Bronchiectasis - Case Study

Case History: Mr. …, 28 years old, day laborer, normotensive, nondiabetic, smoker, hailing from …, presented with frequent cough with profuse expectoration of mucoid sputum for ... months. It is more marked in the morning after waking from sleep. Occasionally, the sputum is purulent or yellowish and foul smelling, relieved after taking antibiotics. The patient also noticed small amount of blood occasionally mixed with sputum. For the last ... months, he also complains of loss of about 5 kg body weight, weakness, malaise, occasional fever and night sweating. There is no history of chest pain,
breathlessness or swelling of the ankle. His bowel and bladder habits are normal. There is history of
measles during childhood. He also gives history of recurrent chest infection for the last 2 years. There
is no history of whooping cough, pulmonary TB or foreign body impaction. There is no family history suggestive of such illness. He smokes about 30 sticks a day for last 10 years but nonalcoholic. He used to take cough syrup frequently, treated with antibiotics several times due to chest infection.

General Physical Examination: 

• The Patient is slightly emaciated
• There is generalized clubbing involving both toes and fingers, but no hypertrophic osteoarthropathy
• No anemia, jaundice, cyanosis, edema, koilonychia or leukonychia
• No thyromegaly or lymphadenopathy
•  Pulse: 88/min
• BP: 120/75 mm Hg
• Respiratory rate: 30/min
• Examination of the sputum cup: Always look at the cup at the side of the patient, if any).

Systemic Examination:

Respiratory System

Inspection:

• Chest movement slightly restricted (mention where). Or, no abnormality.

Palpation:

• Trachea: Central
• Apex beat: In left 5th intercostal space 9 cm from the midsternal line, normal in character
• Vocal fremitus: Slightly increased on both base
• Chest expansion: Normal.

Percussion: 

• Percussion note: Normal
• Liver and cardiac dullness: In normal area.

Auscultation:

• Breath sound: Normal vesicular (may be bronchial over the involved area).
• There are multiple coarse crepitations on the base of both lungs, both in inspiration and expiration,
• reduced (or disappeared) after coughing.
• Vocal resonance: Slightly increased (mention where).

Other systemic examination reveals no abnormalities.

Provisional Diagnosis: Bilateral Bronchiectasis.

(All the above signs may be on the left or right side. Then the diagnosis will be left or right sided

bronchiectasis.)

Important Questions That Can Be Asked In The Exam: 

Q. What are your differential diagnoses?

A. As follows:

• Interstitial pulmonary fibrosis
• Pulmonary TB.

Q. Why it is bronchiectasis?

A. The patient is complaining of cough with profuse expectoration of sputum, more marked in the

morning after waking up from sleep. On examination, there are generalized clubbing and bilateral

basal coarse crepitations, altered by coughing. All are highly suggestive of bronchiectasis.

Q. What investigations do you suggest in bronchiectasis?

A. As follows:

1. Chest X-ray PA view (may be normal). There may be:

- Ring with clear centre (like honeycomb)

- Ring with or without fluid level, may be multiple (cystic bronchiectasis)

-  Linear streaks (tram line)

-  Thick bronchi, signet ring or patchy opacity.

2. High-resolution CT scan: Definitive (preferred investigation).

3. Others:

-  CBC with ESR (may be neutrophilic leucocytosis)

-  X-ray PNS (in Kartagener’s syndrome)

- Lung function tests (obstructive type usually, may be restrictive in advanced case)

- Sputum for Gram staining, C/S, AFB, malignant cell (mention if necessary according to the history)

- Sometimes bronchoscopy to locate the site of obstruction

- Aspergillus precipitin antibody or skin prick test (if ABPA is suspected)

- Serum immunoglobulin: If hypogammaglobulinemia is suspected (10% of adults with bronchiectasis have antibody deficiency, mainly IgA)

- Sweat test for sodium and chloride content: If cystic fibrosis is suspected (sweat chloride content > 60 mEq/L is suggestive of cystic fibrosis)

- Mucociliary clearance (nasal clearance of saccharin): Normally less than 30 minutes. If more, it indicates ciliary dysfunction

- Urine for proteinuria (if amyloidosis is suspected)

- USG of whole abdomen (if situs inversus is suspected).

