Caso Clínico - Case Report -

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Presentation transcript:

Caso Clínico - Case Report - Serviço de Pneumologia Centro Hospitalar de Vila Nova de Gaia/Espinho, 2014 João Cordeiro da Costa Interno de Formação Específica em Pneumologia

Identification M.N.G.R.M., male sex, 66 years-old, retired (previously restaurant owner). Farmer (small farm) in the past 8 years Contact with horses, rabbits and pigeons.

Clinical History Observed in Emergency Room at 02-08-2013: Dyspnea to medium efforts and asthenia (with 1,5 years of evolution) Chronic cough with clear sputum Fever and sore throat in the week before Worsened dyspnea Diarrhea in the day before (self resolution)

Medical Prescription: Clinical Background Rheumatoid Arthritis for 4 years Chronic B Hepatitis Benign Prostate Hyperplasia Previous Surgeries: 2 inguinal hernias No Pulmonary disease known Non-smoker Medical Prescription: Prednisolone 10mg (for 2 years) Leflunamide 10mg (for 2 years) Methotrexate 20mg po/wk Lamivudine 100mg Omeprazole D vitamin Diclofenac (SOS)

Physical Examination (ER) No neurologic deficits Polypnea. No fever. AP: 150/70 mmHg | HR: 90 | SpO2 (O2 4L/min): 97% (92% with conversation) Lung auscultation: bilateral normal respiratory sounds; crackles in the lung bases. Heart auscultation: normal No peripheral edema.

Laboratory Hemoglobin: 12,9 g/dl (13,0-18,0) Leucocyte count: 3750/ul (61% neutrophils; lymphopenia 810/ul [1,0-4,8]) Creatinine: 1,66 mg/dl | Urea: 47 mg/dl Calcium: 11,2 mg/dl [8,4-9,7] CRP: 3,43 mg/dl [0-0,5] Urinary antigens (S. Pneumoniae / Legionella): Negative Blood Gases (4L/min O2): pH 7,46 pCO2 37 pO2 74 HCO3 26,3 Sat 95%

Chest Radiograph

Thoracic AngioCT

Summary 66 years, male, retired. Hobby: farmer. Non-smoker, no pulmonary disease known. Reumatoid arthritis, chronic B hepatitis (leflunamide, methotrexate, lamivudine) Chronic dyspnea, chronic cough, mucous sputum. Acute symptoms: worsening dyspnea, fever. Anemia, leucopenia. Ground-glass appearance on both lungs, from apices to bases, subpleural sparing. Admitted to Hospital and initiated treatment with ceftriaxone, azithromycin, trimethoprim-sulfamethoxazole (TMP-SMX). Immunossupressors suspended.

Differential Diagnosis Pneumonia in immunossupressed patient Drug induced lung toxicity Alveolar hemorrhage Acute exacerbation in patient with previous ILD Acute hypersensivity pneumonitis

Diagnostic Investigation Laboratory: ANA, ANCA ab. normal Serologies: negative to leptospire, aspergillus, CMV, HSV (I, II), Mycoplasma pn., chlamydia pn., EBV, varicela zoster, legionella. HIV / HCV negative Blood (2), urine and sputum cultures negative Pharyngeal Exsudate: negative to Influenza A / B, Adenovírus, Parainfluenza 1 / 2 / 3.

Diagnostic Investigation Bronchoscopy Abundant purulent secretions. Bronchial lavage: Mycobacteria / mycology / bacteria: negative. Pneumocystis jiroveci negative. Cytology: inflammation. Perls staining negative. Differential leucocyte count in BAL not performed because of patient intolerance.

Evolution Good clinical evolution with complete clinical and imagiological resolution.

Diagnosis?? Drug induced lung toxicity?

The end