Fever, Cough and Sputum

Here is another great case which has been anonymised to protect patient confidentiality.

Patient was admitted from Outpatients at another hospital with the following:

• Fever
• Cough with sputum
• Chest Pain
• Headache

The fever had come on after a few days of feeling unwell. The patient had recently suffered with influenza and had overcome that illness in February 07. The fever was constant at about 38 degrees. There were no associated rigors. The patient denied sweats except in the last few days leading up to admission.

The cough was a new problem and was productive of yellow / dark coloured sputum. There was no history of haemoptysis. No recent weight loss, or loss of appetite. The patient was a long-term smoker (20/day for 20 years). There was no history of asbestos or TB exposure.

The patient also suffered with left sided chest pain which was worse on coughing and deep breathing. It was described as Sharp and the part could not take a deep breath. The was no description of cardiac chest pain.

The headache only occurred on coughing and was temporal in origin. No eye symptoms and no neck pain or stiffness.

The patient denied earache or throat pain.

The patient denied any leg pain or swelling and there was no complaint of breathlessness.

Previous History included Atypical Angina (angiography was normal) and some asthma.

Drugs included some inhaler therapy for asthma but no angina treatment.

Family history included lung cancer in a near relative.

Social history - patient was married with two children and was in employment in the electronics industry.

The was a pet dog at home but the patient denied allergies to fur.

On further questioning, the was no history of foreign travel or travel to onsen.

On examination the patient looked well. The temp was still 38 degrees, pulse 80 regular, BP 120/70, Sats 94% on room air, RR= 16/min

There was no evidence of lymphadenopathy.

Cardiovascular, Respiratory and Abdominal examination were entirely normal except for pain when pressing on the patient's anterior left upper ribs.

Legs were described as normal.

Blood results were all normal except for a raised CRP of 15. WCC, Neutrophil % were normal.

Differential Diagnosis based on Hx and Physical

• Drugs-- N/A
• Infection--Bacterial post-influenzal pneumonia (staph aureas), pneumococcal pneumonia, H. influenza, Atypical pneumonia e.g. mycoplasma. chlamydia; mycobacterial e.g. TB

--Viral: Influenzal pneumonia, other respiratory viral infections

--Fungal: Cryptococcus

• Endocrine: N/A
• Trauma: N/A

• Inflammatory: Wegener's Granulomatosis, SLE
• Neoplasia: Lung Cancer, Secondary Lung tumours

• Haematological: Leukaemia, Lymphoma, Pulmonary embolism
• Immunological: Goodpasture's syndrome
• Metabolic: N/A

(This is not a complete list-- this was generated during a teaching session)

The patient was examined it was generally normal apart from the superficial chest pain and it was also pointed out that the patient was quite thin.

Chest Roentogen examination was Abnormal. There was a definite discrete circular lesion in the Right Midzone and a possible second circular area in the Left Upper Zone.
The right lesion at its inferior aspect was more radio-dense (white) than the more radiolucent upper area. There was no fluid level present.

The doctors were asked to also examine the bones and one Resident pointed out a 'Moth-Eaten' Left posterior medial rib which was consistent with a pathological aetiology-- perhaps malignancy.

Differential Diagnosis at this Point

Probable Lung Abscess (despite no air fluid level) secondary to Staph aureus after recent influenza; possible anaerobic causation. TB as previously noted, was also considered.
With the presence of a rib lesion, there was a high suspicion of malignancy.
Lastly, Wegener's Granulomatosis also needed to be considered.

CT scan evaluation confirmed abscesses with thick walls and surrounding pneumonia.

No organisms had been grown on culture. The Echocardiogram performed to look for right sided infective endocarditis was Normal although IE could not be ruled out as a cause as the Modified Duke's Criteria show(see previous case of IE). The patient had not been asked if intravenous drugs were used illicitly.

Sputum examination revealed a polymicrobial flora but no specific infecting organism.

TB Ziel-Nielsen stains were negative on two samples.

Samples had also been sent for cytology.

The patient had been started on a second generation cephalosporin without anaerobic cover.

Suggestions

• PCR of sputum for TB, Skin PPD test, Lowenstein-Jehnsen Culture for TB (4-10 weeks wait for growth!)
  
