CPC Case 3, 01-16-2020

CC: difficulty of breathing

Following the previous group’s approach, we decided to make pulmonary mass as our
take-off point. It can either be due to an infection or neoplasm.

First, we considered lung abscess because of possible immunosuppression (known to

be alcoholic with multiple sexual partners) and has recurrent bouts of pneumonia. It is supported
by the patient’s presentation of dyspnea, fever, night sweats, productive cough, purulent blood
streaked sputum, chest pain and weakness. However, there is absence of copious, foul-
smelling sputum, and upon X-ray, pleural effusion was seen instead of distinct round shape and
air-fluid level. Ruled out

Our next consideration is tuberculoma. Risk factors for this patient: mother (+) history of
TB, 4-pack year smoker, multiple sexual partners (may have contracted HIV ->
immunocompromised), former factory worker (poor ventilation). Tuberculoma is a manifestation
of both primary and post primary TB. It is a well circumscribed nodule or mass located in lungs
caused by Mycobacterium tuberculosis which support the chest ultrasound revealing pulmonary
mass. Signs and symptoms present in the patient are dyspnea, fever, productive and blood
streaked cough, night sweats, back pain, weakness and weight loss (20% in 5 mos PTA). His
chest pain may be because of inflammation of the membranes lining the lungs (pleurisy).
Although tuberculoma is more commonly found in the upper lobes, it can also be found in other
lobes. Cannot totally ruled in, but highly considered as the MCD

Lastly, we considered lung cancer. The patient was noted to be regularly exposed to
paint thinners and is also a current smoker (4-pack years). Both the paint thinners and
cigarettes contain carcinogens which put the patient at risk of lung cancer. Like tuberculoma,
lung cancer may also present as a pulmonary mass. The patient also presented with signs and
symptoms similar to tuberculoma such as dyspnea, chest pain, back pain, productive and blood-
streaked cough, weakness, and weight loss (20% in 5 mos PTA). Also, the patient generally
presented with persistent cough and dyspnea despite being given with antibiotics (treatment for
pneumonia), expectorants, anti-tuberculosis medications, and oxygen support. These add to the
assumption that the patient might have lung cancer. However, lung cancer is generally
associated with ages 40-70 years old with peak incidence during the 50s or 60s, has nearly
linear correlation between the frequency of lung cancer and pack-years of smoking, and the
relationship of exposure to paint thinners to lung cancer is not well-established.
Still, we cannot totally rule out malignancy as the patient presented with more severe
symptoms (persistent cough and dyspnea associated with chest pain, and severe dyspnea upon
admission) despite having a FNAB result of benign lesion. Also, the previous biopsy was done
months before the progression of symptoms, so the mass increasing in size is highly suggestive
of being malignant. A second biopsy was also requested but was refused by the patient.
Cannot totally rule out
PATHOPHYSIOLOGY
 The patient is a 38-year old who has pulmonary tuberculosis with the following risk
factors: 4-pack year smoker, a former factory worker suggestive of poor ventilation, history of
multiple sexual partners and recurrent pneumonia (immunocompromised), & exposure to
mother previously treated for PTB. This PTB could have led to pulmonary tuberculoma.
Majority of pulmonary tuberculomas reduced in size by anti-tuberculosis treatment. However,
during the early period of treatment, a tuberculoma may increase in size which could explain the
progression of the patient’s symptoms.

This pulmonary mass causes several symptoms such as (1) dyspnea due to
obstructed/compressed airway, (2) cough due to irritated or compressed bronchus, and (3)
blood streaked mucus may be due to destruction and structural remodelling of the lung and its
vasculature. Nonpulmonary manifestations are also present such as marked neck vein
engorgement that may be due to superior vena cava compression by the mass, and chest pain
possibly due to contact of parietal pleura with inflammatory irritation/inflammation of the
membranes lining the lungs. Other signs and symptoms include weight loss (20%), weakness,
back pain, night sweats, and fever.

Physical findings upon admission showed unequal chest expansion, chest lag on the
right, dullness on percussion, decreased breath sounds on the right middle to upper lung field,
and no breath sounds on the right lower lung field which is secondary to atelectasis.

During the course in the ward, anti-TB medications was given along with Ipratropium +
Salbutamol & oxygen support. Despite these, there is persistence of symptoms (cough,
dyspnea, tachypnea) and eventual increase in severity. The patient deteriorated as evidenced
by decreasing oxygen saturation from 96% to 83% then 75%, cyanosis, tight air entry. The
persistence of dyspnea and hypoxia lead to respiratory failure and eventually patient’s demise.

CAUSE OF DEATH:
Underlying: Pulmonary tuberculosis (tuberculoma)
Antecedent: Atelectasis
Immediate: Respiratory failure

Other notes:

Pt has recurrent pneumonia since he was treated 9 months PTA due to increased
frequency of cough without associated hemoptysis, fever of 38-39C, back pain, tachypnea, and
tachycardia. He took antibiotic medications regularly, and there was a decrease in the frequency
of cough and relieved of fever. However, 5 months PTA, there was recurrence of fever and
persistent productive cough which may indicate another bout of pneumonia. Also, upon
admission, CBC was requested which showed an increased WBC count and predominance of
neutrophils. Moreover, recurrent bouts of pneumonia may also be associated with
immunocompromised patients.
 ABG
● 1st HD- Partially Compensated Respiratory Alkalosis
○ The patient was tachypneic on the 1st day.
○ Decreased pCO2 concentration
● 3rd HD- Uncompensated Respiratory Acidosis
○ The patient was cyanotic and dyspneic
○ Tight air entry
○ Copious secretions preventing gas exchange
○ Increased pCO2 concentration
● 4th HD- Partially Compensated Metabolic Acidosis
○ Persistent decrease in O2 saturation→ Lactic Acidosis

● Anisocoria - may be secondary to Ipratropium bromide + Salbutamol nebulization

● Hypokalemia - malnutrition, rifampin
● Hyponatremia and hypochloremia - SIADH -> dilutional hyponatremia and
hypochloremia

References: Schwartz, 10th ed

Robbin’s, 9th ed
Harrison’s, 9th and 10th ed

https://bmcnephrol.biomedcentral.com/articles/10.1186/1471-2369-14-13
https://www.ncbi.nlm.nih.gov/pubmed/22612014?fbclid=IwAR22Efm5Jwpu_hwH6Mo3VjrGGxw
PyyA57BtjKuls0-gc3cGLqvNgTBaMVv4
https://www.ncbi.nlm.nih.gov/pmc/articles/PMC2943725/

Rifampin can be associated with Fanconi syndrome which usually presents as mild to moderate
hypokalemia. Fanconi syndrome should be considered in the spectrum of renal diseases
associated with Rifampin. Renal fxn should be closely monitored when Rifampin is used.