پروفسور محمد حسین سلطان زاده

      استاد دانشگاه علوم پزشکی شهید بهشتی
متخصص کودکان ونوزادان
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 دانشگاه علوم پزشکی شهید بهشتی

خانم دكتر سهيلا خليل زاده

عضو هيئت علمي دانشگاه به اتفاق اعضاي هيئت علمي گروه اطفال بيمارستان مسيح دانشوري

خانم دكتر خديجه رياضي كرماني

معرفي كيس

خانم دكتر فاطمه پژوهنده

رزيدنت  بيمارستان لقمان حكيم

خانم دكتر مريم نوري

رزيدنت بيمارستان مفيد

خانم دكتر ناديا دانائي

رزيدنت بيمارستان امام حسين

خانم دكتر انسيه اميري

رزيدنت بيمارستان شهدا

اقاي دكتر حسين علي غفاري پور

فلوشيپ ريه

اقاي دكتر مصلحي

فلوشيپ ريه

اقاي دكتر طباطبائي

فوق تخصص ريه

خانم دكتر محبوبه منصوري

فوق تخصص ايونولوژي و الرژي

خانم دكتر شيرواني

فوق تخصص عفوني اطفال

خانم دكتر خان بابائي

فوق تخصص ريه اطفال

 

خانم دكتر سهيلا خليل زاده

عضو هيئت علمي دانشگاه به اتفاق اعضاي هيئت علمي گروه اطفال بيمارستان مسيح دانشوري

تشخيص:

Invasive

Aspergillosis

CGD

 

خانم دكتر خديجه رياضي كرماني

معرفي كيس

تشخيص هاي افتراقي:

خانم دكتر فاطمه پژوهنده

رزيدنت  بيمارستان لقمان حكيم

Problem list:

A  13 year old boy presented with

Fever

Weight  loss

Right  hemithorax pain

History of previous exposure to active pulmonary TB

History of left inguinal tenderness one month  before

PH/E

Tachycardia

Lung auscultation:crackles
Lab  data
ESR   120
CRP   74
WBC   13000 
HB    9.1
MCV  69
PLT   850
Cr  1.6
INR 1.7
PPD 12
RADIOLOGIC  FINDINGS
a right paracardiac  soft  tissue  is noted   with some area of air bronchogram and consolidation pattern at the center of the lesion wich has mass like appearance
CULTURE
aspergillus
beta hemolytic strep non group
A B C D   CC:1000
coagolase negative  staph CC:1000
 

INFECTION

TUBERCULOSIS

ACTINOMYCOSIS

FUNGAL LUNG INFECTION:

Aspergillosts

Blastomycosis

Histoplasmosis

PARASITIC LUNG INFECTION

PCP

LUNG ABSCESS

GRANULOMATOUS  INFLAMMATORY  DISORDERS

Wegeners  granulomatosis

Sarcoidosis  pulmonary

Churg-strauss   syndrome

ALLERGIC .COLLAGEN.AUTO-IMMUNE DISORDERS

Eosinophilic  pneumonia

Loefflers  eosinophilic pneumonitis

NEOPLASTIC DISORDERS

Hodgkins disease

Metastatic lung disease  (ostosarcoma) (RCC)

