An upper lobe cavitary lesion in a patient with sickle cell disease

How to cite this article:
Jayakrishnan B, Rizavi DM, Al Zeedy K, Al Farsi KS. An upper lobe cavitary lesion in a patient with sickle cell disease. Ann Trop Med Public Health 2014;7:244-5
How to cite this URL:
Jayakrishnan B, Rizavi DM, Al Zeedy K, Al Farsi KS. An upper lobe cavitary lesion in a patient with sickle cell disease. Ann Trop Med Public Health [serial online] 2014 [cited 2021 Apr 13];7:244-5. Available from: https://www.atmph.org/text.asp?2014/7/5/244/154829

Dear Sir,

Patients with upper zone cavitary lesions are often isolated because of a suspicion of tuberculosis. Here, we report a common scenario where the initial suspicion was proved wrong. A 19-year-old male with sickle cell disease presented with fever and cough of nearly 2-weeks duration. His first visit with vasoocclusive crisis (VOC) to adult casualty was a year ago. After that, he was admitted a few times with features of VOC and once with acute sinusitis.

On examination, he was febrile, tachycardic, and tachypneic (temperature: 38°C, respiratory rate: 20/min, and heart rate: 123/min). Oxygen saturation on room air was 96%. Basic work up this time revealed marked anemia with hemoglobin of 5.2 g/dL, white blood cell count of 31.2 × 10 9 /L, and a C-reactive protein concentration of 208 mg/L. Chest radiograph showed a large cavitary lesion with adjoining consolidation [Figure 1]a. Computed tomography (CT) scan of the chest showed a large thick walled cavitary lesion in the right upper lobe with a small air fluid level and perilesional alveolar infiltrates [Figure 1]b. He was started on piperacillin/tazobactam parenteral combination and gentamicin. He received three units of packed blood cells. Sputum and blood cultures did not show growth of any organisms. Sputum was negative for acid-fast bacilli by direct smear. The Mantoux test was negative. Bronchoscopy was unremarkable except for a slightly inflamed right upper lobe bronchus. The bronchoalveolar lavage grew Staphylococcus aureus. By this time, the patient’s temperature touched normal and he was later discharged on oral flucloxacillin for 2 weeks. Chest radiograph done during review showed total clearance of the above lesions, with a residual thin walled airspace suggestive of a pneumatocele [Figure 1]c.

Figure 1: (a) Chest radiograph showing a large cavitary lesion with adjoining consolidation (b) CT scan of the chest showing a large thick walled cavitary lesion in the right upper lobe with a small air fluid level and perilesional alveolar infiltrates (c) Chest radiograph showing total clearance of the lesions with a residual thin walled airspace

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Initially, the patient was isolated as the radiological picture was highly suggestive of active pulmonary tuberculosis. [1] Other differentials of an upper zone cavitary lesion like malignancy, aspiration pneumonia, lung abscess, sarcoidosis, pulmonary infarct, or Wegener’s granulomatosis were unlikely in this situation. In fact, cavitation was noted as one of the features of staphylococcal pneumonia in adults and children. [2] The pneumatoceles are areas of regional obstructive emphysema, usually developing as a complication of acute pneumonia. [3] They are thin walled, air-containing, and cyst-like structures and could be multiple in number. Staphylococci, Pneumococci, Escherichia coli, Klebsiella species, and Pneumocystis jiroveci are the common organisms. The infectious pneumatoceles usually appear in the healing phase, are usually transient, and spontaneous resolution is the rule.

References
1.
Roy M, Ellis S. Radiological diagnosis and follow-up of pulmonary tuberculosis. Postgrad Med J 2010;86:663-74.
2.
Macfarlane J, Rose D. Radiographic features of staphylococcal pneumonia in adults and children. Thorax 1996;51:539-40.
3.
Cantin L, Bankier AA, Eisenberg RL. Multiple cystlike lung lesions in the adult. AJR Am J Roentgenol 2010;194:W1-11.

Source of Support: None, Conflict of Interest: None

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DOI: 10.4103/1755-6783.154829

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