pulmo case pres raw

8/8/2019 Pulmo Case Pres Raw

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JF

24 MUnemployed

Admitted at PGH last Aug 5, 2010 for Surgery

CC: incidental finding of pulmonary nodule on

radiograph (CXR)


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1 YR 10 MOS PTA

PRE-EMPLOYMENT EVALUATION:pulmonary nodule on CXR

(-) cough(-) fever(-) weight loss

(-) dyspneaCT: solitary, well circumscribed nodulemeasuring 1 cm


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These are chest x-ray plates taken in PA view. There is well-

defined nodule on the R upper lung field. The rest of the lung isclear. Ratio. The heart is not enlarged. Trachea is midline.Costophrenic angles and hemidiaphragms are intact. Osseousstructures are unremarkable.


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CT Nov 4 2008


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Multiple axial tomographic sections of the thorax with and without IV contrastwere obtained. No untoward reactions observed.

There is a smoothly marginated nodule with peripheral calcification at the anteriorsegment of the right upper lobe measuring 0.7 x 0.8 x 1 cm.

The rest of the lungs are well serated. No calcifications are noted. There is noatelectasis demonstrated. No signs of pleural thickening or pleural fluid collectionseen. The mediastinum , heart and blood vessels are normal. There are noenlarged nodes. The extrathoracic tissues are not unusual.

The bony thorax, including the ribs, vertebrae and sternum are unremarkable.

The visualized portions of the liver, gallbladder, spleen pancreas and kidneys areunremarkable. There are no adrenal masses.

IMP RESSION: P ulmonary nodule, probably inflammatory in nature, R upper lobe


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CT Nov 4 2008

Nodule measuring 1.0cm in the anteriorsegment of the RUL

- calcifications- atelectasis- pleural fluid collection

Normal mediastinum and heart- enlarged nodesUnremarkable bony landmarks


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1 YEAR PTA

CT: no change in the size of the noduleAFB: (-) x3


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C T Aug 2009

no significant change in the size and character of the smooth marginated nodule (9months)peripheral calcification at anterior segment of RUL (0.7cm x 0.8cm x 1cm)rest of lungs are well aerated- atelectasis

- pleural thickening/pleural fluid collectionIMP RESSION: Solitary pulmonary nodule, RUL,unchanged since 11-04-08


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Present CT images reveal no significant change in the size and character of thepreviously noted smoothly marginated nodule with peripheral calcification at theanterior segment of the right upper lobe measuring 0.7 x 0.8 x 1 cm.


The bony thorax, including the ribs, vertebrae and sternum are unremarkable.The visualized portions of the liver, gallbladder, spleen pancreas and kidneys areunremarkable. There are no adrenal masses.

IMP RESSION: Solitary pulmonary nodule, unchanged, R upper lobe


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3 MONTHS PTA

CT: cavitary pulmonary noduleNo symptoms

Surgeon: Advised to have resection of thenodulePulmonologist: Anti-Koch


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These are chest x-ray plates taken in PA view. There is well-defined nodule onthe R upper lung field. The rest of the lung is clear. Ratio. The heart is notenlarged. Trachea is midline. Costophrenic angles and hemidiaphragms areintact. Osseous structures are unremarkable.


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C T June 2010

Marginated nodule with peripheralcalcification described to be a thin walledlucency (0.9 x 1.4 x 1.1 cm)- parenchymal lesionRest of the previous finding are unchangedIMP

RESSION

: Cavitary formation, RUL


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Present CT images reveal that the previous smoothly marginated nodule has acavitary formation at the anterior segment of the right upper lobe.


The bony thorax, including the ribs, vertebrae and sternum are unremarkable.

The visualized portions of the liver, gallbladder, spleen pancreas and kidneys areunremarkable. There are no adrenal masses.

