Bronchiectasis Clinical Case Surgery

CLINICAL CASE 1 FOR SUMMER PRACTICE
GENERAL SURGERY DEPARTMENT
STUDENT NAME: Afugbuom Chibueze Ikenna

GROUP: IM-530
DATE: 25th July 2023
PROTOCOL
PATIENT PASSPORT DATA;
NAME: Amanda Davis.

COUNTRY: Canada
AGE: 40
CASE BACKGROUND
The patient is 42 years of age, female presenting to the COPD department

with acute pneumonia and shortness of breath. She had a history of
granulomatous tubular formation (tuberculosis) in the lungs 10 years back.
Then she has admitted in a hospital. After CT scan of the chest with
contrast, the impression was, suggestive of bilateral pulmonary
inflammatory lesions and left sided pleural effusion with thickening. Due to
pleural effusion, Thoracentesis has been performed to remove the fluid.
She reports excess sputum production but could not be managed to

expectorate the sputum, chills, cough, chest pain, palpitations, fatigue, and
in extreme conditions fever. Sometimes she felt severe weakness and
sleepy. Her main problem is she reports diculty breathing (shortness of
breath) especially while speaking. At present she has experienced bleeding
about 10-15 ml.
There are no known ill contacts at home. Her family history includes
significant brain stroke disease and her father had shortness of breathing
and her grandmother had sputum problem including sinusitis. She denies
all smoking, alcohol and illegal drug use. There are no known foods, drugs,
or environmental allergies.
COMPLAINTS;
in extreme conditions fever.
Sometimes she felt severe weakness and sleepy. Her main problem is she
reports difficulty breathing (shortness of breath) especially while speaking.
ANAMNESIS MORBI;
She presented to the COPD department with acute pneumonia and

shortness of breath. She had a history of granulomatous tubular formation
(tuberculosis) in the lungs 10 years back. Then she has admitted in a
hospital.

in extreme conditions fever. Sometimes she felt severe weakness and
sleepy. Her main problem is she reports diculty breathing (shortness of
breath) especially while speaking. At present she has experienced bleeding
about 10-15 ml.
ANAMNESIS VITAE;
She had a history of granulomatous tubular formation (tuberculosis) in the

lungs 10 years back.
FAMILY HISTORY;
Her family history includes significant brain stroke disease and her father
had shortness of breathing and her grandmother had sputum problem
including sinusitis.
OBJECTIVE AND PHYSICAL EXAMINATIONS;

Initial physical exam reveals temperature 98o F, heart rate 84 bpm, BP
110/70, HT 156 cm, WT 58kg, BMI 23.8, chest tightness (occasional),
throat pain (recurrent), chest pain (occasional) and O2 saturation 97% on
room air.
Pulmonary/Chest: Tachypnea present, respiratory distress (occasional),

(+) wheezing noted, pleural effusion, PTB, chronic cough. The patient was
barely able to finish a full sentence due to shortness of breath.
Cardiovascular: Normal rate, regular rhythm, and normal heart sound with
no murmur. Lack of any edema sign.
Abdominal: Soft. Not too obese. Bowel sounds are normal. No distension
and no tenderness are found.
Skin: Skin is dry.
Neurologic: Awake, Alert, able to protect her airway. No sensation losses.

Moving all extremities.
WHAT SYNDROMES WERE PRESENT IN THE PATIENT?
- Chronic cough syndrome
PRELIMINARY DIAGNOSIS;
Tuberculosis
PLAN OF INVESTIGATION;
Initial evaluation to elucidate the source of dyspnea was performed and
included CBC to establish if an infectious or anemic source was present,
SGPT/ALT, sonography, S. Creatinine, RBS, S.IgE, C-reactive Protein
(CRP), TSH, Anti-CCP, ANA/ANF, ECG, broncho-provocation test, chest x-
ray, and CT-Scan.
RESULTS OF THE ANALYSIS;
a) X-ray chest PA view showing old healed lesion with Bronchiectatic

changes in the right lower zone.
b) HRCT scan of the chest showing pulmonary inflammatory lesion with

multifocal consolidation and bronchiectasis.
CBC: Unremarkable and non-contributory ndings to establish a diagnosis.

