Medical Grand Round 반복된 Hemoptysis 로 내원한 73 세 남자 환자 Department of Pulmonology R1 황은정 /Prof. 박명재

1 st admission : hemptysis 2 nd admission : massive hemptysis

이 O 은 (M/73) Admission : Chief complaint : Hemoptysis (10~20cc 정도, dark red) on set : 내원 10 일전 Present Illness 상기 73 세 남자환자는 약 50 년전 Tuberculosis 진단, 치료 받은 적 있는 자로 2007 년 7 월 hemoptysis 보여 경찰병원에 입원하였 으나 특이 소견 없었으며 이후 Intermittent 하게 Blood tinged sputum 양상의 hemoptysis 보였고 내원 10 일 전부터 양이 10~20cc 정도로 증가하여 호흡기 내과 외래 통해 이에 대한 evaluation 위해 admission 1 st admission

PMHx DM/HTN/Hepatitis/Tb (-/-/-/+) OpHx(-) Family History Unremarkable Personal History Alcohol(-) Smoking(-) : 5 년전 금연, 0.5 pack/day X 50 yrs

Review of systems General Fatigue (-) Fever (-) Chills (-) Sweats (-) Weight loss(-) Skin Rash (-) Itching (-) Pigmentation (-) Head / Neck Headache (-) Hoarseness (-) Sore thraot (-) Respiratory Cough (+) Sputum (+) Dyspnea (-) Hemoptysis (+) : 10~20cc Cardiac Chest pain(-) Orthopnea(-) Palpitation(-) Edema(-) Palpitations (-) Gastrointestinal Anorexia(-) Nausea(-) Vomiting(-) Diarrhea(-) Constipation(-) Melena(-) Abdominal pain(-)

Physical examination Vital sign 130/80 mmHg – 100 회 /min – 19 회 /min – 36.4 °C General appearance Alert conscious mentality Chronically ill-looking appearance Skin No rash & pigmentation Intact skin turgor Head & Neck No cervical lymph node enlargement Neck vein engorgement (-/-)

Thorax Symmetric lung expansion Coarse breathing sound with crackle on RML Regular heart beat without murmur Abdomen Soft and flat abdomen Td/rTd (-/-) Normoactive bowel sound Body & extremities Peripheral pitting edema(-)

Initial Laboratory Finding CBC/DC 7080/mm3 –12.6g/dl – 36.2% - 345k ( seg: 65 % ) aPTT 39.8 INR 1.05 Chemistry TB/DB : 0.55/0.09mg/dL T-chol : 106mg/dL LD/CK : 340/94 U/L AST/ALT : 18 / 14 U/L Prot/Alb : 7.0 / 3.6 g/dL BUN/Cr : 12/ 0.7 mg/dL Na/K/Cl : 139 / 3.7 / 107 mmol/L Ca/P : 8.8/3.2 mg/dL CRP : 4.2 mg/dL UA RBC 2~4 WBC 0~1

Chest PA

Problem list & Assessment  Hemoptysis  A focal mass opacity on Chest X-ray Tuberculosis r/o Lung cancer r/o Bacterial pneumonia

Plan Diagnostic Plan Sputum Direct smear, Gram stain, AFB, Tb PCR Culture Bronchial fluid Direct smear, Gram stain, AFB, Tb PCR Culture Quantiferon-Gold test Sputum cytology Bronchoscopy : Brushing, Washing Chest CT

Therapeutic Plan Control of hemoptysis Antibiotics

Chest CT

Bronchoscopy

HD #6 S> Hemoptysis (-), Fever (-) O> CRP 5.5mg/dL ( ← 18.4mg/dL) Sputum : Direct smear(-), Gram stain (-), AFB (- ), Tb PCR (-) Bronchial Fluid : Direct smear(-), Gram stain (-), AFB (- ) Tb PCR (-) Quantiferon-Gold test (+) Sputum cytology (-) Brushing and washing cytology (-) A> Lung caner r/o TB, r/o pneumonia P> Antibiotics & conservative management for hemoptysis PCNA

