alexa A Rare Cause of Acute Respiratory Distress Syndrome | OMICS International
ISSN: 2472-1247
Journal of Clinical Respiratory Diseases and Care
Like us on:
Make the best use of Scientific Research and information from our 700+ peer reviewed, Open Access Journals that operates with the help of 50,000+ Editorial Board Members and esteemed reviewers and 1000+ Scientific associations in Medical, Clinical, Pharmaceutical, Engineering, Technology and Management Fields.
Meet Inspiring Speakers and Experts at our 3000+ Global Conferenceseries Events with over 600+ Conferences, 1200+ Symposiums and 1200+ Workshops on
Medical, Pharma, Engineering, Science, Technology and Business

A Rare Cause of Acute Respiratory Distress Syndrome

Babu Sah R and Gothi D*

Department of Pulmonary Medicine, Employee State Insurance- Post Graduate Institute of Medical Science and Research (ESI-PGIMSR), Delhi, India

*Corresponding Author:
Dipti Gothi
Professor, Department of Pulmonary Medicine
ESI- PGIMSR, Delhi, New Delhi – 110015
Tel: +91-9971550550
Fax: 011 25970860
Email: [email protected]

Received date: February 12, 2016; Accepted date: February 27, 2016; Published date: March 01, 2016

Citation: Sah RB, Gothi D (2016) A Rare Cause of Acute Respiratory Distress Syndrome. J Clin Respir Dis Care 2:108. doi: 10.4172/2472-1247.1000108

Copyright: © 2016 Babu Sah R, et al. This is an open-access article distributed under the terms of the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original author and source are credited.

Visit for more related articles at Journal of Clinical Respiratory Diseases and Care

Abstract

A 25-year-old lady presented with acute respiratory distress syndrome following dilatation and curettage. Due to non-responding fever she was investigated further. High resolution computed tomography showed ‘random nodules’ with consolidation suggestive of miliary tuberculosis with acute respiratory distress syndrome, which was confirmed later on transbronchial lung biopsy. She responded to antituberculous therapy and was discharged afebrile with normal vital parameters.

Keywords

Acute respiratory distress syndrome; High resolution computed tomography; Random nodules; Miliary tuberculosis

Abbreviations

Acute respiratory distress syndrome: ARDS; High resolution computed tomography: HRCT; Tuberculosis: TB; Dilatation and curettage: D & C

Introduction

Miliary tuberculosis is a potentially fatal form of tuberculosis, occurs due to haematogenous spread of Mycobacterium tuberculosis. Diagnosis is often delayed because of non-specific clinical manifestations. Cryptic miliary tuberculosis is even more difficult to diagnose because of normal chest radiograph. Rarely miliary TB can lead to acute respiratory distress syndrome. We report a case of cryptic miliary tuberculosis, which presented with acute respiratory distress syndrome following dilatation and curettage.

Case report

A 25-year-old woman, housewife, was referred from postoperative intensive care unit for respiratory distress following the D &C for threatened abortion. She gave history of intermittent low-grade fever of 5 weeks duration. Beside this there were no significant past history. Her vitals before shifting to intensive care unit from procedure room were: pulse rate-140/min, respiratory rate- 32/min, and blood pressure of 108/70 mm Hg and oxygen saturation of 75% at room air. Bilateral fine basal crackles were auscultated on respiratory system examination. Other system examination was normal.

