1. 1. ICU Unit Prof. Ahmed EL Hadidy Prof. Mostafa EL Shazly Prof. Mohammed A.Hakeem Prof. Amani Abuzeid Prof. Mohamed Wafai
2. 2. Complaint Right side chest pain
3. 3. Personal History Male patient 16 years old Born and living in ELfayoum. student. No special habits of medical importance.
4. 4. Present history The condition started 1 year ago by gradual progressive dyspnea on moderate exertion with no orthopnea or PND or chest wheezes . The condition was associated with dry cough . He sought medical advice several times and received non specific medications with no improvement.
5. 5. 3 months ago the patient experienced acute left inframamary stitching chest pain increased with respiration, referred to the back and associated with acute dyspnea The patient saught medical advice at El fayoum chest hospital where CXR and CT chest were done and revealed left side pneumothorax.
6. 6. ICT was inserted and the patient was referred to cardiothoracic surgery where bullectomy operation was done with no available data. 1 week before admission , the patient experienced right inframamary stitching chest pain referred to the back and increase with respiration , the patient sought medical advice at Elfayoum chest hospital where CXR and CT chest were done and revealed right side pneumothorax. ICT was inserted and the patient was referred to our department .
7. 7. No history of hemoptysis or wheezes No history of jaundice ,right hypochondrial pain or lower limb oedema No history of dysphagia or hoarseness of voice No history of skin or joint manifestations. No history of fever, anorexia or loss of weight . The patient is not diabetic or hypertensive
8. 8. Past history No history of TB or contact with TB case No history of previous operation , blood transfusion or drug allergy.
9. 9. Family history His sister was admitted in our department with recurrent pneumothorax
10. 10. Examination
11. 11. General examination Patient is fully conscious ,alert, cooperative oriented to time, place ,and person , of average mood and intelligence lying flat in the bed
12. 12. Vital sign Pulse: 100 beats /minute ,regular ,equal on both sides Blood pressure:110/70 Temperature: 37c R.R: 30breaths /minute BMI : 15 kg/m2
13. 13. Head and neck No Pallor No jaundice No cyanosis No palpable lymph node or thyroid swelling No congested neck veins
14. 14. Upper limb examination No clubbing No cyanosis Lower limb examination No clubbing No lower limb oedema Calf muscle lax not tender Intact Peripheral pulsation
15. 15. Abdominal examination lax not tender No organomegaly or ascites can be detected clinicaly
16. 16. Cardiological examination The apex in left 5th space MCL Normal heart sounds No additional sounds
17. 17. Inspection Shape: symmetrical with ICT inserted on the right side Respiratory movement: thoraco abdominal. Expansion: restricted on the right side
18. 18. Palpation Trachea: central Chest expansion: diminished on RT side TVF: diminished on RT side No tenderness No palpable rub or rhonchi
19. 19. Percussion Upper border of the liver: couldn't be detected. Chest percussion :resonant Kronigs isthmus: resonant. Clavicle :resonant. Bare area: dull Traubs area : tympanic resonant
20. 20. Auscultation Bilateral vesicular breathing with no additional sounds. Despine sign: -ve
21. 21. CXR 18- 7- 2014 before admission
22. 22. 2-7
23. 23. CT chest (6-10-2014)before admission
24. 24. CXR 13-10-2014 on admission
25. 25. HRCT 19-10-2014
26. 26. HRCT CHEST Multiple variable sized thin walled dilated cystic air spaces are noted within both lung fields as well as scattered patches of air trapping . Mild right apical pneumothorax is seen with chest tube seen within it. Lung parenchyma show mosaic pattern . No pleural effusion. Suspected hilar lymphadenopathy for post contrast study.
27. 27. *Pleurodesis was done & the patient was discharged *3weeks later the patient presented to us with right side stitching chest pain associated with dyspnea on mild exertion
28. 28. 22-11-2014 (readmission)
29. 29. 2 weeks later the patient experienced sudden dyspnea with rt sided stitching chest pain referred to the back
30. 30. ICT was inserted on the right side and follow up CT chest was done
31. 31. Complete blood count TLC 9.5 10*3 /cmm (4-11) Hemoglobin 11.8 g/dl (12-15) Hematocrit (PCV) 36.2% (35-45) M.C.V 61.2 fl (80-101) M.C.H 19.9 pg (27-32) Platelet count 193 10*3/cmm (150-450)
32. 32. Clinical Chemistry Report AST 26 U/L (UP TO 50) ALT 44U/L (UP TO 45) Serum albumin 4.7 mg/dl (3.5-5) Serum creatinine 0.7 mg/dl (0.3-1.2) Blood urea 27.8 mg/dl (7-50) Serum calcium 8.1 mg/dl (8.4-10.2)
33. 33. PT 13.6 sec PC 95% INR 1.03 ESR 1st hour 58 ESR 2nd hour 95
34. 34. COLLAGEN PROFILE RF +VE ANCA -VE normalAlpha one antitrypsin
35. 35. PULMONARY FUNCTION TEST FEV1/FVC 93 FVC 25% FEV1 28% 0.75 L
36. 36. ECHO normal CT abdomen & CT brain normal
37. 37. RHEUMATOLOGY CONSULTATION The patient has thin inelastic skin and tall finger high arched foot with hypermobility suspected of Ehlerdanlos syndrome Recomendation Fundus examination for ectopia lentis (normal) Xray hand ( normal)
38. 38. As regard his sister : * 14 years old * 2weeks before admission , the patient experienced left side pneumothorax, ICT was inserted for 1 week then removed * 1 week later , she was admitted with bilateral pneumothorax & bilateral ICT was inserted * Pleurodesis was done on the right side then she was referred to cardiothoracic surgery due to persistent air leak
39. 39. Pathology report Gross 2 irregular rubbery greyish brown flattened tissue pieces ,measuring 2.5x1.5x0.5 cm and 2.5x1x0.5cm both bisected and totally submitted. Microscopic Section examined from the specimen received reveal lung tissue with evidence of emphysema with marked , congestion interstitial lymphocytic infiltrate and mild anthracosis . No evidence of specific granuloma. No evidence of malignancy .
40. 40. diagnosis Lung biopsies ,chronic venous congestion , emphysema ,ruptured bulla.
41. 41. Pathology report(revision) Microscopic Examination of the received slides reveal lung tissue showing moderately edematous alveolar walls with areas of mild to moderate interstitial fibrosis and diffuse interstitial infiltration by lymphoplasmocytic cellular infiltrate .some lymphoid aggregates and few neutrophils.many calcified bodies are detected in the interstitium .few alveoli show bubbly exudate entangling inflamatory cells. Areas of anthracosis are also seen.
42. 42. Diagnosis Picture suggestive of hypersensitivity pneumonitis