been
described
in the
hiterature,’
this
is the
first
case
in
which
this usually
innocuous
pleural
mass has produced
significant
morbidity
and contributed
to a patient’s death.
The special features ofthis case include the demonstration
of local extrinsic
compression
of the airway
seen
on bronchoscopy,
ments,
postobstructive
pneumonia
and local pulmonary
artery
in the
occluded
thrombosis
seg-
morbidity
and
mortality.
ACKNOWLEDGMENTS:
The
writers
thank
John
D. Newell,
M . D. for his assistance
in reviewing
the chest radiographs
and CT
scans;
Cecile
Rose,
M . D. , for reviewing
the manuscript;
and Sharon
,
Godwin-Austen
for preparation
of the manuscript.
thank the patient’s
family
for their cooperation.
in the affected
REFERENCES
lobe.
Development
lectasis
is
of obstructive
thickened
extrinsically
twined
and
struction
a breakdown
by
Hillerdal,’
died
of pneumonia,
tasis
was
and
not
prostatic
count
may
have
even
of thrombosis
the
and
may
this
First,
rise
with
cell
blood
to
initiate
the
presence
of
in the atelectatic
lobe in this patient
alterations
related to the pleural mass the more
ofthis
evidence
case
of small
is the notable
pneumoconiotic
opacwith
the
radiograph
and
histology
in asbestosis
is well
descrihed.
Epler
et al have shown
that approximately
10
percent
of individuals
with
chronic
diffuse infiltrative
lung
disease
have normal
chest
roentgenograms.
That
series
Rockoffand
International
of radiographically
Schwartz
have
estimated
Labour
Organization
in a 10 to 20 percent
interpretation
Several
in cases
articles
probability
inapparent
asbestosis.
that application
of the
classffication
can result
of a normal
radiograph
ofhistologically
have
described
significant
the
chest
associated
demonstrates
with
how
spontaneous
it can
secondarily
resolution,111216
contribute
Ill.
folding
em
Rundherde.
Lung
simulating
peripheral
syndrome).
Thorax
1980;
HM,
fibrosis
with
74
coagulation.
4th
In:
ed.
Human
Philadelphia:
218-26
SelikofflJ.
workers
histopathological
with
Pulmonary
lung
evaluation.
J
N Engl
SD,
tion.
Chest
cancer:
J
Br
GA,
Mikus
in chronic
md
a
Med
1978;
P. Camngton
CB.
infiltrative
lung
diffuse
298:934-39
A. Roentgenographic
by
1988;
Schneider
Gaensler
Med
Schwartz
asbestosis
1980;
TC,
roentgenograms
early
International
underestimation
Labor
Organization
of
Classifica-
93:1088-91
HJ, Felson
B, Gonzalez
LL.
Rounded
ateleetasis.
AJR
134:225-32
Hanke
R,
1980;
Kretzchmar
R. Round
atelectasis.
Semin
Roentgenol
15:174-82
Geremia
G, Mintzer
Chest
1984;
Mintzer
Gore
and
disease.
BA.
RM,
its
Doyle
it,
AJR
case
1981;
Lawler
1984;
15 Greyson-Fleg
Vogelzang
association
Radiology
lung.
An unusual
ofrounded
atelectasis.
86:485-86
BA,
atelectasis
14
1982; 81:457-60
experience
Y, ValcuikasJA,
insulation
McLoud
chest
disease.
13
blood
1987;
asbestos
GR,
9 Rockoff
12
clinical
of disease.
R, Suzuki
and
Normal
11
of asbestos-induced
Chest
44:96-100
8 Epler
10
and
Company,
radiological
1987;
ateleetasis,
mechanisms
Lilis
in
association
atehectasis.
Hemostasis
and
Saunders
The
GA.
with
RL,
Holz
S.
Rounded
asbestos-induced
pleural
139:567-70
CT
features
ofrounded
atelectasis
of the
143:225-28
RT. Lung
biopsy
in rounded
atelectasis.