IMP RESSION: Cavitary formation, R upper lobe


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ROS

(-) cough(-) fever

(-) dyspnea(-) chest pain(-) weight loss

(-) abdominal pain(-) dysuria(-) change in bowel movement


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PERSONAL/SOCIAL HISTORY

Non smokerNon alcoholic beverage drinker

No drug use


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PAST MEDICAL HISTORY

No PTBNo comorbid


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FAMILY MEDICAL HISTORY

(+) Lung Cancer cousin(+) thyroid cancer cousin


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PHYSICAL EXAMINATION

Awake, not in cardiorespiratory distressBP: 120/80 HR: 75 RR: 18 T: afebrile

Pink conjunctivae, anectericsclerae, (-) CLADVesicular breath sounds, (-) rales, (-) wheezeDistinct heart sounds, normal rate, regular

rhythm, (-) murmurFlabby, soft, normoactive bowel sounds, (-)mass

Full pulses, (-) edema, (-) clubbing


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LABS


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DIAGNOSTICS

1 year P TAa. Sputum AFB

-result: (-) 3x-suggests negative mycobacterial infection

b. CT-GAB-patient did not consent

02 August 2010c. CBC

-result: normal WBC, neutrophil, platelet count-suggests absence of systemic infection


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06 August 2010d. blood chemistry

-result: normal except for elevated liver enzymes-differentials: liver injury (viral infection), normal consequence of an ongoing infection, possible

malignancy-also to evaluate the presence of abnormalities which could complicate an invasive procedure

e. PT/PTT-it is necessary to perform coagulation studies and determine the adequacy of the patient's

platelet function prior to undergoing an invasive procedure.

f. ABG- indicated in patients with shortness of breath; also indicated before invasive procedures or

thoracotomy; hypoxia or hypercapnea generally suggests poor tolerability for resective surgery.

g. 12-L ECG-performed to screen for possible cardiac involvement

h. PFT (spirometry)-indicated in patients with shortness of breath; also indicated before invasive procedures or

thoracotomy; aid in determining patients' suitability for lung resection.-used to determine the presence of restrictive and/or obstructive lung diseases


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16 August 2010i. frozen-section biopsy

-result: chronic granulomatousinflammation with Langhans cell

-differentials : tuberculosis, histoplasmosis,cryptococcosis, aspergillosis


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Do you agree with the workup done and the course of action taken? Defend your answer.

-Perform tuberculin skin testing to check for tuberculosis infection.But the test has a low specificity which could present with a false

positive result, such as in the case of a latent infection.-Perform biopsy (CT-GAB) first instead of proceeding right away toperform a resection. This will allow cytopathologic analysis of cellsfrom the nodule and elucidation of their nature.

-AFB could have been repeated prior to the excisional biopsy, giventhe recent development of cavitation. This would then render somelab procedures done (ABG, PFT, PT/PTT) quite unnecessary.


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SOLITARY PULMONARY NODULESRound lesions < 3 cm in diameter and surrounded by pulmonaryparenchyma and without other abnormal findings.

Pulmonary malignancies with the greatest potential for curepresent as solitary nodules.Principal mechanisms responsible for nodule formation: neoplastic,granulomatous, vascular and cystic processesMore than 99% of noncalcified lesions < 4 mm in diameter arebenign (Benign lesions tend to have calcium deposited in central,peripheral, concentric, popcorn or homogenous pattern)

Majority of solitary nodules are accounted to healed infectiousgranulomas.


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As many as 50% of lesions > 8 mm in diameter prove to be malignant (Malignantlesions tend to have eccentric patterns)

20-40% of SPNs prove to be cancers. Of these > 75% are primary lung Cas, and theremainder are metastatic lesions (breast, colon and testicles)60-80% of SPNs prove to be benign.

Of these 85-90% are granulomas; most are tuberculous, but in endemicareas, histoplasmosis and coccidiodomycosis are important considerations.

Of these, 5% are benign pulmonary tumors such as hamartomas

Remaining are bronchogenic cysts, hydatid cysts,pseudolymphomas, arteriovenous malformations and bronchopulmonarysequestrations


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These may be confused with solitary lesionsof lung parenchyma:

Extrapulmonarylesions: Skin lesions - moles, nipples Chest wall and rib lesions Pleural plaques


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Top 3 diagnoses:Granuloma (TB, Parasitic or Fungal infection)Neoplasm (bronchogenic CA or solitary

metastasis)Hamartoma

Additional diagnostic considerations:Round pneumoniaArteriovenous malformation


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CAVITARY PULMONARY NODULECongenital lesions, including sequestration, diaphragmatic hernia,

and bronchogenic cyst can appear as cavitary nodules or masses on chestradiography and are therefore included in the differential diagnoses of cavitary nodules. (Collins and Stern, Chest Radiology: The Essentials)

Top 3 diagnoses for CPNs:TuberculosisFungal diseaseSquamous cell CA (primary or metastatic)

Additional diagnostic considerations:Pyogenic infection (pulmonary abscess, septic emboli)Wegener diseaseRheumatoid arthritis


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Differential Neoplastic DiagnosisP rimary Lung CancerCavitation detected on plain chest radiographs has been reported in 2-16% of

primary lung cancer, and is detected with computed tomography (CT) in22% of primary lung cancers.

