A 48-years-old Male Patient with recurrent hemoptysis.pptx

Aspergiloma

1. A 48 years old male with recurrent hemoptysis Dr. Susen Saha Assistant Registrar Department of Medicine (Unit-III) Bangabandhu Sheikh Mujib Medical College Hospital

2. Particulars of the Patient Md. Siddique 48 years Farmer Married Goalondo , Rajbari Date of admission: 23-06-2022 Date of examination: 23-06-2022

3. Chief Complaints Recurrent episodes of coughing up blood for 18 days.

4. History of Present Illness According to the statement of patient he was reasonably well 8 months back. Since then he developed productive cough with slight expectoration of mucoid sputum. He also complained of low grade continued fever which was more marked in evening & was associated with night sweats. During that period he also had anorexia & lost about 6 kg of body weight. At that time he was diagnosed as a case of Smear Positive Pulmonary TB at Upazila hospital & started anti TB medication.

5. History of Present Illness His follow up sputum after 2 months was became negative. Later he discontinued anti TB drug after 5 months without further monitoring. One & half month later of stopping Anti TB he admitted to Upazila hospital with the complaints of small amount of coughing up blood. Then he was treated conservatively & discharged with anti TB drug again. After 10 days he admitted to our hospital with coughing up blood which was about 1/2 cup in amount(about 150ml).

6. History of Present Illness He had no history of respiratory distress, chest pain, palpitation, leg swelling, abdominal swelling, any childhood pneumonia , measles, whooping cough, hematuria, rashes or digital infarct point.

7. History of Past Illness He is diabetic for last 12 years which was not well controlled with irregular oral medication. He is normotensive & non asthmatic. He has no history of trauma, blood transfusion.

8. Family History Both of his parents are alive and in good health. His wife & 2 children are all fine. No member of his family suffered from this type of illness. No family history of Hypertension, Diabetes.

9. Socioeconomic History Middle Class Family Monthly family income: around 2 0,000/- BDT

10. Personal History He smokes 30 pack year. He is also a betel nut chewer for last 17 years. He is occasional alcoholic.

11. Drug and Treatment History Disease Drug Diabetes Mellitus Tab Linagliptin 2.5mg+ Tab Metformin 850mg Smear positive Pulmonary TB Tab Rimstar 4FDC for 2 months Tab Rimstar 2FDC for 3 months No History of taking any Steroid or any immunosuppressive drug

12. Travel History No recent travelling history.

13. Immunization History Completed EPI vaccine schedule Three dose of COVID-19 vaccine

14. General Examination Ill looking Decubitus : on choice Well nourished Anemia : Absent Jaundice: Absent Oedema: Absent Oral Mucosa: Normal No dehydration No bony tenderness Hair distribution Normal Pulse: 94 b/min, regular BP: Lying-100/70 mmHg Respiratory rate: 18 b/m Temperature: 98 F

15. General Examination … No Clubbing, leukonychia, koilonychia, cyanosis, engorged neck veins, lymphadenopathy & thyroid enlargement.

16. Examination of Respiratory System Inspection: No abnormality Palpation: Trachea: Central in position Apex beat: in left 5 th intercostal space about 9cm from mid sternal line; Normal in character Vocal fremitus: Normal Chest Expansion: Normal

17. Examination of Respiratory System Percussion: Note: Normal Liver & Cardiac Dullness : In normal area Auscultation : Breath Sound: Bronchial in left 2 nd to 4 th intercostal space along mid clavicular line , otherwise vesicular in all area. Added sound: Scattered coarse crepitation over above mentioned area. Vocal resonance : Slightly increased in 2 nd to 4 th intercostal space ;otherwise normal.

18. Other Systemic Examinations Normal findings

19. Salient Feature Mr Siddique 48 years old smoker, diabetic presented with recurrent episodes of hemoptysis for last 18 days which was bright red in color & coughed up about 1/2 cup of blood in latest episode . He was previously diagnosed as a case of smear positive pulmonary TB 7 months back & started CAT 1 anti TB medication but discontinued his treatment after 5 months willingly. After one & half month later he developed small hemoptysis and diagnosed as a case of Smear negative Pulmonary TB and started anti TB medication again as retreatment on clinical basis.

20. Salient Feature He is diabetic for last 12 years which is uncontrolled & he smokes 30 pack a year. On general examination patient was ill looking. On respiratory system examination Breath sound was bronchial in 2 nd to 4 th left intercostal space with scattered coarse crepitation over same area . Vocal resonance was slightly increased in above mentioned area.

21. Provisional diagnosis ???

22. Provisional diagnosis Acute exacerbation of Post TB Bronchiectasis with Diabetes Mellitus

23. Differential diagnoses Cavitary Pulmonary TB Intracavitary Aspergilloma Carcinoma Lung

24. Investigations CBC : Hb% = 11.6 g/dl ESR = 42 mm/ 1 st hour Total WBC = 7,500 / cumm Neutrophil: 52% Lymphocyte: 43% Monocyte: 4% Eosinophil: 1% Platelet count = 2,13,000 / cumm MCV = 82 fl MCH = 24.0 pg MCHC = 29.0 g/dl RDW = 12%

25. Investigations … Sputum for AFB & Gene Xpert : Negative CRP: Negative RBS : 25.0 mmol/L HbA1c: 10.5%

26. Investigations … S. Electrolyte: Na + - 136.4 mmol/L, K + - 4.28 mmol/L, Cl - - 110.4 mmol/L S. Creatinine : 0.88 mg/dl SGPT : 26 U/L S. Billirubin : 0. 7 mg/dl Urine R/M/E : Sugar : ++; Albumin : +

27. CXR PA view Findings: Inhomogeneous dense opacity occupying in upper zone of left lung with crescent air sign .

28. CT SCAN of Chest Cavitary lesion is noted in left upper lobe. Soft tissue density area is noted within the lesion. Inhomogeneous densities are noted in both upper lobes, right middle lobe, left lingular segment ,left lower lobe. IMPRESSION: Suggestive of Bilateral Pulmonary Tuberculosis with Tubercular abscess (left)- containing(?) Fungal Ball

29. HRCT Scan Report

30. Investigations… Sputum for fungal hyphae: Present (++)

31. Final Diagnosis Simple Aspergilloma with Diabetes Mellitus

32. Treatment Inj Tranexamic Acid 500mg Tab Rimstar 2FDC Cap Voriconazole 200mg Insulin ( Basal + Bolus regimen) Patient was advised for Surgery and referred to NIDCH.

33. Thank You