Leukemic/lymphocytic lung infiltrate

Pulmonary lymphangiomatosis

VASCULAR  DISORDERS

Pulmonary embolism

Pulmonary infarction

POISINING

Silicosis

Pneumoconiosis

IMMUNODEFICIENCY

Bruton  agammaglobuulinemia

Common variable immunodeficiency

Human immunodeficiency virus infection

Job syndrome

Severe combined immunodeficiency

Chronic granulomatous disease

RESULTS

TB

FUNGAL  LUNG  INFECTION

WEGNERS GRANULOMATOSIS

CGD

METASTATIC  LUNG  DISEASE

HODGKINS DISEASE

RECOMMENDATION

SPIRAL CHEST CT SCAN WITH CONTRAST

OPEN  BX

WATERS   X RAY  / CT  SCAN

NBT

BONE  SCAN

ANCA

خانم دكتر مريم نوري

رزيدنت بيمارستان مفيد

خرد هر کجا گنجی آرد پدید
ز نام خدا سازد آن را کلید

Problem List
Fever+ weight loss

Left groin pain

Right hemithorax pain

No response to antibiotic therapy

Active TB exposure

Lab test                     plt=850000

ESR=120  corrected ESR=96

CRP=74

PT=16.7   INR=1.7

PPD=12

Imaging                     CXR: Right paracardiac consolidation

Bronchoscopy         culture: Aspergillus

Pathology                 Pulmonary eosinophilic infiltration

Missing Points

Groin pain?

Respiratory Symptoms?

Extra pulmonary signs and symptoms?

History of prior infections?

Response to immunization?

Exact time of TB exposure?

Drug History?

Travel History?

Eosinophil count?

Igs level?

Prick test?

Immune system work-up?

Collagen vascular diseases work-up?

Sweat test?

S/E * 3

Sputum Smear and PCR NOT gastric washing

BAL: total and diff of leukocyte count?

Causes of Pulmonary Eosinophilia

Drug and toxin-induced eosinophilic lung diseases

NSAIDs, Antimicrobials, Phenytoin

Helminthic and fungal infection-related                      Transpulmonary passage of larvae (Lofflers Syndrome)

Pulmonary parenchymal invasion

Heavy hematogenous seeding( Strongyloidiasis,Trichinosis)

Tropical pulmonary eosinophilia

ABPA

Acute eosinophilic pneumonia

Chronic eosinophilic pneumonia

Churg Strauss Syndrome

Other (Idiopathic, Neoplasm)

Differential Diagnosis

TB

 Active TB exposure + Radiologic  changes+  PPD

Sputum Smear and PCR? Tissue PCR?

ABPA

Hypersensitivity reaction when bronchi becomes colonized with Aspergillus.

 Aspergillus is cultured from the sputum in up to two-third of patients with ABPA.

Range of clinical manifestation(asymptomatic pulmonary consolidation fever and respiratory symptoms and signs)

The major diagnostic features:    A history of asthma

Immediate skin test reactivity to Asp. Antigen

Percipitating serum Ab to A.fumigatus

Serum Total IgE>417 IU/ml

Periph.Blood Eos>500

Imaging

Elevated specific serum IgE and IgG to                                      A.fumigatus

Prick test, IgE level?                                                          

Differential Diagnosis

Helminthic  parasitic infections

Lofflers Syndrome            Respiratory symptoms and signs

Transient pulmonary infiltrates

Eosinophilia

S/E * 3? Serologic tests? Sputum analysis(Strongyloides)?  Blood Eos count?

Chronic Eosinophilic Pneumonia

Abnormal accumulation of eos. In the lung

Subacute illness

Fever+cough+weight loss+wheezing+night sweats

Peripheral eosinophilia is common

CXR

Differential Diagnosis

CVID

Decreased IgG with Low level of IgA+/- IgM

Poor or absent response to immunization

Age of onset after puberty

Broad spectrum of disorders (infections, chronic lung disease, GI and liver disorders,)

Normal physical examination

Increased risk of malignancies

Serum concentration of IgG? Response to immunization? GI symptoms?

S/E * 3?

 

Differential Diagnosis

Churg Strauss Syndrome

Sinusitis+ Asthma+ Prominent peripheral  blood eosinophilia

Lung Biopsy

History of prior infections?

Drugs and Toxins

Range of clinical presentation

    Asymptomatic pulmonary infiltration with eosinophilia to chronic cough with or without dyspnea and fever to acute eosinophilic pneumonia

History of groin pain and possible NSAIDs consumption

Elevated PT

Drug History?

