Morning Report #2

Morning report is a daily conference for medical residents. It is done differently at different institutions, but normally a case is presented, often by the post-call team, and discussed by the senior residents and an attending physician. Today's case will be the first in an occasional series. It is best read above the fold first, and then going below the fold after digesting the first part adequately. --PalMD

A fifty year-old woman presented to her primary care physician with hemoptysis (bloody cough). She has a history of emphysema and tuberculosis, which was treated about 25 years ago. She has smoked about one pack of cigarettes per day for the last 41 years. She has a productive cough a few months out of every year, but this is the first time that she has had bright red blood in her sputum. She denies any weight loss, and she has stable, mild shortness of breath. She denies chest pain.

["deny" is medical-speak for having been asked and responded in the negative]

Her physician found her to be relatively hypoxic (low on oxygen) with an oxygen saturation of 89% on room air (normal being in the mid to high nineties). Her lung exam was significant for very quiet breath sounds in all auscultated lung fields. Because of her low oxygen level, he admitted her to the hospital for further work-up.

On evaluation in the hospital, she was indeed hypoxic. A chest X-ray was abnormal, showing a significant amount of scaring with a severe emphysema. Her lab tests were relatively unremarkable, with a hemoglobin of 18.2 g/dL (high) and a sodium of 126 mmol/L (low).

Because of her abnormal chest X-ray, and CT scan was done.

This is a sample image from a CT scan of her chest.

To explain a bit, this picture is a "lung window", meaning it highlights the parenchymal tissue of the lung. It is also contrast-infused, meaning blood vessels are highlighted. The money shot is the big white ball in upper portion, just right of center.

At this point, it is normal to form a "differential diagnosis", or a list of possible causes of the patient's findings.

I'm not looking for sophisticated medical comments (although they are welcome), and I'm happy to expand on any questions.

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Yes, this is a repost, sort of. I first put this up on denialism blog in December of 2008. For various reasons, I haven't had a chance to crank out anything fresh this weekend, but this is still a good one, and I've edited it to freshen it up a bit, so don't complain until you read it. --PalMD…
Morning report is a daily conference for medical residents. It is done differently at different institutions, but normally a case is presented, often by the post-call team, and discussed by the senior residents and an attending physician. Today's case will be the first in an occasional series…

Well, until I read below the fold, I figured simple COPD, which she obviously does have. Looking at the big white thing, I first thought cancerous tumor. But it doesn't look like CAT scans I've seen of lung cancer, which do not have sharp borders like that big white thing. Also, the big white thing looks encapsulated. So, I'm gonna call shenanigans and say that the big white thing is old encapsulated scar tissue from her prior tuberculosis, and she is just presenting with progressive COPD.


I was gonna hold off on commenting, but the line of thought is good.

It is tempting to think of the big white thing as the whole story, but it's not...although it is important.

Meh, it's pretty much the whole story, who am i foolin.

Perhaps a dumb question here. But given her history and that CT scan.. shouldn't her oxygen saturation be a lot less?

Meh. You can get away with a lot on only a few alveoli. Still, she probably desaturates even further with minimal activity.

Often, with chronic lung disease, the radiographs don't correlate well with clinical findings.

hmm, that left lung doesn't look very happy. how compromised is its efficiency, with that big chunk of scarring? you mentioned you can get away with a lot- but is this a situation where one would be winded just climbing stairs?

Her pulmonary function is crappy to start with, so it's rather hard to tell if it's worse.

50 y/o smoker with hemoptysis and copd. First thought...uh-oh. Second thought, "nah, too obvious." I think CPP's line of reasoning sounds quite, well, reasonable. But I'd still like a biopsy of that mass. And respiratory isolation on the patient until she has three negative smears.

Where's she from? That mass could be a fungus (cocci, histoplasmosis, etc, depending on where she's lived and/or travelled).

Then again, that's one huge bleb by the mass, maybe it's all scar tissue and COPD. The hemoglobin suggests that she has had long standing hypoxia and she is only mildly short of breath. Both of these things suggest that whatever's going on, it's been going on a long time.

