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主訴(Principal
Description):
Dry cough with intermittent fever and progressive dyspnea
for 1 month
病史(Brief
History):
The 27-year-old man was a previously
healthy student. He suffered from traumatic fracture of right
fibula and tibia in a traffic accident 2 months ago and
received only traditional bone manipulation. About 1 month
ago, he began to develop a dry cough. Fever occurred several
days later but there was only mild dyspnea. He visited the ER
of a medical center in Taipei on April 8th, 2005.
He did not have myalgia, anorexia or diarrhea. The CxR
revealed bilateral interstitial infiltrates. The WBC count was
21600, with 84% of neutrophils. He was then admitted and
antibiotics (Augmentin and Zithromax) were given. His fever
gradually subsided and cough almost resolved, but the CxR
lesions did not improve. The sputum acid-fast staining was
negative. He was discharged on April 13 and continued to take
oral antibiotic (levofloxacin). Nine days after discharge,
however, fever relapsed and he was sent back to the ER. Some
IV antibiotics were administered and the fever subsided in 2
days. Unfortunately, his cough and fever recurred on May 1.
The CxR showed diffuse reticular pattern, especially in the
right upper lung field. Morxifloxacin was given, and fever
subsided in 2 days and his cough also improved. However,
progressive dyspnea developed after discharge. It progressed
rapidly in 3-4 days, and nonproductive cough also worsened. He
went to the ER in another medical center on May 6 where mild
hypoxemia was found. The CxR (Figure
1) and Chest CT (Figure
2
) showed
interstitial infiltrates and patchy consolidations over the
right lung.
<Past
History>
- Denied systemic disease;
- Smoking(-),Alcohol(-)
- Denied drug allergy, allergy to sea food;
- Surgical history: nil
- Occupation:student
體檢發現(Evident
Physical findings):
Conscious: clear and alert
Vital sign: 36.8 0 C/100/19 BP: 137/55 mmHg
HEENT: Conjunctiva: not pale, Sclera: anicteric
Pupil: isocoric, 3mm/3mm, L/R +/+, prompt
Neck: supple, no LAP, JVE (-), no bruit
Chest: symmetric expansion
Heart: RHB, no murmur
Abdomen: soft and flat, no tenderness, no palpable mass
Liver: palpable, 4cm below RCM
Spleen: impalpable
Bowel sound: normoactive; Operation scar: nil
Extremity: no edema, normal skin turgor, no petechia or ecchymosis
Healed abrasion ulcers at right leg and ankle
Skin: normal skin turgor
LAP: no axillary LAP, no inguinal LAP, no supraclavicular LAP
手術方法及日期(Operation):
94-05-13 VATS biopsy (Lung,middle and upper lobes, right):
Patho: bronchiolitis obliterans-organizing pneumonia (BOOP);
with plugs of spindle mesendymal cells obstruct the air spaces
and bronchioles.
住院治療經過(Course and
Management):
After admission, he developed several
episodes of severe dyspnea and IV steroid was given, with good
response. Bronchoscopy and BAL was performed. Video-assisted
thoracoscopic surgery (VATS) biopsy on May 13 confirmed the
diagnosis of BOOP (Figure
3). IV corticosteroid was given and his dyspnea and
arterial oxygenation improved quickly. He was then discharged
on May 18, with continued oral prednisolone therapy (1
mg/day). The follow-up CxR 2 weeks after discharge (Figure
4
) was almost clear.
