Forty-five year old female, life-long non-smoker presents with with dyspnoea, fever, non productive cough, wheeze, night sweats and weight loss over several weeks. This is her X-ray. What's the diagnosis?
....would like to consider Atypical Pneumonia Syndrome.Multicentric distribution of the Pulmonary infiltrate suggests Hematogenous infection possibly Endocarditis/Thrombophlebitis in which Fever & Dyspnoea is a feature:Staph.Aureus Pneumonia wherein,initially,Inflammatory response is confined to the Pulmonary interstitium.Productive cough is a late feature in this scenario. PCP will show more diffuse infiltration characteristically in the lower lobe & Bil.Hilar Lymphadenopathy won't be there. PTB will also present atypically but consolidation,effusion will be seen later nd mostly involvement will be in patches.Also,productive cough,purulent sputum,pleuritic chest pain,signs of consolidation nd effusion will be there.
.....tnx....for the fresh challenge...I would like to review nd consider A)Chronic Eosinophilic Pneumonia B)Acute Eosinophilic Pneumonia C)Loeffler's Syndrome D)Tropical Eosinophilia as the DDx. wherein...1)Acute Eosinophilic Pneumonia,onset is abrupt,not characterized by Eosinophilia & also sometimes as Eosinopenia,< 40yrs of age,without cough,Dyspnoea,wheeze primarily,CXR-Diffuse infiltrates 2)Tropical eosinophilia dramatic in onset,paroxysmal nocturnal cough,diffuse Lung Disease,later developing into fever& progressive Dyspnoea,typically diffuse infiltrate on CXR.3)Loeffler's syndrome as a simple Pulmonary eosinophilia,with mild to moderate blood Eosinophilia with clinical features:cough,wheeze,Dyspnoea,with transitory patchy infiltrates on CXR 4)Chronic Eosinophilic Pneumonia occurs primarily in middle aged,asthmatic women,can develop in Non Asthmatic too.Typically the symptoms are gradually progressive,including Wt.loss,Dyspnoea,& Fever.Findings include :Rales,wheezing & Hypoxia.Both Airway nd Alveolar obstructive nd restrictive defects.Infiltrates seen r peripherally distributed.Alveoli filled with Eosinophils nd Histiocytes with low grade vasculitis,presence of IL5 in BAL.can progress to Churgh Strauss Syndrome : diffuse lung disease with systemic vasculitis....I would prefer this Dx i.e Chronic Eosinophilic Pneumonia....Tnx..
Well enunciated. Chronic eosinophilic pneumonia is indeed the correct diagnosis.
So characteristic is the peripheral shadowing in the upper and mid zones of the lung (described as a photographic negative of pulmonary oedema), that the radiological appearance is considered pathognomonic of CEL.
The demographics are a clue as well. The condition largely affects female non-smokers.
....tnx for ur continued support....feels gud to be back to the basics....now tht there is no dearth of pts.nd professional demands...it is most logical now to fine tune existing skills nd upgrade nd aim for the best to be able to stand in gud stead for those who repose in me huge confidence nd trust...its now,as if,for the first time not for myself, but for others who look forward to me with Hope in remoteness...!!...ur sharing of ur precious time nd timely help is being saluted frm the core of my heart...I hv informed my pts tht there cases r being overviewed by a " Bodo Daktar"frm UK...nd they continue to be in safe hands....!!...Mamun 26/m getting t/t for DF with a declining platelet count on four occasions to currently 83,000/cmm.Despite a declining count,he is afebrile,return of appetite,headaches no more with gud hydration. The declining Platelets on two last reporting is not in consonance with his current better feel.Wht will be the approach now : will the IV fluids continue,or should I release him...?...Tnx..
About this DF patient, provided BP is normal, pulse pressure is wide, haematocrit is falling rather than rising and urine output is normal, I'd discontinue IV fluids after 48 hours. Longer periods of infusion are usually not needed. The period of plasma leak should be over by 48 hours.