 

خانم دكتر ناديا دانائي

رزيدنت بيمارستان امام حسين

Problem list

13 Y , BOY

Lt inguinal pain & Rt hemithorax pain from 1M ago

Fever & weight loss

Non response to IV antibiotic therapy

Hx of contact to TB

Diffuse crackle

Lab data:

WBC:13000     diff:PMN:76%  ,L:15%

HB:9.1

PLT:850000

 

ESR:120             CRP:74

Cr:1.6

S/E:fatty droplet  positive

pT:16.7        INR:1.7

PPD:12

CXR=Rt paracardiac consolidation

CHEST HRCT=a  RT paracardiac soft tissue is noted with some area of air bronchogram &  consolidation pattern at the center of the lession which has mass like appearance, at the periphery   of the mass some lymphangiectasia    

Direct smear=NL

Culture=aspergillus

TBLB=pulmonary eosinophillic infiltration

BMB=chronic  inflammatory with mild eosinophillic infiltration

DDX

1.TB

*AFB (BAL,TBLB)

2.eosinophilic lung dis.

.   ABPA

.   eosinophilic pneumonia

.   loffler syndrom

.  churg-strauss syndrom

*serum percipitant test

*Aspergillus skin test

*serum Ig E

*CBC ,diff(EO)

*P-ANCA

3.CVD

C-ANCA,P-ANCA,ANA,

*C3,C4,CH50

*HIV Ab,HBS Ag,HBS Ab,HCV Ab

4.Malignancy (lymphoma)

*mediastinal HRCT

5.Non classified

Aspergillosis  in immunocompromised patient:

. N or MQ dysfunction : CGD , SCID

.HIV

*NBT  TEST

*Ig

*CD4

primary malignancy of bone

*immaging

*Ca,ph,Alkp

CF

With thanks

 

خانم دكتر انسيه اميري

رزيدنت بيمارستان شهدا

Case presentation

E. Amiri MD

Problem list

Fever

Hemithorax pain

Weight loss

Inguinal pain

Right paracardiac consolidation

History of contact with active TB patient

FTT

Generalized crackle in both lungs

Lab tests

CRP : 74

ESR : 120 (corrected:72)

WBC : 13,000  (P : 76%- L : 15% )

Hb : 9.1

MCV : 69

PT : 16.7

PTT : 48

S/E : fatty droplets

PPD : 12 mm

Imaging study

Lung CT scan : Consolidation – airbronchogram

Bronchoscopy : Nl

Culture : Aspergillus sp

Pathology

Pulmonary eosinophilic infiltration

Differential Diagnosis

Eosinophilic pneumonia

Aspergilloma- invasive form :

Vasculsar involvement

High eosinophilia

ABPA  :

Secondary to CF , TB cavity , Asthma

↑ Eos

↑ IgE

Bronchiectasis

Recurrent pneumonia

Parasites :

↑ Eos

Granuloma

Chronic eosinophilic pneumonia :

Secondary to asthma and allergy

Bilateral lung involvement

Churg-strauss syndrome & Sarcoidosis :

↑ Eos

Granuloma

Old age

TB

History of contact

PPD=12 mm

Pulmonary symptoms

Malignancy (associated with pulmonary involvement) :

Histyositosis :

Bone tumors

Eosinophilia

Respiratory distress

hepatosplenomegaly

Seborrheic dermatitis

Otorrhea

Bone marrow involvement

Ewing sarcoma

Fever 

Systemic symptoms

Bone involvement in Ph/E and CT scan

Lymphoma

Mediastinal involvement

Lymphadenopathy

Pulmonary involvement

Bone marrow involvement 

Rhabdomyosarcoma

Soft tissue involvement

Pulmonary involvement

Neuroblastoma

Posterior medistinal involvement

Pulmonary involvement

CF

FTT

Pulmonary involvement

Fatty droplets in S/E

 

 

اقاي دكتر حسين علي غفاري پور

فلوشيپ ريه

13 year/old boy,from Tabriz live in tehran

CC:fever&pain of left inguinal

PI:1month  before admission:

Pain of left inguinal,no trauma

low grade fever

Sometimes coughing & right hemithorax chest pain

malaise&weight loss

PMH:

Term/NVD/ G4P3AB1

No NICU admission

Vaccination:full/development:nl

Hospitalization:90/11/03

FH:TB(+)

