Wednesday, February 11, 2009

Interesting Chest Xray (4)

If you see a chest Xray like this, showing multiple cavitating lesions in bilateral lungs, in an IVDU (intravenous drug user) presented with fever, will you just treat it as multiple lung abscesses?


Related posts:
Interesting Chest Xray (3)
Interesting Chest Xray (2)
Interesting Chest Xray (1)

14 comments:

Darren Lee said...

In an IVDU who presented with fever and diffuse patchy changes or multiple lung abscesses, it could be due to septic emboli from an right-sided endocarditis (commonly associated with IVDU), which is the first diagnosis that you must rule out!

Zzzyun said...

hmm.. i didnt know tat. i was thinking of TB due to low immune status?

and how come the endocarditis is rightsided? i mean is there a reason for that?

Darren Lee said...

Good question zzzyun!;)

Unlike the general population, endorcarditis in IVDU is typically right-sided, and they usually have no evidence of prior valve damage. In patient with right-sided IE and septic pulmonary emboli, the clinical picture (respiratory symptoms + chest signs + CXR findings) often mislead the docs to identify the lung as the primary source of infection.

There's no clear unifying mechanism to explain increased prevalance of right-sided IE in IVDU yet, but there are a few proposed mechanism, including bacterial load, differences in valves and cardiac valve endothelium, immunilogic differences in IVDU group, and increased right-side cardiac turbulence etc.

Jing said...

how bout TB should it be ruled out?

Darren Lee said...

Jing: Ya certainly PTB should be ruled out too;)

bingwui said...

I can't see the fluid gas level in the cavities so at first glance i thought they are the cavities of PTB also.

if is IE, on the skin of this patients got lesions?

Jason Lim said...

Dint really think bout IE septic emboli.

I still remember my teacher told me bout ddx for round shadows.(quick one)

-Abcess
-Infection-TB,echinococcus,fungal...
-metastasis
-Autoimmune

but,this is a good x-ray example.

Thanks Darren.

Darren Lee said...

bingwui: Ya as I said, PTB need to be ruled out too. In IE, cutaneous signs (vascular phenomenon) is only one of the minor criteria.

Jason: Ya there are quite a number of differentials for rounded lesion. But remember to be suspicious when you see multiple and in bilateral lungs!

Donna Bong said...

It's interesting how you posts such medical related posts and diagnose them. What's your specialization in? Does it take alot to practise in Malaysia? (Where did you graduate) Quick question as well, since I'm planning to do optometry. are medical practitioners (doctors) allowed to do eye refractions as well? Thanks!

x-ray fluorescence said...

Its amazing x-ray.What are the possible causes of dark/hard radio opaque pinhead shadows in x ray chest without any complains ?.......
x-ray fluorescence

Donna Bong said...

i believe i sent you a comment, more likely as a question but it's weird that it didnt appear.

anyways i was saying, its cool how your posting medical remarks and educating us non-medical students. but where did you do your medicine degree and is there some specific area that you're specializing in?

also quick question, are doctors in malaysia doing eye refractions? because from what i learnt doctors can actually do eye refractions? (was wondering because i'm planning to do optometry, hence wanting to know how far the education is back home in Malaysia. thanks!)

Darren Lee said...

Donna Bong: I'm from IMU and currently specializing in Internal Medicine. I don't think refractions are checked by us here, we'll refer optometrist if necessary. But visual acuity and visual field can be done as a bedside test.

MedicalStudd said...

Hello I;m a medical student... i remember reading somewhere that IVDU's have a greater tendency to develop tricuspid valve endocarditis (right sided endocarditis) because bacteria from repeated injections can travel up the veins from the arms to the SVC and accumulate in the first valves they come into contact with - the tricuspids.
Correct me if I;m mistaken.. still got many years before graduation

Anonymous said...

It is extremely interesting for me to read this post. Thanks for it. I like such topics and anything connected to this matter. I would like to read a bit more soon.

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