Pulmonology
Section 7: Pulmonology
7.1 COMMON CONDITIONS Acute Follicular Tonsillitis
Figure 7.1.1: Acute follicular tonsillitis Photo Courtesy: S Nagabhushana, Bengaluru
Erythematous tonsils with exudate.
Symptoms: Painful swallowing, dry throat, malaise, fever and chills, dysphagia, referred otalgia, headache, muscular aches, and enlarged cervical nodes.
Signs: Dry tongue, erythematous enlarged tonsils, tonsillar or pharyngeal exudate, palatine petechiae, and enlargement and tenderness of the jugulodigastric lymph nodes.
Penicillin is the drug of choice.
Cephalosporins or clindamycin in chronic infections.
Tonsillectomy if (any):
• 7 or more episodes in 1 year
• 5 or more episodes over 2 years
• Tonsillitis causing upper respiratory obstruction
• Tonsillar abscess
Cautery with silver nitrate: For chronically infected tonsillar crypts.
Acute Laryngotracheobronchitis (ALTB)
Figure 7.1.2: ALTB—“Steeple sign”
Photo Courtesy: TU Sukumaran, PIMS, Thiruvalla
Narrowing of subglottic region of the upper airway (steeple sign) is seen.
ALTB is mainly caused by various viruses; the most common is parainfluenza virus type B.
It is the most common form of acute upper airway obstruction.
Symptoms: 1 to 3 days history of upper respiratory tract infection followed by barking cough, hoarseness and inspiratory stridor.
Signs: Hoarse voice, coryza , normal to moderately inflamed pharynx and tachypnea.
The most common site of obstruction is subglottic area.
• Airway management.
• Humidified O2.
• Nebulized racemic/nonracemic epinephrine.
• Oral/nebulized corticosteroids are effective.
• Heliox—helpful in severe croup.
• Other supportive therapy.
• Antibiotics are not indicated in croup.
Acute Otitis Media (AOM)
Figure 7.1.3: Acute suppurative otitis media (ASOM)
Photo Courtesy: S Nagabhushana, Bengaluru
The hyperemic bulging eardrum with loss of cone of light.
AOM can be nonsuppurative or suppurative; both produce middle ear effusion. Bulging, angry-red eardrum (as seen in Fig. 7.1.3) associated with pain and immobility is characteristic of acute suppurative otitis media (ASOM).
Antibiotics: In patients, <6 months of age, even presumed AOM should be treated. For <2 years of age treat all confirmed cases of AOM.
In children >2 years of age, treat confirmed, severe episodes. First line—Amoxicillin. Second line—
co-amoxiclav, cefuroxime axetil, or IM ceftriaxone. The duration of treatment—10 days for <2 years and 3 to 5 days for older children. Rarely myringotomy is necessary.
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Acute Respiratory Distress Syndrome (ARDS)
Figure 7.1.4: ARDS in dengue hemorrhagic fever Photo Courtesy: NK Kalappanavar,
S Kavya, Davangere
X-ray showing areas of relatively normal lung interspersed with atelectatic and consolidated regions that are concentrated towards the dependent zones.
ARDS, the noncardiogenic pulmonary edema, is defined, by the presence of an acute onset respiratory distress with PaO2/ FiO2 ratio ≤300 mm Hg, bilateral infiltrates on chest radiograph, absence of left heart failure.
Causes: Sepsis, pneumonia, near drowning, pumonary embolism, lung contusion, shock, SIRS, etc.
• Eliminate the initiating factor.
• Mechanical ventilation with high PEEP and low tidal volume is the main stay of treatment.
• Other treatment modalities:
– Recruitment maneuver: initial high PEEP (sec to min)
– Inverse ratio ventilation: IT>ET – Permissive hypercapnea – Diuretics
– Prone positioning (“Proning”) – NO (Nitric Oxide).
– Reduce metabolic rate (sedation, treat fever) – Extracorporeal membrane
oxygenation (ECMO) in newborns and small infants, who are unresponsive to mechanical ventilation – Exogenous surfactant.
Adenoid Facies
Figures 7.1.5A and B: (A) Adenoid facies;
(B) X-ray showing adenoid hypertrophy Photo Courtesy: S Nagabhushana, Bengaluru and Vijay Yewale, Navi Mumbai
Typical facies with prominent upper lips, protruded maxillary teeth, suggestive of adenoidal hypertrophy (Fig. 7.1.5A).
Other features could be: high arched palate, snoring, sleep apnea/
hypopnea. Important trigger for posterior nasal drip and asthma.
