Wednesday, September 14, 2005

To treat or not to treat...

Brief case:
49 y/o woman, previously healthy, referred from a thoracic surgeon. Her primary complaint, for months, has been RUQ abdominal pain; during the work-up of this, she had a chest CT showing a RLL mass. Further evaluation of this by MRI showed that the mass was c/w a pericardial fat pad.

In addition, she has complained of intermittant dry cough and chest pressure for several months. It is worse with exertion or when she "leans forward" but she has not noticed any diferences based on the weather, time of day, food intake, or around perfumes or pets. No fevers/chills/sweats. No sinus congestion or post nasal drip. No nocturnal symptoms. As a teacher, she notes worsening when speaking.

She saw a cardiologist for these symptoms, and was prescribed a PPI which she never took.

Her exam is normal.

Spirometry showed a mild obstruction (FEV1 78%), with variablilty in the flow-volume loops but consistent early-flattening/plateau of the expiratory loop. The inspiratory loop was normal.

My primary DDx was cough-variant asthma, GERD, or laryngeal dyskinesis, but the flow-volume loop was concerning. An airway-protocol CT of the trachea and mainstem bronchi with 3-D reconstruction did not show any abnormalities.

A bronch was ordered for an airway exam. The airways were normal; for some reason, a BAL was obtained. This BAL is now growing MAC.

In follow-up, her cough has improved with Advair, as has her chest pressure. She still complains of the abdominal pain/pressure, described as "something pushing up into my lungs." She insists that it is the pericardial fat pad, and that it should be removed. So far, GI w/u is negative.

Here are the questions:
1) Is the MAC real, or a contaminant?
2) She has no sputum production: would you repeat a bronch with BAL to obtain a second sample?
3) Might her MAC be related to her symptoms?

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

Mendez said...

1. May not matter. Is there any exposure hx that may explain this finding (hot tubs)? In the absence of structural lung disease and symptom improvement, I would assume that this bug is not causing her a problem and observe closely.
2. I would repeat bronch depending on symptoms or radiographic changes on follow up.
3. Possibly - such as HP due to the MAC. Her presentation is not consistent with MAC infection. Considering her improvement on Advair - I wonder if she simply has cough variant asthma.

By the way, did her hepatobiliary numbers look fine? Any comment on liver on the CT?

Jeff H said...

Liver is fine on imagine. Normal LFT's across the board. No exposure history.

Mike L said...

In the absence of any radiographic abnormalities, I would not treat her for MAC.
I agree with you diagnosis of C-V asthma and treatment with adviar.
If her PFT's worsen or she becomes more symptomatic, I would consider repeating your radiographs and treating at that time.

Baleeiro said...

My vote is the same as Lazar's. No radiographic abnormalities, no new symptoms, no sputum, no need to treat.

Jennings said...

I second the already seconded notion sicne there was no evidence of invasive disease. It is liklely not the cause for her symptoms. It is a good lesson that one should not order a test if the results will only confuse the matter (referring to the BAL).

Jeff H said...

Agreed. I was actually pretty aggravated that a needless BAL was done--she only needed an airway exam.

And, what is "sicne?"