Case-based discussion

Date: 2022.08.31
Supervisor: VS 高浩倫醫師
Speaker: PGY2 許誌元
 Patient Information

 Name: 張 O 花
 Gender: Female
 Age: 77 year old
 ID: 1780833
 Admission: 2022.02.05
 Expired: 2022.02.11

2
 Chief Complaint

Conscious disturbance, shortness of

breath and general weakness for four
days.

3
 Present illness
2009/01- Frequent visit ER and CHE OPD due to shortness of breath and
2017/08 persistent cough with sputum  diagnosed with bronchial
asthma  Long-term follow up in CHE OPD under steroids.

2012/07- Intermittent bilateral hand joint painful sensation for one month.
The symptom exacerbated especially in the morning and during
increasing daily activity.
 Visited RIA OPD  diagnosed with rheumatoid arthritis
 Long-term follow up in RIA OPD under steroids.

4
 Present illness
2022/01 Chest discomfort last for one month.  visit CHE OPD in 國
泰 hospital on 1/22. X-ray: pneumonia.  Oral antibiotics
were given and the patient's symptoms got improved.

2022/02/01-05 Conscious disturbance with general weakness developed

and deteriorated (slow reaction to questions and in dialogues),
elevated body temperature(37.2-37.3)  sent to TSGH ER
Arrange blood routine, arterial gas analysis, urine routine,
chest X-ray, chest CT and brain CT.

5
 At TSGH ER
Blood routine, BGA Blood biochemistry, Urine routine
pH 7.443 mmHg BUN 37 mg/dL CK 27 U/L
PaCO2 30.8 mmHg Creatinine 1.1 mg/dL Lipase 47 U/L
PaO2 157.3 mmHg AST 68 U/L Glucose 179 mg/dL
HCO3 20.6 mmol/L ALT 27 U/L Pro-BNP 561.5 pg/mL
WBC 3.41 103/uL Total 0.9 mg/dL Troponin-I 26 pg/mL
bilirubin
RBC 385 106/uL Na 133 mmol/L D-dimer 1.75 mg/L
Hb 11.8 g/dL K 5.6 mmol/L Urine WBC 0-2
Platelet 80 103/uL Lactate 2.3 mmol/L Urine RBC 0-2
Neutrophil 78.0 % Ammonia 63 ug/dL Epith. cells 2-5
Lymphocyte 17.6 % PCT 0.36 ng/dL Bacteria 2+

6
 Present illness

2021/02/05 At TSGH ER,

Chest X-ray

Increased interstitial and

ground-glass opacities of
the both lungs are noted.

7
 Present illness

2021/02/05 At TSGH ER,

Chest CT

Miliary nodules and patchy

infiltration in both lungs are
noted. TB should be ruled
out.

8
 Present illness

2021/02/05 At TSGH ER,

Brain CT

Presence of brain
atrophy. No acute infarct
or cerebral hemorrhage
is identified.

9
Electrocardiography

10
 Present illness
2021.
In ER:
02.05 1. Oxygen supply: simple mask 8L/min  6L/min
2. Antibiotics: Cravit 750mg IVA stat
3. Medason 40mg IVA
4. Foley 14Fr. Insertion
5. Insulin Actrapid 6U IVA + Dextrose 50% 60ml IVA +
Vitacal 20ml 1amp IVA
6. Blood culture
 Admission

11
 Past History
 Systemic disease:
1. Rheumatoid arthritis 5. Hyperlipidemia
2. Bronchial asthma 6. Gout
3. Type 2 diabetes
4. Hypertensive cardiovascular
disease

 Operation history:
1. 2009-07-01 Operative arthroscopy with shaving arthroplasty + partial
menisectmoy of medial meniscus, right knee
2. 2012-07-25 Operative arthroscopy with partial meniscectomy, right
knee

12
 Personal history

Patient
• Occupation: retired
Information
• Traveling in recent 3 months: denied
• Contact history: denied
• Cluster history: denied
• Alcohol/betel nut/cigarette: denied
• Allergy to food/drug: bamboo, beans, seafood

13
Family history

HCC

14
 Review of system

Positive finding : Intermittent mild fever, fatigue, dyspnea

Negative finding : headache, dizziness, coughing, wheezing, hemoptysis,

difficulty breathing, chest pain, nausea, frequency, urgency, hematuria,
seizures, hematochezia, night sweats.

