Welcome to Cross-Canada Paediatric - Respiratory Residency Rounds
PRINT PAGE
Page 3 / Case 01 / 02


ANSWER
Our Differential Diagnosis: Diffuse Airspace Disease
– Airspace disease (acute)
– Pulmonary edema (cadiac and non-cardiac)
– Infectious

(viral: infleunza, paqrainfluenza, RSV, CMV, adenovirus, HIV) (bacterial: mycoplasma, staph, strep, anaerobes, nocardia, MTB, NTM) (fungal: histoplasmosis and blastomycosis)
PCP

– Neoplastic (leukemia, lymphoma)
– Blood (goodpasture's, idiopathic pulmonary hemosiderosis, thrombo-embolic disease) – – – Idiopathic (sarcoid, eosinophilic lung disease)
– Airspace disease (chronic)
– Mycobacterium tuberculosis, fungal infection, interstitial pneumonitis, lipoid pneumonia, sarcoid, pulmonary alveolar proteinosis

DIFFUSE INTERSTITIAL DISEASE
– Reticulo-nodular
– Granulomatous - infection; mycobacterium tuberculosis versus non-tuberculous mycobacterium
– Inhalational exposure- organic vs inorganic
– Idiopathic; eosinophilic granulomatosis, sarcoid
– Neoplastic; leukemia
– Hemosiderosis; increased venous pressure
– Repeated hemorrhage; goodpasture's, idiopathic hemosiderosis
? Acute on chronic process (previous bronchopulmonary dysplasia)

FURTHER HISTORY
She had a bronchoscopy and bronchoalveolar lavage in April 1998. The lavage was cloudy, and blood-tinged in appearance. No cell count was available. There were secretions in the RUL. Cultures were negative for viruses, bacteria and fungal stains. Her clinical status improved so she was discharged home on oxygen at 2 L/min with additional planned investigations at follow-up.

At follow-up, she continued to be hypoxemic on room air. Her cardiac evaluation (echocardiogram and EKG) was normal. The interval chest xray was worse although she only required oxygen at night. Follow-up in October 1998 (6 months after presentation), she was noted to have mild clubbing on examination. Interestingly, her father was also noted to have clubbing but no respiratory symptoms.

OTHER INVESTIGATIONS AND RESULTS
Pulmonary function tests: uninterpretable (first attempt), blood work was normal, oximetry showed that she was hypoxemic at rest, worse with exercise. One could argue about the need for a high resolution CT scan to delineate the pathology further. However, it was not done at this point.

BELOW, CHEST X-RAY from October 1998.

Enlarge the CHEST X-RAY LEFT, enlarge the chest x-ray RIGHT.

WHAT ARE YOUR FINDINGS. WHAT WOULD YOU DO NEXT?



Next page / 1 2 3 4 5 6

Archives / Contact us