...Tnx...since all the parameters cited to above is normal hv released him but under observation & his platelets have improved to 1,23000/cmm instant....Badsha Howlader 42/m reported a week back with Fever,Malaise,Coryza,& progressive fatiguability.He tested +ve for Widal 1:160 for O & H(S.Typhi),Hb%12.7gm/dl,& a significantly deranged RBC indices.Further SRL Mumbai reported yestday : RBC-6.52mill/cmm,MCV66.8(83-101),MCH 19.5(27-32),MCHC29.2%(31.5-34.5),Red Cell distribution Width 16.2, Hb Variant Analysis indicate elevated HbA2 4.0%(1.5-3.7)&slightly lower HbA 94%(94.3-98.5)with Hb F,S,D,C in ref range.RBC pix Mild Anisopoikilocytosis,Microcytic,Hypochromic,& Ovalocytes , WBC Normal.suggestive of Beta. Thallasemia trait. S.Total Iron 101micgm/dl(65-175)& S.TIBC 339micgm/dl(250-450),% Saturation is 30% since,the deranged RBC indices poses lot of Anxiety to the Pt.Currently he reported frm Club Med Kanifinolhu resort whr he is stationed, as being afebrile but weak.Ur comments...Tnx..
No doubt you are treating him for typhoid. I am sure he will recover.
Absolutely certain he has beta-thalassaemia trait. You don't even need the Hb electrophoresis. You simply calculate the Mentzer's index- divide MCV by RBC count in millions- in this case 66.8/6.52 = 10.25.
If the Mentzer's index is below 13, it's likely to be beta thalassemia trait. If it's more than 14, it's iron deficiency anaemia. Between 13 and 14, it's indeterminate.
Since his Mentzer's index is only 10.25, i.e. far below 13, he almost certainly has beta-thal trait, which is confirmed on Hb e'phoresis.
Please reassure him that beta-thal trait is benign and compatible with normal longevity. His Hb is near normal at 12.7 and there is no concern at all. However, if his wife too is thal-trait carrier, there is a risk of thal-major in the offspring.
PS: On an unrelated note....you can also use above indices to calculate haematocrit to assess if subject has haemoconcentration, say due to diarrhoea in typhoid, or plasma leak in DF.
Divide Hb by MCHC to get the HCT. In this case 12.7/29.2 = 43.5. Normal HCT is around 45, so his Hb is likely to be accurate and not falsely raised due to haemoconcentration.
....extremely satisfied nd oriented now after ur deliberations on this....will reassure him telephonically...Tnx...the Hajj pilgrimage slated for Oct. nd Umrah which is year long for Mecca....KSA have issued advisory for pilgrims who r old not to make it this time due to MERS(Middle East Respiratory Syndrome),naturally I am flooded with Queries frm the local populace...Ur take on tht nd how difft.its frm SARS...Tnx...!!
....Kabir m/31 is frm Vellasaru island resort & is a follow up case to his one month old complaint of B/L Forearm & LL Burning sensation,with vague pain LL .One mth back he had reported ( S.Na+ 128mmol/l) &( S.Ca++ 8.0mg/dl)with raised AST (46 IU/L),ASO T >200,CRP -ve.his RBC count & Indices were normal.RBS was normal.BP was elevated nd stood at 150/94.For full one mth he took conservative mgmt frm my end away frm me@Island Resort.Today he presented with same symptoms but with BP 100/70.Since he could not spare time nd had a connecting return speed boat transfer ,I couldn't re investigate him.I stopped his BP medication of Amlodipine 2.5mg.He had been taking increased salt in diet with Calcium supplements,Milk nd Yoghurt.But,the burning symptoms persisted even aft these measures nd supplementation, he thought.....your opinion...
The most likely explanation is that he is a secret drinker. He may not have admitted this to you.
The burning pain in the forearms and lower legs strongly suggests alcoholic neuropathy. Alcoholic aetiology would be supported by the raised AST, hyponatraemia due to beer potomania, and slightly low serum Ca due to low albumin (corrected Ca should be normal).
Much rarer causes of a combination of low Na and low Ca would be polyglandular autoimmune syndrome type I due to both adrenal insufficiency and hypoparathyroidism and HIV infection, where low Na & low Ca can coexist.
....Tnx...the Resorts hv High end customers ,though drinking is banned in Maldives Islands with exception to the 160 odd resorts,I had the opportunity to visit quite a few for certifying their facilities.The wine cellars are well stacked nd Bartenders r frm Sri Lanka,Bangladesh,India,Nepal.U r rt.many clients hv confessed to secret drinking habits except this particular case,whom I didn't prod much & it was a mistake.Elevated AST,ALT levels r rampant here not all could be attributed to Infective or Dyslipidemia causes..its a 100pc possibility.Tnx for this fabulous dx...!!
