ACUTE FLUID OVERLOAD SIMULATING UPPER LOBE CONSOLIDATION

A 50 yr old female underwent an operation under ga for fracture rt olecranon.In the immediate postoperative period she started having respiratory distress and falling spo2.On examination bp was160/100,pulse96/min,regular,respiratory rate 46/min,afebrile,no pallor,jvp normal.auscultation revealed bl coarse crepts,more in the basal regions.On investigation tlc21400,n88,lft-wnl,rft-wnl,urine showed6-7 pus cells/hpf.Her chest xray revealed dense consolidation rul and streaky opacities lul.She had no cardiac or pulmonary ailment in the past.She was managed with niv,o2,antibiotics and diuretics. she was relieved within a few hours and the opacities in the chest xray disappeared in the same day. our diagnosis was fluid overload acute heart failure.However what appears confusing is the upper lobe distribution of the opacities,

If you observe carefully the initial xray was taken in the supine position.[ap view].In supine position there is equalization of blood flow in all the lung zones and the effect of gravity is abolished.This gave us the false impression of bacterial consolidation.The raised tlc was probably due to uti where urine c/s showed rich growth of Ecoli.

PULMONARY TUBERCULOSIS WITH LEFT RECURRENT LARYNGEAL NERVE PALSY

A 36 year old female presented with dry cough ,irregular fever,progressive weakness and anorexia since last 6months and hoarseness of voice since 7 days. On examination there was a2*1.5cm lymph node in the right posterior cervical region.Her ESR was 92 and chest xray showed lt upper lobe opacity and elevated lt hemidiaphragm. Lymph node biopsy wasd consistent with granulomatous lymphadenitis with caseation necrosis. Sputum for AFB wasnegative.

So this case was dignosed as SPUTUM NEGATIVE PULMONARY TUBERCULOSIS with TUBERCULOUS LYMPHADENITIS with LEFT RECURRENT LARYNGEAL NERVE PALSY.

BEWARE OF ARTIFACTS ON CHEST XRAY

A very unusual and unsuspecting artifact was seen in the x-ray of a female patient. Artifacts are very common in chest xrays and you need to suspect them whenever you find an unusually clear cut shadow in chest xray
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PULMONARY TUBERCULOSIS WITH NORMAL CHEST XRAY

A 25 year old male presented with high grade intermittent fever with dry cough since 10 days.There was no significant joint pains and bladder and bowel habbits was normal.He was treated with ofloxacin and cefixime for 5 days with no relief in fever.His lab reports were TLC8400,n70,l29,e1%,ESR45,MP,optimal,dengue igm-ve.widal test was -ve and urine RE was within normal limits.LFT was a bit deranged- total bilirubin was 4.2,sgpt152u\l,sgot104u\l..His chest xrays were apparently normal.His usg abdomen showed mild hepatomegaly.Considering cough as a prominent symptom,we did a CT scan of chest.The scan showed bilateral patchy pulmonary infiltrates.His sputum,which was mostly serous did not reveal any AFB.He was treated with inh,ethambutol and streptomycin(altered ATD regime due to deranged LFT).His fever subsided in 2 days and did not return again.
CLINICAL PEARLS: always search for tuberculosis in a patient with pyrexia of unknown origin
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http://www.sustain2green.com/2011/12/pulmonary-tuberculosis-with-normal.html

CHILAIDITI'S SIGN

The interposition of a loop of large gut between the liver and diaphragm is sometime visible in chest xray or straight xray abdomen and is referred to as chilaiditi's sign.This condition is usually asymptomatic.When chilaiditi's sign is symptomatic(usually abdominal pain),it is called chilaiditi,s syndrome. 


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http://www.sustain2green.com/2011/12/chilaiditis-sign.html

BEWARE OF SPURIOUS HYPERKALEMIA

A 40 year old smoker,nonalcoholic male presented with an episode of generalized tonic clonic convulsions followed by unconsciousness(first episode). he regained consciousness after 2-3 hours and had no significant complaints.His CT SCAN brain showed a ring enhancing lesion with surrounding cerebral oedema in left parietal region which was suggestive  of neurocysticercocis.he had no significant past history and was not on any medications.his TLC was 19800,N82%,urea 25,cr0.8,na+135,and most suprisingly k+8.7. His ECG was normal and his urine output was adequate.We panicked and immediately sent a repeat k+ and gave the patient a10%calcium gluconate 10ml i.v. slowly over 3minutes. The repeat k+ was 4.09.
                   So this is a case of spurious hyperkalemia and we must all be very cautious about it.Before jumping into any conclusions and be very aggressive in management we must always do a repeat test.

