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CASE REPORT

CASE REPORT. Istanbul University Istanbul Medical Faculty Department of Pulmonary Disease. Prof. Dr. Orhan Arseven. 22 years-old, female. She does not have respiratory complaints!. One year ago: Fever, night sweats, weight loss A painful palpable mass on gluteal region

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CASE REPORT

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  1. CASE REPORT Istanbul University Istanbul Medical Faculty Department of Pulmonary Disease Prof. Dr. Orhan Arseven

  2. 22 years-old, female • She does not have respiratory complaints!

  3. One year ago: • Fever, night sweats, weight loss • A painful palpable mass on gluteal region She admitted to surgery clinic

  4. Lower abdominal CT: A cystic lesion in the right iliac bone, extending posteriorly to the soft tissue.

  5. Pelvis MRI : A cystic lesion of 5x8x7 cm in size with internal septationsand extending from the bone to the soft tissue

  6. BACTERIOLOGY, BIOPSY • Drainage under US: • Purulan collection • The aerobic and anaerobic cultures: sterile • AFB (-) • Biopsy of the lesion: Chronic inflammation with necrotic regions

  7. PHYSICAL EXAMINATION • The palpable lesion (4-5 cm) in the right pelvic region. • Pulmonary oscultation: Normal, RR: 14/min • Cardiovascular system: Normal BP: 120/80 mmHg, • The other systems were normal.

  8. What is the diagnosis? • Malignancy , metastatic lung • Tuberculosis • Fungal infection • Actinomycosis • No one

  9. ESR: 76mm/hour CRP: 101.1 mg/L WBC:12.000 /µl (64% neutrophil, 22.1% lymphocite) HB: 10 g/dL HCT: %30.3 MCV: 77.8 Fl MCH: 25.8 pg MCHC: 33.2 g/dL PLT: 425000/µl Fe: 17 µg /dL TFBC: 278µg /dL BUN: 16 mg/dl Creatinin: 0.6 mg/dl Na : 139 mmol/L K : 4.4 mg/dl Ca : 8.5 mg/dl P : 4.5 mg/dl ALP: 117 U/L AST: 17 U/L ALT: 12 U/L LDH: 364 U/L GGT : 34 U/L T.Prot : 8.3g/dl Alb : 4.0 g/dl LABORATORY FINDINGS

  10. LABORATORY FINDINGS • Urine analysis : Normal • Sa02 : 98% (In room air) • No sputum

  11. Bilateral innumerable nodular lesions with internal calcifications

  12. Which investigation do you want? • Bronchoscopy, TBB • Abdominal CT or US • Open lung biopsy • Bone marrow biopsy and culture

  13. Thoracoabdominal CT A large hepatic lesion with internal calcifications and adjacent metastatic calcified subpleural lesion

  14. What is the diagnosis ? • Malignancy, metastatic lung disease • Tuberculosis • Aspergillosis • Echinococcal disease • 5. Actinomycosis

  15. Liver biopsy Germinative membranous structures of Echinococcus multilocularis (short arrows) within granulomatous inflammation (arrowheads) in the steatotic liver parenchyma (long arrows)

  16. CLINIC and RADIOLOGIC DIAGNOSIS Echinococcus multilocularis Albendazole :15 mg/kg/day was started.

  17. Echinococcal IgG ELISA TEST : 0.433( 0.411 )

  18. E. Multilocularis … DIAGNOSIS • US and serology ( ELISA ) • A positive serology depends on cyst location and viability • Patients with cysts in the liver are more likely to be seropositive than patients with cysts in the lung. • Serologic assays are less likely to be positive if the cyst is calcified or nonviable.

  19. ECHINOCOCCAL DISEASE • E. granulosus (cystic echinococcosis ) • E. multilocularis (alveolar echinococcosis )

  20. E. multilocularis Infections are less likely to be asymptomatic • Weight loss • Right upper quadrant discomfort due to hepatomegaly • Cholestatic jaundice • Cholangitis • Portal hypertension • Budd-Chiari syndrome

  21. E. multilocularis • Extrahepatic primary disease is very rare (1%) • Multiorgan disease (13% ) (Lung, spleen, brain and liver) • If left untreated, 90% of patients will die within 10 years

  22. TREATMENT • Surgery : The first treatment choice in operable cases is radical surgical resection of the entire lesion, followed by chemotherapy. • In patients with unresectable or incompletely resected lesions, • *Long term chemotherapy is recommended.

  23. TREATMENT Benzimidazoles: Mebendazol Albendazol(10 to 15 mg/kg per day PO in two divided doses ) Other approaches Praziquantel Nitazoxanide

  24. CASE REPORT II Prof. Dr. Orhan Arseven Istanbul University Istanbul Medical Faculty Department of Pulmonary Disease

  25. 30 years old, female • Complaints: Cough, fatique,night sweats • She had admitted to hospital due to diarrhea (4-5 times a day) two months ago. • Diarrhea was stopped by antibiotics therapy. (Ciprofloxasin and metronidazol) Past history: Thyroidectomy (in 1995)

  26. Left paracardiac nodular infiltration

  27. PHYSICAL EXAMINATION Mild anemic appearance Respiratory system:Normal Blood pressure: 120/80mmHg, Pulse:104/min There were no pathological findings in the other systems.

