Mycobacterium tuberculosis in a sequestreted lung – A case report
S. Alaguraja, G. Aruna, S. Subbarao, Bharat Kathi
Department of Pulmonary Medicine, SVRR Government General Hospital, Tirupathi, Andhra Pradesh, India. E-mail: drallaguraja@gmail.com
Background: Pulmonary Tuberculosis, though a common infection, affecting the sequestrated lung is a rare event.
Case Study: A 30 year old female came of cough with expectoration, of breath for 1 with bilateral wheeze on examination. Her investigations were normal and sputum Gene xpert was negative for Tuberculosis. CTChest showed homogenous opacity in right middle and lower lobes. Bronchoscopy revealed nonvisualization of right middle and lower lobe bronchus. Contrast Enhanced CT Chest showed Intralobar Pulmonary sequestration of right middle and lower lobes Due to recurrent infections surgery was done. Bilobectomy sample was positive for Mycobacterium Tuberculosis. Following anti tuberculous therapy patient is doing well.
Discussion: Pulmonary Sequestration a anomaly non functional lung fails to communicate with tracheobronchial tree. Classified into Intralobar Extralobar sequestration. Intralobar sequestration is more common, as non resolving pneumonia, recurrent infections, as in our case and hemoptysis. Diagnosis requires Contrast CT or CT angiogram to demonstrate abnormal blood vessel supplying the sequested segment. Treatment is surgical by removing the involved lobe.
Conclusion: Early Contrast CT chest helps in diagnosis of Pulmonary sequestration in middle aged patients with non resolving pneumonia affecting posterobasal segments.
Horns of A dilemma: A case report
Rupam Kumar Ta, Pronoy Sen, Preetam Goswami
E-mail: rupamkumarta@yahoo.com
Background: Bedaquiline has a mean half-life of 164 days after 8 weeks of treatment. We report a case of Bedaquiline overdose in a patient who accidentally consumed 400 mg (100mg,4 tablets) every day for 45 days after the first two weeks of treatment.
Case Study: An 18 years old male patient diagnosed with Rifampicin-resistant tuberculosis by CBNAAT was started on ‘all oral longer regimen’ containing Bdq, Lfx, Lzd, Cfz and Cs as per body weight. The patient came for follow up after 1.5 months having accidentally consumed in spite of counselling during discharge, 400mg (4 tablets) daily. Patient was asymptomatic and hemodynamically stable with LFT done on day 1 revealing elevated SGPT. LFT, ECG and routine blood done on the following days were normal. The case was reported to the respective committes. The pK (pharmacokinetic) study report showed that blood levels of Bedaquiline remained within therapeutic window. Bacteriological conversion was present in follow-up samples. Currently the patient is at his 13th month of treatment with the remaining drugs with last follow up 15 days back. The patient is completely asymptomatic.
Discussion: Telnov et al. reported a similar case of Bedaquiline overdose where the patient continued to take Bedaquiline even after taking the total 6-month dose of Bedaquiline and similar to our study had no side effects.
Conclusion: This study suggests that in case of accidental overdose regular follow up should be done throughout the course till end of treatment with remaining drugs.
Clinical and spirometry profile of post TB patients in Dhiraj Hospital Waghodiya, Vadodara
Bhavesh Patel, Anchal Jain, Arti D. Shah, Kusum V. Shah
Department of Respiratory Medicine, SBKS MI and RC, Vadodara, Gujarat, India. E-mail: dr.bhavesh0705@gmail.com
Background: TB has affected humans since ancient times. TB is known to cause COPD. However, data is lacking from India, leading to dearth of evidence for proper management of sequelae of TB.
Objective:
1. To assess clinical features in post PTB patient with obstructive airway disease (OAD).
2. To assess pattern of spirometry in post PTB patients.
Methods: An observational and cross-sectional analysis was conducted on patients having post PTB OAD reporting to the Respiratory Medicine, Department, Dhiraj Hospital. Period of research was three months.
Result and Conclusion: Patients with obstructive pattern were graded on the basis of decline in FEV1 hence, mild, moderate, severe and very severe obstruction was present in 5.3%, 42.1%, 44.7% and 7.9% patients respectively were reported. It can be inferred from this research that in post TB patients, the most common abnormal spirometry finding was moderate to severe obstruction in accordance with GOLD classification.
Effectiveness of isoniazide prevention therapy in prevention of TB in adult PLHIV under programmatic conditions
Ananya Prabhu, Ashish Ranjan, Rajesh Kumar, Upasna Agarwal
ART Centre, National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India. E-mail: prabhuananya@gmail.com
Background: PLHIV (People living with HIV) have a 10% annual risk of developing TB against a 10-20% lifetime risk in non-HIV patients. IPT has shown to augment Anti-Retroviral Therapy (ART’s) TB preventive potential by further 35%. However, there is dearth of information on IPT effectiveness under programme conditions.
Methods: A study was conducted to evaluate development of TB in PLHIV who have received IPT from 2014-2017 and the method used was retrospective chart-review analysis.
Results: Among 213 patients tracked who had been initiated IPT, 76.5% of patients (n=163) completed the IPT course, 22% (n=47) of patients defaulted and 2 (1.4%) of patients contracted TB (breakthrough infection) during the IPT course and were switched to Anti-tuberculosis treatment. Only 3.1% IPT completed patients (n=5), developed TB during follow-ups. Insignificant statistical difference was observed between CD4 levels of patients (developed TB vs not developed TB), post IPT. Incidence of TB was very low (0.41 per 100 person years) amongst PLHIV population, who completed IPT and were on ART. Also, interestingly amongst those who developed TB post IPT, 80 % (4/5) developed extra pulmonary microbiologically confirmed cases.
Conclusion: Our study proves IPT to be highly efficacious under programmatic conditions and majority of TB cases were of extra-pulmonary nature. It emphasizes the need for more sensitive and robust screening methods to detect TB of any organ rather than lungs only.
Esophagopleural fistula: A rare entity
Harsh Yadav, Vishal Chopra
Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India. E-mail: harsh1yadav877@gmail.com
Background: Oesophageal pleural fistula is a rare phenomenon and can be seen secondary to instrumentation, malignancy or surgery but it is very rare as spontaneous idiopathic situations.
Case 1: 57 years old male who is chronic alcoholic on ATT on pleural effusion basis came with complaints of chest pain and breathlessness for 5 days and one episode of retching and vomiting 5 days ago. Chest x-ray was suggestive of hydro-pneumothorax after which intercostal drainage tube was placed. Discharge was pus and later there was discolouration of pus. CECT chest was done which was suggestive of esophagopleural fistula and later upper GI endoscopy was done to confirm the diagnosis.
