An 82 years old man was admitted
because of progressive dyspnea for one week.
This man had
been a heavy smoker ( one pack per day ) for about 60 years.
One episode of dyspnea
developed when he was about 30 years old and asthma was told.
However, he had been well and didn't receive any specific treatment
until one year ago. He began to suffer from exertional dyspnea and
productive cough with slightly yellowish sputum intermittently and
has been brought to our ER twice because of dyspnea this year. In
recent one week, productive cough with yellowish sputum and dyspnea
progressed. In addition, left chest pain associated with respiratory
movement was also noted. There was no orthopnea, lower legs edema,
fever, chills, night sweating or weight loss. Because of severe
dyspnea, he was brought to our ER for help on Feb 20,
2000.
On physical
examinations at our ER, the body temperature was 38.0℃, blood
pressure 126/80 mmHg, pulse rate 84 /min, and the respiratory
rate 30 /min. His consciousness was clear. The conjunctivae
were not pale and sclerae were not icteric. Light reflex of
the pupils was prompt and symmetric. The neck was supple and
there was no lymphadenopathy or jugular vein engorgement. The
chest wall was symmetrically expanded. Diffuse wheezes over
bilateral lung fields and crackles at left lower to middle
lung field were noted on ascultation. The heart beats were
irregular. No heart murmur was audible. The abdomen was flat
and soft on palpation. There was no tenderness or rebound
tenderness. The extremities were free movable and there was no
cyanosis, clubbing or pitting edema. All peripheral pulses
were palpable.
The chest X-ray at ER showed increasing
infiltration at left lower lobe. In addition, leukocytosis with left
shift was detected. Because he had severe penicillin allergy
history, under the impression of pneumonia, clindamycin 300 mg IV
Q6H & gentamycin 160 mg IV drip QD were prescribed and he was
admitted to 12C ward for further management.
Laboratory:
1. CBC and differential count:
| |
WBC |
RBC |
Hb |
Plt |
Hct |
MCV |
Band |
Neu |
Baso |
Eos |
Mon |
Lym |
| |
/μl |
M/μl |
g/dl |
K/μl |
% |
fL |
% |
% |
% |
% |
% |
% |
| 2/20 |
7100 |
3.79 |
11.5 |
216 |
35.5 |
93.7 |
0 |
88.7 |
0.1 |
0.1 |
3.4 |
7.7 |
| 2/22 |
11090 |
3.52 |
10.9 |
254 |
33.1 |
94.0 |
1.0 |
82.0 |
0 |
0 |
9.0 |
8.0 |
| 2/29 |
15100 |
3.36 |
10.2 |
340 |
31.4 |
93.5 |
0 |
90.2 |
0.2 |
0.2 |
4.0 |
5.4 |
| 3/07 |
10600 |
3.32 |
10.0 |
272 |
30.3 |
91.3 |
6.0 |
73.0 |
1.0 |
1.0 |
9.0 |
10.0 |
2.
Biochemistry:
| |
A/G |
BilT/D |
ALP |
AST |
ALT |
r-GT |
BUN |
Cre |
Na |
K |
Cl |
| |
g/dl |
mg/dl |
U/L |
U/L |
U/L |
U/L |
mg/dl |
mg/dl |
mM |
mM |
mM |
| 2/20 |
|
0.8/ |
|
45 |
|
|
32 |
1.1 |
138 |
3.5 |
105 |
| 2/22 |
2.3/3.6 |
0.9/0.6 |
255 |
52 |
22 |
99 |
36.3 |
1.1 |
136 |
4.0 |
106 |
| 3/03 |
1.8/4.1 |
3.1/2.4 |
377 |
57 |
24 |
121 |
11 |
0.8 |
127 |
3.7 |
97 |
| 3/10 |
2.5/4.7 |
1.3/0.9 |
554 |
96 |
33 |
182 |
17.8 |
0.8 |
127 |
4.5 |
88 |
| |
Ca |
P |
Mg |
Glu |
LDH |
TG |
T-CHO |
UA |
| |
mM/dl |
mg/dl |
mM/dl |
mg/dl |
U/L |
mg/dl |
mg/dl |
mg/dl |
| 2/22 |
2.16 |
4.2 |
0.9 |
125 |
602 |
105 |
103 |
8.8 |
| 3/03 |
1.81 |
3.1 |
0.82 |
|
560 |
|
|
3.0 |
| 3/10 |
2.01 |
|
|
|
700 |
|
|
|
3.