AJR
1985;
144:1316-17
16
Smith
LS,
exudative
Schillaci
effusion:
RF.
Rounded
spontaneous
atelectasis
resolution.
due
Chest
to
1984;
acute
85:830-
32
asbestosis.
radiographic,
bronchographic,
tomographic
and CT appearance
of
rounded
atelectasis.’#{176}’ In most cases, the plain film shows
a rounded
mass within the lower lobe, as was found in this
patient.
Lateral
tomography
may
show
vessels
and
bronchi
near the mass curving
toward
and
converging
on the edge
of the mass. The CT scan may show a rounded
mass, 4 to 7
cm in diameter,
most dense at its periphery,
which forms an
acute
angle
with the pleura,
with pleural
scarring
thickest
adjacent
to the mass. Vessels
and bronchi
may be seen
curving
toward
the mass. Recognition
of these features,
while not strictly
pathognomonic,’
can generally
forestall
invasive
testing
and
surgical
intervention.”
However,
even
though
rounded
atelectasis
is generally
benign
and
sometimes
60: 19-22
1989; 95:836-41
AC.
WB
chest
six cases
mntrapulmonaler
DW.
Rounded
Chest
7 Kipen
absence
ities,
despite
the
severe
parenchymal
involvement
asbestosis
found
at autopsy.
The dissociation
between
1966;
Walzenatelektasen):
diagnose
and rounded
C.
6 Guyton
thrombosis
makes
local
likely cause.
Chest
und
(Blevosky’s
Cugell
disease
5 Hillerdal
local
Second,
P. Kerr
neoplasm
BA,
pleural
may
in
clotting.
only
of any radiographic
flow
caused by kinking and distortion
of prothrombin
activators
which
to clot formation.#{176}It is possible
thrombosis
in association
with
However,
facet
vessels
of procoagulants
enough
interesting
atelectasis
Dis
114:164-83
Jaques
patients.
blood
of blood
regional
concentration
high
pneumonia.
included
1971;
J
Br
(Kugel-
Differential
CR,
4 Mintzer
age
lung.
35:936-40
atelec-
patient’s
his white
kinking
atelectasis,
blood vessel
may induce
the formation
initiate the cascade
leading
to see pulmonary
vascular
Another
ROEFO
3 Payne
his susceptibil-
increased
though
zur
pulmonary
atelectasis
to rounded
at the site of rounded
ofthe
severe
rounded
that
Beitrag
In a
folded
R. Rundatelektasen
physiology
to rounded
damage
with
A. The
2 Hanke
mecha-
in the airway.
It is possible
twofold.
secondary
vessels
patients
inter-
1 Blevosky
normal.
possibly
decrease
antibacterial
but the relationship
as well,
The causes
are
two
ate-
of
lung, can entrap
bronchi.
With oh-
of infection
carcinoma
was
in rounded
composed
of local
mentioned.
to infection
ity
mass,
and atelectatic
neighboring
the development
and
report
The
pleura
compress
comes
nisms
pneumonia
understandable.
We especially
this
case
to patient
Dialysis-induced
Acidosis*
Judith
RogerC.
*From
Cohn,
M.D.,
Bone,
the
Ph.D.;t
M.D.,
Section
Respiratory
Robert
A. Balk,
M.D.,
F.C.C.P4
and
F.C.C.P
of
Pulmonary
and
Critical
Care
Medicine,
Department
of Internal
Medicine,
Rush-Presbyterian-St.
Luke’s
Medical
Center,
Chicago.
tlnstmctor
of Medicine.
lAssociate
Professor
of Medicine,
and Co-director,
Medical
Intensive Care
Unit.
§Balph
C. Brown
Professor
and Chairman,
Department
of Medicine; Chief,
Section
of Pulmonary
and Critical
Care
Medicine.
Reprint
requests:
Dr
Bone,
Rush-Presbyterian-St.
