UDLCO summary :
A 41 year old man with recent pneumonia was scheduled for a pleural tap when there was some diagnostic uncertainty on if the pleural fluid was tappable as visible on an initially rotated chest film that suggested a loculated pleural effusion. An ultrasound was repeated in the bedside that took the team through a pneumonia differential chasing journey especially pivoting around an organismal ontology given the confusing posterior acoustic shadows that were likely due to inflammatory lung exudates rather than calcification.
Conversational transcripts :
[2/29, 5:12 PM] Rakesh Biswas:
Afternoon session :
Very interesting afternoon with three ultrasounds throwing up lots of revelations. Will YouTube and share the Echo ultrasounds later
[2/29, 5:14 PM] Rakesh Biswas: Guess what the ultrasound revealed? @Metapsychist Medical Student 2 @Metacognitist Mover and Shaker1
[2/29, 5:16 PM] Metapsychist Number 1 Kims 2015: Effusion with/out consolidation?
[2/29, 5:21 PM] Rakesh Biswas: Other possibilities?
[2/29, 5:41 PM] Metacognitist Mover and Shaker1: Clear air bronchograms and Pleural effusion on left sir?
[2/29, 5:44 PM] Metapsychist Number 1 Kims 2015: Sir,is tamponading a possibility here?
[2/29, 5:48 PM] Metacognitist Mover and Shaker1: Cannot be sure.
[2/29, 5:49 PM] Metapsychist Number 1 Kims 2015: Agree sir.
Looking forward for USG findings..
[2/29, 6:26 PM] Rakesh Biswas: Will be uoloading soon. Meanwhile keep the differentials coming. What are the other possibilities inside a lung (think inside the box such as lung and not outside the box such as pleura)!
[2/29, 6:29 PM] Rakesh Biswas: Good point. What lung problem could it be causing that consolidation?
[2/29, 6:30 PM] Metapsychist Number 1 Kims 2015: Abscess?
[2/29, 6:30 PM] Metapsychist Number 1 Kims 2015: Suspected it,but 'borders'?
[2/29, 6:31 PM] Metapsychist Number 1 Kims 2015: Also suspected bronchiectasis,however no signs of hyperinflation?
[2/29, 6:31 PM] Metapsychist Number 1 Kims 2015: Is TB in differential list as well?
[2/29, 6:31 PM] Rakesh Biswas: Well abscess is just a necrotising pneumonia
What organism that can make a large dwelling inside the lung also precipitates pneumonia
He was operated for a liver Tumor that may have been due to the same organism
[2/29, 6:32 PM] Rakesh Biswas: Other than the bacteria box
[2/29, 6:33 PM] Metapsychist Number 1 Kims 2015: Aspergillosis?
[2/29, 6:34 PM] Rakesh Biswas: Closer
Out of the fungal box
Does aspergillosis affect liver like a tumor?
[2/29, 6:35 PM] Dr Shamshed : Hydratid cyst ?
[2/29, 6:36 PM] Metapsychist Number 1 Kims 2015: Recalls of one famous Neet PG question..
Paragnomius westermani?
Parasite involving lung and liver?
[2/29, 6:37 PM] Metacognitist Mover and Shaker1: An amoeba then
[2/29, 6:37 PM] Metapsychist Number 1 Kims 2015: cmv possible too?
Not sure?
[2/29, 6:38 PM] Rakesh Biswas: I worked with the Indian Professor who reported it first in India from North East and his name was there in that chapter in Harrison!
[2/29, 6:41 PM] Rakesh Biswas: But off course we wouldn't think of paragonimiasis in Telangana although going by the latest crested grasshopper we reported from our house in Hyderabad migration perhaps is in full swing due to loss of biodiversity and habitat loss. Even @Sai Charan Kulkarni 2020 KIMS Pg reported a rare parasite from NKP which is very rare (I've forgotten the name, can Charan share the link to that report)
[2/29, 6:39 PM] Metapsychist Medical Student 2: I already know it sir😅
[2/29, 6:39 PM] Metapsychist Medical Student 2: Got to know from @Sreeteja 2023 Kims Med PG
[2/29, 6:42 PM] Rakesh Biswas: Well to be honest we don't! We just made it our ultrasound differential going by all the different data points coming into a single organism centered ontology
@Metapsychist Number 1 Kims 2015
[2/29, 6:43 PM] Metapsychist Number 1 Kims 2015: Ruling in vs ruling out..
Medical cognition project
[2/29, 6:46 PM] Metapsychist Number 1 Kims 2015: Looking forward to know!
Also about the rare parasite from NKP..
[2/29, 6:48 PM] Metapsychist Number 1 Kims 2015: Schistosoma and toxoplasma likely as well?
[2/29, 6:48 PM] Rakesh Biswas: Much more common
[2/29, 6:49 PM] Metapsychist Number 1 Kims 2015: I mean,hep may cause it as well?liver plus lung involvement?
Not sure
[2/29, 6:49 PM] Metapsychist Number 1 Kims 2015: Give up
[2/29, 6:50 PM] Metapsychist Medical Student 2: One of them has already guessed it right above
[2/29, 6:51 PM] Metapsychist Number 1 Kims 2015: Clonorchis?
[2/29, 6:52 PM] Dr Shamshed : E granulosis
[2/29, 6:53 PM] Metapsychist Number 1 Kims 2015: Interesting!
Dog tapeworm?
[2/29, 6:53 PM] Metapsychist Number 1 Kims 2015: How did you arrive at it through USG?
