Anwser,s Dr :ANAS SAHLE 1. Chest clinical case. 2. Chest ct cases. 3. MRCP exam.:http://www.facebook.com/dranas224?ref=hl Saturday, November 17, 2012
chest clinical cases A Pregnant Woman with Fever and Respiratory FailureSubmitted bySonia Vishin, MDFellowDivision of Pulmonary, Allergy and Critical Care MedicineUniversity of Alabama at BirminghamJody Hunt, MDFellowDivision of Pulmonary, Allergy and Critical Care MedicineUniversity of Alabama at BirminghamKeith Wille, MDAssociate ProfessorDivision of Pulmonary, Allergy and Critical Care MedicineUniversity of Alabama at Birmingham
History• A 28-year-old white female at 29 weeks gestation, G2P1, presented to the emergency department with increasing shortness of breath and fever for 3 days.• She also endorsed nausea, loose bowel movements and emesis for 2 days prior to admission.• Prior to this, she was in her usual state of health.• She denied cough, chest pain, joint pain, rash or hemoptysis.• Her past medical history was significant for well-controlled asthma.• However, over the last few days, she had been using her rescue inhaler up to 8 times a day.• She denied any sick contacts.• She had one previous full-term pregnancy and delivered vaginally, with no complications.• Her family history was significant for both parents having hypertension and diabetes mellitus.• Her father also had congestive heart failure.• The patient smokes one pack of cigarettes per day but denies alcohol or illicit drug use.• She is married and lives with her husband and child.• Her medications at the time of admission included folic acid, prenatal vitamins, fluticasone/salmeterol and albuterol MDI as needed. Saturday, November 17, 2012
Physical Exam• On examination, the patient’s pulse was 94 beats per minute and regular.• She had a: – temperature of 101.3 degrees Fahrenheit . – blood pressure of 98/31 mm Hg. – Her oxygen saturation was 84% on 100% O2 by nonrebreather mask . – respiratory rate of 32 breaths per minute.• Cardiovascular exam revealed no murmurs.• Respiratory exam showed bilateral crackles.• Abdominal exam showed gravid uterus, otherwise unrevealing Saturday, November 17, 2012
Lab• Serum chemistries were significant for a: – bicarbonate level of 18 mEq/L . – creatinine of 1.5 mg/dl – Complete blood count was significant for WBC 12.5 x 10^3, – platelet count 145 x 10^3, – hemoglobin 9.4 g/dl. – Differential count was 90% segmented neutrophils and 8% lymphocytes.• Urinalysis showed 3+ blood, 1+ ketones, 1+ protein• Liver function profile was significant for : – AST 148, – ALT 32• Rapid flu test was negative. Saturday, November 17, 2012
Chest radiograph is shown Saturday, November 17, 2012
Continue..• She was intubated urgently for respiratory failure.• Based on the chest radiograph and lab studies, further work up was done, including bronchoscopy with bronchoalveolar lavage (BAL):• BAL fluid: – CMV culture negative – Viral culture negative – Viral respiratory panel positive for Influenza A – Legionella culture negative• Blood cultures negative• Urine Legionella antigen negative• Transthoracic echocardiogram – bilateral ejection fractions >55%, no vegetations, no significant valvular disease Saturday, November 17, 2012
Q1• What is the most likely diagnosis? – A. Community acquired pneumonia – B. Influenza A H1N1 – C. Fungal pneumonia – D. CMV pneumonitis – E. Congestive heart failure Saturday, November 17, 2012
Discussion• Influenza A (H1N1) is a novel strain which has reached pandemic levels this year.• At the time of her illness, 97% of the circulating influenza A virus was the novel strain, H1N1(1).• The virus is spread by respiratory droplets and by contact with contaminated surfaces.• The groups at highest risk for influenza A (H1N1) include pregnant women, children <5 years of age, the elderly, people with chronic co-morbid conditions such as liver disease or heart disease and patients who are immunosuppressed.• The clinical presentation is similar to seasonal Influenza and includes high fevers, cough, shortness of breath, rhinorrhea, headache, myalgias, nausea and vomiting (3).