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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!