Squamous-cell carcinoma the most common histological type of lungcancer to cavitate (82% of cavitary primary lung cancer).

Adenocarcinoma and Large cell carcinoma are other primary lungcancers that cavitate.

Small cell carcinoma is never known to cavitate.


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PRIMARY LUNG CANCER

the radiological features of cavitation thatsuggest malignancy include wall thickness,and speculated or irregular inner and outermarginlinear margin, satellite nodules, bronchial wallthickening, consolidation, and ground-glassattenuation were significantly more frequentin benign cavitary lesions


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primary lung cancer CAN BE RULED OUT asdisease of the patient due to absence of other radiological features that will suggest either benign or malignant neoplasm


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Differential Neoplastic Diagnosis

P ulmonary metastasisMetastatic lung lesions also can cavitate, but thisoccurs less frequently that in primary lung

cancers, The frequency of cavitation in metastatictumor detected by plain radiographis 4%.

Squamous cell carcinoma is the most commoncause of cavitating metastases (69% of theinstances) with head and neck squamous canceras the common source.


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PULMONARY METASTASIS

cavitating metastases have a thick andirregular wall but thin-walled metastases canbe observed with metastases from sarcomasand adenocarcinomascavitating pulmonary metastases present asmultiple lesions, but can present as a singlecavitary lesion.


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most metastases will present with thickening of the wall of the lesion

Compared to the diagnosis o the cavitary lesionof the patient which was characterized as thinwalled lucency.

However, metastases from sarcoma and

adenocarcinomas are noted to be thin-walled and which occurs more oftenly in the upper lobe than in the lower lobe.


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Lymphoma pulmonary lymphoma can alsocavitate but these cavities are usually multiplewith thick walls and have an upper-lobepredominance

Note: We can rule out lymphoma because it usually present with multiple cavities withthick walls.


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Differential Neoplastic DiagnosisB enign lung neoplasms

Pulmonary hamartomas, the most common benigntumors of the lung, are the third most common causeof solitary pulmonary nodulesappear as well-defined, solitary pulmonary nodulesvarying patterns of calcification: irregular popcorn,stippled, or curvilinear pattern, or even a combinationof all 3 pattern

Hamartoma may be confidently diagnosed when asharply marginated, smooth lesion containingcalcification and fat is identified on a CT scan.


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B enign lung neoplasmsBronchial adenomas, central lesions areobserved as well-defined masses that narrow,deform, or obstruct adjacent airways.Diffuse punctuate calcifications are observedin 30% of cases and are characteristic but not

diagnostic of carcinoid.Peripheral parenchymal atelectasis orbronchiectasis is common.


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B enign lung neoplasms

Mucous gland adenomas are the third maintype of benign lung tumor.They're completely malignancy-free, found inthe main or smaller bronchi.

However, Radiographic and CT findings inthese rare tumors have not been wellidentified.


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Overall Note: The radiographic characteristicsshown by the progression of the disease pointsmore of a benign origin of neoplasm rather than a malignant one.

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4 ra io ogic eatures o greatest value in differential diagnosis

1. Absolute size - >80% of benign nodulesmeasure 1cm or less

2. Calcification presence is almost certainevidence of benignity

3. Change in size with time doubling time of malignancies range from 30- 49 0 days

4 . Character of the lung-nodule interface sharply defined nodule with a smooth interface

provides suggestion of a benign lesion.


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The following characteristics points out that the disease of the patient was probably abenign neoplasm of the lung The size of thecavitation also strengthens this conclusion(cavity: 4 mm or less benign, 16mm or more

malignant).

