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CASE PRESENTATION Dr. Nurçin Çimen Private Beylikdüzü Kolan Hospital-İstanbul

CASE PRESENTATION Dr. Nurçin Çimen Private Beylikdüzü Kolan Hospital-İstanbul. Conflict of Interest Declaration I hereby declare that; No stocks, shares or employment in a commercial No membership in advisory board or focus group

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CASE PRESENTATION Dr. Nurçin Çimen Private Beylikdüzü Kolan Hospital-İstanbul

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  1. CASE PRESENTATION Dr. Nurçin ÇimenPrivate Beylikdüzü Kolan Hospital-İstanbul

  2. Conflict of Interest Declaration I hereby declare that; No stocks, shares or employment in a commercial No membership in advisory board or focus group No honorarium payment received for speech, publication or editorials No education nor research grants No congress or symposia sponsorship

  3. U.T • 22 years, male • Computer programmer • Born in İstanbul, lives in İstanbul

  4. COMPLAINTS • Cough • Sputum • Fever

  5. MEDICAL STORY Complaints began 1 week ago, with cough, dark colour sputum. He also had fever of about 39 °C. Postnazal seromucoid secretion and fragility at Little area was detected in ENT examination. Cefuroxim aksetil 500 mg tb 2x1, pseudoephedrine HCL+ Setrizine HCL tb 2x1, had begun to the patient by ENT because of hemorragic nasal secretion 3 days ago.

  6. Medical History: No special feature Family History :No special feature Habits: No smoking, Rare alcohol intake

  7. PHYSICAL EXAMINATION Conscious, coopered, oriented Blood Pressure: 120/70mmHg Pulse: 100/dak Fever: 38.5°C Tiroid palpabl No peripheral LAP

  8. Respiratory system examination: RR:18/min Expiratory duration was increased bilaterally and respiratory sounds were decreased at right lower lob Bilateral CDS open

  9. LABORATORY Hb:12.7 g/dL (14-17.5) Hct:% 37.9 (40-52) WBC:11.1x10³/uL (4.4-11.3) RBC:4.50x106/uL(4.5-5.9) PLT:346x10³/uL(135-486) ESR: 82 mm/h CRP: 8.65 mg/dL (0.01-0.82) IgE: 146 IU/mL (<100) Alb:3.3 g/dL (3.5-5)

  10. Chest X ray (03.06.2011)

  11. CHEST X-RAY: Enlargement of right hilar zone and irregular opasity of about 1,5 x1,5 cm at infrahilar area .

  12. WHAT IS YOUR PREDIAGNOSIS? A-Wegener’s Granulomatosis B-Pulmonary Artery Aneurysm(Behçet's Disease) C-Lung Cancer D-Lymphoma E-Tuberculosis

  13. Ampicillin- sulbactam 1 g 4X1 (IV) treatmentbegantothepatientwith CAP prediagnosis (3.6.2011). Fever of thepatientdid not decreased in 3 dayseventoughtothetreatment. Therewerenonsignificantdecrease in CRP levels . Therewerenosignificantimprovemet in controlchest X-ray.

  14. Chest X-ray (06.06.2011)

  15. Which diagnostic tests would you perform? A-Sputum gram staining- culture B-Sputum ARB (Direct-culture) C-Thorax CT D-Bronchoscopy E-All of them

  16. Sputum gram staining: Epithelial cells, gram positive chain forming cocci, rare gram positive bacilli. • Aerop culture: Alpha hemolytic streptococci. • Antibiogram: sensitive to penicillin, ceftriaxsone, erythromycin, vancomycin, levofloxacine. • Sputum ARB: 3 times negative

  17. Thorax CT: Subcarinal- paraeosaphageal, right hilar and intrapulmoner soft tissue (LAP), heterogenous dansity with air bronchograms at right lung lower lob paramediastinal area, and parenchymal infiltrations nearby. Irregularity at lower lob basal segment becouse of LAP and consolidation.

