Management of a 68-Year-Old Female with Flu-Like Symptoms and Lethargy
This patient requires hospital admission for evaluation and treatment of suspected influenza with possible secondary complications, given her age and prolonged symptoms with worsening lethargy.
Initial Assessment
Clinical Evaluation
- Vital signs: Check for unstable clinical factors 1:
- Temperature >37.8°C
- Heart rate >100/min
- Respiratory rate >24/min
- Systolic blood pressure <90 mmHg
- Oxygen saturation <90%
Laboratory Testing
- Complete blood count: Look for leukopenia or normal WBC with decreased lymphocyte count 1
- Blood chemistry: Assess liver and kidney function, electrolytes
- C-reactive protein and procalcitonin: Elevated levels may suggest bacterial superinfection 1
- Chest X-ray: To evaluate for pneumonia, particularly important given the prolonged duration of symptoms
Treatment Algorithm
1. Antiviral Therapy
Despite symptoms >48 hours, antiviral therapy is still indicated given:
- Patient's age (68 years) places her in high-risk category
- Prolonged symptoms with worsening lethargy suggest possible complications
- Hospitalized patients may benefit from antivirals even when started >48 hours from symptom onset 1
Recommended regimen: Oseltamivir 75 mg orally twice daily for 5 days (adjust dose if creatinine clearance <30 ml/min to 75 mg once daily) 2
2. Antibiotic Therapy
Given the prolonged duration (11 days) and worsening symptoms (lethargy), empiric antibiotic therapy is warranted to cover possible secondary bacterial infection 1, 3
For non-severe influenza-related pneumonia:
For severe influenza-related pneumonia:
- IV combination of broad-spectrum beta-lactamase stable antibiotic (co-amoxiclav or cefuroxime/cefotaxime) plus a macrolide 1
3. Supportive Care 3
- Adequate hydration: IV fluids if unable to maintain oral intake
- Fever management: Acetaminophen or ibuprofen for temperatures >38.5°C
- Oxygen therapy: To maintain SaO2 ≥92% if hypoxic
- Monitor for complications: Respiratory failure, secondary bacterial pneumonia, cardiac complications
Monitoring and Follow-up
During Hospitalization
- Daily assessment of vital signs and clinical status
- Monitor oxygen saturation regularly, especially if respiratory symptoms
- Repeat laboratory tests as clinically indicated
- Consider switching from IV to oral antibiotics once clinically improved and afebrile for 24 hours 1
Discharge Criteria
- Patient should not be discharged if she has two or more of the following 1:
- Temperature >37.8°C
- Heart rate >100/min
- Respiratory rate >24/min
- Systolic blood pressure <90 mmHg
- Oxygen saturation <90%
Post-Discharge Follow-up
- Arrange follow-up clinical review, especially given her age and prolonged symptoms 1
- Provide clear information about the illness, medications, and warning signs requiring prompt medical attention
Special Considerations
Potential Complications to Monitor
- Secondary bacterial pneumonia (most common complication) 4
- Cardiac complications: myocarditis, pericarditis 5
- Neurological complications: confusion, encephalopathy 5
- Exacerbation of underlying medical conditions 4
Differential Diagnosis
- Consider other viral respiratory infections (parainfluenza, adenovirus, respiratory syncytial virus) 1
- Bacterial pneumonia (primary, not secondary to influenza)
- Non-infectious causes that can present similarly (vasculitis, organizing pneumonia) 1
- Adult-onset Still's disease (can present with prolonged fever and influenza-like symptoms) 6
The prolonged duration of symptoms (11 days) with recent worsening (lethargy for 3 days) in an elderly patient warrants aggressive management to prevent further deterioration and complications that could significantly impact morbidity and mortality.