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SELF ASSESSMENT ANSWERS Postgrad Med J: First Published As 10.1136/Pmj.77.907.347F on 1 May 2001

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SELF ASSESSMENT ANSWERS Postgrad Med J: First Published As 10.1136/Pmj.77.907.347F on 1 May 2001 Postgrad Med J 2001;77:347–357 347 SELF ASSESSMENT ANSWERS Postgrad Med J: first published as 10.1136/pmj.77.907.347f on 1 May 2001. Downloaded from An elderly woman with dyspnoea and bronchorrhoea Learning points x The incidence of bronchioloalveolar Q1: What is your diagnosis? carcinoma and lung adenocarcinoma Histological examination of a transbronchial have markedly increased in the last biopsy specimen revealed bronchioalveolar decade. carcinoma of mucinous type, with extensive x A non-resolving consolidative pneumonia, vascular invasion. despite correct treatment in an adult with normal immunity, must raise Q2: What other disorders may show a the suspicion of bronchioloalveolar diVuse alveolar pattern? carcinoma. DiVuse alveolar radiographic pattern may x Diagnosis of primary bronchioloalveolar develop either acutely or as a chronic process. carcinoma can only be made when other The major causes of both presentations are extrathoracic primary adenocarcinomas listed in box 1. have been excluded. Q3: What are other causes of bronchorrhoea? Its distinctive pathological feature is growth DiVerent volumes of daily sputum have been along alveolar septae without distortion of pul- used to define excessive sputum production.1 monary interstitium. Three histopathological Some of its causes are depicted in box 2. Bron- subtypes have been described: mucinous, non- chorrhoea is usually accepted as the produc- mucinous, and sclerotic. tion of >100 ml/day of sputum. Prior pulmonary lesions, some professional exposures, cigarette smoking, and even a viral Discussion agent have been proposed as risk factors for Bronchioloalveolar carcinoma is one of the developing bronchioloalveolar carcinoma.3 four recognised subtypes of lung adenocarci- Males and females are equally aVected. noma. The dramatical increase in the incidence Patients may be asymptomatic in up to half of of lung adenocarcinoma in the last decade, cases. Clinical symptoms include cough, hae- being in some series the most frequent moptysis, chest pain, dyspnoea, and weight histological type among all lung malignancies,2 loss. Two characteristic features, both present seems to be mostly due to the raising incidence in the case under discussion, are large volume of bronchioloalveolar carcinoma. bronchorrhoea and refractory hypoxaemia caused by intrapulmonary shunting. Radiographic patterns include solitary nod- Box 1: Disorders associated with ules or masses, localised or diVuse consolida- diVuse alveolar pattern tion, and diVuse nodules.4 In diVerential diagno- http://pmj.bmj.com/ Acute sis, benign and malignant neoplasms (including x Pulmonary oedema. metastatic disease), lobar pneumonia, conges- x Pneumonia. tive heart failure, alveolar haemorrhage, and x Respiratory distress. alveolar proteinosis must be considered. Prog- x Aspiration. nosis is usually poor,5 and it has been correlated x Pulmonary haemorrhage. with the presence or absence of symptoms, x Allergic bronchopulmonary aspergillosis. tumour extension, and histological type. on October 2, 2021 by guest. Protected copyright. x Leukaemic infiltrates. The clincal course of this patient was rapidly Chronic fatal, and she died on the 11th hospital day x Sarcoidosis. after two episodes of massive haemoptysis. x Tuberculosis. Necropsy confirmed the diagnosis and ex- x Fungal infections. cluded any other primary neoplasm. This was x Bronchioloalveolar carcinoma. an important finding, as several adenocarcino- x Lymphoma. mas may show pulmonary metastases with his- x Alveolar proteinosis. tological pictures indistinguishable from pri- mary bronchioloalveolar carcinoma.6 Final diagnosis Box 2: Causes of excessive sputum Bronchioloalveolar carcinoma. production Postnasal drip syndrome. 1 Smyrnios NA, Irwin RS, Curley FJ. Chronic cough with a x history of excessive sputum production. Chest x Asthma. 1995;108:991–7. 2 Barsky SH, Cameron R, Osann KE, et al. Rising incidence x Gastroesophageal reflux disease. of bronchioloalveolar lung carcinoma and its unique x Bronchitis. clinicopathologic features. Cancer 1994;73:1163–70. Bronchiectasis. 3 Barkley JE, Green MR. Bronchioloalveolar carcinoma. J x Clin Oncol 1996;14:2377–86. x Left ventricular failure. 4 Hill CA. Bronchioloalveolar carcinoma: a review. Radiology DiVuse panbronchiolitis. 1984;150:15–20. x 5 Regnard JF, Santelmo N, Romdhani N, et al. Bronchioloal- x Bronchioloalveolar carcinoma. veolar lung carcinoma. Results of surgical treatment and prognostic factors. Chest 1998;114:45–50. x Cystic fibrosis. 