Download Differential diagnosis of lung infiltrates.

Differential diagnosis of
lung infiltrates.
Lecture № 3
KSMA
The Department of Phthisiology
Fydorova S.V.
Differential diagnosis of lung
infiltrates is actual problem
Mistakes of differential diagnosis of
pneumonia and other inflammatory diseases
are more than 30% of cases.
There is high rate of late diagnosis of
tuberculosis at the level of primary health
care – until 80%.
To make differential diagnosis is
necessary when
there is atypical pathway of disease;
results of examination are typical for many
diseases;
there are any concomitant respiratory
diseases of tuberculous and nontuberculous
nature (tuberculosis and
pneumonia,tuberculosis and cancer etc.) ;
there is wrong interpretation of results of
examination;
there is not effect of treatment.
Definition
Lung infiltrate - part of lung tissue is
characterized by collection of atypical cells
(inflammatory, tumorous, eosinophylic
cells), increased volume and high density.
Groups of lung infiltrates
Lung infiltrates caused by different
microorganisms – pneumonias
(bacterial, viral, fungal) and tuberculosis,
mycobacteriosis, bronchoectasis etc.
Allergic lung infiltrates – eosinophilic
infiltrate, allergic alveolitis etc.
Pulmonary artery embolism
Oncologic lung infiltrates (cancer,
leucosis, lymphoma etc).
Obligatory minimum of
examination
Includes collection of anamnesis, complaints,
general examination, examination by organs
and systems, chest X-ray in direct and lateral
position, direct microscopy of 3 sputum
samples, cultural examination of sputum,
tuberculin skin test, common blood count.
Anamnesis: tuberculosis in previous history,
contact with infectious patient, tuberculosis in
patient’s relatives, concomitant diseases,
factors of high risk of tuberculosis.
Algorithm of differential
diagnosis
Is different in lobar involvement and segmental
or polysegmental involvement of lung tissue.
Spectrum of differential diagnosis should be
separated in lobar lung infiltrates and segmental
lung infiltrates.
Steps of differential diagnose
The 1st step – detection of lung infiltrate by X-ray
and clinical findings.
The main method of lung infiltrate detection is
chest X-ray. Lung infiltrate usually cause opacity
with size more than 1 sm of different intensity.
Structure of X-ray shadow depends on character
of TB process, it’s stage and complaints.
Steps of differential diagnose
The 2nd step – differential diagnosis of
inflammatory and oncologic infiltrates.
Inflammatory lung segmental infiltrates (focal
pneumonia, infiltrative tuberculosis, allergic
infiltrates) should be different from peripheral
lung cancer, which often cause round
shadow at X-ray film.
Inflammatory lung lobar infiltrates usually
occur in pneumonias, tuberculosis and
bronchogenic cancer with atelectasis.
Steps of differential diagnose
The 3rd step – differential diagnosis of
inflammatory infiltrates.
Inflammatory lung segmental infiltrates –
differential
diagnose
between
focal
pneumonia and infiltrative tuberculosis.
It is necessary exclude allergic lung infiltrate.
Inflammatory lung lobar infiltrates occur in
lobar pneumonias and tuberculosis. Usually
differential diagnosis is made between lobar
pneumonia, tuberculous lobitis (as type of
infiltrative
tuberculosis)
and
caseous
pneumonia.
Steps of differential diagnose
The 4th step - if clinical diagnose is
«pneumonia»,
you
should
make
differential
diagnosis
between
pneumonias
caused
by
different
microorganisms:
staphylococci,
streptococci, pneumococci, mycoplasmas
etc.
Lung infiltrates
Pneumonia of the
left lower lobe
Chest X-ray in direct
position
Lung infiltrates
Pneumonia of the left
lower lobe
Chest X-ray in direct
position of the same
patient after he
course of broad
spectrum antibiotics
Lung infiltrates
Pneumonia of the
right upper lobe
Chest X-ray in direct
position
Lung infiltrates
Pneumonia of the
right upper lobe
Chest X-ray in direct
position of the same
patient after 10 days
Lung cancer.
Patients are usually belong to the group of high risk:
– male older than 40 year old;
– smokers;
– patients suffer from chronic bronchitis;
– cancer in previous history;
– cancer in family anamnesis.
Gradual onset of disease, clinical symptoms of
general intoxication and bronchus obturation appear
and increase: weakness, loss of weight, severe dry
cough, after some time – productive cough with
mucous, mucous-purulent or bloody sputum,
haemophthisis, relapses of pneumonia at the same
part of lung tissue, pleural effusion, symptoms of
vena cava superior squeezing.
Lung cancer.
Chest X-ray – hypoventilation, atelectasis, infiltrates, foci.
Tomography, include CT-scan – bronchial constriction or it’s
complete obturation, enlargement of mediastinal lymph nodes.
Fibrobronchoscopy – constriction of bronchi, growth of
tumor.
Lavage fluid – detection of atypical cells.
Biopsy – cancer tissue, cells.
Ultrasound examination – detection of metastasis or
primary tumor, when there are metastasis in lung tissue (liver,
kidneys, pancreas).
Radioisotopic examination – detection of metastasis (liver,
bones) or primary tumor, when there are metastasis in lung
tissue.
Differential diagnosis of lung
cancer.
Is made by bronchoscopy with biopsy,
histological examination or cytological
examination of lavage fluid.