Q. If a patient with bronchiectasis develops nephrotic syndrome (or urine shows proteinuria), what is the likely diagnosis?

A. Amyloidosis (in amyloidosis, there may be splenomegaly). In long standing bronchiectasis, amyloidosis may occur as a complication.

Q. What is the role of CT scan in the diagnosis of bronchiectasis?

A. Conventional CT scan has sensitivity of 60 to 80% while high resolution CT scan has a sensitivity

of more than 90% (previously bronchography was done).

Q. What is the difference between standard CT scan and HRCT?

A. In standard CT scan, the resolution is 10 mm thick. But in HRCT, resolution is 1 to 2 mm thick.

Q. What is bronchiectasis and what are the causes of it?

A. It is the abnormal, permanent dilatation of one or more bronchi with destruction of bronchial wall

proximal to the terminal bronchiole. 

Causes are:

1. Congenital or hereditary:

• Cystic fibrosis
• Kartagener’s syndrome (triad of bronchiectasis, dextrocardia and sinusitis or frontal sinus agenesis)
• Primary ciliary dyskinesia (including immotile ciliary syndrome)
• Hypogammaglobulinemia (of IgA and IgG. It causes recurrent infection and bronchiectasis)
• Yellow nail syndrome
• Young’s syndrome (obstructive azoospermia and chronic sinopulmonary infection, thought to be due to mercury intoxication)
• Sequestrate segment of lung.

2. Acquired:

• In children, pneumonia complicating measles, whooping cough, primary TB and foreign body
• In adults, bronchial neoplasm, pulmonary TB, recurrent aspiration or suppurative pneumonia
• Allergic bronchopulmonary aspergillosis (causes proximal bronchiectasis)

Q. What are the types of bronchiectasis?

A. Three types:

• Saccular or cystic (more severe form).
• Cylindrical.
• Fusiform.

Q. What is the most common site of bronchiectasis?

A. Left lower lobe and lingula.

Q. What are the presentations of bronchiectasis?

A. Cough with profuse expectoration of sputum, usually more marked in the morning after waking

from sleep. Occasionally, hemoptysis and breathlessness in advance cases. Features of secondary

infection may be present.

Q. What are the typical signs of bronchiectasis?

A. On general examination, there is generalized clubbing. On examination of the chest, there are

coarse crepitations that reduce or disappear after coughing. The signs are usually better found on the

back of the chest and are mostly basal.

Q. Why hemoptysis?

A. It is due to bronchial wall hypertrophy, hence mucosa becomes friable, slough out, capillary opens

and bleeding occurs. Erosion of hypertrophic bronchial artery may result in massive hemoptysis.

Q. What abnormalities may be associated with bronchiectasis?

A. As follows:

• Situs inversus or dextrocardia and frontal sinusitis or agenesis (Kartagener’s syndrome)
• Obstructive azoospermia and chronic sinopulmonary infection (Young’s syndrome).

Q. What are the complications of bronchiectasis?

A. As follows:

• Secondary infection (pneumonia and pleurisy), common organisms are Staphylococcus aureus ,Haemophilus influenzae and Pseudomonas aeruginosa
• Lung abscess
• Pleural effusion, empyema or pneumothorax
• Pulmonary hypertension and cor pulmonale
• Respiratory failure
• Amyloidosis (commonly involving spleen or kidney) in long standing case
• Brain abscess (metastatic cerebral abscess)
• Aspergiloma in the bronchiectatic cavity.

Q. How will you treat bronchiectasis?

A. As follows:

• Postural drainage, keeping the affected part remaining up and percussion over it. It is done for 5 to 10 minutes, once or twice daily
• Antibiotic, if infection
• Chest physiotherapy
• Surgery (lobectomy)
• Bronchodilator drugs. Also, nebulized salbutamol may be used in asthma, COPD, cystic fibrosis 
• Inhaled or oral steroid can decrease the rate of progression.
• In bilateral extensive bronchiectasis, lung transplantation is required.

Indications of surgery: Usually in young patient. Indications are –

• Unilateral and localized to a single lobe or segment
• Severe and recurrent hemoptysis.