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Influenza case report

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Influenza case report

  1. 1. <ul><li>Fever T max 104 F with chills x 3-4 days with
  2. 2. Cough non productive, sore throat
  3. 3. Sinus congestion
  4. 4. Myalgias
  5. 5. Diffuse joint pain
  6. 6. Headache
  7. 7. Chest pain – Rt sided Pleuritic type chest pain.
  8. 8. No sob/ palpitations
  9. 9. No abdominal pain / N/V/D.</li></ul>10/2/2011<br />1<br />Ms. X , 71 Y,Somalian refugee admitted with …<br />
  10. 10. <ul><li>Past history:
  11. 11. HTN
  12. 12. Dyslipidemia
  13. 13. Osteoporosis
  14. 14. Ch. Allergic rhinitis
  15. 15. Ch. Headaches
  16. 16. Social history:
  17. 17. Lives with her daughter
  18. 18. Denies h/o smoking , alcohol abuse or drugs of abuse.</li></ul>10/2/2011<br />2<br />
  19. 19. <ul><li>Family history:
  20. 20. h/o sick contacts in the family – grand children.
  21. 21. Health maintenance:
  22. 22. Got flu shot for this season.</li></ul>10/2/2011<br />3<br />
  23. 23. <ul><li>Medications:</li></ul>Atenolol 50 mg daily<br />Hydrochlorthiazide 25mg daily<br />Felodipine 5 mg daily<br />Lipitor 10 mg daily HS<br />Fosomax 70 mg weekly<br />Loratidine 10 mg daily<br />Os cal + Vit D 500mg daily<br />Multivitamin daily<br />Tylenol prn.<br />10/2/2011<br />4<br />
  24. 24. <ul><li>Exam:
  25. 25. Temp -36.3 C , Bp – 122/60, HR – 60 - 80 , RR -20 , SPO2 -94 – 99% on RA .
  26. 26. HEENT – No sinus congestion. Ears and throat normal. No JVD. No LN.
  27. 27. Heart – S1S2 n. no murmur, rub, gallop.
  28. 28. Lungs – CTA b/l.
  29. 29. Skin – No rash.
  30. 30. Ext: Joints normal. No edema.</li></ul>10/2/2011<br />5<br />
  31. 31. <ul><li> Na – 139, K – 3.6, Cl – 103, Co2 – 27, AG – 9.
  32. 32. Ca – 8.7, Mg – 1.5, Phos – 2.5.
  33. 33. BUN – 12, S.cr – 0.8
  34. 34. Glucose – 137.
  35. 35. CIP X2 Negative.
  36. 36. Wc – 4.6, N-66, L- 21, H/H – 34.6 /12.1, platelet – 242.
  37. 37. U/A – Negative.
  38. 38. LFT – Normal </li></ul>10/2/2011<br />6<br />Labs…<br />
  39. 39. C x ray…02/23/09<br />Moderate cardiomegaly – cardiomyopathy or pericardial effusion.<br />Increased interstitial markings at the lung bases – atelectasis, early interstitial edema, mild viral infection.<br />1.3 cm sclerotic density rt. Humeral head. <br />10/2/2011<br />7<br />
  40. 40. TSH – normal<br />Mumps, rubella, varicella, rubeola antibody positive.<br />RF - <20 neg.<br />ANA- <50.<br />Esr – 37 ( 0 – 30 )<br />CRP – 23.3 (02/25)<br />RAPID ANTIGEN TESTING FOR INFLUENZA – NEGATIVE.<br />10/2/2011<br />8<br />
  41. 41. <ul><li>Any other tests ???</li></ul>10/2/2011<br />9<br />Diagnosis???<br />
  42. 42. <ul><li>Echo 2 D: 02/24/09.</li></ul> Normal Lv. <br /> EF: 55 – 60%<br /> No wall motion abnormalities.<br /> Moderate to severe size circumferential pericardial effusion with echo irregular echo densities ? Mass ? Organisingexudate.<br /> no signs of tamponade.<br />10/2/2011<br />10<br />
  43. 43. Resp virus PCR panel 02/24/09 – positive for Influenza A H1virus.<br />Negative for rhino, entero and adenovirus.<br />10/2/2011<br />11<br />
  44. 44. Interim recommendations for the selection of antiviral treatment using laboratory test results and viral surveillance data, United States, 2008-09 season<br /><ul><li> 2008–09 INFLUENZA PREVENTION & CONTROL RECOMMENDATIONS </li></ul>12<br /> cdcinfo@cdc.gov<br />
  45. 45. 50 influenza A(H1N1) viruses identified in the U.S. from October 1 through December 13, 2008 and tested by CDC, 49 (98%) were resistant to oseltamivir. <br /> all A(H1N1) viruses tested thus far are susceptible to amantadine and rimantadine). All influenza A (H3N2) and influenza B viruses tested to date have been susceptible to oseltamivir and all influenza A (H1N1) and A (H3N2) and influenza B viruses tested have been susceptible to zanamivir. <br /> Resistance to the adamantanes among A (H3N2) viruses remains high so far this season, consistent with the last three influenza seasons, with 100% of viruses tested to date found to be adamantane-resistant.<br /><ul><li> 2008–09 INFLUENZA PREVENTION & CONTROL RECOMMENDATIONS</li></ul>13<br />Influenza Antiviral Medications<br />10/2/2011<br />
  46. 46. Cardiac tamponade and heart failure as a presentation of influenza<br /> University of Manchester, Manchester, United Kingdom. Exp ClinCardiol. 2007 Winter; 12(4): 214–216. <br />Symptomatic Pericarditis After Influenza Vaccination*- Report of Two Cases, belgium. CHEST June 2000 vol. 117 no. 6 1803-1805 <br />Review Myopericarditis: Etiology, management and prognosis. Int J of cardiology 2008. juneedn, Italy.<br />10/2/2011<br />14<br />Similar Case reports …<br />