Patient was investigated. Her arterial blood gas analysis at FiO2 of 21% (room air) revealed pH-7.459, PCO2- 34.3 mm of Hg, PO2- 33.5 mm of Hg, SpO2-67.8 and HCO3 - -24.6 mEq/L, with PO2/ FiO2 ratio of 159.5 mm of Hg suggestive of acute respiratory distress syndrome (ARDS). She was started empirically on injectable antibiotics (imipenem, gentamicin and levofloxacin) for suspected genitourinary infection and septicemia, steroids for ARDS, and non-invasive ventilation for acute respiratory failure with a working diagnosis of ARDS secondary to septicemia. There was no evidence of giving intravenous fluid during the procedure. Initial biochemical reports were normal. Her haemogram showed haemoglobin -9.4 gm/dl, total leucocyte count of 6300/mm3 with normal differential cell percentage. Enzyme link immunosorbant assay for human immunodeficiency virus was negative. The chest radiograph prior to surgery was available, is shown in Figure 1. The chest radiograph in the ICU is shown in Figure 2. Transvaginal sonography was normal. Widal test for enteric fever, peripheral smear for malarial parasite, dengue serology, blood culture and urine culture were negative. The histopathology of specimen obtained after D & C showed only decidua without any evidence of infection. Echocardiography revealed trivial mitral regurgitation with normal ejection fraction. The patient was transferred to ward after 5 days with partial improvement. Fever during the ICU stay had reduced but on omitting levofloxacin, gentamicin and imipenem the fever spikes increased. HRCT thorax was advised for non-responding fever, showed bilateral ground glass opacity with patchy consolidation in both upper lobes and dense consolidation in both lower lobes. It also showed presence of ‘random nodules’ in both lung fields with bilateral pleural effusion (Figure 3). The patient was started on anti-tuberculosis treatment based on HRCT finding. Transbronchial lung biopsy was performed after partial clinical improvement, which showed epitheloid cell granuloma with necrosis on histopathology (Figure 4). Fever responded and she was discharged with normal vital parameters. One month after the discharge chest radiograph and HRCT were repeated and are shown in Figure 5 and 6.

clinical-respiratory-pleural-effusion

Figure 1: Chest radiograph prior to D & C showing doubtful left sided pleural effusion.

clinical-respiratory-bilateral-consolidation

Figure 2:Chest radiograph following D & C showing bilateral consolidation.

Discussion

Acute respiratory distress syndrome describes a condition characterized by the acute onset of bilateral infiltrates on chest radiograph, hypoxaemia (defined as a PaO2/FiO2 ratio of <200 mmHg) and no evidence of left atrial hypertension [1]. As per the new definition ARDS is categorized into mild, moderate and severe ARDS. Our case had findings consistent with moderate ARDS i.e. PaO2/FiO2 between 100-200 mmHg [2]. Miliary tuberculosis is a rare cause of ARDS [3,4]. However, the mortality is very high ranges from 33% to as high as 100%, 4 which is far higher than for ARDS from other causes. Due to low causal association, the diagnosis of miliary tuberculosis as the cause of ARDS is delayed or often missed.

clinical-respiratory-random-nodules

Figure 3a and 3b: HRCT thorax showing presence of ‘random nodules’ in both upper lobes and consolidation and effusion in both lower lobes.

clinical-respiratory-epitheloid-granuloma

Figure 4:Transbronchial lung biopsy showing epitheloid granuloma with necrosis.

clinical-respiratory-Normal-chest

Figure 5:Normal chest radiograph after 1 month of treatment.

clinical-respiratory-showing-improvement

Figure 6a and 6b: HRCT thorax after 1 month of treatment showing improvement but persistence of a few random nodules confirming ‘cryptic miliary’.

Early diagnosis and timely treatment due to characteristic HRCT abnormality saved our patient. The HRCT showed areas of consolidation with “random nodules”. “Random nodules” are small nodules seen on HRCT distributed haphazardly throughout the lungs along the pleura and fissures, at the ends of small arteries, and also in a centrilobular location [5]. These nodules on HRCT are seen in miliary tuberculosis, fungal infection, and metastasis and Langerhans cell histiocytosis. Possibility of fungal infection was low because she was immunocompetent. Metastasis was also unlikely because of young age and absence of primary malignancy. Langerhans cell histiocystosis was also unlikely because of fever and relatively acute onset of disease. Hence, on clinico-radiological correlation the most plausible diagnosis was miliary tuberculosis presenting with ARDS. The diagnosis was further proved on lung biopsy.

The possible mechanism of ARDS is that tuberculosis causes accumulation of inflammatory cells in the alveolar spaces leading to release of granular enzymes and oxidants resulting in damage to the alveolar basement membrane. Increase in cellular permeability due to alveolar basement damage aggravates oxygen dysfunction and consequently causes ARDS [6].