Group A streptococci are the causative agents. X-ray adenoid (Fig. 7.1.5B) shows soft tissue bulge (adenoids) narrowing the nasopharynx.
• Penicillin—the drug of choice cephalosporins or clindamycin may be more efficacious in chronic infections.
• Adenoidectomy—in chronic adenoiditis.
Allergic Rhinitis
Figure 7.1.6: Allergic rhinitis
Photo Courtesy: S Nagabhushana, Bengaluru and Devaraj Raichur, Hubli
“Allergic Salute” of allergic rhinitis is demonstrated.
Dennie Morgan Line (nasal crease) is seen.
• Avoidance of known allergens.
• Oral antihistamines.
• Intranasal steroids.
• Oral/nasal alpha-agonists.
• Specific allergen immunotherapy.
• Monoclonal recombinant humanized anti-IgE.
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Asthma
Figure 7.1.7: Asthma–hyperinflated lungs Photo Courtesy: Devaraj Raichur, KIMS, Hubli
Hyperinflated lungs, indicating air-trapping, are seen.
Asthma is a chronic inflammatory condition of the lung airways resulting in episodic airflow obstruction.
Intermittent dry coughing and/or expiratory wheezing are the most common chronic symptoms of asthma.
Respiratory symptoms can be worse at night, especially during prolonged exacerbations triggered by respiratory infections or inhalant allergens.
• Eliminating and reducing problematic environmental exposures.
• Treat co-morbid conditions
• Management in acute exacerbation:
– Oxygen and inhaled short- acting β-agonists.
– Systemic corticosteroids – Nebulized anticholinergic
(Ipratropium bromide).
– IV Magnesium sulfate infusion – IV Aminophylline.
– Epinephrine 0.01 mg/kg SC or IM
– Terbutaline IV infusion.
• Home treatment: Depends on severity of the chronic symptoms.
Barrel-Chest in a Ventilated Baby
Figure 7.1.8: Barrel-chest in a ventilated baby Photo Courtesy: Devaraj Raichur, KIMS, Hubli
Increased AP diameter of the chest is evident.
This could be due to MAS but in a ventilated baby, hyperinflation of the lungs due to unduly high positive end-expiratory pressure (PEEP) in an improving lung disease can also result in such a picture.
• Keep PEEP low.
• Avoid generation of significant auto-PEEP.
• Allow enough expiratory time.
Bronchiectasis
Figure 7.1.9: Bronchiectasis
Photo Courtesy: TA Shepur, KIMS, Hubli
Bilateral dilatation of the bronchi at various levels is visible; left > right.
Bronchiectasis: Irreversible abnormal dilatation of the bronchial tree.
Symptoms: Cough and copious purulent sputum; Others:
Hemoptysis, fever, anorexia and poor weight gain.
Signs: Crackles localized to the affected area, wheezing, and digital clubbing.
• The initial therapy is to decrease airway obstruction and control infection.
• Chest physiotherapy.
• Bronchodilators 2 to 4 weeks of antibiotics.
• Chronic prophylaxis: Oral macrolide or nebulized antibiotics.
• Underlying disorder should be addressed.
• Sometimes segmental or lobar resection is done in localized bronchiectasis.
• Rarely lung transplantation.
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Empyema
Cellulitis in the Dangerous Area of Face
Figure 7.1.11: Cellulitis of the nose–dangerous area of the face
Photo Courtesy: S Nagabhushana, Bengaluru
Swelling, redness and tenderness of the tip of the nose are present.
Infections in the “Dangerous area of the face” can lead to cavernous sinus thrombosis.
• Antibiotics covering Streptococci, Staphylococcus aureus, and H.
influenzae. (e.g. Co-amoxyclav).
• Symptomatic therapy.
Bronchiolitis
Figure 7.1.10: Bronchiolitis
Photo Courtesy: Devaraj Raichur, KIMS, Hubli
Hyperinflated lungs are seen.
Common age: 2 months to 2 years.
Predominantly a viral disease.
Respiratory syncytial virus (RSV) is the most common cause. Other agents include parainfluenza and adenoviruses, Mycoplasma, and other viruses.
Starts as mild upper respiratory tract infection (URTI) followed by respiratory distress with wheezy cough, dyspnea and irritability.
• Mainly supportive.
• Cool humidified O2.
• Bronchodilators.
• Corticosteroids are not recommended in previously healthy children.
• In children with congenital heart or lung disease, ribavirin may be administered by aerosol.