SGPT/ALT- within the normal range (18 U/L)
S. Creatinine: within the normal range (0.9 mg/dl)
Random Blood Sugar: 6.3 mmol/L
S.IgE; within normal limit (21.0 IU)
Ultrasound report: liver, gall bladder, kidneys, pancreas, spleen, urinary

bladder, uterus, adnexae etc. all are in normal size and position.
C-reactive Protein (CRP)- normal (<5.0 mg/L) TSH- 2.32 uIU/ml

Anti-CCP- Non detected (<0.40 U/ml) ANA/ANF- negative (18.97)
Broncho-provocation test: Bronchoprovocation test is mildly

Hyperresponsive Airways. An interpretation after this test are, C/C during
the test: cough; Baseline Spirometry: Mild restriction; FEV1 is reduced by
17% at 25.0 mg/ml; reversibility: good
ECG: Normal sinus rhythm with non-specific ST changes in inferior leads.
Chest X-ray
Findings: Features are suggestive of the pulmonary inflammatory lesion

(right). Pleural thickening/reaction (left)
Radiologist Impression: Reticular/nodular opacities with suspected

bronchiectasis inside. Chronic lung infection, inammatory processes are
possible. Minimal left basal pleural thickening. Right curvature of the
thoracic spine. Deformity of lateral right 8th rib.
CONFIRMATORY EVALUATION;
The patient is getting sick again and again. Continuing to suppress the
temporary disease through the application of antibiotics, but not fully
recovering. His lungs become like honeycombs, giving way to all kinds of
germs and thus getting affected. She got tested many times, but the reason
for the disease remains unknown.
Testing was performed to include sputum AFB, sputum for gram stain,
sputum for Eosinophils, GeneXpert detection of Mycobacterium
tuberculosis, Mycobacterium tuberculosis complex and NTM, PCR
(sputum), CT guided FNAC and CT scan of the chest. CT scan of the chest
was investigated several times for anatomical abnormalities.
Sputum culture: Incubated aerobically at 37oC for 24/48/72 hours; Z-N

test- yielded no growth
Gram Stain: Smear shows a moderate number of gram-negative

coccobacilli and pus cells/HPF Eosinophils: Eosinophils cells are not seen.
Xpert MTB/RIF: MTB and RIF both are not detected.
Mycobacterium tuberculosis complex: Negative
Non-tuberculosis mycobacteria (NTM): Positive
CT Guided FNAC
CT Findings- A small soft tissue lesion is seen in the right middle lung
along with the destruction of the rib.
Aspiration Note- A needle is introduced. The needle tip is identified within

the lesion. Aspirated a few drops of hemorrhagic material. No immediate
complication is seen.
Microscope description- Smear shows adequate cellular material

containing plenty of degenerating polymorphs, lymphocytes and histiocytes
in the background of extensive caseation necrosis. A few epithelioid cells
are seen in the background.
Dx- Lung middle right (CT guided FNAC): Granulomatous inflammation,
tubercular
HRCT-Scan of chest
Multiple axial 2 mm HRCT Scan of chest were performed.
Findings: Increased attenuated areas having air bronchogram are noted in

both medial and lateral basal segments of middle lobe and apical, posterior
and lateral basal segments of right lower lobe. Few intervening cystic
lucent areas are noted in medial basal segment of middle lobe. Multiple
subpleural nodules and thickened septa and few nodules.
Impression: CT finding consistent with pulmonary inflammaroty lesion with

multifocal consolidation and bronchiectasis (right), possibly PT.
CLINICAL DIAGNOSIS;
Granulomatous inflammation, tubercular, of the middle right lung
TREATMENT;
Her medications include Azithromycin 500mg, Levofloxacin 500mg,

