MGR Cough를 주소로 내원한 젊은 여자 2례 호흡기 내과 R1 정수웅/Prof. 박명재

History Chief Complaint Cough onset : 3 days ago Present illness Admission 2012.04.20 F/26 허ㅇ 난 Chief Complaint Cough onset : 3 days ago Present illness 26/F, 2011년 4월 hematuria로 내원하여 AIHA (autoimmue hemolytic anemia), latent SLE 진단받고, prednisolone, HCQ (hydroxychloroquine) 복용해 오던 자로, 약 20일전부터 chest discomfort , feeling of breathlessness 있어 외부병원 방문하여 경구 항생제 복용하였으나 큰 호전 보이고 있지 않던 중 3일 전부터 소량의 가래섞인 기침, 37.8’C 의 mild fever 있어 호흡기 내과 내원함.

Past Medical Hx Personal Hx Family Hx DM/HTN/TBc/Hepatitis (-/-/-/-) Autoimmune hemolytic anemia, diagnosed on 2011.4 currently on prednisolone 5mg qd Latent SLE, diagnosed on 2011.4 currently on hydroxychloroquine 300mg qd celecoxib 200mg qd Medication (+) , described as above Past surgical history (-) Personal Hx Smoking (-) Alcohol (+) social drinker Family Hx None

Review of System(1) 1. General Generalized weakness(-) Fatigue(-) Fever(+) : mild Chills(-) Myalgia(-) 2. Skin Rash(-) Pigmentation(-) Urticaria(-) 3. HEENT Headache(-) Visual disturbance(-) Oral ulcer(-) Otorrhea(-) PND(-) Nasal obstruction(-) Rhinorrhea(-) Sore throat(-) Swallowing difficulty(-) 4. Respiratory Dyspnea(-) Cough(+) Sputum(+) Pleuritic pain(-) Hemoptysis(-)

Review of System(2) 5. Cardiac Chest pain(-) Orthpnea(-) DOE(-) 6. Abdominal A/N/V/D/C (-/-/-/-/-) Abd. pain(-) Melena(-) Hematochezia(-) 7. Renal/Urinary Dysuria(-) Incontinence(-) Frequency(-) Urgency(-) Hematuria(-) Flank pain (-) 8. Musculoskeletal Swelling(-) Myalgia(-) Arthralgia(-) 9. Nervous Dizziness(-) Syncope(-) Seizure(-) FENa 7.55% FEUrea 69.02%

Physical Examination(1) 증례 1 (F/27) Physical Examination(1) Height : 159.5cm Weight : 47.6kg BMI : 18.7 Vital Sign : 110/70 – 102 – 20 – 37.7℃ 1.General appearance alert & oriented, in no acute distress 2. Head & neck normocephaly, LN enlargement(-), neck vein engorgement(-) 3.ENT isocoric pupil with PLR (++/++) pinkish conjunctiva, whitish sclera pharyngeal injection(-/-), PTH(-/-) 120/70 mmHg- 84회/분- 20회/분 -36.7°C 183cm 90kg (BMI : 26.9)

Physical Examination(2) 증례 1 (F/27) Physical Examination(2) 4. Chest Symmetric chest expansion Clear breathing sound without rale and wheezing Regular heart beat without murmur 5. Abdomen soft/ flat abdomen hyperactive bowel sound tenderness(-), rebound tenderness(-) ,palpable mass(-) 6. Back&extremities CVA Td(-/-), pressure sore(-) 7. Motor, sensory: intact

Initial Lab Finding 1.CBC/DC 6220/㎕ – 13.7g/㎗ – 42.3% - 240K/㎕ (seg 42.3%) 2.Chemistry Total Bilirubin 0.48mg/㎗ BUN/Cr 8/0.7 mg/dL Protein/Albumin 8.3/4.6 g/㎗ Na/K/Cl 135/3.8/96 mEq/L AST/ALT 16/11 IU/L Ca/P/Mg 9.0/4.0/2.2mg/dL ALP/rGT 62/28 IU/L Uric acid 7.2mg/dL CRP 3 .08mg/dL LD 275 u/L ESR 56mm/hr 3.U/A RBC 0~1/HPF WBC 2~4/HPF Blood - Protein - Glucose - S.G 1.014 pH 7.0

증례 1 (F/27) Initial Chest X-ray C/T ratio 0.5 No active lung lesion

ECG 증례 1 (F/27)

Initial Problem Lists Initial assessment 증례 1 (F/27) Initial Problem Lists #1. nodular opacity on Rt. upper lobe #2. elevated CRP, ESR #3. low grade fever Initial assessment #1. r/o Community acquired pneumonia #2. r/p Lupus pneumonitis #3. r/o Tuberculosis

Dianostic Plan Sputum study as follows Sputum gram stain & culture Sputum AFB stain ,Tb culture (solid & liquid), and Tb PCR Sputum fungus culture Serology & Urinary Ag test for specific pathogen Urinary antigen for S.pneumoniae & L.pneumophilia Mycoplasma IgM/IgG, cold agglutinin antibody Quantitative ANA, C3,C4 Enhanced Chest CT Bronchoscopy washing for gram stain & culture, AFB stain & Tb culture, fungus culture

증례 1 (F/27) CHEST CT

증례 1 (F/27) C/T ratio 0.67

Cold agglutinin antibody <1:4 Urinary Ag for S.pneumoniae Mycoplasma IgM negative Mycoplasma IgG equivocal Cold agglutinin antibody <1:4 Urinary Ag for S.pneumoniae Urinary Ag for L.pneumophilia

