پروفسور محمد حسین سلطان زاده

استاد دانشگاه علوم پزشکی شهید بهشتی
متخصص کودکان ونوزادان
طی دوره بالینی عفونی از میوکلینیک آمریکا
دبیر برگزاری کنفرانس های ماهیانه گروه اطفال
دانشگاه علوم پزشکی شهید بهشتی

خانم دكتر سهيلا خليل زاده

عضو هيئت علمي دانشگاه به اتفاق اعضاي هيئت علمي گروه اطفال بيمارستان مسيح دانشوري

خانم دكتر خديجه رياضي كرماني

معرفي كيس

خانم دكتر فاطمه پژوهنده

رزيدنت بيمارستان لقمان حكيم

خانم دكتر مريم نوري

رزيدنت بيمارستان مفيد

خانم دكتر ناديا دانائي

رزيدنت بيمارستان امام حسين

خانم دكتر انسيه اميري

رزيدنت بيمارستان شهدا

اقاي دكتر حسين علي غفاري پور

فلوشيپ ريه

اقاي دكتر مصلحي

فلوشيپ ريه

اقاي دكتر طباطبائي

فوق تخصص ريه

خانم دكتر محبوبه منصوري

فوق تخصص ايونولوژي و الرژي

خانم دكتر شيرواني

فوق تخصص عفوني اطفال

خانم دكتر خان بابائي

فوق تخصص ريه اطفال

خانم دكتر سهيلا خليل زاده

عضو هيئت علمي دانشگاه به اتفاق اعضاي هيئت علمي گروه اطفال بيمارستان مسيح دانشوري

تشخيص:

Invasive

Aspergillosis

CGD

خانم دكتر خديجه رياضي كرماني

معرفي كيس

تشخيص هاي افتراقي:

خانم دكتر فاطمه پژوهنده

رزيدنت بيمارستان لقمان حكيم

Problem list:

A 13 year old boy presented with

Fever

Weight loss

Right hemithorax pain

History of previous exposure to active pulmonary TB

History of left inguinal tenderness one month before

PH/E

Tachycardia

Lung auscultation:crackles
Lab data
ESR   120
CRP   74
WBC   13000
HB    9.1
MCV 69
PLT   850
Cr 1.6
INR 1.7
PPD 12
RADIOLOGIC FINDINGS
a right paracardiac soft tissue is noted   with some area of air bronchogram and consolidation pattern at the center of the lesion wich has mass like appearance
CULTURE
aspergillus
beta hemolytic strep non group
A B C D   CC:1000
coagolase negative staph CC:1000

INFECTION

TUBERCULOSIS

ACTINOMYCOSIS

FUNGAL LUNG INFECTION:

Aspergillosts

Blastomycosis

Histoplasmosis

PARASITIC LUNG INFECTION

PCP

LUNG ABSCESS

GRANULOMATOUS INFLAMMATORY DISORDERS

Wegeners granulomatosis

Sarcoidosis pulmonary

Churg-strauss syndrome

ALLERGIC .COLLAGEN.AUTO-IMMUNE DISORDERS

Eosinophilic pneumonia

Loefflers eosinophilic pneumonitis

NEOPLASTIC DISORDERS

Hodgkins disease

Metastatic lung disease (ostosarcoma) (RCC)

Leukemic/lymphocytic lung infiltrate

Pulmonary lymphangiomatosis

VASCULAR DISORDERS

Pulmonary embolism

Pulmonary infarction

POISINING

Silicosis

Pneumoconiosis

IMMUNODEFICIENCY

Bruton agammaglobuulinemia

Common variable immunodeficiency

Human immunodeficiency virus infection

Job syndrome

Severe combined immunodeficiency

Chronic granulomatous disease

RESULTS

FUNGAL LUNG INFECTION

WEGNERS GRANULOMATOSIS

CGD

METASTATIC LUNG DISEASE

HODGKINS DISEASE

RECOMMENDATION

SPIRAL CHEST CT SCAN WITH CONTRAST

OPEN BX

WATERS X RAY / CT SCAN

NBT

BONE SCAN

ANCA

خانم دكتر مريم نوري

رزيدنت بيمارستان مفيد

خرد هر کجا گنجی آرد پدید
ز نام خدا سازد آن را کلید

Problem List
Fever+ weight loss

Left groin pain

Right hemithorax pain

No response to antibiotic therapy

Active TB exposure

Lab test plt=850000

ESR=120 corrected ESR=96

CRP=74

PT=16.7 INR=1.7

PPD=12

Imaging CXR: Right paracardiac consolidation

Bronchoscopy culture: Aspergillus

Pathology Pulmonary eosinophilic infiltration

Missing Points

Groin pain?