• Add either Clindamycin iv or Metronidazole orally [good bioavailability] (see Sanford Guide 2006 under Lung Abscess)
• Consider bronchoscopy for obtaining brushings, BAL for microbiological analysis (bacteria, mycobacteria and fungi) and cytology and even abscess drainage if necessary
• ANCA test for Wegener's
• Immunoprecipitins for Cryptococcus
• Beta-D-Glucan for identifying presence of invasive fungal infection
• Isotope bone scan to rule in/out metastases in the event that the rib lesion is cancerous
  

The usual cause of lung abscess is from aspiration of anaerobic oral flora. The symptoms consist of fever, cough and dirty sputum. Rigors invariably do not occur in these patients.

Other causes include Staph and occasionally strep species. TB is another cause of lung abscess and should never be forgotten.

Fungal infections include cryptococcus, blastomyces, candida etc...

Atypical type organisms can occur from infections derived from infective endocarditis from the Right Heart in IV drug users.

Non-infective causes include lung malignancy.

Wegener's Granulomatosis results in a necrosis of lung tissue which may simulate lung abscess formation. However, this patient did not have joint symptoms, upper respiratory symtpoms or signs of renal impairment making it an unlikely cause of this disorder.

Dr Aoki

Yesterday, Dr Aoki visited our Institution to be put through his paces on a great case.

The conference went on for 2 and a half hours and I was able to follow most of what was said in Japanese, and even Dr Aoki's jokes !!

It was great to see Dr Aoki's energy for Infectious Diseases and how he broke the case down into its small pieces to come up with a differential diagnosis containing the right answer !!

It reminded me of Dr Tierney's visit last year, although Makoto-san tells better jokes !


The first year doctors have definitely improved in their way of thinking through cases and were easily able to provide answers on how to work up a complex infectious case.

Dr Aoki went through organ systems then specific abnormalities of those systems by using 'VINDICATE' as a medical sieve.

Following the great conference, we went for a meal and ate some great 'Tsubame' locally.

Multiple Pathology-- Pleural Effusions

Today's discussion is about pleural effusions-- it is not a full history today.

A retired male presented with dyspnoea. He was dehydrated and confused and so history was poor.

It was identified that he had a pleural effusion both clinical examination and on chest Xray.

It was noticed that he also had unilateral foot oedema which raised a suspicion of a deep vein thrombosis.

However, his calves were normal temperature, not tender, no distended veins, not red....

The effusion was tapped from the right hemithorax but it became slightly bloody as the liver may have been inadvertedly hit during the procedure.

CT scan was performed which revealed a mass sitting in amongst the pleural fluid.

It was immediately assumed to be a neoplastic lesion, but there were additional ideas !

The analysis of the fluid suggested it was an exudate rather than a transudate making diseases such as heart failure / nephrosis / liver failure unlikely.

On the other hand, with the fluid being bloody and with a possible DVT, it was considered the possibility of PE as a cause for the effusion. Moreover, chronic infections such as Tuberculosis (TB) can cause effusions.

Other causes considered included:

Infection -- as above TB, para-pneumonic effusion, sub-phrenic abscess, unusual parasitic infections
Endocrine -- Hypothyroidism


Inflammatory-- Rheumatoid lung, SLE
Neoplasia: Primary Ca Lung, Secondary tumours, Lymphoma, Lymphangiitis Carcinomatosa

Haematological: Pulmonary Embolism (PE)
Metabolic: Uraemia

The patient underwent ultrasonography revealing a proximal DVT and the spiral CT revealed PE !! However, the pleural fluid was subjected to Ziel Nielsen Stain which was negative BUT the PCR was POSITIVE for TB !!

Hence, in this rather unusual case, it would appear that the cause of respiratory problem was due to multiple pathology.

Infection, for example pneumonia, can increase the risk of PE especially in the first two weeks after an infection although the risk can last for up to a year (Smeeth et al, 2006). This was demonstrated for community acquired pneumonias and not specifically for TB infection.

Moreover, this patient had been lying in bed for several days which again, increased the risk of DVT / PE.

Hence, this patient was treated for TB and PE, both relatively uncommon diagnoses in modern Japan.

Nevertheless, malignancy still needed to be ruled out in this patient, but there were no results confirming this diagnosis.

Things to bear in mind, that despite one cause being found for an underlying disease, if there is a possibility of another cause(s), then they should also be investigated and ruled out alike.