Brief History

Brief History

Name:
Name:

XX
XX

Sex: female
Sex: female

Age: 43 years old
Age: 43 years old

Occupation: housewife
Occupation: housewife

Married status: married
Married status: married
Chief Complaint
Chief Complaint

Cough with
Cough with
mucoid
mucoid
sputum for more than
sputum for more than
5 years
5 years
Present Illness
Present Illness

History of
History of
bronchiectasis
bronchiectasis

Regular felt chest tightness, cough with
Regular felt chest tightness, cough with
mucoid
mucoid
sputum, paroxysmal cough at mid
sputum, paroxysmal cough at mid
-
-
night, short of breath and
night, short of breath and
dyspnea
dyspnea
.
.
Personal History
Personal History

Food allergy: nil
Food allergy: nil

Drug allergy: nil
Drug allergy: nil

Smoking: denied
Smoking: denied

Betel nut chewing: denied
Betel nut chewing: denied

Alcohol drinking: denied
Alcohol drinking: denied
Past History
Past History

Medical history:
Medical history:
bronchiectasis
bronchiectasis
with
with
regular follow
regular follow
-
-
up in our hospital.
up in our hospital.

Surgical history: denied
Surgical history: denied
Family History
Family History

Grandfather: asthma
Grandfather: asthma
Lab Data
Lab Data
( ( 07615975) 07615975)
Normal Pharyngeal Flora Normal Pharyngeal Flora Isolated 1 Isolated 1
Sputum culture ( Sputum culture ( ) )
Sputum culture ( Sputum culture (
) )
1124 1124
950824 950824
5081869097 5081869097
5081869097 5081869097
1213 1213
950818 950818
Image
Image

Chest x
Chest x
-
-
ray
ray

Fibrotic
Fibrotic
change with
change with
cystic appearance at
cystic appearance at
Right lower lung.
Right lower lung.

Repeat
Repeat

chronic
chronic
inflammatory process
inflammatory process
of lung is noted.
of lung is noted.

It is suggested
It is suggested
bronchiectasis
bronchiectasis
.
.
Image
Image

HRCT: bronchial wall dilated and thickening
HRCT: bronchial wall dilated and thickening
Image
Image
HRCT: right pleural thickening. no HRCT: right pleural thickening. no lymphadenopathy lymphadenopathy and and
there are no there are no perihilar perihilar masses. masses.
Image
Image
HRCT: mediastinum is centered and of normal width. no
evidence of masses in the anterior, middle and posterior
compartment.
Key Image
Key Image

Differential diagnosis:
Differential diagnosis:
1. 1.
Bronchiectasis
Bronchiectasis
2. 2.
Allergic
Allergic
bronchopulmonary
bronchopulmonary
aspergillosis
aspergillosis
3. 3.
Cystic fibrosis
Cystic fibrosis
4. 4.
Emphysema
Emphysema
5. 5.
bronchitis
bronchitis
6. 6.
Postprimary
Postprimary
tuberculosis
tuberculosis
Differential Diagnosis
Differential Diagnosis

Bronchiectasis
Bronchiectasis
:
:

cystic changes and
cystic changes and
R
R
ing shadows
ing shadows
(air
(air
-
-
fluid
fluid
level.)
level.)

dilated
dilated
and
and
thickening
thickening
bronchial wall
bronchial wall
Allergic
Allergic
Bronchopulmonary
Bronchopulmonary
Aspergillosis
Aspergillosis

ABPA: h
ABPA: hypersensitivity ypersensitivity
to to aspergillosis aspergillosis. Frequently . Frequently
in in asthmatics asthmatics. Often . Often
associated with associated with eosinophilia eosinophilia. .
Central Central bronchiectasis bronchiectasis, ,
allergic consolidation, allergic consolidation,
cavication cavication. .
Upper and central lung Upper and central lung
field. field.
Cystic fibrosis
Cystic fibrosis
Cystic fibrosis: Cystic fibrosis: multisystemic multisystemic, ,
autosomal autosomal recessive recessive disorder . disorder .
Two elevated sweat chloride Two elevated sweat chloride
levels (60 levels (60 mEq mEq/L) /L)
CXR: CXR:
1. 1. Upper lung field: ill Upper lung field: ill- -defined defined
consolidation or consolidation or cavitation cavitation. .
2. 2. Bronchiectasis Bronchiectasis and bronchial and bronchial
wall wall thicking thicking ( upper lung ( upper lung
field) field)
Emphysema
Emphysema

