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Facing breathing difficulty. History of diabetes and hypertension. Will pleural fluid tapping help?

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Pulmonologist
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I was having fever and headache for a month. dry cough for about 3 weeks, suddenly started having difficulty breathing.

Got a chest xray which showed pleural effusion in both lower lungs. Ultra sound showed about 200cc to 250cc of pleural effusion.

CT scan result shows: Multiple moderate to large poorly enhancing Prevascular right Paratracheal, Paratracheal and Precannal Lymphadenopathy of 1 to 2.5 cm noted. The conglomerate right paratracheal node measuring about 8.89 x 5.7 x 6.3 cm. Extensive patchy consolidations across both lower lobe.

The doctor has put me under Piptaz antibiotic for 10 days. Fever and cough is in normal but Headache is still there. Going for Pleural fluid tapping will it help ? What should be done ?

History:
Obese
Diabetic
Hyper Tension
Posted Sun, 17 Feb 2013 in General Health
 
 
Answered by Dr. Gyanshankar Mishra 9 hours later
Hi,
Thanks for posting the query on XXXXXXX After going through the query, I would like to comment the following:

1. You seem to be suffering from diabetes with hypertension with bilateral synpneumonic pleural effusion.

2. As piptaz has been started , you need to complete a 2 to 3 weeks total course of antibiotics also Tb. claribid ( clarithromycin) 500 mg bid can be started under supervision of your doctor.

3. Please get yourself clinically evaluated in detail with a pulmonologist.

4. Pleural fluid tapping is definitely recommended and pleural fluid should be sent for these investigations: ADA, AFB STAIN AND CULTURE, GRAM STAIN AND CULTURE, BIOCHEMISTRY - PROTEIN, SUGAR, CYTOLOGY.

5. Also if possible a CT guided FNAC from mediastinal lymph nodes or a bronchoscopic TBNA from the same can be done.

6. Based on the investigation report, further management line can be titrated accordingly.


I hope I have answered your query. I will be glad to answer follow up queries if any.
Please accept my answer if you have no follow up queries.

Regards

Dr. Gyanshankar Mishra
MBBS MD DNB
Consultant Pulmonologist
Above answer was peer-reviewed by
 
Follow-up: Facing breathing difficulty. History of diabetes and hypertension. Will pleural fluid tapping help? 1 hour later
>> As piptaz has been started , you need to complete a 2 to 3 weeks total course of antibiotics also Tb. claribid ( clarithromycin) 500 mg bid can be started under supervision of your doctor.
They have stopped the dose of piptaz via IV after 10 days, did not give any antibiotics in the past 24 hours and may start an oral antibiotic.

>> Also if possible a CT guided FNAC from mediastinal lymph nodes or a bronchoscopic TBNA from the same can be done.
The doctor advised bronchoscopic TBNA, but we are sceptical about the procedure. The risks involved in it. Are the lymph nodes a major concern ? can they be just enlarged because of the pneumonia and may improve with pleural fluid tapping and antibiotics ?

The doctor said that lymph node is out side the trachea, so the sample will collected through the trachea into the lymph node, and there are 40% chances that the sample they get is inadequate. Then why do the procedure.

She is taking medical oxygen and maintaining ~94% SpO2 level. Without oxygen level comes to ~90%.

Is the headache related with the infection ? Paracetamol tablets are not helping reducing the headache and the doctor is giving only that.

There is neither fever nor cough now. 7 days back fever was consistently at ~101C with dry cough.

We are going ahead with Pleural Fluid Tapping.

She is right now in hospital, can we continue with the medicines at home ? (if required medical oxygen can be arranged)
 
 
Answered by Dr. Gyanshankar Mishra 42 minutes later
Hi,

Thanks for the follow up query. After going through the follow up query, I would like to comment the following:

1. A FNAC is required for confirmation of diagnosis and the etiology of the lymphadenopathy. If there is apprehension regarding bronchoscopic TBNA then a CT guided FNAC may be an option.

