interesting case - srinakharinwirot university
TRANSCRIPT
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Interesting case
Pichaya Petborom M.D.
Division of Respiratory Disease and Critical care,
Department of Medicine, Faculty of Medicine, HRH
princess Maha Chakri Sirindhorn Medical Center
Hospital Srinakharinwirot University
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• หญิงไทยคูอ่าย ุ39 ปี อาชีพ รับจ้างซกัผ้า รีดผ้า ภมูิล าเนา นครนายก
• อาการส าคญั: ไอเป็นเลือด 1 สปัดาห์ก่อนมา รพ.
• ประวตัิปัจจบุนั: 7 ปีก่อนมา รพ. ผู้ ป่วยมีไอเสมหะสีขาวมีเลือดเก่าๆ สีน า้ตาลปนปริมาณไมม่าก บางครัง้มีเลือดสดปน ไมมี่ไข้ ไมมี่เบ่ืออาหาร ไมมี่น า้หนกัลด มีอาการอยู ่1 เดือนมาตรวจท่ี รพ. CXR พบ increase opacity RLL with cavity สง่ sputum AFB negative x 3 days ได้ท า CT guided fine needle aspiration ท่ี RLL ผลตรวจไมพ่บเชือ้วณัโรคและมะเร็ง แพทย์วินิจฉยัวา่เป็น smear negative pulmonary TB ได้รับการรักษาด้วย 2 HRZE/7 HR หลงัรักษายงัมีไอเสมหะปนเลือดเก่าๆ สีน า้ตาล ปริมาณไมม่ากบางวนั
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• 7 เดือนก่อน มา รพ. มีไอเสมหะปนเลือดสดทกุวนั ครัง้ละประมาณ 1 ช้อนชา มีน า้หนกัลดลง 2 kg มีอาการ 1 สปัดาห์ มาพบแพทย์ CXR พบ increase opacity RLL ตรวจ sputum AFB –negative x 3 days, PCR for MTB-positive, C/S for mycobacterium – no growth แพทย์วินิจฉยัsmear negative pulmonary TB ได้รับการรักษาด้วย 2 HRZE/4 HR หลงัรักษาอาการดีขึน้ ไอลดลงเสมหะสีขาว ไมมี่เลือดปน น า้หนกัขึน้ 1.2 kg
• 1 สปัดาห์ก่อนมา รพ. ผู้ ป่วยไอเป็นเลือดสดทกุวนั ปริมาณครัง้ละ 1 ช้อนชาปนกบัเสมหะสีขาว ไมมี่ไข้ ไมเ่หน่ือย นอนราบได้ ไมเ่จ็บหน้าอก ไมเ่บ่ืออาหาร ไมมี่น า้หนกัลด ไมมี่เลือดออกผิดปกติท่ีอ่ืนจงึมา รพ.
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• ประวตัิอดีต: ปฏิเสธโรคประจ าตวัใดๆ เดิมแข็งแรงดีมาตลอด
• ประวตัิครอบครัว : ปฏิเสธวณัโรคปอด โรคมะเร็งในครอบครัว ไมมี่ใครมีอาการเหมือนผู้ ป่วย
• ประวตัิสว่นตวั : ปฏิเสธสบูบหุร่ี ดื่มสรุา ไมไ่ด้ใช้สารเสพตดิใดๆ
• ประวตัิยา: ปฏิเสธแพ้ยา ไมไ่ด้ใช้ยาใดๆ เป็นประจ า
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Physical examination
• V/S: T 37.3°C, BP 144/78 mmHg, P 84/min,
RR 16/min, BW 61 kg
• GA: Alert, not pale, no jaundice, no
tachypnea, no clubbing of fingers, no edema
• CVS: PMI at 5 th ICS left midclavicular line,
no heaving, normal S1, S2 no murmur
• RS: trachea in midline, equal chest
expansion, resonance on percussion both
lungs, normal BS, no adventitous sound,
equal vocal resonance
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• Abdomen: soft, not tender, liver and
spleen can’t be palpated, liver span 8 cm, splenic percussion sign-negative
• LN: no superficial lymphadenopathy
• Skin: no rash
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Problem list
• 1. Nonmassive hemoptysis 1 wk PTA
• 2. History of relapsed smear negative
pulmonary TB 7 years and 7 months PTA
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Differential diagnosis
• Infected bronchiectasis
• Aspergilloma
• CA lung
• Relapsed pulmonary TB
• Bleeding aneurysm (Rasmussen’s aneurysm)
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15/10/57
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1/12/57
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15/9/57
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• CBC(15/10/57): Hct 36.3 % , Hb 12.4 g/dL,
WBC 10,410, neutrophil 41%, lymphocyte
31.7%, eosinophil 10.4%, monocyte 8%,
platelet 376,000
(absolute eosinophil = 1,083)
• PT 11.6 s, aPTT 29.2 s, INR 0.99
• BUN 13.5 mg/dL , Cr 0.68 mg/dL
• Sputum AFB-negative x 3 days
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CT chest 30/10/57
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CT chest 30/10/57
• Hypodensity lesion internal air bubbles
at anterobasal segment of RLL
(measuring 1.3 x 1.3 cm), favoring lung
abscess or necrotizing pneumonia.
Subsegmental atelectasis of anteobasal
segment of RLL, no pleural effusion or
pneumothorax. No mediastinal or hilar adenophathy is seen.