DH:(-)

PHYSICAL EXAMINATION

GA:alert and ill no toxic

VS:               AT:37         RR:24   

PR:120      BP:100/60

weight(for age percentiles):5%

height(for age percentiles):25%

H&N:conjunctive:pale  &  no lymphadenopathy

Heart:nl

Lung:fine crackles

Abdomen:no organomegaly

Extremities:nl

LAB TESTS

WBC:13000 /N:76%/L:15%

RBC:3500000

HGB:9,1/HCT:28,5/MCV:69/MCH:23,5 /MCHC:33        RDW:16,8

PLT:850000

ESR:120

CRP:74

LDH:261

URIC ACID:2 /ure: 12 /Cr:1,6 

ADA:37

PPD:12mm

Gastric washing:

Direct smear:(-)

PCR(for MBT): (-)

Report of spiral ct scan

A right paracardiac soft tissue is noted, with some area of air bronchogram and consolidation pattern at the center of the lesion which has mass like appearance at the periphery of the mass some lymphagiectasia also seen and right hilum prominency.

Spiral abdomen&pelvic ct scan:

Normal

Bone marrow aspiration:

Normocellular

Bronchoscopy:

Normal

discharge for:

direct- smear:negative

culture:

Aspergillus  sp

Pathology

Transbronchial  lung  biopsy:

pulmonary  eosinophilic  associated with

chronic  non specific inflammatory process.

Negative for malignancy.

Negative for granuloma.

 

 

اقاي دكتر مصلحي

فلوشيپ ريه

Question remind unclear about case

Trend of growth?

Recurrent  infectious (pneumonia or AOM or sinusitis,…)?

Symptoms after vaccination?

Hx of diseases in other sibling

Leg pain?

Hx of trauma?

Night sweating, exertional dyspnea, cough

Cyanosis, Clubbing?

Parental relative?

Drug Hx?

Diff- U/A-BS-LFT

 

EOSINOPHILIC LUNG DISEASES
(PIE)

 Early description :

   pulmonary symptoms or CXR abnormalities and

   PB eosinophilia

 After 1970 description :

characterized  by  increase  in  BAL eosinophil number but not necessarily blood eosinophils

Some affect the airways predominantly,          some  affect  the  lung  parenchyma,  and some affect  predominantly  the  lung  vasculature.

From subtle symptoms and are self-limited to  respiratory failure.

Subtype:

Group I, Löffler syndrome or simple pulmonary eosinophilia

 Group II, prolonged pulmonary eosinophilia

 Group  III,  Weingartens  syndrome  or tropical  eosinophilia

Group  IV,  pulmonary  eosinophilia  with asthma

 Group V, polyarteritis nodosa

Parasitic  infection (Ascaris) & drug reactions are currently an important etiology

No cause in 1/3 of cases

Mild febrile illness with myalgias ,nonproductive cough, and dyspnea.

No abnormalities on physical examination, but sometimes a few crackles or wheezes  are  heard

Parasites That Cause
Eosinophilic Lung Disease

Ancylostoma sp.

Ascaris sp.

Echinococcus sp.

Schistosoma sp.

Strongyloides stercoralis

Toxocara sp.

Trichinella spiralis

Wuchereria bancrofti

 

Patients with Ascaris infection are usually febrile with a nonproductive  cough  and  chest  pain. In  severe  cases  hemoptysis occurs. 

CXR: abnormalities  are usually bilateral and peripheral, pleural  based

Parasites  and  ova  are sometimes  found  in  the stool after the resolution of the  pul. illness

larvae can be isolated from gastric aspirates or sputum

Weingarten = tropical  eosinophilia =

severe  spasmodic cough,  massive peripheral  eosinophilia,  diffuse  mottling  in  both  lungs

endemic  in  India, Sri Lanka  due to  Wuchereria  bancrofti

DRUG-INDUCED

Cough,  dyspnea,  and  fever

Histologically : interstitial edema with a lymphocytic and eosinophilic infiltrate, (alveoli contain  eosinophils  and  histiocytes)