                   The causes of spurious hyperkalemia are:     

               1.hemolysis during venipuncture

                     2.release of k+ from muscle during the seizure attack.

                     3.release of k+ from muscle distal to the tourniquet.

                      4.release of k+ from clotted blood during severe leucocytosis(>50,000) or thrombocytosis

                        (>10,00,000)

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BACTERIAL PNEUMONIA MIMICKING PULMONARY TUBERCULOSIS

A 30 year old muslim female presented with low grade fever,cough with expectoration and myalgias.Her chest xray revealed right upper lobe consolidation,TLC15700,n80%,ESR130,MT 17*19mm,sputum for AFB was negative on 3 consequetive days,sputum for gram stain showed gram positive cocci in pairs.She was treated with coamoxyclav625 bid for 3 days-there was no relief in symptoms.she was then given cefpodoxime-clavulanate200 bid for 10 days.there was almost complete clearance of RUL opacity after 10 days.
http://www.sustain2green.com/2011/12/bacterial-pneumonia-mimicking-pulmonary.html
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ACUTE DYSPNOEA DUE TO SUB CARINAL LYMPH NODE COMPRESSION AND ACUTE MYOCARDIAL INFARCTION PRESENTING AT THE SAME TIME

a 50 year old man presented with acute onset shortness of breath since last 5 days which was associated with central chest discomfort for the first 2-3 days. The shortness of breath became agravated intermittently,mainly after prolonged lying down, got relief within a few minutes after sitting up.He had mild cough and was febrile initially.He had no past history of hypertension or diabetes.He had a past history of pulmonary TB which was adequately treated. He was a non smoker and coal miner by occupation. His investigations revealed TLC-14300,n82,L16,E2,ESR65,fbs105,ppbs176,urea41,cr1.6.His troponin T was positive. His chest xray pa view revealed an illdefined rounded mass in left upper lobe and left lateral view revealed a subcarinal rounded mass. CT chest and upper abdomen showed a large calcified mass in left upper lobe of lung and left lobe of liver. There was also a large subcarinal lymph node and bilateral emphysematous changes.We plan to do a bronchoscopy followed by trans bronchial needle aspiration of the subcarinal node to reach a final tissue diagnosis.

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AMI PRESENTING AS LEFT VENTRICULAR FAILURE WITH CLASSICAL BAT'S WING PATTERN IN CHEST X RAY

A 60 year old non diabetic,hypertensive female presented with acute onset breathlessness.Her ECG showed antero lateral infarction,CXR-classical bats wing pattern,TROP-T was positive and her CPK-MB was 120 u/l.

She was managed with iv streptokinase,nitroglycerine,diuretics,oxygen,aspirin,clopidogrel and atorvastatin and she recovered within 4-5 days.

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HYPOTHYROID AND BRONCHIAL ASTHMA COEXISTENCE

In my clinical practice i have seen many hypopothyroid patient having coexistent bronchial asthma.Whether there is any factor that having one of these disease predispose an individul to the other needs to be proved.

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INH POWDER APPLICATION LOCALLY IN PERSISTENT SINUS TRACT IN TUBERCULOSIS

A 18 year old female suffering from pulmonary tuberculosis,on regular ATD since last 2 months, suddenly noticed a small fluctuant swelling over lower part of the sternum which ruptured in a few days and a persistent sinus tract was created. She was initially treated with antibiotics along with ATD but there was no response and the sinus tract persisted along with drainage.She was then given INH powder for local application over the wound along with oral ATD and within 7 days time the wound healed completely.INH at adose of 300mg was applied for 15 days in total.There was no recurrence till 2 months of follow up.

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INH INDUCED GYNAECOMASTIA

A 45 year old male,being treated for tubercular pleural effusion since last 4months, presented with the complaint of mild swelling and pain over both nipple and areolar region. He was non diabetic and his liver and kidney functions were within normal limits.He took INH,rifampicin,ethambutol and pyrazinamide for the first 2 months and was currently on INH and rifampicin.He was diagnosed as a case of drug induced gynaecomastia and the culprit drug in this case was INH.
DISCUSSION: Gynaecomastia is hypertrophy of breast tissue in males. It is usually transient,bilateral,symmetrically distributed, It has various causes(hepatic and renal failure/endocrine disorders/drugs). Two antitubercular drugs can cause gynaecomastia- INH and ethionamide. Here we have to continue INH for 2 more months. Meanwhile we need to reassure the patient that the disorder is transient and will recover once INH is stopped.

