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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
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Particulars of patient
� Age: 55 years
� Sex: Male
� Smoker (30 pack years)
� Non alcoholic
� Married
� Low socioeconomic condition
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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
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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
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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
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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
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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.
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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)
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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
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Provisional Diagnosis
Left sided pleural effusion due to Bronchial carcinoma
D/D:
1. Disseminated TB ( left sided pulmonary TB, pleural effusion/empyema, vocal cord TB)
2. Left sided Para pneumonic effusion
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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
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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
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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.
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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.
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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
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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.
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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.
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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.
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Investigations
� Fiber optic bronchoscopy:Endobronchial growth was seen in left upper lobar bronchus almost completely occluding the lumen with left vocal cord palsy.
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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
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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
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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.
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Disclosure of interest
Nothing to disclose.
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Thank you for your attention !