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PROVOCARE DIAGNOSTICA – CE POATE ASCUNDE gRANULOMATOZA

PROVOCARE DIAGNOSTICA – CE POATE ASCUNDE gRANULOMATOZA. Sectia Medicala II Spitalul Universitar de Urgenta Militar Central Dr. Carol Davila Medic rezident , Oana Stancu , anul I. Anamneza. 61 ani, bărbat

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PROVOCARE DIAGNOSTICA – CE POATE ASCUNDE gRANULOMATOZA

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  1. PROVOCARE DIAGNOSTICA – CE POATE ASCUNDE gRANULOMATOZA Sectia Medicala II Spitalul Universitar de Urgenta Militar Central Dr. Carol Davila Medic rezident, Oana Stancu, anul I

  2. Anamneza • 61 ani, bărbat • INTERNARE 2012 : fatigabilitate, astenie, dispnee, scădere ponderala aproximativ 10kg in 2-3 luni. • APP: -hiperuricemie, guta cronica tofacee, nefropatie urica -diabet zaharat tip II echilibrat cu ADO -dislipidemie • tratament cronic alopurinol, rosuvastatin, ADO (diaprel).

  3. Examenul clinic • deformarearticulatiilormicimainisipicioare • tofigutosivoluminosicoatesipicioare • ficat cu margineainferioara 4 cm sub rebord, rotunjita, consistentacrescuta

  4. Date biologice • Sindrom biologic inflamator VSH 51mm/h ( <10mm/h), CRP 24mg/dl ( <6mg/dl), fibrinogen 920 mg/dl ( 183-383 mg/dl). • Hiperuricemiesiretentieazotata ac. uric 11.5g/dl ( 2,6-7,2 g/dl), creatinina 1.5 mg/dl ( 0,6-1,3 mg/dl). • Glicemie135 mg/dl( 74-106mg/dl), HbA1c 6.8 Sindrom de colestazasicitoliza hepatica GGT 425 ui/ml ( 5-85ui/l), ALP 311ui/l (50-136ui/l), TGO 94 ui/l (15-37ui/l), TGP 311 ui/l ( 30-65ui/l). Markerivirali ( AgHbs, AC.anti VHC)- negativi

  5. Ecografieabdominala • Ficat cu dimensiunicrescute, structuradifuzsiintens neomogena, colecist cu pereteingrosat , aspect edematiat , cu imagini de calculi; RD cu structuracompletremaniata cu stergerea conturuluidintrecorticalasimedulara.

  6. ExplorariparacliniceRx cord pulmon • hiluricu arie de proiectiemarita; conturpoliciclic; posibilecalcificari in interior; desen interstitial accentuat. • opacitatimicronodularesinodulare , parahilardreaptasistanga .

  7. CT TORACE Micronodulisinoduli cu dimens. maxime 1 cm localizati in segm ventral LSD siparahilar Adenopatiimediastinaleparatraheale, infracarinale, intertraheobronsicedreptedimens.max 2/1,4 cm. CT abdominal : ficat cu dimensiunimultcrescutesimiciadenopatii in pediculul hepatic

  8. Bronhoscopie laringe cu dinamicaprezenta; coardavocalastanga la polul posterior cu buchet de granuloame ulcerate; arborelebronsic bilateral cu aspect bronsitic, peteantracotice, faraaspecte proliferative; Aspiratbronsic– BK absent in frotiu direct; culturi BK – in lucru; LBA - limfocitoza cu CD4/CD8multcrescut.

  9. Biopsie hepatica Fragmentebiopsice de tesut hepatic cu arhitecturalobularaconservata, prezentandfibrozasiinfiltratinflamatoralcatiut din limfocite predominant si din rare eozinofile la nivelulspatiilorporte, faraprezenta de leziuni ale ductelor; se gasescdeasemeneasigranuloameepiteloidegigantocelulare, faraprezenta de necroza de cazeificare , atat la nivelulspatiilorporte cat siintralobular, sugerandinflamatiegranulomatoasasarcoidozica.

  10. Date suplimentare • S-a determinatenzima de conversie a angiotensinei 102 u/l (N 12-68). • Examenoftalmologicsi dermatologic- faraparticularitati. • Avand in vedereprezentagranulomului hepatic sarcoidozicsiaspectul LBA, celmaiprobabilafectareapulmonara are aceeasietiologie. • Polip de coardavocalaexcizat-polipangioedematosasociate cu fragmente de mucoasaacoperite de epiteliuscuamospapilomatos, marcathiperkeratozic, moderatdisplazic

  11. Diagnostic • 1. Sarcoidoza hepatica sipulmonara • 2. Hiperuricemie. Gutacronicatofacee. Nefropatieuricainterstitiala. Boalacronica de rinichi • 3. Diabetzaharat tip II echilibrat cu ADO • 4. Formatiunetumoralacoardavocalastanga.

  12. Tratament • Prednison40 mg /zi ( 0,5mg/kgc) • Milurit 100 mg 1cp/zi • Diaprelmr 35 mg 2cp/zi 1 luna • Evolutie cu ameliorareclinicasemnificativainvolutiahepatomegalieisi a sindromului de colestaza

  13. BK prezent in culturi , dupa 2 luni TUBERCULOZAPULMONARA

  14. Internareftiziologiemai 2012 se instituietratament H300R600Z2000E1600 7/7

  15. Evenimenteleulterioare • NOIEMBRIE 2013 - Reevaluarepneumologie: • Bronhoscopiecu LBA siaspiratbronsic: citologienormala, flora farasemnificatiepatogenica, BK absent in frotiudirect; • BK in culturi - in lucru; • - CT toracic- faramodificaripatologice. • - Biologic: usoaracolestazasicitolizahepatia (TGO 65ui/l; TGP 105ui/l; GGT 160ui/l; ALP 186ui/l • IANUARIE 2014: Medicala II • Hepatomegalie cu consistentacrescuta; TGO 128 ui/l ( 15-37ui/l), TGP 136 ui/l ( 30-65ui/l), GGT 621 ui/l ( 5-85ui/l); ALP 558ui/l (50-136ui/l); • Eco abdomen: faradilatatie de CBP si CBIH; aspect neomogen • S-a repetatbiopsia hepatica- aspect similar anterioara; • Reluareacorticoterapiei- Prednison 40 mg/zi ( 0,5mg/kgc) cu scadereatreptata a dozei. • -evolutieclinicasiparaclinicasatisfacatoare la 4 luni.

  16. Diagnostic final • 1. Sarcoidoza hepatica sipulmonara • 2. Tuberculozapulmonara • 3. Hiperuricemie. Gutacronicatofacee. Nefropatieuricainterstitiala. Boalacronica de rinichi • 4. Diabetzaharat tip II echilibrat cu ADO • 5. Formatiunetumoralacoardavocalastanga.

  17. Discutii • Prezentaconcomitenta a celordouapatologii la acelasipacient- RARA (putinecazuri in literatura). • Provocarediagnostica: proceduridiagnosticesimilare • Capcanapentruclinicieni- prezentauneia nu poate exclude existentaceleilalte. • Gandiremedicalasiconduitaterapeuticaampla in fata unuiastfel de caz

  18. Vamultumesc!

  19. Examen radiologic Rx maini Cresterea intensitatiitesuturilormoiadiacente art metacarpofalangianadeget II-III manastanga, epifizadistalametacarpian II cu structuraosoasademineralizatasicontursters. Rx bazinsiarticulatiisacroiliace Coxartrozaavansata bilateral osteocondensareversantiososarticulatiisacroiliace

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