Izmke Medical
Center,
1Th3 West Congress
Parkway,
Chicago
60612
CHEST
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21620/ on 06/17/2017
I 98 I 5 I NOVEMBER,
1990
1285
The
inability
cot
retention
to increase
and acute
alveolar
ventilation
can
lead to
respiratory
acidosis
in patients
with
ventilatory
limitation.
In this case,
a young woman
receiving
maximum
ventilatory
support
was unable
to
excrete
excess
CO, associated
with
increasing
dianeal
concentrations
of peritoneal
dialysis.
Since
the patient’s
lung disease
had necessitated
a large amount
of ventilatory
support,
the patient
was unable
to increase
VE appropriately to handle
excess CO,.
Peritoneal
dialysate
was an
additional
source
of carbohydrates.
Peritoneal
dialysate
is
an
additional
carbohydrate
source
that may result
in
hypercapnia
and respiratory
acidosis
in patients
with respiratory
compromise.
To our knowledge,
this is the first
case report
in an adult which demonstrates
that peritoneal
dialysis
with
high glucose
loads
produced
an acute respiratory
acidosis that was reversed
by decreasing
the glucose
concentrations
in the
dialysate.
Excess
CO2 production
should be considered
with respiratory
disorders
associated
with dialysis.
(Chest
1990;
98:1285-88)
ventilatory
status.
Peritoneal
monia
and
SLE
=
systemic
lupus
RQ = respiratory
erythematosus;
quotient;
ANA
total
TPN
antinuclear
parenteral
often
seen
results
with
muscular
an
fever,
A 27-year-old
cough
and
when
she
or
from
parenteral
with chronic
empyemas,
and
was
a facial
hemolytic
and
CO,
obstructive
lung
in those
recovering
in the
maximum
concentration
chest
ARDS
with
Vco,.
who
disease,
from
injury,
trauma.3
in those
ARDS,
We present
developed
acute
the use of increased
peritoneal
Increased
Vco,
skin
dialysis
ventilatory
resulted
fluid.
support
patient
and a decrease
in a return
to baseline
saturation.
Her
dialysis
receiving
course
in the
and
4.25
of breath,
a
revealed
methenamine
stain
oxygenation
status
ventilatory
support.
adequate
prior
resolved
each
arterial
High
oxygen
worsened
in the
of exchange
the
rate
was
this
to
3 fIb
period
and
the
PEEP”
of moderate
1). The
been
increased
of these
after
the
control
made
4 L/h.
dialysate
As can
be
(Fig
throughout
in the
In the
settings.
second
appreciated
The
1). The
this
In the
episode
from
Table
30 L.
ventilatory
and
from
dianeal
mode
approximately
dianeal
episodes.
to 1 .5 g percent
were
was
.
was
increase
of “occult
time
volume
changes
episodes
(Table
had
to each
back
decreased
of exchange
acidosis
dialysate
g percent
was
efforts
seven
Her
by two
respiratory
and no significant
episode
the rate
Prior
After
subsequently
peritoneal
ventilated
development
with
initiated
silver
to maintain
time
first
in the dianeal
was
Bronchoscopy
mechanical
was complicated
acute
acidosis
was
gb-
a homogeneous
was begun.
concentration
to 3.0
necrotizing
chest
shortness
fever.
insufficiency
at that
pain
and
with
increasing
carinii.
knees
noted
insufficiency
plasmaphoresis.
low-grade
wrists,
pleuritic
Therapy
and
developed
renal
1, the VE during
and
SLE.
required
also
renal
1:640
and the
and
patient
acidosis
acid-base
hospital
concentration
with
of
subsequently
demonstrated
was
hemorrhage
hyperglycemia
respiratory
in patients
biopsy
titer
Pneumocysti.s
were
peritoneal
1.5
concentrations
was
PEEP
was
of breath,
to admission
hands,
edema
revealed
and she required
and
The
bilateral
a patient
for
prior
She
on exertion,
and
pulmonary
Flo,
is
she
cough
another
ill patients
shortness
in her
Evaluation
ANA
yet
year
of dyspnea
suggestive
positive
one
hypertension.
