Septic pulmonary emboli in a 26-year-old male-the maze solution
Arya Krishnan, G. N. Srivastava
Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India. E-mail: aryakrishnan.10024@gmail.com
Introduction: Septic pulmonary emboli refer to the embolization of infectious particles (intravascular thrombus containing microorganisms) into the lungs via the pulmonary arterial system. Septic pulmonary emboli is a rare phenomenon especially in a young non IV drug abuser. Here we present such a case, who was misdiagnosed and referred as a case of lung metastasis and later diagnosed as biopsy proven pulmonary tuberculosis with septic embolism.
History: A 26-year-old male who is a known chronic alcoholic, electrician by occupation, presented with complaints of high-grade fever, productive cough and shortness of breath of 2 weeks duration. He had history of hospitilisation for treatment for acute pancreatitis prior to development of the above mentioned symptoms. There was history of treatment with oral hypoglycemic agents for diabetes mellitus for past 6 months.
Clinical Findings: On physical examinaton, patient was thin built, moderately nourished. Pallor, icterus were present. He was febrile with tachycardia, tachypnea and hypotension. Respiratory system examination revealed increased chest movements with increased tactile and vocal fremitus, Air entry was reduced bilaterally with occasional crepitations.
Diagnosis Management: Patient underwent routine investigations which showed raised leukocyte counts with neutrophilic predominance, deranged liver function test and had a sequential organ failure assessment (SOFA) score of 7. Radiological features included multiple nodular opacities with peripheral predominance and occasional cavitation and the differential diagnosis included Septic emboli, metastasis (canon ball lesions), or other cavitatory lesions including infectious diseases like tuberculosis, invasive aspergillosis and vasculitis lesions. His blood culture reports, sputum investigations were negative and computed tomography guided biopsy from the lung lesion led to the histopathological diagnosis of tuberculosis. Patient was started on anti-tubercular therapy and on follow up there was radiological resolution of the previous lesions favoring our diagnosis.
Learning Points: Tuberculosis presenting with radiological features of septic emboli itself is a rare phenomenon and can cause diagnostic dilemma. But being an endemic country, we have to rule out this infectious disease with these kind of presenations and in all immunocompromised conditions. Also, septic emboli in a nonintravenous drug abuser is also a matter of concern at present. We have to consider the fact that, with the available antitubercular therapy, timely diagnosis and management, the prognosis is also good in these kind of patients.
Comparison of conventional diagnostic methods with molecular method for tuberculosis
Monika Sharma, Shobha Broor, Megha Maheshwari, D. P. S. Sudan
E-mail: monica303s@gmail.com
Background: Tuberculosis remains one of the deadliest communicable diseases. Prompt diagnosis of active tuberculosis cases facilitates timely therapeutic intervention and minimizes the community transmission. Although conventional microscopy has low sensitivity, still it remains the corner stone for the diagnosis of pulmonary tuberculosis in high burden countries like India. On the other hand, Nucleic acid amplification techniques due to its rapidity and sensitivity not only help in early diagnosis and management of tuberculosis but also curtail the transmission of the disease. This study therefore aimed at assessing the diagnostic performance of Ziehl-Neelsen (ZN), Auramine Staining methods (AO) and Gene X pert/ CBNAAT (Cartridge based nucleic acid amplification test) in the diagnosis of Pulmonary Tuberculosis.
Methods: A prospective comparative study was done on the sputum samples of 1583 adult patients from November 2018 to May 2020 suspected of having pulmonary tuberculosis and visiting the Designated Microscopic Centre of SGT Medical College, Budhera, Gurugram. Each sample was subjected to ZN staining, AO staining, and was run on CBNAAT as per National Tuberculosis Elimination Program (NTEP) guidelines. The sensitivity, specificity, PPV and NPV and Area under the curve of ZN microscopy and Fluorescent Microscopy were calculated taking CBNAAT as reference in absence of culture.
Results: Out of the 1583 samples analyzed, 145 (9.15 %), 197 (12.44 %), and 246 (15.54 %) were positive for Mycobacterium tuberculosis using FM, ZN, and CBNAAT assays respectively. AO Staining was also able to detect more pauci-bacillary cases than ZN Staining. While CBNAAT detected Mycobacterium tuberculosis in 49 sputum samples which were missed by both methods of microscopy. Whereas there were 9 samples which were positive for AFB by both the smear microscopy techniques but were negative by CBNAAT, and these were considered as Non-Tuberculous Mycobacteria. Seventeen samples were rifampicin resistant which were further evaluated for sensitivity to other drugs before initiating treatment for MDR.
Conclusion: Auramine Staining technique is more sensitive and less time consuming for the diagnosis of pulmonary tuberculosis as compared to the conventional ZN Staining. CBNAAT can be a useful tool for early diagnosis of patients with high clinical suspicion of pulmonary tuberculosis and detecting rifampicin resistance.
