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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_3063_Библиотеки_им_академика_М_И_Перельмана
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shows that decreased physical activity/exercise is a risk factor for the development of asthma
and that exercise may prevent the onset of asthma especially in the pediatric population.
The term “exercise-induced bronchoconstriction (EIB)” is a more accurate reflection of the
underlying pathophysiology and is generally preferred. EIB varies from 5–20% of the
population in the United States. The proposed mechanism of action of EIB is mainly based on
the concept of minute ventilation (MV) rising with exercise. EIB probably results from changes
in airway physiology triggered by the large volume of relatively cool, dry air inhaled during
exercise.
Alternatively, surrogate tests to assess bronchial hyperresponsiveness (example, cold air
hyperventilation, methacholine, histamine, or mannitol inhalation challenge) may be performed
in the pulmonary function lab, but do not always correlate with the presence of EIB.
Measurement of peak expiratory flow rates before and after exercise help with the diagnosis.
Therapy of EIB varies somewhat with the clinical setting. All patients with asthma should have
a rapid-acting beta agonist available when exercising for relief of symptoms.
In patients with well-documented asthma and typical asthma symptoms following exercise,
formal exercise/provocative testing is not usually needed.
In patients without documented asthma, an exercise challenge test is the most direct way to
establish a diagnosis of EIB. This usually involves an ergometer or treadmill exercise,
sufficient to raise the heart rate to 85% of the predicted maximum.
For patients with uncontrolled asthma, the first priority is to step up treatment to achieve
control of asthma.
For patients with well-controlled asthma but frequently experience asthma symptoms with
exercise, administer prophylactic use of a rapid-acting beta agonist 10 minutes prior to
exercise (in cases where beta-agonist use causes side effects, administer a cromoglycate
15–20 minutes prior to exercise).
191
Final Diagnosis
Exercise-induced asthma
When neither a prophylactic beta-agonist nor a cromoglycate is adequate to prevent
exercise-induced bronchoconstriction, add an inhaled glucocorticoid or leukotriene agent
rather than use a long-acting beta agonist.
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Case 3
Chief Complaint
Dyspnea on exertion with generalized fatigue
History and Physical Examination
A 25-year-old African American woman comes to the clinic complaining of dyspnea on
exertion along with a cough on and off for 1 year. The cough is nonproductive, and it has
worsened in the last 4 months. She feels tired, has occasional low-grade fever, mild
dyspnea on exertion, and has lost 5 pounds in 1 month. The patient has no history of
asthma or tobacco use. She has experienced intermittent pain in her shoulder and knees.
She has also noticed that her vision has worsened in the last 2 weeks.
She is well nourished and is in no acute distress. Pulmonary examination reveals bilateral
dry crackles. She has knee pain with motion. Painful red nodules are seen on the anterior
aspect of the legs with tenderness on palpations of both achilles tendon.
Differential Diagnosis
Initial Management
Tuberculosis1.
Lymphoma, especially Hodgkin2.
Sarcoidosis with Löfgren’s syndrome3.
Systemic lupus erythematosus4.
193
Setting: outpatient
Initial Diagnostic Plan Results
CXR: symmetric bilateral hilar enlargement. CT
chest: reticular nodular disease involving the
bronchovascular bundle with paratracheal and
bilateral hilar adenopathy
Normal
< 5 mm, negative
Negative and no growth
Both negative
CCS NOTE
If you are asked what type of chest x-ray to request, the most appropriate is a
posteroanterior and lateral done in the radiology department.
Anytime you need additional details, order a chest CT scan.
Chest x-ray, then chest CT
1.
CBC
2.
Purified protein derivative skin test & IGRA
3.
Acid-fast stain and sputum culture
4.
Antinuclear antibodies and C-ANCA
5.
Lateral decubitus films are for effusions
Portable films are for patients too ill to move or stand
Lordotic films are no longer useful
194
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Assessment
The patient presents with progressive cough and constitutional symptoms. There is also
evidence of erythema nodosum, polyarthralgias and enthesitis. The differential is broad and
includes rheumatologic diseases, collagen vascular disease, sarcoidosis, malignancy, infection
(including HIV disease).
A young woman with the symptoms of polyarthralgia, visual changes, erythema nodosum, and
bilateral hilar adenopathy is likely to have sarcoidosis. Patients are PPD and gamma release
assay negative ruling out latent TB. Elevation of angiotensin-converting enzyme is non-specific
and not part of the diagnostic criteria. An elevated 24-hour urine calcium is sometimes evident
and due to increased conversion of vitamin D.
Lymphoid malignancy may present as a mediastinal mass, nodal involvement, or pulmonary
involvement inducing chronic cough with associated constitutional symptoms. However, the
symmetrical nature of the hilar involvement is atypical. Since lymphoma and sarcoidosis mimic
each other it is important to make a tissue diagnosis through transbronchial biopsy or
endoscopic bronchial ultrasound fine needle aspiration to confirm a diagnosis.
Infectious etiologies include other granulomatous diseases such as fungus and tuberculosis.
Infection would be higher on the differential diagnosis if there were a history of exposure or
immune suppression.
Collagen vascular disease is not supported by the negative serologies. However, small vessel
vasculitis such as granulomatosis with polyangiitis (Wegener’s) can also present on biopsy
with non-caseating granulomas. Also the occupational lung disease known as berylliosis, or
chronic beryllium disease (CBD) can also present with non-caseating granulomas on biopsy.
HIV disease may also present as fever, weight loss, interstitial pneumonia, and adenopathy
(there should be a low threshold to screen for HIV).