Case 2: 28 years old male came with history of high-grade fever, cough with expectoration and chest pain for 2 months. Intercostal drainage tube was put form private hospital. Sputum and pus from tube was positive for AFB. Bronchopleural fistula was patent, and patient was started on ATT. A week later patient complaint of passing food particles from tube. Barium swallow was done to see left side esophagopleural fistula.
Discussion: Esophagopleural fistula is an uncommon entity where symptoms can be vague like lassitude, chest pain, fever, dyspnoea and foul-smelling regurgitation. Radiologically it can be seen as hydro-pneumothorax.
Conclusion: A patient who presents with similar history with spontaneous hydro-pneumothorax should be investigated for esophagopleural fistula, so that early treatment can be started.
A case report of Extra Pulmonary Tuberculosis with drug induced liver injury, pancytopenia and pancreatitis in the same patient
Poonam Subramanian, Subramanian Natarajan
E-mail: poonamsubramanian@gmail.com
This is a case report of a patient with Extra Pulmonary Tuberculosis who had drug induced liver injury, pancytopenia and pancreatitis due to different anti tuberculous drugs. This is an isolated case of a young male having Rifampicin induced hepatitis, who subsequently developed drug induced {Isoniazid, pyrazinamide, ethambutol} pancytopenia and later on also developed Isoniazid induced pancreatitis. Our case was unique in that our patient had life-threatening complications due to anti TB drugs in different stages of treatment. Multiple complications can occur due to anti tuberculous drug treatment which need a multi systemic approach.
Vitamin-D levels in patients of newly diagnosed tuberculosis
Divesh Heda, Priti Meshram, Smita Agale, V. V. Pujari, R. R. Hegde
Department of Pulmonary Medicine, Grant GMC Mumbai, Maharashtra, India. E-mail: diveshheda65@gmail.com
Objective: To study Vitamin-D levels in patients with newly diagnosed Tuberculosis.
Background: Vitamin-D deficiency has been implicated in activation of tuberculosis. Our study aimed to study Vitamin-D levels in patients with newly diagnosed Tuberculosis.
Methods: e retrospectively extracted data of patients who visited our OPD over period of three months and were newly diagnosed with Tuberculosis. Patients were evaluated for Vitamin-D levels at the time of diagnosis and data regarding same was collected.
Results: Of studied 56 patients, 27 were female and 29 were male. 31 patients had PTB and 25 patients had EPTB. Of 31 patients of PTB 23 were having Drug Sensitive TB and 8 were having Drug Resistant TB. Among 25 patients of EPTB, 24 were having DS TB and 1 had DR TB. All patients in study had low Vitamin-D levels. Median Value of Vitamin-D levels in Patients with TB were 14.86. In patients with DSTB and DRTB vitamin-D values were 14.7 and 15.2 respectively. Vitamin-D level in patients with DS PTB was 15.2 and DS EPTB was 14. In patients of MDR PTB and MDR EPTB vitamin-D levels were 15.3 and 11.4 respectively. Overall median vitamin-D levels in males was 15.8 and female was 14.6.
Conclusions: Vitamin-D insufficiency is seen in all patients of Tuberculosis. Patients with EPTB have more reduced Vitamin-D level. No significant difference between male and female. No significant difference between Drug sensitive and Drug resistant Tuberculosis.
IgA - Vasculitis associated with multi drug resistant-tuberculosis a rare case report
J. S. Vijayalakshmi Akshata, B. P. Raghu, Swathi Karanth
Department of Pulmonary Medicine, SDS and Rajiv Gandhi Institute of Chest Diseases, Bengaluru, Karnataka, India. E-mail: sharadhaurs@gmail.com
Background: IgA vasculitis (IgAV), a small vessel vasculitis of type 3 hypersensitivity reaction, rarely encountered in adults. Amongst several triggering factors, Tuberculosis (TB) is one.
Case Report: 37 year female presented with three week history of cough, fever, weight loss with no co-morbidities. Chest radiograph showed left upper zone consolidation with pleural effusion. Sputum acid fast bacilli smear was positive, Rifampicin resistance detected in gene-Xpert. She was started on all oral longer Bedaquiline containing MDR-TB regimen.
4 weeks later, she presented with palpable pruritic rashes, arthralgia, pedal edema. Investigations revealed proteinuria, hematuria, anemia, hypoproteinemia. Skin biopsy was suggestive of IgAV, direct immunofluorescence-positive for IgA, C3 in vessel wall. She was started on oral corticosteroids and anti-tuberculosis treatment (ATT) continued. Over a period of 3 months vasculitis has resolved. Currently on follow up with low dose steroids, 7th month of ATT with sputum smear conversion.
Discussion: Pruritic rash in tuberculosis may result from Adverse drug reaction to ATT, TB Vasculitis, IgAV. EULAR/PRINTO/PRES criteria was used for diagnosis in this case. IgAV in Tuberculosis may occur due to the presence of circulatory immune complex mainly IgA against glycoprotein antigen of M.tuberculosis, however it is extremely rare in adults and only eight such cases are published in literature till now.
Conclusion: Pruritic rash in TB patients on ATT, most commonly attributed as adverse drug reaction However prompt diagnosis of exact etiology is crucial. IgAV in adults although rare but should be suspected in Tuberculosis patients if presents with rash, arthritis, edema.
A case report of isolated TB spleen
M. BhavyaSri, C. N. Prasad, M. Ramulu, S. Sai Sharath
Department of Respiratory Medicine, Prathima Institute of Medical Sciences, Karimnagar, Telangana, India. E-mail: mothikibhavyasri@gmail.com
Background: Among the involvement of solid viscera by Tuberculosis in the abdomen, involvement of spleen is rare. Globally, 15-20% of newly diagnosed TB cases were extrapulmonary, out of which 3-5% comprised abdominal TB, in which splenic involvement was rare.
Case Study: This is a case of a middle aged South Indian Diabetic male who presented with left hypochondriac pain of 15 days duration and diagnosed to have multiple splenic abscesses on evaluation. Conservative management failed and splenectomy was done and sent for histopathological examination which showed granulomatous lesions suggestive of Koch’s etiology with CBNAAT being negative. Other organ involvement was not detected.
Discussion: Spleen can be involved by tuberculosis either as a part of disseminated TB or as isolated splenic TB. It can occur in both immunocompetent and immunosuppressed individuals. There is no specific feature to diagnose splenic TB clinically and is usually recognised on imaging or on histopathological examination of splenectomy specimen.
Conclusion: The possibility of splenic tuberculosis should always be suspected in a case of splenic abscess, particularly when there is a component of immunosuppression in the patient.
Tuberculosis of breast
P. Pravinya, C. N. Prasad, M. Ramu, M. BhavyaSri
Department of Respiratory Medicine, Prathima Institute of Medical Sciences, Karimnagar, Telangana, India. E-mail: pravinyachikki203@gmail.com
Background: Breast Tuberculosis is a rare manifestation of extra-pulmonary TB disease, accounts for <0.1% of breast conditions in developed countries, 3-4% in regions of high TB incidence.