Respiratory Symptoms?

Extra pulmonary signs and symptoms?

History of prior infections?

Response to immunization?

Exact time of TB exposure?

Drug History?

Travel History?

Eosinophil count?

Igs level?

Prick test?

Immune system work-up?

Collagen vascular diseases’ work-up?

Sweat test?

S/E * 3

Sputum Smear and PCR NOT gastric washing

BAL: total and diff of leukocyte count?

Causes of Pulmonary Eosinophilia

Drug and toxin-induced eosinophilic lung diseases

NSAIDs, Antimicrobials, Phenytoin

Helminthic and fungal infection-related Transpulmonary passage of larvae (Loffler’s Syndrome)

Pulmonary parenchymal invasion

Heavy hematogenous seeding( Strongyloidiasis,Trichinosis)

Tropical pulmonary eosinophilia

ABPA

Acute eosinophilic pneumonia

Chronic eosinophilic pneumonia

Churg Strauss Syndrome

Other (Idiopathic, Neoplasm)

Differential Diagnosis

Active TB exposure + Radiologic changes+ PPD

Sputum Smear and PCR? Tissue PCR?

ABPA

Hypersensitivity reaction when bronchi becomes colonized with Aspergillus.

Aspergillus is cultured from the sputum in up to two-third of patients with ABPA.

Range of clinical manifestation(asymptomatic pulmonary consolidation – fever and respiratory symptoms and signs)

The major diagnostic features: A history of asthma

Immediate skin test reactivity to Asp. Antigen

Percipitating serum Ab to A.fumigatus

Serum Total IgE>417 IU/ml

Periph.Blood Eos>500

Imaging

Elevated specific serum IgE and IgG to A.fumigatus

Prick test, IgE level?

Differential Diagnosis

Helminthic parasitic infections

Loffler’s Syndrome Respiratory symptoms and signs

Transient pulmonary infiltrates

Eosinophilia

S/E * 3? Serologic tests? Sputum analysis(Strongyloides)? Blood Eos count?

Chronic Eosinophilic Pneumonia

Abnormal accumulation of eos. In the lung

Subacute illness

Fever+cough+weight loss+wheezing+night sweats

Peripheral eosinophilia is common

CXR

Differential Diagnosis

CVID

Decreased IgG with Low level of IgA+/- IgM

Poor or absent response to immunization

Age of onset after puberty

Broad spectrum of disorders (infections, chronic lung disease, GI and liver disorders,…)

Normal physical examination

Increased risk of malignancies

Serum concentration of IgG? Response to immunization? GI symptoms?

S/E * 3?

Differential Diagnosis

Churg Strauss Syndrome

Sinusitis+ Asthma+ Prominent peripheral blood eosinophilia

Lung Biopsy

History of prior infections?

Drugs and Toxins

Range of clinical presentation

Asymptomatic pulmonary infiltration with eosinophilia to chronic cough with or without dyspnea and fever to acute eosinophilic pneumonia

History of groin pain and possible NSAIDs consumption

Elevated PT

Drug History?

خانم دكتر ناديا دانائي

رزيدنت بيمارستان امام حسين

Problem list

13 Y , BOY

Lt inguinal pain & Rt hemithorax pain from 1M ago

Fever & weight loss

Non response to IV antibiotic therapy

Hx of contact to TB

Diffuse crackle

Lab data:

WBC:13000 diff:PMN:76% ,L:15%

HB:9.1

PLT:850000

ESR:120 CRP:74

Cr:1.6

S/E:fatty droplet positive

pT:16.7 INR:1.7

PPD:12

CXR=Rt paracardiac consolidation

CHEST HRCT=a RT paracardiac soft tissue is noted with some area of air bronchogram & consolidation pattern at the center of the lession which has mass like appearance, at the periphery of the mass some lymphangiectasia

Direct smear=NL

Culture=aspergillus

TBLB=pulmonary eosinophillic infiltration

BMB=chronic inflammatory with mild eosinophillic infiltration

DDX

1.TB

*AFB (BAL,TBLB)

2.eosinophilic lung dis.