• Rapid influenza testing is reported to have a low sensitivity (10-50%) for novel influenza A (H1N1), and therefore rapid testing methods should not be relied upon to exclude the presence of disease.• The diagnosis is established definitively by PCR analysis of respiratory fluid (3).• However, the diagnosis is highly suspected in patients with positive rapid testing for influenza A and treatment should be initiated immediately.• Pregnant women are at higher risk during their pregnancy and 2 weeks post-partum(4).• Poorer outcomes in mothers and newborns have been associated with novel influenza A.• The spectrum of perinatal complications includes: preterm labor and birth, pneumonia, acute respiratory distress syndrome and death.• Some risk factors among pregnant patients have been identified and include obesity, current cigarette smoking and third trimester of gestation (4). Saturday, November 17, 2012
Discussion• This patient ultimately had BAL fluid PCR test positive for influenza A H1N1.• She developed ARDS and had a prolonged ICU course on mechanical ventilatory support. Saturday, November 17, 2012
Question 2• What is the best treatment for this patient?• A. Theraflu• B. Oseltamivir• C. Amantadine• D. Zanamivir• E. Peramivir Saturday, November 17, 2012
Question 3• Which of the following patients does not initially require influenza A H1N1 vaccination?• A. Healthy 19-year-old male• B. 43-year-old female with asthma• C. 70-year-old male• D. 30-year-old healthy female with 4-month- old son• E. 55-year-old nurse Saturday, November 17, 2012
Discussion• The CDC recommends that the first groups who should be immunized against novel influenza A (H1N1) include: – pregnant women, – caretakers of children under the age of 6 months, – healthcare and emergency service workers, – those between the ages of 6 months and 24 years and – those aged 24-64 years who have chronic co-morbid conditions that put them at higher risk .• Once all these at-risk groups receive the vaccine, it will then be offered to all persons above the age of 65.• The FDA has approved a one-dose vaccine for all persons above the age of 10.• Infants under the age of 6 months should not be immunized.• There are two vaccine forms available.• The first is an inactivated virus vaccine, which is administered by intramuscular injection.• The second is a live virus vaccine, which is administered Saturday, November 17, 2012 intra-nasally.
HRCT-3• Find 3 pleural nodules in the right lung.• Find an example of thickened bronchovascular interstitium in the right lung.• Find thickened fissural pleura with nodules along the outer portion in the left lung.• Find interlobular septal nodules.
HRCT-4• Find nodules along 2 interlobular septa originating from the right fissure.• Find a group of centrilobular nodules in the right lung. Outline this group of centrilobular nodules.• Find a nodule at the proximal end of thickened bronchovascular interstitium in the right lung.
Pleural AbnormalitiesThe pleural surface ofthis lung shows multiplenodules correspondingto the pleural nodulesnoted in the first imageabove.
HISTOLOGY What is the histologic distribution of the lesions? B = Bronchovascular bundle I = Interlobular septum
HISTOLOGY High magnification of a single nodule illustrated above. What is the diagnosis of this lesion?
HISTOLOGY High magnification of a single nodule illustrated above. What is the diagnosis of this lesion? Non-necrotizing granuloma composed of epithelioid histiocytes, multinucleated giant cells, and lymphocytes
DISCUSSION• Differential diagnosis of nodules and lines on HRCT: Diagnoses include – sarcoidosis . – lymphangitic tumor.• Architectural distortion, as shown on image 2 is frequent in sarcoidosis, but not with lymphangitic tumor.• Histologic differential diagnosis: – Infectious granulomatous disease (tuberculous or fungal). – Sarcoidosis. – hypersensitivity pneumonia (granulomas are usually less well-formed). – and reaction to tumor or drug should be considered.
