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MedPix Medical Image Database COW - Case of the Week Case Contributor: MS-4 USU Teaching File Affiliation: Uniformed Services University.

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Presentation on theme: "MedPix Medical Image Database COW - Case of the Week Case Contributor: MS-4 USU Teaching File Affiliation: Uniformed Services University."— Presentation transcript:

1 MedPix Medical Image Database COW - Case of the Week Case Contributor: MS-4 USU Teaching File Affiliation: Uniformed Services University

2 MedPix No: 6416 - History Pt Demographics: Age = 32 y.o. Gender = woman The patient is a 32 year old white female G1P1 with a five year history of Langerhans cell histiocytosis (LCH) who presents for initial evaluation of her LCH in the military health care system.After the birth of her son in 1994, the patient curtailed her recreational athletic activities, including her study of dance. She began to notice mild shortness of breath with exertion, but attributed this to decreased conditioning secondary to her decreased activity. In 1998, while she was ill with bronchitis, she broke a rib during an episode of violent coughing. A chest x-ray revealed granulomatous disease. Bronchoalveolar lavage was negative. A surgical biopsy of the middle lobe of her right lung revealed LCH. She was not treated beyond being advised to stop smoking. Since then, she has experienced significant shortness of breath on exertion, which prevents her from running, but does not interfere with activities of daily living.The patient has also noticed that over the past few years she has had constant outbreaks and remissions of erythematous, pruritic, flat lesions, 1-2 cm in diameter, which appear from her toes to her pelvic region and lower back, and on her scalp (thorax, upper extremities, and face unaffected).PMH:1. Langerhans cell histiocytosis, diagnosed by surgical biopsy of the right lung in 1998.2.Mitral valve prolapse (per patient).PSH:1.LEEP for cervical dysplasia, 1999.Medications:1.Albuterol.2.Erythromycin (for recent URI).3.Benzonatate (for recent URI).Allergies: NKDA.Social History: Patient is married to an active duty Army sergeant and has a nine year old son. She works as a cashier in AAFES. She has smoked one pack of cigarettes per day for the last sixteen years, and drinks alcohol socially/occasionally.Family History: Noncontributory. Parents alive and well.ROS:General: No recent weight gain or loss. No fever, chills, or night sweats. No lymphadenopathy.Skin: Rash and pruritis as above. No jaundice. HEENT: No headaches. No recent change in hearing or vision. No discharge or bleeding from eyes, ears, nose.Lungs: Exertional shortness of breath as above. No hemoptysis. No chronic cough.CV: No chest pain. No tachycardia or skipped beats.GI: No dysphagia or odynophagia. No diarrhea, constipation, or abdominal pain. No hematemesis, hematochezia, or melena.GU: No dysuria, frequency, or urgency. No hematuria.Musculoskeletal: No weakness/arthralgias/myalgias/bone pain/fractures.Neuro: No numbness, tingling, loss of balance, or syncope. Downloaded by (-1)

3 MedPix No: 6416 - EXAM & LABS Vital signs: T 98.4 P 80 BP 110/70 R 20 Wt 56.8kg (125#) Ht 172.7cm (58)General: Thin, well developed female who appears her stated age. Pleasant. Converses appropriately.HEENT: No sign of trauma. Scalp without lesion. No lymphadenopathy. No mastoid tenderness. No maxillary or frontal sinus tenderness.Eyes: Pupils equal, round, reactive to light; extraocular muscles intact. Sclera and conjunctiva clear, nonicteric.Ears: Pinnae unremarkable. Hearing grossly normal.Nose: Nares patent. No discharge.Mouth: Moist mucus membranes. Good dentition. Oropharynx no lesions seen.Neck: Supple, full active range of motion. Trachea midline. No lymphadenopathy. Chest: Symmetric excursion with respiration.Lungs: Mild crackles at bases bilaterally. No wheezes/rales heard.Back: Cervical and upper thoracic spinous processes palpable; no deviation. No CVA tenderness.Cardiac: Regular rhythm. Distinct S1 and S2 with no murmurs heard. No JVD.Abdomen: Active bowel sounds. Soft; nontender to palpation. No organomegaly felt.Skin/extremities: Scaly lesions, 1-2 cm diameter, nontender, nonerythematous, bilateral lower extremities, 3-4 on each leg. No other lesions seen trunk, upper extremities, scalp. Mild clubbing of fingertips.

4 PA CXR PA and lateral chest radiographs 27 March 2003. There are surgical sutures in the right upper lung. There are diffuse bilateral increased interstitial markings, slightly more prominent in the upper lobes than the lower lobes. These findings are nonspecific but would be consistent with the patients reported history of Langerhans cell histiocytosis. In addition, there are more patchy areas of increased density in the left mid lung adjacent to the fourth anterior rib as well as in the right upper lung adjacent to the anterior fifth rib. These areas could represent part of the patients granulomatous disease but are nonspecific, and other concurrent disease cannot be excluded. Cardiac silhouette and pulmonary vasculature are within normal limits. No evidence for pneumothorax or pleural effusion. No gross adenopathy. - - Impression: Diffuse bilateral interstitial lung disease, slightly more prominent in the upper lobes, which would be compatible with patients reported history of LCH. - Downloaded by (-1)

5 Lateral CXR PA and lateral chest radiographs 27 March 2003. There are surgical sutures in the right upper lung. There are diffuse bilateral increased interstitial markings, slightly more prominent in the upper lobes than the lower lobes. These findings are nonspecific but would be consistent with the patients reported history of Langerhans cell histiocytosis. In addition, there are more patchy areas of increased density in the left mid lung adjacent to the fourth anterior rib as well as in the right upper lung adjacent to the anterior fifth rib. These areas could represent part of the patients granulomatous disease but are nonspecific, and other concurrent disease cannot be excluded. Cardiac silhouette and pulmonary vasculature are within normal limits. No evidence for pneumothorax or pleural effusion. No gross adenopathy. - - Impression: Diffuse bilateral interstitial lung disease, slightly more prominent in the upper lobes, which would be compatible with patients reported history of LCH. - Downloaded by (-1)

6 FINDINGS PA and lateral chest radiographs 27 March 2003. There are surgical sutures in the right upper lung. There are diffuse bilateral increased interstitial markings, slightly more prominent in the upper lobes than the lower lobes. These findings are nonspecific but would be consistent with the patients reported history of Langerhans cell histiocytosis. In addition, there are more patchy areas of increased density in the left mid lung adjacent to the fourth anterior rib as well as in the right upper lung adjacent to the anterior fifth rib. These areas could represent part of the patients granulomatous disease but are nonspecific, and other concurrent disease cannot be excluded. Cardiac silhouette and pulmonary vasculature are within normal limits. No evidence for pneumothorax or pleural effusion. No gross adenopathy.Impression: Diffuse bilateral interstitial lung disease, slightly more prominent in the upper lobes, which would be compatible with patients reported history of LCH.

7 DIFFERENTIAL DIAGNOSIS What is your Differential Diagnosis? Interstitial lung diseases; hypersensitivity pneumonitis, sarcoidosis, idiopathic pulmonary fibrosis, pneumoconioses.

8 Diagnosis: Langerhans cell histiocytosis. Dx Confirmed by:

9 DISCUSSION

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