case presentation dr. nurçin Çimen private beylikdüzü kolan hospital-İstanbul
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CASE PRESENTATION
Dr. Nurçin Çimen
Private Beylikdüzü Kolan Hospital-İstanbul
Conflict of Interest Declaration
I hereby declare that;
No stocks, shares or employment in a commercial
No membership in advisory board or focus group
No honorarium payment received for speech, publication or editorials
No education nor research grants
No congress or symposia sponsorship
• U.T
• 22 years, male
• Computer programmer
• Born in İstanbul, lives in İstanbul
COMPLAINTS
• Cough
• Sputum
• Fever
MEDICAL STORY
Complaints began 1 week ago, with cough, dark
colour sputum. He also had fever of about 39 °C.
Postnazal seromucoid secretion and fragility at
Little area was detected in ENT examination.
Cefuroxim aksetil 500 mg tb 2x1, pseudoephedrine
HCL+ Setrizine HCL tb 2x1, had begun to the
patient by ENT because of hemorragic nasal
secretion 3 days ago.
Medical History: No special feature
Family History :No special feature
Habits: No smoking, Rare alcohol intake
PHYSICAL EXAMINATION
Conscious, coopered, oriented
Blood Pressure: 120/70mmHg
Pulse: 100/dak
Fever: 38.5°C
Tiroid palpabl
No peripheral LAP
Respiratory system examination:
RR:18/min
Expiratory duration was increased bilaterally and
respiratory sounds were decreased at right lower lob
Bilateral CDS open
LABORATORYHb:12.7 g/dL (14-17.5)
Hct:% 37.9 (40-52)
WBC:11.1x10³/uL (4.4-11.3)
RBC:4.50x106/uL(4.5-5.9)
PLT:346x10³/uL(135-486)
ESR: 82 mm/h
CRP: 8.65 mg/dL (0.01-0.82)
IgE: 146 IU/mL (<100)
Alb:3.3 g/dL (3.5-5)
Chest X ray (03.06.2011)
CHEST X-RAY:
Enlargement of right hilar zone and irregular
opasity of about 1,5 x1,5 cm at infrahilar area .
WHAT IS YOUR PREDIAGNOSIS?
A-Wegener’s Granulomatosis
B-Pulmonary Artery Aneurysm (Behçet's Disease)
C-Lung Cancer
D-Lymphoma
E-Tuberculosis
Ampicillin- sulbactam 1 g 4X1 (IV) treatment began
to the patient with CAP prediagnosis (3.6.2011).
Fever of the patient did not decreased in 3 days
eventough to the treatment.
There were non significant decrease in CRP levels .
There were no significant improvemet in control chest
X-ray.
Chest X-ray (06.06.2011)
Which diagnostic tests would you perform?
A-Sputum gram staining- culture
B-Sputum ARB (Direct-culture)
C-Thorax CT
D-Bronchoscopy
E-All of them
• Sputum gram staining: Epithelial cells, gram
positive chain forming cocci, rare gram positive
bacilli.
• Aerop culture: Alpha hemolytic streptococci.
• Antibiogram: sensitive to penicillin, ceftriaxsone,
erythromycin, vancomycin, levofloxacine.
• Sputum ARB: 3 times negative
Thorax CT:Subcarinal- paraeosaphageal, right hilar and
intrapulmoner soft tissue (LAP), heterogenous dansity with
air bronchograms at right lung lower lob paramediastinal
area, and parenchymal infiltrations nearby.
Irregularity at lower lob basal segment becouse of LAP and
consolidation.
WHAT IS YOUR PREDIAGNOSIS?
A-Wegener’s granulomatosis
B-Lymphoma
C-Lung cancer
D-Tuberculosis
E-Carcinoid tumor
Sputum tuberculosis culture (MGIT): Sterile
Blood culture: Sterile
Which diagnostic test would you perform ?
A-Sputum Cytology
B-c-ANCA, p-ANCA
C-PET-CT
D-Bronchoscopy
E-Mediastinoscopy
PET-CT (07.06.2011)
PET-CT:
Increased pathological FDG (Early SUV max:16.1 , Late SUV
max: 19.4) at right lower lob paramediastinal heterogenous dansity
consolidation and infiltration areas.
Pathological FDG (Early SUV max: 14.9, Late SUV max: 21.7)
(metastasis?) at subcarinal, paraeosophageal, right hilar and
intrapulmoner conglomerated lymph nodes .
BRONCHOSCOPY (06.06.2011)
BRONCHOSCOPY:
Main carina deviated to the right, norrowing of the left side wall
of the intermediair bronchus by extrinsic compresssion.
Endobronchial lesion at the entrance of right lower lob, causing
bulging at the posterior wall, with nodularity and mucosal
infiltration on it.
Right system lavage , and forceps biopsy from the lesion is taken.
TBNA was not performed because of hemorrage.
YOUR DIAGNOSIS?
A-Lung Cancer
B-Sarcoidosis
C-Lymphoma
D-Tuberculosis
E-Wegener’s Granulomatosis
Right lower lob lesion biopsy: Necrotizing granulomatous bronchitis
PATHOLOGY:
Bronchial Lavage Microbiology :
Gram Staining: Epithelial cells, gram positive chain
forming cocci, rare gram positive bacilli.
Aerop Culture: Growth of normal flora of throat .
Fungal culture: No growth of pathogen fungi.
EZN Staining: No asid resistant microorganism
Tuberculosis culture (MGIT): Growth of
Mycobacterium tuberculosis.
