Hemoptysis Following a Chronic Illness

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  Hemoptysis following a chronic illness Differential Diagnosis Dr Sanders: Although the chief complaint suggests an acute illness characterized  by hemoptysis and 2 weeks of lower respiratory tract symptoms, the main feature is really one of a chronic illness for 12 months with intermittent episodes of fever, constitutional symptoms, and a 30-lb weight loss. The patient has also had chronic lung abnormalities for an unknown period, which may predispose him to unusual pathogens. Taking into consideration all the clinical manifestations but  being greatly influenced by findings on his plain chest film, my first 3 diagnostic considerations would be tuberculosis, tuberculosis, and tuberculosis. Any patient presenting with hemoptysis and chronic pulmonary disease should also be evaluated for lung cancer; however, in this particular case, findings on the x-ray film do not suggest an oncologic process. Anytime we diagnose tuberculosis today, we must consider underlying HIV infection. Our patient does not have prominent risk factors or other medical illnesses that would support this diagnosis, but I would still obtain HIV testing for completeness. Other possible causes of his cavitary lung disease besides  Mycobacterium tuberculosis  would be atypical mycobacteria, including  Mycobacterium avium-intracellulare  and some rapidly growing mycobacteria. Early in the course of his management, I would like to obtain a sputum sample to be examined for acid-fast organisms and for polymerase chain reaction testing for atypical mycobacteria. Fungal infections are possibilities and, in our region,  blastomycosis is endemic. Histoplasmosis is also a possibility, although with this infection, cavities are rare. Cryptococcal infection is quite uncommon in an otherwise normal host and usually does not produce this x-ray picture. Coccidioidomycosis would require a supportive travel history; if his fishing trip to Texas was in western Texas, infection with Coccidioides  might be a  possibility. With underlying lung disease and chronic infection, secondary invasion by an organism such as pneumococcus could produce the acute symptoms. Examination of the sputum might offer some information concerning this  pathogenesis. Finally, 2 other organisms that occasionally produce chronic lung disease with cavitary lesions are  Actinomyces  and  Nocardia.  My initial management steps and treatment would include examination of sputum with acid-fast stains and gene probes, a purified protein derivative skin test, serologic tests for the fungal organisms I have mentioned, and empiric therapy for tuberculosis with a consideration of beginning antibiotics for  pathogens associated with community-acquired pneumonia. Subsequent management would be dependent on results of our initial testing. For this patient, therapy with intravenous cefotaxime was begun following initial evaluation in the emergency department. The patient was admitted to an isolation room, where a 4-drug regimen for tuberculosis was begun: isoniazid,  pyrazinamide, ethambutol, and rifampin. He was also treated with albuterol and ipratropium by aerosolization and was given 2 L of oxygen by nasal cannula. The latter treatment appeared to make him much more comfortable. The sputum Gram stain showed moderate numbers of gram-positive cocci in chains, a few gram-positive cocci in clusters, and occasional diphtheroid organisms. Acid-fast stains were positive, and cultures of 3 sputum samples all grew  M avium-intracellulare.  Results of a gene probe for  M tuberculosis  were negative.  HIV serology was negative, and the lymphocyte profile was normal. CT of the chest with and without contrast showed bilateral upper lobe cavitary lesions, 1-cm para-aortic and cardiodiaphragmatic nodes, and paraseptal emphysema. A Mantoux test was negative on initial and repeated testing. A skin test for histoplasmosis was positive at 10 mm, and a skin test for coccidioidomycosis was negative. Therapy for  Mycobacterium avium  complex (MAC) infection was started with azithromycin (250 mg bid), rifampin (600 mg/d), and ethambutol (15 mg/ kg/d), and the patient was discharged to outpatient management after 10 days of hospitalization. Sumber :  
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