1. MGR
Cough를 주소로 내원한 젊은 여자 2례
호흡기 내과 R1 정수웅/Prof. 박명재

2. History Chief Complaint Cough onset : 3 days ago Present illness
Admission
F/ 허ㅇ 난
Chief Complaint
Cough onset : 3 days ago
Present illness
26/F, 2011년 4월 hematuria로 내원하여 AIHA (autoimmue hemolytic
anemia), latent SLE 진단받고, prednisolone, HCQ (hydroxychloroquine)
복용해 오던 자로, 약 20일전부터 chest discomfort , feeling of
breathlessness 있어 외부병원 방문하여 경구 항생제 복용하였으나
큰 호전 보이고 있지 않던 중 3일 전부터 소량의 가래섞인 기침,
37.8’C 의 mild fever 있어 호흡기 내과 내원함.

3. Past Medical Hx Personal Hx Family Hx DM/HTN/TBc/Hepatitis (-/-/-/-)
Autoimmune hemolytic anemia, diagnosed on
currently on prednisolone 5mg qd
Latent SLE, diagnosed on
currently on hydroxychloroquine 300mg qd
celecoxib 200mg qd
Medication (+) , described as above
Past surgical history (-)
Personal Hx
Smoking (-) Alcohol (+) social drinker
Family Hx
None

4. Review of System(1) 1. General
Generalized weakness(-) Fatigue(-) Fever(+) : mild
Chills(-) Myalgia(-)
2. Skin
Rash(-) Pigmentation(-) Urticaria(-)
3. HEENT
Headache(-) Visual disturbance(-) Oral ulcer(-)
Otorrhea(-) PND(-) Nasal obstruction(-)
Rhinorrhea(-) Sore throat(-) Swallowing difficulty(-)
4. Respiratory
Dyspnea(-) Cough(+) Sputum(+)
Pleuritic pain(-) Hemoptysis(-)

5. Review of System(2) 5. Cardiac Chest pain(-) Orthpnea(-) DOE(-)
6. Abdominal
A/N/V/D/C (-/-/-/-/-) Abd. pain(-)
Melena(-) Hematochezia(-)
7. Renal/Urinary
Dysuria(-) Incontinence(-) Frequency(-)
Urgency(-) Hematuria(-) Flank pain (-)
8. Musculoskeletal
Swelling(-) Myalgia(-) Arthralgia(-)
9. Nervous
Dizziness(-) Syncope(-) Seizure(-)
FENa 7.55%
FEUrea 69.02%

6. Physical Examination(1)
증례 1 (F/27)
Physical Examination(1)
Height : 159.5cm Weight : 47.6kg BMI : 18.7
Vital Sign : 110/70 – 102 – 20 – 37.7℃
1.General appearance
alert & oriented, in no acute distress
2. Head & neck
normocephaly, LN enlargement(-), neck vein engorgement(-)
3.ENT
isocoric pupil with PLR (++/++)
pinkish conjunctiva, whitish sclera
pharyngeal injection(-/-), PTH(-/-)
120/70 mmHg- 84회/분- 20회/분 -36.7°C
183cm 90kg (BMI : 26.9)

7. Physical Examination(2)
증례 1 (F/27)
Physical Examination(2)
4. Chest
Symmetric chest expansion
Clear breathing sound without rale and wheezing
Regular heart beat without murmur
5. Abdomen
soft/ flat abdomen
hyperactive bowel sound
tenderness(-), rebound tenderness(-) ,palpable mass(-)
6. Back&extremities
CVA Td(-/-), pressure sore(-)
7. Motor, sensory: intact

8. Initial Lab Finding 1.CBC/DC
6220/㎕ – 13.7g/㎗ – 42.3% - 240K/㎕ (seg 42.3%)
2.Chemistry
Total Bilirubin mg/㎗ BUN/Cr /0.7 mg/dL
Protein/Albumin /4.6 g/㎗ Na/K/Cl /3.8/96 mEq/L
AST/ALT /11 IU/L Ca/P/Mg /4.0/2.2mg/dL
ALP/rGT /28 IU/L Uric acid mg/dL
CRP mg/dL LD u/L
ESR mm/hr
3.U/A
RBC 0~1/HPF WBC 2~4/HPF
Blood Protein Glucose -
S.G pH 7.0

9. 증례 1 (F/27)
Initial Chest X-ray
C/T ratio 0.5
No active lung lesion

10. ECG
증례 1 (F/27)

11. Initial Problem Lists Initial assessment
증례 1 (F/27)
Initial Problem Lists
#1. nodular opacity on Rt. upper lobe #2. elevated CRP, ESR #3. low grade fever
Initial assessment
#1. r/o Community acquired pneumonia
#2. r/p Lupus pneumonitis
#3. r/o Tuberculosis

12. Dianostic Plan Sputum study as follows Sputum gram stain & culture
Sputum AFB stain ,Tb culture (solid & liquid), and Tb PCR
Sputum fungus culture
Serology & Urinary Ag test for specific pathogen
Urinary antigen for S.pneumoniae & L.pneumophilia
Mycoplasma IgM/IgG, cold agglutinin antibody
Quantitative ANA, C3,C4
Enhanced Chest CT
Bronchoscopy
washing for gram stain & culture, AFB stain & Tb culture, fungus culture

13. 증례 1 (F/27)
CHEST CT

14. 증례 1 (F/27)
C/T ratio 0.67

15. Cold agglutinin antibody <1:4 Urinary Ag for S.pneumoniae
Mycoplasma IgM
negative
Mycoplasma IgG
equivocal
Cold agglutinin antibody
<1:4
Urinary Ag for S.pneumoniae
Urinary Ag for L.pneumophilia