Association of cartridge based nucleic acid amplification test grading on the basis of cycle threshold value with time to culture positivity
Tanuja Pilli, A. Ayyappa
Andhra Medical College, Visakhapatnam, Andhra Pradesh, India. E-mail: tanujacurie@gmail.com
Background: The interpretation of the result of CBNAAT is done on the basis of CT value as high, medium, low and very low. CT value may correlate with time to positivity in culture.
Methods: This is a prospective study with 163 gene X pert positive sputum samples analysed for correlation between CT value and time taken for growth in culture. Samples were sent for culture (MGIT) as well as CBNAAT. Association between CT value and time for growth was analysed by chi square test (p value < 0.005). Spearman correlation was used to determine correlation of X pert CT values with TTCP.
Results: Out of 163 X pert positive samples, 29.44 % (n=48) samples were culture positive, 63.19% (n=103) were negative and 7.36% (n=12) were contaminated. Mean CT value and mean TTCP among culture positives are 22.18 and 30.87 respectively. There is significant association between CT values and time for growth (p value <0.05). Spearman correlation of mean CT value with TTCP in culture showed moderate positive correlation. Linear regression analysis found association between MGIT TTCP in culture and CT value of CBNAAT (R2=0.22).
Conclusion: Samples with high and medium detected CT values have shown early culture positivity.
Pyrazinamide-induced Steven-Johnson syndrome in an immune competent adult with tuberculosis
D. Shiva Kumar, M. Sravan Kumar, P. Ravi
Kakatiya Medical College, Warangal, Telangana, India. E-mail: shivadharavath32@gmail.com
Background: Steven-Johnson syndrome (SJS) is an acute reaction to the skin and mucous membranes that is characterised by damage and flaking of the skin, accompanied by pain and can cause death. Treatment with anti-TB drugs sometimes results in skin lesions that range from mild self-limiting reactions to severe forms like steven-Johnson syndrome. Incidence and mortality are quite rare.
Case Study: A 30 years male presented with fever, erythema and multiple bullous lesions, ulcers with oozing of pus all over the body with oral and genital involvement. Hyperpigmentation with crusting was noted over the body accompanied by itching for 7 days. A diagnosis of Steven-Johnson syndrome was made. ATT was kept on hold for 2 weeks and systemic corticosteroid, antihistamines and antibiotics were given. ATT rechallenging was done as per national guidelines and the offending drug was identified as pyrazinamide and replaced. Patients were advised to continue modified ATT as per guidelines. Patients were stable and had no cutaneous adverse reactions.
Discussion: First-line ATT are key to eradicating the infection. Moreover, reactions to an ATT such as SJS have varied incidents and the high mortality caused by those reactions should become a concern for the physician. Cautions in using any agent especially antimicrobial which is known as a significant cause in SJS and also general check-ups before starting any medication should be highlighted.
Conclusion: SJS is an emergency requiring high attention and intensive care evaluation. Early recognition, prompt withdrawal of suspected ATT drug and the administration of intravenous systemic steroids are mainstay management.
Pediatric Dr. TB: A neglected epidemic
Sarika Gupta1, Ajay K. Verma2, Surya Kant2
1Department of Pediatrics, KGMU, Lucknow, Uttar Pradesh, India, 2Department of Respiratory Medicine, KGMU, Lucknow, Uttar Pradesh, India. E-mail: sgguptasarika@gmail.com
Background: Amidst fight against COVID-19 pandemic, efforts to mitigate other communicable disease threatening public health including TB has taken a back step. Limited evidence exists about the change in prevalence of Pediatric Dr. TB post 2020.
Objective: The study aimed to find out the change in prevalence of Pediatric DR TB pre and post 2020.
Methods: Descriptive retrospective and prospective study. Pediatric Dr. TB was defined on the basis of Gene X pert/ line probe assay and/ or drug susceptibility testing (DST).
Results: Prevalence of Pediatric Dr. TB in year 2018, 2019, 2020 and 2021 (January-September) were 17.4%, 15.1%, 18.4% and 16.6% respectively in the age group of 1-18 years. Majority (93.9%, 90.5%, 89.5%, 96.8%) had pulmonary TB. Cumulative prevalence of Pediatric Dr. TB for the 24 months of year 2018 & 2019 was 16.3% while it was 17.6% for the 21 months of year 2020 & 2021 (January-September). It reveals an increase of 4.1%. On extrapolating the prevalence rate of Dr. TB for the 9 months of year 2021, prevalence rate of Dr. TB by the end of year 2021 is expected to be 22.1%. Among Dr. TB, prevalence (%) of XDR TB;MDR TB; monoresistant TB for year 2018, 2019, 2020 & 2021 was (10.9,88.0,1.1), (5.1,92.8,2.1), (3.4,94.9,1.7) and (7.4,91.6,1.0) respectively.
Conclusion: With this report of increase in prevalence of Pediatric Dr. TB, it has become the need of the hour to start focusing on TB vigorously and to take uncompromising relentless measures to achieve the country’s vision to eliminate TB by 2025.
