Case:

Robbie was in his 4th year medicine proper. His first rotation as a clinical clerk is surgery for 8 weeks. Now he is about to finish his 8-week rotation in medicine. He was looking forward to a more relaxed free block which is actually a 4-week stint in the community. Robbie was not expecting that the clinical year would be very demanding, i.e. long duty hours, hurried cafeteria meals, endorsements, etc. all worn him down.

The free block however didnt do much to improve his strength. He still felt tired, has not regained any of his lost weight, had actually lost a few more, and had a light cough. Robbie arranged for his chest x-ray, which showed only a few calcified lesions. Robbie discussed the findings with his resident in medicine, who recommended a skin test for tuberculosis. Robbie said he had been PPD-negative when tested in the immunology laboratory last year.

QUESTIONS:

1. What is the most common cause of calcified lesions in the lungs?

Calcified granulomas - scars from prior lung infections that become calcified over time
y Histoplasmosis y Coccidiomycosis y Tuberculosis y Asbestos exposure (pleural calcification)

2. Describe PPD. How does it differ from OT?

PPD
The PPD skin test is a method used to diagnose tuberculosis. PPD stands for purified protein derivative. PPD tuberculin is a precipitate of non-speciesspecific molecules obtained from filtrates of sterilized, concentrated cultures. Tuberculin is a glycerol extract of the tubercle bacillus.

OT
The Tine test is a multiple puncture tuberculin skin test used to aid in the medical diagnosis of tuberculosis (TB).

How the test is performed:

PPD
The test site (usually the forearm) is cleansed. The PPD extract is then injected under the top layer of skin, causing a blister to form on the skin. The reaction will take 48 - 72 hours to develop. You must return to your health care provider within that time to have the area checked. This will determine whether you have had a significant reaction to the PPD test. A reaction is measured in millimeters of hard swelling (induration) at the site.

OT
This test uses a small "button" that has four to six short needles coated with TB antigens (tuberculin). The needles are pressed into the skin (usually on the inner side of the forearm), forcing the antigens into skin. The test is read by measuring the size of the largest papule. A negative result is the presence of no papules.

3. Describe the use of PPD and the interpretation of the reactions to PPD.

A standard dose of 5 Tuberculin units (0.1 mL) is injected intradermally (between the layers of dermis) and read 48 to 72 hours later. A person who has been exposed to the bacteria is expected to mount an immune response in the skin containing the bacterial proteins. The reaction is read by measuring the diameter of induration (palpable raised hardened area) across the forearm (perpendicular to the long axis) in millimeters. If there is no induration, the result should be recorded as "0 mm". Erythema (redness) should not be measured. If a person has had a history of a positive tuberculin skin test, another skin test is not needed. But if negative another test may be needed.

4. Do calcified lesions eliminate tuberculosis and histoplasmosis from the differential diagnosis?

No, because both diseases would be differentially diagnosed by lung calcifications. Though location of calcifications in the lungs would give higher level of suspicion of either disease entity, again depending in the location on chest xray.

5. Why werent skin test for fungal infections requested?

We do not test by skin test fungal infections because the common systemic fungal infections like histoplasmosis and coccidiodes is widespread that majority of the population has been exposed causing asymptomatic presentations. Therefore, this would most likely result in a positive skin test which is not helpful for the diagnosis, thus most of the population would test positive anyway.

6. What features in this case, if any, suggest mycoplasma pneumonia?

Light cough and ambulatory patients are some of the features exhibited by the patient that may also give a differential diagnosis of mycoplasma pneumonia. Streaky infiltrates are seen in patients with atypical pneumonia, but this is not seen in our case.

7. How is the microscopic diagnosis of tuberculosis established?

Sputum acid fast staining is a simple procedure in diagnosing tuberculosis. Acid fast bacilli are seen in oil immersion objective after using the ZiehlNeelsen stain.

. Sputum culture or TB culture- when no acid fast bacilli is observed on smear or isolated in culture. Done together with sputum AFB. y Both are done by collecting serially (usually 3 consecutive days, preferably in the morning)

8. How is the microbiologic diagnosis of histoplasmosis established?

Histoplasmosis can be diagnosed by samples containing the fungus taken from sputum, blood, or infected organs. The standard for diagnosis is isolation of H. capsulatum from culture. However, it usually requires 4 weeks to grow and has a low sensitivity rate (15%) in self-limited histoplasmosis. The knobby appearance of macroconidia and microconidia indicated by Lactophenol Cotton Blue Stain of the mold form from fungal cultures is characteristic of H. capsulatum