Lung infiltrates
Central cancer of
the right upper lobe
with atelectasis and
pneumonia
Chest X-ray in direct
position
Lung infiltrates
Central cancer of
the right upper lobe
with atelectasis and
pneumonia
Tomogram of the
same patient
Lung infiltrates
Atelectasis of the
left upper lobe
Chest X-ray in direct
position
Lung infiltrates
Atelectasis of the
left lung with
obturation of the
left main bronchus.
Central cancer of
the left main
bronchus with
atelectasis.
Tomogram.
Lung infiltrates
Lymphogranulomatosis
Chest X-ray in direct
position
Allergic lung diseases.
Eosinophilic lung infiltrate is also called
flying infiltrate or simple lung eosinophilia
or Leffler’s syndrome;
C.b.c. – high level of eosinophiles;
Long pulmonary eosinophilia;
Lung infiltrate is changed it’s localization;
Negative effect of antibiotic treatment.
Lung infiltrates
Eosinophilic
pneumonia of the
left upper lobe
Chest X-ray in direct
position
Lung infiltrates
Eosinophilic
pneumonia of the left
upper lobe. Infiltrate
has dissolved.
Tomogram of the
same patient after 3
days
Infarct-pneumonia in
thromboembolism of lung artery.
Factors of high risk in anamnesis:
smoking, hypodynamia etc.
Phlebitis of foot and pelvic veins.
Development of clinical symptoms of
pneumonia after acute attack of dyspnoe,
chest pain, cough (severity of this clinical
symptoms depends on size of affected
vessel).
Findings of examination in
thromboembolism of lung artery :
Chest X-ray – lung infiltrates without any typical sings
ECG – SI QIII, negative Т in V 1, V 2.
Perfusion scan of pulmonary tissue – focal decreasing of
isotope collection – 100% confirmation of diagnose, even in
normal chest X-ray.
Angiopulmonography – vessels are not crowded with
contrast mass or are not visible in the area of involvement –
signs of Vestermark.
Phlebography – detection of area of thrombosis.
C.b.c. – anemia in massive involvement, leukocytosis,
increasing of ESR.
Biochemical analysis – hyperbilirubinaemia in massive
involvement.
Urine analysis – nonspecific changes, protein, leukocytes,
oliguria-anuria – in shoke.
Influenza and acute viral
respiratory infections.
The main difference from pneumonia –
local involvement of lung tissue and
local physical symptoms are absent.
Symptoms of cough and general
intoxication are not specific.
But you should remember, that acute
viral respiratory infections and influenza
may be complicated with pneumonia.
Often only laboratory and x-ray methods
allow to detect pneumonia.
Influenza and acute viral
respiratory infections.
X-ray – normal.
Laryngitis, pharyngitis, фарингит, rhinitis.
Sputum analysis – neutrophiles, epithelial
cells.
C.b.c. – lymphocytosis.
Idiopathic allergic alveolitis
Gradual, but constant progression of dyspnoe.
Acute form doesn’t have any clinical difference from
bacterial pneumonia.
Antibiotics are usually not effective, but there is a good
effect of corticosteroid treatment, which allows to
suppose and then to confirm by objective methods
clinical diagnose of alveolitis.
Exogenous allergic alveolitis
relation with allergen;
effect of elimination;
positive effect of corticosteroid
treatment;
In toxic fibrotic alveolitis there is relaiton
with toxic agent (medicines,
professional effect of toxic substations).
Reasons of late TB
detection.
Lower level of knowledges of primary
health care physicians about TB;
Acute onset of respiratory disease;
Lower lobe localization of TB process,
often with destruction of lung tissue;
Concomitant diseases which are factors
of high risk of TB (chronic bronchitis,
focal sclerosis, heart failure);
Reasons of late TB
detection.
•
MBT have not been detected by classic
microbiological methods (even when
destruction of lung tissue is present);
• Non adequate X-ray examination without
control X-ray;
• Wrong interpretation of x-ray findings by
physicians include specialists;
Reasons of late TB
detection.
• Non adequate interpretation of broad spectrum
antibacterial treatment lower effect in
suspected nonspecific inflammatory disease;
• Factors of high risk have not been detected
during procedure of collection of anamnesis
(contact with infectious patient, diabetes
mellitus, alcoholism, long corticosteroid of
immunodepressive treatment, lower social
and economical status of patient etc).
Lung infiltrates
Round TB infiltrate
with cavity of the
left upper lobe
Chest X-ray in direct
position
Lung infiltrates
Periscissuritis of the
right upper lobe
Chest X-ray in direct
position
Lung infiltrates
Infiltrative
tuberculosis of the
right upper lobe
with cavity
Chest X-ray in direct
position
Lung infiltrates
Cloudy-like
infiltrate with cavity
of the right upper
lobe
Tomogram
Lung infiltrates
Infiltrative
tuberculosis of the
right upper lobe
(lobitis) with cavity
and foci of
bronchogenous
dissemination
Tomogram
Lung infiltrates
Caseous
pneumonia of the
left lung
Chest X-ray in direct
position
Lung infiltrates
Caseous
pneumonia of the
left lung
Tomogram of the
same patient
Lung infiltrates
Infiltrative
tuberculosis of the
both upper lobes
complicated with
right-side
exudative pleurisy
Chest X-ray in direct
position
Lung infiltrates
Pleurisy.
Total opacity of the
right lung.
Chest X-ray in direct
position
Conclusions:
Modern diagnosis of pulmonary TB is
an
important
objective
of
as
phthisiologists as other specialists,
because lung health of population in our
country mainly depends on it.
Adequate using of modern diagnostic
methods’ abilities will allow to decrease
the rate of TB hyper diagnosis and
possible negative consequences of
wrong antituberculosis treatment.
Thank you
for attention!