4. The Combo



Peter and I were on call that Saturday. It was a 24-hour shift and 13 hours had already passed. There was so much work to be done that we hadn’t even seen each other until 8 PM. I was exhausted in the on-call room when he came in with a cup of coffee. Just the smell of it already made me feel a little better.

‘It’s for you.’ He handed me the cup.

‘What?’

‘I see your 4-cups-in-the-morning routine, Diaz.’ He grinned. Smart guy. ‘You owe me one though.’

‘Fine.’ I answered as I sipped that satisfying taste. ‘And where is your coffee?’

‘Are you crazy?’ He frowned. ‘I don’t drink this thing. Bitter as hell.’

‘Freak.’ 


After a couple of hours, Jane knocked on the door.

‘Excuse me, doctors. There is a new admission for you.’

It was Peter’s turn to get it, so he lifted from the chair and took the chart.

‘Jay Ericksen, 50 years old, water tank cleaner, came in with moderate respiratory distress. He is now receiving oxygen therapy through a catheter and is stable.’ He read out loud. ‘Thank you, Jane. I’ll be right there.’

Jane went away and Peter turned back to get his white coat. He stopped before heading out.

‘Do you want to come with me, Lisa?’

I hesitated. I wasn’t expecting that. But why not, right? I was a little bored after all.

‘Sure.’ I answered.


Mr. Ericksen looked a little over 50 years old. He was bald, a bit overweight, and seemed tired. By his side was an elegant woman with a worried expression, maybe his wife.

‘Hi, Mr. Ericksen. I’m Dr. Peter Allen.’ He smiled. ‘And this is my colleague, Dr. Lisa Diaz. How are you feeling?’

Mr. Ericksen seemed off. He took some time to answer, and then mumbled something that didn’t make sense.

‘I’m sorry, he is not well. I am Lynn, Jay’s wife.’ The woman greeted us. ‘He hasn’t been himself the past few days, that’s one of the reasons I brought him.’

Peter turned to her, ‘Nice to meet you, Lynn. I am sorry to hear that. Can you tell me what happened?’

‘For the past week, he has been coughing a lot. He had a high fever and was finding it hard to breathe. So I tried convincing him to come to the hospital, but he said he was going to be fine and took some Amoxicillin we had at home.’ Her eyes were tearful. ‘But it’s only getting worse, and since last night he seems confused, not making any sense.’ She held his hand.

‘I see.’ Peter continued. ‘And did he have anything else? Nausea, vomiting? How was the cough?’

She went on to tell Peter about Jay’s symptoms. He was also having watery diarrhea, and his fever got to 40 ÂșC, accompanied by chills and myalgia. In his past medical history, Mrs. Ericksen said Jay was also a heavy smoker and had COPD. When asked about medications she said he was using corticoids for an eye problem in the past month or so, but couldn’t remember the name. She denied any other medical conditions or drugs. After talking to her, Peter proceeded to examine him.

‘Alright, Mr. Ericksen. I am going to get your x-ray now and we will be right back.’ Peter said after he finished the physical.

Jay nodded and we left the room. 


‘So, what are you thinking, Peter?’

‘Well. At first, I thought about typical community-acquired pneumonia. But it should be improving by now.’

‘Yeah. It should. What about the diarrhea?’

‘Antibiotic related?’

‘Hmm... That sounds plausible.’ I said. ‘How was the physical exam?’

‘Pneumonia findings, you know. Crackles on the left especially. ’

We got to the radiology department and Mr. Ericksen’s x-ray was already waiting for us. It showed, like expected, an important consolidation in the left lower lobe, but also diffused opacities throughout other lung fields. We kept staring at the image.

‘What if the diarrhea wasn’t caused by the antibiotic?’ I broke the silence.

‘What do you mean?’

‘What if it is part of what he has. Pneumonia and GI symptoms.’

‘Okay, that’s possible. Maybe atypical pneumonia.’

We were going through the information the wife provided us when Jane came rushing through the door.

‘Dr. Allen, Mr. Ericksen is not well. Can you come see him, please?’

Peter and I bolted to Jay’s room.


Jay was obviously agitated, throwing things at the ground and pushing the nurses away. Peter took charge and gave him a light sedative.

‘He started saying that this was not his home.’ Lynn was crying now. ‘That I had destroyed his house, that there is dirt everywhere and he can listen to the rats in the pipes.’

Peter glanced at me. He checked Jay’s vitals and we headed to the hallway.

‘That can’t be just hypoxemic confusion. His O2 sat is not that low with the catheter. And it can’t be febrile either, his temperature is normal now.’

‘You’re right. But what then?’

‘Well, then it has to be another symptom.’ 

‘Okay.’ I thought out loud. ‘So he has what seems like a bug infection that is going after his lungs, his intestines, and his brain. What a combo.’ I sighed.

    ‘That’s it!’ Peter said. ‘And that bug also didn’t respond to the beta-lactam he took. It could be Legionella!’

‘He does have risk factors.’ I said following his line of thinking. ‘He smokes, has COPD, and is using corticoids.’

‘Yeah. And to top it off, he cleans water tanks.’


We went back, ordered a workup for Mr. Ericksen, and started him on Azithromycin. His blood work showed hyponatremia, which according to Peter is more common in legionnaire’s disease than in other types of pneumonia. Jay’s urinary Legionella antigen came back positive and he kept on getting better with the macrolide we prescribed him. A couple of days later Jay was discharged home feeling well.

At the end of the shift, we gathered our stuff and exited the hospital. 

‘See you tomorrow, Lisa. Thanks for your help.’ He grinned. His light hair was falling in his eyes.

‘You were the one that figured it out. See you, Peter. You are not that bad after all.’

He laughed. ‘It was nice working with you too, Diaz.’


...

Want to know more about Legionellosis?

https://www.nejm.org/doi/full/10.1056/nejm199709043371006?casa_token=mB8pbF1TFjIAAAAA:Xt3Wfk6s1uGVzTj54fjngmKhfEQPIDr-LbfXJMDmhzlXDk_oT-GY7Mr6AjsD9Zt70wlhC24yiYwMTpdO


Want to read real cases of Legionellosis?

https://legionella.org/about-the-disease/share-your-story/




Clinical Board
 
PNA: pneumonia; GI: gastrointestinal; CNS: Central Nervous System; Tt: treatment

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