Overinflation
Overinflation
of all or
of all or
a portion of one or both
a portion of one or both
Lungs.
Lungs.

Arterial
Arterial
deficiency(AD
deficiency(AD
)
)
severe
severe
overinflation
overinflation
and
and
peri
peri
-
-
hilar
hilar
vascular
vascular
deficiency.
deficiency.
Overinflation
Bronchitis
Bronchitis
Irregular bronchovascular markings, and lines that leave the right hilum
horizontally show irregular borders because of chronic inflammation
Postprimary
Postprimary
tuberculosis
tuberculosis
CXR:right CXR:right mediastinal mediastinal
adenopathy adenopathy and bilateral, and bilateral,
uniformly tiny nodules. uniformly tiny nodules.
Cavitation Cavitation, pleural , pleural
effusion. effusion. Upper lung area Upper lung area
Biopsy by means of Biopsy by means of
video video- -assisted thoracic assisted thoracic
surgery (VATS), and surgery (VATS), and
miliary miliary tuberculosis was tuberculosis was
diagnosed. diagnosed.
PPD, and a pleural PPD, and a pleural
effusion that was positive effusion that was positive
for acid for acid- -fast bacilli (AFB). fast bacilli (AFB).
Final Diagnosis
Final Diagnosis
1. 1.
Bronchiectasis
Bronchiectasis
Discussion
Discussion

Epidemiology
Epidemiology
Onset: middle aged
Onset: middle aged

Pathophysiology
Pathophysiology
1. 1.
Chronic inflammatory or infectious pulmonary
Chronic inflammatory or infectious pulmonary
process.
process.
2. 2.
Results in multiple
Results in multiple
dilatations
dilatations
of small bronchi,
of small bronchi,
due to destruction change in the
due to destruction change in the
elastic and
elastic and
muscular layers
muscular layers
of brachial walls
of brachial walls
Discussion
Discussion

Common cause of
Common cause of
bronchiectasis
bronchiectasis
1. 1.
Allergic
Allergic
Bronchopulmonary
Bronchopulmonary
Aspergillosis
Aspergillosis
2. 2.
Immunoglobulin deficiencies predisposing to
Immunoglobulin deficiencies predisposing to
chronic respiratory infections.
chronic respiratory infections.
3. 3.
Cystic fibrosis (CF)
Cystic fibrosis (CF)
4. 4.
Immotile cilia or
Immotile cilia or
Kartagener
Kartagener

s
s
syndrome
syndrome
(
(
triad: sinusitis,
triad: sinusitis,
situs
situs
inversus
inversus

infertility
infertility
).
).
5. Bronchial obstruction
5. Bronchial obstruction
6. Alpha1
6. Alpha1
-
-
antitrypsin deficiency
antitrypsin deficiency
Symptoms
Symptoms

Productive cough
Productive cough

Copious sputum
Copious sputum
(200
(200
-
-
500 ml/day)
500 ml/day)

Sputum thick,
Sputum thick,
mucopurulent
mucopurulent
and foul
and foul
-
-
smelling
smelling

