Necrotizing tracheobronchitis caused by influenza and Staphylococcus aureus co-infection

Excerpt

A 69-year-old man with a history of hypertension, untreated diabetes, and current tobacco use presented to the emergency department on 15th Dec 2017 with rigors and dyspnea. He had 2 days of fever and appetite loss, and 1 day of vomiting and diarrhea. Vital signs: BP 100/70, P 144, R 48, T 38.0 °C, and SpO2 88 on air. Rapid influenza test was positive for type B. Macular erythematous rash was seen on his extremities and trunk. Laboratory studies showed: WBC 5200/μL, platelet 138,000/μL, BUN 44 mg/dL, Cr 1.3 mg/dL, CK 1580 IU/L, procalcitonin 73.4 ng/ml, glucose 400 mg/dL, HbA1c 11.9%, urine ketone body 3+, and lactate 16.3 mmol/L. PT-INR, apTT, fibrinogen, FDP and d-dimer were 1.22, 27.5 s, 648 mg/dL, 18.9 μg/mL and 7.7 μg/mL, respectively. Sputum Gram stain revealed 3 + GPC in cluster and 1 + GNR. In the ER he received peramivir 300 mg, was intubated, and was started on meropenem 0.5 g q6h, vancomycin 1 g q24h, IV insulin, and hydration. After identifying MSSA in sputum culture, antibiotics were switched to cefazolin 2 g q8h which continued for 4 weeks. Since copious dark sputum was suctioned every hour, bronchoscopy was performed on day 4, revealing necrotizing tracheobronchitis, and repeated on day 7 for digital imaging (Fig. 1a–c); necrotizing pneumonia was diagnosed by CT scan. The rash improved and exfoliated on day 7, etiology likely toxic shock syndrome. Tracheotomy was performed on day 13, clinical improvement noted on day 27 (Fig. 2a–c), and he was discharged to home on day 45. …