75yr old chronic smoker male presented with c/o Hemoptysis and sob(NYHA III).He had 4-5 episodes of Hemoptysis. On Ix: counts were normal,Esr normal,sputum for AFB -ve,X-ray chest shows mediastinal lymph nodes. In view of CT Thorax what's the D/d & the line of treatment.

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Possibilities... Sarcoidosis.. Tubercular lympadenopathy with associated COPD... Atypical mycobacterial disease.. Interstitial lung disease.... Post tubercular bronchiectasis, Fungal disease like histoplasmosis.. Although rare in India.. Malignancy... The diagnosis needs tissue sample other tests will be supportive and may not help... Search for any cervical or axillary lympadenopathy from where FNAC can be done... If not then Mediastinoscopy or EBUS may be tried... In the meantime conservative management of haemoptysis should be continued

D/D 1. POST TUBERCULAR BRONCHIECTASIS 2. CA LUNG 3 . TUBERCULAR LYMPHADENOPATHIES 4. SACOIDOSIS. FIRSTLY SINCE HE IS HAVING HAEMOPTYSIS WE HAVE TO STOP HAEMOPTYSIS, THEN TO COME TO FINAL DIAGNOSIS PLEASE ADV CT GUIDED FNAC FROM MEDIASTINAL LYMPH NODES, TO FIND OUT ANY PALPABLE LYMPH NODES IN CERVICAL, SUPRA CLAVICULAR,AND AXILLARY FOR FNAC THEN PLAN FOR THE TREATMENT ACCORDINGLY.

ct chest shows emphysematous changes with lot of bullae particularly in left side one of cuts of liver shows some metastatic deposits and few in lung do cect thorax and bronchoscopy to rule out malignancy of lung and gi tract .also do cect abdomen and if required colonoscopy. have to keep watch on patient if breathless increases it may be rupture of bulla and may necessatise icd insertion.

possibilty of miliary tuberculosis . bronchiectasis and malignancy are high in list .sarcoidosis is rare in this age ild and fungal infections are also possible.

Doctor that's why i have posted HRCT for a differential to be made.

India haemoptysis Koch's common do Broncoscopic biopsy HP

Its may be due to bronchiectasis, miliary TB, Sarcoidosis... In this HRCT mottling are there

first is to rule out bronchogenic carcinoma since he being a smoker since many years and with considering the age its important to r/o malignancy

IMPENDING BRONCHECTIASIS

It's post tubercular bronchiectasis.

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