Case Presentation

1. Case Presentation Ass.prof. Hala AbdulHameed MBBCH , MSc ,MD,FCCP Pulmonolary and Critical Care. Alminya University

2. Presenting complaint A Sudanese male aged 52 years old non smoker he worked as a shepherd C/O • productive cough >4 months with large amount of yellowish sputum odurless with occasional shortness of breath • with no loss of weight or appetite or fever • No past history of pulmonary tuberculosis (TB) or chronic illness.

3. Physical Examination On examination, the patient was clinically stable . He was not dyspnoeic no pyrexia no clubbing of the fingers.

4. Physical Examination Cont., • no hepatosplenomegally. • Over the chest , an impaired percussion note was detected over the right infrascapular area, but the breath sounds were normal with diminished intensity and there were bilateral scattered mid- crackles • workup followed toward differential diagnosis.

5. Roentgenograrm of the chest

6. Laboratory findings

7. Laboratory findings Cont., Sputum microscopy for AFB 3 samples were -ve and DNA Direct Technique -ve. PPD test -ve (less than 5mm) Sputum Gram stain showed few pus cells, no organism seen and by bacterial culture there was no growth

8. Laboratory findings Cont., • Urine analysis---- at this time showed no red blood cells, and no parasites were identified on urine or stool microscopy also ,urine cytology showed no evidence of malignancy. • Biochemical indices of hepatic and renal function were normal. • Ca 2.23,Na 139, K 4.96,mg 0.89

9. High resolution computed tomography of the chest (HRCT)

13. Conclusion: • Bilat. ill defined soft tissue masses in RUL LUL,RML - prominent calcified anterior mediastinal and hilar nodes --- nodular pattern seen throughout both lungs, evenly distributed

14. CT Abdomen with contrast : Normal except for 2 small stones in the mid pole of the right kidney with no hydronephrosis

15. Differential Diagnoses • Tuberculous Mycobacterial Infections • lung neoplasms • Sarcoidosis, • , silicosis, • atypical pneumonia

16. Fiberoptic bronchoscopy • Fiberoptic bronchoscopy revealed no changes in the bronchial tree. • Both the research of the TB bacillus , fungi and other bacteria in bronchial lavage were -ve. • Cytology was also negative for malignant cells. • Post bronchoscopic sputum for TB was -ve • It was decided, then, thoracotomy and biopsy.

17. Thoracotomy • Right mini thoracotomy revealed multiple nodules and masses involving most of the right lung, parietal pleura is not involved and wedge biopsy of lung was taken from the right upper lobe.

18. Histopathoogical ex. • AFB and Grocott's stain revealed negative results.

19. Start Anti tuberculous or not?

20. Deeper section showed collection of multiple schistosomal ovai. Some of which are viable and others are clacified • Several sections revealed no significant arterial lesion caused by the Schistosoma infection nor other non-schistosomal lesions . • No evidence of malignancy

22. Bilharsial Granuloma of lung What is the diagnosis Bilharsial Granuloma of lung

23. Is patient needs TTT or not ? A diagnosis of schistosomiasis should prompt initiation of treatment, even if the patient is asymptomatic, since adult worms can live for years . The patient was treated with praziquantel (40 mg/kg) as a single dose without complications.

24. F/U • One month after treatment, a subjective improvement as regards better general condition, decrease amount of sputum change to whitish a chest CT scan showed a no changes on previous findings i.e. no more lesions appear

25. After 3 months

28. Broncho-Pulmonary Bilharziasis (Schistosomiasis)

29. Preview Incidence: >200million people all over the world .Bilharzial lesions in the lung were found in 33 percent of post-mortems of cases with bilharzial infection (AJR 2006;186:1300-1303)

30. At least 75 countries in the tropical and subtropical areas of Africa, Asia, South America and the Caribbean have endemic foci of schistosomiasis

32. Acute lung disease • Invasion of migrating schistosomules (larvae) may cause a transient pneumonitis immunologic (type 3) reaction (Loeffler’s syndrome).simple esinophlic pneumonia • The development of adult worms in the next 2–4 weeks results in an acute e ‘‘Katayama syndrome’ • Verminous pneumonitis • reactionary pneumonitis

33. Chronic lung disease • Chronic schistosomiasis results from Bilharzial oval embolization And granuloma formation in Response to the schistosome eggs (type 4) reaction

34. Two types of chronic pulmonary schistosomiasis are recognizable pathologically: • 1 . Cardiovascular typewhich is characterized by a necrotizing arteriolitis with endarteritis obliterans and perivascular tubercles Dis Chest 1963;43;317-319

35. Chronic lung disease • Parenchymatous or bronchopulmonary type. • Its pathologic incidence is more common than the former type and it is less serious clinically as in the present case Rev Bras TerIntensiva 2009;21(4):461-464

37. Radiographic appearances • are of interstitial infiltrates, typically nodular or micronodular, and there may be frank fibrosis. • Later CT findings include cardiomegaly and pulmonary arterial enlargement. • Rarely large mass lesions pseudo tumor

38. Diagnosis • as pulmonary affection occurs several years after infection so eggs may be not found in stool or urine . under this circumstances demonstrating characteristic pathologic changes and ova in tissues or +ve serology settle the diagnosis. • Demonstration of bilharzial ova in the sputum was also reported. RadioGraphicsJanuary-February 2005 Volume 25 ● Number 1

39. Home Massage • to stress having bacteriologic proof before accepting the clinical diagnosis of tuberculosis. • It is proposed that, in endemic areas, pulmonary schistosomiasis is considered a differential diagnosis for complex structures, as pulmonary masses even with absense of sure diagnostic criteria, and pulmonary hypertension. pseudotumoral schistosomiasis • Pulmonary bilharziasis may be arrested at any stage, and the patient may live his normal span of life. • diagnosis of schistosomiasis should prompt initiation of treatment, even if the patient is asymptomatic, since adult worms can live for years .

40. THANK YOU