiotic. Ipratropium bromide and Albuterol (DuoNeb) are helping with wheezing and shortness of breath.

There is also a list of medications that can be given “as needed”. They include, acetaminophen (Tylenol) for mild pain or fever, Albuterol (Proventil) for shortness of breath. Dextrose via IV to help with the patient’s fluid loss and gives carbohydrates to his body. Glucagon a hyperglycemic medication is preventing the patient’s glucose from becoming too low. Melatonin is treating his insomnia. Oxycodone (Roxicodone) is being given when the patient has severe pain at a grade of 8 to 10. Ondansetron (Zofran) is helping prevent the patient from becoming nauseated which can cause vomiting.

The next list of medications are continuous and are being given to the patient intravenously. Sodium Chloride to treat and prevent sodium loss. Methylprednisolone to treat severe inflammation. Fentanyl to treat severe pain. Midazolam, a sedative to relax the patient. It was initially Propofol but had to be changed due to high triglycerides. Norepinephrine for blood pressure support with his heart failure. Heparin is an anticoagulant that is being given to keep the patients sepsis from forming blood clots in different organs and parts of his body.

Prognosis

The patient was consulted personally by a physician and palliative care was discussed with the patient and his family. The patient’s body was starting to fail and there was no sign that the patient’s health was going to improve. Everyone agreed that palliative care would be best for him. Afterwards, the patient was transferred to a hospice where he will be receiving the kind of care he needs.

References

• Anderson, J. L. (2015). NORVASC (Amlodipine): Treats High Blood Pressure and Angina (Chest Pain). CreateSpace Independent Publishing Platform.
• Council, S. L. (2013). Epoprostenol (Flolan). Pulmonary Hypertension Association, 45.
• Cristina Gasparetto, D. S. (2017). Understanding Multiple Myeloma. World Headquarters: Jones & Bartlett Learning.
• Fernandez, R. (2012). Severe Sepsis and Septic Shock Understanding a Serious Killer. IntechOpen.
• Medicine, W. J. (2000, April). Severe Neutropenia: A Diagnostic Approach, p. 172.
• Medscape. (n.d.). Nozin Nasal Sanitizer Advanced Antiseptic (ethyl alcohol intranasal). Retrieved from Medscape: https://reference.medscape.com/drug/nozin-nasal-sanitizer-advanced-antiseptic-ethyl-alcohol-intranasal-999968
• WebMD. (2019). Ciprofloxacin Oral: Uses, Side Effects, Interactions, Pictures, Warnings & Dosing. Retrieved from WebMD: https://www.webmd.com/drugs/2/drug-7748/ciprofloxacin-oral/details