WRITING A CLINICAL VIGNETTE
1. Write a summary of the case
CASE:
Pneumocystis jiroveci pneumonia in HIV patients uncommonly cavitates but when
present, the cavitary process may mimic other more common cavitary entities such
as tuberculosis (TB). Understanding the lobar and segmental lung anatomy and
cavitary disease predilection can assist in determining causation.
A 44 year old Vietnamese male with HIV for 10 years but off anti-retroviral therapy
for 5 years, presented with a cavitary pneumonitis after one week of subjective
fever, cough of white phlegm without hemoptysis, 3-4 lb weight loss and two days of
azithromycin therapy from his primary care provider. He denied shortness of breath
or dyspnea.
His past medical history included a diagnosis of TB 20 years ago in Vietnam with one
and a half years of treatment using a two drug regimen. Six months prior to his
presentation he had returned to Vietnam for a visit.
Other than a resting tachycardia, his exam revealed an occasional crackle in both
lungs. A CBC showed a WBC of 10.1K with a normal differential. The rest of his labs
were normal. The two view chest x-ray demonstrated a diffuse heterogeneous
consolidation in the right lung and the lateral aspects of the upper, mid and lower
left lung fields. A 3.4 cm thick walled cavity was identified in the anterior segment of
the right upper lobe.
He was started on IV hydration and admitted to airborne isolation for a high
suspicion of active tuberculosis. However, empiric anti-infective treatment was not
initiated. A CT scan of the chest confirmed the right upper lobe thick walled cavity
and identified a smaller 1.3 cm thin walled cavity in the right lower lobe. A PPD was
negative and three poor quality sputum specimens were negative on acid fast
staining.
By the 5th hospital day, he had started to become dyspneic and short of breath. A
biopsy of the larger cavity was performed via interventional radiology. On hospital
day 7, his O2 saturation dropped to 74% on room air and high flow oxygen was
started. A repeat chest x-ray was unchanged and a CT angiogram of the chest was
negative for pulmonary embolus. Bactrim and Prednisone were initiated with
dramatic improvement by day 9. On day 10 the biopsy results came back with the
silver stain positive for pneumocystis.
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2. Add a discussion to the summary
CASE:
Pneumocystis jiroveci pneumonia in HIV patients uncommonly cavitates but when
present, the cavitary process may mimic other more common cavitary entities such
as tuberculosis (TB). Understanding the lobar and segmental lung anatomy and
cavitary disease predilection can assist in determining causation.
A 44 year old Vietnamese male with HIV for 10 years but off anti-retroviral therapy
for 5 years, presented with a cavitary pneumonitis after one week of subjective
fever, cough of white phlegm without hemoptysis, 3-4 lb weight loss and two days of
azithromycin therapy from his primary care provider. He denied shortness of breath
or dyspnea.
His past medical history included a diagnosis of TB 20 years ago in Vietnam with one
and a half years of treatment using a two drug regimen. Six months prior to his
presentation he had returned to Vietnam for a visit.
Other than a resting tachycardia, his exam revealed an occasional crackle in both
lungs. A CBC showed a WBC of 10.1K with a normal differential. The rest of his labs
were normal. The two view chest x-ray demonstrated a diffuse heterogeneous
consolidation in the right lung and the lateral aspects of the upper, mid and lower
left lung fields. A 3.4 cm thick walled cavity was identified in the anterior segment of
the right upper lobe.
He was started on IV hydration and admitted to airborne isolation for a high
suspicion of active tuberculosis. However, empiric anti-infective treatment was not
initiated. A CT scan of the chest confirmed the right upper lobe thick walled cavity
and identified a smaller 1.3 cm thin walled cavity in the right lower lobe. A PPD was
negative and three poor quality sputum specimens were negative on acid fast
staining.