Just to go for the really wild zebras, how about this: She has P vera and a pulmonary embolus. What's her Jak2 mutational status and D-dimer? (Not but if that's a PE it's a record breaker.)

I think MarkH's got it...if one detail is correct: is this a contrast or non-contrast CT?

It's non-contrast, the vessels are the same signal as the tissues. Even so, if it's old clotted blood it might not light up. It might not be an actively increasing hemothorax.

Rx, well, nothing. I wouldn't put a chest tube into her for fear of making her worse unless that thing got a lot worse or was already pretty damn big. I'd say supportive and hope it resorbs.

You're right, it's non-contrast therefore it's blood. But it's probably fresh blood based on the acuity of the symptoms and visibility on CT. (I suppose there could be a larger clot of older blood around the visible blood. But we didn't get to see a contrast scan.) Going on the one section, it looks like a pretty big collection of blood, but it's hard to say for sure without further sections. Supportive care with close monitoring sounds reasonable. (Also make sure she's not taking any aspirin, NSAIDs, anti-coagulants, naturopathic meds, etc that might make the bleeding worse.) Long term, she might be a candidate for lung reduction surgery. That bleb right beside looks ready to pop too.

MarkH: it's contrast-infused. Meaning I suppose that blood would show up bright white . . . ?
It would explain the hemoptysis, but not all of the hypoxy, except that she's got lung scarring from tuberculosis and 40 years worth of smoking.

I await being told why I'm wrong!

The patient almost certainly has baseline hypoxia: remember her hemoglobin? 18.2 is not normal-depending on the lab the normal range might go as high as 16, but 18 is almost certainly abnormal. Further hypoxia might have occurred when she flooded one of her three or so remaining alveoli with blood. Which means that the most important treatment that she can have at this point is smoking cessation. She needs to stop now!

COPD is a miserable way to die. To give an illustrative anecdote, I met a patient once who had had a lung transplant for COPD. He had had a miserable course after transplant, infection following rejection, following infection as his anti-rejection meds were increased and decreased. Nonetheless, he told me that his quality of life was much, much better after the transplant: being able to breathe, even with infection, beats not being able to breathe I guess.

You guys are great. I'm certainly not going to stop the discussion, but the CT (in toto) is strongly suggestive of fungus ball, probably aspergilloma.

In the bad old days, when TB was more common and not very treatable with drugs, it was not uncommon for cavities left by TB (or even by emphysema) to become colonized by fungus. Of course, the big problem now is what the hell to do about it. Oh, and I refer your google-fu to "Monod's Sign".

whoa. told you I looked forward to being told why I was wrong!
a fungal infection ?
Dianne suggested the possibility.
Me, I thought "her TB is back" and then dismissed the idea as being silly in this day and age.
As for what to do about it, call me Captain Obvious, but we need to get rid of the damn fungus before it kills her.
As to how. find something that'll kill the fungus without killing the patient.

Get her to inhale Nystatin :p.

At least, that's what I do with my experimental caterpillars...

Dam, I thought it was blood once Mark pointed out the possibility...

Treatment: You basically have two choices for what to do: surgery and drugs. Just how bad a surgical candidate is she? Do you have PFTs, cardiac function, etc on her? All in all I can't imagine that any surgeon would be thrilled with a patient like this and anyway you can't replace lung once it's taken out whereas you can always take out more if medical therapy fails. So, drugs. Do you know for sure it's aspergillosis? A sputum sample might be nice to make sure. Traditionally, ampho B would be the drug of choice, but you might try an azole first. Or in addition to. BTW, why is she immunosuppressed? Is she on chronic steroids? Do you have an HIV on her?

I dunno Pal. Fungus ball, TB, and cancer would be on the differential. But you have hemoptysis, big bullae, and what looks like a hemothorax extending to the posterior portion of the CT. I wouldn't rule out a hemothorax yet especially since it has the exact density of blood in the aorta.

Tap it, see what you get - except that could be dangerous in her. Presumptively treat with antifungals? Probably can't hurt. She's not a great surgical candidate whatever the diagnosis so it might be the best course. Whether it would even resolve with treatment in such a diseased lung...

Can I get a CBC with Diff and a metabolic panel?