15
 Physical examinations
Vital signs:
TPR: 37.6 ℃/ 122 次 / 24 次
HEENT:
BP: 145 / 98 mmHg
no cervical lymphadenopathy, no oral
SpO2: 99%
ulcer or petechiae
Conscious: alert
GCS: E4V5M6
Heart: regular HB , no murmur , no
Chest: heave or thrill
Well expansion, coarse
breathing sound, no rhonchi,
no wheezing, bilateral Skin: Senile skin turgor
crackles

Abdomen:
Flat Extremities:
Normoactive bowel sound no pitting edema, normal ROM
No tenderness
No rebounding pain 16
 Tentative diagnosis
1. Community-acquired pneumonia, bilateral upper and
lower lobes.
2. Bronchial asthma
3. Rheumatoid arthritis under monthly golimumab (Simponi)
and immunosuppressants
4. Hypertensive cardiovascular disease
5. Hyperlipidemia
6. Type 2 diabetes
7. Gout

17
Hospital Course

18
 Hospital Course
2022/02/05 Empirical antibiotic treatment:
Betamycin 3.375g Q6H IVD
Klaricid XL 500 mg 1tab QOD PO
Oxygen: simple mask 6L/min  nasal cannula 3L/min  nasal cannula 3.5L/min
SpO2: 90-98%
GCS ： E4V3-5M6
PCR test(blood): P. jirovecii, HSV and CMV
Blood antigen screen for Cryptococcus
Antibody screen for Mycoplasma
Sputum culture and acid-fast stain x3

2022/02/06 Oxygen: nasal cannula 3L/min

SpO2: 91-96%
GCS ： E4V3-5M6
19
 Hospital Course
2022/02/07 Follow up blood routine, biochemistry, urine routine, chest X-ray
06:10 Oxygen: nasal cannula 3L/min  nasal cannula 4L/min
SpO2: 90-92%
GCS ： E4V4M5-6
Chest X-ray: bilateral pneumonia with mild improvement
Low urine output  Add Rasitol 20mg QD IV
Arrange urine culture

2022/02/07 Desaturation with SpO2 dropped to 88% at 12:53.  Blood gas analysis,
12:53 blood routine, biochemistry and blood culture.
Oxygen: nasal cannula 4L/min  simple mask 6L/min  simple mask 8L/min
SpO2 : 94-95%
Consult INF for antibiotics adjustment  Add Meroxin 0.5G Q12H to replace
Betamycin 3.375g Q6H IVD
Suggest endotracheal tube intubation refused by the family
20
 Laboratory examinations
02/07 06:10
Blood routine, biochemistry and urine routine
WBC 2.51 103/uL Na 137 mmol/L Total calcium 9.5 mg/dL
Hb 9.5 g/dL K 4.2 mmol/L Mg 1.8 mg/dL
Platelet 57 103/uL BUN 49 mg/dL Urine WBC 0-2
Neutrophil 84.8 % Creatinine 1.5 mg/dL Urine RBC >100
Lymphocyte 9.2 % AST 48 U/L Epith. Cell 2-5
CRP 3.09 mg/dL ALT 21 U/L Bacteria Not found
Albumin 2.4 g/dL Cl 110 mmol/L Occult blood 3+
HbA1c 7.7 % Uric acid 5.5 mg/dL

21
 Radiologic findings
2022/02/05 2022/02/07

22
 Hospital Course
2022/02/07 Follow up blood routine, biochemistry, urine routine, chest X-ray
06:10 Oxygen: nasal cannula 3L/min  nasal cannula 4L/min
SpO2: 90-92%
GCS ： E4V4M5-6
Chest X-ray: bilateral pneumonia with mild improvement
Low urine output  Add Rasitol 20mg QD IV
Arrange urine culture

2022/02/07 Desaturation with SpO2 dropped to 88% at 12:53.  Blood gas analysis,
12:53 blood routine, biochemistry and blood culture.
Oxygen: nasal cannula 4L/min  simple mask 6L/min  simple mask 8L/min
SpO2 : 94-95%
Consult INF for antibiotics adjustment  Add Meroxin 0.5G Q12H, DC
Betamycin 3.375g Q6H IVD
Suggest endotracheal tube intubation refused by the family
23
 Laboratory examinations
02/07 14:10
Blood routine, biochemistry, gas analysis and infection survey
WBC 3.19 103/uL Na 137 mmol/L
Hb 10.3 g/dL K 4.3 mmol/L
Platelet 59 103/uL BUN 48 mg/dL
Neutrophil 86.5 % Creatinine 1.5 mg/dL
Lymphocyte 8.8 % pH 7.343
CRP 2.79 mg/dL PaCO2 33.2 mmHg
AST 56 U/L PaO2 78.7 mmHg
ALT 28 U/L HCO3 17.6 mmol/L
P. jirovecii Negative
PCR(blood) CMV Negative
HSV Negative
Antigen
Cryptococcus Negative
screen(blood) 24
 Hospital Course
2022/02/08 Follow up blood routine, biochemistry, SMA and vein gas analysis
Oxygen: simple mask 8L/min  simple mask 10L/min
SpO2: 97-99%  93%
GCS: E4V4-5M6
NG tube insertion due to poor intake chest X-ray follow up
DNR was signed except drug(DNR 除藥 ).
Albutein 50ml QD IV was added.
Patient restraint PRN was agreed due to irritation and attempt to get off the
mask.