Amoxycillin (500mg) + Clavulanic Acid (125mg), Doxycycline 100mg,
Moxifloxacin 400mg, Clarithromycin 500mg, Frabex 500mg, Doxiva 200
mg, Provair 100mg, Pantoprazol 20 mg, Salbutamol 100mcg/puff,
Salmeterol Xinafoate (25 mcg+250 mcg/puff), Levocetirizine 5 mg.
For PTB treated six months course. These drugs were given depending on
the severity of the disease of patient.
NB: Patients are at risk for developing a coexistent bacterial infection, and
appropriate antibiotics should be considered after 2 to 4 months of known
infection if symptoms are still present
VACCINATIONS;
The patient was given Pneumovax 23 in every 5 years interval and Influvax
every year
CONCLUSION;
The patient was suffering for a long time and had taken so many drugs as
per the prescription of the physicians. In the sputum test, NTM had been
diagnosed while Mycobacterium tuberculosis complex was negative. NTM
are ubiquitous organisms in the environment and can be inhaled or
ingested from water, soil, and dust with different consequences according
to individual and organism characteristics. According to the patient, she
was not exposed to too much dust, and she led a very healthy life. At
present she has experienced bleeding about 10-15 ml.
High resolution Computed Tomography (HRCT) features were also

investigated as NTM pulmonary disease was suspected. After HRCT scan
of the patient confirmed the presence of bronchiectasis. Bronchiectasis is
no longer a neglected disease.
Discovering the underlying etiology of bronchiectasis could make a real

difference in the management and prognosis of patients and could delay
the progression of lung involvement when treated. This female patient
experienced the fact. She took lots of medicines given by her physicians
who could not diagnose the disease accurately. During March April every
year, her severity of disease increased.
Currently, she feels better while taking Azithromycin 500mg one day
intervals along with montelukast 10 mg. Therefore, physicians should be
familiar with her key clinical history and CT features that can raise the
suspicion of a specific cause of bronchiectasis and lead to improved
treatment

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CLINICAL CASE 1 FOR SUMMER PRACTICE

GENERAL SURGERY DEPARTMENT

STUDENT NAME: Afugbuom Chibueze Ikenna

PATIENT PASSPORT DATA;

NAME: Amanda Davis.

The patient is 42 years of age, female presenting to the COPD department

She reports excess sputum production but could not be managed to

She presented to the COPD department with acute pneumonia and

She reports excess sputum production but could not be managed to

She had a history of granulomatous tubular formation (tuberculosis) in the

OBJECTIVE AND PHYSICAL EXAMINATIONS;

Pulmonary/Chest: Tachypnea present, respiratory distress (occasional),

Skin: Skin is dry.

Neurologic: Awake, Alert, able to protect her airway. No sensation losses.

WHAT SYNDROMES WERE PRESENT IN THE PATIENT?

- Chronic cough syndrome

RESULTS OF THE ANALYSIS;

a) X-ray chest PA view showing old healed lesion with Bronchiectatic

b) HRCT scan of the chest showing pulmonary inflammatory lesion with

CBC: Unremarkable and non-contributory ndings to establish a diagnosis.

Random Blood Sugar: 6.3 mmol/L

S.IgE; within normal limit (21.0 IU)

Ultrasound report: liver, gall bladder, kidneys, pancreas, spleen, urinary

C-reactive Protein (CRP)- normal (<5.0 mg/L) TSH- 2.32 uIU/ml

Broncho-provocation test: Bronchoprovocation test is mildly

ECG: Normal sinus rhythm with non-specific ST changes in inferior leads.

Findings: Features are suggestive of the pulmonary inflammatory lesion

Radiologist Impression: Reticular/nodular opacities with suspected

Sputum culture: Incubated aerobically at 37oC for 24/48/72 hours; Z-N

Gram Stain: Smear shows a moderate number of gram-negative

Xpert MTB/RIF: MTB and RIF both are not detected.

Mycobacterium tuberculosis complex: Negative

Non-tuberculosis mycobacteria (NTM): Positive

Aspiration Note- A needle is introduced. The needle tip is identified within

Microscope description- Smear shows adequate cellular material

Multiple axial 2 mm HRCT Scan of chest were performed.

Findings: Increased attenuated areas having air bronchogram are noted in

Impression: CT finding consistent with pulmonary inflammaroty lesion with

Granulomatous inflammation, tubercular, of the middle right lung

Her medications include Azithromycin 500mg, Levofloxacin 500mg,

High resolution Computed Tomography (HRCT) features were also

Discovering the underlying etiology of bronchiectasis could make a real

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