C3 112 (88~201mg/dL) C4 26.4 (16~47 mg/dL) ANA speckled (1:32o) 증례 1 (F/27) C3 112 (88~201mg/dL) C4 26.4 (16~47 mg/dL) ANA speckled (1:32o)

증례 1 (F/27) Bronchoscopy

Bronchoscopy (2012.4.23) 증례 1 (F/27)

Sputum AFB smear & tb PCR 3/7 Mycobacterium tuberculosis 1st step : Auramine-rhodamine stain 2nd step : ziehl neelsen stain

Final diagnosis Endobronchial tuberculosis, actively caseating type

증례 1 (F/27) Clinical course 2012.10.28 2013.4.24 3/5 Diagnosed with AIHA, latent SLE AFB (+) Tb complex PCR (+) AFB (-) Tb culture (-) C/T 0.58 11.4 12.4.24 12.7.12 13.1 13.4 M. tuberculosis Hydroxychloroquine, PDL HERZ HER

History Chief Complaint Present illness Cough onset : 6 months ago 기침 발생하여 호흡기 내과 외래 방문함

Past Medical Hx Personal Hx Family Hx DM/HTN/TBc/Hepatitis(-/-/-/-) Medication (-) Past surgical history (-) Personal Hx Smoking (-) Alcohol (+) social drinker Family Hx None

Review of System(1) 1. General Generalized weakness(-) Fatigue(-) Fever(-) Chills(-) Myalgia(-) 2. Skin Rash(-) Pigmentation(-) Urticaria(-) 3. HEENT Headache(-) Visual disturbance(-) Oral ulcer(-) Otorrhea(-) PND(-) Nasal obstruction(-) Rhinorrhea(-) Sore throat(-) Swallowing difficulty(-) 4. Respiratory Dyspnea(-) Cough(+) Sputum(+) : yellowish Pleuritic pain(-) Hemoptysis(-)

Review of System(2) 5. Cardiac Chest pain(-) Orthpnea(-) DOE(-) 6. Abdominal A/N/V/D/C (-/-/-/-/-) Abd. pain(-) Melena(-) Hematochezia(-) 7. Renal/Urinary Dysuria(-) Incontinence(-) Frequency(-) Urgency(-) Hematuria(-) Flank pain (-) 8. Musculoskeletal Swelling(-) Myalgia(-) Arthralgia(-) 9. Nervous Dizziness(-) Syncope(-) Seizure(-) FENa 7.55% FEUrea 69.02%

Physical Examination(1) 증례 2 (F/34) Physical Examination(1) Height : 162cm Weight : 53kg BMI : 20.2 Vital Sign : 110/70 – 80 – 15 – 36.4℃ 1.General appearance alert & oriented, in no acute distress 2. Head & neck normocephaly, LN enlargement(-), neck vein engorgement(-) 3.E/ENT isocoric pupil c PLR (++/++) pinkish conjunctiva, whitish sclera pharyngeal injection (-/-), PTH(-/-) 120/70 mmHg- 84회/분- 20회/분 -36.7°C 183cm 90kg (BMI : 26.9)

Physical Examination(2) 증례 2 (F/34) Physical Examination(2) 4. Chest Symmetric chest expansion Clear breathing sound with crackle Regular heart beat without murmur 5. Abdomen soft/ flat abdomen hyperactive bowel sound tenderness(-), rebound tenderness(-) ,palpable mass(-) 6. Back&extremities CVA Td(-/-), pressure sore(-) 7. Motor, sensory: intact

Initial Lab Finding 1.CBC/DC 6680/㎕ – 13.0g/㎗ – 38.5% - 217K/㎕ (Seg. Neutrophil 75.5%) 2.Chemistry Total Bilirubin 0.42mg/㎗ BUN/Cr 11/0.6 mg/dL Protein/Albumin 7.9/4.3 g/㎗ Na/K/Cl 138/3.8/103 mEq/L AST/ALT 22/17 IU/L Ca/P/Mg 8.5/2.9/2.2mg/dL ALP/rGT 78/32 IU/L Uric acid 4.0mg/dL CRP 0.93mg/dL 3.U/A RBC 0~1/HPF WBC 2~4/HPF Blood - Protein - Glucose - S.G 1.014 pH 7.0

증례 2 (F/34) Initial Chest X-ray C/T ratio 0.5 No active lung lesion

증례 2 (F/34) ECG

Initial Problem Lists Initial assessment 증례 2 (F/34) Initial Problem Lists #1. patchy opacity on RUL #2. chronic cough with scanty amount of sputum #3. mild elevated CRP Initial assessment #1. r/o Pulmonary tuberculosis #2. r/o Atypical pneumonia #3. r/o Cough variant asthma

Dianostic Plan Pulmonary function test Sputum study as follows Sputum gram stain & culture Sputum AFB stain ,Tb culture (solid & liquid), and Tb PCR Sputum fungus culture Chest CT Pulmonary function test

증례 2 (F/34) PFT

증례 2 (F/34) CHEST CT

증례 2 (F/34)

증례 2 (F/34) Bronchoscopy

Bronchoscopy (2013.1.23) 증례 2 (F/34)

Sputum AFB smear & tb PCR 3/5 3/7 C/T 0.58

증례 2 (F/34) Final diagnosis Endobronchial tuberculosis, Tumorous type

Clinical course 2012.12.24 2013.6.24 M. tuberculosis AFB (+) Tb PCR (+) C/T 0.58 12.12.31 13.1.22 13.2.21 13.7.10 AFB (+) Tb culture (+) AFB (-) Tb culture (-) HERZ HER HERZ