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?
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Well, basically the question is whether this TB. Because if it is not TB, there would be no intervention (i.e. if you get MAC from the upper lobe in an asymptomatic individual, you would just follow him). So I think it would be reasonable to try to induce sputum and send for AFB, and leave it at that. I'd like to see what others think, but going to a BAL seems unnecessary in this asymptomatic patient if he has no TB exposure risk factors (what is his occupation, social history, living conditions, sick contacts?).
I assume he has no previous PPDs or you would have mentioned that.
First, I find that radiologists seem to overcall "tree-in-bud" patterns all of the time. Sometimes, this can just reflect a transient inflammatory process (which may or may not have a definable cause). The distribution is not typical for MAC. In the absence of any constitutional symptoms, or other risk factors, I think the likelihood of active TB is pretty low. If the PPD is positive, than I would induce sputum or do a BAL to document latent vs active TB and proceed accordingly. If the PPD is negative, than I think repeat imaging in 6-8 weeks is reasonable, so long as she remains asymptomatic. If the radiographic abnormalities fail to resolve, then I'd proceed with bronch/BAL to look for atypical mycobacterium etc.
Thanks for the comments. she is not working because of her blindness, and does not have much of an exposure history. No sick contacts. She lives at home, has a pool and enjoys sunbathing...there is "mold" growing on their house'siding and roof (like many houses in this area)requiring cleaning every 2 years...I went back and looked at her previous X-rays. I found one from December 04. "in retrospect" as if there was a tiny infiltrate starting in the same area, and that has obviously increased on the most recent CXR. I am trying to post the X-rays and CT images, but it wouldn't let me.
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