Case Study: 42 years female from poor socioeconomic status presented with history of lump in the left breast for 3 months, night sweats and evening rise of temperature since one week. A firm lump palpable in the upper outer quadrant of the left breast noted. No discharging sinuses over the surface. Blood investigations revealed leucocytosis (13 x 109 /l), elevated CRP (70 mg/l) & elevated ESR (50mm/hr). Mantoux test was positive. Mammography & Ultrasound of the Left Breast showed well defined heterogeneously hypoechoic lesion of 19 x 10mm with internal septations, s/o Benign etiology. FNAC done from Left Breast and sent for histopathological examination revealed presence of epithelioid abscess with Langhan’s giant cells and caseous necrosis and suggestive of granulomatous mastitis possibly koch’s etiology.
Discussion: Breast tuberculosis is a rare form of Extra Pulmonary TB. It was classified into five different types by Mckeown and Wilkinson.
(i) Nodular tubercular mastitis, (ii) Disseminated or confluent tubercular mastitis, (iii) Sclerosing tubercular mastitis, (iv) Tuberculosis mastitis obliterans, (v) Acute miliary tubercular mastitis.
Conclusion
TB should always be suspected in any mass in the breast, particularly in a TB endemic country like India.
Clinical and radiological profile of drug resistant TB in a tertiary care hospital
Alaguraja, G. Aruna, Subbarao, Bharatkathi
Department of Pulmonary Medicine, SVRRGGH, Tirupathi, Andhra Pradesh, India. E-mail: drallaguraja@gmail.com
Background: Drug resistant TB is one of the main challenges in treating a patient with TB. India is one among the high burden Drug Resistant TB countries in the world.
Objective:
1. To describe the clinical and radiological profile of drug resistant TB patients.
2. To describe the burden of Isoniazid monoresistance among Drug resistant TB patients.
Methodology: This study is a prospective study of patients who were diagnosed as having drug resistant TB presenting at TB,over a period of six months (Jan 2021 to June 2021).After informed consent, history was taken and x rays were reviewed. Data was entered in Microsoft excel and analyzed.
Results: In our study out of 93, majority of patients were male with 70 (75.3%). Common age group affected was 51-70yrs (43%). The common symptom was cough (100%) followed by fever (51.6%). Smoking and Diabetes Mellitus were most common risk factors seen in 44 (47.3%) and 38 (40.9%) patients respectively. Newly diagnosed drug resistant patients were 64 (68.8%). Most common resistant pattern was Isoniazid monoresistance seen in 47 (50.5%). The most common radiological abnormality was non homogenous opacity 83 (89.2%).
Conclusion: This study shows the burden of Isoniazid resistant patients the significance of non homogenous opacity with drug resistant TB patients and search of new molecular methods for diagnosing Isoniazid monoresistance.
QT prolongation and arrhythmias in drug resistant tuberculosis patients receiving bedaquiline containing regimen registered under drug resistant tuberculosis centre in a tertiary care hospital
Raghul Raj1, Rupam Kumar Ta1, Sandip Mukhopadhyay2
1Department of Pulmonary Medicine, Burdwan Medical College and Hospital, Burdwan, West Bengal, India, 2???, Indian Council of Medical Research, National Institute of Cholera and Enteric Diseases, Kolkata, West Bengal, India. E-mail: s.raghulraj@gmail.com
Background: Variable incidences of QT changes have been reported in the preliminary studies with Bedaquiline (BDQ) and Delamanid (DLM) during the treatment of DR-TB. Validation of such findings are necessary among different ethnic and geographic groups.
Methods: A prospective observational study for a period of one year was conducted among 50 DRTB patients, receiving BDQ containing regimen under DRTB Centre. During the study period, QT prolongation (calculated by Fridericia formula), arrhythmias and other possible adverse events along with the clinical outcome in terms of mortality, morbidity, sputum conversion and stoppage of the regimen were assessed and managed according to the Programmatic Management of DRTB (PMDT) 2019 guidelines.
Results: Total of 6 (12%) patients (two males and four females) out of total 50 had developed QT prolongation between the days 4 to 10 during the first 2 weeks of initiation of the regimen. Four patients had grade 1 and two patients had grade 2 severity of QT prolongation without any clinical symptom and electrolyte imbalance. The regimen was temporarily stopped for 4 days in 1 out of 6 patients who had QT interval > 500 milliseconds. Clinical improvement and sputum conversion were noted in 99% of the patients.
Conclusion: BDQ containing regimen is effective in DRTB patients though may produce asymptomatic QT prolongation in limited number of patients. However, more studies are recommended to generalize these findings to the community.
Observation study of risks of pneumonia in patients of pulmonary tuberculosis
Rajeev Ranjan
Chest Clinic, Chapra, Bihar, India. E-mail: drallaguraja@gmail.com
Background: Tuberculosis has been a major public health concern which has led to 1.5 million deaths worldwide. Tuberculosis and pneumonia are two lung disorders that often exist concomitantly. After mycobacterium tuberculosis is cured, TB patients often stay at risk of developing pneumonia due to major complications like residual anatomic changes and impaired lung functions.
Methods: A prospective observational study conducted in Bihar region was conducted between September 2021 to December 2021. A total of 100 pulmonary tuberculosis (PTb) patients who had been newly diagnosed in the last two years were randomly selected for this study. The hazard ratios and the incidence rates of pneumonia were calculated by sex, comorbidity and age.
Results: The findings of this study showed that the incidence of pneumonia in the PTb patients were higher by 1.9 folds. It was also found that the risk for pneumonia was greater for men as compared to women, however, lower in cases of young adults. The risk of pneumonia is also aggravated for asthmatic patients. Among PTb patients who are comorbid with asthma, pneumonia had 2.5 folds higher chances of occurrence than an average PTb patient. Another assessment of risks of respiratory health for asthmatic patients showed a 2-fold elevated risk of pneumonia. These risks are however lesser in comparison to patients of heart diseases.
Conclusion: Lung infection with tuberculosis presents a chronic consumptive disorder leading to higher chances for acute pneumonia.
A rare case of endobronchial tuberculosis with tracheo-bronchial stenosis
Ningappa Karalingannavar, K. N. Mohan Rao, Ganesh Pratap, N. Kiran
Department of Pulmonary Medicine, Sapthagiri Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India. E-mail: drninguk@gmail.com
Background: Endobronchial tuberculosis [TB], refers to involvement of trachea and bronchi by TB. Reported incidence is between 6% to 54%. It is more common in young age and in females.