  28. ESR:27 mm/h CRP:26.7 mg/L WBC:11000 /µl (67.9% neutl, 19.9% lymph) HGB: 10.9 g/dL HCT: 34.1 % MCV: 77.3 Fl MCH: 24.8 pg MCHC:32.1 g/dL PLT: 413000/µl Fe: 21 µg /dL TFBC: 199µg /dL BUN : 13 mg/dl Creatinin: 0.7 mg/dl Na : 141 mmol/L K : 4.9 mg/dl Ca : 9.3 mg/dl P : 4.1 mg/dl LDH :214 U/L ALP :162 U/L AST :12 U/L ALT :12 U/L GGT : 50 U/L T.Prot :6.7g/dl Alb :4.0 g/dl LABORATORY FINDINGS

  29. LABORATORY FINDINGS • Urine analysis:Normal • Microscopy of gaita: Normal, parasite  • Abdominal US: Normal

  30. Nodular infiltration in the lingula and the lower lobe antero-bazal segment in the left lung

  31. WHAT IS THE DIAGNOSIS ? • Tuberculosis • Malignancy • Sarcoidosis • Legionella pneumonia • Lymphoma

  32. Bronchoscopy Endobronchial lesion (-) Bronchial lavage: - AFB (-), - Nonspesific cultures: No pathogen bacteria - Fungus culture :  - Cytology: (-)

  33. TREATMENT • Ampicillin/sulbactam…….. Amox / Clavulonat • ESR : 14 mm / hour • No changes in the lung lesions • She was discharged while waiting for the result of tbc culture.

  34. THREE MONTHS LATER • Complaints: Fatique, diarrhea, abdominal pain, nausea, pruritic skin eruption • Anamnesis: Diarrhea (last 15 days, 2 to 6 times a day), rash

  35. New nodular infiltration on the right lung !

  36. ESR:66 mm/hour CRP:83.9 mg/L CBC WBC:17.600 /µl (73% neut, 18% lymp) HB:10.4 g/dL HCT:32.9 MCV:77.4 Fl MCH:24.4 pg MCHC: 32.1 g/dL PLT: 234.000/µl Fe:21 µg /dL TFBC:199µg /dL Folat: 2.2 ng/ml BUN: 12 mg/dl Creatinin: 0.7 mg/dl Na: 141 mmol/L K: 4.9 mg/dl Ca 9.3 mg/dl P: 4.1 mg/dl LDH:551 U/L ALP: 242 U/L AST:12 U/L ALT:12 U/L GGT: 50 U/L T.Prot:6.7g/dl Alb:4.0 g/dl LABORATORY FINDINGS

  37. PHYSICAL EXAMINATION On the abdomen and legs : * Papular lesions in 2-3 mm diameter with pruritis The other systems examination: Normal

  38. WHAT IS YOUR DIAGNOSIS NOW ? • Tuberculosis • Vasculitis • Malignancy / metastasis • Sarcoidosis • Lymphoma • Others

  39. LABORATORY Thyroid Function Tests : Normal TBC culture: Negative Skin biopsy: * Focal paraceratosis, * Superficial dermatitis with mild acantosis * Vasculitis 

  40. C3-C4: normal Anti-Jo1 Anti-RNP Anti-Scl70 Anti-Sm Anti-SS-A(Ro) Anti-SS-B(La) C-anca P-anca RF ANA LABORATORY NEGATİVE

  41. Transthorasic needle aspiration biopsy * Fibrin rich material with rare histiocytes

  42. WHICH TEST DO YOU PERFORM ? • PET Scan • Transthorasic needle aspiration biopsy (repeat) • Open lung biopsy • Colonoscopy • Bone marrow aspiration/ biopsy

  43. COLONOSCOPY • There were a number of aphthous ulcers on the mucosa of cecum and ascending colon, • There were a number of similar ulcers on the transvers and descending colon, skipped areas of cubbelstone appereance made up by normal mucosa

  44. DIAGNOSIS Normal terminal ileum, segmental colitis Inflammatory bowel disease Crohn's disease !

  45. PATHOLOGY • Large intestine, cecum-ascending colon-transvers colon-descending colon-sigmoid colon-rectum, endoscopic biopsy; Aphthous ulcers, rare criptic abscess, active colitis with areas of criptitis

  46. TREATMENT Salofalk 500 mg 3x2 Nidazol 500mg 3x1 Ferrosanol duodenal 2x1 Folbiol 1x1

  47. ONE MONTH LATER Because ofhigh ESR and CRP increase * Prednol 16mg 2x1 was added

  48. Two months later (after treatment)

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