By the 5th hospital day, he had started to become dyspneic and short of breath. A
biopsy of the larger cavity was performed via interventional radiology. On hospital
day 7, his O2 saturation dropped to 74% on room air and high flow oxygen was
started. A repeat chest x-ray was unchanged and a CT angiogram of the chest was
negative for pulmonary embolus. Bactrim and Prednisone were initiated with
dramatic improvement by day 9. On day 10 the biopsy results came back with the
silver stain positive for pneumocystis.
DISCUSSION:
This case illustrates several points. Although very uncommon (2-7 % of cases in HIV
patients), Pneumocystis can cavitate with either thick-walled or thin-walled cavities.
Knowing lung segment anatomy and its relationship on chest x-ray and chest CT
scans allows for more specific localization of a cavity. The segmental location of a
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lung cavity can be helpful in formulating a differential diagnosis and initiating
appropriate empiric treatment.
In this case, the admitting team prioritized TB to the top of the differential list and
decided not to initiate other empiric anti-infective therapy while waiting for
confirmation of TB even though the patient showed clinical progression. However,
tubercular cavities preferentially arise in the upper lobe apical and posterior
segments with sparing of the anterior segment. The superior segment of the lower
lobe is also a preferential location.
As in this case, the finding of a cavity in the anterior segment of the upper lobe
dramatically reduces the likelihood of tuberculosis, so much so that other etiologies
should be considered first.
3. Add a few pertinent references
CASE:
Pneumocystis jiroveci pneumonia in HIV patients uncommonly cavitates but when
present, the cavitary process may mimic other more common cavitary entities such
as tuberculosis (TB). Understanding the lobar and segmental lung anatomy and
cavitary disease predilection can assist in determining causation.
A 44 year old Vietnamese male with HIV for 10 years but off anti-retroviral therapy
for 5 years, presented with a cavitary pneumonitis after one week of subjective
fever, cough of white phlegm without hemoptysis, 3-4 lb weight loss and two days of
azithromycin therapy from his primary care provider. He denied shortness of breath
or dyspnea.
His past medical history included a diagnosis of TB 20 years ago in Vietnam with one
and a half years of treatment using a two drug regimen. Six months prior to his
presentation he had returned to Vietnam for a visit.
Other than a resting tachycardia, his exam revealed an occasional crackle in both
lungs. A CBC showed a WBC of 10.1K with a normal differential. The rest of his labs
were normal. The two view chest x-ray demonstrated a diffuse heterogeneous
consolidation in the right lung and the lateral aspects of the upper, mid and lower
left lung fields. A 3.4 cm thick walled cavity was identified in the anterior segment of
the right upper lobe.
3 of 7
He was started on IV hydration and admitted to airborne isolation for a high
suspicion of active tuberculosis. However, empiric anti-infective treatment was not
initiated. A CT scan of the chest confirmed the right upper lobe thick walled cavity
and identified a smaller 1.3 cm thin walled cavity in the right lower lobe. A PPD was
negative and three poor quality sputum specimens were negative on acid fast
staining.
By the 5th hospital day, he had started to become dyspneic and short of breath. A
biopsy of the larger cavity was performed via interventional radiology. On hospital
day 7, his O2 saturation dropped to 74% on room air and high flow oxygen was
started. A repeat chest x-ray was unchanged and a CT angiogram of the chest was
negative for pulmonary embolus. Bactrim and Prednisone were initiated with
dramatic improvement by day 9. On day 10 the biopsy results came back with the
silver stain positive for pneumocystis.
DISCUSSION:
This case illustrates several points. Although very uncommon (2-7 % of cases in HIV
patients), Pneumocystis can cavitate with either thick-walled or thin-walled cavities.
Knowing lung segment anatomy and its relationship on chest x-ray and chest CT
scans allows for more specific localization of a cavity. The segmental location of a
lung cavity can be helpful in formulating a differential diagnosis and initiating
appropriate empiric treatment.
In this case, the admitting team prioritized TB to the top of the differential list and
decided not to initiate other empiric anti-infective therapy while waiting for
confirmation of TB even though the patient showed clinical progression. However,
tubercular cavities preferentially arise in the upper lobe apical and posterior
segments with sparing of the anterior segment. The superior segment of the lower
lobe is also a preferential location.