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PULMONARY TUBERCULOSIS PRESENTING LIKE LOBAR PNEUMONIA

A 50 year old male presented with dry cough since 3months, irregular fever since 20 days,left anterior chest pain since 3-4 days. He was non hypertensive and non diabetic. His TLC was 9300;60%neutrophils,38%lymphocytes and 2%eosinophils.SPUTUM for AFB was negative for 3 consequetive days and MT was negative.His chest xray showed left mid zone consolidation.He was given cefuroxime500 bd for 7 days and there was no improvement in symptoms.

His sputum pyogenic culture was negative but sputum culture by BACTEC method yielded mycobacteria. He responded very well to 6 months antitubercular therapy and was asymptomatic at the end of treatment.

clinical pearls: Here pulmonary tuberculosis presented like lobar pneumonia and chest pain was the aggravating symptom which brought the patient to the doctor.

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AZATHIOPRINE INDUCED MYELOSUPPRESSION

A 24 years old male presented with exertional shortness of breath since 10-15days. He was a diagnosed case of crohn's disease and was taking mesalazine since last 4 years and azathioprine since last 6 months.On clinical examination the only positive findings were severe pallor and mild icterus. His investigations revealed hb-4.5gm/dl, TLC2600,platelet count180000.His peripheral blood film,liver function and kidney function tests were normal. 6months back before starting azathioprine his blood reports were hb-10.5gm/dl, TLC-8400 and platelet 429000. we diagnosed the case as azathioprine induced myelosuppression and stopped the drug immediately. He is still under follow up and his further reports will confirm our diagnosis.

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PNEUMONIA WITH ATYPICAL PRESENTATION

A fifty year old diabetic hypetensive male,presented with mild fever since one day,chest discomfort and restlessness since last 1 hour.His BP was 140/80,pulse100/min,respiratory rate was 28/min,afebrile at the time of examination.His spo2 was66%.his resting ecg was normal and chest xray showed a dense right upper lobe consolidation.TLC was 24400,90% were neutrophils and random blood sugar was 251.his sputum for AFB was negative and gram stain revealed gram positive cocci in chains.
CLINICAL PEARLS:This is acase of lobar pneumonia with atypical presentation.Diabetes is responsible for such altered appearance of the disease.The patient deteriorated rapidly without any prior warning signs or symptoms.So one has to be very careful while dealing with a diabetic pneumonia.
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TREATMENT OF TUBERCULOSIS IN CHRONIC RENAL FAILURE PATIENTS

Treatment of tuberculosis in chronic renal failure patients is slightly different from that of a patient with normal renal function.Avoid aminglycosides.INH and rifampicin can be used in their usual doses as these drugs are excreted primarily in bile. Ethambutol should be used at dosage of 15mg/kg body wt three times weekly and pyrazinamide at dosage of 25mg/kg body wt three times weekly. the duration of treatment remains the same as for any tuberculosis patient

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AN UNUSUAL PRESENTATION OF RENAL FAILURE

A 75 year old man presented to the opd with the chief complaint of shortness of breath since last 2-3 months which worsened during last 3-4 days.There was no fever,cough,chest pain,swelling of body,bowel or bladder problems.On examination his bp was 160/80,pulse84/min,regular,respiratory rate was 24/min,no cyanosis, clubbing,pedal oedema.his chest was clear and heart sounds normal,abdominal examination did not reveal any abnormality.he was a non smoker,non alcoholic,ex tailor. His spo2 was 84% in room air.He was hospitalized for investigation and management.His chest xray and resting ECG was normal.The only abnormality in his blood reports was raised urea(200)and creatinine(13.6) values.He was suggested urgent haemodialysis to which he denied,left hospital and was lost to follow up.
CLINICAL PEARLS :
This was a case of acute renal failure ,probably in the background of chronic renal failure which was not detected earlier.So beware,shortness of breath may be the sole presenting feature of renal failure,in the absensce of any other signs or symptoms
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Heat can be dangerous for humans and can cause heat stroke leading to death

A fifty five year old man presented to our hospital with altered sensorium, tachypnoea, tachycardia and normal BP. There was history of lower limb weakness just half an hour before losing conciousness. His body temperature was 106 degree farenhiet, ECG was normal. There was no focal neurological defecit. He was diagnosed as heat stroke. Active cooling was started with ice water bath, IV fluids, cold saline gastric lavage. In the next fifteen minutes he started having massive haemoptysis. In the next ten minutes suddenly patient had a severe hypotension followed by cardio respitory arrest.

Cinilcal pearls:

Heat stroke may have a subtle presentation and when recognised it may be too late to salvage the patient. So in a tropical country like India when the outside temperature is very often more than 45 degrees centigrade in summer months, one needs to be very careful with proper hydration and avoid out door job as much as possible during this period.

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