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  Table of Contents    
Year : 2011  |  Volume : 28  |  Issue : 3  |  Page : 222-225  

A cavitary lesion in the lung crossing the fissure

1 Department of Medicine, JSS Medical College Hospital, Mysore, India
2 Department of Pulmonary Medicine, JSS Medical College Hospital, Mysore, India
3 Department of Microbiology, JSS Medical College Hospital, Mysore, India

Date of Web Publication19-Aug-2011

Correspondence Address:
Basavanagowdappa Hathur
Department of Medicine, JSS Medical College, Mysore, Karnataka
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Source of Support: None, Conflict of Interest: None

DOI: 10.4103/0970-2113.83987

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How to cite this article:
Hathur B, Mahesh P A, Babu SM, Shankarappa VG, Jayaraj B S. A cavitary lesion in the lung crossing the fissure. Lung India 2011;28:222-5

How to cite this URL:
Hathur B, Mahesh P A, Babu SM, Shankarappa VG, Jayaraj B S. A cavitary lesion in the lung crossing the fissure. Lung India [serial online] 2011 [cited 2020 May 28];28:222-5. Available from: http://www.lungindia.com/text.asp?2011/28/3/222/83987

   Case Summary Top

A 60-year-old dravidian male hailing from Chamarajanagar, Karnataka, agriculturist by occupation, who smoked cannabis five-five times everyday for the last 30 years was admitted to our emergency department (ED) with history of cough and breathlessness for a month. Breathlessness was of acute onset and the patient could not walk for more than 100 m. Productive sputum was purulent in nature and was less than 50 ml/day. Two courses of antibiotics (ciprofloxacin and azithromycin) received from his family practitioner for five days each did not give any relief to his symptoms. He was under treatment for COPD with steroid bursts for three-five days (prednisolone 5 mg) five-six times per year and bronchodilators during acute exacerbations since three years. He used to smoke around five beedis (hand rolled tobacco leaves) every day and consumed alcohol socially for the last 30 years.

Physical examination

At the time of presentation to the ED, he was cyanosed and had bilateral pitting pedal edema with an elevated JVP (5 cm) with prominent "a" and "v" waves. Vital signs revealed tachypnea and tachycardia with a blood pressure of 110/60 mm Hg.

Respiratory system examination revealed a barrel shaped chest with kyphosis. Hyper resonant note was heard on percussion all over the lung fields with obliteration of cardiac and liver dullness. Bilateral rhonchi and basal crepitations were heard. Heart sounds were muffled with a short systolic murmur in the tricuspid area. Per abdominal examination revealed a non-tender liver palpable just below the costal margin.

Laboratory findings

The CBC count showed hemoglobin of 12.6 g/dl, leucocytosis with shift to left (14000 cells / micro liter, with 89% neutrophils) and an elevated ESR of 80 mm at 1 h. Blood chemistry analysis showed a BUN of 62 mg/dl, a creatinine level of 1.4 mg/dl, and a random blood sugar of 166 mg/dl. Liver function tests and serum electrolytes were within normal limits and he was seronegative for human immunodeficiency virus. ECG showed multifocal atrial tachycardia. Pulmonary function testing revealed a post bronchodilator FEV 1 of 52% with insignificant reversibility. Arterial blood gas measurement revealed a PaO 2 of 56 mm Hg and combined respiratory and metabolic acidosis. Chest radiograph revealed a cavitating infiltrate in the right lung crossing the minor fissure and a consolidation in the left lung [Figure 1]. Grams staining study of the sputum for three successive days revealed plenty of pus cells and all three samples were negative for acid fast bacillus by conventional ZN staining. Modified acid fast staining using 1% sulfuric acid as the decolorizer revealed branching acid-fast bacilli irregularly stained consistently in all three samples [Figure 2]. Sputum was cultured on 5% sheep blood agar and LJ medium. On blood agar, the growth (white, dry friable colony) was seen after 72 h. On Sabourauds Dextrose agar without antibiotics medium dry, cream colored colonies were seen after 48 h.
Figure 1: Chest X-ray PA view showing a consolidation in the right upper lobe with cavitation, infiltrating through the minor fissure. A patchy consolidation is also noted in the left mid zone

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Figure 2: Weak acid staining (1%) by modified ZN staining revealed branching acid fast bacilli (Magnification, ×1000)

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Patient was admitted to the hospital and treated with oral cotrimoxazole (trimethoprim 20 mg/kg/day) along with treatment for his COPD and cor pulmonale. Patient significantly improved and was discharged after two weeks. Patient continued follow-up once a week until four weeks when he showed a near complete resolution of the pulmonary opacity. He tolerated the drug well and was asked to continue treatment with oral cotrimoxazole for six months, but was lost to follow-up after six weeks.

Q1. What is your diagnosis?

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   References Top

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2.Subhash HS, Christopher DJ, Roy A, Cherian AM. Pulmonary nocardiosis in human immunodeficiency virus infection: a tuberculosis mimic. J Postgrad Med 2001;47:30-2.  Back to cited text no. 2
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15.Uttamchandani RB, Daikos GL, Reyes RR, Fischl MA, Dickinson GM, Yamaguchi E, et al. Nocardiosis in 30 patients with advanced human immunodeficiency virus infection: Clinical features and outcome. Clin Infect Dis 1994;18:348-53.  Back to cited text no. 15
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  [Figure 1], [Figure 2]


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