Saturday, September 03, 2005

Follow up on recurrent pneumonias

Excellent comments/suggestions (see original case here).

This patient had an office job and is now retired. No history of exposures relevent to hypersensitivity pneumonitis or occupational lung disease, no asbestos in particular. There is a family history of asthma. She had a cardiac w/u prior to her referral which was normal, including a surface echo. Her chem 10, CBC, ANA, ANCA, IgE, were (-). Her ESR was mildly elevated. Her films from 2000 were requested but never received.

Unfortunately I do not have any digital images from the CT to share, but the degree of pleural reaction/thickening at the lung bases was significant, and is seen much better on the CT. There weren't any calcified plaques, enlarged pulmonary vessels, or significant emphysema. I reviewed her films with radiology (BG) who agreed that the pattern of infiltrate/scarring did not point to any particular IIP, and thought the adjacent pleural reaction was highly atypical for an IIP.

2 weeks later the fungal cultures returned positive for a branching gram positive rod.

Now what?

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

Jennings said...

Very interesting. Did it look like this? http://pulmonaryroundtable.blogspot.com/2005/08/follow-up-to-patient-with-solitary.html
In other words, actinomycetes can be branching like the above picture; but unlike the aspergillus and mucor, it is gram positive. Nocardia can also look like it's brnching and stains gram positive. An acid fast stain should separate out these 2 (actinomycetes would be weakly acid-fast, while nocardia would be acid-fast negative).
So she has asthma and had previous courses of steroids. Given her lack of poor dentition, I would guess that the steroids are the risk factor for her to get this. Treatment is penicillin-g for 6 weeks or if nocardia, Bactrim.