Case Study: A 24-year-old male patient with Pulmonary TB on ATT since 2 months developed left lung collapse due to complete stenosis of left main bronchus. An attempt to dilate the stenosed bronchus was abandoned due to complications developed during procedure. Later, after 3 months patient came to us with stridor and breathlessness. MDCT & later bronchoscopy revealed tracheal web with two small openings, 2.5cms distal to vocal cords with narrowing of trachea. Tracheal web was dissected using electrocautery and serial balloon dilatation was done followed by Mitocmycin C application in three sitting. Later treated with ATT and steroids. Patient showed improvement on follow up.
Discussion: Endobronchial TB may have an acute presentation as respiratory failure, subacute or insidious presentation. Symptoms appear during or years after pulmonary TB treatment. Chemotherapy is same as Pulmonary TB. Corticosteroids with ATT have shown benefits in some cases. Various bronchoscopic modalities and surgical treatment are available. Mitomycin C seems effective in endoscopic treatment of tracheal stenosis.
Conclusion: Even with timely anti-TB treatment, a significant proportion of patients have progression of endobronchial TB thus needing airway interventions. Close surveillance, radiographic monitoring, timely bronchoscopic assessment and intervention of such patients is very important.
All that consolidates is not pneumonia
Rahul Mittal, Subramanian Suriyan, N. Nalini Jayanti, P. B. Vandana
SRM Medical College Hospital and Research Centre, Kanchipuram, Tamil Nadu, India. E-mail: drrahul5964@gmail.com
Background: Community acquired pneumonia is the most frequent cause of death in developing countries responsible for more than 3 million deaths a year across the world. With different diseases having similar clinicoradiological presentation of pneumonic consolidation, the evaluation needs a bird’s eye view for early diagnosis and management.
Case Study: The diagnostic evaluation of three cases with clinicoradiological features of pneumonia is discussed in this case series. All cases presented with fever, cough, shortness of breath with consolidation on imaging.
Case 1: A 15 year old female treated elsewhere as pneumonia presented with severe respiratory distress, sepsis with DIC. Careful physical examination revealed diagnostic clue for scrub typhus which lead us to select appropriate antibiotic and save the patient from near death from severe ARDS.
Case 2: A 60 year old diabetic female admitted with clinical diagnosis of Pneumonia and Acute on CKD. Even though patient improved with initial antibiotic therapy, persistent opacities in X ray and renal dysfunction lead us to final diagnosis of C- ANCA associated vasculitis with cresentric glomerulonephritis.
Case 3: A 55 year old female diagnosed as CAP showed worsening in spite of adequate antibiotics according to initial susceptibility pattern. FOB done later in the course of illness showed resistant variant of klebsiella pneumonia sensitive only to colistin.
Conclusion: The vast differentials of consolidation should be borne in mind when the response is delayed in contrary to our expectation.
A study on assessing the duration and the reasons for time delay between symptoms onset and treatment initiation in new sputum-smear positive pulmonary tuberculosis
M. Akilan, K. Krishnamoorthy, T. Joseph Pratheeban, E. Mathan, O. M. Rahman Shahul Hameed
Department of Respiratory Medicine, Tirunelveli Medical College and Hospital, Tirunelveli, Tamil Nadu, India. E-mail: akilanmmc@gmail.com
Background: Tuberculosis is caused by Mycobacterium Tuberculosis. There are many factors that plays a role in delayed presentation and treatment initiation in pulmonary tuberculosis patients which leads to increased morbidity and mortality. This study aims at finding out these factors of delay. Thus early diagnosis and treatment is possible in order to decrease the tuberculosis burden of the country.
Method: It’s a cross-sectional study with study size of 150 patients. After taking consent from the patients, basic information of the patient were noted. Clinical history along with the duration were recorded, past medical history, drug history for both past and present illness; smoking and alcohol consumption habits were recorded. Specific questions related to the study like education, medical knowledge, job, drug history, medical records, and previous investigation records were asked and the duration for each and every hospital visit and also for investigations and the reason for time delay between the onset of symptoms and the diagnosis of tuberculosis and the initiation of treatment in the form of patient delay, doctor delay and treatment delay were assessed.
Results: The mean duration of patient delay was 56 days and doctor delay was 21 days. Mean diagnostic delay was recorded as 70 days with negligence and symptomatic management as the most common causes of patient delay and doctor delay respectively.
Conlusion: If these delays were addressed as early as possible, it reduces the morbidity and mortality in pulmonary tuberculosis patients. Thus making India a TB free nation.
Anti tubercular drug induced Stevens-Johnson syndrome: A rare case
Kota Rajashekar, Praveen Kotipalli, Archana Andhavarapu
Department of Pulmonary Medicine, Malla Reddy Medical College for Women, Hyderabad, Telangana, India. E-mail: rajashekar.kota1@gmail.com
Background: Stevens-Johnson syndrome/toxic epidermal necrolysis (SJS/TEN) is a life-threatening cutaneous reaction most commonly associated with medications such as oxicams, phenytoin, allopurinol. It involves the mucous membranes of the eye, mouth, and/or genitals and is characterized by tissue death and detachment. Anti-tubercular drug-induced SJS is extremely rare.
Case Study: A 19-year-old female presented with shortness of breath, fever, generalized rash over the body for 1week, along with severe erosions of the oral mucosa. She was diagnosed with cerebellar granuloma, for which she was initiated on antitubercular (ATT) treatment 11 days back. On evaluation, she was found to have hepatic and renal dysfunction along with coagulopathy. A diagnosis of SJS was considered and ATT was stopped. The patient was started on systemic and topical corticosteroids and managed through supportive care.
Discussion: Although it is considered an immune-mediated hypersensitivity reaction, the pathophysiology of SJS is not well understood. Among the anti-tubercular drugs, rifampicin has the maximum potential to cause SJS.
Conclusion: First-line ATT drugs are essential to eradicate tuberculosis. However, physicians should be cautious if patients report any hypersensitivity reactions. Early identification and diagnosis of SJS followed by withdrawal of the offending drug and timely steroid therapy could be lifesaving.
Tuberculosis presented with bilateral anterior chest wall mass - An uncommon presentation
Soumitra Mondal, Sibes Kumar Das
Department of Respiratory Medicine, Medical College, Kolkata, West Bengal, India. E-mail: soumitramondal.sm@gmail.com
Background: Tuberculosis is a contagious disease caused by Mycobacterium tuberculosis primarily affecting lungs. However unusual presentations are common leading to delayed diagnosis and treatment.
Case Study: A 21-year-old non-diabetic female presented with bi-lateral anterior chest wall swelling (R>L) with right sided chest pain, intermittent fever for 8 months with no contact history of tuberculosis. General examination showed a 2x2cm firm non-tender lymph node without any sinus tract or raised local temperature in the right supra-clavicular region. She had cystic non-tender swellings with normal local temperature measuring approx 5x3cm on right and 4x2cm on left chest wall. CECT Thorax showed soft tissue lesion at RUZ (43X52 mm) directly extending to anterior chest wall, cystic lesions in both upper anterior chest wall and left encysted effusion. Pleural fluid study and FNAC from lymph node were non-diagnostic. Histopathologocal Examination of USG guided TruCut biopsy of chest wall swelling showed necrotizing granulomatous inflammation and growth of Mycobacterium tuberculosis on 3rd week in MGIT 960 culture.
