Tuesday, October 24, 2006

tree in bud in a 66 year old.

66-year-old lady who presented initially to our Pulmonary Clinic 2 years ago for evaluation of a one-time episode of hemoptysis. A CT of her chest showed focal areas of local bronchiectasis, tree-in-bud pattern. There was a concern about atypical mycobacteria and sputum cultures were obtained. Only one of those was positive for
non tuberculous mycobacteria. Since she was asymptomatic she was merely followed. A year later she has a bit of a nagging cough but no constitutional symptoms. However, a follow-up chest CT showed decrease in the nodularity in the outer lower
aspect of the right upper lobe, but increased atelectasis
and thickening around several bronchi the areas in the medial segment
of the right middle lobe.

In terms of management, how would you proceed, given the slight worsenening radiographically?

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

Mendez said...

Questions:

1. Species of NTM that was previously isolated - I assume it wasn't a worrisome strain

2. Is she a smoker?

I would proceed with a bronch - micro to r/o other organism, confirm Dx of NTM, and rule out malignancy.

Jennings said...

They said is was not avium complex and not TB. It could not otherwise be id'd even after 74 days.
She is a non-smoker (quit 1967.

Baleeiro said...

I would also bronch her.

Mike L said...

Agreed with the bronch.
I would also place a PPD skin test and send fungal serologies (you are making a case for RML syndrome, although we cannot see the CT).
Anything in the mediastinum?

Jennings said...

the mediastinum had the occassional small node that was calcified.
In terms of PPD and it's utility in this case, if it is positive would you treat with 4 drugs or treat as latent, or just ignore?

Jeff H said...

1) I agree with bronchoscopy to evaluate for infection, including atypical mycobacteria.

**parenthetically, I just got a report back from a bronch of a similar patient with a cough and mild bronchiectasis: After 2 months, it's growing M. terrae. I can't find much regarding this as a pathogen or not...**

2) I would not place a PPD unless I planned to treat if it is positive. There is a low suspicion here, and I'd be doing a bronch anyway. If the cultures are negative for M-Tb, then you could treat for latent TB if the PPD is positive, although if cultures grew non-TB mycobacteria you still need to consider a false +. In that case, I'd consider a Quantiferon ELISA. Alternatively, you could sent the BAL for nucleic acid amplification and get your answer.

Jennings said...

I saw her and she has a cough 2-3 x a day that is productive of cloudy or occassionally green scant sputum. Therefore I am sending her home to collect 3 sputums for AFB instead of the bronchoscopy.

Jorge Palanovitz D.O. said...

Comeon- this is a serious discussion! For those of you who feel they need to use this website as a joke please choose another form of recreation.

Tuti said...

Dr. Palanovitz?
As in the same Palanovitz who lives in New Jersey and has the thickest moustache this side of the Mississippi? I remember you! Oh, and you will pay my friend. You will pay dearly.

Jorge Palanovitz D.O. said...

Tuti,
I do not have a moustache. You must have me confused with someone else.
Regardless why would you want to make anyone pay dearly? Why do you have so much anger Tuti? The pulmonary round table was meant to bring people together for intellectual banter and as an educational tool. You and Jeebs Goldman have turned it into a bafoonery. Tsk tsk.