“I knew she was sick when she didn’t want a cigarette.” The case of Ruth R.
Ruth R.’s case illustrates that influenza can be extremely serious, even fatal, especially in elderly or debilitated persons. The most significant facts in this case were the history of cigarette smoking and the failure to obtain an influenza vaccination. When the patient first appeared, she was in the prodromal phase of influenza. Mild lymphocytosis confirmed the viral nature of her illness. Her second appearance was at the height of the acute phase of the influenza syndrome, but the marked granulocytosis (neutrophilia) and widespread pulmonary infiltrates suggested a secondary bacterial infection. Bacterial pneumonia can be a nosocomial (hospital- or clinic-acquired) infection, and she might have picked it up on her initial visit. An important question is whether or not antibiotics should have been prescribed at that point.
In light of the near-fatal course of this case of influenza, it is tempting to believe that doing so might have prevented the bacterial pneumonia. There is no guarantee, however, that the bacterium that infected her would have been susceptible to the antibiotic chosen, and there remains the possibility that killing off her normal flora might have encouraged infection by an even more dangerous bacterium. Points to Remember
• Cigarette smoking causes lung disease and increases risks associated with other lung disease.
• Influenza vaccination is important in elderly or debilitated people, especially those with lung disease.
• Bacterial pneumonia is a common complicating illness in patients with chronic lung disease.