Question 6

A 33-year-old abattoir worker presented to the Emergency Department with a 2 week history of increasing shortness of breath and haemoptysis. He had previously been fit and well.

On examination he is alert, normotensive but tachypnoeic (35 breaths per minute), centrally
cyanosed (SaO2 85% on 10L/min O2) and tachycardic (120 beats per minute). Auscultation reveals a systolic murmur at the lower left sternal edge and coarse inspiratory crackles bibasally. The remainder of the examination was unremarkable.

His chest radiograph demonstrates bibasal consolidation.

List the most likely differential diagnoses, and for each diagnosis, list the specific investigations needed to confirm the diagnosis and the specific treatment required.

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College Answer

Cause	Investigation	Treatment
Pneumonia Bacterial S. pneumonia, H. _nfluenza K. pneumonia	Sputum MC&S Blood Culture	3rd Generation cephalosporin (or similar) plus Azithromycin (or similar)
Atypical Viral- Influenza	Serology / PCR Viral PCR	± Oseltamivir / Ribavarin
Other infective Infective endocarditis Leptospirosis	TTE/TOE, bld culture Serology, PCR	Antibiotics  surgery Doxycycline / cefotaxime / benzyl penicillin
Q fever Anthrax	Serology for C. burnetii Blood culture	Doxycycline, ciprofloxacin Doxycycline, ciprofloxacin, benzyl penicillin
Vasculitis Goodpasture’s syndrome Wegener’s granulomatosis	Anti-GBM Abs cANCA	) Steroids ) Plasmapheresis ) Cyclophosphamide
Cardiovascular Acute mitral regurgitation Pulmonary infarction	TTE/TOE, screen for acute MI CTPA, V/Q scan	Surgery Anticoagulation

Discussion

This question favours the candidate with a physician background.

Really, it's a pub trivia question. "Which bugs can cause pneumonia and haemoptysis in an abbatoir worker?" Most physicians would immeadiately yell "Q Fever!" And that would be the most likely explanation. It tends to produce an atypical pneumonia and endocarditis.

Instead of delving into the specifics of Q Fever, the college model answer unfocuses broadly on thedifferentials of haemoptysis, with an infectious flavour. Table 1 in the linked article lists the usual suspects. That is the concise version.

A less concise version is presented in the answer to Question 2 from the first paper of 2012 (yes, this exact same paper)

Causes of Haemoptysis
Infectious Mycobacteria (particularly tuberculosis) Fungal infections (including mycetoma) Necrotizing pneumonia and lung abscess (Klebsiella pneumoniae, Pseudomonas aeruginosa,Staphylococcus aureus, Streptococcus pneumoniae, other Streptococcus spp. and Actinomyces spp.) Bacterial endocarditis with septic emboli Parasitic (paragonimiasis, hydatid cyst) Neoplastic Bronchogenic carcinoma Endobronchial tumors (carcinoid, adenoid cystic carcinoma) Pulmonary metastases Sarcoma Pulmonary Bronchiectasis (including cystic fibrosis) Chronic bronchitis Alveolar hemorrhage and underlying causes Vascular Pulmonary artery aneurysm (Rasmussen aneurysm, mycotic, arteritis) Bronchial artery aneurysm Pulmonary infarct (embolism) Pulmonary hypertension Congenital cardiac or pulmonary vascular malformations Airway-vascular fistula Arteriovenous malformations Mitral stenosis Left-ventricular failure	Vasculitis Wegener's granulomatosis Goodpasture's syndrome Behçet's disease Systemic lupus erythematosus Trauma Induced by diagnostic bronchoscopy (brushing/biopsy) Related to interventional pulmonology procedures (dilation, metallic stent placement, high-dose brachytherapy) Catheter-induced PA rupture Blunt or penetrating chest injury Transtracheal procedures Hematological Coagulopathy (congenital, acquired or iatrogenic) Platelet disorders Drugs and toxins Penicillamine Solvents Crack cocaine Trimellitic anhydride Bevacizumab Miscellaneous Endometriosis Lymphangioleiomatosis Broncholithiasis Cryptogenic Foreign body aspiration Lung transplantation

References

Talwar, D., et al. "Massive hemoptysis in a respiratory ICU: causes, interventions and outcomes-Indian study." Critical Care 16.Suppl 1 (2012): P81.

Maurin, M., and D. fever Raoult. "Q fever." Clinical microbiology reviews 12.4 (1999): 518-553.

Bidwell, JACOB L., and Robert W. Pachner. "Hemoptysis: diagnosis and management." Am Fam Physician 72.7 (2005): 1253-1260.

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