Transcript Commenatry case

Commenatry
case
By
Prof Dr /Fawzy Megahed
Asst lec /Rafaat Saied
• A 71-year-old man had been well until
approximately 6 months before this
admission, when fatigue, fever, chills,
shortness of breath, and erythema in the right
leg developed. The condition was associated
by myalgia arthralgia ,headache
• A chest radiograph showed band atelectasis in
the left lower lobe.
• Computed tomography (CT) of the chest that
was performed on the same day revealed
multifocal bilateral ground glass opacities
throughout the lungs, consolidation in the
lingula and lower lobes, and enlarged
mediastinal lymph nodes.
• During the next 6 months, multiple episodes
occurred that consisted of fatigue and
decreased appetite, followed by chills, severe
weakness, dyspnea, fevers (to a temperature
of 39.4°C), and hypoxemia.
• During that time, the patient was admitted
at least six additional times to two different
hospitals.
• Multiple CT scans of the chest, the most
recent of which had been obtained 6 weeks
before this admission, showed improvement
of the air-space opacities in the lower lobes
but persistence of the upper-zone groundglass opacities.
• Transthoracic echocardiography were normal,
• An electrocardiogram revealed sinus
tachycardia at a rate of 102 beats per minute
• Bronchoscopic examination with bronchoalveolar
lavage (BAL) was performed 3.5 months before
this admission, and the BAL fluid reportedly
contained 30% neutrophils, 24% lymphocytes,
32% macrophages, and 2% eosinophils.
• A video fluoroscopic swallowing study
revealed mild oropharyngeal dysphagia that
cleared with spontaneous subsequent
swallows.
• CT of the sinuses revealed moderate
opacification in the left maxillary sinus and left
infundibular obstruction.
• He reported night sweats, weight loss of 6.4
kg that he attributed to multiple
hospitalizations and no wheezing, cough,
chest pain, difficulty swallowing, or known
aspiration.
• He had hypertension, dyslipidemia, mild
psoriasis,, and depression.
• He lived with his wife and three adult dogs,
worked primarily in an office.
• No known exposure to asbestos, birds,
reptiles, or hay.
• Medications were atorvastatin, omeprazole,
and fluoxetine. He was allergic to
cephalosporins
• There was no family history of lung or
autoimmune disease.
TO SUMMERIZE
• This 71-year-old man presented with a 6month history of episodes of intermittent
fatigue, decreased appetite, fever, dyspnea,
hypoxemia,
• pulmonary infiltrates, and elevated
inflammatory markers that typically resolved
within 8 days.
• usually after the administration of antibiotics
and without the administration of systemic
glucocorticoids.
• There were no definite inciting events or
environmental exposures and no clearly
effective interventions.
Examination
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the temperature was 38.9°C,
the blood pressure 155/76 mm Hg,
the pulse 104 beats per minute,
the respiratory rate 24 breaths per minute, and
the oxygen saturation 93% while the patient was
breathing ambient air.
The remainder of the examination was
unchanged
• body-mass index 28.1.
• The chest rose symmetrically, without use of
accessory muscles or wheezing. Sparse
crackles were heard at the right lung base,
• and 1+ leg edema was present, without
cyanosis or clubbing.
• The remainder of the examination was
normal.
LABOTATORY
• The platelet count, red-cell indexes, plasma
anion gap, and results of serum
electrophoresis and tests of coagulation,renal
and liver function were normal,
• blood levels of electrolytes, calcium, ionic
calcium, albumin, globulin, lactic acid,lactate
dehydrogenase, ferritin, Vitamin B12, folate,
IgG, IgA, and IgM were normal,
• Blood levels of N-terminal pro–B-type
natriuretic peptide (NT-proBNP) , troponin T
and thyrotropin were normal.
• serum testing for galactomannan, 1,3-β-dglucan were normal.
• Other test results are shown in Table 1.
• combined positron-emission tomography and
CT revealed widespread bilateral groundglass
opacities and associated peri bronchiolar
consolidation predominantly in the lower
lobes; these findings had minimal 18Ffluorodeoxyglucose avidity.
D:D
• Microbiologic testing and cytologi
examination were negative
• Blood cultures were sterile, and results of
urine cultures were consistent with
contamination.
• Testing for antineutrophil cytoplasmic
antibodies, anti-PR3 and anti- MPO
antibodies, antibodies to double-stranded
DNA, and antinuclear antibodies was negative
The differential diagnosis of chronic
peripheral consolidation Includes
1. Organizing pneumonia.
2. Sarcoidosis.
3. Cancer, including lymphoma and
adenocarcinoma.
4. Hypersensitivity pneumonitis .
5. Desquamative interstitial pneumonia.
6. Alveolar hemorrhage.
7. OTHERS.
Sarcoidosis
• Sarcoidosis is unlikely because of the rapidly
relapsing and remitting nature of the
pulmonary infiltrates, the atypical findings on
imaging studies.