cyclophosphamide
of therapy,
with
until
extremity
A renal
An
deteriorated
during
respiratory
dianeal
The
and
source
in critically
presented
well
have
lower
rash.
highly
weeks
was
to
represents
polyarthralgias
anemia.
prednisone,
increased
with
noted
merulonephritis.
increase
in
carbohydrate
metabolism
has been
retention
and failure to wean in patients
who have sustained
associated
of
hyperthyroidism,
an additional
REPORT
woman
symmetrical
case
of therapy
had been
She
and ankles. Bilateral
time. She complained
antinutn-
or excessive
use of carbohydrates
hyperalimentation.”
An
excessive
with
associated
SLE
white
fever.
developed
respiratory
acidosis
or the
from mechanical
ventilation
assessment
sepsis,
activity
enteral
VCO,
in
of acute
a patient
This
of this form
failure.
nonproductive
he development
inability
to wean
be
can
CASE
diffuse
T
solutions
hydrothorax.
complication
with renal
pattern,
body;
tion
dialysis
of carbohydrate
load for patients
with limited
ventilatory
status
and can lead to acute
respiratory
acidosis.
The
pulmonary
complications
ofperitonial
dialysis include acute
pulmonary
edema,
pleural
effusion,
basal atelectasis,
pneu-
support
resulted
led
to
in hypotension.
the
She
70
.60
50
40
7.40
7.32
7.25
7.18
/
7.10
3.75
2.50
FIGURE
1. Respiratory
acidosis
during
poniods
of increased
dialysate
dianeal
concentration.
The
arrows
show
two episodes
of respiratory
acidosis
coincident
with the increase
of glucose
in the dianeal
to 3.0 and
4.25 g percent,
respectively.
1286
i.zs
17
18
19
20
21
22
TI
23
24
25
26
27
28
29
30
31
BaH,
Bone)
(DAYS)
Dialysis-induced
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21620/ on 06/17/2017
Respiratory
Acidosis
(Cohn,
tonitis
or those
organ
dysfunction
Nolph
KD,
Publishers,
5 Pepe
PE,
related
ed.
Peritoneal
1989;
289-318
Rev
ventilated
Respir
Dis
and
peritoneal
the
Boston:
positive
patients
1982;
fate
of uremic
dialysis.
Kluwer
Academic
end-expiratory
with
pressure
airflow
in
obstruction.
Epstein
complicating
FH.
Hyperglycemia
peritoneal
dialysis.
and
Am
hyperosMed 1967;
Intern
Ann
67:568-72
7 Gault
MH,
Ferguson
electrolyte
EL,
complications
solutions.
Ann
8 Whang
R,
dialysis
Med
Shuck
JS,
Corbin
ofpentoneal
Intern
JM,
in burned
Sidhu
dialysis:
1971;
Fluid
choice
and
GR.
A hazard
hyperosmolar
10
GP, Blumenkrantz
JW.
Glucose
absorption
neal
dialysis.
Kidney
Nolph
KD,
et
Continuous
al.
Sorkin
experience
11
et al.
TE,
M,
term
J,
J Trauma
Moran
1970;
13
Verger
Arfania
D,
Intern
Prowant
B, Fruto
dialysis:
Med
Mjaland
1980;
5, Phal
C,
K, Berg
peritonitis
and
MK,
P, et
al.
dialysis.
Chuah
15
dialysis.
GA,
Gibson
J,
during
CAPD
Fabris
A, Biasioli
et
al.
dialysis
M,
is often
lung
Adverse
only
of
(CAPD):
1983;
J,
Moorhead
A 43-year-old
nonsmoker
and
smear
in
infectious
Baillod
mide.
effects
of
hypertonic
1983;
results
with
1982;
Hildreth
B,
dialysis
fluid
2:1421
M, Pisani
E, Ronca
ambulatory
respiratory
peritoneal
dynamics.