Urinalysis:
| |
Outlook |
PH |
Pro |
Sugar |
KB |
OB |
Bil |
Urobil |
RBC |
WBC |
Epi |
| 2/20 |
Y,C |
5.0 |
>300 |
- |
- |
2+ |
1+ |
1.0 |
2-4 |
1-2 |
1-3 |
4. ABG:(O2 nasal cannula 3l/min)
| |
PH |
PaCO2 |
PaO2 |
BE |
HCO3 |
SaO2 |
| 2/20 |
7.533 |
21.5 |
117.6 |
-2.1 |
18.2 |
99.1% |
| 2/22 |
7.47 |
26.0 |
118.5 |
-3.8 |
18.6 |
99.2% |
5. Stool
(2/22):occult blood (-)
6. Blood
culture (2/20): Streptococcus pneumoniae, resistant to penicillin
Sputum culture (2/29):Klebsiella
pneumoniae (1+)
7. CEA
(3/01): 4.6 ng/ml
8.
Cytology:Bronchial
brushing (3/01): negative
Bronchial washing (3/01): positive, squamous
cell carcinoma
Sputum (3/01): positive, squamous
cell carcinoma
9. Pathology:
Lung, left,
bronchoscopy with biopsy, non-small cell carcinoma,squamous cell
carcinoma is most likely
10.Bone scan (3/07):focal area of increased
activity at the r't posterior L5 region
Image study:Chest X-ray, Bronchoscopy, Chest echo, Chest CT
Course and Treatment:
After admission, the blood culture on Feb. 20 revealed Streptococcus pneumoniae which was
resistant to penicillin. Inspite of clindamycin and gentamycin
treatment, the wheezing and dyspnea progressed. Therefore, the
antibiotic was shifted to vancomycin 500 mg iv drip Q8H. In
addition, inhalation therapy with bricanyl ( terbutaline ) &
atrovent ( ipratropium )and IV aminophylline were also prescribed
for his dyspnea and wheezes. However, his fever did not subsided and
dyspnea persisted. Physical exam five days after admission, showed
that the breathing sounds were diminished at left lower lung fields
and the wheezes disappeared. The follow-up CXR on Feb.28
showed progression of pneumonia with lung volume reduction.
Therefore, obstructive pneumonitis was suspected. Besides, Gram's
stain of the sputum smear on Feb. 28 showed numerous PMNs with G(+)
cocci & G(-) bacilli. Therefore, aztreonam 1.0 g IV drip had
been administered since Feb. 28.Bronchoscopy was performed on
Mar. 01 and an endobronchial tumor with total obstruction at left
lower second carina was noticed and the biopsy was done. The
pathology revealed squamous cell carcinoma. Chest echo also revealed
left lower lobe collapse with fluid-bronchogram and central cavity. Echo-guided
aspiration was performed for microbiologic study and drainage
of abscess. His condition improved gradually. The staging
work-up revealed at least stage IIIa squamous cell carcinoma
of the lung. Because of poor general condition, his family
refused radiotherapy and he received only conservative
treatment.
 病例分析:
臨床上面對一個過去病史有長年抽煙習慣者以wheezing發作來表現時,往往被診斷為COPD,
而忽略了COPD的好發年紀以及確切的診斷標準,以本案例而言八十多歲才發生wheezing,
似乎不太尋常,一定要詳細評估其發作的原因,尤其是一些引起airway obstruction的疾病。
其次,如何評估pneumonia的病人之嚴重程度以決定其治療的方針,目前已經有許多不錯的預判方法, 例如
Fines' prediction rule,它可以評估出病人的risk, mortality
rate以及建議的治療方式。另外,面臨pneumonia治療一段時間後效果不佳或更惡化者， 也要加以
仔細評估診斷是否正確?是否能確認pathogen?用藥是否正確？
host本身有沒有其他的原因會影響我們的治療?以本案例而言,追蹤chest x-ray後發現左側肺葉的體積變小了, left
hilum變大,左下肺葉塌陷,這時候的pneumonia稱之為obstructive pneumonitis,
表示有bronchus complete or partial obstruction,
造成的原因可以是endobronchial obstruction, bronchial stenosis
或external compression, 另外，我們可以回溯病人過去serial CXR
的變化，可以發現1997年時(圖一)，大致上沒有特別的
lesion，但是在1999年11月第一次來急診時(圖二)，左側 hilum
已經明顯變大許多了，此時應該就要進一步 work up 。所以進一步可以安排bronchoscopy以取得病灶組織的
診斷,另外,需再安排chest echo with transthoracic aspiration以便取得細菌培養之結果,
而得以改變用藥,使pneumonia可以獲得控制,以利進一步的治療。
|
Case Discussion