Laboratory
findings:
| |
WBC /mm3 |
Hb g/dL |
MCV /fL |
Hct % |
Plt K/μL |
| 05/06 |
20750 |
13.2 |
88 |
40.2 |
483 |
| 05/08 |
14910 |
12.2 |
86.9 |
37 |
511 |
| |
Alb g/dL |
T-bil g/dL |
GOT U/L |
GPT U/L |
ALP U/L |
γ-GT U/L |
LDH U/L |
| 05/06 |
4.0 |
0.57 |
83 |
130 |
625 |
259 |
470 |
| CK U/L |
BUN mg/dL |
Cr mg/dL |
Na mM |
K mM |
CRP mg/l |
| 53 |
5.8 |
0.8 |
134 |
4.3 |
23.2 |
| Anti-DNA(FA) |
1:10 - |
| Anti-ENA(Jo-1) |
Negative |
| Anti-ENA(RNP) |
Negative |
| Anti-ENA(SCL-70) |
Negative |
| Anti-ENA(SM) |
Negative |
| Anti-ENA(SSA) |
Negative |
| Anti-ENA(SSB) |
Negative |
| Anti-ENA(Scl-70) |
Negative |
| Anti-ENA(Sm) |
Negative |
| Anti-Nuclear Antibody |
1:80 + Speckle |
| C3 Quantitation |
139.0 |
| C4 Quantitation |
9.8 |
| IgA |
258.0 (mg/dl) |
| IgG |
1560.0 (mg/dl) |
| IgM |
102.0 (mg/dl) |
| RA Factor (Nephelometry) |
< 20.0 (IU/mL) |
| Mycoplasma Pneumoniae IgM Ab |
Negative |
細菌室(BA)
BRONCHIAL WASHING:
Common
Pathogens
1: (2+) Neisseria
species
2: (2+) Viridans
streptococci
PLEURAL
EFFUSION
No aerobic&anaerobic pathogens
Lung biopsy : No
aerobic&anaerobic pathogens:, No fungus
BRONCHIAL
WASHING Acid fast bacilli
- negative
BRONCHOALVEOLAR
LAVAGE Acid fast
bacilli - negative
病理報告(Pathology
Report):
Bronchiolitis obliterans-organizing pneumonia (BOOP)
Pulmonary function:
| Flow-Volume Test
(BTPS, Sitting Position) |
| |
Observed |
Predicted |
% Predicted |
Post-Test |
| FVC (L) |
1.97 |
4.05 |
48.7 |
1.69 |
| FEV1.0(L) |
1.41 |
3.59 |
39.3 |
1.29 |
| % FEV1.0 (%) |
71.6 |
87.0 |
|
76.33 |
| |
Observed |
Predicted |
% Predicted |
Post-Test |
| VC |
1.97 |
4.05 |
48.7 |
1.71 |
| IC |
1.28 |
|
|
1.05 |
| ERV |
0.69 |
1.69 |
40.8 |
0.66 |
| FRC |
2.11 |
3.15 |
67.1 |
1.95 |
| RV |
1.23 |
1.24 |
98.9 |
1.45 |
| TLC |
3.19 |
5.29 |
60.3 |
3.16 |
| RV/TLC(%) |
38.6 |
23.4 |
|
45.89 |
| Diffusion Capacity
(ml/min/mmHg, STPD) |
| |
Observed |
Predicted |
% Predicted |
| DLCO |
11.02 |
29.21 |
37.72 |
本病例為一位原來身體健康良好之青年。主要的表現為乾咳及發燒等症狀，經過胸腔X光片發現肺葉有疑似肺炎的病灶，於是在一開始被診斷為一般細菌引起的社區性肺炎治療，但是效果並不理想。後來經過切片才診斷為阻塞性細支氣管炎合併器質化肺炎（bronchiolitis
obliterans with organizing pneumonia,
BOOP）。在使用類固醇藥物後，病人的症狀很快得到了改善。
器質化肺炎是肺臟針對許多不同病因所造成急性損害的一種修護反應，但是病變只侷限於小氣道、肺泡管、及細支氣管旁肺泡等。BOOP是一種特殊的疾病分類，具有一些獨特的臨床及病理特徵。病因大多不明，可與藥物、器官移植有關。臨床上是一種類似肺炎的疾病，但病理上顯示小氣道的管腔被纖維化或肉芽組織填塞，而這些纖維化或肉芽組織會擴展至肺泡管（alveolar
ducts）及肺泡（alveoli）。由於細支氣管的管腔被阻塞，所以，也稱之為阻塞性細支氣管炎合併器質化肺炎（bronchiolitis
obliterans with organizing pneumonia,
BOOP）。本病例為一典型病例。在臨床上懷疑肺炎的病人，當有一個慢性的病程，同時又對一般抗生素無效時，必須要考慮其他原因引起之肺實質化。
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Case Discussion
繼續教育考題