Health and services

Abnormal radiological signs
Female patient 71 years old , known dibetic and CRF on dialysis , presented with severe anemia (Hb. 7gm/dl) , fever ,shivering , pleuritic ,right sided chest pain and productive cough with rust colored sputum , follwed by progressive dyspnea and orthopnea , permanent catheter (permicath.) was located , CBC revealed leucocytosis . Together with this illustrated x-ray .
(Q) What are the differential diagnosis?

(Q) How could this condition be managed ?
Discussion :
Notice the right middle and lower zone patchy parenchymal consolidation containing discrete dark patches ( air bronchogram) (red arrows) .along with the right cardiac border distorting the outlines of the right hilum and right atrium , on the left the outlines of the aortic arch ,left hilum and left ventricle are clear . Notice also the right pneumomediastinum (black arrow) which is presence of exraluminal gas within the mediastinum .

Notice also the multiple thin walled air filled cystic like cavities (pneumatoceles) {blue arrows} - The mediastinum is slightly displaced to the left . There is hydropneumothorax , the right hemidiaphragm is indistinguishable with blunting of the costophrenic angle . This x-ray demonestrates one of the possible complications of staphylococcal pneumonia with multiple pneumatoceles and pneumomediastinum .
Differential diagnosis :
From other causes of necrotizing pneumonias and lung abscesses (A) Infectious causes : (1) Staphylococcal pneumonia : most common in diabetics , dialysis patients , with permenant iv catheter , rapidly progressive ,characterized by cavty and pneumatocele formation , pleural effusion is common , pneumothorax can occur (2) klebisella pneumoniae :common in alcoholics with poor dentition and poor nutrition aspiration is common with aerobic and micro aerophilic oral flora .

(3) septic pulmonary emboli : associated with iv drug use or intravascular prosthetic material .
Uncommon bacterial infections :
Actinomycosis - Nocardia -meliodosis -rhodococcus equi
- Mycobacterial : Mycobacterium tuberculosis - Mycobacterium avium complex
Fungal : pulmonary aspergillosis - zygomycosis -histoplasmosis -blastomycosis- coccidiomycosis -cryptococcosis
(B) Non infectious causes :
-Primary lung cancer - Wegener's granulomatosis - Sarcoidosis -primary amyloidosis -pulmonary infarction and necrosis

Management : - Removal of foci of infection whenever possible - Antibiotics - Insertion of chest tube - supportive and symptomatic management