• Antibiotics only in secondary bacterial pneumonia.
Figures 7.1.12A and B: (A) Right Empyema;
(B) Right Empyema–CT scan Photo Courtesy: NK Kalappanavar, S Kavya, Davangere
Empyema, collection of pus in pleaural space, is usually a complication of untreated or inadequately treated pneumonia.
Symptoms: Cough, dyspnea, retractions, tachypnea, orthopnea, or cyanosis.
Physical findings: Signs suggestive of pleural effusion.
Empyema is usually differentiated from serofibrinous pleurisy by thoracocentesis.
Cross-section CT thorax showing pleural collection with collapsedright lung (Fig. 7.1.12B).
• Antibiotics.
• Thoracentesis and chest tube drainage with or without a fibrinolytic agent.
• Video-assisted thoracoscopic surgery (VATS) or open decortications.
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Hydropneumothorax/Pyopneumothorax
Figure 7.1.13: Hydropneumothorax–left side Photo Courtesy: TU Sukumaran, PIMS, Thiruvalla
Air-fluid level indicates presence of gas and liquid in the pleural space.
Treatment: as in pleural effusion/
empyema.
Klebsiella Pneumonia
Figure 7.1.14: Klebsiella pneumonia
Photo Courtesy: TU Sukumaran, PIMS, Thiruvalla
Upper lobe involvement with pneumatoceles and loculated empyema is suggestive of Klebsiella pneumonia.
Klebsiella pneumonia is common in newborns. Sputum appears like
‘Red Currant Jelly’. X-ray may show
‘Bulging fissure sign’.
Antibiotics effective against Klebsiella:
• Amoxicillin-clavulanate (20–45 mg/kg /24 hr divided q 8–12 hr PO).
• Ceftriaxone (50–75 mg/kg q 24 hr IV or IM).
• Amikacin (15–25 mg/kg/24 hr divided q 8–12 hr IV or IM).
Klebsiella Pneumonia—‘Bulging Fissure Sign’
Figure 7.1.15: Klebsiella pneumonia—Bulging fissure sign
Photo Courtesy: Devaraj Raichur, KIMS, Hubli
Bulging lower border of
consolidated right upper lobe is suggestive of Klebsiella pneumonia.
Antibiotics effective against Klebsiella:
• Amoxicillin-clavulanate (20–45 mg/kg /24 hr divided q 8–12 hr PO).
• Ceftriaxone (50–75 mg/kg q 24 hr IV or IM).
• Amikacin (15–25 mg/kg/24 hr divided q 8–12 hr IV or IM).
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Lung Abscess
Figure 7.1.16: Lung abscess
Photo Courtesy: TU Sukumaran, PIMS, Thiruvalla
Localized area of thick-walled cavity is seen in the right mid-zone.
Etiologic agents: Anaerobic and aerobic bacteria. Fungi in immunocompromised patients.
Symptoms: Cough, fever, dyspnea, chest pain, vomiting, sputum production, weight loss, and hemoptysis.
Signs: Tachypnea, retractions with accessory muscle use, decreased breath sounds, and dullness to percussion in the affected area.
• For uncomplicated cases, antibiotics for 4 to 6 weeks, covering S. aureus, anaerobes and gram-negative bacteria.
• For severely ill patients who fail to improve after 7 to 10 days of antimicrobial therapy, surgical interventions like percutaneous aspiration techniques, and rarely thoracotomy with lobectomy and/or decortication may be necessary.
Measles Bronchopneumonia
Figure 7.1.17: Measles bronchopneumonia Photo Courtesy: Devaraj Raichur, KIMS, Hubli
Fine, reticular interstitial opacities are evident in the radiograph of a child having measles with respiratory distress.
Measles bronchopneumonia (Giant cell pneumonia) is caused directly by measles virus.
It should be differentiated from superimposed bacterial infections, which are also common.
• Airway humidification and supplemental oxygen.
• Ventilator support—in case of respiratory failure.
• Prophylactic antimicrobial therapy is not indicated.
Antimicrobials are used if bacterial pneumonia cannot be ruled out.
• Vitamin A supplementation.
Meconium Aspiration Syndrome (MAS)
Figure 7.1.18: Barrel-chest in MAS
Photo Courtesy: Devaraj Raichur, KIMS, Hubli
Increased anteroposterior (AP) diameter of chest is seen in a neonate with MAS.
Meconium staining of the skin and the umbilical cord are commonly seen.