16. C3 112 (88~201mg/dL) C4 26.4 (16~47 mg/dL) ANA speckled (1:32o)
증례 1 (F/27) C3
(88~201mg/dL) C4
(16~47 mg/dL)
ANA
speckled (1:32o)

17. 증례 1 (F/27)
Bronchoscopy

18. Bronchoscopy ( )
증례 1 (F/27)

19. Sputum AFB smear & tb PCR
3/7
Mycobacterium tuberculosis
1st step :
Auramine-rhodamine stain
2nd step :
ziehl neelsen stain

20. Final diagnosis Endobronchial tuberculosis, actively caseating type

21. 증례 1 (F/27)
Clinical course
3/5
Diagnosed with
AIHA, latent SLE
AFB (+)
Tb complex PCR (+)
AFB (-)
Tb culture (-)
C/T 0.58
M. tuberculosis
Hydroxychloroquine, PDL
HERZ HER

22. History Chief Complaint Present illness Cough onset : 6 months ago
기침 발생하여 호흡기 내과 외래 방문함

23. Past Medical Hx Personal Hx Family Hx DM/HTN/TBc/Hepatitis(-/-/-/-)
Medication (-)
Past surgical history (-)
Personal Hx
Smoking (-)
Alcohol (+) social drinker
Family Hx
None

24. Review of System(1) 1. General
Generalized weakness(-) Fatigue(-) Fever(-)
Chills(-) Myalgia(-)
2. Skin
Rash(-) Pigmentation(-) Urticaria(-)
3. HEENT
Headache(-) Visual disturbance(-) Oral ulcer(-)
Otorrhea(-) PND(-) Nasal obstruction(-)
Rhinorrhea(-) Sore throat(-) Swallowing difficulty(-)
4. Respiratory
Dyspnea(-) Cough(+) Sputum(+) : yellowish
Pleuritic pain(-) Hemoptysis(-)

25. Review of System(2) 5. Cardiac Chest pain(-) Orthpnea(-) DOE(-)
6. Abdominal
A/N/V/D/C (-/-/-/-/-) Abd. pain(-)
Melena(-) Hematochezia(-)
7. Renal/Urinary
Dysuria(-) Incontinence(-) Frequency(-)
Urgency(-) Hematuria(-) Flank pain (-)
8. Musculoskeletal
Swelling(-) Myalgia(-) Arthralgia(-)
9. Nervous
Dizziness(-) Syncope(-) Seizure(-)
FENa 7.55%
FEUrea 69.02%

26. Physical Examination(1)
증례 2 (F/34)
Physical Examination(1)
Height : 162cm Weight : 53kg BMI : 20.2
Vital Sign : 110/70 – 80 – 15 – 36.4℃
1.General appearance
alert & oriented, in no acute distress
2. Head & neck
normocephaly, LN enlargement(-), neck vein engorgement(-)
3.E/ENT
isocoric pupil c PLR (++/++)
pinkish conjunctiva, whitish sclera
pharyngeal injection (-/-), PTH(-/-)
120/70 mmHg- 84회/분- 20회/분 -36.7°C
183cm 90kg (BMI : 26.9)

27. Physical Examination(2)
증례 2 (F/34)
Physical Examination(2)
4. Chest
Symmetric chest expansion
Clear breathing sound with crackle
Regular heart beat without murmur
5. Abdomen
soft/ flat abdomen
hyperactive bowel sound
tenderness(-), rebound tenderness(-) ,palpable mass(-)
6. Back&extremities
CVA Td(-/-), pressure sore(-)
7. Motor, sensory: intact

28. Initial Lab Finding 1.CBC/DC
6680/㎕ – 13.0g/㎗ – 38.5% - 217K/㎕ (Seg. Neutrophil 75.5%)
2.Chemistry
Total Bilirubin mg/㎗ BUN/Cr /0.6 mg/dL
Protein/Albumin /4.3 g/㎗ Na/K/Cl /3.8/103 mEq/L
AST/ALT /17 IU/L Ca/P/Mg /2.9/2.2mg/dL
ALP/rGT /32 IU/L Uric acid mg/dL
CRP mg/dL
3.U/A
RBC 0~1/HPF WBC 2~4/HPF
Blood Protein Glucose -
S.G pH 7.0

29. 증례 2 (F/34)
Initial Chest X-ray
C/T ratio 0.5
No active lung lesion

30. 증례 2 (F/34)
ECG

31. Initial Problem Lists Initial assessment
증례 2 (F/34)
Initial Problem Lists
#1. patchy opacity on RUL #2. chronic cough with scanty amount of sputum #3. mild elevated CRP
Initial assessment
#1. r/o Pulmonary tuberculosis
#2. r/o Atypical pneumonia
#3. r/o Cough variant asthma

32. Dianostic Plan Pulmonary function test Sputum study as follows
Sputum gram stain & culture
Sputum AFB stain ,Tb culture (solid & liquid), and Tb PCR
Sputum fungus culture
Chest CT
Pulmonary function test

33. 증례 2 (F/34)
PFT

35. 증례 2 (F/34)
CHEST CT

36. 증례 2 (F/34)

37. 증례 2 (F/34)
Bronchoscopy

38. Bronchoscopy ( )
증례 2 (F/34)

39. Sputum AFB smear & tb PCR
3/5
3/7
C/T 0.58

40. 증례 2 (F/34)
Final diagnosis
Endobronchial tuberculosis, Tumorous type

41. Clinical course
M. tuberculosis
AFB (+)
Tb PCR (+)
C/T 0.58
AFB (+)
Tb culture (+)
AFB (-)
Tb culture (-)
HERZ HER
HERZ