The
few
had
Trans
to our
regular
pulse
rate
28:270-74
distress
ferred
was
raised
Fatal Pulmonary
with Disseminated
and there
angle
ventricle
showed
We
report
ratory
Chu-Pak
MB.;
and
a fatal
complicating
rapidly
MB.;
case
bronchogemc
progressive
failure.
Hong
1288
Kong,
MB.
pulmonary
carcinoma
which
embolism
presented
pulmonary
A clotting
miliary
shadows
profile
abnormality
the major
pulmonary
vessels
infarcts.
Histologic
examination
the
Ng,
of occult
with
disseminated
intravascular
Postmortem
examination
showed
*Fmm
Departments
Queen
was
Mary
clots
and
Hospital,
Hong
Pathology,
Kong.
acute
respiratory
pressure
a sinus
pressure
over
both
Repeated
shadow
but
of 85 mm
venous
petechiae
chest
had
enlarged
infiltrate
(Fig
tachycardia
of
12 seconds);
partial
seconds
(control
28.2
seconds
(control
14.3
g/L);
200
gfml.
and
She
1).
An
150
per
was
the
However,
she
of more
0. 1 gIL
110
than
110
1.46
ofmore
spectrum
to
than
antibiotics,
respiratory
rapidly
seconds
than
(normal
product
broad
hypoxic
46
of more
time
degradation
with
for
coagula-
time,
time
fibrinogen,
treated
Laboratory
intravascular
thrombin
fibrinogen
pulmonary
made.
prothrombin
thromboplastin
seconds);
ventilation
support.
mm;
seconds);
a serum
of diffuse
was
of disseminated
(control:
3.38
diagnosis
cor pulmonale
picture
8,000/cu
Her
noted.
relatives
of the
occluding
University
cyanosis,
were
hilar
trans-
and
failure,
succumbed
in
the
next
hour.
left
and areas
of pulmonary
revealed
fibrin deposition
of Medicine
right
severe
was
a weak
jugular
pulmonary
further
revealed
or tenderness.
the
hemop-
had
and
blood
The
only
count,
inotropic
compatible
was
coagulation
extensive
with
systolic
A presumptive
with
the
platelet
mechanical
and respi-
active.
revealed
tion:
Lou, M.D.;
Wmng-Fung
that
miliary
revealed
pathology
result
As
a low
of the jaw. There
diffuse
the
she
central
study
deteriorated
echocardiogram
excluded
any pericardial
effusion.
In
the pulmonary
artery and the right heart chambers
were
with an impaired
right ventricular
contraction.
The left
alveolar
An Unusual Case Masquerading
Miliary Tuberculosis
minute,
of
partial
dropped
admission,
circulation.
count
An
enlarged
Coagulation*
count
Examination
was no calf swelling
bilateral
addition,
Intravascular
and
pyrazina-
cytology
embarrassment
unit.
per
peripheral
to the
minute.
Embolism
care
minute,
after
antitu-
and
although
platelet
circulatory
of 150 beats
poor
with
days
and
rapidly
dyspnea,
The
local
on
platelet
sputum
She
the
started
(prothrombin
The
a
Sputum
of
a low
cells.
increasing
with
intensive
of 40 per
Hg
normal.
Five
opacity.
streptomycin,
except
profile
stopped.
hibar
was
of
was
roentgenogram
Because
she
malignant
with
mm.