Discussion: She was diagnosed as disseminated Tuberculosis and subsequently put on anti TB therapy. So Tuberculosis can present as lung mass with chest wall invasion.
Conclusion: Patients presenting with mass lesion in Chest-x-ray should also be evaluated for Tuberculosis as it is potentially curable. High clinical suspicion and proper workup is necessary to confirm the diagnosis and rule out neoplasia.
The great masquerader – Tubercular bacilli incidentally detected in thyroid gland of a lady presenting with mediastinal lymphadenopathy
Sujith Thomas Chandy
Department of Respiratory Medicine; Christian Medical College, Vellore, Tamil Nadu, India. E-mail: sujithchandy05@gmail.com
Background: There is relative resistance of the thyroid gland to TB infection. Some possible protective factors are, thyroid capsule, high iodine levels, bactericidal action of colloid and thyroid hormones and abundant vascular supply. Thyroid involvement more commonly occurs as part of disseminated spread as in this case, where there was mediastinal lymphadenopathy.
Case Study: A 62 year old nurse, Diabetic, presented with epigastric pain with loss of weight for 3 months. On evaluation, her TSH was low, CT Thorax showed bulky mediastinal nodes with right paratracheal being 16mm and thyroid nodules. USG Neck showed TIRADS4 nodule in left lobe of thyroid. EBUS TBNA was done from stations 4R and 7, ROSE showed granulomas. Cell block revealed granulomas with no conspicuous necrosis and hence steroids were started, with Sarcoidosis as the possible etiology. Meanwhile, left lobe of thyroid FNA smears showed patchy necrosis and stain for AFB was positive. Pathologists then reviewed the TB stain of the mediastinal nodes FNA smears and AFB were detected. Steroids were stopped and she was started on ATT with which she had clinical and radiological improvement.
Discussion: The occurrence of isolated mediastinal lymphadenopathy decreases with increasing age. In her case, the incidentally detected thyroid nodules with low TSH levels and loss of weight prompted an early FNA which led to the diagnosis of Tuberculosis.
Conclusion: Tuberculosis of the thyroid gland is rare even in high prevalent countries. However, those with thyroid hormone abnormalities and nodules must proceed with FNA or biopsy.
Utility of cbnaat in the diagnosis of tubercular plueral effusion: Observational cross-sectional study
Vasavi Cheguri, Arti D. Shah, Kusum V. Shah, Bhavesh Patel
E-mail: vasavicheguri011@gmail.com
Background: Tuberculosis (TB) is one of the top 10 causes of death worldwide. India is not only estimated to have the highest burden of TB cases, but also MDR TB cases. This study is undertaken to study the role of CBNAAT in establishing an effective diagnosis of pleural tuberculosis.
Objective: To study the detection rate of MTB in pleural fluid with CBNAAT.
1) To study biochemical profile of pleural fluid.
2) To find out Rifampicin resistance in pleural effusion.
3) To compare the ADA levels of pleural fluid with CBNAAT results.
Methods:
1) We are going to analyze the medical records of patients having pleural tuberculosis reporting to the Respiratory Medicine Department, Dhiraj Hospital.
2) Diagnosis will be done on the basis of biochemical evaluation of pleural fluid, AFB smear and CBNAAT.
3) Detailed Statistical analysis of results is done.
Results: Here, out of the 90 samples, 12 samples were detected to have MTB. Out of these 12, about 92 % (n=11) had MTB sensitive to rifampicin whereas only one sample (8%) had MTB resistance to rifampicin. Out of all the Pleural effusions with ADA value 40 U/L and above, 7(13.33%) cases were diagnosed with CBNAAT, 5 (8.77%) cases were diagnosed as tuberculosis even though ADA value less than 40 U/L.
Conclusion: We concluded that CBNAAT should be used in routine initial work up as it can offer definitive diagnosis and also can be helpful in solving the problem of delay in diagnosis and detecting drug resistance.
Study of bi-directional screening of tuberculosis and COVID-19 in a rural tertiary care hospital, in Vidharbha Region of Maharashtra
Deepak Bhanushali, R. K. Rathod, Sanjay Mutyepod, Durgesh Deshmukh
Shri Vasantrao Naik Government Medical College, Yavatmal, Maharashtra, India. E-mail: djsbhanushali@gmail.com
Introduction: The aim of this study is to estimate the prevalance of Tuberculosis in COVID-19 patients and to find out the incidence of COVID-19 in Tubercular patients. Enhanced screening of patients will enable prompt detection, early isolation and initiation of treatment, thereby reducing the morbidity and mortality in TB and COVID-19 patients.
Methods: This is a prospective observational study conducted at 1000 bedded teaching hospital with a standalone 500 bedded DCH. Study subjects were divided into 2 groups. In group A, 1085 COVID positive patients were screened for Tuberculosis. In group B, 430 notified Tubercular patients were screened for COVID -19.
Results: Of 1085 pts in group A, 17 (1.5%) pts were newly detected as tuberculosis Out of 17, 10 (58.8%) were PTB, 7 (41.2%) were EPTB In EPTB, 4 (23.5%) had pleural effusion, 2 (11.7%) had TBM and 1 (5.8%) had miliary Tuberculosis. 1 (5.8%) pt of Covid-TBM co-infection died during treatment. Of 430 TB pts in group B, 7 (1.6%) were detected COVID- 19 positive. Of these 7 COVID- 19 positive patients, 6 (85%) required <10 days of hospitalisation, while 1 (15%) required >10 days of hospitalization with no mortality.
Conclusion: Significant proportion of COVID- 19 patients were detected to be Tubercular and vice versa.Hence Bi-directional screening of Tuberculosis and COVID-19 should be strengthened at all the health care facilities in India.
Comparison of available purified-protein derivative tuberculin skin test antigen solutions in detecting latent tuberculosis infection in tertiary care centers in India
N. Priya, J. Devasahayam Christopher, Balamugesh Thangakunam
E-mail: drpriya2005smailbox@rediffmail.com
Background: In India, the prevalence of Latent TB infection (LTBI) is estimated to be around 40%. Various formulations of PPD (Purified protein derivative) are available for TST, for diagnosis of LTBI, which may give variable responses in various populations. The commercially available PPD in India is by Arkray Healthcare. It is unclear if this product may have a similar sensitivity compared to other internationally accepted tuberculins (Tubersol).
Objective: To compare the bio-equivalency of TUBERSOL and Arkray, and to assess the performance of the two TSTs with the IGRA QFT Gold plus (fourth generation tests).Blood sample was collected for QFTtest.Both the TSTs were placed in the right and the left volar aspect of the forearms and 48 hrs later, the subject came back to the study site for reading.