The predisposing factors for development of ARDS in a case of miliary TB are prolonged illness, absolute lymphocytopaenia, elevated alanine transferase (ALT), aspartate transaminase (AST), diabetes mellitus, D-dimer, low hemoglobin, and albumin [7,8]. None of the studies have shown surgery as a risk factor for development of ARDS. However surgery is known to disseminate unrecognized tuberculosis [9]. D & C possibly led to the development of ARDS in our case with existing ‘cryptic miliary TB’, which was missed during preoperative evaluation. ‘Cryptic miliary TB’ often remains undiagnosed because typical chest radiograph findings are not absent. D & C thus can be added as a risk factor for development of ARDS due to miliary TB.

Initial mortality due to ARDS in our patient was averted possibly because of antimycobacterial action of gentamicin [10], levofloxacin and imipenem [11]. Partial response of ARDS and miliary TB can only be explained by antimycobacterial action of antibiotics, as she had no evidence of pyogenic infection. Steroid also had possibly helped our patient because promising results regarding the efficacy of steroids as a treatment modality for ARDS caused by miliary tuberculosis has been reported [12].

In conclusion, thorough preoperative evaluation is indicated prior to any surgery. Presence of ‘random nodule’ is an important clue to the diagnosis of miliary TB in a case of ARDS. Early diagnosis and prompt treatment of ARDS due to miliary TB averts mortality.

Acknowledgements

We would like to thank Dr. Suprithi Kohli, HOD, and Radiology for providing the images.

References

Select your language of interest to view the total content in your interested language
Post your comment

Share This Article

Relevant Topics

Recommended Conferences

  • Annual Congress on Research and Innovations in Medicine
    July 02-03, 2018 Bangkok, Thailand
  • Global Physicians and Healthcare Congress
    June 25-27, 2018 Dubai, UAE
  • International Conference on Medical and Health Science
    August 24-25, 2018 Tokyo, Japan
  • 8th International Congress on Health and Medicine
    October 08-09, 2018 Osaka, Japan

Article Usage

  • Total views: 8120
  • [From(publication date):
    March-2016 - Dec 15, 2017]
  • Breakdown by view type
  • HTML page views : 8050
  • PDF downloads : 70

Review summary

  1. Gwen Loven
    Posted on Aug 29 2016 at 12:32 pm
    The authors described the case of a young woman with respiratory problems after a gynecological intervention. The diagnostics revealed a miller tuberculosis. The paper is well written, the case is consistently described.
 

Post your comment

captcha   Reload  Can't read the image? click here to refresh

Peer Reviewed Journals
 
Make the best use of Scientific Research and information from our 700 + peer reviewed, Open Access Journals
International Conferences 2017-18
 
Meet Inspiring Speakers and Experts at our 3000+ Global Annual Meetings

Contact Us

Agri & Aquaculture Journals

Dr. Krish

[email protected]

1-702-714-7001Extn: 9040

Biochemistry Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Business & Management Journals

Ronald

busine[email protected]

1-702-714-7001Extn: 9042

Chemistry Journals

Gabriel Shaw

[email protected]

1-702-714-7001Extn: 9040

Clinical Journals

Datta A

[email protected]

1-702-714-7001Extn: 9037

Engineering Journals

James Franklin

[email protected]

1-702-714-7001Extn: 9042

Food & Nutrition Journals

Katie Wilson

[email protected]

1-702-714-7001Extn: 9042

General Science

Andrea Jason

[email protected]

1-702-714-7001Extn: 9043

Genetics & Molecular Biology Journals

Anna Melissa

[email protected]

1-702-714-7001Extn: 9006

Immunology & Microbiology Journals

David Gorantl

[email protected]

1-702-714-7001Extn: 9014

Materials Science Journals

Rachle Green

[email protected]

1-702-714-7001Extn: 9039

Nursing & Health Care Journals

Stephanie Skinner

[email protected]

1-702-714-7001Extn: 9039

Medical Journals

Nimmi Anna

[email protected]

1-702-714-7001Extn: 9038

Neuroscience & Psychology Journals

Nathan T

[email protected]

1-702-714-7001Extn: 9041

Pharmaceutical Sciences Journals

Ann Jose

[email protected]

1-702-714-7001Extn: 9007

Social & Political Science Journals

Steve Harry

[email protected]

1-702-714-7001Extn: 9042

 
© 2008- 2017 OMICS International - Open Access Publisher. Best viewed in Mozilla Firefox | Google Chrome | Above IE 7.0 version