Case presentation 15

Muhammad Uzair bin Ag. Duraim

BM12110057

Patient Profile
Madam N
58 years old lady
Rungus, Christian
Married but separated
Housewife
Resident of Kg. Bangau, Kudat
D.O.A 29th June 2016
M.O.A emergency

Chief Complaints
Coughing of blood for 5 days

History of presenting illness

My patient is a known case of bronchiectasis diagnosed
since 2006 confirmed by CT thorax at QEH.
She is under respiratory follow up pf respiratory clinic in
Kudat Hospital
She presented to casualty due to 3 episode of bloody
cough since 5 days ago
Claimed worsening 1 day before admission early morning
Associated with purulent, foul smelling sputum - 1
cup/day, more in the morning and on/off fever without
chills & rigors

History of presenting illness

There is h/o chest tightness worsening with
coughing and movement, relieved by stay still

Systemic reviews
There was no h/o night-sweats or weight loss.
There was no h/o dyspnea, orthopnea and PND or palpitations.
There is no history of skin allergy, rash, conjunctivitis, joint
pains, subcutaneous nodules.
No h/o ear discharge or hearing loss.
No h/o hematuria, facial or pedal edema.
No h/o paresthezias, numbness or any neurological deficit
There is no h/o epigastric pain and retro-sternal burning,
nausea or vomiting.

Past medical/surgical history

She has background history of dyslipidemia
She has h/o 2 times admission on 2006 and 2013 with
similar complaints of hemoptysis
Otherwise she has no underlying disease such childhood
asthma, TB, hypertension, diabetes mellitus, or chronic
heart disease.
No surgical history, accidents or injury.

Family history
Father passed away since childhood unsure of the
cause
Mother passed away due to colon cancer
Youngest among 4 siblings, 2 brother & 1 sister all
alive & healthy
Has a 4 child
Otherwise there is no other known family illness

Family tree

Menstrual history
Menarchi at the age 15 y/o
Regular
2-3 pad
No dysmenorrhea, menorrhagia
No contraception
Menopause at the age 48 y/o
No abnormal bleeding/ pervaginal bleeding

Drug History
Tab. Simvastatin 5mg OD
No known drug and food allergies.

Social history
Lives with family in own house with 5 family members
Single wooden house with some basic amenities
Education at primary level
Lower-middle class.
Financially support by her children
She was non-smoker and non-alcohol consumer.

Summary
A 58 years old lady with a background history of
bronchiectasis over 10 years presented with
hemoptysis, chest tightness and coughing of copious
purulent sputum and intermittent fever without chills
and rigors for last 5 days.

Physical Examination
A 58 years old, lean lady, sitting in the bed
She is alert, conscious and not in pain or respiratory distress.
She is anemic by evidence of subconjuctiva & palmar pallor
There is an intravenous branula on her right dorsum of the hand.
Her height & weight is appropriate

Vitals:
BP :102/59mmHg
Pulse: 70/min, regular rhythm, good volume, normal character
Temp: 98.6F
R/R :18/min
SpO2: 97%

Stable

Physical Examination
Height : 158 cm
Weight: 49 kg
BMI: 19.1 (normal)

General Physical Examination

Pallor +ve
Cyanosis ve
Clubbing .......... ve
Lymph nodes ve
Jaundice .. ve
Pedal oedema . ve
Skin rash . ve
Purpura ve
Subcutaneous nodules . ve
Nose deformity..-ve

Respiratory system
Inspection
Respiratory rate 18/min.
Normal shape chest.
Thoraco-abdominal respiration.
Chest is moving equally on both sides with respiration.
No scars or prominent veins.

Respiratory system
Palpation
Trachea is central
Apex beat in left 5th ICS just medial to mid-clavicular line.
No tenderness
Bilateral Equal chest movements.
normal vocal fremitus bilaterally

Percussion
normal percussion note bilaterally
Upper border of liver in 5th ICS anteriorly

Respiratory system
Auscultation
vesicular breathing with equal air entry.
normal vocal resonance bilaterally.
Bibasal coarse crepitations throughout the lung
field.

