10 year old boy opaque hemithorax - tb , presented in pulmocon 2019

1. Pulmocon
“2019

2. MEET THE EXPERTS

3. A 10 year Old Boy with
Opaque Hemithorax
Dr Tanveer Kamal
Resident–Phase B , MD (Pulmonology)
National Institute of Disease of Chest
and Hospital (NIDCH)

4. Particulars of the Patient
 Master Arman
 10 years
 Madhabpur, Habigonj
 Admitted on 20/10/19

5. Chief Complaints
 Fever for 8 months
 Cough for 8 months
 Shortness of breath for same duration

6. H/O of Present Illness

7. Quite well 8 months back
Fever
-Initially high grade
-Later low grade,recurrent,
intermittent
-Associated with
chills,sweating
-partially responding to
antipyretics
Cough with sputum
production
-Usually mucoid
-Occasionally
purulent,foul smelling
- 3-4 teaspoons every
day
-no hemoptysis
Occassional
Breathlessness
-Associated with
fever &cough
-mMRC grade II

8. Frequently suffered from respiratory tract infections
since early childhood
Past illness

9. Birth and Development History
 Uneventful pregnancy period
 Born of normal vaginal delivery at home
 No complications occurred during and immediately
after delivery

10.  Developed respiratory distress one week after birth
 Treated by village physicians
 All the developmental milestones were delayed
 That’s why , could not go to school and was
incapable of actively playing in the fields

11. Family History
• 2 brothers and 1 sister
• Parents have consanguineous marriage
• All are in good health

12. GENERAL EXAMINATION

13.  Ill-Looking
 Underweight
- BMI 13.9 kg/m²
 Anaemic
 Clubbing present
 Cervical Lymphadenopathy
( Right & left Posterior )
 Pulse: 100 beats/min
 Temperature: 99°F
 Respiratory rate: 16 /min
 Blood pressure: 100/70
mmHg

14. SYSTEMIC EXAMINATION

15. RESPIRATORY SYSTEM EXAMINATION

17. No abnormality
OTHER SYSTEMIC EXAMINATION

18. INVESTIGATIONS

19. Complete Blood Count 22/10/19 30/10/19
Hb 9.3 gm/dl 10 gm/dl
ESR 120 mm 1st hr 70mm 1st hr
Total WBC count 13,800/cu.mm 17,000/cu.mm
Neutrophil 75% 82%
Lymphocyte 21% 12%
Eosinophil 03% 04%
Basophil 00 00%
Monocyte 01% 02%

20. Sputum Culture No growth
Sputum for AFB Absent
Sputum for Gene
Xpert
Absent
MT Negative ( 2 mm )
S. Creatinine 0.6 mg/dl
SGPT 19 u/L
RBS 5.9 mmol/l
Fasting Blood
Glucose
4.5 mmol/l
2 Hour After Meal 4.8 mmol/l
HbA1c 5.9%
Serum FT4 23.2 pmol/L
(reference range
11.4-22.1)
Serum TSH 1.86uIU/ml
(reference range
0.7-5.7 for 02-15
yrs)
Serum Albumin 3.8 g/dl

21. FIBER OPTIC BRONCHOSCOPY
• Comment : Inflammatory lesion (left)
• BAL for AFB : Negative
• BAL for Cytology : Negative for malignant cell
• BAL fungal stain : Negative
• BAL for C/S : Acinetobactor
(Sensitive to: Ciprofloxacin,Levofloxacin,Co-
Amoxyclav,Cephalexin,Amikacin,Pipercilin-
Tazobactum,Colistin,Tigecyclin )

22. USG of Whole Abdomen Normal Study
Lymph Node FNAC
(Posterior Cervical )
Reactive Change
Sweat Chloride Test 41.17 mEq/L
( 40-60 mEq/L – borderline
> 60 mEq/L – positive )
IgG 21 g/l
(reference value 7-16g/l)
IgM 1.27 g/l
(reference value 0.4-2.3 g/l)
IgA 0.699 g/l
(reference value 0.7- 4.0 g/l)

23. Chest X-ray done
on 8/9/19

24. Chest X-ray done
on 17/9/19

25. Chest X-ray done
on 25/9/19

26. Chest X-ray done
on 17/10/19

27. CXR done
on 5/11/19

28. X-ray PNS

29. CT scan of
chest done
on 26/9/10

33. What is the diagnosis ???
Diagnostic Dilemma

34. What should be the management plan
in this child ??
Further Dilemma