Case Discussion <Case Presentation>      A 79 year-old man presented with aggravated cough, shortness of breathing and left-sided chest pain for 2 weeks.      This patient had been a coal miner for 30 years. He was a case of diabetes using oral hypoglycemic agents for more than 10 years with a poor compliance. He had had pulmonary tuberculosis about 8 years ago, which was treated with a complete course of anti-tuberculosis medication for 2 years.      He was brought to this hospital because of exacerbated respiratory condition even after taking oral antibiotics from another hospital. On admission, the temperature was 39.8°C, the pulse was 95, and the respiration was 26. The blood pressure was 145/ 67 mmHg. After admission, intravenous amoxicillin/ clavulanic acid and gentamicin was given. However, severe left-sided chest pain occurred 2 days after admission. Auscultation showed total absence of respiratory sound of the left lower lung region. Chest X-ray (Fig.1 ) revealed accumulation of left-sided pleural effusion. Under echographic guidance, turbid pleural effusion was aspirated and the laboratory analysis of pleural effusion was as following: WBC 27,000/μl, RBC 30/μl, Lymphocyte/ Neutrophil/ Histiocyte: 0/ 82/ 18 Acid-fast stain (-), Gram’s stain: Gram (-) bacilli, Glucose 261 mg/dl, Total protein 4 g/dl, LDH 1916 U/L, cytology shows polymorphonuclear cells only. Culture of pleural effusion yielded Klebsiella pneumonia that was resistant to ampicillin only. Left lower lobe, B6 segment abscess formation was noticed but resolved gradually under antibiotic treatment with pipracillin and tazobactem. Chest tube drainage of the empyema was performed under antibiotic coverage. His general condition improved after above treatment, and the chest x-ray revealed resolution of the pneumonic patch (Fig. 2 ). <Laboratory Data> Table 1. Hematologic laboratory values   WBC /μL Hb g/dL MCV fL Plt k/μL Neu % Lym % On admission 5500 9.2 92.2  362 66.9 16 7th day of admission 6500 8.5 94 391 68.6 16 12th day of admission 8300 9.9 91.6 383 77.7 13.4 Table 2. Blood chemical values   Glusos e mg/dL Bilirub in mg/dL AST/AL T U/L BUN mg/d L Creatini ne mg/dL Na mM K mM On admission 213 0.4/0.2 13/22 12  0.8 137 4.3 12th day of admission 158   19/ 11 1.1 141 4.0  Fe 28, TIBC 174, HbA1C 12.4%.       <病案分析>      本病例為控制不佳之糖尿病患者，發生Klebsiella pneumonia之肺炎感染，在台灣本土是相當常見的糖尿病相關併發症。第二型糖尿病患者的長期追蹤，可檢查病人的糖化血色素。若糖化血色素超過8%，代表病人最近兩三個月平均血糖值約在180 mg/dL以上。也就是說，血糖控制相當的差！此時必須考慮增加原有的藥量，或者是改成其他的藥物來治療。本病例之糖化血色素高達12%，在臨床上，若遇到這樣的病患，一定要特別注意，因為血糖200 mg/dL以上就會影響到人體的細胞型免疫力(cellular immunity)及白血球的吞噬能力，使病患容易發生嚴重的感染。 繼續教育考題 1. (B) Which of the samples of pleural fluid is most suggestive of empyema? Fluid sample Color PH Protein G/L Glucose Mg/dL LDH U/ml WBC Total (per μL) N : L : M&H* (A) Clear yellow 7.15 35 20 600 2000 5 : 94 : 1 (B) Thick green 7.00 40 20 600 10,000 90 : 8 : 2 (C) Clear yellow 7.30 15 80 150 200 50 : 49 : 1 (D) Pink-tinged 7.40 30 80 600 3000 50 : 36 : 14 (E) Clear yellow 7.30 35 60 150 2000 95 : 3: 2 *N: Neutrophil; L: lymphocyte; M&H: mesothelial cell and Histiocyte.               2. (A) Which of the following samples of pleural fluid is most suggestive of tuberculosis pleurisy? Fluid sample Color PH Protein G/L Glucose Mg/dL LDH U/ml WBC Total (per μL) N : L : M&H* (A) Clear yellow 7.15 35 20 600 2000 5 : 94 : 1 (B) Thick green 7.00 40 20 600 10,000 90 : 8 : 2 (C) Clear yellow 7.30 15 80 150 200 50 : 49 : 1 (D) Pink-tinged 7.40 30 80 600 3000 50 : 36 : 14 (E) Clear yellow 7.30 35 60 150 2000 95 : 3: 2 *N: Neutrophil; L: lymphocyte; M&H: mesothelial cell and Histiocyte.               3. (B) Which statement concerning Klebsiella infections is correct? A Most clinical isolates are obtained from the respiratory tract. B Predisposing factors for Klebsiella pneumonia include alcoholism and DM. C Klebsiella is closely related to Psuedomonas species. D Treatment with antibiotics is mandatory if Klebsiella growth from a sputum culture obtained from an intubated patient is detected. E Three days use of antibiotics is sufficient for established Klebsiella infections. 