Clinical meeting case presentation in Africa

2. BIODATA
 Mrs. I.B a 48 year old female trader who hails
from Imo State but resides at Rumuigbo, Port
Harcourt.
 Married, a Christian of Pentecostal
denomination with secondary level of
education.

3. PRESENTING COMPLAINT
 Cough X 1 year
 Breathlessness X 1/12

4. HISTORY OF PRESENTING COMPLAINT
 She was in her usual state of health until about a year
prior to presentation when she developed cough which is
said to have been recurrent with current episode noticed
a month ago, productive of copious whitish sputum,
distressful, non paroxysmal, with associated
haemoptysis, drenching night sweat and unintentional
weight loss.

5.  There is no chest pain, fever or history of
contact with chronically coughing adult.
 She does take tobacco products and has no
exposure to biomass fuel, not a known
asthmatic.

6. She has been treated for pulmonary
tuberculosis on three occasions (2000, 2008,
2022 ) in a peripheral hospital and was said
to have completed the six months duration
The first and second PTB diagnosis was
based on sputum AFB result, however, the
third PTB diagnosis was made via chest X-ray.

7. About a month prior to presentation, patient
developed breathlessness which was initially
on moderate activity but progressively
worsened to occur even at rest, there is
associated easy fatigability, orthopnea but no
paroxysmal nocturnal dyspnea, no leg
swelling, abdominal or facial swelling.

8. No history of long distance travel, or recent
surgery.
No frothiness of urine or reduction in urine
output.

9.  At the onset of symptoms, patient was
admitted in a peripheral hospital where
sputum GeneXpert and retroviral screening
done were both negative. With worsening of
symptoms she presented to UPTH for expert
care.

10. PAST MEDICAL HISTORY
Not a known hypertensive and not known to
be living with DM.

11.  No known drug allergy

12.  FAMILY AND SOCIAL HISTORY
 No known family history of Hypertension ,
Diabetes mellitus, Asthma or Epilepsy.
 She is married with three children in a
monogamous family setting.
 Does not take alcohol .

13. SUMMARY
 Mrs. I.B, a 48 year old female who presented with
complaints of recurrent cough of a year duration,
with current episode noticed 1/12 ago and
breathlessness of 1/12 duration, with associated
history of hemoptysis, drenching night sweat,
and unintentional weight loss. There is also a
history of three previous treatment for
pulmonary tuberculosis.

14.  Post TB bonchiectasis in
exacerbation
 Pulmonary TB re-infection
 Chronic Pulmonary Aspergillosis

15. GENERAL EXAMINATION
 Middle aged woman in respiratory distress,
evidenced by intercostal and subcostal
recession, afebrile (36.7*c), pale, anicteric,
acyanosed, not dehydrated, no palpable
peripheral lymphadenopathy, grade 3 finger
clubbing, no pedal oedema.

16.  RR: 40CPM
 Trachea was deviated to the right.
 Reduced chest expansion on the right upper
and mid lung zones.
 Reduced tactile and vocal resonance on the
upper right and mid lung zones,
 Dull percussion nodes on the right upper and
mid lung zone,
 Bronchial breath sounds on the right upper
and mid lung zones, with coarse
crepitations bibasaly
 Other lung zones are essentially normal.
 SPO2: 75% on 4-5l/min of oxygen via nasal
prong.

17.  Pathological summary: right upper and mid
lung zone fibrosis.

18.  Pulse: Rate 100bpm, Full Volume, Regular,
no thickened arterial wall, no locomotor
brachialis.
 Radio-radial synchrony, no radio-femoral
delay.
 Other peripheral pulses were present and
normal.
 Blood Pressure: 130/80mmHg
 Jugular Venous Pressure: not elevated
 Precordium: normoactive
 Apex beat: 5LIS MCL
 Heart sounds: 1st 2nd no murmurs.

19.  Full, moves with respiration
 No area of tenderness
 Liver and spleen not palpably enlarged
 Kidneys not ballotable
 Bowel sounds present and normoactive

20. - Conscious & Alert
- Well oriented in TPP
- No neck stiffness
- No obvious cranial nerve deficit.

21.  TONE - RUL LUL RLL LLL
N N N N
 POWER 5/5 5/5 5/5 5/5
 Normoeflexia on all limbs

22.  Mrs. I.B, a 48 year old female who presented with
complaints of recurrent cough of a year duration,
with current episode noticed 1/12 ago and
breathlessness of 1/12 duration, with associated
history of hemoptysis, drenching night sweat, and
unintentional weight loss. There is also a history
of three previous treatment for pulmonary
tuberculosis. In respiratory distress, pale with
grade 3 finger clubbing and Pathological summary:
right upper and mid lung zone fibrosis.

23.  Post TB bronchiectasis in
exacerbation to r/o chronic
pulmonary Aspergillosis and PTB
reinfection.

24.  CXR,
 Sputum GeneXpert,
 Sputum MCS,
 FBC +ESR,
 LFT, E/U/Cr
 RVS, HBsAg, HCVAb,
 Urinalysis,
 Chest CT Scan.
 Aspergillus IgG serology,
 Sputum Fungal MCS.

