READING COMPREHENSION

PRESENTADO POR:

YULIS PAOLA MESA GARCIA

DOCENTE

FRANCISCO EMIRO PEREA

NRC
7644

Corporación Universitaria Minuto De Dios – CR Urabá Administración De

Empresas – Ingles 3
2020
The ‘hole’ story of a lung:

COMPLETE

1. In consultation with the pulmonology service, inhaled fluticasone was initiated

because of a _ History of asthma and obstructive lung disease on _ spirometry.

2. The soft tissue density portion of _ The lesion had some punctate areas of
increased density representing inspissated mucus or calcification.

3. The patient underwent right Thoracotomy and open lung-wedge resection

4. A biopsy of the right nasal turbinate Was performed . Nasal mucosal cultures
were negative.
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The ‘hole’ story of a lung: Questions

Aadil Kakajiwala1 & Priyanka Fernandes2 & Bruce R. Pawel 3,4 & Sandra Amaral1,4

Received: 23 June 2016 /Revised: 24 June 2016 /Accepted: 27 June 2016 /Published online: 18 July
2016 # IPNA 2016 Keywords Renal transplantation . Immunosuppression . Fevers . Pulmonary
cavitary lesion

Background

A 14 year-old male patient with prune belly syndrome and chronic kidney disease (CKD) who
underwent his second renal transplant 2 years earlier was admitted with a worsening cough.

Transplant and immunosuppression

The patient underwent his first living-related donor renal transplant at the age of 3 years from his
mother. Eight years later, the transplant failed secondary to recurrent urinary tract infections (UTI)
and chronic allograft nephropathy. The first transplant had been managed with thymoglobulin
induction, prednisone, tacrolimus, mycophenolate mofetil (MMF), and sirolimus. He received a
second living-related donor renal transplant from his father at the age of 12 years. He was induced
with thymoglobulin and maintained on prednisone, MMF, and tacrolimus. One month after his
second transplant, he was noted to have BK viremia, with titers of 5,236,070 copies/ml. In response,
MMF was discontinued, and he was started on leflunomide. Four months later, he experienced a
gradual increase in creatinine, with renal biopsy findings of mild chronic allograft nephropathy,
focal interstitial inflammation, tubular atrophy, and focal vascular hyalinosis, suggestive of
calcineurin toxicity. He was started on sirolimus for immunosuppression (with a goal sirolimus
level of 5–8 ng/ml) and continued on a very low dose of tacrolimus of 1 mg twice daily, prednisone
5 mg (initially daily and switched to every other day 8 months after the transplant), and leflunomide
15 mg daily. He developed significant Epstein Barr virus (EBV) viremia 14 months after
transplantation (titers up to 903,013 copies/ml). The EBV viremia improved by 18 months
posttransplantation (52,498 copies/ml). BK viremia also resolved and leflunomide was
discontinued. Twenty months after transplantation, his tacrolimus was discontinued due to another
rise in EBV titers (up to 645,692 copies/ml).

Past medical history

Following his second transplant, he had multiple admissions for UTIs and fevers of unknown
origin. About a year after the transplant, he presented with fevers and abdominal pain. His white
cell count was 31,000/μl and absolute neutrophil count 23,636/μl. Blood and urine cultures at the
time were negative. Within this context, his EBV DNA titers were found to be elevated to 903,013
copies/ml. Computed tomography (CT)

Summary

In consultation with the pulmonology service, inhaled fluticasone was initiated because of a history
of asthma and obstructive lung disease on spirometry. Mycoplasma and pertussis polymerase chain
reaction (PCR) were negative. Two days after admission, a CT scan without contrast of the sinuses,
chest, abdomen, and pelvis was obtained due to elevated EBV DNA titers (3,186,970 copies/ml).
CT of the lungs showed a nonspecific 2.8-cm cavitary lesion in the right lower lung [Fig. 1]. The
soft tissue density portion of the lesion had some punctate areas of increased density representing
inspissated mucus or calcification.

There were patchy opacities in the right middle and left lower lobes most suggestive of atelectasis.
There were no pathologically enlarged lymph nodes in the chest, abdomen, or pelvis. The patient
underwent right thoracotomy and open lung-wedge resection. Tissue from the lung biopsy specimen
was sent for staining and cultures for aerobic and anaerobic bacteria, fungi, and mycobacteria, as
per recommendation from the immunocompromised infectious diseases service.

Biopsy images and histology are displayed in Fig. 2. Based on the results, our patient was started on
appropriate therapy. The CT scan of the sinuses showed near complete opacification of the
paranasal sinuses, with an air–fluid level in the right maxillary sinus suggesting acuity. Hyperdense
secretions were noted in the ethmoid air cells, with lacy septations and mucosal thickening of the
sphenoid sinuses. A biopsy of the right nasal turbinate was performed. Nasal mucosal cultures were
negative. Nasal mucosal pathology showed nonkeratinized squamous mucosa with focal mild
inflammation, fibrovascular tissue with numerous mucous glands, and mild chronic inflammation.

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