Chest
a right
normal
was
for
apparently
31,000/cu
to
She
negative.
coagulation
days
because
weeks.
isoniazid,
were
negative
next
tysis
hospital
three
tuberculosis,
time)
were
respiratory
M, Feriani
relationship
JB,
mm.
to a chest
for
and
was
with
electrocardiogram
Wong,
can
oftubercubosis.
shadows
data
thromboplastin
ambulatory
admitted
bacilli
treatment
roentgenogram
Cheng,
prognosis
with
correct
diagbe improved.
and
REPORT
no history
miliary
Laboratory
with
Cheuk-Kit
Chun-Ho
ill patient
an early
hemoptysis
of pulmonary
59,000/cu
R, Sweny
had
acid-fast
berculosis
legs,
Occult
the
was
and
bilateral
for
in the
Young
in continuous
Organs
that
woman
dyspnea
showed
23:823-31
continuous
SM,
5, Chiannonte
Soc Artiflntern
in a critically
However,
way
exertional
Nephron
changes
with
Young
Lancet
metabolism
difficult
shadows.
is the
transport
1981; i:1409-12
SM,
[letter].
Acute
mt
Kidney
experience
Lancet
Hobson
C, et al. Buffer
Am
P, Raferty
KD.
properties
injury.
years’
Young
Nolph
transport
mechanical
Three
peritoneal
14
HL,
and
coagulation
CASE
year
KJ, Aas TW,
water
peritoneal
A, Moore
moi’phobogy
Chan
embolism
prevalence
Luger
98:1288-90)
embolism
is known to be associated
the clinical diagnosis
of pulmonary
L,
three
92:609-13
in transperitoneal
ambulatory
peritoneal
intravascular
lthough
pulmonary
with malignancies,
nosis
pento-
1984; 38:238-47
12
disseminated
=
diffuse
JK, Coburn
ambulatory
pentoneal
changes
continuous
JD,
continuous
Ann
LC,
DIC
1990;
19:564-67
Rubin
center.
Smeby
Long
during
during
1981;
ambulatory
at one
Wideroe
MJ, Kopple
mt
I
(Chest
of dialysis
10:338-43
9 Grodstein
embolism
started.
of peritoneal
coma.
microvasculature
pulmonary
75:253-62
Kempers
patients:
RE
compatible
with DIC.
Cases
of
with DIC have previously
been reported,
but this is the first case with pathologic
confirmation. Thus,
unusual
presentation
with diffuse
lung shadow
and
DIC
should
not deter
the clinician
from
correct
diagnosis
so that appropriate
treatment
can be promptly
the
in
In:
126:166-70
J, Gill GN,
molality
catheter
receiving
dialysis.
JJ. Occult
Marini
mechanically
6 Boyer
to the
in patients
lung.
and
agreed
The
right
were
filled
from
the
found
pulmonary
arteries
with
anterior
causing
to a limited
pulmonary
clots which extended
shaped
pulmonary
of
only
main
to distal
miliary
(Fig
tumor
segment
distal
were
vessels.
infa.rcts
Occuft
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21620/ on 06/17/2017
was
Both
nodules,
right
examination
and both
dilated
occluded
There
2).
of the
collapse.
postmortem
artery
with
were
fresh
patches
pulmonary
and
upper
Histologic
Fatal Pulmonary
of wedgeparenchyma
a tumor
lobe
the
blood
mass
arising
bronchus
examination
Embolism
was
revealed
(Wong et a!)
tonitis
or those
organ
dysfunction
Nolph
KD,
Publishers,
5 Pepe
PE,
related
ed.
Peritoneal
1989;
289-318
Rev
ventilated
Respir
Dis
and
peritoneal
the
Boston:
positive
patients
1982;
fate
of uremic
dialysis.
Kluwer
Academic
end-expiratory
with
pressure
airflow
in
obstruction.
Epstein
complicating
FH.
Hyperglycemia
peritoneal
dialysis.
and
Am
hyperosMed 1967;
Intern
Ann
67:568-72
7 Gault
MH,
Ferguson
electrolyte
EL,
complications
solutions.
Ann
8 Whang
R,
dialysis
Med
Shuck
JS,
Corbin
ofpentoneal
Intern
JM,
in burned
Sidhu
dialysis:
1971;
Fluid
choice
and
GR.
A hazard
hyperosmolar
10
GP, Blumenkrantz
JW.
Glucose
absorption
neal
dialysis.