Results: Among the 512 subjects who were tested with both TST1 (Tubersol) and TST2 (Arkray diagnostics, 139 (27%) subjects tested positive for TST1 (>=10mm), whereas 203 subjects (39.6%) tested positive for TST2. There was good agreement between the two tests with k= 0.75 (95% CI 0.6-0.93). However, there was poor agreement between both the TSTs with QFT Gold Plus ( Fourth generation QFT), with kappa value of 0.196 for Tubersol and 0.172 for Arkray.
Conclusion: The IndianTST (Arkray diagnostics) has shown good agreement with the internationally accepted Tubersol. However there was poor agreement between the TSTs and QFT Gold plus test.
Study of outcome of extra pulmonary drug resistant tuberculosis patient at nodal drug resistance tuberculosis centre, Nahsik
Kappagantu Surya, Chaitanya Neeladrirao Subbarao, Ravindra J. Shinde
Department of Respiratory Medicine, Dr. Vasantrao Pawar Medical College, Nashik, Maharashtra, India. E-mail: chaitanya.kappagantu95@gmail.com, drravi42@gmail.com
Background: India leads in highest share of global burden followed by China and the Russian Federation. In 2019, MDR/RR TB was found in 3.3% new TB cases and 18% in previously treated cases. There is limited information on the prevalence and the drug-resistant patterns of MTB in patients with extra-pulmonary tuberculosis (EPTB).
Objective: This study was aimed to determine the drug resistance patterns of M.TB in patients with EPTB and outcome of those affected.
Materials and Methods: Retrolective study was conducted during period of December 2020 to March 2021 on patients diagnosed as extra pulmonary multidrug resistant tuberculosis. Study was done study the clinical profile and treatment outcome.
Results: Our study found 54 patients to have extra pulmonary drug resistant tuberculosis, 66.6% were females while males were 33.3% and were age group of 21-29 (26.4%). Lymph node involvement most common in our study group. 74% patients were resistant to rifampicin. Treatment showed favorable outcome in majority of cases.
Conclusion: We found 8.85 % of EP DR TB cases at our centre and with good treatment outcome and stressing the fact concomitant history of pulmonary TB in 14.81%.
A rare case of disseminated tuberculosis mimicking metastatic cancer
Suraj S. Kothawale, P. L. Meshram, V. V. Pujari, R. R. Hegde
Grant Government Medical College Mumbai, Maharashtra, India. E-mail: suraj.kothawalepatil@gmail.com
Background: Disseminated tuberculosis (TB) is defined as lymphohematogenous dissemination of Mycobacterium tuberculosis. The multiple organ involvement in disseminated TB can mimic various diseases including metastatic cancer making the diagnosis of TB difficult. Frequent false negative results necessitate, repeating samples for histopathology and microbiological evaluation.
Case Study: 19-year-old immunocompetent female with no comorbidities presented with generalised weakness, fever, loss of appetite and loss of weight, bilateral lower limb weakness and swelling over skull of one month duration. Chest x-ray showed mediastinal widening. CT thorax showed mediastinal lymphadenopathy. PET Scan showed anterior mediastinum mass extending to right paratracheal region (SUVMAX 15.7), multiple lytic sclerotic lesions in bone (frontal bone, vertebrae, iliac bone, scapula, sternum, ribs) all showing SUVMAX more than 10, reported as Lymph Node Metastases and metabolically quiescent pulmonary metastasis. Bence Jones protein came negative. Prevertebral abscess and mediastinal mass biopsy sent for CBNAAT showed MTB detected rifampicin resistance not detected. Patient underwent corpectomy with fusion. She gradually improved with Anti tubercular drugs.
Discussion: Disseminated TB is defined as tuberculous infection involving the blood stream, bone marrow, liver, or two or more non-contiguous sites. The various extra-pulmonary TB (EP-TB) involvement with multiple negative microbiologic tests in immunocompetent patient leads to various differential diagnoses including: multiple myeloma, metastatic cancer, lymphoma and fungal infection.
Conclusion: Tuberculosis should be considered in differential diagnosis of patients in endemic areas even when PET shows metabolically active lesions. Differential diagnosis should be thoroughly ruled out. Delay in treatment leads to poor patient outcome.
A study on Mdr TB among young females aged <30 years
S. Gowtham, S. Raghu, S. Lakshmi Kumari
Guntur Medical College, Guntur, Andhra Pradesh, India. E-mail: drgowtham1995@gmail.com
Background and Aims: MDR tb has become a major challenge for control in young females. The aim of this study was to asses the patterns of drug resistance, outcomes & risk factors of MDR-TB among young females aged <30 years attended Government Fever Hospital, Guntur, Andra Pradesh, India.
Methods: A retrospective, observational, hospital based study conducted from January 2019-December 2020.
Results: Out of 78 cases of DR-TB, no of Secondary resistant cases was 49 (63%) while Primary resistance was 29 (37%). Among new cases 26 (90%) developed DR-TB without having exposure history. In secondary cases 27 (55%) had completed full course of treatment & only 12 (24%) were declared cured, while others being failure (7%) & defaulter cases (14%). Regarding risk factors only 3 (10%) in new cases & 2 (4%) in secondary cases had HIV. Regarding treatment outcomes, among new cases (29), cured cases were 12 (41%) & treatment completed cases were 3 (11%).While percentage of failure, defaulter & died cases being 0%, 3% & 3% respectively. In Secondary cases (49), 25 (51%) completed their treatment. While percentage of failure, defaulter & died cases being 0%, 2% & 12% respectively. In new cases MDR-RR is predominant, while in secondary cases both H-mono/poly and MDR-RR are common irrespective of previous treatment.
Conclusion: Emegence of MDR TB in young femlaes has become a serious public health problem with more no of cases of secondary resistance with high mortality over primary resistance.Hence more efforts are required to decrease the emergence of DR-TB & to prevent transmission in the community.
Adverse drug reactions of linezolid in Mdr/Xdr Tb patients leading to withdrawal of the drug; A rising hindrance to the effective treatment
R. Subrahmanian, Priti L. Meshram, Viswanath Vasant Pujari, Rohit R. Hegde
Department of Pulmonary Medicine, Grant Government Medical College, Mumbai, Maharashtra, India. E-mail: drsubbu93@gmail.com
Background: Linezolid is an oxazolidinone class of drug, a part of group B 2nd line AKT, Forms the important component of MDR/XDR TB treatment. However, it causes serious adverse effects which affect patient compliance & hinder in therapy to a larger extent. To effectively deliver the available treatment regimen and ensure patient compliance, it is important to manage ADRs more efficiently.
