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Case presentation 1

Case presentation 1. Dr REESAUL R. Case 1. Male 25 years old Ref on 06/04/2006 to poudre d`or hospital from private GP Cough hemoptysis and dyspnea. Case 1. He had several visits AHC and private doctors for cough since early childhood :

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Case presentation 1

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  1. Case presentation1 Dr REESAUL R

  2. Case 1 • Male 25 years old Ref on 06/04/2006 to poudre d`or hospital from private GP • Cough hemoptysis and dyspnea

  3. Case 1 • He had several visits AHC and private doctors for cough since early childhood : ATB , cough mixture and discharge with diagnosis acute bronchitis • Since last 4 months severe cough and night fever he visited 4 AHC and twice casualty VH , each visits : ATB , cough mixture , PCM discharge home diagnosis acute bronchitis • Refer on 6/4/06 by private doctor to chest clinic

  4. Case 1 • Single • work in `pizza hut` since 5 years • Brother had TB 6 years back • Smokes 5 cig daily since 10 years • IVDA since 3 years • Alcohol on/off

  5. Case 1 • Examination : 1m74 ,52 kg cachexia weight loss 10kg/4 months • Temp 38.5 , productive cough, dyspnoea with orthopnea, mild haemoptysis and L chest pain • Crackles 2 lungs • Bp 120/80, pulse 120

  6. Case 1 • Spo2 : 87 % at rest • CXR (7/4/06): R + L opacities left effusion • ABG at rest : Po2: 59 mmhg, Pco2 : 34mmhg, Ph 7.39 • Tapping Left effusion 100 ml protein: 3.5g/l , glucose: 6.5mmol cytology : lymphocytes +++ no malignant cells • Sputum analysis

  7. CXR on admission 6/4/06

  8. Cytology report effusion

  9. Case 1 • Diagnosis young male-IVDA-bilateral DIL opacities U>L with exsudative effusion with lymphocytes hypoxia-hypocapnia • Atypical pneumonia or viral pneumonia? • Pleuro-pneumonia in IVDA? • Pulmonary tuberculosis with pleural TB? • Cystic fibrosis with chest infection involvement? • Pneumocystose Jirovecy immuno-suppression? • Pulmonary oedema with endocarditis in IVDA? • Systemic disease with lung involvement? • Malignancy with lung involvement? • PE?

  10. Case 1 • FbC N with ESR 40 , SGOT/SGPT raise • Mantoux test : 12mm • Blood culture : negative • Serology HIV : negative • Sputum : pseudomonas aeruginosa +++ • Sputum AFB direct : +++ • Sweat test normal at VH lab • Serology chlamydia and mycoplasma negative • ANF negative • ECG normal , Echo doppler cardiac normal • D-dimer negative

  11. Sputum result 12/4/06

  12. Blood test HIV

  13. Blood test FBC ESR

  14. Blood test LFT

  15. Positive findings AFB direct +++ Pseudomonas A +++ Exsudative lymphocytic effusion Mantoux 12mm other findings HIV negative Blood culture negative Serology mycoplasma chlamydia negative Sweat test normal ANF negative Cytology effusion no malignancy Echo Doppler cardiac normal D-dimer negative case1

  16. Case 1 • Diagnosis : pulmonary TB and with pseudomonas infection • Initiated on anti TB drugs : IRP and Ethambutol • IV ceftazidime 1g TDS + colistin neb 1mu bd + IV amikacin 750mg od • Solumedrol 40mg iv od • O2 : 3-4 l/m • IV fluids

  17. Case 1 • Clinical improvement on antibiotics and anti TB drugs • Day 6th sputum pathogen negative with still sputum direct AFB ++ • Final Diagnosis pulmonary TB • Antibiotics and steroids stop after 7 days • continuation of Anti TB drugs

  18. Case 1 • Day 10th severe skin rash with pruritis • ATT stop and initiated on anti-H1 and prednisone 40mg • Reintroduction pyrazinamid then ethambutol then rifampicin • On 50mg isoniazid pruritis and rash • Desensitization to isoniazid

  19. Case 1 • Day 30th : sudden onset dyspnea and R chest pain in ward • Temp 36 • BP 130/60 pulse 130 • Spo2 : 87% • Hypoventilation right lung • Possible diagnosis ? PNO- PE

  20. CXR Sudden dyspnea

  21. Case 1 • CXR : complete R pneumothorax • Chest drain inserted R side in surgical unit SSRN • 5th day complete re-expansion R chest and drain removed transfer back to poudre d`or hospital

  22. CXR insertion R chest drain

  23. CXR chest drain remove day 5

  24. Case 1 • Sputum month 1 AFB + • Sputum month 2 AFB + • Sputum month 3 AFB negative • CXR : improving • Discharge on IR and B6 follow up OPD chest Clinic • Culture sputum M tuberculosis sensitive to IRES

  25. Sputum result month 1

  26. Sputum result month 2

  27. Sputum result month 3

  28. CXRafter 6 month treatment

  29. Culture sputum

  30. Culture/Sensitivity results

  31. Case 1 • Regular follow up at chest clinic out patient • Off all respiratory symptoms • CXR improving • Sputum AFB negative • HR CT scan thorax cause PNO : emphysema causes : smoking Deficiency alpha anti- trypsin ? • Spirometry obstructive lung disease • Complete course of 6 months regiment anti Tb

  32. HR CT scan thorax

  33. HR CT scan thorax

  34. CRX after 1 year

  35. we have several thousands years of TB behind us………..still24th march 1905

  36. Thank you Merci

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