@Rakesh Biswas
[2/29, 6:54 PM] Metapsychist Number 1 Kims 2015: Nice inputs
Wonder which amoeba may cause liver+lung involvement.
Would love to learn more about it
[3/1, 8:09 AM] Sai Charan Kulkarni 2020 KIMS Pg: Capillaria Phillipensis sir..?
[3/1, 8:21 AM] Sai Charan Kulkarni 2020 KIMS Pg: Surprisingly he was admitted in one of the named corporate hospitals in Hyderabad, evaluated for everything, all scopes from possible sites and radiological scans ( CT and MR abd ) were done but they missed stool and we got this organism in his stool.
[3/1, 8:25 AM] Rakesh Biswas: Share the general knowledge history of this organism. Where was it first discovered and reported from in the world?
[3/1, 8:32 AM] Sai Charan Kulkarni 2020 KIMS Pg: [7/11, 12:47 PM] saicharankulakarni:
Human intestinal capillariasis caused by Capillaria philippinensis is an endemic disease in Philippines[1] and Thailand.[2] C. philippinensis infection is mainly acquired by ingestion of raw, undercooked, small fresh water or brackish water fi sh, in which larval forms of the parasite develop. This infection mainly involves small intestine (jejunum) and patients suffer from chronic diarrhoea, protein losing enteropathy, borborygmus and electrolyte loss.[1] If early diagnosis and treatment is not given, it can be fatal.
Only two cases have been reported from India. No case was reported from Andhra Pradesh. The fi rst case from India was reported by Kang et al. in 1994 from Vellore[6] and the second case by Rana et al. in 2009 from Chandigarh.[7] This is the third case report from India and the fi rst case from Andhra Pradesh to the best of our knowledge
[7/11, 12:48 PM] saicharankulakarni:
C. philippinensis is a nematode belonging to class Adenophorea, subclass Enoplia, order Trichurida and family Trichinellidae.[8] In the life cycle of C. philippinensis, fi sh eating birds are natural defi nite hosts. Adult worms present in the intestine of birds release ova. Bird droppings along the fl yways disperse these eggs into water bodies, where f i sh become infected. Larval forms develop in fi sh and it is the source of infection to man and bird.
C. philippinensis infection is mainly acquired by ingestion of raw, undercooked, small fresh water or brackish water fish.
Simple wet mount examination of stool sample and identifi cation of ova, larvae and adult worm in the stool sample can clinch the diagnosis. But ova of C. philippinensis need to be differentiated from those of Trichuris trichura. Ova of C. philippinensis can be identifi ed by their peanut shape, fl attened mucous plugs and striations in the wall. Adult worms vary in sizes from 2 to 5 mm. Male worms are shorter (1.5 – 3.9 mm) compared to female worms (2.3 – 5.3 mm). They are identifi ed by their characteristic stichosome, a muscular oesophagus surrounded by rows of stichocytes. Male worms have single sheathed spicule. Female uterus contains numerous thick-shelled eggs and thin-shelled eggs with or without embryos or larvae. Larvae found in stool sample in different stages of development and hence are diffi cult to identify as C. philippinensis larvae.[1]
Reference link in the blog sir
This was the first case from then Andhra Pradesh published from our college
[3/1, 8:36 AM] Rakesh Biswas: Alright so given the name we can assume that it was first reported from the Philippines
[3/1, 8:43 AM] Sai Charan Kulkarni 2020 KIMS Pg: Capillaria philippinensis is a parasitic nematode which causes intestinal capillariasis. This sometimes fatal disease was first discovered in Northern Luzon, Philippines, in 1964.
[3/1, 9:11 AM] Rakesh Biswas: The UDLCO summary is in the description box of this video
@Rahul healthcare 2.0 @Metacognitist Mover and Shaker1 @Sadhana Sharma Nri Med @Sai Charan Kulkarni 2020 KIMS Pg
[3/1, 9:37 AM] Sai Charan Kulkarni 2020 KIMS Pg: Seems like effusion with underlying lung collapse with dynamic air Bronchogram ( appearing as calcified lesions ) and decreased pleural slide and tissue like architecture on lung usg.
Intrested to know radiologist view on this..?
[3/1, 9:56 AM] Rahul healthcare 2.0: Shot in the dark from a Google searching learner -
The WA group title says tumor in liver 20 years ago.. any chance the loculated pleural effusion is something cancerous in the lung? Does pt have pain in the chest? Any other clinical observations?
https://www.intechopen.com/chapters/62305
[3/1, 10:13 AM] Rakesh Biswas: Yes we still don't know the etiology of his pneumonia. Till now we were trying to pivot around an organismal ontology and neoplasia is the next frontier to be explored for this man if when it turns out to be a non resolving pneumonia.
Here's an interesting video around this by one of our elective students around one of our patients also starring @Metacognitist Mover and Shaker1 that was comissioned by a US Medical college where my ex colleague worked👇
[3/1, 10:43 AM] Rakesh Biswas: Thanks for sharing the lung windows that start here at 1:40
CT video link :
Suggests a mass like consolidation affecting the posterior segment of left upper lobe and left lower lobe!
@Rahul healthcare 2.0 It looks very amenable to trans thoracic needle biopsy similar to what we did years back recorded in the other video link we shared in the collective group. Only we need an enthusiastic resident like @Metacognitist Mover and Shaker1 to be here! Can @Metapsychist Medical Student 2 attempt it depending on feedback from the radiologist's report and after discussion with Aditya, Keerti and Pulmo team and relatives even before we can pronounce it non resolving?
Or better to simply wait and see if it resolves spontaneously as there may be no first mover advantage here?
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