41 year old with HIV and fever

This is a 41 year old man with AIDS, CD4 below 10, who presented with shortness of breath and fever. He was admitted to a general ward but trasnferred to the unit a few days later for tachypnea. On the general floor, his vitals were normal except for some tachycardia. He was 97% on 2 l NC. CXR:



a full workup was done to look for infectious source.
sputums: AFB negative x 3, fungal negative. PCP negative (no PCR, no bacteria
CSF - negative for infection.

What kinds of things could be causing these findings and what would you do?

C. diff, C. diff run, run diff run

This is more of a critical care (or general care, if you will) than true pulmonary.
I have been seen a lot of docs (including some ID) treating uncomplicated C. diff colitis with PO vanco up front instead of Flagyl. Have recommendations changed? Do you use much PO vanco?

Follow up to vocal cord paralysis

A new question from anonymous regarding the case on vocal cord paralysis

Has anyone scoped his GI tract to R.O esophageal disease?

Vocal cord paralysis

This 61 y/o man was sent to our office by ENT for w/up of a vocal cord paralysis. He has had subacute-onset hoarseness for the past 2-3 months and ENT found a unilateral R vocal cord paralysis. He did a CT (see the images below), which only showed some mediastinal and hilar (R>L) adenopathy much of which is calcified.
He has had a PET scan which showed some very faint (SUV<4) style="display: block; text-align: center;" alt="" src="http://photos1.blogger.com/x/blogger/7040/842/320/933316/Vocal.jpg" border="0">

LUL nodule with ipsilateral LAD

25 yo female with no PMH presents with above.
She was well until April when she travelled to Phoenix to visit friends. When she returned, she had a bad URI. Her PCP obtained a CXR which showed a shadow in the L hilum, and a CT was recommended.
The CT was from an OSH and resembles the CT shown below. The L hilar fullness is a node clearly visualized in the OSH CT; the CT I show is without contrast (she got hives after the first CT). The rec on the CT was to obtain a repeat in 3 months. This is the 3 month CT.

She is currently asymptomatic other than a 20 lb weight loss since 4/06. She has not changed her eating habits or exercising habits.

PMH: Non-smoker but moderate second-hand smoke from her parents.
















Labs: CBC, chemistries, U/a are all normal.

What would you do?

Follow up to the 66 year old with tree in bud

This woman had presented with hemoptysis once and a CT scan showed tree in bud pattern and some nodularity. She presented a year later with cough and sputum. A culture had previously shown 1/3 AFB + but non-TB and non-avium. Her symptoms are the daily cough without constitutional symptoms and no shortness of breath.
I sent off a sputum and it showed Many PMNs, few Epithelial cells, many Gram positive cocci in pairs, chains and clusters and rare Gram negative bacilli.

What would you do now?

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?

Abnormal CxR

I usually don't like those boards-type question that ask "what would you do next?" and only let you choose one option since we often do more than one thing in real life.
Having said that, I am curious as to what you would do next in this case. This is kind of a VIP patient so she was referred to a couple different specialists at the same time.
She is in her early 70s, quit smoking in 1972, near normal PFTs (FEV1~70%, normal DLCO) and has an abnormal CxR. It started as an URI and then she developed a "deeper" cough with purulent sputum production and some pleuritic CP.
The abnormal CxR (and some CT cuts) are shown below.

She had no adenopathy on the CT.
What would be your first step?

fluid filled lesion

"Anonymous" sent us the following CT slices of a 38 year old who presented with cough and fever. AFB were negative x 3. He was not very productive of sputum and what they did get had many epithelial cells.
How would you proceed if this was your patient?

35 year old with cough, chills

35 year old without PMhx except a MVA 5 years ago, anxiety and depression. Now with chills and subjective fever and weight loss for the past few months. Meds: Paxil. Fhx: brother died of liver failure, patient does not know etiology. SH denies IVDA. 2 PPD x 20 years. Quit 5 yrs ago. HIV negative. Exam Afebrile. VSS. Some decr breath sounds upper lung zones b/l. WBC 11.


What would you do next?

Prune-belly

I have just seen a 26 y/o patient in the office for recurrent respiratory tract infections. He has a Hx of prune-belly syndrome (poor abdominal muscle development with severe urinary tract abnormalities) and has been on HD after a failed renal Txp.
These patients tend to have a restrictive physiology because of the oligohydramnios and sometimes even have hypoplastic lung. Indeed his TLC is ~66%. His Cxr is pretty unremarkable but he also has an associated obstructive defect: FEV1 is ~36% witha ratio of<70%. Has anybody seen this condition (or similar ones) be associated with asthma/reactive airways disease?