6 Rosenblatt MB, Lisa JR, Collier F. Primary and metastatic bronchiolo-alveolar carcinoma. Dis Chest 1967;52:147–52. www.postgradmedj.com 348 Self assessment answers Unexplained weight loss and a palpable scarring. Follow up computed tomography abdominal mass in a middle aged woman showed thickened bowel loops in the right iliac Postgrad Med J: first published as 10.1136/pmj.77.907.347f on 1 May 2001. Downloaded from fossa with some calcification visible in the Q1: What does the barium enema study mesenteric nodes. She remains well 18 months (figs 1 and 2; p 341) show? after treatment. A small bowel study showed normal stomach and upper small bowel and a somewhat Discussion featureless terminal ileum. The caecum and Abdominal tuberculosis remains rare, and its right hemicolon appeared abnormal and a incidence over the last decade has remained barium enema was suggested. The barium stable despite variation in reported rates of enema (figs 1 and 2) shows classic radiographic pulmonary tuberculosis.2 It is more common in features of ileocaecal and colonic tuberculosis1 patients with AIDS. As with pulmonary tuber- confirming a diVusely abnormal terminal culosis most reported cases in the UK are ileum with a long stricture aVecting the immigrants. Our patient had never travelled caecum, ascending colon, and proximal por- outside the UK but may have been exposed to tion of the transverse colon with shortening of tuberculosis at the same time as her brother. these bowel segments. The left hemicolon Another possible source was her neighbours, appears normal. both recent immigrants, who were found through contact tracing to have active pulmo- Q2: What is the diVerential diagnosis and nary tuberculosis. what test should be performed to confirm Her chest radiograph was normal on two the diagnosis? occasions. Reports suggest that 20% of patients The main diVerential diagnosis is between ileo- with abdominal tuberculosis have coexistent colonic Crohn’s disease or tuberculosis. While pulmonary disease on chest radiography at an intestinal lymphoma or colonic malignancy presentation, but reported rates vary widely could produce similar radiological findings, the (6%–86%). Non-specific symptoms at presen- extent of the colonic involvement in a relatively tation are not unusual and a high index of sus- asymptomatic patient is against these. Other picion is required to make the diagnosis. In infections—for example, gastrointestinal addition to weight loss (66%), abdominal pain amoebiasis, actinomycosis or yersinia, though (85%), diarrhoea (20%), fever (35%–50%), rare, are possible causes. weakness, nausea, vomiting, melaena, or rectal The patient was further investigated with a bleeding may be presenting features. An colonoscopy. This revealed ulceration and nar- abdominal mass, usually in the right lower rowing at the level of the mid-transverse colon quadrant, is palpable in 25%–50% of patients.3 that could not be crossed. Biopsy samples were Investigations typically show a normal white taken both for standard histological assessment cell count. Mild anaemia is common with and for tuberculosis culture. Haematoxylin and inflammatory markers characteristically raised. eosin stains of the biopsy samples showed Abdominal ultrasound or computed tomogra- acutely inflamed granulation tissue but normal phy may confirm an abdominal mass or underlying colonic mucosa with no evidence of enlarged lymph nodes but are often unhelpful http://pmj.bmj.com/ an underlying inflammatory bowel disease, in distinguishing the underlying cause. Lapar- infection or neoplastic process. Ziehl-Neelsen oscopy and biopsy can be helpful but are safer stains were negative for acid-fast bacilli; if ascites is present, reducing the risk of bowel however, three weeks following the colonos- perforation. copy a positive tuberculosis culture was Our case illustrates the value of colonoscopy, reported. Mycobacterium tuberculosis sensitive to biopsy, and culture in establishing the diagno- isaniazid, rifampicin, and ethambutol was sis. Classical caseating granulomas on routine grown. histology or Ziehl-Neelsen staining may give an on October 2, 2021 by guest. Protected copyright. immediate answer but may be negative. Fine Q3: What treatment would you initiate? needle aspiration cytology at colonoscopy may The treatment of Crohn’s disease and abdomi- improve the diagnostic yield when nodular nal tuberculosis diVer widely. Blind treatment lesions are seen.4 The major disadvantage with with steroids may lead to deterioration in a tuberculosis culture of biopsy samples is the patient with tuberculosis. Fortunately, our time taken to get the result. Because of this new patient had only mild symptoms allowing the “rapid culture” methods have been developed. delay of definitive treatment until the results of Approximately 85% of patients will have a tuberculosis culture were available. A nine positive purified protein derivative or Mantoux month course of standard antituberculous test, but a negative result does not exclude the treatment was started
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