Alveolar hemorrhage
• Alveolar hemorrhage can have an intermittent
course, and the absence of hemoptysis in this
patient does not rule out this diagnosis.
• However, blood tests for anti-PR3 and antiMPO antibodies were negative, and no blood
was reportedly present in the BAL fluid;
therefore, vasculitis-associated alveolar
hemorrhage is unlikely.
Hypersensitivity Pneumonitis
• This patient’s history suggests acute exposure
related hypersensitivity pneumonitis, since his
condition seemed to rapidly improve when he
was in the hospital, presumably after he was
removed from exposure to the unidentified
offending agent.
• The absence of any known suspicious
occupational, avocational, or medication
exposures does not rule out the diagnosis of
hypersensitivity pneumonitis
• The nodules and ground-glass opacities that
were seen on multiple imaging studies are
consistent with hypersensitivity pneumonitis;
• patients with this diagnosis may have groundglass opacities, nodules, air trapping, reticular
changes, and in chronic cases, fibrosis.
• However, the patient had no known exposures
and his symptoms recurred.
• these features are not consistent with an
exposure-related diagnosis, unless repeated
exposure resulted in persistent inflammation.
• On the fourth day, the percentage of
eosinophils in the peripheral blood rose to
5.9% (reference range, 0 to 5), with an
absolute eosinophil count of 320 per cubic
millimeter.
• Bronchoscopic examination with BAL was
performed, and the BAL fluid contained 58%
macrophages, 18% neutrophils, 10%
lymphocytes, 2% monocytes, and 12%
eosinophils;
• the fluid also contained 19% CD4+ T
lymphocytes (reference range, 40 to 58) and
57% CD8+ T lymphocytes (reference range, 10
to 40),
with a CD4:CD8 ratio of 0.33 (reference range,
0.56 to 4.27).
• No ova or parasites were seen in a stool
specimen.
• antibodies to strongyloides was negative.
• thick and thin blood smears for parasites;
blood levels of total tryptase, mature tryptase,
IgG, IgA, IgM, and IgE were normal
• Polymerase-chain-reaction testing for
adenovirus was negative.
• No organisms or malignant cells were seen,
and
• pathological examination of a transbronchialbiopsy specimen reportedly showed evidence
of acute focal lung injury ,hyperplasia of type
II pneumocytes, and mild chronic interstitial
pneumonitis.
•THE DIAGNOSIS
IS ------------------
Eosinophilic lung disorders
1. Chronic eosinophilic pneumonia.
2. Acute eosinophilic pneumonia.
3. Eosinophilic granulomatosis with
polyangiitis.
4. The hypereosinophilic syndrome.
5. Eosinophilia associated with one of many
other disorders.
• What is the next step ?
•A thoracoscopic lung
biopsy
• A Lung Biopsy in this otherwise healthy man
who has a recurrent lung disease that appears
to be one of
• several plausible interstitial lung diseases,
• each with a different prognosis and approach
to management.
• The patient underwent a thoracoscopic lung
biopsy
• On histopathological examination of the
frozen sections, some lobules of lung had
alveolar filling with histiocytes. Some alveoli
contained scattered eosinophils amid the
histiocytes
• and other alveoli contained large numbers of
eosinophils that accounted for up to 10% of
the cells.
• Eosinophils could also be found in the
interstitium around blood vessels (Fig. 2A and
2B).
Differential Diagnosis
Chronic Eosinophilic Pneumonia
• Interstitial lung disease due to chronic
eosinophilic pneumonia.
Chronic Eosinophilic Pneumonia
• The features of this patient’s clinical
presentation are consistent with chronic
eosinophilic pneumonia but not with the
other eosinophilic disorders.
• Chronic eosinophilic pneumonia tends to
occur in nonsmoking women who are in their
40s.
• features of the presentation include an
indolent cough, dyspnea, fever, and migratory
pulmonary infiltrates.
• Affected patients typically have eosinophilia in
peripheral blood and in BAL fluid.
• It is important to rule out other causes of
eosinophilia.
• Chronic eosinophilic pneumonia generally
does not resolve spontaneously but does
respond quickly to glucocorticoids
• However, he is not a middle-aged woman, his
lungs had spontaneous improvement without
glucocorticoid therapy, and there was a
paucity of eosinophils in the BAL fluid and
peripheral blood.
• the diagnostic yield of transbronchial biopsy is
often limited by inadequate sample size of
alveolar tissue and by crush artifact.
• In addition, a small sample may not indicate
the full scope of pathological features that
would be present in a larger sample of lung
tissue, particularly in a patient with interstitial
lung disease.
Management
•Glucocorticoid therapy
(prednisone, 40 mg daily) and
• appropriate gastrointestinal and infectious
prophylaxis were administered
• Chest radiography was stable, and pulmonaryfunction tests suggested only a mild restrictive
defect.
• The patient was discharged home on the
seventh hospital day. Six months after
discharge, the patient had not had a
recurrence of the acute episodes, was gaining
weight, and had normal oxygen saturation
while he was breathing ambient air.
Thanks