  18. WHAT IS YOUR PREDIAGNOSIS? A-Wegener’s granulomatosis B-Lymphoma C-Lung cancer D-Tuberculosis E-Carcinoid tumor

  19. Sputumtuberculosisculture (MGIT): Sterile Blood culture: Sterile

  20. Which diagnostic test would you perform ? A-Sputum Cytology B-c-ANCA, p-ANCA C-PET-CT D-Bronchoscopy E-Mediastinoscopy

  21. PET-CT (07.06.2011)

  22. PET-CT: Increased pathological FDG (Early SUV max:16.1 , Late SUV max: 19.4) at right lower lob paramediastinal heterogenous dansity consolidation and infiltration areas. Pathological FDG (Early SUV max: 14.9, Late SUV max: 21.7) (metastasis?) at subcarinal, paraeosophageal, right hilar and intrapulmoner conglomerated lymph nodes .

  23. BRONCHOSCOPY (06.06.2011)

  24. BRONCHOSCOPY: Main carina deviated to the right, norrowing of the left side wall of the intermediair bronchus by extrinsic compresssion. Endobronchial lesion at the entrance of right lower lob, causing bulging at the posterior wall, with nodularity and mucosal infiltration on it. Right system lavage , and forceps biopsy from the lesion is taken. TBNA was not performed because of hemorrage.

  25. YOUR DIAGNOSIS? A-Lung Cancer B-Sarcoidosis C-Lymphoma D-Tuberculosis E-Wegener’s Granulomatosis

  26. PATHOLOGY: Right lower lob lesionbiopsy: Necrotizinggranulomatousbronchitis

  27. BronchialLavageMicrobiology: Gram Staining: Epithelialcells, gram positivechainformingcocci, rare gram positivebacilli. AeropCulture: Growth of normal flora of throat . Fungalculture: No growth of pathogenfungi. EZN Staining: No asidresistantmicroorganism Tuberculosisculture (MGIT): Growth of Mycobacteriumtuberculosis.

  28. According to the information obtained from Tuberculosis Contol Dispansery registrations; Antitb treatment had begun to the patient at 21.06.2011 at I.U Istanbul Medical Faculty. There were no problem during follow up, and kontrol chest X ray was reported to be normal.

  29. Endobronchial Tuberculosis (EBTB) It ıs the tracheobronchial tree tuberculosis infection proved with microbiologic and histopathologic findings*. According to the autopsy results bronchial tuberculosis causing atelectasis and consolidation in lung parenchyma and involving the bronchi is about 40-80% **. * Yılmaz A, Alıcı O.İ, Demirci N.Y ve ark. Radyolojik Olarak Maligniteyi Taklit Eden Endobronşiyal Tüberküloz Olgularının Klinik ve Bronkoskopik Özellikleri.Solunum 2011; 13(3): 170–175 ** Yosunkaya Ş, Gök M. Akciğer kanseri ile karışan iki endobronşial tüberküloz olgusu . Genel Tıp Derg 2005;15(3):125-128

  30. It is one of thecomplications of pulmonarytuberculosis *. Endobronchialtuberculosisdevelopmentinsidence is about 5.88 % **. Real insidence? * Park MJ, Woo IS, Son JW, et al. Endobronchialtuberculosiswithexpectoration of trachealcartilages. EurRespirJ 2000;15:800-2. **Chung HS, Lee JH. Bronchoscopicassessment of theevolution of endobronchialtuberculosis. Chest2000;117:385-92.

  31. In our country age distrubution is different from west countries. In the study of Tahaoğlu and coworkers ıt is reported to be more frequent in the second and third decades*. * Tahaoğlu K, Kızkın Ö, Karagöz T ve ark. Endobronşial tüberküloz. Solunum 1993;18:146-53.

