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Old 01-10-2012
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Question Daily Questions #2 ( not been himself since this morning)

A 70-year-old Russian man is brought to your office by his son who states that his father has not been himself since this morning. He believes that he is in Russia. The son states that his father has been fine and that he went on a trip and stayed in small hotels. One week after his return, he had what seemed to be the flu. He was coughing and complained of body aches, headaches, diarrhea, and abdominal pain. The patient had a myocardial infarction five years ago and still smokes cigarettes. His temperature is 102 F, respiratory rate is 32/min, blood pressure is 140/80 mm Hg, and the oxygen saturation is 95% on room air. His chest x-ray reveals scattered patchy infiltrates bilaterally. His sodium is 127 mEq/L, and the transaminases are mildly increased. What is the most sensitive and specific method of confirming the diagnosis?

(A) Blood culture
(B) Urine antigen
(C) Antibody serology
(D) Lumbar puncture
(E) Direct fluorescent antibody on sputum
(F) Culture on blood agar
(G) Gram's stain
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Old 01-10-2012
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b) urine antigen - legionella?
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Old 01-10-2012
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Quote:
Originally Posted by podebrad View Post
A 70-year-old Russian man is brought to your office by his son who states that his father has not been himself since this morning. He believes that he is in Russia. The son states that his father has been fine and that he went on a trip and stayed in small hotels. One week after his return, he had what seemed to be the flu. He was coughing and complained of body aches, headaches, diarrhea, and abdominal pain. The patient had a myocardial infarction five years ago and still smokes cigarettes. His temperature is 102 F, respiratory rate is 32/min, blood pressure is 140/80 mm Hg, and the oxygen saturation is 95% on room air. His chest x-ray reveals scattered patchy infiltrates bilaterally. His sodium is 127 mEq/L, and the transaminases are mildly increased. What is the most sensitive and specific method of confirming the diagnosis?

(A) Blood culture
(B) Urine antigen
(C) Antibody serology
(D) Lumbar puncture
(E) Direct fluorescent antibody on sputum
(F) Culture on blood agar
(G) Gram's stain
(B) Urine antigen for Legionella Pnemonia.
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Old 01-11-2012
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urine antigen-legionaarie's pneumonia...
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Old 01-11-2012
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(B) Urine antigen - I also think its Legionella, especially with its pulmonary and renal effects. However, I am not sure about its CNS effects.
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Old 01-11-2012
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B. Urine Antigen
Explanation:
This patient most likely has Legionella pneumonia. The clue to this diagnosis is the presence of gastrointestinal symptoms, altered mental status, hyponatremia, and abnormal liver function tests in a person with pneumonia. Legionella is a gram-negative aerobic bacillus that does not grow on routine media and enters the lung through aspiration in older men with lung disease, particularly smokers and those who are immunocompromised. It is mostly found in water tanks and old water conditioners. Patients present with the usual symptoms of pneumonia, as well as some additional atypical symptoms, such as malaise, headache, mental status changes, and gastrointestinal symptoms, such as abdominal pain and diarrhea. The chest x-ray is relatively nonspecific. There can be the usual lobar infiltrates or bilateral patchy disease.

The diagnosis of Legionella is complex because the organism cannot be reliably seen on Gram stain or grown on standard culture media. The most sensitive and specific test overall is culture on a special-buffered, charcoal, yeast-extract media. It does not grow on standard blood agar. Blood culture and lumbar puncture have no utility in the diagnosis. The urine antigen has virtually 100% specificity when it is positive. It has 99% sensitivity for Legionella pneumophila type 1, which makes up about 80% of isolates. Although serum antibody testing and direct fluorescent antibody testing of sputum are very specific as well, their sensitivity on initial presentation is <40%.
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