Follow-up to AFB

This was the 83 y/o man with no COPD, no TOB Hx with a respiratory tract infection with AFB growth from the sputum.
I ended up doing a combination of the suggestions from JJ and Jeff H: I hoped and assumed the AFB was not TB but with the positive PPD, and since I should not start just INH, I did initiate therpay with 4 drugs for TB.
The Cxs came back with a pan-sensitive MTb, ETH was discontinued and he is doing very well on RIF/PZA/INH.
Are you surprised at the paucity of symptoms and fairly benign CxR? I know Tb can present in many unusual ways but I like to see at least something abnormal with TB...

Sweat test

I am an 49 year old female with extended family history of severe asthma, allergies, some CF. I have diagnosis of common variable immune deficency, severe asthma, bronchiectasis, 10 sinus surgeries, 5 on the frontal alone...all to clean out polyps. Have malabsorption and arthritis. I have been on oral Prendisone for 10 years along with many other breathing medications. Do long term steroids (Prednisone) affect swest tests? My sweat test is negative, dna analysis only shows 1 CF gene. Does anyone care to share any info about if long term Prednisone can affect sweat tests?

AFB

This 83 y/o man with no COPD, no TOB Hx was referred to us by his PCP for 2-3 days of cough and low-grade fevers at home. He had had a cold the week before with some rhinorrhea and then developed low-grade fevers (~100) at home with scant purulent sputum and dyspnea as well as malaise. No night sweats, chills, weight loss or hemoptysis.
His exam was only remarkable for B/L ronchi, worse on the right. On admission, he had the fairly benign CxR above; WBC ~9K with a left shift and no other biochemical abnormalities. He had minimal hypoxemia and was started on ABTx for a purulent tracheobronchitis with dyspnea in an 83 y/o patient. He had a great clinical response within the first 24 hours and was D/C'ed home off O2 in 2 days.
His sputum smears were non-contributory but 2 weeks later I got a call from our lab that he was growing AFB in his sputum Cx.
Would you assume it is TB or would you favor a non-TB mycobacteria? Clinically he was doing great at this time and had finished his ABTx (doxycycline). What would you do next?

left lower lobe lesion. What would you do next?

67-year-old Caucasian female who was a previous RN, presents because prior to getting her vascular surgery, she was having a double aortofemoral bypass for claudication. Had a chest x-ray done showed an abnormal opacity on the left lower lobe. She says that she has had worsening shortness of breath for one and half years and has
really had any cough. Denies any fever, chills, rigors, chest pain, or weight loss. Denies any hemoptysis. Denies any previous infections. Denies any headache, nausea, vomiting, or diarrhea.

AST MEDICAL HISTORY: Peripheral vascular disease, hypertension, hyperlipidemia, previous history of smoking.

MEDICATIONS: Atenolol, Protonix, Procardia, hydrochlorothiazide, Lipitor, TriCor, aspirin, multivitamins, and Tylenol 3.
SOCIAL HISTORY: 50-pack-year smoking history, stopped 2 years ago. No ETOH or drug.







No mediastinal or hilar adenopathy.
Repeat CT 1 month later showed no change in size.

Patient was bronched with non-diagnostic tissue.
Cytology brush from left lower lobe was negative for malignant cells.
Micro on BAL: 30000 CFU per ml alpha-hemolytic Streptococcus, 8000 CFU Neisseria; 9000 CFU Micrococcus; 5000 CFU Streptococcus, non-hemolytic.

What would be your next step (or any other questions you have)?

PCP prophylaxis

User submitted question:

A patient of mine has RA-ILD and is on methotrexate. She will be on it for at least 3 months (or longer if it works). Do you prophylax for PCP with Bactrim in this case?

Like father like son...

Father and son both hospitalized with shortness of breath and malaise. Both were healthy prior to present illness.


















What's on your short list?

Hemoptysis

This is a 41 y/o man with a dramatic HIV Hx: he was diagnosed in '94 when he presented with PCP and a CD4 of 7 (!). He survived long enough to be started on HAART with a great clinical response. His most recent CD4 was ~260 though he still has a detectable viral load. His HIV infection was due to remote IVDA.
His course has also been complicated by CAD, previous AMI and CHF. He presented this time with acute-on-chronic R heart failure with increasing edema. He responded well to therapy but prior to D/C he developed a cough productive of bloody sputum and had the above CxR.
He is on his HAART (nevirapine, tenofovir and the lopinavir-ritonavir combo) and SMZ-TMP prophilaxis. He has a Hx of 2 negative PPDs.
Would you isolate him? How would you treat him?

Tree in bud work up

Krayem submitted the following

I saw a 62 year old woman (blind but otherwise healthy) for an abnormal CXR, showing a minimal infiltrate in the RUL. non smoker. no cough or sputum production. no constitutional symptoms. CT showed a tree in bud appearance in the RUL posterior segment. no bronchiectasis.
PPD skin test is pending.

how would you approach this in this asymptomatic patient? go straight to BAL? try to induce sputum? wait and see?