But to further strengthen the diagnosis of aneoplastic origin of the diseas, histopathology of the pulmonary lesion is deemed necessary.

ff l d h f


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Differentials considering the presence of cavitary infiltrates (non-malignant, non-

infectious/infectious)TB (infectious)Wegener s granulomatosis

SarcoidosisPulmonary Rheumatoid nodulesPulmonary langerhans cell histiocytosis (PLCH)

Saccular bronchiecstasis (infectious)


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TuberculosisChest X-rayInitial suspicion is based on abnormal chest radiographic findings in apatient with respiratory symptom

Classic picture upper lobe disease with infiltrates and cavitiesfrequency of false-negative examinations

approximately 1% in the adult immunocompetent population increases to 7% 15% in HIV-seropositive individuals

CT scanUseful in interpreting questionable findings on plain chest radiographyHelpful in diagnosing extrapulmonary tuberculosis

MRIUseful in diagnosis of intracranial tuberculosis


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What MAY RULE IN tuberculosis? (postprimary)Presence of a solitary pulmonary nodule in the upper lobeof the lungLack of differentiation between the first and second follow

up may indicate a radiologically stable active or inactivetuberculosisperceived calcifications may be due to healing of the lesionthrough fibrosispresence of cavity as seen in the CT scan 3mos. PTA may be

due to associated necrosispresence of minute centrilobular nodules mostly seen inthe level of bifurcation of the trachea


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What MAY RULE OUT tuberculosis? (postprimary)Absence of right hilar and paratracheallymphadenopathies which are primary hallmarks of tuberculosisAbsence of parenchymal opacities situated in the apicaland posterior segments of the upper lobes and thesuperior segment of the lower lobes

Absence of parenchymal involvement, whichcommonly manifests as heterogeneous opacities andcan be observed radiating outwardfrom the hilum or inthe periphery of the lung


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What type of tuberculosis?differentiation between active and inactivedisease

reliably made on the basis of temporal evolution Lack of radiographic change over a 4- to 6-month

interval generally indicates inactive disease But if associated with culture-positive disease, it

should be described as radiographically stablerather than inactive


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Wegener s granulomatosis

Characterized by granulomatous vasculitis of theupper and lower respiratory tracts together withglomerulonephritis

Radiographic features: Multiple, bilateral, and cavitary infiltrates Manifested as asymptomatic infiltrates or clinically

expressed as cough, hemoptysis, dyspnea, and chest

discomfort (85-90% of patients)Eye involvement (52% of patients), skin lesions(46% of atients), renal disease (77% of patients)


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Wegener s granulomatosis can be ruled out by laterality


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Sarcoidosis

Inflammatory disease characterized by non-caseatinggranulomas predominantly in the upper lobe95% Pulmonary involvementLiver, skin and the eye may also be affectedCommonly presents as a 2-4 week history of cough anddyspneaMost common complaints are symptoms related tocutaneous and ocular disease

Radiographic features CT scan: patchy reticular nodularities Chest roentgenogram: bilateral hilar adenopathy


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Pulmonary rheumatoid nodules

Secondary to rheumatoid arthritis (RA) RA is a chronic multisystem disease of an unknown cause Has a variety of systemic manifestations Characteristic feature: persistent inflammatory synovitis,

usually involving peripheral joints in a symmetricdistribution Pleuropulmonary manifestations: pleural disease,

interstitial fibrosis, rheumatoid nodules, pneumonitis andarteritis

Radiographic features: may appear singly or in clusters;on occasion, may cavitate and produce pneumothoraxor bronchopleural fistula


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PLCH

Rare, smoking-related, diffuse lung diseaseMost common clinical manifestations atpresentation are cough, dyspnea, chest pain,weight loss, and feverPneumothorax (25%)Radiographic features:

combination of ill-defined or stellate nodules (2-10mm in diameter), reticular or nodular opacities, andbizarre-shaped upper zone cysts

HRCT: combination of nodules and thin-walled cysts(diagnostic)


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Saccular bronchiecstasis

One of the three patterns of bronchiecstasisAbnormal and permanent dilatation of bronchiConsequence of inflammation and destruction of the structuralcomponents of the bronchial wall, which is usually caused by infection of P seudomonas aeruginosa and Haemophilus influenza

Presents with persistent or recurrent cough and purulent sputumproductionHemoptysis in 50-70% of patientsMay also have systemic symptoms such as fatigue, weight loss, andmyalgiasPE: any combination of crackles, rhonchi, and wheezes may be heard

Radiographic features: Findings are often nonspecific prominent cystic spaces, either with or without air-liquid levels, corresponding

to the dilated airways (crowded together in parallel)


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of cavitary infiltrates (FUNGAL,infectious)

HistoplasmosisCoccidioidomycosis

BlastomycosisAspergillosisMucormycosis


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Histoplasmosis

Etiology: Histoplasma capsulatumClinical manifestations:

Ranges from asymptomatic to life-threatening illness Symptoms usually occur 2-4 weeks after exposure Heavy exposuresleads to flulike illness with fever, chills, sweats,headache, myalgia, anorexia, cough, dyspnea, and chest pain

Radiographic features: Hilar or mediastinal adenopathy Pulmonary infiltrates may be focal with light exposure or diffuse

with heavy exposure Usually shows upper-lobe infiltrates, cavitation and pleuralthickening


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Coccidioidomycosis

Etiology: Coccidioides immitis and Coccidioides posadasii

Radiographic features: single pulmonary nodules located in the upper

lobes and less than or equal to 4cm in diameter nodules are often discovered on a routine chest

radiograph in an asymptomatic patient calcification is uncommon


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Blastomycosis

Etiology: Blastomyces dermatitidisRadiographic features:

Most common findings are alveolar infiltrates withconsolidation, with or without cavitation, massleasions that mimic bronchogenic carcinoma, andfibronodular infiltrates

Pleural effusions and hilar adenopathy areuncommon


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Mucormycosis

Also called zygomycosisEtiology: Rhizopus and Rhizomucor

Radiographic features: cavitations


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Aspergillosis

Pulmonary aspergillomaAspergillosis usually develops in open spaces in the body, such ascavities in the lungs caused by preexisting lung disorders. In thesinuses and lungs, aspergillosis develops as a ball (aspergilloma)composed of a tangled mass of fungus fibers, blood clots, and white

blood cells. The ball gradually enlarges, destroying lung tissue in theprocess, but usually does not spread to other areas.

SymptomsA fungus ball in the lungs may cause no symptoms and may bediscovered only when a chest x-ray is taken for other reasons. Or itmay cause repeated coughing up of blood and, rarely, severe, evenfatal bleeding. A rapidly invasive infection in the lungs often causescough, fever, chest pain, and difficulty breathing. Withouttreatment, this form of invasive aspergillosis is fatal.


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DiagnosisOn chest X-ray and computed tomography pulmonaryaspergillosis classically manifests as an air crescentsign. An air crescent sign is due to a lung cavity that is

filled with air and has a round radioopaque mass (seefigure below). The CT scan and chest radiographicappearances of an aspergilloma are similar, crescentsigns are manifested in both modalities. The fungal ballis seen as a mass of soft-tissue attenuation within a

pulmonary cavity. An anterior air crescent is visible if the patient is supine. The mass can have a mobilenature which is characterized by shifting location whenthe patient move from supine to prone infection.


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AV MALFORMATION IN THE LUNGS

Pulmonary arteriovenous malformation(PAVM) is an abnormal communicationbetween the pulmonary artery and thepulmonary vein. PAVMs are usually congenitalin origin; however, they may be acquired in avariety of conditions, such as hepatic cirrhosis,

schistosomiasis, mitral stenosis, trauma,actinomycosis, and metastatic thyroidcarcinoma.


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Pulmonary arteriovenous malformation may besuspected in the following clinical situations:

An incidental finding of a solitary pulmonarynodule on chest radiographsThe presence of mucocutaneoustelangiectasesA situation in which the patient presents with

clinical findings of dyspnea, hemoptysis,hypoxemia, polycythemia, clubbing, cyanosis,cerebral embolism, or brain abscess


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Whenever a PAVM is suspected, the presence of a right-to-left shunt should be confirmed by the performance of a100% oxygen study, contrast-enhanced echocardiography,or radionuclide perfusion lung scanning. A definitivediagnosis is established by means of direct imaging of thePAVM with a contrast-enhanced study, such as a computedtomography (CT) scan or a pulmonary angiogram.

Chest radiography reveals some abnormality in mostpatients. However, further evaluation is needed, with a testto confirm the presence of a right-to-left intrapulmonaryshunt and with an imaging study to confirm the presence of PAVM.


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Contrast-enhanced echocardiography is extremely sensitivein detecting clinically important PAVMs. If contrast-enhanced echocardiography is not available, radionuclideperfusion lung scanning may be used.Contrast-enhanced CT scanning remains the criterionstandard in the diagnosis of PAVM. Although pulmonaryangiography is less sensitive than contrast-enhanced CTscanning, it is performed to accurately define the anatomy,specifically before therapeutic embolization is performed.Although pulmonary angiography may also be a criterionstandard for confirmation of a PAVM, angiography isrequired only when further intervention is planned.Otherwise, in most situations, contrast-enhanced CTscanning is sufficient to confirm the diagnosis.