Diagnosis: Sarcoidosis.• Summary of diagnostic features of sarcoidosis on HRCT – Pleural, bronchovascular and interlobular septal interstitial nodules – Upper lung predominance common – Architectural distortion frequent
Q1An 18 month old boy presents with recurrent cough.The following make a diagnosis of recurrent aspiration more likely:A- Cerebral palsyB- History of coughing with feeds .C- Presence of dextracardia .D- Presence of failure to thrive .E- Coughing spasms ending in vomiting . 11/17/2012
A1An 18 month old boy presents with recurrent cough.The following make a diagnosis of recurrent aspiration more likely:A- Cerebral palsy (true)B- History of coughing with feeds .(true)C- Presence of dextracardia .(false)D- Presence of failure to thrive .(false)E- Coughing spasms ending in vomiting .(false) 11/17/2012
Q2Acute laryngotracheal bronchitis(croup):A- Is usually caused by RSV infection.B- Is usually preceded by 2-3 days of coryza.C- Responds best to risinic adrenaline.D- If agitated, the patient should receive mild sedation.E- May require intravenous antibiotics 11/17/2012
A2Acute laryngotracheal bronchitis(croup):A- Is usually caused by RSV infection. (false)B- Is usually preceded by 2-3 days of coryza. (true)C- Responds best to risinic adrenaline. (false)D- If agitated, the patient should receive mild sedation.(false)E- May require intravenous antibiotics(true) 11/17/2012
Q3Characteristic features of obstructivesleep apnoea/hypoventilation include:A- Apnoea occurring during REM sleep.B- Symptoms developing after tonsillectomy.C- Desaturations detected by pulse oximeter.D- Chronic hypercapnia.E- Association with Downs Syndrome. 11/17/2012
A3Characteristic features of obstructivesleep apnoea/hypoventilation include:A- Apnoea occurring during REM sleep.(true)B- Symptoms developing after tonsillectomy.(false)C- Desaturations detected by pulse oximeter. (true)D- Chronic hypercapnia.(true)E- Association with Downs Syndrome.(true) 11/17/2012
Q5Regarding central cyanosis:A- It can be reliably diagnosed when >5g/dl ofdesaturated haemoglobin are present.B- If the haemoglobin is 6g/dl, the child will be pre-terminal before cyanosis appears.C- Central cyanosis is indicated by circum-oralblueness.D- It can be associated with a normal arterial PO in 2methaemoglobinaemia.E- May be caused by right to left shunts 11/17/2012
A5Regarding central cyanosis:A- It can be reliably diagnosed when >5g/dl ofdesaturated haemoglobin are present. (True)B- If the haemoglobin is 6g/dl, the child will be pre-terminal before cyanosis appears. (True) .C- Central cyanosis is indicated by circum-oral blueness. (false)D- It can be associated with a normal arterial PO in 2methaemoglobinaemia. (True)E- May be caused by right to left shunts (True) 11/17/2012
Q6Wheeze in infancy:A- Is strongly associated with bronchial hyper-reactivity.B- Is indicative of chronic respiratory symptomsneeding inhaled corticosteroids therapy.C- As responsive to bronchodilator therapy as witholder children.D- Is not correlated with family smoking habits.E- Has a good prognosis. 11/17/2012
A6Wheeze in infancy:A- Is strongly associated with bronchial hyper-reactivity. (True)B- Is indicative of chronic respiratory symptoms needing inhaled corticosteroids therapy. (false).C- As responsive to bronchodilator therapy as with older children. (false).D- Is not correlated with family smoking habits. (false).E- Has a good prognosis. (True) 11/17/2012
Q7The following are characteristicpresentations of cystic fibrosis:A- A 26 week gestation infant with x-ray appearance ofmeconium ileus.B- An 8 month old girl admitted the second time withlower respiratory tract changes on chest x- ray.C- A 9 month old Indian girl with failure to thrive.D- A 3 week old term female with prolongedunconjugated jaundice.E- A 4 year old boy with mouth breathing due to nasalpolyps 11/17/2012
A7The following are characteristicpresentations of cystic fibrosis:A- A 26 week gestation infant with x-ray appearance ofmeconium ileus. (true)B- An 8 month old girl admitted the second time withlower respiratory tract changes on chest x- ray. (true)C- A 9 month old Indian girl with failure to thrive.(false)D- A 3 week old term female with prolonged un-conjugatedjaundice.(false)E- A 4 year old boy with mouth breathing due to nasalpolyps (true). 11/17/2012
Q8Bronchiolitis:A- Is rare outside infancy.B- Is usually caused by parainfluenza viruses.C- May be caused by influenza viruses A or B.D- Commonly presents with cough and wheeze.E- Paroxysms of coughing can be mistaken forpertussis 11/17/2012
A8Bronchiolitis:A- Is rare outside infancy. (true)B- Is usually caused by parainfluenza viruses.(false)C- May be caused by influenza viruses A or B.(true)D- Commonly presents with cough and wheeze.(true)E- Paroxysms of coughing can be mistaken forpertussis. (true) 11/17/2012
Q9Regarding total lung capacity:A- It is a specific measure of lung size.B- It depends on the thickness of the alveolarwall.C- It is reduced in severe cerebral palsy.D- It is increased in infants with cystic fibrosis.E- It can be measured by the helium dilutiontechnique 11/17/2012
A9Regarding total lung capacity:A- It is a specific measure of lung size. (true)B- It depends on the thickness of the alveolar wall.(false)C- It is reduced in severe cerebral palsy. (true)D- It is increased in infants with cystic fibrosis.(false)E- It can be measured by the helium dilutiontechnique. (true) 11/17/2012