HISTORY

A 65 years old male presents to the emergency department complaining of SOB (shortness of
breath), chest pain, fatigue, persistent cough, flushed for two days. Prior to presentation he has
been complaining of fatigue and persistent cough. On examination, he looks flushed and has a
temperature of 38.8 C, his pulse rate is 115/min and his blood pressure is 135/75mmHg. His
respiratory rate is 27/min and oxygen saturation is 88%. Percussion is reduced at the basis
posteriorly, auscultation over these areas reveals coarse crackles and bronchial breathing. Sputum
produced by the patient is purulent and flecked with blood. When questioned further the man
admits to smoking approximately 15 cigarettes daily for the last 35 years. He also has a history of
antibiotic use and recently he had a course of Augmentin with unresolved symptoms

65 yrs-old male

SOB, chest pain, fatigue, persistent cough, flushed

Temp = 38.8 C

PR = 115/min

BP = 135/75mmHg

RR = 27/min

OxS = 88%

ORGAN SYSTEM INVOLVED

 Respiratory

DIFFERENTIAL DIAGNOSIS
 Lung cancer
o Heavy smoking
o Blood flecked sputum
o Reduced percusion
 Lobar pneumonia
o Reduced percussion
o Coarse crackles
o High temperature
o Increased heart rate
 Bronchopneumonia
o Reduced percussion
o Coarse crackles
o Bronchial breathing
o Purulent sputum
o High temperature
o Increased heart rate
 Tuberculosis
o Reduced percussion
 o Blood-flecked sputum
o Bronchial breathing
 There is no evidence in the history that the patient has had exposure to silicon particles, or
that he suffers from asthma as the symptoms are not consistent with bronchospasm or
wheezing. Cystic fibrosis is a congenital disorder that would have presented shortly after
birth
 The respiratory rate is high and oxygen saturation is low which is consistent with lung
disorder and consolidation of the lungs. Normally the respiratory rate is 12-20/min and
oxygen saturation is 95-100%

INVESTIGATIONS
 Blood tests
o Haematology
o Biochemistry
 Bronchoscopy – examination of the lower respiratory tract
o Bronchial washing sample taken and sent to:
 Cytopathology
 Microbiology
o Biopsy
 Histopathology

Haematology Blood Test Results

 The blood test performed in haematology show evidence of an infection or inflammation,

indicated by the abnormal results highlighted in red. For example: increased white cell
count, increased neutrophils and increased erythrocyte sedimentation rate, all of which
indicate infection
 We also see evidence of anaemia, inflammation or chronic disease as indicated by the
results highlighted in blue. For example, the red blood cell count and haemoglobin values. A
decrease in these values indicated anaemia.
 The blood film also shows signs of infection due to the neutrophilia with presence of
metamyelocytes.
  These results are consistent with infection and inflammation and anaemia.

Biochemistry Blood test results

 The blood test performed in biochemistry showed evidence of respiratory acidosis due to
the infection or inflammation as detected by the abnormal results highlighted in red:
decreased pH, increased CO2 in the blood – pCO2 and decreased oxygen levels in the blood
– pO2; we also see inflammation due to increased levels of C-reactive protein

 these results of respiratory acidosis and inflammation are consistent with a respiratory
infection or inflammation

Bronchial Washing

 Cytopathology
o Shows a cell population demonstrating pleomorphic shape, hyperchromasia,
coarsely granular chromatin (abnormal) and large, prominent nucleoli; the
cytoplasm is keratinised with an orange, thick glassy texture
o These findings are consistent with SCC.
 Microbiology
o The bronchial washing specimen was cultured producing yellow colonies, whilst a
gram stain showed small clusters of gram positive cocci
o A Ziehl-Neelsen stain was negative, effectively ruling out tuberculosis
 These findings are consistent with MRSA – Methicillin-resistant Staphylococcus aureus

Histopathology results (biopsy)

  Revealed islands of malignant tumour cells, invading and infiltrating the normal bronchial
tissue
 These cells demonstrate pleomorphism, irregular nucleus shape and hyperchromasia; the
cytoplasm of these cells is keratinised and characteristic keratin pearls are also characteristic
within the island masses.
 These findings are also characteristic with SCC

Medical Imaging

 Demonstrated on the CT investigation is right sided broncho-occlusive, bronchopulmonary

mass and also lower lobe pneumonitis as well as a moderate size posterior pulmonary
effusion.

