Bronchiectasis Case Study

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Bronchiectasis: An illustrative case

A 25-year-old woman was referred to the pulmonary service because of

exacerbation of asthma and recurrent pneumonia. Asthma had been diagnosed 5

years earlier on the basis of symptoms. Since then, she had been treated with

inhaled albuterol, ipratropium bromide, and corticosteroids, plus oral

antibiotics as needed for flare-ups, but with no long-lasting improvement.

The patient described recurrent exacerbations of fever, cough, wheezing,

shortness of breath, and pleuritic chest pain. Her cough usually produced 4

to 8 oz of green, thick sputum per day. The expectorant occasionally was

foul-smelling and blood-tinged. She had no symptoms of gastroesophageal

reflux disease, sinusitis, or otitis. Her past medical history was remarkable

for multiple childhood respiratory tract infections, but she had no specific

history of tuberculosis or pertussis. She had never smoked tobacco or used

illicit drugs.

On physical examination, the patient appeared to be healthy and in no acute

distress. Her temperature, respiratory rate, pulse rate, and blood pressure

were all normal. Hemoglobin saturation in room air, as measured by pulse

oximetry, was 97%. Lung examination revealed bibasilar inspiratory and

expiratory coarse crackles with occasional expiratory wheezing. Except for

slight clubbing of her fingers, the other physical findings were normal.

A chest film showed multiple bibasilar cysts and infiltrates. The

radiographic findings were unchanged from those noted on a chest film 5 years

previously. A high-resolution computed tomographic (CT) scan of the chest

showed multiple large, fluid-filled cysts predominantly in the lower lobes of

the lungs, consistent with severely dilated airways. The left lower and right

middle lobes were entirely replaced with bronchiectasis. Pulmonary function

testing revealed a mixed obstructive and restrictive ventilatory defect.

Sputum cultures grew Escherichia coli, sensitive to ciprofloxacin. Complete

blood cell count with manual differential, tuberculin skin test (purified

protein derivative), sweat chloride test, serum immunoglobulin levels, sputum

acid-fast bacilli smears, and bronchoscopy with endobronchial biopsy and

electron microscopic examination of respiratory cilia were all negative or

normal. Genotyping revealed no evidence of a mutation of the transmembrane

conductance regulator associated with the cystic fibrosis gene.

A diagnosis of bronchiectasis was established, and the patient was started on

a regimen of ciprofloxacin, inhaled albuterol and ipratropium bromide, and

daily chest physiotherapy. When symptoms persisted after 3 weeks, the patient

was admitted to the hospital and treated with intravenous ciprofloxacin and

tobramycin, along with aggressive postural drainage. She responded well and

was discharged a week later. She continued intravenous antibiotic therapy at

home and returned to the respiratory therapy section for weekly chest

physiotherapy and pulmonary toilet.

Antibiotics were discontinued after 2 weeks and physiotherapy after 1 month.

The patient started a year-long regimen of oral ciprofloxacin for the first

14 days of every month. Since her inpatient stay, she has had only one

exacerbation. She has resumed her normal daily activities and has had minimal

symptoms to date.

Becki

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