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Pulmonary Nodule, most probablynonmalignant

Rationalization:Asymptomatic

Incidental findingNo risk factors for Lung malignancy:

Young age Non-smoker

Mass is not growing


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SUMMARY OF DIFFERENTIALS

Tuberculosis - Because the patient lives in thePhilippines, tuberculosis should always beconsidered if a lesion on chest X-ray isdiscovered unless proven to be anotherdisease. It is also consistent with the finding of a well-circumscribed mass which is not

growing.


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SUMMARY OF DIFFERENTIALS

Fungal This diagnosis is unlikely since thepatient is most probably immunocompetenthaving no diseases such as diabetes mellitus.The patient did not report any history of priorTuberculosis which could have helped theformation of a nodule by opportunistic fungi.


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SUMMARY OF DIFFERENTIALSNeoplastic Another consideration for SPN is a neoplastic condition. Aneoplastic nodule could be benign, malignant or metastatic.

It is unlikely to be malignant because of the small size of the nodule, the slowgrowth (no growth was observed using X-ray and CT) and the young age of thepatient. If histopathology findings show it to be malignant, it could bebronchogenic CA most probably squamousnonsmall cell lung carcinoma

A metastatic nodule rarely presents as a lone solitary nodule. It usuallypresents a multiple nodules spread throughout the parenchyma. List of benign conditions. Majority of the patients with these conditions are

asymptomatic.AdenomaClear cell (sugar) tumorGranular cell tumor

HamartomaInflammatory pseudotumorLangerhans cell histiocytes


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RULED OUT DIAGNOSISInfectious

Pathogenic fungal disease Histoplasma, Cocciodiodes, Blastomyces Patient had no historyof travel to endemic areas

Neoplastic Benign

Lymphangiomyomatosis Disease is progressive and presents with dyspnea. Malignant not absolutely rule out; just very low probability

Small cell lung CA -


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MANAGEMENT

W hat was done to the patient?As advised by a TCVS surgeon, the patientdecided to have his pulmonary nodule resected.Right posterolateralthoracotomy and wedgebiopsy of the right upper lobe nodule wereperformed and frozen section was obtainedwhich then revealed chronic granulomatousinflammation with Langhans cell. Before

resection, patient was also referred to apulmonologist who advised initiation of anti-Koch s.


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W as pulmonary nodule resection appropriate for the patient?Pulmonary nodule resection was appropriate for the patient.Indications for resection include presence of an anteriorly placedcavity which, in the patient, was also presented as an upper lobelesion. Resection is also highly suggested in certain instances of

undiagnosed lesions like when a firm diagnosis of tuberculosiscannot be made and in such cases wherein cancer is a possibility.During the time of resection, there was still no definite diagnosis,thus, resection can be done to obtain a biopsy specimen.

If proper work-up (AFB smear, culture, biopsy) of the patient scondition was done leading to a more specific diagnosis, thenresection would be deemed to be inappropriate.


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Absolute IndicationsTuberculoma lesion > 2cm in diameter (body cannot absorb and heal alesion of this size and at best can only encapsulate the lesion)Lesions Associated with Broncho-Stenosis (prone to bronchial fistula,secondary resection, abscess formation)

Lower Lobe Disease (difficult to treat as compared to upper lobe)Failed collapse therapyDestroyed Lung or LobeAnteriorly P laced Cavities (upper lobe lesion is difficult to treat bythoracoplasty)Cold Abscess of Bronchus

TuberculousBronchoectasisTuberculousEmpyema


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Relative Indications

Segmental Lesions

Cavities in the apex of Lower LobeAcute TBTension Cavities

Fibro-caseous Upper Lobe Disease


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AdvantagesLeaves the body with a less formidable task of controlling the remaining disease

Functions of remaining lung tissue not impaired(due to less interference with chest wall and itsmovements)No fear of unclosed cavities or residualbronchiectasisB est for undiagnosed or unproven lesion toprevent progression in case it is a CA


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D isadvantagesgreater risk at operation and a higher post-operativecomplication rate (as compared to thoracoplasty)

more serious post-operative complicationsuncertainty about the stability of the Px from a long-term POVdead space problem due to removal of lung tissue (maylead to empyema, latent TB reactivation)limited to unilateral controlled diseaserisk of producing a respiratory cripple


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W as the management done for the patientappropriate?The management was appropriate in the givensituation. But with the proper consent from thepatient, a better management of the case can bedone. First, the AFB smear should have beenrepeated since there was a change in theradiologic findings. Second, sputum culture

should also be done in order to confirm thepresence of the bacteria even if the sputumsmear is negative.