Normally, infants have relatively higher AP diameter than older children and adults, but the ball- valve mechanism of the aspirated meconium increases the AP diameter further.
• Supportive care and standard management of respiratory distress.
• Exogenous surfactant in severe cases.
• Continuous positive airway pressure (CPAP) and mechanical ventilation in moderate-to-severe MAS.
• High frequency ventilation (HFV).
• inhaled nitric oxide (iNO).
• Extracorporeal membrane oxygenation (ECMO).
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Miliary Tuberculosis of the Lungs
Figure 7.1.19: Miliary tuberculosis of the lungs Photo Courtesy: Devaraj Raichur,
HS Surendra, KIMS, Hubli
The fine, round, millet-like opacities in both lung fields (miliary
mottling) with right paratracheal lymphadenopathy.
Miliary tuberculosis is the most clinically significant form of disseminated tuberculosis.
More common in infants, malnourished and
immunocompromised children.
• Antitubercular therapy (ATT)—
2HRZE3 + 4HR3 (DOTS regimen) given for 6 months.
• Fever usually declines within 2 to 3 weeks of starting ATT.
• Corticosteoids relieve symptoms faster.
Pleural Effusion
Figure 7.1.20: Bilateral pleural effusion in congenital Chikungunya
Photo Courtesy: Devaraj Raichur, KIMS, Hubli
Bilateral thin layer of opacity separating the rib-cage from the lungs.
• Supportive therapy.
• Therapeutic pleural tap if severe respiratory distress occurs.
Pleural Effusion/Empyema
Figure 7.1.21: Left pleural effusion with left lung collapse-consolidation
Photo Courtesy: Devaraj Raichur, KIMS, Hubli
Homogeneous opacity obliterating left costophrenic angle with mediastinal shift to right is seen.
Pleural effusion could be a transudate or an exudate.
Commonest cause—bacterial pneumonia. Large effusions produce cough and respiratory distress.
Signs: Mediastinal shift to opposite side, fullness of the intercostal spaces, reduced tactile fremitus, stony dullness, decreased or absent breath sounds.
• Treat the underlying disease.
• Therapeutic thrococentesis.
• Chest tube drainage—when fluid reaccumulates to cause respiratory embarrassment or if fluid is purulent.
• In parapneumonic effusion with pleural fluid pH <7.20 or glucose level <50 mg/dl, tube thoracostomy is done.
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Pneumocystis jiroveci (carinii) Pneumonia
Figures 7.1.22A and B: Pneumocystis jiroveci (carinii) pneumonia
Photo Courtesy: Vinod Ratageri, TA Shepur KIMS, Hubli
(Fig. 7.1.22A) Right upper zone and lower zone consolidation;
Left upper zone and middle zone consolidation; Sparing of right middle zone suggesting Pneumocystis jiroveci pneumonia:
It is a life-threatening infection in the immunocompromised children without prophylaxis,~40% of children with AIDS, 12% of children with leukemia, and 10% of patients with organ transplant recipients experience P. carinii pneumonia.
(Fig. 7.1.22B) Bilateral extensive poorly defined nodular shadows seen mainly in the right lobe. Thick walled cavitatory lesion seen in right lower lobe apical segment.
Thickening of the bronchovascular interstitium seen in bilateral parahilar region.
• (A and B) Trimethprim- sulfamethoxazole (TMP-SMZ) (15–20 mg TMP/kg/day divided qid).
• Duration: 3 weeks in AIDS and 2 weeks for others.
• Alternatively, pentamidine isethionate (4 mg/kg as a single daily dose IV).
• Atovaquone (750 mg bid with food, for >13 years of age).
• Other effective therapies include trimetrexate glucuronate or combinations of trimethoprim plus dapsone, or clindamycin plus primaquine.
• Corticosteroids (Prednisolone) are used for moderate to severe cases.
Pneumococcal Pneumonia
Figure 7.1.23: Collapse—consolidation of right upper lobe
Photo Courtesy: TU Sukumaran, PIMS, Thiruvalla
Lobar/segmental distribution of pneumonia. Commonly seen with pneumococcal pneumonia.
Pneumococcal pneumonia manifests as tachypnea, increased work of breathing, cyanosis and respiratory fatigue. Chest auscultation -crackles and wheezing.
• Multidrug resistant (MDR) strains of have been reported.
• Penicillin-G—drug of choice for sensitive organisms.
• High-dose cefotaxime and ceftriaxone are effective, even in cephalosporin-resistant strains.
• For MDR pneumococci:
Vancomycin (resistance has not been seen to date). Linezolid is an alternative.