CXR show  interstitial or alveolar infiltrates  and Kerley B lines

Skin testing  with either patch  or prick  tests  is  usually  negative

ACUTE EOSINOPHILIC PNEUMONIA

Idiopathic

febrile  illness  of  1  to 5  days + myalgias,  pleuritic chest pain, and severe hypoxemia

basilar or diffuse crackles

CXR: diffuse alveolar infiltrates involving all  lobes

Small to moderate-sized pleural effusions are common

CHRONIC EOSINOPHILIC PNEUMONIA

middle-aged women

fever,  night  sweats,  weight  loss

cough,  dyspnea,  and  wheezing (asthma)

lymphadenopathy  and hepatomegaly

Pb & BAL eosinophil

ESR & IgE  is elevated

CXR; bilateral, peripheral infiltrates negative image of pulmonary edema =dignostic

CT : peripheral airspace disease  and  may  show hilar lymphadenopathy

ALLERGIC ANGIITIS AND GRANULOMATOSIS

allergic rhinitis and asthma for years

peripheral eosinophilia with values up to 80%

small and medium-sized arteries and veins.

sinusitis, rhinitis, and nasal polyps

GI:abdominal pain, diarrhea, bleeding, and obstruction;

cardiovascular: pericarditis, and heart failure.

Renal

CNS

CXR: patchy and transient infiltration

Eosinophilic pleural effusions and hilar adenopathy

IDIOPATHIC HYPEREOSINOPHILIC SYNDROME

elevated eosinophila for >6 months,

or for <6 months with evidence of organ (heart) damage

most common in adults 20 to 50 years - male

ABPA

1% to 2% of asthmatics and 7% to 9% of cystic fibrosis

Minimal Diagnostic Criteria:

Acute or subacute clinical deterioration

Total  serum  IgE >500 IU/mL

Immediate  cutaneous  reactivity  or RAST

(a)IgG  antibody  to A. fumigatus; or (b) new or recent abnormalities on CXR or chest  CT that  have  not cleared with antibiotics and standard physiotherapy

 

Hypersensitivity Pneumonitis

HP = extrinsic allergic alveolitis

recurrent inhalation of organic antigens 

pet birds molds (Aspergillus, Penicillium)

mean  age=10 y

Male

u-like syndrome  with  fever,  chills,  cough,  myalgias,  and  malaise

leukocytosis  with neutrophilia,  elevated  CRP & ESR

 

ill appearing  child with  dyspnea  and  basilar  crackles

CXR : bilateral lower lobes reticulonodular  inltrates

CT: ground-glass appearance and centrilobular nodules

Acute eosinophilic pneumonia, P. carinii pneumonia, and some drug induced lung diseases have Eosinophils in the BAL fluid

Acute  & chronic  eosinophilic  pneumonia,  ILD,  and  tropical eosinophilia usually lead to a restrictive defect

Immunologic:

+ve: Weigh + Aspergillosis

CGD

Hyper IGE (skin-face-teeth-AOM-pneumonia-staph pneumatoceles-mucocutaneous candidiasis)

Rheumatology:

+ve: Weigh + kidney

PAN (heart-joints-skin-GI-Renal-eye lung-CNS-PNS)

JRA

SLE

DDx lung consolidation + lymphangectasis may include :

Obstractions

Infections

Aspergillosis (invasive/infection or allergic)

Ascariasis

Hydatid cyst

TB

Blastomycosis

Cryptococcosis

 IDDM

CGD

ABPA (CF)

Lymphoma

TB

PAN-JRA

HIV

 

TEST

BS

NBT or DHR àCGD

SCT

IgE - Prick test

PFT

Lung Biopsy

 

اقاي دكتر طباطبائي

فوق تخصص ريه

 

خانم دكتر محبوبه منصوري

فوق تخصص ايونولوژي و الرژي

 

خانم دكتر شيرواني

فوق تخصص عفوني اطفال

 

خانم دكتر خان بابائي

فوق تخصص ريه اطفال