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Case 199

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Female patient, 53 years old, former smoker, with diabetes and hypertension, admitted to the HC-UFMG complaining of non-productive cough, dyspnea on moderate efforts and low-grade fever, as well as weight loss (2 kg) in the last 2 months. Reports empirical treatment for atypical community-acquired pneumonia with azithromycin, after performing chest radiography (attached), about one month and a half ago, with no improvement. Physical examination shows SpO2 87% in room air and creptations in right infrascapular region. AFB smear research was done in the sputum, the first sample was negative. It was requested high resolution computerized tomography (HRCT), presented below.

What is the main diagnosis and the most appropriate management?

a) Complicated Community acquired Pneumonia; thoracentesis for diagnosis.

25%

b) Pulmonary Tuberculosis; new request for AFB in sputum.

25%

c) Other than lung carcinoma small cell tumor; lung biopsy.

25%

d) Pneumocystosis; Pneumocystis jirovecii research in sputum.

25%
   

Image analysis

 

Images 1 and 2: Plain chest radiography in posterior-anterior and right lateral views: heterogeneous pulmonary alveolar consolidations in the lower right lobe and along the ipsilateral pulmonary hilum, with imprecise limits (red shading). Left lung with normal transparency.

 

Image 3: Chest computed tomography, high resolution technique without intravenous contrast. Axial section, subcarinal level, mediastinal window: alveolar consolidation in the top segment of the lower lobe of right lung (red shading) with air bronchogram (blue arrows) and digging (yellow arrow). In some other levels there are paratracheal lymphadenomegaly without signs of necrosis.

 

Image 4: Chest computed tomography, high resolution technique without intravenous contrast. Axial section, lower level, lung window: pulmonary alveolar consolidations in the lower right lobe and the back edge of the middle lobe (red shading) with air bronchogram (blue arrow) associated with bronchial fills (green shading).

Highlights

- Major Measures to control TB: early diagnosis and correct treatment of immediate start.

- Sputum AFB allows detection of 60% to 80% of cases of pulmonary tuberculosis. It is required to be performed on at least two samples.

- Simple Chest Radiography: for all patients with suspected pulmonary TB. In patients with positive smear, allows exclusion of pulmonary disease associated.

- Radiographic Characteristics: small opacities with imprecise limits; segmental or lobar images with heterogeneous aspect; small nodules and/or streaks; single or multiple cavitation, usually without air-fluid level.

- HRCT: Diagnosis of active TB and latent TB or atypical pulmonary or extrapulmonary, often in HIV-infected patients. The occurrence of airspace nodules associated with centrilobular nodules and tree-in-bud pattern suggests active disease.

References

-Manual de Recomendações para o Controle da Tuberculose no Brasil – Ministério da Saúde. Brasília: 2011.

-Marchiori, E. ; Junior, A.S.S.; Capítulo III - Manifestações radiológicas pulmonares nos portadores da síndrome da imunodeficiência adquirida. Curso de diagnóstico por imagem do tórax. Jornal de Pneumologia 25(3), mai-jun, 1999.

-Elicker, B. et al. Padrões tomográficos das doenças intersticiais pulmonares difusas com correlação clínica e patológica. J. bras. Pneumol. 34(9), Set/2008. Available at: http://www.scielo.br/scielo.php?pid=S1806-37132008000900013&script=sci_arttext. Accessed on July 30th, 2015.

Author

Daniela de Souza Braga, 4th year medical student at UFMG

E-mail: danibragamed[at]gmail.com

Supervisor

Teresa Cristina de Abreu Ferrari, professor of the Internal Medicine Department of the Medical School and coordinator of the Residency Program in Internal Medicine at the Hospital das Clínicas-UFMG.

Reviewers

Luanna Monteiro, Gustavo Campos, Fábio Satake, Luísa Bernardino, Professor Viviane Parisiotto and Professor José Nelson.

Translated by

Gustavo de Francisco Campos, 6th year medical student at UFMG.

E-mail: fcamposgustavo[at]gmail.com

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