이 O 은 (M/73) Admission : Chief complaint : Hemoptysis - Remote on set : 내원 6 개월 전 - Recent on set : 내원 1 일전 Present Illness 상기 73 세 남자환자는 젊은 시절 Tuberculosis 진단, 치료 받은 적 있는 자로 2007 년 7 월 hemoptysis 보여 경찰병원에 입원하였 으나 특이 소견 없었으며 이후 Intermittent 하게 hemoptysis (Blood tinged sputum) 보였고 양 증가하여 입원했던 자로 외래 F/U 당시 나온 culture 결과에서도 tuberculosis 나 특정 bacteria 자라는 소견 보이지 않아 conservative manage 유지하기로 한 자로 F/U loss 되었다가 내원 1 일전과 금일 아침 종이컵 한 컵 분량 brownish color 의 Hemoptysis 로 응급실 통해 입원함 2 nd admission

Review of systems General Fatigue (-) Fever (-) Chills (-) Sweats (-) Weight loss(-) Skin Rash (-) Itching (-) Pigmentation (-) Head / Neck Headache (-) Hoarseness (-) Sore thraot (-) Respiratory Cough (-) Sputum (-) Dyspnea (-) Hemoptysis (+) Cardiac Chest pain(-) Orthopnea(-) Palpitation(-) Edema(-) Palpitations (-) Gastrointestinal Anorexia(-) Nausea(-) Vomiting(-) Diarrhea(-) Constipation(-) Melena(-) Abdominal pain(-)

Physical examination Vital sign 130/90 mmHg – 78 회 /min – 20 회 /min – 36.8 °C General appearance Alert conscious mentality Chronically ill-looking appearance Skin No rash & pigmentation Intact skin turgor Head & Neck No cervical lymph node enlargement Neck vein engorgement (-/-)

Eye & ENT Pinkish conjuctiva Whitish sclera Isocoric pupil with PLR (++/++) Thorax Symmetric lung expansion Clear breathing sound without crackle Regular heart beat without murmur Abdomen Soft and flat abdomen Td/rTd (-/-) Normoactive bowel sound Body & extremities Peripheral pitting edema(-)

Initial Laboratory Finding CBC/DC 7380/mm3 –10.2g/dl – 31.1% - 549k ( seg: 69.4% ) aPTT 39.8 INR 1.05 Chemistry TB/DB : 0.35/0.00mg/dL T-chol : 106mg/dL AST/ALT : 21 / 13 U/L LD/CK : 340/94 U/L Prot/Alb : 6.1 / 2.6 g/dL BUN/Cr : 9/ 0.8 mg/dL Na/K/Cl : 138 / 4.4 / 107 mmol/L Ca/P : 8.8/3.2 mg/dL CRP : 5.5 mg/dL UA RBC 5~9 WBC 0~1

Chest PA 1 st admission2 nd admission

Initial problem list #1. Recurrent hemoptysis with RML mass #2. Anemia

Initial assessment & Plan #1. Lung cancer r/o TB r/o pneumonia P> Chest CT & Bronchoscopy Control Hemoptysis (Embolization or Surgical resection) #2. Anemia

Chest CT

1 st admission2 nd admission 30 일 후

Bronchoscopy

HD #7 S> Hemoptysis (+), Fever (-) O> CRP 5.9mg/dL ( ← 4.9mg/dL) Sputum : Direct smear(-), Gram stain (-), AFB (- ), Tb PCR (-) Bronchial Fluid : Direct smear(-), Gram stain (-), AFB (- ) Tb PCR (-) Quantiferon-Gold test (+) Sputum cytology (-) Brushing and washing cytology (-)

Recurrent Hemoptysis Tb evaluation negative except Q-gold (+) Rt. air apace consolidation size 증가 Bronchoscopy : Washing & Brushing (-) #1. Pul TB with massive hemoptysis (Pulmonary a) #2. r/o actinomycosis  Pulmonary a. embolization or surgical resection

Operation Pre op. Dx : Tuberculosis Op : RML lobectomy via lateral thoracotomy Op. findings RML : very hard and fibrotic Pleural effusion (-) No mass or mass like lesion

Gross finding

Microscopic finding

Final Diagnosis Pulmonary Actinomycosis Ampicillin 750mg Q6hrs for 4wks → Amoxicillin 500mg po tid for 3~6mons Or Ceftriaxone 1~2g iv Q24hrs for 4wks