Stephanie Christina

MORNING REPORT 1 SEPTEMBER 2015

Identitas : Ferry Fangky Rumayar / laki-laki / 31 tahun / 12.42.90.51

Tanggal : 31-8-2015
Klinis : suspect TB paru
Kiriman : Poli Perawatan Intermediate Penyakit Infeksi
Permintaan : Foto Thorax PA

Foto Thorax PA :
Cor : besar dan bentuk normal
Pulmo :
 Tampak fibroinfiltrat disertai multiple cavitas berdinding tebal, tepi dalam
ireguler, dengan ukuran terbesar +/- 4 x 3,4 cm di lapang paru kanan dan
parahiler kiri
 Tampak pula cavitas berdinding tebal dengan tepi dalam yang ireguler,
dengan air-fluid level di dalamnya di parahiler kiri
Sinus phrenicocostalis kanan kiri tajam
Tulang – tulang tampak baik

Kesan :
TB paru dengan abcess paru

Foto Thorax AP tanggal 10-7-2015 (IRD, keterangan klinis: B20+vomiting):

Cor : besar dan bentuk normal

Pulmo : tampak reticulogranular pattern di kedua lapang paru
Sinus phrenicocostalis kanan kiri tajam

Kesan :
Reticulogranular pattern di kedua lapang paru dapat merupakan DD/:
1. TB milier
2. Interstitial pneumonia

Foto Thorax AP tanggal 11-8-2015 (GDC, keterangan klinis: susp.TB paru):

Cor : besar dan bentuk normal

Pulmo : tampak infiltrat di suprahiler kanan dan parahiler kiri disertai multiple
cavitas
Sinus phrenicocostalis kanan kiri tajam

Kesan :
Keradangan paru dapat merupakan proses spesifik
 Stephanie Christina

PARENCHYMAL LUNG DISEASES

1. Airspace Disease
- fluffy, cloud like, hazy
- confluent, indisctinct margin
- dapat localized atau diffuse
- air bronchogram (+)
- silhouette sign (+)
- DD :
Akut :
a. Pneumonia (eksudat)  patchy, segmental, or lobar airspace disease; air
bronchogram (+)
b. Alveolar edema (fluid)  bilateral perihilar airspace disease, batwing appearance,
air bronchogram (-) karena cairan juga mengisi bronchus, efusi pleura, penebalan
fissure mayor dan minor
c. Pulmonary hemorrhage
d. Aspiration (>> lower lobes or posterior portions of the upper lobes; >> right lower
lobe)
e. Near – drowning (water)
Kronik :
a. Bronchoalveolar cell carcinoma
b. Alveolar cell proteinosis
c. Sarcoidosis
d. Lymphoma

2. Interstitial Disease
- Discrete particles of disease, separated by normal aerated lung
- Margin are usually sharp and discrete
- Dapat focal atau diffuse
- Air bronchogram (-)
- 3 patterns of presentation : reticular, nodular, reticulonodular
- DD :
a. Reticular predominant
Idiopathic pulmonary fibrosis
Pulmonary interstitial edema
Rheumatoid lung
Scleroderma
b. Nodular predominant
Bronchogenic carcinoma
Metastase
Silicosis
Miliary TB
c. Mix reticular & nodular  sarcoidosis
 Stephanie Christina

PNEUMONIA

 S.pneumonia; silhouette sign

(+)
 S.aureus, P.aeruginosa

 viral, M.pneumonia, PCP

 posterior, lower lobes

Other infectious agents that produce cavitary disease:

 Staphylococcal pneumonia can cavitate and produce thin-walled pneumatocoeles.
 Streptococcal pneumonia, Klebsiella pneumonia, and coccidiomycosis can also
produce cavitating pneumonias. 

 Stephanie Christina

Note : bronchiectasis umumnya di 1/3 medial paru, bronchial wall thickening (+)

Air-
containing
lesions

Dinding tebal Dinding tipis

(> 3 mm) = (< 3 mm)
CAVITAS

Dinding < 1 mm, Dinding sangat tipis,

Regular inner diameter ≥ 1 cm, ukuran kecil,
Irregular
wall, fuzzy outer Dinding ≥ 1 mm,
inner wall >> pada emphysema, di pleura visceralis
wall diameter ≥ 1 cm
e.c. airflow (outside internal lung
obstruction capsule), >> di apex
Outer wall
Air-fluid Air-fluid
: spiculate
level (+) level (-)
sign (+)
Cyst Bullae Blebs

Lung Lung
Lung TB
tumor abcess
Congenital Acquired

Aktif : Inaktif :
dinding dinding
tebal tipis i.e. pneumatocele
(akibat infeksi
Staphylococcus /
Pneumocystis)

Notes :
 Cavitas  lucency within pulmonary consolidation, mass, or nodule; vary in size, occur in the lung
parenchyma and result from a process that produces necrosis of the central portion of the lesion
 Fluid develops as a result of infection, hemorrhage, or liquefaction necrosis
 Bila lesi terisi penuh oleh cairan, akan tampak seperti massa solid. Air-fluid level terbentuk bila ada
hubungan antara lesi dengan bronchial tree  sebagian cairan dikeluarkan melalui bronchial tree.