As in this case, the finding of a cavity in the anterior segment of the upper lobe
dramatically reduces the likelihood of tuberculosis, so much so that other etiologies
should be considered first.
REFERENCES
1. Gallant JE, Ko AH. 1996. Cavitary Pulmonary Lesions in Patients with Human
Immunodeficiency Virus. Clin Inf Dis. 22:671-682.
2. Aviram G, Fishman JE, Sagar M. 2001. Cavitary Lung Disease in AIDS: Etiologies
and Correlation with Immune Status. AIDS Patient Care and STDs. 15(7):353361.
3. Ryu JH, Swensen SJ. 2003. Cystic and Cavitary Lung Diseases: Focal and Diffuse.
Mayo Clin Proc. 78:744-752.
4. Van Dyck P, Vanhoenacker FM, Van den Brande P, De Schepper AM. 2003.
Imaging of Pulmonary Tuberculosis. Eur Radiol. 13:1771-1785.
5. Gadkowski LB, Stout JE. 2008. Cavitary Pulmonary Disease. Clin Micro Rev.
21(2):306-333.
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4. Reduce the case summary and discussion to 400
words
Pneumocystis jiroveci pneumonia in HIV patients uncommonly cavitates but when
present, the cavitary process may mimic other more common cavitary entities such
as tuberculosis. Understanding the lobar and segmental lung anatomy and cavitary
disease predilection can assist in determining causation.
A 44 year old Vietnamese male with HIV presented with a cavitary pneumonitis after
one week of subjective fever, nonproductive cough, 3-4 lb weight loss and two days
of azithromycin therapy from his primary care provider. He denied shortness of
breath or dyspnea.
His past medical history included a diagnosis of tuberculosis 20 years ago in Vietnam
treated using a two drug regimen for 1 ½ years. Six months prior to his presentation
he had returned to Vietnam for a visit.
Other than a resting tachycardia, his exam revealed an occasional crackle in both
lungs. A CBC showed a WBC of 10.1K with a normal differential. The rest of his labs
were normal. The two view chest x-ray demonstrated a diffuse heterogenous
consolidation in the right lung and the lateral aspects of the upper, mid and lower
left lung fields. A 3.4 cm thick walled cavity was identified in the anterior segment of
the right upper lobe.
He was started on IV hydration and admitted to airborne isolation for a high
suspicion of active tuberculosis. However, empiric anti-infective treatment was not
initiated. A CT scan of the chest confirmed the right upper lobe thick walled cavity
and identified a smaller 1.3 cm thin walled cavity in the right lower lobe. A PPD was
negative and three poor quality sputum specimens were negative on acid fast
staining.
By the 5th hospital day, he had started to become dyspneic and short of breath. A
biopsy of the larger cavity was performed via interventional radiology. On hospital
day 7, his O2 saturation dropped to 74% on room air and high flow oxygen was
started. A repeat chest x-ray was unchanged and a CT angiogram of the chest was
negative for pulmonary embolus. Bactrim and Prednisone were initiated with
dramatic improvement by day 9. On day 10 the biopsy results came back with the
silver stain positive for pneumocystis.
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This case illustrates the importance of lung cavity location. Tubercular cavities
preferentially arise in the apical and posterior segments of the upper lobe and the
superior segment of the lower lobe. Finding a cavity in the anterior segment of the
upper lobe dramatically reduces the likelihood of tuberculosis, and should prompt
clinicians to suspect other etiologies.
REFERENCES
6. Gallant JE, Ko AH. 1996. Cavitary Pulmonary Lesions in Patients with Human
Immunodeficiency Virus. Clin Inf Dis. 22:671-682.
7. Aviram G, Fishman JE, Sagar M. 2001. Cavitary Lung Disease in AIDS: Etiologies
and Correlation with Immune Status. AIDS Patient Care and STDs. 15(7):353361.
