Clinical Radiological Pathological Conference

CASE 1: A 59-year-old female Housekeeper Live in Phuket, Thailand Progressive dyspnea for 1 year

Present illness 1 year PTA : She developed dyspnea on exertion She had dry cough without hemoptysis, anorexia with weight loss 4 kgs. She denied arthritis, rash or fever. Due to her abnormal CXR, she had to collect sputum for AFB stains and the results were negative.

Past history Underlying disease : HT; on Amlodipine 5 mg/day No other medication use No smoking No history of contact TB No any pets No family history of cancer, genetic disease, connective tissue disease

Physical examination GA: Good consciousness V/S: BT 37 c RR 20/min PR 86/min BP 140/80 mmhg HEENT: not pale, no jaundice, no malar rash, no discoid rash, no oral ulcer, no peripheral lymphadenopathy Heart: normals1s2, no murmur, no loud P₂ Lungs: clear, normal breath sound both lungs Abdomen: no distension, normoactive bowel sound, soft, not tender, no organomegaly Ext: no pitting edema, no rash, no petechiae, no arthritis Neuro sign: grossly intact

Question (1) Are there any useful investigations? A. Anti-HIV B. Serology profile for connective tissue disease C. Bronchoscopy with BAL D. All of them

Question (2) Can we provide the diagnosis from HRCT?

Question (3) Do we need tissue diagnosis? A. Yes B. No C. I am not sure

Question (4) Is this disease likely reversible? A. Yes B. No C. I don t know

CASE 2: A 72-year-old male Gardener Live in Songkhla, Thailand Chronic cough for 3 months

Present illness 4 years PTA : He had chronic cough which was diagnosed pulmonary tuberculosis After complete treatment, his clinical was improved. 1 year PTA : He developed right pleural effusion then pleural tapping was performed which was considered to be parapneumonic effusion. The patient was admitted for intravenous antibiotic. 3 months PTA : He developed chronic cough again with abnormal CXR. He had uncertain weight loss but no fever.

Past history Underlying disease: Old myocardial infarction, on antiplatelet Smoking 20 packs-year

Physical examination GA : Good consciousness V/S: BT 36.5 c RR 28/min PR 60/min BP 132/60 mmhg HEENT: not pale, no jaundice, no peripheral lymphadenopathy Lungs: decrease breath sound at right lung with dullness on percussion Heart : normal S1S2, no murmur Abdomen: soft, not tender, no organomegaly Ext: no rash, no petechiae

Question (1) What is the most likely diagnosis of RLL infiltration? A. Pulmonary tuberculosis B. Aspergillosis C. Aspiration pneumonia D. Actinomycosis

Question (2) Where is normal site of the inhabited organisms? A. Teeth B. Gingival margins C. Upper lobes D. Nasal cavity

CASE 3: A 49-year-old male Employee Live in Pattani, Thailand Incidentally found abnormal CXR during admission

Present illness Known case of intrahepatic duct stones S/P ERCP with stone removal x 4 times Admitted due to chronic abdominal pain with significant weight loss (10 kgs in 2 months)

Physical examination GA: A Thai male, cachexia, no dyspnea V/S : BT 36 c BP 110/70 mmhg PR 85/min RR 20/min SpO₂ room air 100% BW 30 kgs HEENT: mildly pale, no jaundice Lungs: clear both lungs, no adventitious sound Heart: normal S1S2, no murmur Abdomen: normoactive bowel sound, soft, not tender, hepatomegaly 2 cm below RCM, no splenic dullness, no shifting dullness

Past history No other underlying disease Smoking 15 packs-year, quitted 6 months ago No alcohol used Herbal used due to chronic abdominal pain

Investigations CT abdomen An ill-defined hepatic mass of progressive delayed enhancement and associated upstream dilated bile ducts in lateral segment of right lobe A few residual IHDs stones in lateral left hepatic lobe Multiple necrotic nodes

Investigations Failed EUS Consult IVR for mesenteric lymph node biopsy : USG revealed multiple cystic lesions around the mesenteric root, thrombosis of the SMV and partially extension to the main portal vein. Biopsy of the mesenteric cystic lesion -> 3 ml of mucous content was obtained. Cytology-Pathology report : suspicious for mucinous tumor

Consult Chest due to abnormal CXR and chest CT

23/9/2012 (Before admission) 23/12/2013 (admission) 7/1/2014

Chest CT 25/12/2013

Whole abdominal CT 25/12/2013

Question (1) What is the etiology of lung parenchymal abnormality? A. Septic emboli B. BAC C. Hematogenous metastasis D. Lymphoma

CASE 4: A 71-year-old female Housekeeper Live in Patthalung, Thailand Chronic cough for 6 months

Present illness 6 Months PTA : She had productive cough (more than one glass per day) without hemoptysis. Her symptom was predominant at night. Her sputum exams for AFB smears were negative. She took medications from a private clinic but her symptoms got worse. She had weight loss 2 kg recently.

Past history Underlying disease : HT, Dyslipidemia Passive smoker for 30 years No known drug allergy

Physical examination GA : no cachexia, afebrile V/S : BP 142/86 mmhg PR 94/min RR 20/min BW 44 kg Height 155 cm HEENT: not pale, no jaundice, no cervical lymphadenopathy Heart: normal S1S2, no murmur Lungs: coarse crepitation both basal lungs

13/9/2011

Question (1) What is the most likely diagnosis? A. PAP B. BAC C. BOOP D. CEP

CASE 5: A 52-year-old female Housekeeper Live in Pattani, Thailand Chronic cough for 3 months

Present illness 3 months PTA: She had a cough with purulent sputum She had no hemoptysis or dyspnea. 1 month PTA: She had a progressively worsening cough with recurrent non-massive hemoptysis. She developed progressive dyspnea, weight loss 6 kgs but no fever. She was received bronchodilators and cough suppressant but her symptoms were not improved. Her sputum exams for AFB smears were negative.

Physical examination GA : Good consciousness, afebrile V/S : RR 26/min PR 96 bpm BP 120/70 mmhg SpO₂ room air 88% BW 43 kgs HEENT: not pale, no jaundice, no cervical lymphadenopathy Breast : no mass Heart : normal S1S2, no murmur Lungs: clear both lungs Ext: no clubbing of fingers

02/11/2011

Question (1) What is the most likely diagnosis? A. Pulmonary infarction from pulmonary embolism B. Pulmonary metastasis C. Tumor emboli D. BOOP