195
Further Diagnostic Plan Results
Noncaseating granulomas, AFB
negative and culture negative
Findings consistent with a restrictive
intrinsic pattern. It is usually necessary
to get baseline PFTs prior to initiating
therapy particularly for respiratory
reasons in sarcoid patients
Treatment Plan
Discussion
Sarcoidosis is a multisystem disorder of unknown etiology that is characterized pathologically
by the presence of noncaseating granulomas in involved organs. It typically affects young
adults. In ~50% of cases, it is detected in asymptomatic individuals as a result of incidental
Bronchoscopy (commonly done with endobronchial
ultrasound) with biopsy is the gold standard. It needs
to be done especially in patients with symptoms of
weight loss and other constitutional symptoms to
exclude lymphoma and tuberculosis.
1.
PFTs with bronchodilator response
2.
FEV1 and FVC are decreased
Ratio of FEV1/FVC is normal to
high
Decreased TLC and mildly
decreased DLCO with no significant
bronchodilator response.
Oral corticosteroids
1.
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radiographic abnormalities (e.g., bilateral hilar adenopathy, reticular opacities). Common
presenting symptoms include cough, dyspnea, chest pain, eye lesions, and/or skin lesions.
Perform a comprehensive evaluation on all those with suspected sarcoidosis, including history,
physical exam, chest x-ray, PFTs, peripheral blood counts, serum chemistry, urinalysis,
electrocardiogram, ophthalmologic exam, and an evaluation for latent TB (PPD or interferon
gamma release assay). The purpose is to obtain additional data supporting the diagnosis of
sarcoidosis and to assess disease severity, while eliminating alternative diagnoses.
Pulmonary imaging plays an essential role in the diagnosis of sarcoidosis, starting with a chest
x-ray and often followed by high resolution CT. The classic chest x-ray reveals bilateral hilar
adenopathy. This finding, however, may be absent or, if present, may occur in combination with
parenchymal opacities.
PFTs are obtained in all patients with suspected sarcoidosis to assess for respiratory
impairment; they characteristically demonstrate a restrictive defect with reduced gas exchange
and reduced functional status. The diagnosis of sarcoidosis requires compatible clinical and
radiographic manifestations, exclusion of other diseases that may present similarly, and
histopathologic detection of noncaseating granulomas. Patients who present with asymptomatic
bilateral hilar adenopathy or a classical Löfgren syndrome of fever, erythema nodosum,
arthralgias, and bilateral hilar lymphadenopathy or Heerfordt syndrome (uveitis, parotid gland
enlargement, facial nerve palsy and fever) do not require biopsy. If available, biopsy of
accessible peripheral lesions (eg, cutaneous lesions, palpable lymph nodes, conjunctival
lesions) is preferred to an invasive procedure.
If an accessible lesion cannot be identified, the choice of procedure depends on the pattern
and location of lung parenchymal abnormalities, the presence and location of enlarged
thoracic lymph nodes, and the available expertise and equipment.
If U/S-guided endoscopy or flexible bronchoscopy cannot be performed or is nondiagnostic,
the next step is usually surgical mediastinal lymph node biopsy, followed by surgical lung
biopsy via thoracoscopy or thoracotomy.
197
Noncaseating granulomas are the characteristic histopathologic abnormality in sarcoidosis. The
differential diagnosis of granulomatous lung diseases includes many conditions; it is
particularly important to exclude infections and malignancy. Most patients with pulmonary
sarcoidosis do not require treatment, as a high proportion have asymptomatic, nonprogressive
disease or experience a spontaneous remission.
Final Diagnosis
Sarcoidosis
For asymptomatic patients with no significant extrapulmonary involvement, do not initiate
therapy with oral glucocorticoids; just monitor symptoms, chest radiograph, and pulmonary
function.
For patients with bothersome symptoms, worsening radiographic opacities, and increasing
pulmonary function impairment, initiate oral glucocorticoids rather than continued
observation.
198
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Case 4
Chief Complaint
Purified protein derivative skin test results
History and Physical Examination
A 39-year-old man comes to your office as part of a routine screening examination for a
new job. He is without symptoms and feels generally well. He is HIV-positive and has
had a purified protein derivative (PPD) skin test in the past. His CD4 cell count is 550,
and he is on no medications. He comes today for a routine examination and for the results
of his PPD test, which your nurse placed 2 days ago.
His temperature is 37 C (98.6 F), blood pressure 110/70 mm Hg, pulse 72/min, and
respirations 12/min. Physical examination shows normal eyes, ears, nose, and throat. The
chest is clear bilaterally, and cardiovascular exam is normal. Abdomen is normal. There
is no lymphadenopathy present. His skin test shows 8 mm of induration.
Differential Diagnosis
Initial Management
Setting: outpatient
Active tuberculosis (TB)1.
Latent tuberculosis (prior infection)2.
Bacille Calmette-Guérin administration3.
199
Initial Diagnostic Plan Results
The initial diagnostic plan should always be to rule out active tuberculosis.
Normal
Normal
CLINICAL PEARL
Develop the habit of thinking about what vaccinations should be given in any office or
clinical setting. Because of the HIV, this patient should receive both influenza and
pneumococcal vaccines.
Assessment
A PPD skin test >5 mm in HIV-positive patients is considered positive. The question then
becomes, Does this patient have active TB or latent tuberculosis (prior infection)?
Patients with active TB have weight loss, fever, cough, sputum, and night sweats; the chest x-
ray should show evidence of an apical lesion consistent with reactivation. If a patient has latent
TB (only positive PPD), consider treatment with isoniazid; no hospitalization is needed.
Active TB mandates isolation (hospitalization) and treatment with a 4-drug regimen.
Generally, nontuberculous mycobacteria will not give >5 mm of induration.
Chest x-ray
Liver function tests
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