DD Cavitas :
C : carcinoma
A : autoimmune (Wegener’s granulomatosis, sarcoidosis)
V : vascular (thromboemboli, metastasis)
I : infeksi (TB, abcess)
T : trauma (bronchogenic cyst)
Y : youth (kelainan kongenital i.e. bronchogenic cyst kongenital, intralobular
bronchopulmonary sequestration, congenital cystic adenomatoid malformation
 Stephanie Christina

PULMONARY TUBERCULOSIS

TB primer
 >> asimtomatik, hanya 5% yang progresif dan menjadi TB milier
 Lokasi dapat di semua bagian paru
 Primary TB affects the upper lobes slightly more than the lower and produces airspace
disease that may be associated with ipsilateral hilar adenopathy (especially in children)
and large, often unilateral, pleural effusions (especially in adults)
 Cavitation is rare in primary TB
 Khas : ipsilateral hilar & mediastinal (paratracheal lymphadenopathy)
 Ghon focus = tuberculoma yang telah mengalami kalsifikasi (sequel dari TB primer)
 Ranke complex = Ghon focus + calsified ipsilateral hilar lymphadenopathy
 (Primary complex = focus primer, lymphangitis, lymphadenitis)
 Komplikasi tersering : pleuritis, atelectasis (akibat penekanan bronchus oleh
pembesaran KGB hilus)

Post-primary tuberculosis (reactivation tuberculosis)

• Cavitation is common. 

• The cavity is usually thin-walled and has a smooth 
 inner margin and no air-fluid level
• Post-primary tuberculosis almost always affects the apical or posterior segments of
the upper lobes or the 
 superior segments of the lower lobes. 

• Bilateral upper lobe disease is very common. 

• Transbronchial spread (from one upper lobe to the opposite lower lobe or to another
lobe in the lung) should make you think of infection with Mycobacterium tuberculosis.


• Healing of post-primary TB usually occurs with fibro- sis and retraction.

Miliary tuberculosis
• Considered to be a manifestation of primary TB, although 
 the clinical appearance of
miliary TB may not occur for 
 many years after the initial infection. 

• When first visible, the small nodules measure only 
 about 1 mm in size; they can
grow to 2-3 mm if 
 untreated (Fig. 7-9). 

• When miliary TB is treated, clearing is usually rapid. 
 Miliary TB seldom, if ever, heals
with residual calcification. 


Tuberculomas or tuberculous granulomas are a well defined focal mass that results
from Mycobacterium tuberculosis infection, and is one of several morphological forms of
tuberculous disease. Tuberculomas occur most commonly in the brain and the lung.
Macroscopically, a tuberculoma is a well defined firm nodule. Histologically it consists of a
central core of caseating necrosis with a surrounding wall of a granulomatous reaction
containing Langhans giant cells, epithelioid histiocytes and lymphocytes.
 Stephanie Christina

Manifestasi TB paru
Primer Post Primer
Inaktif - Normal - Normal
- Fibrosis - Fibrosis
- Kalsifikasi paru / KGB - Kalsifikasi paru / KGB / pleura
- Residual cavity (kecil, dinding tipis)
Aktif - Infiltrat / konsolidasi bisa - Infiltrat / konsolidasi di segmen
di mana saja apical / posterior lobus superior,
- Lymphadenopathy hilus & segmen apical lobus inferior,
paratrachea cavitas, lesi endobronchial
- Efusi pleura / pericard - Efusi pleura / pericard
- TB milier - TB milier
Indeterminate Tuberculoma Tuberculoma
Komplikasi - Pleuritis / efusi pleura - Schwarte
- Atelektasis (>> anterior - Destroyed lung
segment of upper lobe, - Bronchiectasis
medial segment of right
middle lobe)

Klasifikasi TB sekunder menurut American Tuberculosis Classification :

1. Minimal TB
- Garis median, apex, costae 2
- Cavitas (-)
2. Moderately advanced TB
- Infiltrat < 1 paru atau konsolidasi < 1 lobus (luas total)
- Diameter cavitas total < 4 cm
3. Far advanced TB
- Infiltrat > 1 paru atau konsolidasi > 1 lobus (luas total)
- Diameter cavitas total > 4 cm

Notes :
Infeksi sekunder tersering pada TB : aspergillosis ?
Fungus ball : konsolidasi, crescent sign (+)