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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2693_Библиотеки_им_академика_М_И_Перельмана.pdf
498
polugaoCsisonetslartimereveS
amuarTseidobngieroF
C. V. Pollack, Jr. et al.
sisolucrebutyranomluPsisatceihcnorB
amonicraccinegohcnorBamolligrepsa—seitivacnisnoitcefnilagnuF
seihta
msilobmeyranomluPsitilucsaV
Causes of severe hemoptysis. [Bansal A, Kantroo V. Massive hemoptysis. In:
Chawla R, Todi S, editors. ICU protocols [Internet]. India: Springer India; 2012
[cited 2015 May 28]. p. 65–70. Available from: http://www.springerlink.com/
index/10.1007/978-81-322-0535-7_8] Caption from original
Findings That Conrm Diagnosis
• Witnessed expectoration of blood conrms the diagnosis; without rsthand
evidence, it is difcult to know with certainty that there is a respiratory tract
source.
Factors That Suggest Diagnosis
• A reported history of hemoptysis in a patient at risk for one or more common
etiologies of hemoptysis (acute or chronic lung infection, chronic obstructive
pulmonary disease [COPD], mitral stenosis, coagulopathy, or pulmonary
embolism) should prompt diagnostic evaluation for one of these causes.
Factors That Exclude Diagnosis
• Clinically, hemoptysis cannot be excluded. The history of blood expectoration should be evaluated thoroughly on the supposition that the patient’s
history is accurate.
Ancillary Studies
Laboratory
• Patients with active hemoptysis and those with a history of repeated or chronic
episodes should be evaluated with a complete blood count (CBC).
• Patients on warfarin anticoagulation should be checked for international
normalized ratio (INR); patients on unfractionated heparin should be evalu-
33 Hemoptysis
ated for activated partial thromboplastin time (aPTT); patients taking an
injectable low-molecular-weight heparin should be checked for renal function, and the time of last dose should be noted.
embolism.
• Sputum evaluation may be helpful.
Electrocardiography
• In general, ECG should be performed in ill patients but is unlikely to be
particularly helpful in the evaluation of hemoptysis.
Imaging
• Chest x-ray is an essential rst step in evaluating hemoptysis. Look for mass
lesions, infection, signs of chronic lung disease, or evidence of a foreign body.
• A computed tomographic pulmonary angiogram is indicated if pulmonary
embolism is suspected.
499
Other Studies
• Bronchoscopy may be indicated.
Special Populations
Age
• Older patients have a higher risk of lung cancer, COPD, pulmonary embolism,
and pneumonia.
• Hemoptysis in children is less common than in adults and has a different
differential diagnosis. Infection of the lungs is less likely to manifest as
hemoptysis in children. Instead, consider foreign body aspiration or
• bronchial adenoma
• congenital vascular anomalies
500
Co-morbidities
• COPD
• Lung cancer
• Bronchitis
• Pneumonia
• Therapeutic anticoagulation
• Tobacco abuse
Pitfalls inDiagnosis
Critical Steps Not toMiss
• Evaluation for satisfactory oxygenation
• Evaluation for hemodynamic stability
• Evaluation for correctable coagulopathy
• Altered mental status may signal respiratory failure.
• Chest x-ray should be done early.
C. V. Pollack, Jr. et al.
Mimics
• Upper GI bleed
• Posterior epistaxis
Time-Dependent Interventions
• Immediate evaluation for adequate gas exchange and hemodynamic stability
• Chest x-ray early
Overall Principles ofTreatment
• Stabilize hemodynamic and ventilatory status.
• Evaluate for etiology.
• Treat accordingly with antibiotics, bronchoscopic intervention, reversal of
anticoagulation, etc.
33 Hemoptysis
501
Algorithm for diagnosis and management of hemoptysis due to Behçet’s syndrome.
[Seyahi E, Tascilar K, Yazici H.Behçet’s syndrome: clinical presentations affecting
prognosis and survival. In: Khamashta MA, Ramos-Casals M, editors. Autoimmune
diseases [Internet]. London: Springer; 2011 [cited 2015 May 28]. p. 163–84.