 Additionally, we see upper lung emphysema and … disease of the aortic arch which is likely
an outcome of the patient’s cigarette addiction

SUMMARY OF RESULTS
 The haematology results show evidence of infection and anaemia as seen in pneumonia and
cancer.
 The biochemistry results demonstrated the presence of infection as seen in pneumonia
 The microbiology results revealed an infection with mephycilin resistant staphylococcus
aureus
 Histopathology and cytology confirmed the presence of a primary squamous cell carcinoma
(SCC) of the bronchus
 Chest X-Ray and CT examination revealed patchy consolidation in the lower lobes of both
lungs consistent with bronchopneumonia and consolidation in the region of the right
bronchus consistent with SCC
 No lymph nodes involvement was detected
FINAL DIAGNOSIS
 SCC of the bronchus and bronchopneumonia

SCC of the Bronchus

 Correlates with a smoking history, a major risk factor and main cause of lung cancer
 It arises centrally in the major bronchi and then invades the lung tissue
 It is often preceded by squamous hyperplasia, metaplasia and dysplasia in the bronchial
epithelium which then transforms into carcinoma in situ with the abnormal growth confined
in the epithelial layer. This can be present for many years before full symptoms arise.
Carcinoma in situ may then progress to invasive carcinoma.

 Eventually it may spread to the local hylal lymph nodes and when the tumour obstructs the
lumen of the bronchus it predisposes to infections, especially if the patient has had a history
of antibiotics such as Augmentin and has acquired MRSA. This can lead to pneumonia as in
our patient.

Bronchopneumonia

 Infection of the lung

  Consolidation and inflammation is distributed throughout the lung as patches close to the
airways
 Many different bacteria can cause this type of pneumonia including: streptococcus
pneumoniae, klebsiella pneumoniae, haemophilus influenzae and staphylococcus aureus
 Seen in very young or very old especially if these individuals are debilitated, immune
suppressed or have some other abnormality within their respiratory system such as in this
case where the patient has SCC of the bronchus
 It has an irregular course as different focal area undergo different stages of inflammation at
different times, for e.g. we may see acute congestion, red and grey hepatisation in the same
lobe
 Whilst resolution may occur, typically we see organization and scaring of the lung tissue in a
patchy distribution; so patients with repeated bouts of bronchopneumonia will show
evidence of fibrosis and permanent distension of the bronchi and bronchioles

PROGNOSIS AND MANAGEMENT

 The management of this patient will require various methods of treatment
 Bronchopneumonia and SCC require separate sets of treatments
 In this case SCC of the bronchus has a good prognosis as the tumour is in stage 1 –
relatively small tumour, confined to the lung, with no lymph node involvement or
metastasis; it will require removal by surgery, radiation therapy treatment and ongoing
management by the clinician
 Bronchopneumonia also has a good prognosis if effective treatment is administered;
since the patient is elderly intravenous antibiotics are required; since the blood oxygen
levels are low it may receive oxygen therapy too
 Upon discharge Chinese medicine may also be administered; studies have shown that
herbal medicine may improve the quality of life of patients and can also help restore the
body into a balanced state

QA

1. Which feature in the clinical presentation of the patient helped you to form the differential
presentation?
a. Smoking history and high temperature
b. Blood-flecked purulent sputum
c. Reduced percussion and coarse crackles
d. All of the above
2. As opposed to normal lungs, what pathological changes do we see in this patient’s lungs?
a. Patchy consolidation, organization and scarring
b. Malignant transformation of bronchial epithelium
c. Choices A and B are correct
d. Consolidation of a whole lobe followed by resolution
3. Which laboratory test results aided the diagnosis of this patient’s lung disorders? Select all
correct options.
a. High neutrophil count
b. High Pco2 and low Po2 levels in the blood
c. Gram positive cocci grown in culture
d. Pleomorphic, hyperchromatic cells with keratin pearl formation
4. Which medical radiation result was consistent with laboratory findings?
 a. Right sided bronchopulmonary mass
b. Left sided pneumonia
c. Lower lung fibrosis
d. All of the above
5. What methods of treatment are advised for this patient
a. Administration of IV antibiotics
b. Surgery radiation therapy
c. All of the above