. ABPA

. eosinophilic pneumonia

. loffler syndrom

. churg-strauss syndrom

*serum percipitant test

*Aspergillus skin test

*serum Ig E

*CBC ,diff(EO)

*P-ANCA

3.CVD

C-ANCA,P-ANCA,ANA,

*C3,C4,CH50

*HIV Ab,HBS Ag,HBS Ab,HCV Ab

4.Malignancy (lymphoma)

*mediastinal HRCT

5.Non classified

Aspergillosis in immunocompromised patient:

. N or MQ dysfunction : CGD , SCID

.HIV

*NBT TEST

*Ig

*CD4

primary malignancy of bone

*immaging

*Ca,ph,Alkp

With thanks

خانم دكتر انسيه اميري

رزيدنت بيمارستان شهدا

Case presentation

E. Amiri MD

Problem list

Fever

Hemithorax pain

Weight loss

Inguinal pain

Right paracardiac consolidation

History of contact with active TB patient

FTT

Generalized crackle in both lungs

Lab tests

CRP : 74

ESR : 120 (corrected:72)

WBC : 13,000 (P : 76%- L : 15% )

Hb : 9.1

MCV : 69

PT : 16.7

PTT : 48

S/E : fatty droplets

PPD : 12 mm

Imaging study

Lung CT scan : Consolidation – airbronchogram

Bronchoscopy : Nl

Culture : Aspergillus sp

Pathology

Pulmonary eosinophilic infiltration

Differential Diagnosis

Eosinophilic pneumonia

Aspergilloma- invasive form :

Vasculsar involvement

High eosinophilia

ABPA :

Secondary to CF , TB cavity , Asthma

↑ Eos

↑ IgE

Bronchiectasis

Recurrent pneumonia

Parasites :

↑ Eos

Granuloma

Chronic eosinophilic pneumonia :

Secondary to asthma and allergy

Bilateral lung involvement

Churg-strauss syndrome & Sarcoidosis :

↑ Eos

Granuloma

Old age

History of contact

PPD=12 mm

Pulmonary symptoms

Malignancy (associated with pulmonary involvement) :

Histyositosis :

Bone tumors

Eosinophilia

Respiratory distress

hepatosplenomegaly

Seborrheic dermatitis

Otorrhea

Bone marrow involvement

Ewing sarcoma

Fever

Systemic symptoms

Bone involvement in Ph/E and CT scan

Lymphoma

Mediastinal involvement

Lymphadenopathy

Pulmonary involvement

Bone marrow involvement

Rhabdomyosarcoma

Soft tissue involvement

Pulmonary involvement

Neuroblastoma

Posterior medistinal involvement

Pulmonary involvement

FTT

Pulmonary involvement

Fatty droplets in S/E

اقاي دكتر حسين علي غفاري پور

فلوشيپ ريه

13 year/old boy,from Tabriz live in tehran

CC:fever&pain of left inguinal

PI:1month before admission:

Pain of left inguinal,no trauma

low grade fever

Sometimes coughing & right hemithorax chest pain

malaise&weight loss

PMH:

Term/NVD/ G4P3AB1

No NICU admission

Vaccination:full/development:nl

Hospitalization:90/11/03

FH:TB(+)

DH:(-)

PHYSICAL EXAMINATION

GA:alert and ill no toxic

VS: AT:37 RR:24

PR:120 BP:100/60

weight(for age percentiles):5%

height(for age percentiles):25%

H&N:conjunctive:pale & no lymphadenopathy

Heart:nl

Lung:fine crackles

Abdomen:no organomegaly

Extremities:nl

LAB TESTS

WBC:13000 /N:76%/L:15%

RBC:3500000

HGB:9,1/HCT:28,5/MCV:69/MCH:23,5 /MCHC:33 RDW:16,8

PLT:850000

ESR:120

CRP:74

LDH:261

URIC ACID:2 /ure: 12 /Cr:1,6

ADA:37

PPD:12mm

Gastric washing:

Direct smear:(-)

PCR(for MBT): (-)

Report of spiral ct scan

A right paracardiac soft tissue is noted, with some area of air bronchogram and consolidation pattern at the center of the lesion which has mass like appearance at the periphery of the mass some lymphagiectasia also seen and right hilum prominency.

Spiral abdomen&pelvic ct scan:

Normal

Bone marrow aspiration:

Normocellular

Bronchoscopy:

Normal

discharge for:

direct- smear:negative

culture:

Aspergillus sp

Pathology

Transbronchial lung biopsy:

pulmonary eosinophilic associated with

chronic non specific inflammatory process.

Negative for malignancy.

Negative for granuloma.

اقاي دكتر مصلحي

فلوشيپ ريه

Question remind unclear about case

Trend of growth?

Recurrent infectious (pneumonia or AOM or sinusitis,…)?

Symptoms after vaccination?

Hx of diseases in other sibling

Leg pain?

Hx of trauma?

Night sweating, exertional dyspnea, cough

Cyanosis, Clubbing?

Parental relative?

