A 68-year-old man with chronic obstructive pulmonary disease comes to the physician due to fever and malaise. He developed abrupt-onset fever, headache, nonproductive cough, severe body aches, and generalized weakness about 24 hours ago. He has a 43-year history of smoking but quit 2 years ago. His medications include tiotropium daily and albuterol as needed. The patient has no other medical problems. He visited his grandchildren a week ago during Christmas and reports that his 6-year-old grandson was sick with similar symptoms.
His temperature is 38.9 C (102 F), blood pressure is 124/84 mm Hg, pulse is 96/min, and respirations are 18/min. Pulmonary auscultation shows decreased breath sounds bilaterally but no focal crackles.
Chest x-ray shows flat hemidiaphragms bilaterally but no focal infiltrate. A rapid influenza antigen test is negative. Laboratory results are as follows:

Which of the following is the most appropriate treatment at this time?

Question

A 68-year-old man with chronic obstructive pulmonary disease comes to the physician due to fever and malaise.  He developed abrupt-onset fever, headache, nonproductive cough, severe body aches, and generalized weakness about 24 hours ago.  He has a 43-year history of smoking but quit 2 years ago.  His medications include tiotropium daily and albuterol as needed.  The patient has no other medical problems.  He visited his grandchildren a week ago during Christmas and reports that his 6-year-old grandson was sick with similar symptoms.
His temperature is 38.9 C (102 F), blood pressure is 124/84 mm Hg, pulse is 96/min, and respirations are 18/min.  Pulmonary auscultation shows decreased breath sounds bilaterally but no focal crackles.
Chest x-ray shows flat hemidiaphragms bilaterally but no focal infiltrate.  A rapid influenza antigen test is negative.  Laboratory results are as follows:

Which of the following is the most appropriate treatment at this time?

Quizplus · Accepted Answer

11ec193a_984e_a0f9_853d_b54650478fae_MD0002_00 In this patient with an influenza-like illness (fever plus cough and/or sore throat), the clinical suspicion for influenza is high (winter season, abrupt symptom onset, sick contact). In addition, the patient's age (>65) and chronic obstructive pulmonary disease (COPD) place him at high risk of influenza complications (Table). Early antiviral therapy may decrease symptom duration, illness severity, and complication rates, particularly in high-risk patients and those with severe disease. Because this high-risk patient is within the first 48 hours of symptom onset, a neuraminidase inhibitor such as oseltamivir or zanamivir is recommended, rather than symptomatic therapy alone (Choice D). However, zanamivir should be avoided in patients with chronic pulmonary disease (eg, COPD, asthma) as it can precipitate bronchospasm and respiratory function decline (Choice E). Although diagnostic testing for influenza is recommended in immunocompromised or high-risk immunocompetent patients with influenza-like illness, treatment should not be delayed pending results availability. It also should not be stopped due to a negative rapid antigen test result in patients in whom suspicion for influenza is high (as in this patient) due to the test's low sensitivity (40%-60%) in diagnosing influenza. Reverse transcriptase polymerase chain reaction (RT-PCR) testing (more sensitive but less readily available) is preferred and should be performed for confirmation if available. (Choice A) Adamantanes (eg, amantadine, rimantadine) are effective against some influenza A viruses but are not currently recommended due to high drug resistance. (Choice C) Ribavirin is used to treat immunosuppressed patients with suspected lower respiratory tract infection from respiratory syncytial virus (RSV); it is not effective against influenza. Educational objective: Antiviral therapy is recommended for patients at high risk for influenza complications, particularly within the first 48 hours after symptom onset. In the absence of suspected resistance, oseltamivir is the treatment of choice for patients with suspected influenza infection with underlying pulmonary disease. __________ References: Antiviral agents for the treatment and chemoprophylaxis of influenza (http://www.ncbi.nlm.nih.gov/pubmed/21248682) Seasonal influenza in adults and children--diagnosis, treatment, chemoprophylaxis, and institutional outbreak management (http://www.ncbi.nlm.nih.gov/pubmed/19281331)

A 68-Year-Old Man with Chronic Obstructive Pulmonary Disease Comes to the Physician