1. AN INTERESTING CASE OF HAEMOPTYSIS IV Medical Unit Chief :- Dr. MOSES K DANIEL Assistant Professors:- Dr. DAVID PRADEEP KUMAR Dr. K.SENTHIL Dr. GANESH BABU

2. CASE SUMMARY Mr. Sheik Mohammed, 60/M, Cooly, Madurai Complaints:- A known case of Type II DM for 12 yrs admitted with complaints of cough with expectoration for 2 months Sputum - Yellow in Colour, 30ml/d, foul smelling, blood stained H/O frequent episodes of haemoptysis + 2 months No H/O fever/ breathlessness/ chest pain No H/O loss of weight/ loss of appetite No H/O swelling of lower limbs/ facial puffiness / ed urine output/ polyuria No H/O abdominal pain/ nausea/ vomiting

3. Past H/O Type II DM - 12 years On Inj Insulin for 2 months No H/O SHT No H/O CAD/ PT Personal H/O Non Smoker/ Non Alcoholic/ Non snuff user G/E Pt conscious/ Oriented/ Afebrile No jaundice/ pallor/ pedal edema/ cyanosis Grade I Clubbing + Vitals :- Pulse Rate - 90/min BP 120/80 mmHg RR - 18/min

4. CVS - S 1 S 2 + No murmur RS - Trachea - Midline Air entry B/L equal – NVBS + Crepitations + B/L mammary, infraclavicular, interscapular areas No bronchial breath sounds Abdomen - Soft no organomegaly CNS - Higher function N No FND CLINICAL IMPRESSION:- Type II DM ?Pulmonary TB/ To R/O Malignancy

5. INVESTIGATIONS PG(F) - 210mg/dl B. Urea - 41 PG(PP) 2hrs - 350mg/dlSr. Creatinine - 1.4mg/dl Urine - Alb - TraceUrine acetone (-ve) Sugar - +++ Dep – 3-5 pus cells Tc – 9500 cells/cumm Dc - p53% L45% E2% Hb% - 6.0gm% ESR -65mm/hr

6. INVESTIGATIONS:- LFT :- T.Bil - 0.8mg/dl AST - 23mg/dl Conj - 0.4mg/dlALT - 13mg/dl Unconj - 0.4mg/dlALP - 196mg/dl T Proteins - 6.9mg/dl Alb - 4mg/dl ECG:- Normal Sputum AFB (-ve) Sputum culture coagulase -ve staphylococci

14. X-Ray Chest PA view (Radiologist opinion):- B/L Pneumoniae developing cavities with air fluid levels suggestive of lung abscess CT Chest :- B/L Necrotising pneumonia complicating into lung abscess

15. Rx GIVEN 1.Inj HA 15(m) 15 (e) Inj HM 15(m) 15(e) 2.Inj Ceftriaxone 1gm IV bd 3.Inj Ampicillin 1gm IV tds 4.T. Ranitidine 1bd

16. AIM OF THIS PRESENTATION Rarity of Bilateral lung abscess Suppression of typical clinical features –Uncontrolled DM/ Old age Possible virulence of commensal organisms

17. AIM OF THIS PRESENTATION Apart from micro and macro vascular complications of diabetes, Infections also cause significant morbidity in diabetic patients Host Defence Mechanism:- Diabetes cause multiple defects in host immune system leading to increased susceptibility to infections Primary Factors :- 1.Granulocyte adherence, Chemotaxis, Phagocytic dysfunction 2. Decreased Intercellular killing 3.Defect in opsonic binding site of C3 complement (Candidial infection)

18. 4. CD4/CD8 balance altered. 5. IgG and IgA decreased. No effect on humoral response and response to vaccines normal All these dysfunctions improve with good glycemic control Secondary factors :- Microvascular disease, frequent hospitalisation, Chronic Kidney disease, frequent IV lines and malnutrition.

19. RESPIRATORY INFECTIONS 1.Community acquired pneumonias are not increased in frequency but bacteraemias have delayed resolution and recurrences are higher 2.Infections due to certain organisms are common staph aureus, gram -ve bacteria, mycobacterium, TB, Mucor 3.Aspergillus species, coccidioides, cryptococcus can cause primary pneumonia in diabetic hosts 4.TB Higher incidence of lower lobe disease, cavitation, pleural effusion, multilobar involvement, because glycerol is increased in DM which is a good medium of growth for TB bacilli

20. INFECTION Common in diabetic patients:- UTI, RTI, Soft tissue infections Infections predominantly occuring in diabetic patients:- Malignant otitis externa,rhinocerebral mucormycosis,necrotising fascitis,emphysematous cholecystitis/ pyelo nephritis and papillary necrosis Infections strongly associated with diabetes:- Staph and rubella infections, liver abscess, thyroid abscess, endophthalmitis, campylobacter, salmonella enteritis,chronic hepatitis C and candidiasis.

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