Kidney
Nolph
KD,
et
Continuous
al.
Sorkin
experience
11
et al.
TE,
M,
term
J,
J Trauma
Moran
1970;
13
Verger
Arfania
D,
Intern
Prowant
B, Fruto
dialysis:
Med
Mjaland
1980;
5, Phal
C,
K, Berg
peritonitis
and
MK,
P, et
al.
dialysis.
Chuah
15
dialysis.
GA,
Gibson
J,
during
CAPD
Fabris
A, Biasioli
et
al.
dialysis
M,
is often
lung
Adverse
only
of
(CAPD):
1983;
J,
Moorhead
A 43-year-old
nonsmoker
and
smear
in
infectious
Baillod
mide.
effects
of
hypertonic
1983;
results
with
1982;
Hildreth
B,
dialysis
fluid
2:1421
M, Pisani
E, Ronca
ambulatory
respiratory
peritoneal
dynamics.
The
few
had
Trans
to our
regular
pulse
rate
28:270-74
distress
ferred
was
raised
Fatal Pulmonary
with Disseminated
and there
angle
ventricle
showed
We
report
ratory
Chu-Pak
MB.;
and
a fatal
complicating
rapidly
MB.;
case
bronchogemc
progressive
failure.
Hong
1288
Kong,
MB.
pulmonary
carcinoma
which
embolism
presented
pulmonary
A clotting
miliary
shadows
profile
abnormality
the major
pulmonary
vessels
infarcts.
Histologic
examination
the
Ng,
of occult
with
disseminated
intravascular
Postmortem
examination
showed
*Fmm
Departments
Queen
was
Mary
clots
and
Hospital,
Hong
Pathology,
Kong.
acute
respiratory
pressure
a sinus
pressure
over
both
Repeated
shadow
but
of 85 mm
venous
petechiae
chest
had
enlarged
infiltrate
(Fig
tachycardia
of
12 seconds);
partial
seconds
(control
28.2
seconds
(control
14.3
g/L);
200
gfml.
and
She
1).
An
150
per
was
the
However,
she
of more
0. 1 gIL
110
than
110
1.46
ofmore
spectrum
to
than
antibiotics,
respiratory
rapidly
seconds
than
(normal
product
broad
hypoxic
46
of more
time
degradation
with
for
coagula-
time,
time
fibrinogen,
treated
Laboratory
intravascular
thrombin
fibrinogen
pulmonary
made.
prothrombin
thromboplastin
seconds);
ventilation
support.
mm;
seconds);
a serum
of diffuse
was
of disseminated
(control:
3.38
diagnosis
cor pulmonale
picture
8,000/cu
Her
noted.
relatives
of the
occluding
University
cyanosis,
were
hilar
trans-
and
failure,
succumbed
in
the
next
hour.
left
and areas
of pulmonary
revealed
fibrin deposition
of Medicine
right
severe
was
a weak
jugular
pulmonary
further
revealed
or tenderness.
the
hemop-
had
and
blood
The
only
count,
inotropic
compatible
was
coagulation
extensive
with
systolic
A presumptive
with
the
platelet
mechanical
and respi-
active.
revealed
tion:
Lou, M.D.;
Wmng-Fung
that
miliary
revealed
pathology
result
As
a low
of the jaw. There
diffuse
the
she
central
study
deteriorated
echocardiogram
excluded
any pericardial
effusion.
In
the pulmonary
artery and the right heart chambers
were
with an impaired
right ventricular
contraction.
The left
alveolar
An Unusual Case Masquerading
Miliary Tuberculosis
minute,
of
partial
dropped
admission,
circulation.
count
An
enlarged
Coagulation*
count
Examination
was no calf swelling
bilateral
addition,
Intravascular
and
pyrazina-
cytology
embarrassment
unit.
per
peripheral
to the
minute.