Objectives:
1. To study the various ADRs of linezolid in drug resistant TB patients and its association with demographic factor and comorbidities
2. To study the Average duration taken to produce the side effect, role of early recognition of ADRs and reduction of dose /withdrawal of the drug and its effects.
Methods: Patients on linezolid containing regimen over one year period were screened. 34 patients were found to have developed linezolid induced ADRs. They were further studied with above mentioned aims and objectives.
Results: Of the 230 drug resistant TB patients screened, 34 patient developed Linezolid induced ADRs like Peripheral neuropathy, optic neuritis, bicytopenia, blackening of teeth in decreasing frequency. Age, female gender, low body weight, preexisting DM, concomitant use of Cycloserine were found to be the common factors associated with ADRs. Most of the patient had to stop/or reduce the dose. Symptoms improved mostly once drug was stopped /reduced the dose at the earliest.
Conclusion: Early recognition of ADRs and action is associated with better patient compliance to DR-TB treatment and also early replacement in case Linezolid has to be discontinued.
Situational analysis of diagnosis and treatment outcome of tuberculous meningitis in tertiary care hospital
K. Karthik, K. Krishnamoorthy, T. Joseph Pratheeban, E. Mathan, O. M. Rahman Shahul Hameed
Department of Respiratory Medicine, Tirunelveli Medical College and Hospital, Tirunelveli, Tamil Nadu, India. E-mail: dr.karthik1992@gmail.com
Background: Tuberculous meningitis (TBM) is the severe form of infection caused by Mycobacterium tuberculosis, resulting in death or disability in more than half of those affected. TBM needs to be diagnosed and treated early as it is associated with high mortality and severe morbidity especially in endemic countries like India. The aim of this study is to do situational analysis of diagnosis and treatment outcome of TB meningitis in tertiary care hospital.
Methods: It’s a cross-sectional study with sample size of 50 patients. After obtained consent from the patients, basic information of the patient were noted. The patients were evaluated clinically and investigated with routine blood investigations. Lumbar puncture was done and CSF analyzed. CT/MRIbrain was taken for all patients. All diagnosed Patients were started on ATT regimens based on the standard FDC treatment regimens by NTEP. After completion of ATT patients were categorized as asymptomatic with or without persistent neurological sequel.
Results: All patients were treated with standardized FDC regimens and most of the patients received ATT for 9 months (83%). The treatment outcome with the standard FDC regimen showed a treatment completed in 72%, lost to follow up in 12% and mortality rate of 16%. Among the Cinically and radiologically diagnosed patients, 70% completed treatment and 18% reported to have persistent neurological deficit.
Conclusion: Duration of antituberculosis treatment regimens about 9 months had a better outcome and early diagnosis of TBM and early initiation of ATT was the most important factor for deciding the outcome in TB Meningitis.
Pattern of lung disease in a decade post pulmonary tuberculosis
N. Abirami, V. Viswambhar, V. Jereen, Sreekaanth
Department Respiratory Medicine Shri Sathya Sai Medical College and Research Institute, Kanchipuram, Tamil Nadu, India. E-mail: abiraminallathambi@gmail.com
Aim: To assess the lung function abnormality and differentiate the pattern in patients with Pulmonary Tuberculosis (PTB) sequelae who were treated for PTB a decade ago.
Methods: It is a cross-sectional descriptive study conducted in a tertiary care hospital with a total of 80 patients with PTB Sequelae who were treated for PTB 10 years ago, who were assessed with Spirometry and DLCO. Patients with active pulmonary tuberculosis patients, extra-pulmonary tuberculosis patients, and severe respiratory distress were excluded.
Results: Of the 80 patients, the mean age was 52.6±12.2 years, 50 patients were male and 30 patients were female, Mixed pattern was the most common one which was seen in 33 (41.2%) patients, followed by an obstructive pattern in 20 (25%) patients and restrictive pattern in 19 (23.8%) patients and 8 (10%) had Normal pattern, 20 subjects (25%) had small airway obstruction disease and 15 (18.8.6%) patients had severe DLCO. Among subjects with restrictive pattern (n=19), 7 (36.8 %) had severe restriction.
Conclusion: PTB has a significant effect on lung function even after a decade post successful completion of treatment. Routine use of spirometry and early identification of these patients will decrease the burden of post Tuberculosis sequelae in India and also around the World.
A cross-sectional study to determine the psychological distress among pulmonary tuberculosis patients during COVID-19 pandemic
Ankita Mandal1, Ajay Kumar Verma1, Surya Kant1, Sujit Kumar Kar2
1Department of Respiratory Medicine, KGMU, Lucknow, Uttar Pradesh, India, 2Department of Psychiatry, KGMU, Lucknow, Uttar Pradesh, India. E-mail: lona.sonu@gmail.com
Background: COVID-19 pandemic had adverselyaffected the services of National TB Elimination Programme (NTEP).which ultimately led to psychological distress among pulmonary tuberculosis patients.
Methods: ACross-sectional, hospital-based study which included 361 Pulmonary Tuberculosis patients.Three pre-defined questionnaireswere used for the analysis:1. Semi-structured questionnaire to evaluate anxiety-related to COVID-19. (D. Roy, et al). 2.Patient Health Questionnaire, (PHQ-9) for depression and 3. The Fear of COVID-19 Scale (FCV-19S) questionnaire (Griffith, et al).
Results: Among the 361 of the Pulmonary Tuberculosis patients, 13%(n=47) hadCOVID-19 infection. Younger age group,18 to 30 years constituted majority of the study subjects i.e.,61%(n=220) and majority of them had drug resistant tuberculosis 66% (n=165, p=0.002). Out of the total subjects 69%(n=250) were drug resistant.The proportion of anxiety,fear and depression due to COVID-19was found in 49% (n=177), 23% (n=83), 67% (n=247) of the subject respectively. Delay in initiation of anti-tubercular treatment was found in 58% (n=210) of the study population, among which majorityi.e.,69% (n=172, p=0.011) were with drug resistance tuberculosis. The trend analysis of the psychological distress showed peak in accordance with the COVID-19 pandemic.
Conclusion: Most of the drug resistant pulmonary tuberculosis patients had delay in initiating the anti-tubercular treatment during the pandemic. Preponderance of younger age group was seen in the pulmonary tuberculosis patients and majority of them had drug resistant pulmonary tuberculosis. Depression was the predominant psychological distress among the study subjects during the pandemic.
Multi-drug resistant tuberculosis and combined coagulation factors deficiency-caveat in management!!
Raghul Raj1, Rupam Kumar Ta1
Department of Pulmonary Medicine, Burdwan Medical College and Hospital, Bardhaman, West Bengal, India. E-mail: s.raghulraj@gmail.com
Background: The management of MDR-TB with multiple drugs in the regimen in a case of coagulation defect is not well-documented in literature. A number of anti-TB drugs can cause haematological abnormalities.
