Dual Pathology in a single lung...ICS medial to MCL. Vocal fremitus diminished on left side. Dull...

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ESMO Preceptorship Programme

Dual Pathology in a single lung !( Left sided bronchial carcinoma with Tubercular pleural effusion)

Dr. Mst Shamima AkterMBBS, MD (Pulmonology)

Registrar, Respiratory Medicine,

National Institute of Diseases of the Chest & Hospital

Dhaka, Bangladesh

NSCLC- Singapore, November 2018

ESMO PRECEPTORSHIP PROGRAMME

Particulars of patient

� Age: 55 years

� Sex: Male

� Smoker (30 pack years)

� Non alcoholic

� Married

� Low socioeconomic condition

Chief Complaints

� Productive cough for more than 3 weeks

� Fever for 3 weeks

� Left sided chest pain for 3 weeks

� Breathlessness on exertion for 2 weeks� Voice change for 2 weeks

History of Present Illness

� Productive cough for more than 3 weeks(sputumwasscanty, mucoid in nature, whitish, odourless,occasionally mixed with streaks of blood)

� Fever for 3 weekswhich was high grade intermittent,associated with chill and rigor.

� Left sided chest pain for 3 weeks, which waspersistently dull aching, localized to upper part of chestand aggravated by coughing, relieved partially withanalgesics

H/O Present Illness

� Breathlessness on moderate physical exertion, with no contributory /trigger factors for 2 weeks.

� Loss of appetite, weight loss andfatigue for 2 weeks

� Voice change along with fever and cough for 2 weeks

H/O Present Illness

� No history of

• jaundice,

• nausea, vomiting,

• headache, confusion, seizer, personality change

• unconsciousness

• abdominal pain/lump, bony pain

• contact with any known TB patient

Treatment history

� He was initially diagnosed as a case of CAP in a rural hospital and treated with Inj. Ceftriaxone, Tab. Levofloxacin along with other supportive medications.

� As his condition was not improved, he was referred to NIDCH (National Institute of Diseases of the Chest and Hospital), Dhaka, Bangladesh.

General Examination:

� Anxious� Wasted� Mildly anemic ( but jaundice, cyanosis absent)� Clubbing present� Lymph node : Not palpable� Pulse – 78 b/min, BP- 100/60 mm Hg, Temperature –

100O F, Respiratory rate- 20/min

� (No oedema/ dehydration, skin pigmentation, bony tenderness. JVP – normal, Thyroid gland- normal)

Examination of Respiratory System

� Shape of chest - Normal

� Chest movement & expansion was restricted on leftside. Trachea central in position , Apex beat in left 5th

ICS medial to MCL. Vocal fremitus diminished on leftside.

� Dull percussion note and diminished breath sound(with few crackles ) present from2nd ICS todownwards in MCL, from4th ICS to downwards inMAL, from 6th ICS to downwards in DSL

� Right side : Normal findings

Provisional Diagnosis

Left sided pleural effusion due to Bronchial carcinoma

1. Disseminated TB ( left sided pulmonary TB, pleural effusion/empyema, vocal cord TB)

2. Left sided Para pneumonic effusion

Investigations

� CBC: Hb- 11.4 gm/dl; ESR- 32 mm in 1st hour; WBC-16,000/cu mm; N- 91 %, L-7 %, M- 1%, E- 1%

� RBS: 73 mg/dl

� Blood urea: 35 mg/dl; S. creatinine: 1.0 mg/dl

� S. bilirubin: 0.4 mg/dl; SGPT: 68 U/L; S. total protein: 72 gm/dl; S. Albumin: 35gm/dl

� CRP: 3.01 mg/dl

� S. Electrolytes: Within Normal Limit

� Urine R/E: Normal

� ECG: Within Normal Limit

Investigations

Sputum Examination:

� Sputum for Gram staining: No significant organism was seen

� Sputum C/S: No growth after 72 hours

� Sputum for AFB: Negative

� Sputum for Xpert MTB/RIF: MTB not detected

� Sputum for Malignant cell: Negative

Investigations

CXR P/A view:� Dense homogenous opacity in

left mid and lower zoneobscuring left costophrenic &cardiophrenic angles .

� Mediastinumis shifted to right

Comment: Left sided moderatepleural effusion.

Investigations

USG of chest:Encysted pleural effusion with pleural thickening wasnoted in left hemithorax with fewinternal septations andcompression of adjacent lung. No peripheral mass lesionwas noted in any hemithorax.

Investigations

Pleural fluid study-oCytology: plenty of lymphocytes, neutrophils, histiocytes

and proteinaceous material in the background

Total number of WBC: 200/cu mm

DC: Neutrophils: 05%, Lymphocytes: 60%, Histiocytes: 35%

o Malignant cell: No malignant cell was seen.

o Pleural fluid protein: 3.1gm/dl

o Pleural fluid glucose: 99mg/dl

o Pleural fluid for ADA: 46.7 U/L

Investigations

o Pleural fluid for AFB: No AFB seen

o Pleural Fluid for Xpert MTB/RIF: MTB detected. RIF sensitive.

� Pleural tissue for Histopathology:Microscopic sections showpleural tissue. They revealedmultiple granulomas with Langhan’s type of giant celland caseation necrosis.

Diagnosis: Granulomatous inflammation consistent withTuberculosis.

Then anti-tubercular treatment started.

But in spite of getting antiTBCategory-1 treatment ,the patient was deteriorating . He developed frequenthaemoptysis as well as more cough than before andcontinued losing his weight .

We ask for doing CT scan of chest but the patient could not afford.

Investigations

Post aspiration CXR P/A view ( After getting Anti TB Rx for 2 weeks):Opacity in left hilar region and also in left upper zone.

Investigations

� Fiber optic bronchoscopy:Endobronchial growth was seen in left upper lobar bronchus almost completely occluding the lumen with left vocal cord palsy.

Investigations

BAL ( Broncho-alveolar lavage fluid) analysis -o AFB- not seen

o Malignant cell- not seen

Bronchial brush smear: showed plenty of neutrophils, benign bronchial epithelial cells mixed lymphocytes in the background of RBCs. No malignant cell seen.

Bronchial tissue for Histopathology: Squamous cell carcinoma, Grade II

Confirmatory Diagnosis:

Left sided bronchial carcinoma with left recurrentlaryngeal nerve palsy and left sided tubercular pleuraleffusion.

�We advised the patient to continue antiTBcat-1treatment for 6 months and referred himto NICRH(National Institute of Cancer research and Hospital) formanagement of lung cancer

Conclusion:TB and bronchial carcinoma may co-exist in a singlepatient and it is not rare in high TBburden country likeBangladesh, India etc.

Tuberculosis may be found as coincidence in somecommon malignancy like bronchial carcinoma, head-neck cancers and some haematological malignancies.

Tuberculosis is a common finding in cancer patientwhose immune systemis suppressed with cancertreatment.

TB may cause delay to reach the diagnosis of cancer.

Disclosure of interest

Nothing to disclose.

ESMO Preceptorship Programme

Thank you for your attention !

Dual Pathology in a single lung...ICS medial to MCL. Vocal fremitus diminished on left side. Dull...

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