....would like to consider Atypical Pneumonia Syndrome.Multicentric distribution of the Pulmonary infiltrate suggests Hematogenous infection possibly Endocarditis/Thrombophlebitis in which Fever & Dyspnoea is a feature:Staph.Aureus Pneumonia wherein,initially,Inflammatory response is confined to the Pulmonary interstitium.Productive cough is a late feature in this scenario.
ReplyDeletePCP will show more diffuse infiltration characteristically in the lower lobe & Bil.Hilar Lymphadenopathy won't be there.
PTB will also present atypically but consolidation,effusion will be seen later nd mostly involvement will be in patches.Also,productive cough,purulent sputum,pleuritic chest pain,signs of consolidation nd effusion will be there.
All reasonable thoughts. However, if I now reveal that the lady has had fairly marked eosinophilia for several months....would that be any help?
ReplyDelete.....tnx....for the fresh challenge...I would like to review nd consider A)Chronic Eosinophilic Pneumonia B)Acute Eosinophilic Pneumonia C)Loeffler's Syndrome D)Tropical Eosinophilia as the DDx.
Deletewherein...1)Acute Eosinophilic Pneumonia,onset is abrupt,not characterized by Eosinophilia & also sometimes as Eosinopenia,< 40yrs of age,without cough,Dyspnoea,wheeze primarily,CXR-Diffuse infiltrates 2)Tropical eosinophilia dramatic in onset,paroxysmal nocturnal cough,diffuse Lung Disease,later developing into fever& progressive Dyspnoea,typically diffuse infiltrate on CXR.3)Loeffler's syndrome as a simple Pulmonary eosinophilia,with mild to moderate blood Eosinophilia with clinical features:cough,wheeze,Dyspnoea,with transitory patchy infiltrates on CXR 4)Chronic Eosinophilic Pneumonia occurs primarily in middle aged,asthmatic women,can develop in Non Asthmatic too.Typically the symptoms are gradually progressive,including Wt.loss,Dyspnoea,& Fever.Findings include :Rales,wheezing & Hypoxia.Both Airway nd Alveolar obstructive nd restrictive defects.Infiltrates seen r peripherally distributed.Alveoli filled with Eosinophils nd Histiocytes with low grade vasculitis,presence of IL5 in BAL.can progress to Churgh Strauss Syndrome : diffuse lung disease with systemic vasculitis....I would prefer this Dx i.e Chronic Eosinophilic Pneumonia....Tnx..
Well enunciated. Chronic eosinophilic pneumonia is indeed the correct diagnosis.
ReplyDeleteSo characteristic is the peripheral shadowing in the upper and mid zones of the lung (described as a photographic negative of pulmonary oedema), that the radiological appearance is considered pathognomonic of CEL.
The demographics are a clue as well. The condition largely affects female non-smokers.
....tnx for ur continued support....feels gud to be back to the basics....now tht there is no dearth of pts.nd professional demands...it is most logical now to fine tune existing skills nd upgrade nd aim for the best to be able to stand in gud stead for those who repose in me huge confidence nd trust...its now,as if,for the first time not for myself, but for others who look forward to me with Hope in remoteness...!!...ur sharing of ur precious time nd timely help is being saluted frm the core of my heart...I hv informed my pts tht there cases r being overviewed by a " Bodo Daktar"frm UK...nd they continue to be in safe hands....!!...Mamun 26/m getting t/t for DF with a declining platelet count on four occasions to currently 83,000/cmm.Despite a declining count,he is afebrile,return of appetite,headaches no more with gud hydration. The declining Platelets on two last reporting is not in consonance with his current better feel.Wht will be the approach now : will the IV fluids continue,or should I release him...?...Tnx..
DeleteMany thanks, shonkus. It's a pleasure.
ReplyDeleteAbout this DF patient, provided BP is normal, pulse pressure is wide, haematocrit is falling rather than rising and urine output is normal, I'd discontinue IV fluids after 48 hours. Longer periods of infusion are usually not needed. The period of plasma leak should be over by 48 hours.
