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Page 5 / Case 09.03

ANSWER


Comparison of the serial Chest X-rays:
– Severity of the bronchiectasis is markedly worse
– There are more cystic bronchiectatic changes
– More peribronchial thickening is noted
– More mucus plugging, atelectasis and consolidation
– More generations of bronchi are affected

CT of the chest shows all these features very clearly as well as showing extensive bronchiectasis, mediastinal lymphadenopathy, pulmonary nodules and the tree-in-bud sign. The tree-in-bud sign represents dilated mucus filled bronchioles in a Y shaped branching pattern. It is a feature of tuberculous and MAC bronchiolar disease, bacterial infections in CF, as well as CMV and pneumocystis pneumonitis.

SUMMARY AND DIAGNOSIS
14 year old pancreatic insufficient CF patient with worsening clinical status, frequent exacerbations, progressively worsening radiographic findings and 3 consecutive heavy growths of MAC. There had been reasonable efforts to exclude other causes of CF pulmonary exacerbations. ETV was therefore diagnosed with active MAC infection and in consultation with the Division of Infectious Diseases; she was started on combination therapy.


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