Embolism
care
minute,
after
antitu-
and
although
platelet
circulatory
of 150 beats
poor
with
days
and
rapidly
dyspnea,
The
local
on
platelet
sputum
She
the
started
(prothrombin
The
a
Sputum
of
a low
cells.
increasing
with
intensive
of 40 per
Hg
normal.
Five
opacity.
streptomycin,
except
profile
stopped.
hibar
was
of
was
roentgenogram
Because
she
malignant
with
mm.
Chest
a right
normal
was
for
apparently
31,000/cu
to
She
negative.
coagulation
days
because
weeks.
isoniazid,
were
negative
next
tysis
hospital
three
tuberculosis,
time)
were
respiratory
M, Feriani
relationship
JB,
mm.
to a chest
for
and
was
with
electrocardiogram
Wong,
can
oftubercubosis.
shadows
data
thromboplastin
ambulatory
admitted
bacilli
treatment
roentgenogram
Cheng,
prognosis
with
correct
diagbe improved.
and
REPORT
no history
miliary
Laboratory
with
Cheuk-Kit
Chun-Ho
ill patient
an early
hemoptysis
of pulmonary
59,000/cu
R, Sweny
had
acid-fast
berculosis
legs,
Occult
the
was
and
bilateral
for
in the
Young
in continuous
Organs
that
woman
dyspnea
showed
23:823-31
continuous
SM,
5, Chiannonte
Soc Artiflntern
in a critically
However,
way
exertional
Nephron
changes
with
Young
Lancet
metabolism
difficult
shadows.
is the
transport
1981; i:1409-12
SM,
[letter].
Acute
mt
Kidney
experience
Lancet
Hobson
C, et al. Buffer
Am
P, Raferty
KD.
properties
injury.
years’
Young
Nolph
transport
mechanical
Three
peritoneal
14
HL,
and
coagulation
CASE
year
KJ, Aas TW,
water
peritoneal
A, Moore
moi’phobogy
Chan
embolism
prevalence
Luger
98:1288-90)
embolism
is known to be associated
the clinical diagnosis
of pulmonary
L,
three
92:609-13
in transperitoneal
ambulatory
peritoneal
intravascular
lthough
pulmonary
with malignancies,
nosis
pento-
1984; 38:238-47
12
disseminated
=
diffuse
JK, Coburn
ambulatory
pentoneal
changes
continuous
JD,
continuous
Ann
LC,
DIC
1990;
19:564-67
Rubin
center.
Smeby
Long
during
during
1981;
ambulatory
at one
Wideroe
MJ, Kopple
mt
I
(Chest
of dialysis
10:338-43
9 Grodstein
embolism
started.
of peritoneal
coma.
microvasculature
pulmonary
75:253-62
Kempers
patients:
RE
compatible
with DIC.
Cases
of
with DIC have previously
been reported,
but this is the first case with pathologic
confirmation. Thus,
unusual
presentation
with diffuse
lung shadow
and
DIC
should
not deter
the clinician
from
correct
diagnosis
so that appropriate
treatment
can be promptly
the
in
In:
126:166-70
J, Gill GN,
molality
catheter
receiving
dialysis.
JJ. Occult
Marini
mechanically
6 Boyer
to the
in patients
lung.
and
agreed
The
right
were
filled
from
the
found
pulmonary
arteries
with
anterior
causing
to a limited
pulmonary
clots which extended
shaped
pulmonary
of
only
main
to distal
miliary
(Fig
tumor
segment
distal
were
vessels.
infa.rcts
Occuft
Downloaded From: http://journal.publications.chestnet.org/pdfaccess.ashx?url=/data/journals/chest/21620/ on 06/17/2017
was
Both
nodules,
right
examination
and both
dilated
occluded
There
2).
of the
collapse.
postmortem
artery
with
were
fresh
patches
pulmonary
and
upper
Histologic
Fatal Pulmonary
of wedgeparenchyma
a tumor
lobe
the
blood
mass
arising
bronchus
examination
Embolism
was
revealed
(Wong et a!)