Cardiovascular System
No visible chest deformity, pulsations, scar mark, visible
veins.
Apex beat in left 5th ics medial to mid-clavicular line,
normal in character.
S1, S2 of normal intensity with no added sound

GIT
Normal shape, no scar mark, no mass or prominent
veins visible
No hepatosplenomegaly.
Fluid thrill & shifting dullness ve
Bowel sounds audible.

CNS
Higher mental functions intact
Cranial nerves intact
Sensory system intact
Motor system intact

Case Summary
A 58 years old lady with history of bronchiectasis over

10 years presented with hemoptysis for 5 days and,

chest tightness and intermittent fever without chills and
rigors, worsening since 1 day before the admission with
purulent sputum and mucus plug. Upon examination she
is anemic and there is bibasal coarse crepitations
throughout the lung field

Investigation
1.FBC
29/6

30/6

1/7

Referrence
level

WBC

7.0

9.6

8.2

(4-11) 103/uL

RBC

4.05

HB

10.7

10.6

9.4

HCT

34.3

31.7

28.8

MCV

84.7

(76-96) fL

MCH

26.4

(27-32) pg

PLT

265

NEU

5.0

(4.6-6.5)
106/uL

267

269

(13-18) g/dL
(40-54) %

(150-400)
103/uL
(1.7-7.7)
103/uL

Investigation
29/6 (A&E)

30/6

Reference
level

Na

142

149

135-145 mmol/L

4.1

4.2

3.5-5.0 mmol/L

Urea

2.8

3.4

2.5-6.5 mmol/L

Creat

51

61

60-130 mol/L

ESR

48

0-20 mm/hr

PT

12.4

11-13 s

APTT

33.7

25-35 s

BUSE/creat

Investigation
Sputum AFB 3x: -ve
Blood C+S : result pending
ECG : normal
Serum IgE : not available

Chest X-ray

Bibasal patchy opacity with

bronchiectatic changes

CT Chest with I/V contrast (not

available)

CT Chest with I/V contrast (not

done)
1. Consolidation with air bronchogram
2. Para-tracheal & Hilar lymphadenopathy
3. Finger-like projections due to mucus plugging
( broncho-coele )

Provisional Diagnosis
Most probable diagnosis is acute exacerbation of
bronchiectasis
Points for
h/o of hemoptysis, cough with purulent sputum and fever
On examination there is presence of bibasal coarse
crepitations throughout the lung field
CXR shows bibasal patchy opacity with bronchiectatic
changes.

Differential Diagnosis
Point for
Hemoptysis, cough &
sputum

Point against
Daily sputum <3month,
no cyanosis, no wheeze

Pulmonary
tuberculosis
(post-primary)

Cough & hemoptysis

No weight loss, night

sweat, & malaise

Lung
carcinoma

hemoptysis

No weight loss, clubbing,

lymphadenopathy,

Chronic
bronchitis

Discussion of course of disease

Definition:
Abnormal and permanent dilatation of bronchi and
bronchioles greater than 2 mm

Reids classification
depending on the findings of the CT scan it is classified
as :
1. Cylindical bronchiectasis has a tram track lines in
longitudinal section or signet ring in case of a
horizontal section and the adjacent pulmonary artery
representing the stone.
2. Varicose bronchiectasis : has irregular or beaded
bronchi with alternating dilatation and constriction.
3. Cystic bronchiectasis has large cystic spaces and a
honey comb appearance. This contrasts with blebs of

MUCOUS PLUGS

DILATED
BRONCHIOLE

PATHOGENESIS

NORMAL HOST RESPONSE TO BRONCHIAL INSULT

BRONCHIAL INSULT

RETURN TO HEALTH

MUCOCILLIARY CLEARENCE

INFLAMMATION

ABNORMAL HOST RESPONSE TO BRONCHIAL

INSULT
BRONCHIAL INSULT

BRONCHIECTASIS

INFLAMMATION

BRONCHIAL DAMAGE

IMPAIRED MUCOCILLIARY
CLEARENCE

FURTHER INFLAMMATION

BRONCHIAL OBSTRUCTION

PATHOGENESIS
OBSTRUCTION
INFLAMMATION

Allergic Bronchopulmonary
Aspergillosis (ABPA)
Mainly in Asthmatics
Sensitization to
aspergillous
Raised IgE level
Tubular Bronchiectasis

CLINICAL PRESENTATION
SYMPTOMS
Persistent cough
Purulent sputum
(green and foul smelling)

