Monday, August 27, 2007

Hemoptyis and bilateral infiltrated UPDATE

The case below was posted last week. Since that time I obtained a high res CT and autoimmune panel. The ANCA and ANA were normal. The BAL (clear non-bloody) was negative for any infection. The cell count of about 500 was predominantly macrophages. He is still short of breath (mostly on exertion but to a lesser extent at rest). He has no fevers or other constitutional symptoms. No more hemoptysis.

CT (no hilar adenopathy, by the way):

63 year old man with one week of hemoptysis. The hemoptysis is described as streaks of blood with the underlying sputum being slighltly light green or white. No malaise. Just some shortness of breath. No fevers or night sweats. No anorexia or weight loss. He feels pretty well except for the mild increase in SOB.
He is a 48 pack year smoker now quit. No significant exposure or travel history. For what its worth (if anything), he was cleaning out his gutters about a week before the symptoms. Lots of decayed leaves etc.

On exam he is WNWD and NAD. Vitals and pulsox are normal. No LAD and the lungs are clear to auscultation.

His WBC is 14 and in June it was 7.
His xray from 3 years ago:

The xray from today is seen here:

He has persistent dyspnea despite a course of azithro for presumed mycoplasma. The BAL was negative for virus or fungi.
His new cxr is here:

What is your differential dx?

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

darenberg said...

I suppose he could just have a pneumonia with some bleeding from chronic bronchitis, but you wouldn't be throwing up a softball like that on your blog Jeff, so where do we go from here?

Normally in a guy with this history I'd be pushing for an airway exam because of the risk of cancer, but the CXR suggests a diffuse process, which is possibly the source of blood. I see he has sternal wires...does he have CAD? Or mitral valve disease? Is he on plavix or other anti-coagulant? Any abnormalities on urinalysis, or renal function to suggest a systemic problem?

Jennings said...

What's interesting is he is not sick with this fairly dramatic x-ray. This makes mycoplasma high on the list because the CXR can be out of proportion of the symptoms.
In Detroit though, TB can present in funcky ways. In the presence of cough, there can be aspiration from the primary site to other lobes, even bilateral like this xray. What argues against this is that he would be much sicker with an xray like this if it was TB.
Good point about the plavix/bronchitis angle; he is only on aspirain however.
We gave him a z-pak. He is to get a PPD as well. Also IgM for mycoplasma and some sputum cups for AFB. If he doesn't improve on the z-pack and AFB's are negative, we may proceed to bronch.

Anonymous said...

blastomycosis is failry endemic in the michigan area

darenberg said...

Well, I am interested in how this turns out, so I'll throw a vasculitic process against the wall (ANCA associated) and see if it sticks.

I'm not sure I'd say Blasto is endemic in Michigan to the same degree as Histo. We do see the occasional case of blastomycosis, but if someone has a fungal granuloma in Michigan, and you bet on Hitso, you are much more likely to be right. Neither Histo nor Blasto are the likely cause of this diffusely abnormal CXR and hempotysis in my opinion, unless the guy is immunocompromised.