Hemoptysis
Hemoptysis

Wheezing
Wheezing

dyspnea
dyspnea

Halitosis
Halitosis

Fatigue
Fatigue

Weight loss to Emaciation
Weight loss to Emaciation
Signs
Signs

Lung auscultation
Lung auscultation

Coarse or moist crackles
Coarse or moist crackles

Rales
Rales
and
and
Rhonchi
Rhonchi

Wheezing
Wheezing

Diminished breath sounds
Diminished breath sounds

Cyanosis
Cyanosis

Digital clubbing
Digital clubbing
Lab data
Lab data

Sputum
Sputum
forms layers on standing
forms layers on standing

Top: Mucus
Top: Mucus

Middle: Clear fluid
Middle: Clear fluid

Bottom: Pus
Bottom: Pus

Sputum culture: not diagnostic (mixture
Sputum culture: not diagnostic (mixture
of organisms)
of organisms)

Fungal Culture
Fungal Culture
Typical Image
Typical Image

Tram tracks
Tram tracks
: Parallel
: Parallel
lines in peripheral lung
lines in peripheral lung
field
field

thickened
thickened
bronchial wall.
bronchial wall.

Ring shadows
Ring shadows
: air
: air
-
-
fluid level.
fluid level.
Typical Image
Typical Image

definitive diagnosis: High
definitive diagnosis: High
-
-
resolution
resolution
computed tomography
computed tomography
In 1950, Reid characterized
In 1950, Reid characterized
bronchiectasis
bronchiectasis
as
as
cylindrical
cylindrical
,
,
varicose
varicose
, or
, or
cystic
cystic
in nature
in nature
Cylindrical Cylindrical bronchiectasis bronchiectasis

Signet
Signet
-
-
ring
ring
appearance
appearance

luminal airway
luminal airway
diameter is greater
diameter is greater
than the diameter of
than the diameter of
the adjacent vessel
the adjacent vessel
Varicose
Varicose
Bronchiectasis
Bronchiectasis
Varicose Varicose bronchiectasis bronchiectasis

a
a
bulbous appearance
bulbous appearance
with a dilated
with a dilated
bronchus .
bronchus .

interspersed sites of
interspersed sites of
relative
relative
constriction
constriction
-
-
>
>
Post
Post
-
-
obstructive
obstructive
Pneumonitis
Pneumonitis
.
.
Cystic
Cystic
Bronchiectasis
Bronchiectasis

Cystic or
Cystic or
saccular
saccular
bronchiectasis
bronchiectasis

ballooned appearance
ballooned appearance
that may have air
that may have air
-
-
fluid levels.
fluid levels.
Prognosis
Prognosis

Overall, the prognosis is good, but it
Overall, the prognosis is good, but it
varies with the underlying or predisposing
varies with the underlying or predisposing
condition.
condition.

In general, patients do well if they are
In general, patients do well if they are
compliant with all treatment regimens and
compliant with all treatment regimens and
practice routine preventive medicine
practice routine preventive medicine
strategies.
strategies.
Treatment
Treatment

Medical therapy
Medical therapy
1. 1.
General therapy
General therapy
2. 2.
Antibiotics :
Antibiotics :
Augmentin
Augmentin
3. 3.
Bronchial hygiene
Bronchial hygiene
4. 4.
Bronchodilator:
Bronchodilator:
Meptin
Meptin
,
,
Frandyl
Frandyl
5. 5.
Anti
Anti
-
-
inflammatory medication: oral
inflammatory medication: oral
steroid:
steroid:
Compesolon
Compesolon
Treatment
Treatment

Surgical treatment
Surgical treatment

Medical treatment failure or cystic
Medical treatment failure or cystic
bronchiectasis
bronchiectasis
1. 1.
Reduction of acute infective episodes
Reduction of acute infective episodes
2. 2.
Reduction of excessive sputum production
Reduction of excessive sputum production
3. 3.
Massive
Massive
hemoptysis
hemoptysis
(Alternatively, bronchial
(Alternatively, bronchial
artery
artery
embolization
embolization
may be attempted for the
may be attempted for the
control of
control of
hemoptysis
hemoptysis
.)
.)
Treatment
Treatment
4. Foreign body or tumor removal
4. Foreign body or tumor removal
5. Consideration in the treatment of
5. Consideration in the treatment of
Aspergillus
Aspergillus
species infections
species infections