Drug Hx?

Diff- U/A-BS-LFT

EOSINOPHILIC LUNG DISEASES
(PIE)

Early description :

pulmonary symptoms or CXR abnormalities and

PB eosinophilia

After 1970 description :

characterized by increase in BAL eosinophil number but not necessarily blood eosinophils

Some affect the airways predominantly, some affect the lung parenchyma, and some affect predominantly the lung vasculature.

From subtle symptoms and are self-limited to respiratory failure.

Subtype:

Group I, Löffler syndrome or simple pulmonary eosinophilia

Group II, prolonged pulmonary eosinophilia

Group III, Weingarten’s syndrome or tropical eosinophilia

Group IV, pulmonary eosinophilia with asthma

Group V, polyarteritis nodosa

Parasitic infection (Ascaris) & drug reactions are currently an important etiology

No cause in 1/3 of cases

Mild febrile illness with myalgias ,nonproductive cough, and dyspnea.

No abnormalities on physical examination, but sometimes a few crackles or wheezes are heard

Parasites That Cause
Eosinophilic Lung Disease

Ancylostoma sp.

Ascaris sp.

Echinococcus sp.

Schistosoma sp.

Strongyloides stercoralis

Toxocara sp.

Trichinella spiralis

Wuchereria bancrofti

Patients with Ascaris infection are usually febrile with a nonproductive cough and chest pain. In severe cases hemoptysis occurs.

CXR: abnormalities are usually bilateral and peripheral, pleural based

Parasites and ova are sometimes found in the stool after the resolution of the pul. illness

larvae can be isolated from gastric aspirates or sputum

Weingarten = tropical eosinophilia =

severe spasmodic cough, massive peripheral eosinophilia, diffuse mottling in both lungs

endemic in India, Sri Lanka due to Wuchereria bancrofti

DRUG-INDUCED

Cough, dyspnea, and fever

Histologically : interstitial edema with a lymphocytic and eosinophilic infiltrate, (alveoli contain eosinophils and histiocytes)

CXR show interstitial or alveolar infiltrates and Kerley B lines

Skin testing with either patch or prick tests is usually negative

ACUTE EOSINOPHILIC PNEUMONIA

Idiopathic

febrile illness of 1 to 5 days + myalgias, pleuritic chest pain, and severe hypoxemia

basilar or diffuse crackles

CXR: diffuse alveolar infiltrates involving all lobes

Small to moderate-sized pleural effusions are common

CHRONIC EOSINOPHILIC PNEUMONIA

middle-aged women

fever, night sweats, weight loss

cough, dyspnea, and wheezing (asthma)

lymphadenopathy and hepatomegaly

Pb & BAL eosinophil

ESR & IgE is elevated

CXR; bilateral, peripheral infiltrates negative image of pulmonary edema =dignostic

CT : peripheral airspace disease and may show hilar lymphadenopathy

ALLERGIC ANGIITIS AND GRANULOMATOSIS

allergic rhinitis and asthma for years

peripheral eosinophilia with values up to 80%

small and medium-sized arteries and veins.

sinusitis, rhinitis, and nasal polyps

GI:abdominal pain, diarrhea, bleeding, and obstruction;

cardiovascular: pericarditis, and heart failure.

Renal

CNS

CXR: patchy and transient infiltration

Eosinophilic pleural effusions and hilar adenopathy

IDIOPATHIC HYPEREOSINOPHILIC SYNDROME

elevated eosinophila for >6 months,

or for <6 months with evidence of organ (heart) damage

most common in adults 20 to 50 years - male

ABPA

1% to 2% of asthmatics and 7% to 9% of cystic fibrosis

Minimal Diagnostic Criteria:

Acute or subacute clinical deterioration

Total serum IgE >500 IU/mL

Immediate cutaneous reactivity or RAST

(a)IgG antibody to A. fumigatus; or (b) new or recent abnormalities on CXR or chest CT that have not cleared with antibiotics and standard physiotherapy

Hypersensitivity Pneumonitis

HP = extrinsic allergic alveolitis

recurrent inhalation of organic antigens

pet birds – molds (Aspergillus, Penicillium)

mean age=10 y

Male

ﬂu-like syndrome with fever, chills, cough, myalgias, and malaise

leukocytosis with neutrophilia, elevated CRP & ESR

ill appearing child with dyspnea and basilar crackles

CXR : bilateral lower lobes reticulonodular inﬁltrates

CT: ground-glass appearance and centrilobular nodules

Acute eosinophilic pneumonia, P. carinii pneumonia, and some drug induced lung diseases have Eosinophils in the BAL fluid