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Answers on p 107.
An otherwise healthy non-smoking 59 year old welder gave a two week history of flu-like symptoms and a one week history of progressive shortness of breath, pleuritic chest pain, and cough productive of purulent sputum.
On examination he was unwell with a pyrexia and an oxygen saturation of 87% on air. He had atrial fibrillation with a pulse of 150 beats/min and blood pressure of 109/69 mm Hg. He was jaundiced with epigastric and right upper quadrant abdominal tenderness. Respiratory examination revealed tachypnoea, right mid-zone coarse crepitations, and a right sided pleural rub.
Investigations showed a raised white cell count with a neutrophilia, significant renal impairment with a urea concentration of 23.3 mmol/l and creatinine of 248 μmol/l, oxygen pressure of 7.1 kPa and carbon dioxide pressure of 2.5 kPa on air, and an abnormal chest radiograph with consolidation of his right middle lobe (fig 1A). Liver function tests were also abnormal with a bilirubin of 137 μmol/1 and alanine aminotransferase of 123 U/1. His blood cultures grew Streptococcus pneumoniae and his influenza A titre was markedly raised.
Despite starting intravenous amoxicillin and clarithromycin, he developed bronchial breathing in his left lower lung. His renal function worsened and he became anuric. Ultrasound scan showed normal sized kidneys with no hydronephrosis. The gall bladder was distended but the liver appeared normal. He was started on haemodialysis and showed initial clinical improvement.
Six days after admission he deteriorated. He developed a spiking pyrexia and expectorated copious amounts of purulent sputum. A leucocytosis developed. A further chest radiograph was taken which is shown here (fig 1B). Sputum culture grew Pseudomonas aeruginosa. His antibiotic therapy was subsequently changed to imipenem and metronidazole.
What do the chest radiograph (fig 1B) and computed tomogram of the thorax (fig 1C) show and how would the clinical and radiological findings be best treated?
Is the high influenza A titre relevant to this case?
What is the cause of his acute renal failure?
What is the cause of his abnormal liver function tests?