Primary Complex
Figure 7.1.24: Primary complex Photo Courtesy: KE Elizabeth, GMC Thiruvananthapuram
Spindle shaped effusion into the minor fissure in a child with strongly positive Mantoux test.
2HRZE3 + 4HR3 as per the revised category I of RNTCP (2011).
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Respiratory Distress
Figure 7.1.25: Respiratory distress in a neonate Photo Courtesy: Devaraj Raichur, KIMS, Hubli
Respiratory distress manifested as: Chest retractions (subcostal retractions) and intercostal retractions.
Other manifestations could be acting alae nasii, and accessary muscles of respiration, cyanosis.
Various airway and pulmonary parenchymal conditions can produce chest retractions.
• Assess ABCs
• O2 therapy
• Maintain PaCO2
• CPAP
• IMV
• Treat the underlying disorder.
Respiratory Distress Syndrome (RDS)
Figure 7.1.26: RDS in a neonate
Photo Courtesy: Devaraj Raichur, KIMS, Hubli
Ground-glass appearance of lungs with air-bronchogram.
Borders of the heart are ill-defined.
Clinical manifestations: Primarily premature infants, tachypnea, grunting, intercostal and subcostal retractions, nasal flaring, and duskiness/cyanosis. Later shock ensues.
Breath sounds: Normal or diminished ± fine rales.
• Most are self-limited.
• Avoid hypothermia.
• Warm humidified O2 to maintain PaO2 50 to 70 mm Hg.
• Surfactant therapy in moderate to severe cases of RDS.
• CPAP/IMV if PaO2 cannot be maintained above 50 mm Hg.
• Other modalities of treatment are high frequency ventilation, ECMO and inhaled nitric oxide (iNO).
Retropharyngeal Abscess
Figures 7.1.27A and B: (A) Retropharyngeal abscess; (B) Lateral X-ray of retropharyngeal abscess
Photo Courtesy: JK Lakhani, Gadag
(Fig. 7.1.27A) The swelling of face, and the torticollis produced by a retropharyngeal abscess.
Symptoms: Fever, irritability, decreased oral intake and drooling.
Neck stiffness, torticollis and refusal to move the neck.
Signs: Muffled voice, stridor, and respiratory distress. Physical examination- Bulging of the posterior pharyngeal wall, cervical lymphadenopathy may be present.
(Fig. 7.1.27B) Lateral X-ray of neck of the above patient clearly shows the increased space between the pharyngeal air shadow and the vertebrae.
Posterior pharyngeal wall is bulging.
• Intravenous antibiotics with or without surgical drainage.
• A third generation cephalosporin with ampicillin-sulbactam or clindamycin to provide anaerobic coverage is effective.
• Patients who have respiratory distress or who fail to improve with intravenous antibiotics can be treated with surgical drainage.
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Cavitatory Tuberculosis with Necrotizing Bronchopneumonia
Figures 7.1.28A and B: Cavitatory tuberculosis with necrotizing bronchopneumonia: (A) X-ray and (B) CT scan
Photo Courtesy: Devaraj Raichur, KIMS, Hubli
(Fig. 7.1.28A) Cavitatory lesions in the right lung with extensive infiltrates in left lung in a child with sputum positive tuberculosis.
Cavitatory pulmonary tuberculosis is uncommon in children, but may be seen, as in this instance.
(Fig. 7.1.28B) CT scan of the same child as above, clearly depicting the necrotizing nature of the lesions.
Drug regimen for revised categories under Rural National Tuberculosis Control Programme (RNTCP) (2011) are:
• Cat I (New): 2HRZE3 + 4HR3
• Cat II (Previously treated):
2HRZES3 + 1HRZE3 + 5HRE3 Steroids—in bronchial obstruction, massive pleural effusion and miliary tuberculosis.
Staphylococcal Pneumonia
Figure 7.1.29: Staphylococcal pneumonia Photo Courtesy: TU Sukumaran, PIMS, Thiruvalla
Extensive destruction of lung parenchyma with formation of cavities bilaterally is visible indicating staphylococcal pneumonia.
S. aureus produces confluent bronchopneumonia.
Characterized by the presence of extensive areas of hemorrhagic necrosis and irregular areas of cavitation of the lung parenchyma, ending in pneumatoceles, empyema or at times, bronchopulmonary fistulas.
• Cloxacillin or cefazolin- Initial antibacterial for serious infections thought to be due to methicillin- susceptible S. aureus (MSSA).