2022/02/08 Irritation with SpO2 dropped to 86-88% at 08:30.  Diphenhydramine 30mg

PM 08:30 IV ST for sedation
Oxygen: simple mask 10L/min  Non-rebreathing mask 15L/min
SpO2 : 91-95%

25
 Laboratory examinations
02/08 05:57
Blood routine, biochemistry, SMA and vein gas analysis
WBC 3.33 103/uL Na 139 mmol/L ALP 75 U/L
Hb 9.8 g/dL K 4.0 mmol/L Total bilirubin 0.7 mg/Dl
Platelet 56 103/uL BUN 46 mg/dL Total protein 6.0 g/dL
Neutrophil 87.4 % Creatinine 1.5 mg/dL HbA1c 7.9 %
Lymphocyte 7.8 % Albumin 2.6 g/dL pH 7.380
CRP 4.19 mg/dL Cl 109 mmol/L PvCO2 33.6 mmHg
AST 58 U/L Total calcium 9.4 mg/dL PvO2 65.2 mmHg
ALT 28 U/L IP 2.9 mg/dL HCO3 19.4 mmol/L

26
 Radiologic findings
2022/02/05 2022/02/07 2022/02/08

27
 Hospital Course
2022/02/08 Follow up blood routine, biochemistry, SMA and vein gas analysis
Oxygen: simple mask 8L/min  simple mask 10L/min
SpO2: 97-99%  93%
GCS: E4V4-5M6
NG tube insertion due to poor intake chest X-ray follow up
DNR was signed except drug(DNR 除藥 ).
Albutein 50ml QD IV was added.
Patient restraint PRN was agreed due to irritation and attempt to get off the
mask.

2022/02/08 Irritation with SpO2 dropped to 86-88% at 08:30.  Diphenhydramine 30mg

PM 08:30 IV ST for sedation
Oxygen: simple mask 10L/min  Non-rebreathing mask 15L/min
SpO2 : 91-95%

28
 Hospital Course
2022/02/09 Oxygen: Non-rebreathing mask 15L/min  Non-rebreathing mask 12L/min
SpO2: 94-98%
GCS: E4V3-4M6
Add Medason 40mg in case of interstitial lung disease.
Sputum suction for TB culture was arranged.
Few clot through NG tube drainage  Pantoloc 40mg IV ST 、 Vitamin K1 10mg
IV ST 、 Vitamin C 100mg IV ST 、 Hemoclot 500mg IV ST  Gastric OB 3+
Consult RIA to rule out rheumatoid arthritis-related pulmonary disease.

Irritation due to sputum suction with SpO2 dropped to 75-80% at 14:40. 

2022/02/09 Diphenhydramine 30mg IV stat for sedation  Arterial gas analysis
14:45 Oxygen: Non-rebreathing mask 15L/min  High-flow nasal cannula 60L/min +
Non-rebreathing mask full  SpO2 : 80%, GSC: E3-4V3M5
Sinus tachycardia(HR: 140-150bpm)  Herbesser 50mg IV ST
Portable X-ray follow up and confirm DNR status with the family
29
 Laboratory examinations
02/09 15:24 02/09 18:09
Blood routine, biochemistry and arterial gas analysis Arterial gas analysis
WBC 4.75 103/uL BUN 41 mg/dL D-dimer 1.77 mg/L
Hb 9.8 g/dL Creatinine 1.1 mg/dL pH 7.269
Platelet 59 103/ul Cl 110 mmol/L PaCO2 41.9 mmHg
Neutrophil 86.3 % Lactate 3.7 mmol/L PaO2 48.3 mmHg
Lymphocyte 11.4 % Glucose 353 mg/dL HCO3 18.8 mmol/L
CRP 10.08 mg/dL Troponin I 676 pg/mL
AST 54 U/L pH 7.315
ALT 24 U/L PaCO2 41.4 mmHg
Na 141 mmol/L PaO2 59.3 mmHg
K 4.2 mmol/L HCO3 20.5 mmol/L

30
 Radiologic findings
2022/02/08 2022/02/09

31
 Hospital Course
2022/02/10 Oxygen: High-flow nasal cannula 60L/min + Non-rebreathing mask full
SpO2 : 77-82%
GSC: E3-4V3M5  E2M3-4V1  E1V1M3
Shortness of breath  Morphine 3mg IV ST
Tracheal aspiration was collected for acid-fast stain and TB culture
Acid-fast stain: moderate(3+)  Negative-pressure isolation
Tracheal aspiration culture:  Staphylococcus aureus(Methicillin-sensitive
staphylococcus aureus)

2022/02/11 Arrange TB PCR to confirm the result  Positive

Inform Taiwan CDC due to notifiable disease.
BP and HR declined gradually and the patient expired at 10:23, Feb. 11, 2022.

