A 17 year old boy presents with recurrent cough with expectations since childhood. routine blood investigation are normal , sputum for AFB is negetive, already taken 2course of att for same problems at different places. Case posted for discussion please reg further investigation and management.

(Edited)

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Finally hi everyone, time to present the final outcome in this case, Based on the CT scan findings of cystic cavities, Lt lung , grossly compensated RT lung as evidenced by the pseudo herniation of RT lung into the Lt hemi thorax, young age with recurrent problem since childhood, a diagnosis of congenital cystic bronchiectasis of Lt lung with? Hypoplastic Lt lung was made and further investigations done. Cardiac evaluation to rule out RT heart failure/ Pulmonary hypertension was done which was normal. Fob showed e/o mid LMB narrowing but beyond that obstruction branch and segmental opening normal with moderate thick secretions present. BAL neg for AFB . After adequate preparation he was taken up for pneumonectomy. Surgery was uneventful with pt recovering in a week , icd removed in 2days . Hpe report enclosed. Totally no e/o TB . This case is presented for 2 reasons Not all chest inf are Tuberculosis Surgical option can provide a definite cure in many of the cases

Thanks for a wonderfully completely worked up case and taking it to logical conclusion. A great learning exercisr
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I agree with Dr.S.P Sanjeevaiah.

Is it diaphragmatic hernia? soon I realized that the mefiastinal shift to the same side is against this. Does the CT scan suggest bronchiectasis. I thought the classical tram line sign is not there.

This is a classical case of cystic bronchiectasis - non tubercular. There are lot of congenital causes for same. You may do a pft , BAL analysis and culture and treat underlying infection with appropriate antibiotics. He must be managed at a higher (tertiary ) centre

Resp dr shilpa when there is clear history of att for two times .Should not be this pic taken as post tubercular bronchiectasis. Why we should think of congenital which is much rare entity in comparison of post tubercular
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Left destroyed lung probably due to old healed infection with shift of mediastinum and herniation of right lung to left side. D/D hypoplasia of left lung

Destroyed fibrosed cavitated volume lost left lung That is post tubercular bronchiectasis super added sec infections and sometimes haeptysis is very common in such a lung This leads to clubbing also and sometimes sec renal amyloidosis also appears leading to nephritic syndrome type pic.. In some pts due to less resp reserve this may turn to rt hrt failure

Further management sir?
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MDR/XDR tuberculosis.Xray showing fibrocavitory lesions in left apical and mz.Trachea pulled toward left.Left lower zone fibrosis.Should be investigated at higher center for sputum culture, HIV and other immunocompromised states.Till then to be treated symptomatically.

CXR shows fibrocavitatory lesion in the left lung. Trachea has been pulled to left side because of the fibrosis. Approach as a case of MDR/XDR TB. Investigate further for TB. Treatment mainly symptomatic at present and to be started with inhaled corticosteroids, mucolytics.

Old healed cavitatory destroyed left lung. Advised for Gram stain, CBC, Sputum microscopy and if Sputum is negative for AFB than CBNAAT test is to be done.

fibrocavitory lasions on left side with mediastinal pulling ... Should be investigated for MDR tuberculosis...repeatedly. continue respiratory management as a case of COPD....interstitial lung disease. Inhalational corticosteroids and As n when needed ...go for antibiotics mucolytics in acute phase of the illness ...sos admission. High protein diet and breathing exercises.

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