A 41-year-old man presents to his doctor with a persistent cough. This has been present for the past six months and for the past two weeks he has been coughing up blood on a daily basis. He also feels more short-of-breath when exerting himself than normal. He is a non-smoker and has no past medical history of note. On examination he is noted to have reduced air entry in the right upper zone. A chest x-ray shows a right upper lobe collapse and a subsequent bronchoscopy demonstrates a cherry-red lesion in the right superior lobar bronchus.
What is the most likely diagnosis?
Correct Answer C: The 'cherry-red' lesion is a typical finding of lung carcinoid.
Lung cancer: carcinoid:
The vast majority of bronchial adenomas are carcinoid tumours, arising from the amine precursor uptake and decarboxylation (APUD) system, like small cell tumours. Lung carcinoid accounts 1% of lung tumours and for 10% of carcinoid tumours. The term bronchial adenoma is being phased out.
Lung carcinoid:
Management:
You are reviewing a 40-year-old man who is known to have bronchiectasis.
What organism is most likely to be isolated from his sputum?
Correct Answer C: Bronchiectasis: most common organism = Haemophilus influenzae.
Bronchiectasis: management:
Bronchiectasis describes a permanent dilatation of the airways secondary to chronic infection or inflammation.
After assessing for treatable causes (e.g. immune deficiency) management is as follows:
Most common organisms isolated from patients with bronchiectasis:
A 37-year-old woman who is being treated as an inpatient for Mycoplasma pneumonia is reviewed. Unfortunately she is unable to tolerate clarithromycin due to severe nausea.
What is the most suitable alternative antibiotic?
Correct Answer E: Mycoplasma pneumonia if allergic/intolerant to macrolides - doxycycline.
Mycoplasma pneumoniae:
Mycoplasma pneumoniae is a cause of atypical pneumonia which often affects younger patients. It is associated with a number of characteristic complications such as erythema multiforme and cold autoimmune haemolytic anaemia. Epidemics of Mycoplasma pneumoniae classically occur every 4 years. It is important to recognize atypical pneumonias as they may not respond to penicillins or cephalosporins.
Features:
Complications:
Diagnosis:
A 60-year-old female with a history of COPD presents to the Emergency Department with shortness of breath. Blood pressure is 120/80 mmHg and he pulse is 90 bpm. The chest x-ray shows a pneumothorax with a 2.5 cm rim of air and no mediastinal shift.
What is the most appropriate management?
Correct Answer A:
Pneumothorax:
The British Thoracic Society (BTS) published updated guidelines for the management of spontaneous pneumothorax in 2010. A pneumothorax is termed primary if there is no underlying lung disease and secondary if there is.
1- Primary pneumothorax:
Recommendations include:
2- Secondary pneumothorax:
3- Iatrogenic pneumothorax:
A 27-year-old man with no significant past medical history of note presents to the Emergency Department with a one day history of dyspnoea and right-sided pleuritic chest pain. A chest x-ray is taken which shows a right pneumothorax with a 2.5cm rim of air and no mediastinal shift. Aspiration is performed by the admitting doctor. He is reviewed four hours later. His dyspnoea has resolved but the chest x-ray shows that whilst the pneumothorax has improved there is still a 1.5cm rim of air.
Correct Answer E: The British Thoracic Society algorithm for spontaenous pneumothorax suggests that if following aspiration the rim of air is < 2cm and the breathing has improved then discharge should be considered with outpatient review.
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