According to the information obtained from Tuberculosis
Contol Dispansery registrations;
Antitb treatment had begun to the patient at 21.06.2011 at I.U
Istanbul Medical Faculty. There were no problem during follow
up, and kontrol chest X ray was reported to be normal.
It ıs the tracheobronchial tree tuberculosis infection
proved with microbiologic and histopathologic findings*.
According to the autopsy results bronchial tuberculosis
causing atelectasis and consolidation in lung parenchyma
and involving the bronchi is about 40-80% **.
* Yılmaz A, Alıcı O.İ, Demirci N.Y ve ark. Radyolojik Olarak Maligniteyi Taklit Eden Endobronşiyal Tüberküloz
Olgularının Klinik ve Bronkoskopik Özellikleri.Solunum 2011; 13(3): 170–175
** Yosunkaya Ş, Gök M. Akciğer kanseri ile karışan iki endobronşial tüberküloz olgusu . Genel Tıp Derg
2005;15(3):125-128
Endobronchial Tuberculosis (EBTB)
It is one of the complications of pulmonary tuberculosis *.
Endobronchial tuberculosis development insidence is about
5.88 % **.
Real insidence?
* Park MJ, Woo IS, Son JW, et al. Endobronchial tuberculosis with expectoration of tracheal cartilages. Eur RespirJ 2000;15:800-2.
**Chung HS, Lee JH. Bronchoscopic assessment of the evolution of endobronchial tuberculosis. Chest2000;117:385-92.
In our country age distrubution is different from west countries.
In the study of Tahaoğlu and coworkers ıt is reported to be more
frequent in the second and third decades*.
* Tahaoğlu K, Kızkın Ö, Karagöz T ve ark. Endobronşial tüberküloz. Solunum 1993;18:146-53.
Pathogenesis of EBTB is not fully understood.
Five potential mechanisms*:
• Direct extension from adjacent parenchymal focus,
• Implantation of organisms from the infected sputum,
• Hematogenous dissemination,
• Lymph node erosion into the bronchus,
• Through lymphatic drainage from parenchyma to the
peribronchial region.
*Kashyap S, Mohapatra PR, Saini V. Endobronchial tuberculosis.Indian J Chest Dis Allied Sci 2003;45:247-256
Clinical findings are various* ;
cough and sputum production, wheezing , chest pain and fever is
mostly seen during active disease ,
at fibrosis stage dyspnea and wheezing are the main symptoms.
Most frequent symptom is cough **.
* Baran A, Akbaba B, Bilgin S ve ark. Endobronşiyal Tüberküloz: Klinik ve Bronkoskopik Özellikleri.Akciğer Arşivi 2007; 8: 44-7.
** Akman M, Yılmaz T, Çelik N ve ark. Akciğer kanserini taklit eden endobronşiyal tüberküloz. Solunum Hastalıkları 1995;6:441-9.
Differantial Diagnosis of EBTB
• Lung Cancer
• Pneumonia
• Bronchial asthma
• Foreign body
• Athelectasis
• Karsinoid tumour
• Fungal infections
• Lymphoma
• Sarcoidosis
Bacteriologic diagnosis is limited in endobronchial tuberculosis *.
In studies performed in our country bacille positiviy rate is about
14-50% **
* Ip MSM, So SY, Lam WK, Mok CK. Endobronchial tuberculosis revisited. Chest 1986; 89:727-30.
** Kırkıl G, Deveci F, Muz H ve ark Akciğer Kanserini Taklit Eden Endobronşiyal Tüberküloz Olgusu Solunum Hastalıkları2006;17: 88-91.
Radiologic findings are various*;
hilar and perihilar mass,
athelectasis and mediastinal enlargement.
Right lung involvement, especially upper lob is more frequent .
*Kurasawa T, Kuze F, Kawai M, et al. Diagnosis and management of endobronchial tuberculosis. Intern Med 1992;31:593-8.
Saygı et al reported twenty-nine patients with EBTB aged between
12-76. Bronchoscopic examination revealed involvement of
EBTB most frequently at right upper and right main bronchus in
51.7% of the subjects.
In the differential diagnosis of chronic cough resistant to
antitussive therapy, EBTB must be explored in order to prevent
complications*.
*Saygı A, Süngün F, Çağlayan B ve ark. Endobronşial Tüberküloz Olgularının Retrospektif İncelenmesi . İstanbul Tabip
Odası-Klinik Gelişim Dergisi Cilt 9 / No: 12 / Aralık1996
The most frequent bronchoscopic finding is ulceration with mucosal hyperemia and erosion , and granulation tissue *.
Chung and co-workers classified to seven subtypes according to bronchoscopic findings **.
* Saleemi S, Khalid M, Zeitouni M, Al-Dammas S. Tuberculosis presenting as endobronchial tumor. Saudi Med J 2004;25:1103-5.
** Chung HS, Lee JH, Han SK, et al. Classification of endobronchial tuberculosis by the bronchoscopic features. Tuberc Respir Dis 1991;38:108-15.
Classified to seven subtypes according to bronchoscopic findings (I) Actively caseating , (II) Edematous - hyperemic,
(III) Fibrostenotic, (IV) Tumorous, (V) Granular, (VI) Ulserative, (VII) Nonspecific bronchitis (Atatürk Göğüs
Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi 7. Göğüs Hastalıkları Kliniği arşivinden)*
*Yılmaz A, Alıcı O.İ, Demirci N.Y ve ark. Radyolojik Olarak Maligniteyi Taklit Eden Endobronşiyal Tüberküloz
Olgularının Klinik ve Bronkoskopik Özellikleri. Solunum 2011; 13(3): 170–175
I II III
IV V VI VII
THANK YOU …
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