4. (D) A 81-year-old male heavy smoker with COPD walked into your clinic, and complained productive cough with purulent sputum and fever for 3 days. He lived in an above-average community with his wife and daughters. The CxR showed a RLL pneumonia patch. Which pathogen below might possess the least probability to cause his pneumonia? A Influenza virus B Moraxella catarrhalis C Pneumococcous D Staphyloccus aureus E Nocardia spp. 5. (E) A 45-year5-old female presents with fever and dry cough for three days. She has had no past medical problems. Her body temperature was 39.6℃ and diffuse rales presented on chest auscultation. The hemogram also revealed an elevated white count with a left-shifted differential. CxR showed patchy bilateral infiltrates. Which antibiotic below is the most reasonable choice at this time? A Cefotaxime B Ciprofloxacin C Erythromicinp D Ampicillin plus azithromycin E Ampicillin plus sulbactam plus erythromycin 6. (D) Klebsiella pneumoniae is intrinsically resistant to some antibiotics. Indicate them. (I) Ampicillin (II) Ticarcillin (III) Piperacillin A I only B II only C III only D I and II E I and II and III 7. (B) Which statement about HbA1C is incorrect? A HbA1C is the measurement of glycated hemoglobin, which can reflect the glycemic history over the previous 2 to 3 months. B When HbA1C is inaccurate, such as hemolytic anemia, we can alternatively use the degree of glycation of other proteins, such as glucosamine assay for glycated globulin measurement. C When measured by HPLC, an HbA1C value of 7% indicates that the mean plasma glucose value is approximately 150mg/dL. D HPLC is the current standard reference method for most glycated hemoglobin measurement. E Hemoglobinopathies, hemolytic anemia and uremia may interfere with the HbA1C result. 8. (A) A 70-year-old female with type 2 DM presents with severe ear pain, drainage, fever and leukocytosis. Besides, she has facial nerve palsy with the same side of her painful and swelling ear. Which statement below is true? A It is usually caused by Psueomonas aeruginosa. B With appropriate treatment, the mortality rate is low. C A 4-week course of antibiotics treatment is sufficient. D Surgical debridement is rarely required. E Head CT is typically unremarkable and unnecessary. 9. (E) The immune system function of a patient with poor-controlled diabetes mellitus is generally impaired. Some highly virulent microorganisms readily colonized on these patients. Which microorganisms in the following list is the exception? A Staphylococcus aureus B Pseudomonas aeruginosa C Mucormycosis D Candida glabrata E All microorganisms above can colonize on patients with DM. 10. (C) Which of the following statements was not true? A Pneumonia, urinary tract infections are more common in the diabetic population B Hyperglycemia results in abnormal cell-mediated immunity and phagocyte function C Infections seen almost exclusively in the diabetic patients includes rhinocerebral aspergillosis D Complications of urinary tract infection include emphysematous pyelonephritis and cystitis E All of above are correct

答案解說 (B). When the following criteria are met, indicating more likelihood of empyema, a procedure more invasive than a thoracocentesis is needed: loculated pleural fluid, pleural fluid pH below 7.20, glucose less than 60 mg/dL, positive Gram stain or culture of the pleural fluid, or the presence of gross pus in the pleural space. (A). The diagnosis of tuberculous pleural effusion is suggested by the following findings: clear and yellow; pH<7.20; protein >30 g/L; glucose <25 mg/dL; LDH > 450 U/ml and a lymphocytosis. (B). Klebsiella is related to Serratia and Enterobacter. Most clinical isolates come from the urinary tract. However ailing a patient looks, the Klebsiella growing in his sputum does not promise a true Klebsiella infection; therefore, antibiotic treatment is not mandatory. But as long as true Klebisella pneumonia is confirmed, a course of seven to fourteen-days use of effective antibiotics is necessary. (D). For an elder with community-acquired pneumonia, all other microorganisms than Staphylococcus aereus are candidates. (E). Although "atypical" pathogens of community-acquired pneumonia should be highly suspected for this case, aerobic bacteria should be covered too. (D). Klebsiella pneumoniae is intrinsically resistant to ampicillin and ticarcillin. (B). Hemoglobinopathies, hemolytic anemia and uremia may interfere with the HbA1C result. In this situation, we can use the degree of glycation of other proteins for substitution, such as fructosamine assay for glycated albumin measurement. However, please keep in mind that these alternative assays cannot replace HbA1C as a standard and routine indicator of glycemic history. (A). She is a case of malignant external otitis, which is usually cause by Psuedomonas aeruginosa. The mortality rate can reach 50% despite early diagnosis and appropriate treatment. At least a course of 6-week anti-Pseudomonas antibiotics use should be administered, and surgical debridement is often indicated. The head CT can reveal the soft tissue and bone involvement. (E). Both humoral and cellular immunity are impaired in DM patients with poor blood glucose control. Therefore, many extracellular and intracellular microorganisms can colonize readily on these patients and cause severe infection frequently. (C). Infections seen almost exclusively in the diabetic patients includes rhinocerebral Mucormycosis. Top of Page