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W ould you have managed the patient with anti-Koch s during that time?At the time resection was done, there was no definite diagnosis yet. Theonly information available were the negative result of the AFB smear(done a year ago) and the cavitary lesion seen in radiologic procedures.With the negative result of the AFB smear, other possible treatmentshould have been utilized. As recommended by the Philippine Society forMicrobiology and Infectious Diseases, the recommended treatmentregimen for newly diagnosed smear negative pTB patients is a short-course chemotherapy [Grade C]. This includes 2HRZE/4HR for pTBpatients with no/unknown status of HIV infection. Because the patientshowed cavitation in CXR, which is correlated with high rates of relapse,the continuation phase should be extended for 3 months more, with samemedications making a total of 9 months of medication. However, acavitary lesion seen in the radiologic test may also suggest that there maybe a lesser probability of a successful chemotherapy. There is a highprobability that patients with cavitary lesions are more likely to harbordrug-resistant organisms (Yoder et al., 2004).


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W hat is the ideal management for the patient (giventhat the final diagnosis is P TB )?

S tandard Treatment RegimenFor a newly diagnosed smear-positive or smear-negative patient (with no history of treatment):Short-course chemotherapy regimen consisting of Isoniazid, Rifampicin, Pyrazinamide and Ethambutol for2 months (2HRZE), and Isoniazid and Rifampicin for thesubsequent 4 months (4HR).


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Supervision of Treatment To ensure the patient s completion of and compliance to theregimen:The treatment should be patient-centered and directly-observed inDOTS-accredited health care facilities

Self-administered and unmonitored therapy is not recommended.Include treatment partners (health workers, community volunteersor trained family members) in the management plan.Regular home visits, reminder letters, cash incentives and healtheducation enhance compliance.

Always consider the patient s unique social, cultural and clinicalcircumstances.


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M onitoring of Response and Outcomes DuringTreatment For smear-negative patients :Signs and symptoms are monitored on each visit.Sputum smears are performed at the end of the2nd month.Serial chest x-ray (6 months apart) isrecommended to assess the stability of the lesionWith no signs of improvement, a chest x-ray onthe 3 rd month is recommended.


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M anagement of Adverse ReactionsTests to monitor adverse reactions:

Undergo baseline liver function tests before treatment (serumlevels of hepatic aminotransferase and serum bilirubin)

If normal, routine monitoring of liver and renal function is notnecessary for the patient

Visual acuity and color vision tests at monthly intervals tomonitor the side effects of ethambutol.

Management of adverse reactions: Mild adverse effects can be treated symptomatically. For severe adverse drug reactions, the offending drug should bestopped and patient should switch to single drug formulations.


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F irst-line drugs should not be discontinued without adequate justification.With evidence of drug-induced hepatotoxicity:

Pyrazinamide is removed from the regimen and replaced withStreptomycin.

For AST levels >5x elevated with or without symptoms, or >3x elevatedwith symptoms, all hepatotoxic drugs should be stopped.With hypersensitivity reactions:

Rechallenge to determine which drug is causing the reaction. Antihistamines should be given for minor rashes Petechial rash suggestive of thrombocytopenia could be due to

Rifampicin; discontinue and monitor platelet count until it returns tobaseline With generalized erythematous rash, all medications should be

stopped


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Surgery

In the present state of drug therapy, the role of surgery in management of PTB is limited and can bedescribed under the following:

P ts with multi-drug resistance mycobacteria and persisting cavitiesPts with localized destroyed pulmonary parenchyma with evidence of relapsing disease

Pts with serious complications, notably aspergilloma or life threatening hemoptysisSerious bronchial stenosis with distant non-healing cavityPts with tuberculousbronchiectasis not responding to therapyBronchopleural fistula and empyema (Kerti et al 2008)Treating TB or previous surgery complications (Moghissi et al 2003)

Multi-resistant myobacteria is an indication for surgery in a pulmonary TB patient. The cavitarylesion present in the patient may lead to an assumption that organisms are more likely to be drugresistant and thus first line therapy (2HRZE/4HR) would not be appropriate.

pulmo case pres raw

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