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Aerobic culture of tracheal aspiration

Organism Staphylococcus aureus

Penicillin-g 　 Resistant Rifampin Susceptible
Oxacillin 　 Susceptible Teicoplanin Susceptible
Clindamycin 　 Resistant Tigecycline Susceptible
Erythromycin 　 Resistant Linzolid Susceptible
Vancomycin 　 Susceptible Moxifloxacin Susceptible
Trimeth/sulfame Susceptible Daptomycin 　 Susceptible
Fusidic acid Susceptible

33
 Hospital Course
2022/02/10 Oxygen: High-flow nasal cannula 60L/min + Non-rebreathing mask full
SpO2 : 77-82%
GSC: E3-4V3M5  E2M3-4V1  E1V1M3
Shortness of breath  Morphine 3mg IV ST
Tracheal aspiration was collected for acid-fast stain and TB culture
Acid-fast stain: moderate(3+)  Negative-pressure isolation
Tracheal aspiration culture:  Staphylococcus aureus(Methicillin-sensitive
staphylococcus aureus)

2022/02/11 Arrange TB PCR to confirm the result  Positive

Inform Taiwan CDC due to notifiable disease.
BP and HR declined gradually and the patient expired at 10:23, Feb. 11, 2022.

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 Desaturation to 75%
Desaturation to 88% NRM Add HFNC(FiO2: 92%)
At admission: N/C simple mask
simple mask (FiO2: 45%)
6L/min(FiO2: 45%)

Desaturation to 86%
simple mask  NRM(FiO2: 80-90%)

35
 Radiologic findings

2022/02/05 2022/02/07 2022/02/08 2022/02/09

36
WBC counts Platelet

37
CRP level D-dimer

38
Pro-BNP Troponin I

39
40
 Cause of death

Pneumonia, bilateral upper and lower lobes(Methicillin-susceptible

Staphylococcus aureus and pulmonary tuberculosis) with acute respiratory
failure and multiple organ dysfunction syndrome including acute
decompensated heart failure, acute renal failure, disseminated intravascular
coagulation, and upper gastrointestinal bleeding.

41
 Final diagnosis
1. Pneumonia, bilateral upper and lower lobes(Methicillin-susceptible
Staphylococcus aureus and pulmonary tuberculosis) with acute
respiratory failure and multiple organ dysfunction syndrome including
acute decompensated heart failure, acute renal failure, disseminated
intravascular coagulation, and upper gastrointestinal bleeding.
2. Rheumatoid arthritis under monthly golimumab (Simponi) and
immunosuppressants
3. Bronchial asthma
4. Hypertensive cardiovascular disease
5. Hyperlipidemia
6. Type 2 diabetes
7. Gout 42
 Review:
Tuberculosis

43
 General principles
1. Approximately 1.7 billion people are infected with tuberculosis but less than
15% of them progress to active disease.
2. Increased prevalence of multidrug-resistant tuberculosis (MDR-TB,
resistant to both rifampin and isoniazid) is observed. A similar trend is also
noted for extensively drug-resistant tuberculosis (MDR-TB plus resistance
to fluoroquinolones and at least one of three injectable second-line
drugs).
3. Latent tuberculosis infection(LTBI) is a misnomer referring to. someone
who has infection but not disease(clinical and radiological evidence of
active disease)

44
 Clinical presentation

General: Extrapulmonary manifestation:

Fatigue, malaise, fever, Cervical lymphadenopathy, dysuria,
weight loss, night sweats hematuria, flank pain/swelling, skin
pallor, micturition, anorexia

Chest: Actually, the extrapulmonary disease

Persisted cough(for could present as osteomyelitis, miliary
weeks), dyspnea, dissemination, meningitis, peritonitis,
hemoptysis or chest pericarditis or other non-pulmonary
pain/tightness diseases.

45
 Diagnostic testing

Clinical manifestation, past history, personal history(TOCC) and examination finding

 Radiological examination:  Biochemistry examination:

• Chest x-ray • Acid-fast stain
• Chest computed tomography • Culture of sputum specimens
• PCR(NAAT, nucleic acid
amplification test)
• Tuberculin skin test(TST) /
interferon-γ release
assay(IGRA) — for LTBI

46
Primary
tuberculosis

47
Post-primary
tuberculosis

48
Miliary
tuberculosis

49
 Conference
1. The Washington manual of medical therapeutics, 36th ed.
2. The Massachusetts general hospital handbook of internal medicine, 7th ed.
3. Interpreting chest x-ray: illustrated with 100 cases
4. Chest radiology: patterns and differential diagnosis, 7th ed.
5. Radiopaedia

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Thank you for listening

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