Hemoptysis
Dyspnea
Wheeze
Fever
Severe Pneumonia
Asymptomatic
Non Productive Cough

CLINICAL PRESENTATI0N
SIGNS
On GPE

Digital Clubbing
Cyanosis
Plethora
Muscle wasting

On Auscultation
Crackles
Wheeze
Ronchi

Work-up

 Patient history
Childhood infections, exposure to pulmonary
pathogens, aspiration of foreign bodies, pulmonary
symptoms in siblings
Physical examination
Auscultation for focal wheezes or other adventitial
sounds, examination of nares and upper respiratory
tract for polyps or evidence of chronic sinusitis
Laboratory tests
Routine hematology is non specific but may show
anaemia and increased white blood count. It may
also show polycythemia as a response to chronic
hypoxia.

 Quantitative immunoglobulin levels of IgG, IgM and IgA

areuseful to exclude hypogammaglobulinemia.
Quantitative serum alpha 1 anti trypsin levels used to
rule out AAT deficiency

SPUTUM ANALYSIS
Amount of sputum
24 hr Sputum Production
Mild
< 10 ml/day
Moderate <150 ml/day
Severe >150 ml/day

Visual Impression
Microbiology

Streptococcus pneumoneae
Hemophillus influenzae
Aspergillus
Psedomonas
E. coli

 Routine bacterial, fungal, and mycobacterial cultures

may reveal other organisms.
Pilocarpine ionophoresis (Sweat test) for the
evaluation of CF
Skin test* Aspergillusantigen
Aspergillus Precipitin test
Diagnostic criteria 1000 IU/ml or a greater than 2 folds increase
from the base-line

 Auto-immune screening test

For RA and other auto-immune diseases. For ex ANA antibody
assay.

Computerized tomography
HRCT is has almost completely replaced bronchography. The
sensitivity and specificity are 84-89% and 82-99% respectively.
additional advantages include non invasiveness, avoidance of
possible allergen to contrast media and information regarding
other pulmonary processes.

Management plan in Kudat

Hospital
Vital sign monitoring
Allow orally
Hemoptysis charting
Medication :

IV Augmentin 1.2 g stat

IV Tranexamic acid 1g stat
Tab. Erythromycin Ethylsuccinate 800mg BD
Tab. Bromhexine 8mg TDS

Plan for chest physiotherapy

Supportive Treatment
Cessation of smoking
Avoidance of second-hand smoking
Adequate nutritional intake
Immunizations for influenza and pneumococcal
pneumonia
Conformation of immunizations for measles, rubella and
pertusis
Oxygen therapy is reserved for patients with hypoxemia
and end stage complications such as cor-pulmonale

Modalities of treatment
1. Treatment of infection
2. Clearance of the secretion
3. Reduction of the inflammation
4. Treatment of the underlying problem

Bronchial hygiene
Proper mechanical and devices with proper positioning
of the patient can help the patients with copious
secretions.
Postural drainage with percussion and vibration helps in
effective clearance.

Tapping of the chest

wall to dislodge the
secretions

Positional drainage and

physiotherapy

Surgical resection
- Helpful in advanced or complicated disease.
Indications :
1. Patients who have focal disease that is poorly controlled by antibiotics.
2. Reduction of acute infective episodes
3. Massive haemoptysis (Alternatively bronchial artery embolization may
be attempted)
4. Foreign body or tumor removal
5. Consideration in the treatment of MAC or Aspergillus specific infections

Complications :
empyema, haemmorrhage, prolonged air leak and
persistent atelectasis. Mortality is <1 %.
Lung transplantation
Single or double lung transplantation for severe
bronchiectasis, predominantly related to CF. FEV1 < 30
and in younger patients it may be considered.

Other treatment
Inhaled Broncho dilators
Inhaled aerosolized aminoglycosides

Reference
NR Colledge, BR Walker, RH Ralston, Davidsons Principle &
Practice of Medicine, 21st ed, 2010 Elsevier Pub
NJ Talley, S OConnor, Clinical Examination, 6th ed 2010, Elsevier
Pub.
HH Soo, LG Lau, PH Chew, Sarawak Handbook of Medical
Emergencies, 3rd edition, 2011 C.E. Pub