  47. 47. Trivalent inactivated vaccine (TIV) - FLUZONE, FLUVIRIN, FLUARIX, FLULAVAL, AFLURIA<br /> A 0.5-mL dose contains 15 mcg each of A/Brisbane/59/2007 (H1N1)-like, A/Brisbane/10/2007 (H3N2)-like, and B/Florida/4/2006-like antigens. <br /> Preservative - thiomersal<br /> Live attenuated influenza vaccine (LAIV) – FLUMIST.<br /> A 0.2-mL dose contains 106.5–7.5 fluorescent focal units of live attenuated influenza virus reassortants of each of the three strains for the 2008–09 influenza season: A/Brisbane/59/2007(H1N1), A/Brisbane/10/2007(H3N2), and B/Florida/4/2006. <br /> LAIV: egg allantoic fluid, monosodium glutamate, sucrose, phosphate, and glutamate buffer; and hydrolyzed porcine gelatin. <br />10/2/2011<br />15<br />Influenza Vaccination <br />
  48. 48. <ul><li>antiviral drugs for treatment and chemoprophylaxis of influenza is a key component of influenza outbreak control in institutions.
  49. 49. instituting droplet precautions and
  50. 50. establishing cohorts of patients with confirmed or suspected influenza,
  51. 51. re-offering influenza vaccinations to unvaccinated staff and patients,
  52. 52. restricting staff movement between wards or buildings, and
  53. 53. restricting contact between ill staff or visitors and patients.</li></ul>10/2/2011<br />16<br />Control Influenza Outbreaks in Institutions<br />
  54. 54. <ul><li>viral culture,
  55. 55. serology,
  56. 56. rapid antigen testing,
  57. 57. polymerase chain reaction (PCR),
  58. 58. immunofluorescence assays.
  59. 59. nasopharyngeal specimens are typically more effective than throat swab specimens. </li></ul>10/2/2011<br />17<br />Diagnostic tests<br />
  60. 60. Parasternal long axis view of the pericardial effusion on transthoracic echocardiography.<br />de Meester A. et.al. Chest 2000;117:1803-1805<br />©2000 by American College of Chest Physicians<br />
  61. 61. ECHO…<br /><ul><li>25 CC OF FLUID
  62. 62. Can be performed at bedside
  63. 63. May not detect small loculated effusions
  64. 64. False positives : pleural effusion, pericardial fat pad, Pericardial thickening, mediastinal masses.</li></ul>10/2/2011<br />19<br />
  65. 65. 10/2/2011<br />20<br />
  66. 66. 10/2/2011<br />21<br />
  67. 67. EKG findings lack sensitivity<br />Low voltage QRS: 42% sensitivity (CI 0.32-0.53)<br />Electrical alternans: 16-21% sensitivity<br />Cardiomegaly on CXR was fairly useful<br />89% sensitivity (CI 0.73-1.00)<br />10/2/2011<br />22<br />
  68. 68. 10/2/2011<br />23<br />
  69. 69. Chest x ray<br /><ul><li>250CC OF FLUID
  70. 70. WATER BOTTLE APPEARANCE
  71. 71. ELARGED CARDIAC SCHILLOUTE
  72. 72. NON DIAGNOSTIC.</li></ul>10/2/2011<br />24<br />
  73. 73. CT Chest …<br /><ul><li>50 cc of fluid
  74. 74. Fewer false positive than ECHO.
  75. 75. More specific for pericardial calcifications or masses.</li></ul>10/2/2011<br />25<br />
  76. 76. Diastolic right ventricular collapse<br />Right atrial collapse/inversion<br />Exagerated respiratory variation in inflow velocity<br />Exagerated respiratory variation in inferior vena cava flow<br />Dilated IVC in the right setting<br />10/2/2011<br />26<br />Echo Findings in Pre-tamponade Physiology<br />
  77. 77. In observational studies, NSAIDS relieved CP in 85-90% of patients: ASA, Indomethacin or Ibuprofen.<br />Indomethacin may impair coronary blood flow in CAD. <br />In a multicenter trial of 51 patients who had recurrent pericarditis despite tx with NSAIDS, glucocorticoids, pericardiocentesis or some combination. Only 7 of those treated with colchicine had a recurrence during 1004 patient-months of follow up.<br />10/2/2011<br />27<br />
  78. 78. Typically CP improves within days of initiating antinflammatorytx. <br /><ul><li>If CP persists after two weeks of tx with an NSAID, a different NSAID should be given or colchicine should be added to provide combination therapy.
  79. 79. Glucocorticoids should be considered if CP persists after combination tx.
  80. 80. Lack of response to steroids often reflects the use of an inadequate dose or too rapid tapering. </li></ul>10/2/2011<br />28<br />
  81. 81. Use of steroids should be reserved for patients with CTD, recurrent severe pericarditis that is unresponsive to combination of NSAIDS and colchicine.<br />Some studies suggest that the early use of these drugs may increase the risk of recurrence (exception colchicine). <br />Observational data suggest that physical invasion of the pericardium (pericardiotomy or a window) promotes recurrences.<br />10/2/2011<br />29<br />

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