Available from: http://link.springer.com/10.1007/978-0-85729-358-9_11] Caption
from original
502
C. V. Pollack, Jr. et al.
Disease Course
• Course is determined by acuity of presentation and underlying etiology.
• The vast majority of hemoptysis cases are not life threatening, although the
underlying etiology may be signicant.
Related Evidence
Papers of particular interest have been highlighted as:
** Of key importance
Review
Ketai LH, Mohammed TL, Kirsch J, Kanne JP, Chung JH, Donnelly EF, Ginsburg
ME, Heitkamp DE, Henry TS, Kazerooni EA, Lorenz JM, McComb BL, Ravenel
JG, Saleh AG, Shah RD, Steiner RM, Suh RD; Expert Panel on Thoracic Imaging.
ACR appropriateness criteria® hemoptysis. J Thorac Imaging. 2014
May;29(3):W19-22. https://doi.org/10.1097/RTI.0000000000000084. PMID:
24717602. http://www.ncbi.nlm.nih.gov/pubmed/24717602 **
Singh D, Bhalla AS, Veedu PT, Arora A.Imaging evaluation of hemoptysis in
children. World J Clin Pediatr. 2013 Nov 8;2(4):54-64. https://doi.org/10.5409/
wjcp.v2.i4.54. eCollection 2013 Nov 8. PMID: 25254175. http://www.ncbi.nlm.
nih.gov/pubmed/25254175 **
Jaroszewski DE, Webb BJ, Leslie KO.Diagnosis and management of lung infec-
tions. Thorac Surg Clin. 2012 Aug;22(3):301-24. https://doi.org/10.1016/j.thor-
surg.2012.05.002. PMID: 22789595. http://www.ncbi.nlm.nih.gov/
pubmed/22789595 **
Hurt K, Bilton D.Haemoptysis: diagnosis and treatment. Acute Med. 2012;11(1):39-
45. PMID: 22423349. http://www.ncbi.nlm.nih.gov/pubmed/22423349 **
Kapur S, Louie BE.Hemoptysis and thoracic fungal infections. Surg Clin North
Am. 2010 Oct;90(5):985-1001.
PMID: 20955879. http://www.ncbi.nlm.nih.gov/pubmed/20955879 **
Dudha M, Lehrman S, Aronow WS, Rosa J.Hemoptysis: diagnosis and treatment.
Compr Ther. 2009 Fall-Winter;35(3-4):139-49. PMID: 20043609. http://www.
ncbi.nlm.nih.gov/pubmed/20043609 **
Fartoukh M, Parrot A, Khalil A.Aetiology, diagnosis and management of infective
causes of severe haemoptysis in intensive care units. Curr Opin Pulm Med. 2008
May;14(3):195-202.
18427242. http://www.ncbi.nlm.nih.gov/pubmed/18427242 **
https://doi.org/10.1097/MCP.0b013e3282f79663. PMID:
https://doi.org/10.1016/j.suc.2010.06.006.
33 Hemoptysis
503
Bidwell JL, Pachner RW. Hemoptysis: diagnosis and management. Am Fam
Physician. 2005 Oct 1;72(7):1253-60. PMID: 16225028. http://www.ncbi.nlm.
nih.gov/pubmed/16225028 **
Use PubMed Clinical Queries to nd the most recent evidence. Use this search
strategy:
“Hemoptysis”[Mesh] OR “Hemoptysis”
Chapter 34
Herpes Zoster
ChristopherJ.Rees, CharlesV.Pollack,Jr., andVictoriaG.Riese
Name andSynonyms
Herpes Zoster; Shingles
Incidence/Epidemiology
• The Centers for Disease Control and Prevention (CDC) estimates that up to
one- third of the adult population in the United States will be diagnosed with
shingles at some point in their lives.
• There are about 1 million to 1.2 million cases annually in the United States.
• It may occur in all adult age groups, but the incidence increases dramatically
after age 50.
• It is unusual in children.
• Shingles has a very low mortality and is rarely life threatening but has substantial morbidity, mostly as the result of postherpetic neuralgia (PHN).
