case presentation

1. ICU Unit
Prof. Ahmed EL Hadidy
Prof. Mostafa EL Shazly
Prof. Mohammed A.Hakeem
Prof. Amani Abuzeid
Prof. Mohamed Wafai

2. Complaint
Right side chest pain

3. Personal History
 Male patient
 16 years old
 Born and living in ELfayoum.
 student.
 No special habits of medical importance.

4. Present history
 The condition started 1 year ago by gradual
progressive dyspnea on moderate exertion with no
orthopnea or PND or chest wheezes .
 The condition was associated with dry cough .
 He sought medical advice several times and received
non specific medications with no improvement.

5.  3 months ago the patient experienced acute left
inframamary stitching chest pain increased with
respiration, referred to the back and associated with
acute dyspnea
 The patient saught medical advice at El fayoum chest
hospital where CXR and CT chest were done and
revealed left side pneumothorax.

6.  ICT was inserted and the patient was referred to
cardiothoracic surgery where bullectomy operation
was done with no available data.
 1 week before admission , the patient experienced right
inframamary stitching chest pain referred to the back
and increase with respiration , the patient sought
medical advice at Elfayoum chest hospital where CXR
and CT chest were done and revealed right side
pneumothorax.
 ICT was inserted and the patient was referred to our
department .

7.  No history of hemoptysis or wheezes
 No history of jaundice ,right hypochondrial pain or
lower limb oedema
 No history of dysphagia or hoarseness of voice
 No history of skin or joint manifestations.
 No history of fever, anorexia or loss of weight .
 The patient is not diabetic or hypertensive

8. Past history
• No history of TB or contact with TB case
• No history of previous operation , blood transfusion or
drug allergy.

9. Family history
His sister was admitted in our
department with recurrent
pneumothorax

10. Examination

11. General examination
 Patient is fully conscious ,alert, cooperative
oriented to time, place ,and person , of average
mood and intelligence
 lying flat in the bed

12. Vital sign
 Pulse: 100 beats /minute ,regular ,equal on both sides
 Blood pressure:110/70
 Temperature: 37˚c
 R.R: 30breaths /minute
 BMI : 15 kg/m2

13. Head and neck
 No Pallor
 No jaundice
 No cyanosis
 No palpable lymph node or thyroid swelling
 No congested neck veins

14. Upper limb examination
 No clubbing
 No cyanosis
Lower limb examination
 No clubbing
 No lower limb oedema
 Calf muscle lax not tender
 Intact Peripheral pulsation

15. Abdominal examination
 lax not tender
 No organomegaly or ascites can be detected clinicaly

16. Cardiological examination
The apex in left 5th space MCL
Normal heart sounds
No additional sounds

18. Inspection
Shape: symmetrical with ICT inserted
on the right side
 Respiratory movement: thoraco
abdominal.
Expansion: restricted on the right side

19. Palpation
Trachea: central
Chest expansion: diminished on RT
side
TVF: diminished on RT side
No tenderness
No palpable rub or rhonchi

20. Percussion
 Upper border of the liver: couldn't be
detected.
 Chest percussion :resonant
 Kronig’s isthmus: resonant.
 Clavicle :resonant.
 Bare area: dull
 Traub’s area : tympanic resonant

21. Auscultation
• Bilateral vesicular breathing with no
additional sounds.
• Despine sign: -ve

23. CXR 18- 7- 2014 before admission

24. 2-7

26. CT chest (6-10-2014)before
admission

28. CXR 13-10-2014 on admission

29. HRCT 19-10-2014

33. HRCT CHEST
Multiple variable sized thin walled dilated cystic air
spaces are noted within both lung fields as well as
scattered patches of air trapping .
Mild right apical pneumothorax is seen with chest tube
seen within it.
Lung parenchyma show mosaic pattern .
No pleural effusion.
Suspected hilar lymphadenopathy for post contrast
study.

34. *Pleurodesis was done & the patient was
discharged
*3weeks later the patient presented to us
with right side stitching chest pain
associated with dyspnea on mild
exertion

35. 22-11-2014 (readmission)

38. 2 weeks later the patient experienced
sudden dyspnea with rt sided stitching chest
pain referred to the back

42. ICT was inserted on the right side and
follow up CT chest was done

46. Complete blood count
 TLC 9.5 10*3 /cmm (4-11)
 Hemoglobin 11.8 g/dl (12-15)
 Hematocrit (PCV) 36.2% (35-45)
 M.C.V 61.2 fl (80-101)
 M.C.H 19.9 pg (27-32)
 Platelet count 193 10*3/cmm (150-450)

47. Clinical Chemistry Report
 AST 26 U/L (UP TO 50)
 ALT 44U/L (UP TO 45)
 Serum albumin 4.7 mg/dl (3.5-5)
 Serum creatinine 0.7 mg/dl (0.3-1.2)
 Blood urea 27.8 mg/dl (7-50)
 Serum calcium 8.1 mg/dl (8.4-10.2)

48. PT 13.6 sec
PC 95%
INR 1.03
ESR 1st hour 58
ESR 2nd hour 95

49. COLLAGEN PROFILE
RF +VE
ANCA -VE
normalAlpha one antitrypsin

50. PULMONARY FUNCTION TEST
FEV1/FVC 93
FVC 25%
FEV1 28% 0.75 L

51. ECHO normal
CT abdomen & CT brain normal

52. RHEUMATOLOGY CONSULTATION
The patient has thin inelastic skin and tall finger high
arched foot with hypermobility suspected of Ehlerdanlos
syndrome
Recomendation
Fundus examination for ectopia lentis (normal)
Xray hand ( normal)

53. As regard his sister :
* 14 years old
* 2weeks before admission , the patient experienced left
side pneumothorax, ICT was inserted for 1 week then
removed
* 1 week later , she was admitted with bilateral
pneumothorax & bilateral ICT was inserted
* Pleurodesis was done on the right side then she was
referred to cardiothoracic surgery due to persistent air
leak

58. Pathology report
Gross
2 irregular rubbery greyish brown flattened tissue pieces
,measuring 2.5x1.5x0.5 cm and 2.5x1x0.5cm both bisected
and totally submitted.
Microscopic
Section examined from the specimen received reveal lung
tissue with evidence of emphysema with marked ,
congestion interstitial lymphocytic infiltrate and mild
anthracosis .
No evidence of specific granuloma.
No evidence of malignancy .

59. diagnosis
Lung biopsies ,chronic venous congestion , emphysema
,ruptured bulla.

60. Pathology report(revision)
Microscopic
Examination of the received slides reveal lung tissue
showing moderately edematous alveolar walls with
areas of mild to moderate interstitial fibrosis and
diffuse interstitial infiltration by lymphoplasmocytic
cellular infiltrate .some lymphoid aggregates and few
neutrophils.many calcified bodies are detected in the
interstitium .few alveoli show bubbly exudate
entangling inflamatory cells. Areas of anthracosis are
also seen.

61. Diagnosis
Picture suggestive of hypersensitivity pneumonitis