EMQs in Clinical Medicine.pdf - Peshawar Medical College

40 Respiratory medicine
disease and there should be a high index of suspicion of an acute
underlying ischaemic event, e.g. myocardial infarction.
G
E
A
A 24-year-old man initially complaining of cough and intermittent
haemoptysis presents a few weeks later with haematuria. Biopsy
confirms a crescentic glomerulonephritis. Renal biopsy shows linear
pattern deposition on immunofluorescence.
This patient has presented with a pulmonary renal syndrome. Differential
diagnosis includes Wegener’s granulomatosis, microscopic polyangiitis
and Goodpasture’s disease (GD). Serology may assist in diagnosis in that
Wegener’s granulomatosis is associated with cANCA (cytoplasmic antineutrophil
cytoplasmic antibody) (PR3) and anti-glomerular basement
membrane (GBM) antibodies of the IgG type can be found in GD. The
definitive diagnosis is made on renal biopsy where GD shows a classic
linear staining on direct immunofluorescence. Renal biopsy also allows
an assessment of the severity of the renal lesion.
GD is a condition resulting from the presence of anti-GBM antibodies. It
is believed that the binding of these antibodies to the kidney glomerular
membrane and lung alveolar membrane mediates a type II hypersensitivity
reaction, which is responsible for the pathology in those organs.
There is a strong association with HLA-DR2. The disease is said to occur
more frequently in smokers and those exposed to the fumes of hydrocarbon
solvents. Sufferers should avoid smoking, which can aggravate
respiratory symptoms and increase the likelihood of lung haemorrhage.
Treatment for this condition is immunosuppressive, e.g. corticosteroids,
but plasmapheresis to remove the anti-GBM antibodies is also successful.
A 34-year-old woman originally complaining of nasal obstruction
develops cough, haemoptysis and pleuritic chest pain. Her chest
radiograph shows multiple nodular masses.
Wegener’s granulomatosis is a small artery vasculitis (PR3 ANCA positive),
which is characterized by lesions involving the upper respiratory tract,
lungs and kidneys. Look out for eye signs that are present in up to 50 per
cent, e.g. scleritis, uveitis, retinitis. However, the vasculitis and granuloma
deposition can affect any organ and so less common associated symptoms
and signs are legion. Treatment options include the use of immunosuppressive
medications, e.g. high-dose corticosteroids with cyclophosphamide.
A 22-year-old man presents with fever, nightsweats, weight loss and
cough productive of cupfuls of blood. Ziehl–Neelsen stain is positive
for acid-fast bacilli (AFB).
The symptoms are suggestive of TB but the diagnosis is clinched by the
presence of AFBs with Ziehl–Neelsen staining. Although the lung is the
most commonly affected organ in TB, infection may present in other
sites, e.g. urinary tract, bone, central nervous system (CNS). Miliary TB