2. After an initial course of iv antibiotics you need to be shifted on oral antibiotics , especially as the lesion is still there. A total of 3 to 4 weeks of antibiotic course is required.

3. The pleural fluid investigations are required and it is good that you are going ahead with them.

4. The persistent headache is sometimes associated with atypical pneumonia, hence advised clarithromycin. Please get her serum sodium and potassium levels done. Also a clinical examination regarding stiff neck or signs of meningeal irritation need to be checked for. A CT head will be required if no cause of headache is arrived at.

5. Her low oxygen saturation is due to bilateral involvement of lungs and will gradually improve once her lung lesions get healed. Till then she will need supplemental oxygen therapy.

I hope I have answered your query. I will be glad to answer follow up queries if any.
Please accept my answer if you have no follow up queries.

Regards

Dr. Gyanshankar Mishra
MBBS MD DNB
Consultant Pulmonologist
Above answer was peer-reviewed by
 
Follow-up: Facing breathing difficulty. History of diabetes and hypertension. Will pleural fluid tapping help? 5 hours later
Just came from plueral tapping, the doctors were unable to get a single drop of fluid, the tube was empty. Is there a chance they punctured the lungs, the doctors are denying though. How can they get no fluid ? Is obesity an issue ?

However the latest ultrasound showed around 50-70cc of fluid remaining. So that's reduced as in the start it was 200-250cc. The remaining fluid can be reduced by antibiotics as well right ?

We are planning to discharge her from hospital and monitor her health from home, Will go for a check up next week just to make sure she is improving.

Planning to leave lymph nodes diagnosis for now. This test can be done later as well ? We will go for a chest x-ray next week.

One of the pharmacist advised "Reactin 50mg" as a pain killer. Should we be taking it as an SOS for headaches ?
 
 
Answered by Dr. Gyanshankar Mishra 1 hour later
Hi,
Thanks for the follow up query. After going through the follow up query, I would like to comment the following:

1. Yes, obesity can sometimes lead to dry tapping. In such cases a USG guided tapping can be done.

2. As of now, it is a reasonable choice to go for a 2 to 3 week course of antibiotics but however if there is no response, then you need to go ahead with evaluation of the lymph nodes as outlined in previous posts. A chest xray after the antibiotic course will also help.

3. Yes, reactin can be taken as and when required as a pain killer.


I hope I have answered your query. I will be glad to answer follow up queries if any.
Please accept my answer if you have no follow up queries.

Regards

Dr. Gyanshankar Mishra
MBBS MD DNB
Consultant Pulmonologist
Above answer was peer-reviewed by
 
Follow-up: Facing breathing difficulty. History of diabetes and hypertension. Will pleural fluid tapping help? 3 hours later
- USG guided tapping can be done. yes they performed an ultrasound guided tapping, which was empty. They said about 80cc of fluid is left which is fine.

- She will start on Claribid 500 mg, This is twice a day? after breakfast and after dinner ? correct ?

- Reactin for SOS headaches

- Oxygen till breathing becomes normal. Is 80cc pleural fluid a cause of worry ?

- Fruits, vegetables both raw and juices.

- Wait for a 7-10 days then get a checkup done.

This sounds right ?
 
 
Answered by Dr. Gyanshankar Mishra 12 minutes later
Hi,

Thanks for the follow up query.
After going through the follow up query, I would like to comment the following:

1. 80 cc of fluid is minimal and should respond to antibiotics if infective etiology is present.

2. Her antibiotics should be Tb claribid 500 mg twice daily (After breakfast, after dinner) and also tb augmentin duo 625 mg thrice daily (after breakfast , lunch, dinner) (if no other antibiotic has been added by your physician). Please take this under supervision of a doctor.

3. Fruits and vegetables can be taken. Avoid cold stuff. Take all food items at room temperature or hot.

4. Re evaluation can be done after 2 weeks.

I hope I have answered your query. I will be glad to answer follow up queries if any.
Please accept my answer if you have no follow up queries.

Regards

Dr. Gyanshankar Mishra
MBBS MD DNB
Consultant Pulmonologist
Above answer was peer-reviewed by
 
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