Determinants for drug resistance in tuberculosis patients from perspective of NTEP
Shivangi Goswami, Lokendra Dave, Hareesh Pathak
Department of Respiratory Medicine, Gandhi Medical College, Bhopal, Madhya Pradesh, India. E-mail: goswami.shivangi641@gmail.com
Background: Tuberculosis (TB), caused by Mycobacterium tuberculosis is an infectious airborne disease and a major health problem world-wide A total of 1.5 million people died from TB in 2020 (including 214 000 people with HIV). Although the recent NTEP is the best till now but still the drug resistance patients are on rise. Some factors like poor training of DOTS providers, non availability of drugs, poor funding in the programme, improper counseling, increased distance from home to drug distribution center (>1 hour/50 km) could be some of the leading factors developing drug resistance.
Methods: Study Design - Cross sectional, Observational Study, Study Area - Nodal Dots plus site and OPD/ IPD of TB Hospital, Regional Institute of Respiratory Disease (RIRD), Lalghati, Bhopal (MP) Department of Respiratory Medicine, GMC, Bhopal.
Results: Inadequate training of the Dots provider, inadequate distribution of direct benefit transfer to patient and improper counseling in the program showed significant correlation in the development of MDR TB. (P value < 0.05) Non-availability of drugs and increased distance from home to treatment center (> 50 km/ > 1 hours) were also seen as factors for development of MDR TB but their statistical value were not significant.
Conclusion: Health care workers should be trained and motivated more and timely updated about latest protocols. Proper funding and availability of equipment (like ex. CBNAAT machine and its cartridge) should be ensured at every center in order to have timely reports and drug resistance pattern.
Enlightening the insight on cardiotoxicity and hepatotoxicity of bedaquiline
K. Vignesh1,2, Boopala Aravindhan1,2, P. Arulkumaran1,2, P. M. Ramesh1,2
1Department of Respiratory Medicine, Government Kilpauk Medical College, Chennai, Tamil Nadu, India, 2Government Thiruvotteeshwarar Hospital of Thoracic Medicine, Chennai, Tamil Nadu, India. E-mail: vicky.kumar2992@gmail.com
Background: Bed aquiline is the newly introduced drug in the treatment of MDR/XDR TB under PMDT since 2019. In India, the studies on Bed aquiline are lacking, as the drug is recently introduced in the regimen. This study aims at evaluating the incidence of the two adverse effects, QT prolongation and liver function derangements in the Longer Oral Regimen started for the treatment of MDR/XDR TB during the first 6 months of Bed aquiline containing course of the treatment.
Materials and Methods: This is a prospective observational study where 60 Microbiologically confirmed MDR TB patients both MDR /XDR are enrolled in the study. The ECG and LFT – Serum bilirubin, SGOT and SGPT is taken prior to the initiation of the regimen and at the end of 2nd week and at the end of each month for up to 6 months. The QTC is calculated using the fridericia correction and the Liver parameters Serum bilirubin, SGOT, SGPT values are analysed and compared. Other adverse events are also monitored.
Results: Of the 60 microbiologically confirmed MDR patients who are analysed with 70% Male and 30% Female. The study showed an incidence of 1.66% with only 1 out of 60 had QT prolongation and NIL incidence for any Liver Function Defects. The other adverse effects noted are Nausea about 23.3%. Arthralgia 18.3%, Vomiting 13.3%, Peripheral Neuropathy 8.3%, Thrombocytopenia 6.6% and Optic Neuritis 3.3%.
Conclusion: There is no significant incidence of QT prolongation and Liver Function Derangements due to Bed aquiline. We conclude that the Bed aquiline containing Longer Oral Regimen is safe for the treatment of MDR/XDR TB. There is an increased incidence of other non-dreaded events due to other drugs like Levofloxacin, Linezolid, Clofazamine, Cycloserine which are included in the regimen.
Smoking pattern and behaviour among tuberculosis patients presenting to the tertiary teaching hospital
Love Gupta, Indranil Halder
College of Medicine and JNM Hospital, Kalyani, West Bengal, India. E-mail: lovegupta992@gmail.com
Background: Smoking is associated with unfavourable treatment outcomes like failures and defaults among the TB patients.
Objectives: To study the pattern of tobacco use among the pulmonary tuberculosis (PTB) patients presenting to College of Medicine and JNM Hospital, Kalyani West Bengal and study the association of various socio-demographic variables with current smoked and smokeless tobacco users.
Methods: An Observational study was conducted among 323 Tuberculosis patients from Kalyani, West Bengal from Jan 2021 to August 2021. Tobacco Questions for Surveys, A subset of Key Questions from the Global Adult Tobacco Survey (GATS) 2nd Edition, 2011. CDC and World Health Organisation was used.
Results: Among 323 smokers at the time of diagnosis, 81% patients tried to cut short and 19% quitted smoking after TB diagnosis. Similarly, prevalence of Bidi smoking at the time of TB diagnosis was 31.8% and cigarette smoking was 68.2%. Male and lower education level was associated with current smoking. Similarly, female and lower education level was associated with current smokeless tobacco use.
Conclusions: Smoking has been proven to be an important risk factor for development of Tuberculosis. Health programme needs to concentrate on PTB patients who continue to use smoked or smokeless tobacco during their treatment; necessary interventions need to be planned.