• Vancomycin for the initial treatment for penicillin-allergic individuals and for suspected serious S. aureus infections that might be due to MRSA (Alternatives: linezolid or teicoplanin).
Figure 7.1.30: Staphylococcal pneumonia Photo Courtesy: Devaraj Raichur, KIMS, Hubli
Bilateral consolidation with cavities is seen.
• Cloxacillin or cefazolin- Initial antibacterial for serious infections thought to be due to methicillin- susceptible S. aureus (MSSA).
• Vancomycin- for the initial treatment for penicillin-allergic individuals and for suspected serious S. aureus infections that might be due to MRSA (Alternatives: linezolid or teicoplanin).
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Tuberculoma of Right Lung
Figure 7.1.31: Tuberculoma of right lung Photo Courtesy: Vinod Ratageri, TA Shepur KIMS, Hubli
Calcified nodular (round) lesion involving middle and lower lobe of right lung is clearly visible.
Drug regimen for revised categories under RNTCP (2011) are:
• Cat I (New): 2HRZE3 + 4HR3
• Cat II (Previously treated):
2HRZES3 + 1HRZE3 + 5HRE3 Steroids—in bronchial obstruction, massive pleural effusion and miliary tuberculosis.
Tuberculoma of Right Lung—CT Scan
Figure 7.1.32: Tuberculoma of right lung—
CT scan
Photo Courtesy: TA Shepur, KIMS, Hubli
CT scan depicting the calcified lesion in the right middle lobe region.
Drug regimen for revised categories under RNTCP (2011) are:
• Cat I (New): 2HRZE3 + 4HR3
• Cat II (Previously treated):
2HRZES3 + 1HRZE3 + 5HRE3 Steroids—in bronchial obstruction, massive pleural effusion and miliary tuberculosis.
Tuberculosis—Right Middle Lobe Collapse Consolidation
Figure 7.1.33: Tuberculosis-right middle lobe collapse consolidation
Photo Courtesy: Devaraj Raichur and Pushpa Panigatti, KIMS, Hubli
Collapse consolidation of middle lobe of right lung is evident.
Cardiac Silhouette’s sign
(obliteration of the right margin of the heart) is present.
Drug regimen for revised categories under RNTCP (2011) are:
• Cat I (New): 2HRZE3 + 4HR3
• Cat II (Previously treated):
2HRZES3 + 1HRZE3 + 5HRE3 Steroids—in bronchial obstruction, massive pleural effusion and miliary tuberculosis.
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Tuberculous Pleural Effusion—Right Side with Hilar Lymphadenopathy
Figure 7.1.36: Tuberculous pleural effusion—
right side with hilar lymphadenopathy Photo Courtesy: TU Sukumaran, PIMS, Thiruvalla
Small pleural collection with obliteration of costophrenic angle on right side associated with right hilar lymphadenopathy is evident.
Drug regimen for revised categories under RNTCP (2011) are:
• Cat I (New): 2HRZE3 + 4HR3
• Cat II (Previously treated):
2HRZES3 + 1HRZE3 + 5HRE3 Steroids—in bronchial obstruction, massive pleural effusion and miliary tuberculosis.
Tuberculosis—Bilateral Paratracheal Lymphadenopathy
Figure 7.1.34: Tuberculosis—bilateral paratracheal lymphadenopathy Photo Courtesy: TA Shepur, KIMS, Hubli
The oval opacities on both sides of the lower trachea.
Drug regimen for revised categories under RNTCP (2011) are:
• Cat I (New): 2HRZE3 + 4HR3
• Cat II (Previously treated):
2HRZES3 + 1HRZE3 + 5HRE3 Steroids—in bronchial obstruction, massive pleural effusion and miliary tuberculosis.
Tuberculosis—Hilar Lymphadenopathy
Figure 7.1.35: Tuberculosis—Hilar lymphadenopathy
Photo Courtesy: TU Sukumaran, PIMS, Thiruvalla
The lymph node prominences in hilar regions.
Lungs are the most common site for tuberculosis.The disease in lungs varies from a small parenchymal lesion to disseminated disease.
The clinical manifestations depend on underlying pulmonary lesion.
TB in children is mostly paucibacillary.
Drug regimen for revised categories under RNTCP (2011) are:
• Cat I (New): 2HRZE3 + 4HR3
• Cat II (Previously treated):
2HRZES3 + 1HRZE3 + 5HRE3 Steroids—in bronchial obstruction, massive pleural effusion and miliary tuberculosis.