Pulmonology Procedures |

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Melvin Tay*, MMed; Kay Leong Khoo, MMed; Pyng Lee, MMed
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National University Hospital, Singapore, Singapore

Chest. 2012;142(4_MeetingAbstracts):888A. doi:10.1378/chest.1389518
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SESSION TYPE: Bronchology Global Case Report Posters

PRESENTED ON: Tuesday, October 23, 2012 at 01:30 PM - 02:30 PM

INTRODUCTION: We present a case of a middle aged woman with chronic cough who was found to have cavitating lung lesions on CT thorax. We describe the bronchoscopic techniques employed to clinch the diagnosis.

CASE PRESENTATION: A 56-year-old Chinese housewife, previously healthy and a life-long non-smoker consulted her family physician for fever and prolonged cough productive of greenish sputum with occasional episodes of hemoptysis. She did not complain of dyspnea, chest discomfort, night sweats or weight loss. She was prescribed several courses of antibiotics and her chest radiograph showed several ill-defined nodular infiltrates over the right mid and lower lung zones. Pulmonary metastases were suspected and she was referred to Medical Oncology. CT thorax, abdomen and pelvis showed two thin walled cavities in the right lower lobe, one measuring 11 x 18 mm in size and the other measuring 16 x 26 mm. A tiny7 x 7 mm sized cavity was also seen in the right upper lobe in the periphery. Both lungs showed scattered tree in bud type of opacities in almost all lobes in a peripheral distribution. The inferior aspect of the lingula and the medial segment of the right middle lobe also revealed cicatrization bronchiectasis. She was hospitalized for further work up. She had low grade fever and her nutrition was fair. There were no clubbing of fingers or cervical lymphadenopathy, and examination of the abdomen, breasts and neurological system was unremarkable. Auscultation only revealed scattered crackles over the lower third of the right hemithorax. Complete blood count, urea and electrolytes, liver function and calcium level were normal. Three induced sputum samples for acid fast bacilli and TB molecular (GeneXpert test) were negative. Bronchoscopy with washing of the right middle lobe followed by bronchoscopic lung biopsy of the right lower lobe cavitatory nodule, aided by navigational bronchoscopy and radial endobronchial ultrasound (EBUS) was performed. Bronchoscopy revealed a normal tracheobronchial tree. Bronchial washing of the right middle lobe was sent for cytology, bacterial and mycobacterial cultures. The right laterobasal bronchial segment B9(a) leading to the largest cavitating lesion was accurately localized by navigational bronchoscopy and confirmed real time by EBUS radial probe and fluoroscopy. Bronchoscopic lung biopsies and brushing were performed using guide-sheath method. Histology of bronchoscopic lung biopsy showed an area of central caseous necrosis with positive Ziehl Neelson stain for numerous acid fast bacilli. No malignant cells were detected. Culture of lung tissue yielded Mycobacterium Kansasii, while the bronchial aspirate and induced sputum cultures were sterile. She was started on rifampicin, isoniazid and ethambutol, and her symptoms had completely resolved at the last clinic review.

DISCUSSION: The combination of bronchoscopic techniques allows precise targeting of peripheral lung lesions, which would otherwise been traditionally approached via CT-guided transthoracic needle aspiration. This reduces the risk of pneumothorax, which is more common with the latter approach.

CONCLUSIONS: In the last decade, there has been tremendous advances in bronchoscopic techniques to achieve higher yields for both central and peripheral lung lesions. Our case illustrates the strategy of combination techniques to arrive at the diagnosis.

1) Hergott CA, Tremblay A. Clin Chest Med. 2010 Mar;31(1):49-6

DISCLOSURE: The following authors have nothing to disclose: Melvin Tay, Kay Leong Khoo, Pyng Lee

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National University Hospital, Singapore, Singapore




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