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Sputum fresh smear
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Egg of Paragonimus westermani
Eggs range in size from 68-118 µm x 39-67 µm. They are yellow-brown and
ovoidal or elongated, with a thick shell. They are often asymmetrical, which
one end slightly flattened. At the large end. The operculum is visible
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• ประวตัิเพิ่มเติม ผู้ ป่วยรับประทานส้มต าปเูป็นประจ า เฉลี่ยอาทิตย์ละ 2 ครัง้ เพิ่งหยดุประมาณ 7 เดือน
• Stool concentration for parasite : not found
• Diagnosis: pulmonary paragonimiasis• Treatment: praziquantel 25 mg/kg po tid x 3 days
[praziquantel(600 mg) 2.5 tab po tid pc x 3 days]
• หลงัได้ยาอาการดีขึน้ ไอลดลง ไม่มีไอเป็นเลือด เสมหะสีขาวปริมาณไมม่าก
• F/U sputum fresh smear อีก 1 สปัดาห์ตอ่มา : not found paragonimus egg
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Clinical manifestations
• Incubation period may vary from 1 to 2 months
• Pulmonary paragominiasis is the commonest clinical
form occurring in 76-90% of cases
• Abdominal pain, diarrhea, and urticaria occur during
the acute phase (peroid of invasion and migration of
immature flukes)
• Initial symptoms are followed a few days later by fever,
cough, dyspnea, malaise, and sweats
• Acute phase usually persists for several weeks
Rosen MJ, et al. Chest. Jan 2006;129(1 Suppl)
T. Shantikumar Singh, et al. Indian J Med Res
136, August 2012
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• Chronic pulmonary symptoms consist of dry cough
followed by a cough productive of tenacious and
rusty brown sputum, pleuritic chest pain, dyspnea
and occasional hemoptysis
• Pulmonary symptoms begin ~ 6 months after
infection and are often mistaken for symptoms of
tuberculosis
Rosen MJ, et al. Chest. Jan 2006;129(1 Suppl)
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• Clubbing of fingers occasionally occurs
• Lung are normally clear but rales, egophony, or
dullness on percussion may occur with complications
such as pneumonia or pleural effusion
• Extrapulmonary paragonimiasis divided into
cerebral, abdominal (liver, spleen, kidney, intestinal
wall, peritoneum), and miscellaneous forms
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Laboratory studies
• CBC reveals eosinophilia in 10-30%
• Obtain clinical samples for ova and parasites
- Definitive diagnosis requires detection of eggs in
sputum, feces, pleural fluid, cerebrospinal fluid
(CSF)
- Worms or eggs may be found in biopsies
• Egg detection rates is 25-35% for a single sputum
specimen, 50% with multiple examinations, 53-67%
via bronchoscopy
• Stool examinations are very useful to diagnose in
children because children tend to swallow sputum
Vidamaly S,et al. Trans R Soc Trop Med Hyg. Jan 2009 Tsang KW, et al. Respirolgoy. Nov 2008;13(7)
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Imaging studies
• CXR abnormalities in 80-90% of patients
• Three radiographic stages of pulmonary infection have
been described
- Migration of larvae result in pneumothorax with
consolidation or exudative pleural effusions
- During fluke maturation nodular or cystic lesions
predominantly develop in the periphery of the middle
and lower lobes. Bronchiectasis can also occur
- Following treatment lesions gradually disappear over
3-26 months
Tsang KW, et al. Respirolgoy. Nov 2008;13(7)
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A 47-year-old Korean woman with pulmonary paragonimiasis showing cysts within an area
of consolidation (A) CXR shows relatively well-defined patchy opacity in RUL that contains
cystic cavities (arrows). (B) CT scan shows air-filled cysts (arrows) within the mass-like
consolidation
(http://www.isradiology.org/tropical_deseases/tmcr/chapter22/radiological2a.htm
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Pulmonary paragonimiasis in a 39-year-old Korean man with sudden onset of
chest pain 3 weeks after eating pickled fresh-water crabs. CXR shows bilateral
hydropneumothoraces (arrows) . This radiograph was obtained at the time of
larval penetration into the visceral pleura.
Radiographics1993
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Other tests
• Serology tests aid in diagnosis extrapulmonary
disease where eggs are not shed in sputum or stool
- Complement fixation test
- Enzyme-linked immunosorbent assay(ELISA) has
92% sensitivity and is specific
- Rapid immunoblot test is 96% sensitive and 99%
specific but cannot be used to differentiate active
from past infection
• Intradermal skin testing with an extract of adult Paragonimus
Lui Q, et al. Trends Parasitol. Jul 2008; 24(7)
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Treatment
• Praziquantel is the drug of choice for both
pulmonary and extrapulmonary paragonimiasis,
the recommended dose is 25 mg/kg TID pc
x 3 days
• Bithionol 40 mg/kg in two equally divided doses
on alternate days for a course of 10 to 20 doses
(S/E urticaria)
• Triclabendazole administered in a single
dosage of 10 mg/kg body weight had
comparable efficacy, safety and tolerability
with praziquantelLui Q, et al. Trends Parasitol. Jul 2008; 24(7)
Belizario VY, et al. Southeast Asian J Trop Med
Public Health 2007; 38 (Suppl 1)
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Prevention & Control
• Never eat raw freshwater crabs or
crayfish. Cook crabs and crayfish for to
at least 145°F (~63°C)
CDC(Centers of disease control and prevention)
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Thank you for your attention