• Most cases occur in healthy individuals, but the incidence increases among
the immunocompromised.
C. J. Rees
Emergency Department, Pennsylvania Hospital, Philadelphia, PA, USA
C. V. Pollack,
Department of Emergency Medicine, Thomas Jefferson University,
Philadelphia, PA, USA
V. G. Riese
Librarian Consultant, Eldersburg, MD, USA
C. V. Pollack, Jr. (ed.), Differential Diagnosis of Cardiopulmonary Disease,
https://doi.org/10.1007/978-3-319-63895-9_34
Jr. ()
505© Springer Nature Switzerland AG 2019
506
C. J. Rees et al.
Differential Diagnosis
• Coxsackievirus and herpes simplex virus also may cause a vesicular rash in a
dermatomal distribution.
Pathophysiology andEtiology
• The varicella-zoster virus (VZV) causes shingles.
• Primary infection with VZV causes chickenpox.
• After primary infection, the virus may become dormant in the dorsal root ganglia of the spinal cord. It may lie dormant for decades, but in response to immunosuppression, or the waning of innate immunity due to aging, the virus may
reactivate. The virus travels down the corresponding sensory nerve of the
involved dorsal root ganglion to cause the rash along those sensory dermatomes.
Reactivation usually involves just one dermatome, but may involve several or
many dermatomes, especially if there is an underlying immunosuppression.
• The exact mechanisms and causes of reactivation are unknown.
Presentation
Typical/“Classic”
• Symptoms usually start with pain in one sensory dermatome. Patients also often
note paresthesias or itching in the area of pain. The dermatomal distribution of
the pain sometimes is not recognized by either the patient or the physician.
• In retrospect, most patients also describe a prodrome of malaise with a mild
headache.
• The rash classically erupts within 1-10 days (most typically 3) of symptom
onset.
• The skin lesions often start as an erythematous maculopapular rash. Vesicles
then erupt. The vesicles are generally small and closely grouped into clusters
of lesions. The grouped vesicles remain on an erythematous base. The vesicles initially contain clear uid, but the uid becomes cloudy and appears
more purulent over the next several days. Ultimately the lesions dry, ulcerate,
and crust over. It may be 2 weeks until the lesions crust, and then another 2
weeks for the scabs to fall off.
• The lesions do not cross the midline.
• The vesicles may be of differing sizes, and they may be of differing stages in
the same areasimialr to primary chicken pox.
• The thorax and face are the most commonly affected areas, but shingles may
occur anywhere on the body.
34 Herpes Zoster
507
Vesicles in a dermatomal distribution represent herpes zoster. [Allen
HB. Vesiculobullous Disorders (Including Dermatitis/Eczema). In: Dermatology
Terminology [Internet]. London: Springer London; 2010 [cited 2016 Aug 22].
p. 15–32. Available from: http://link.springer.com/10.1007/978-1-84882-840-7_2]
Caption from original
Early stage of shingles with clear vesicles on an erythematous base. [Gilsdorf J,
Shope T.Viral exanthems of childhood. In: Fekety R, editor. External manifestations
508
C. J. Rees et al.
of systemic infections. Philadelphia: Current Medicine; 1996. 237 p. (Mandell GL,
editor. Atlas of infectious diseases; vol. 6.) ISBN: 0-443-07760-6]
More developed stage of shingles with crusting. [Gilsdorf J, Shope T.Viral exanthems of childhood. In: Fekety R, editor. External manifestations of systemic infections. Philadelphia: Current Medicine; 1996. 237 p. (Mandell GL, editor. Atlas of
infectious diseases; vol. 6.) ISBN: 0-443-07760-6]
Atypical
• Shingles may occur less commonly in more than one dermatome, or be
generalized.
• There is some thought and evidence that zoster may cause a syndrome of
dermatomal pain without a rash: zoster sine herpetica.
Primary Differential Considerations
• Pain from shingles may precede the appearance of the rash, making early
diagnosis more challenging. Differential diagnoses that should be considered
include:
• Acute coronary syndrome
• Pulmonary embolism
• Pleurisy