25.  IV Augmentin 1.2g 12 hourly X 5/7
 Tabs Azithromycin 500mg daily X5/7
 Tabs prednisolone 30mg mane X 5/7
 Caps omeprazole 40mg daily X 5/7
 Tabs Albendazole 400mg stat
 S/c Enoxaparin 40mg dialy X 5/7
 Oxygen @ 8-10L/min via non
rebreather face mask.
 Encourage chest physiotherapy
 KIV ICU admission

26. INVESTIGATION RESULT RANGE REMARK
1.FBC
PCV:
WBC:
NEU:
LYMPH:
MONO:
ESR:
RVS:
HBSAg
HCV
34 %
7.5X 10^9/L
74%
10%
14%
75mm/hr
Sero negative
Non reactive
Non reactive
40-54%
4-10.810^9/L
40-75
20-45
2-10
0-22mm/hrs
Low
Normal
Normal
Low
Low
High
2. Serum
E/U/Cr
Sodium:
Potassium:
Bicarbonate:
Urea
Creatinine
128mmo/l
3.6mmol/
24mmol/l
4.8mmol/l
60mmol/l
135-145mmol/l
3.5-55mmol/l
24-30mmol/l
2.4-6.2mmol/l
60-130mmol/l
Low
Normal
Normal
Normal
normal

27. INVESTIGATION RESULT REMARK
URINALYSIS
WET PREP:
COLOUR:
SG
PH:
GLUCOSE:
PROTEIN:
NITRATE:
KETONE;
BLOOD:
LEUCOCYTE:
bacteria +
amber
1.020
6.5
NEG
15mg/dl
NEG
NEG
NEG
NEG

28. LIVER FUNCTION
TEST
VALUE RANGE REMARK
TOTAL BILIRUBIN 6uMOL/L ( 2-21 ) Normal
AST 21uMOL/L ( < 31 ) Normal
ALT 28 umol/L ( < 35 ) Normal
ALP 60umol/L ( 30-120 ) Normal
GGT 36umol/L (( < 32 ) Normal
TOTAL PROTIEN 77g/L ( 66-83 ) Normal
ALBUMIN 35g/L ( 35_ 52 ) Normal
SPUTUM GENEXPERT: MTB NOT DETECTED.

29. Widespread reticular opacities with background
cystic changes in both lung fields.
An ill defined thick walled rounded cavity is
seen in the right upper lung zone and left
mid lung zone, measuring 4.0 x 3.5cm and
4.5 x 4cm respectively.
IMP: Features are in keeping with pulmonary
tuberculosis r/o reactivation.
DD: Interstitial Lung Disease.

30.  Patient showed mild clinical improvement
evidenced by regression of symptoms (cough
and breathlessness).
 A diagnosis of post TB bronchiectasis
exacerbated by chronic pulmonary
aspergillosis was made and patient was
encouraged to do Chest CT, Aspergillus
fumigatus IgG and sputum fungal analysis.

31.  PLAN:
 Tabs Itraconazole 200mg BD
 Caps Astyfer T daily
 One egg white daily
 Tabs Augmentin 1g bd for 7 days
 Tabs prednisolone 20mg mane
 Tabs Xarelto 10mg dly
 Intranasal Oxygen therapy @ 4-5l/min.
 Encourage Patient to do outstanding
investigations.

32.  Sputum MCS; moderate growth of candida
albicans spp.
 Plan;
 Fortide Inhaler1 puff bd x 2/52
 Reduce oxygen flow to 2-3L/min
 Sample was sent for Aspergillus fumigatus
IgG and fungal study.
 Continue ongoing treatment.

33. Extensive fibro-cystic changes in the right lung
fields with associated tracheal deviation to
the right.
Note also opacifications of the lung apices,
worse on the right.
Thin walled cysts are also seen in the right
apex.
IMP: findings are in keeping with pulmonary TB
with upper lobar fibro-cystic changes
?activity.

34. Patient has made significant clinical
improvement, still on low flow intermittent
oxygen therapy.
c/o mild leg swelling
PLAN:
Continue intermittent oxygen @ 1-2L/min
Tabs frusemide 20mg daily x 1/52
Counsel on the need for LTOT
Continue ongoing management.

35.  Patient has made remarkable improvement,
could walk a short distance without oxygen
though desaturates intermittently.
 Aspergillus Fumigatus IgG ( Positive )
 Value: 340 mgA/L (0.00 – 66.45)
 Leg swelling has subsided
 Patient was no longer coughing and
breathless.
 Care givers were able to provide oxygen
concentrator.

37. PLAN:
Tabs Voriconazole 200mg bd x 2/52
Tabs Xarelto 10mg dly x 2/52
Tabs Astyfer T dly x 2/52
Fortide inhaler 1 Puff bd
Intranasal 02 via concentrator PRN
Discharge Home
Counsel on the need for COVID-19 vaccine &
pneumovax.
See in MOPC ( respiratory clinic in 2/52)

38.  c/o leg swelling and abdominal swelling.
 Echocardiography done at the peripheral
hospital showed LV concentric remodeling
with reduced LV systolic function and grade 3
diastolic dysfunction.
 There is hypokinesia of the septal wall of LV,
no intracardiac shunt, thrombi or vegetations
noted.
 The internal diameter of RV and RA are
severely dilated, the pulmonary artery
appears dilated.

40. A diagnosis of cor-pulmonale with pulmonary
hypertension from post TB lung
disease/chronic pulmonary Aspergillosis was
made.

41.  Tabs Voriconazole 200mg BD X 1/12
 Tabs Frusemide 40mg BD X 2/52
 Tab Sprinolactone 25mg daily X 2/52
 Tabs Xarelto 10mg daily X 2/52
 Tabs Tadalafil 10mg daily x 2/52
 Continue LTOT
 Refer to cardiology clinic.