Thursday, August 25, 2005

Positive PPD

Patient is a 49-year-old woman with a history of cough thatshe noted since early May. She had traveled to Puerto Rico for 1 week and when she returned, she noticed a dry, nonproductive cough that was sporadic. No fever, weight loss or other constitutional symptoms. In June, Vasotec was held by PCP w/o any change in sxs. However, in July, she returned with continued cough and now with fevers and chills. Fevers were documented up to 102. At that time, an x-ray was performed, PA and lateral, which revealed prominent hila. This was followed by a CT scan of the abdomen and chest with IV contrast. The CT scan revealed hilar mediastinal adenopathy. A right paratracheal node was noted to be 1.7 cm. There were also non-calcified <5mm nodules noted in the right middle lobe, the right lower lobe and lingular nodule as well. She was treated with Zithromax for 5 days after which she had improvement in her symptoms - no fevers, decreased cough. She otherwise feels fine. She was referred to us for the abnormal CT findings and a PPD placed 48 hours previously.

On the day of visit, she continues to feel better. No history of sick contacts, swollen lymph nodes or rashes. She has not had any heartburn or any sinus problems. At this time, her medications include Hyzaar. She has no known drug allergies.

Past medical/surigcal history is significant for C-section. Family history is noncontributory.
Social history: She has worked in a bank and does not note any occupational exposures there. She does not have any pets or birds. She is never a smoker and is not exposed to second hand smoke. There has been no significant change in her environmentin recent time. She is from India and has not been there since last year. She has lived in the US for <20 years. She did receive a BCG when she was a child. She does not recall any TB contacts that she knows of.

VSS, Exam unremarkable except:
PPD placed 48 hours ago and this, as measured in our clinic, is20 mm x 18 mm with red induration.

Data: Spirometry reveals an oximetry of 100% on room air. FEV1 is 1.95 L (74%), FVCis 2.75 L (80%), FEV1/FVC ratio is 93% of predicted. The flow-volume loopappears mildly coved.
OSH CT as above.

What next?

8 comments - CLICK HERE to read & add your own!:

Mike L said...

We would love to see the images of her CT.
There is no argument about the size of that PPD. It is positive regardless of the circumstances.

I think you probably have apples and oranges in this case, but TB burns you when you ignore it. Especially in people from Asia or who have travelled to Asia. Therefore, I will not assume she has sarcoidosis and a recent bronchitis.

Presuming she is not coughing, I would:
1. Bronch with BAL in the upper lobe
2. Sample the paratracheal node with a Wang needle
3. Transbronchial biopsies of the upper lobe x3, middle lobe x3 and lower lobe x 3 to see if she has any granulomas.
4. Get an EKG to r/o conduction abnormalities (Cardiac sarcoid can present as sudden death if you do not look for it).

If all of this is negative for AFB, I would treat her for 9 months with INH and Vit B6.
I would bring her back in 3 months to repeat the PFT's.

Mendez said...

Unfortunately, I can't get you the images, but heres the report:

There are many enlarged right hilar and mediastinal lymph nodes. Manynodes are relatively low in attenuation. Right paratracheal lymphnodes measure up to 17 mm in short axis. Right hilar lymph nodes
measure up to 19 mm. Enlarged nodes are also shown in the pretrachealand subcarinal regions. There are many borderline lymph nodes in theleft paratracheal region. There is a small-to-moderate pericardial
effusion.There are several pulmonary nodules without detectable calcification
as follows:
4 mm middle lobe image 101
5 mm middle lobe image 112
9 mm middle lobe subpleural image 114
5 mm right lower lobe image 120
Lingular atelectasis with possible 9 mm nodule image 139
There are no definable liver lesions. The adrenal glands and pancreas
have a normal configuration. Splenic outline is normal. No enlarged abdominal lymph nodes.

Mendez said...

Bronch:
BAL: grew aspergillus niger, AFB smear neg. AFB Cx neg. Cytology neg.
TBNA: epitheloid histiocytes and giant cells. No malignant cells.

Jennings said...

Yet another case of someone getting a PPD without thinking it out. Now we are stuck with it; I guess you're going to have to treat her for latent TB (now that you ruled out active).

Problem 2 is unrelated and is the adenopathy. I agree with lazar's w/u for problem 2 to r/o sarcoid. Problem 3 is aspergillus in the BAL. Since adenopathy is pretty rare with this, prob 3 is liklely not related to prob 2. But, the fevers, with nodules and mild obstruction of spiro may indicate that ABPA is present. Might start with an IgE or go on to an HRCT if suspicion is still high. On the other hand, the aspergillus may be not of any significance.

I suppose that one way to put all of the above together would be lymphoma (adenopathy) with increased susceptibility to infection (fevers, nodules. And then airway aspergillus (non-invasive since that degree of immunocompromise is not evident here) with subsequent mild reactive airways disease.

Mike L said...

Did you get a biopsy on the bronch?
Are epitheliod histeocytes on a TBNA good enough to make a diagnosis of sarcoidosis.

Aspergillus can be a colonizer in the sinuses. So, I would not do any work for ABPA yet; however, if she becomes symptomatic with worsened PFT's, I would consider a course of itraconazole.

Baleeiro said...

The PPD is clearly positive and the BCG is irrelevant in her case as Mike L pointed out. I'm not sure how good the epithelioid histios are: they are present at the outer layers of any organizing granuloma (including TB).
I agree with JJ that the Aspergillus is unrelated to the other problems. I am not even sure I would treat because it can colonize/contaminate so many specimens.
However, I am not sure I would completely dismiss TB or other granulomatous infections yet. Even Lymphoma is harder to rule in/out on a TBNA. Any chance of talking her into a mediastinoscopy?

Mendez said...

This is one of those positive PPDs that isn't quite straight forward.

We agreed that her BCG is irrelevant and that she AT LEAST has latent TB. However, the guidelines don't say much about lymphadenopathy without evidence of parenchymal abnormalities. So the question is: Is it likely that the adenopathy represents active TB? As ML pointed out, TB burns you when you ignore it. Would we burned if we didn't start multidrug therapy until we new that she definitely wasn't active?

As everyone pointed out, there are different scenarios that could explain her presentation. She could have contracted a fungal respiratory tract infection on her trip to PR which her body appropriately fought off. The nodules, adenopathy, and granulomas would represent sequelae of infection.
Alternatively, we could be incidentally discovering sarcoid in the setting of an atypical pneumonia that was appropriately treated with Azithromycin.

Back to TB. Unfortunately, in this case, as in many, there are no prior images for comparison and no previous PPD so we don't know if she is a recent converter. Also, it is not unheard of for TB to present with hilar adenopathy without parenchymal abnormalities. However, she is otherwise healthy and given the spontaneous resolution of her symptoms and no AFB organisms on staining (unforutnately no pcr), our suspicion for active TB was low.
In the end, we decided to have her follow up in a short period of time - giving the cultures an appropriate period of time to grow followed by nine months of INH. A follow up CT will be performed at a short interval to assess for change. The other key here will be close f/u to assess for the other possible Dx's (sarcoid, lymphoma).

We agree that the Aspergillus is a contaminant.

krayem said...

I agree with Dr Baleiro. I would not dismiss active TB. Active TB presenting as adenopathy is definitely a possibility (although it tends to happen more in younger patients or in HIV patients). I would not treat with isoniazid only at this time. I would rather obtain more tissue, (by mediastinoscopy), and if the patient is resistant to that, I might even consider 4 drug therapy, with short term radiographic follow up...