  32. Pathogenesis of EBTB is not fully understood. • Five potential mechanisms*: • Direct extension from adjacent parenchymal focus, • Implantation of organisms from the infected sputum, • Hematogenous dissemination, • Lymph node erosion into the bronchus, • Through lymphatic drainage from parenchyma to the peribronchial region. *Kashyap S, Mohapatra PR, Saini V. Endobronchial tuberculosis.Indian J Chest Dis Allied Sci 2003;45:247-256

  33. Clinical findings are various* ; cough and sputum production, wheezing , chest pain and fever is mostly seen during active disease , at fibrosis stage dyspnea and wheezing are the main symptoms. Most frequent symptom is cough **. * Baran A, Akbaba B, Bilgin S ve ark. Endobronşiyal Tüberküloz: Klinik ve Bronkoskopik Özellikleri.Akciğer Arşivi 2007; 8: 44-7. ** Akman M, Yılmaz T, Çelik N ve ark. Akciğer kanserini taklit eden endobronşiyal tüberküloz. Solunum Hastalıkları 1995;6:441-9.

  34. Differantial Diagnosis of EBTB • Lung Cancer • Pneumonia • Bronchial asthma • Foreign body • Athelectasis • Karsinoid tumour • Fungal infections • Lymphoma • Sarcoidosis

  35. Bacteriologic diagnosis is limited in endobronchial tuberculosis *. In studies performed in our country bacille positiviy rate is about 14-50% ** * Ip MSM, So SY, Lam WK, Mok CK. Endobronchial tuberculosis revisited. Chest 1986; 89:727-30. ** Kırkıl G, Deveci F, Muz H ve ark Akciğer Kanserini Taklit Eden Endobronşiyal Tüberküloz Olgusu Solunum Hastalıkları2006;17: 88-91.

  36. Radiologic findings are various*; hilar and perihilar mass, athelectasis and mediastinal enlargement. Right lung involvement, especially upper lob is more frequent . *Kurasawa T, Kuze F, Kawai M, et al. Diagnosis and management of endobronchial tuberculosis. Intern Med 1992;31:593-8.

  37. Saygı et al reported twenty-nine patients with EBTB aged between 12-76. Bronchoscopic examination revealed involvement of EBTB most frequently at right upper and right main bronchus in 51.7% of the subjects. In the differential diagnosis of chronic cough resistant to antitussive therapy, EBTB must be explored in order to prevent complications*. *Saygı A, Süngün F, Çağlayan B ve ark. Endobronşial Tüberküloz Olgularının Retrospektif İncelenmesi. İstanbul Tabip Odası-Klinik Gelişim DergisiCilt 9 / No: 12 / Aralık1996

  38. The most frequent bronchoscopic finding is ulceration with mucosal hyperemia and erosion , and granulation tissue *. Chung and co-workers classified to seven subtypes according to bronchoscopic findings **. * Saleemi S, Khalid M, Zeitouni M, Al-Dammas S. Tuberculosis presenting as endobronchial tumor. Saudi Med J 2004;25:1103-5. ** Chung HS, Lee JH, Han SK, et al. Classification of endobronchial tuberculosis by the bronchoscopic features. Tuberc Respir Dis 1991;38:108-15.

  39. Classified to seven subtypes according to bronchoscopic findings (I) Actively caseating , (II) Edematous - hyperemic, (III) Fibrostenotic, (IV) Tumorous, (V) Granular, (VI) Ulserative, (VII) Nonspecific bronchitis (Atatürk Göğüs Hastalıkları ve Göğüs Cerrahisi Eğitim ve Araştırma Hastanesi 7. Göğüs Hastalıkları Kliniği arşivinden)* *Yılmaz A, Alıcı O.İ, Demirci N.Y ve ark. Radyolojik Olarak Maligniteyi Taklit Eden Endobronşiyal Tüberküloz Olgularının Klinik ve Bronkoskopik Özellikleri. Solunum 2011; 13(3): 170–175 III I II IV V VI VII

  40. THANK YOU …

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