Pummie Cases

Front 1

- A 35-year-old Indian male presents with 6 weeks of fever, night sweats, weight loss, and cough. He has been on multiple course of empiric oral antibiotics over this time to treat bronchitis and pneumonia. He reports occasionally expectorating blood. He has no past medical history; doesn’t smoke, drink alcohol, or use illicit drugs. He immigrated to US 2 years ago from Mumbai.
- On exam:
o non ill-appearing
o 39ºC (fever), HR 80, RR 26 (a little tachypnea); 110/70
o Lungs: tubular and amphoric breath sounds in right apical-posterior zone
- Amphoric breath sounds: blowing across top of coke bottle
• Listen to apex at supraclavicular level with diaphragm
- Infiltrate in R upper lobe
- Minor Fissure on R is angled
- Sputum Acid-fast stain is shown: 4+ bacilli (AFB)

Back 1

Probe Sputum Sample (NTD-PCR, Gen Probe) to check for active TB

 Start at least 4 drugs: 2 months – no combo drugs right now
• Isoniazid (INH)
• Rifampin (RIF)
• Pyrazinamide (PZA)
• Ethambutol (EMB)
• Vit B6 to counter INH effects

Front 2

- A 35-year-old Indian male presents for immigration physical exam to obtain a “green card” after living in the US for the past 2 months. He denies fever, night sweats, weight loss, cough, or hemoptysis. He has no past medical history; doesn’t smoke, drink alcohol, or use illicit drugs.
- TST reveals 20 mm induration.
- Normal CXR

Back 2

• This is latent TB infection, so offer 9 months of INH

Front 3

- A 35-year-old HIV-infected male has been on isoniazid and rifampin for the past 5 months for pulmonary TB. His chest radiograph at initial presentation is shown:
o CXR: bilateral areas of consolidation
Cavity in upper L lobe
Dense consolidation in R middle lobe
- He had initially been started on isoniazid, rifampin, pyrazinamide, and ethambutol. When susceptibility testing revealed the isolate was isoniazid-sensitive, ethambutol was discontinued, and he completed 2-months of isoniazid, rifampin, and pyrazinamide under directly observed therapy.
- Repeat sputum culture at this point is positive for M. tuberculosis but repeat sensitivities are pending.

Back 3

Drug Resistant TB!!!

• Started with cavitary disease at outset (high vacillary load)
o Higher the load, less effective treatment is
 Call an expert!!
 Add 3 new drugs patients never seen (go into 2nd line therapy)
• FQ
• Amikasin
• Cycloserine

Front 4

- A 22-year-old male presents with progressive dry cough and dyspnea on exertion. He states he has been experiencing occasional low-grade fever and night sweats for the past several days. He denies injection drug use but admits to having unprotected, anally-receptive sex with several men for the past couple years. He has no past medical history and denies known drug allergies.
- On exam:
o Moderately tachypneic
o Nontoxic-appearing
o No cyanosis
o T 38.6ºC; BP 120/80; RR 30; pulse 110 and regular
o HEENT: exudative thrush
o neck: shotty adenopathy
o Lungs: bilateral rales throughout all lung zones; no rhonchi or wheezes
- O2 Saturation
o @ rest: 90%
o after 1 min. of exercise: 82%
o low A/A gradient – ability to oxygenate the lungs is impaired
o pulmonary edema increases A/A gradient bec hypoxic but not having prob getting CO2 out
- LABS
o WBC 3.8
 (80% S; 2% B;16% Lymphocytes)
 Hb 11.0 g/dL
 PLT 100K
 Na+ 135 mEq/L
 creatinine 1.4 mg/dL
 Serum LDH 500 U/L (lactate dehydrogenase)
 Rapid HIV: positive
- CXR: diffuse patchy infiltrates in all lobes
o Reticulonodular kind of picture (kind of a way to say interstitial pattern and there’s nodules)

Back 4

 Pneumocystis
 Get sputum sample – patient has non-productive cough though
 Induced Sputum – patient inhales nebulized hypertonic saline mist that stimulates loosening of secretions deep in airway and cough up
 Bronchoscopy – definitive diagnosis for pneumocystis
o See the pneumocystis on silver stain
 Trimethoprim Sulfamethoxerol – AB – DOC!!!!

Front 5

37 year old lady presents with a non-productive, intermittent cough for 2 months associated with mild dyspnea. no nocturnal aggrevation, orthopnea or paroxysmal nocturnal dyspnea.
she denies fever, night sweats, anorexia, or loss of weight but feels lethargic. she also noticed a transient, painful erythematous rash over her shins for the last six months. her medical hx is otherwise normal.
she does not smoke and has no family hx of lung disease

lungs clear, no clubbing, no cyanosis, no peripheral edema. mild pallor

bilateral hilar adenopathy
elevated ACE
noncaseating granulomas, no AFB or fungi

Back 5

sarcoidosis
prenisone