8. Ryu JH, Swensen SJ. 2003. Cystic and Cavitary Lung Diseases: Focal and Diffuse.
Mayo Clin Proc. 78:744-752.
9. Van Dyck P, Vanhoenacker FM, Van den Brande P, De Schepper AM. 2003.
Imaging of Pulmonary Tuberculosis. Eur Radiol. 13:1771-1785.
10. Gadkowski LB, Stout JE. 2008. Cavitary Pulmonary Disease. Clin Micro Rev.
21(2):306-333.
5. Add a catchy title
UPPER LOBE LUNG CAVITIES – IS TB ALWAYS FIRST IN THE
DIFFERENTIAL?
Pneumocystis jiroveci pneumonia in HIV patients uncommonly cavitates but when
present, the cavitary process may mimic other more common cavitary entities such
as tuberculosis. Understanding the lobar and segmental lung anatomy and cavitary
disease predilection can assist in determining causation.
A 44 year old Vietnamese male with HIV presented with a cavitary pneumonitis after
one week of subjective fever, nonproductive cough, 3-4 lb weight loss and two days
of azithromycin therapy from his primary care provider. He denied shortness of
breath or dyspnea.
His past medical history included a diagnosis of tuberculosis 20 years ago in Vietnam
treated using a two drug regimen for 1 ½ years. Six months prior to his presentation
he had returned to Vietnam for a visit.
6 of 7
Other than a resting tachycardia, his exam revealed an occasional crackle in both
lungs. A CBC showed a WBC of 10.1K with a normal differential. The rest of his labs
were normal. The two view chest x-ray demonstrated a diffuse heterogenous
consolidation in the right lung and the lateral aspects of the upper, mid and lower
left lung fields. A 3.4 cm thick walled cavity was identified in the anterior segment of
the right upper lobe.
He was started on IV hydration and admitted to airborne isolation for a high
suspicion of active tuberculosis. However, empiric anti-infective treatment was not
initiated. A CT scan of the chest confirmed the right upper lobe thick walled cavity
and identified a smaller 1.3 cm thin walled cavity in the right lower lobe. A PPD was
negative and three poor quality sputum specimens were negative on acid fast
staining.
By the 5th hospital day, he had started to become dyspneic and short of breath. A
biopsy of the larger cavity was performed via interventional radiology. On hospital
day 7, his O2 saturation dropped to 74% on room air and high flow oxygen was
started. A repeat chest x-ray was unchanged and a CT angiogram of the chest was
negative for pulmonary embolus. Bactrim and Prednisone were initiated with
dramatic improvement by day 9. On day 10 the biopsy results came back with the
silver stain positive for pneumocystis.
This case illustrates the importance of lung cavity location. Tubercular cavities
preferentially arise in the apical and posterior segments of the upper lobe and the
superior segment of the lower lobe. Finding a cavity in the anterior segment of the
upper lobe dramatically reduces the likelihood of tuberculosis, and should prompt
clinicians to suspect other etiologies.
REFERENCES
11. Gallant JE, Ko AH. 1996. Cavitary Pulmonary Lesions in Patients with Human
Immunodeficiency Virus. Clin Inf Dis. 22:671-682.
12. Aviram G, Fishman JE, Sagar M. 2001. Cavitary Lung Disease in AIDS: Etiologies
and Correlation with Immune Status. AIDS Patient Care and STDs. 15(7):353361.
13. Ryu JH, Swensen SJ. 2003. Cystic and Cavitary Lung Diseases: Focal and Diffuse.
Mayo Clin Proc. 78:744-752.
14. Van Dyck P, Vanhoenacker FM, Van den Brande P, De Schepper AM. 2003.
Imaging of Pulmonary Tuberculosis. Eur Radiol. 13:1771-1785.
15. Gadkowski LB, Stout JE. 2008. Cavitary Pulmonary Disease. Clin Micro Rev.
21(2):306-333.
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