...Tnx...since all the parameters cited to above is normal hv released him but under observation & his platelets have improved to 1,23000/cmm instant....Badsha Howlader 42/m reported a week back with Fever,Malaise,Coryza,& progressive fatiguability.He tested +ve for Widal 1:160 for O & H(S.Typhi),Hb%12.7gm/dl,& a significantly deranged RBC indices.Further SRL Mumbai reported yestday : RBC-6.52mill/cmm,MCV66.8(83-101),MCH 19.5(27-32),MCHC29.2%(31.5-34.5),Red Cell distribution Width 16.2, Hb Variant Analysis indicate elevated HbA2 4.0%(1.5-3.7)&slightly lower HbA 94%(94.3-98.5)with Hb F,S,D,C in ref range.RBC pix Mild Anisopoikilocytosis,Microcytic,Hypochromic,& Ovalocytes , WBC Normal.suggestive of Beta. Thallasemia trait. S.Total Iron 101micgm/dl(65-175)& S.TIBC 339micgm/dl(250-450),% Saturation is 30% since,the deranged RBC indices poses lot of Anxiety to the Pt.Currently he reported frm Club Med Kanifinolhu resort whr he is stationed, as being afebrile but weak.Ur comments...Tnx..
DeleteNo doubt you are treating him for typhoid. I am sure he will recover.
ReplyDeleteAbsolutely certain he has beta-thalassaemia trait. You don't even need the Hb electrophoresis. You simply calculate the Mentzer's index- divide MCV by RBC count in millions- in this case 66.8/6.52 = 10.25.
If the Mentzer's index is below 13, it's likely to be beta thalassemia trait. If it's more than 14, it's iron deficiency anaemia. Between 13 and 14, it's indeterminate.
Since his Mentzer's index is only 10.25, i.e. far below 13, he almost certainly has beta-thal trait, which is confirmed on Hb e'phoresis.
Please reassure him that beta-thal trait is benign and compatible with normal longevity. His Hb is near normal at 12.7 and there is no concern at all. However, if his wife too is thal-trait carrier, there is a risk of thal-major in the offspring.
PS: On an unrelated note....you can also use above indices to calculate haematocrit to assess if subject has haemoconcentration, say due to diarrhoea in typhoid, or plasma leak in DF.
Divide Hb by MCHC to get the HCT. In this case 12.7/29.2 = 43.5. Normal HCT is around 45, so his Hb is likely to be accurate and not falsely raised due to haemoconcentration.
....extremely satisfied nd oriented now after ur deliberations on this....will reassure him telephonically...Tnx...the Hajj pilgrimage slated for Oct. nd Umrah which is year long for Mecca....KSA have issued advisory for pilgrims who r old not to make it this time due to MERS(Middle East Respiratory Syndrome),naturally I am flooded with Queries frm the local populace...Ur take on tht nd how difft.its frm SARS...Tnx...!!
Delete....Kabir m/31 is frm Vellasaru island resort & is a follow up case to his one month old complaint of B/L Forearm & LL Burning sensation,with vague pain LL .One mth back he had reported ( S.Na+ 128mmol/l) &( S.Ca++ 8.0mg/dl)with raised AST (46 IU/L),ASO T >200,CRP -ve.his RBC count & Indices were normal.RBS was normal.BP was elevated nd stood at 150/94.For full one mth he took conservative mgmt frm my end away frm me@Island Resort.Today he presented with same symptoms but with BP 100/70.Since he could not spare time nd had a connecting return speed boat transfer ,I couldn't re investigate him.I stopped his BP medication of Amlodipine 2.5mg.He had been taking increased salt in diet with Calcium supplements,Milk nd Yoghurt.But,the burning symptoms persisted even aft these measures nd supplementation, he thought.....your opinion...
DeleteThe most likely explanation is that he is a secret drinker. He may not have admitted this to you.
ReplyDeleteThe burning pain in the forearms and lower legs strongly suggests alcoholic neuropathy. Alcoholic aetiology would be supported by the raised AST, hyponatraemia due to beer potomania, and slightly low serum Ca due to low albumin (corrected Ca should be normal).
Much rarer causes of a combination of low Na and low Ca would be polyglandular autoimmune syndrome type I due to both adrenal insufficiency and hypoparathyroidism and HIV infection, where low Na & low Ca can coexist.
....Tnx...the Resorts hv High end customers ,though drinking is banned in Maldives Islands with exception to the 160 odd resorts,I had the opportunity to visit quite a few for certifying their facilities.The wine cellars are well stacked nd Bartenders r frm Sri Lanka,Bangladesh,India,Nepal.U r rt.many clients hv confessed to secret drinking habits except this particular case,whom I didn't prod much & it was a mistake.Elevated AST,ALT levels r rampant here not all could be attributed to Infective or Dyslipidemia causes..its a 100pc possibility.Tnx for this fabulous dx...!!
Delete