Case Study
Case 1: A 30-year-old diabetic male born of a consanguineous marriage with combined Factors V and VIII deficiency mild severity disease with similar history among his sisters, presented with fever, weight loss, anorexia, productive cough with recurrent haemoptysis for 3 months. His chest radiograph showed right middle and lower zone patchy infiltrates. He was treated with FFP for haemoptysis. He was diagnosed as rifampicin resistant TB on sputum CBNAAT and treated with Shorter MDR regimen (PMDT 2019).
Case 2: A 16-year male born of a non-consanguineous marriage with severe Haemophilia B with similar illness among his family members, presented with haemoptysis and fever for a month. Radiologically he had right middle and lower lobe consolidation with cavitary lesion and was diagnosed as rifampicin resistant TB on CBNAAT. After starting the shorter all oral regimen with Bedaquiline, he developed hepatotoxicity two months later which was managed by withholding the regimen for 2 weeks and restarted. He received factor VII administration throughout the treatment as before.
Discussion: Some of the anti-TB drugs such Linezolid, Pyrazinamide, Rifampicin, Isoniazid in the order of frequency can cause haematological abnormalities which should be administered with caution and close monitoring.
Conclusion: MDR-TB can be treated safely in a patient with coagulation factors deficiency under close supervision and regular follow-up to avoid risk of bleeding.
Beyond Mycobacterium tuberculosis
Sana Ansari
Department of Respiratory Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, India. E-mail: ssanaa3@gmail.com
Background: NTM mainly exist in the environment as saprophytes. One of them is Mycobacterium chimaera, an environmental contaminant. It is an opportunistic pathogen. Respiratory infections may develop through inhalation of aerosolized particles containing the pathogen, usually in immunocompromised patients and who have a history of cardiac bypass surgery and have been on ECMO.
Case Study: A 60 year old male presented with history of fever, productive cough and shortness of breath on and off for last 5 years. He had taken ATT twice for smear positive pulmonary TB with partial resolution of symptoms and recurrence. On detailed evaluation, his sputum smear was positive for AFB, CBNAAT was negative and AFB culture showed growth of Mycobacterium chimaera. Patient was started on a regimen of clarithromycin, rifampicin and ethambutol.
Discussion: M. chimaera is mainly a water-borne NTM of Mycobacterium avium complex (MAC) group. It is transmitted through inhalation of aerosolized particles containing the pathogen. It has been mainly reported following open heart surgery requiring ECMO due to the use of contaminated heater-cooler units. It is an indolent infection causing disseminated disease. Clinical features are often non-specific.
Conclusion: NTM is a rare entity but should be focused upon in certain clinical situations. NTM like M. chimaera can remain clinically dormant for years and therefore making the diagnosis timely is a challenge.
Risk factors and predictors of outcome in patients with non ICU hospital acquired pneumonia
Aparna S. Nirmal, V. Rajesh, Jolsana augustine, R. Divya, Melcy Cleetus, Anand Vijay
Department of Pulmonary Medicine, Rajagiri Hospital, Aluva, Kochi, Kerala, India. E-mail: nirmalrose91@gmail.com, rajeshdhanya@rediffmail.com
Background/Introduction: Most studies of nosocomial pneumonia have focused on ventilated ICU patients. There has been a paucity of studies of HAP outside ICU. Previous studies have identified an incidence ranging from 1.6 to 3.67 cases per 1,000 admissions for non-ICU HAP; however, few studies have reported the risk factors for HAP and outcomes outside the ICU.
Aims/Objectives: To determine the incidence of non-ICU HAP, to elucidate the risk factors for the same, estimate mortality and to find out the determinants of poor outcome.
Methodology: Patients admitted to ward with no features of pneumonia at admission were included and followed up on a daily basis for development of HAP. Lower respiratory specimens were collected to determine the etiology. They were followed up with regard to length of hospital stay, need for ICU care, need for mechanical ventilation and in-hospital mortality. Multivariate regression analysis was done to find out the risk factors associated with occurrence of HAP and determinants of poor outcomes in HAP.
Results: 1377 patients were admitted within the study period of which 431 with stay of < 48 hours were excluded. 114 patients developed HAP giving an incidence of 12%. The risk factors associated with the development of HAP were > / = 2 hospitalisations in the previous year, diabetes mellitus and group D COPD. Risk factors for poor outcome included prior carbapenem use, HAP with NF-GNB and past history of CVA. 11 patients with HAP expired during the hospital stay giving a crude mortality rate of 10%.
Conclusion: The incidence of non-ICU HAP in pulmonary wards was 12%. Crude mortality rate was noted to be 10%. Well defined risk factors were identified for development of HAP as well as poor outcomes in HAP.
Pulmonary mucormycosis: Incidental finding in case of dengue with type 1 diabetes mellitus
Shubhra Srivastava
JN Medical College, AMU, Aligarh, Uttar Pradesh, India. E-mail: shubhrasrivastava62@gmail.com
Background: Pulmonary Mucormycosis is uncommon but serious opportunistic fungal infection caused by fungi of Mucor genus through spores inhalation. Risk factors are diabetes mellitus, hematologic malignancy, transplant and moderate to severe COVID. Here we present a case of 18-year female, with new onset diabetes mellitus with dengue, finally diagnosed as a case of pulmonary mucormycosis.
Case Study: 18-year female with high grade fever, dry cough, presented in diabetic ketoacidosis (new onset diabetes). Blood investigations revealed metabolic ketoacidosis, leucocytosis, thrombocytopenia, HbA1C of 14.4, ketone and glucose in urine examination, dengue serology positive. She was admitted in ICU under broad spectrum antibiotics, insulin infusion and platelet transfusion. Chest X-ray suggested bilateral inhomogeneous nodular opacities. Chest computed tomography showed multiple groundglass nodules and focal consolidation. Bronchoscopy done for nonresolving pneumonia suggested crusting at opening of right lowe lobe apical segment. Biopsy taken which resulted in diagnosis of pulmonary mucormycosis. Patient started on oral Posaconazole (300mg) along with insulin to manage diabetes and currently under follow-up.
Discussion: In our case hyperglycemia, ketoacidosis, dengue all act to suppress innate immune response and provide facultative environment for fungal proliferation. Diagnosis based on both histopathology and cultures. Our patient is young age and clinically/vitally stable, so we started Posaconazole (300mg) while majority of published studies recommended liposomal amphotericin-B.
Conclusion: Pulmonary mucormycosis can even occur in young age with new-onset type 1 diabetes mellitus.
Follow up of patients with drug resistant tuberculosis in Puducherry - Retrospective follow up study
Agnus Hanna Ria Panicker1, R. Pajanivel1, Muthuraj2, Govindarajan3
1Department of Pulmonary Medicine, MGMCRI, Puducherry, India, 2Intermediate Reference Laboratory, Puducherry, India, 3State Tuberculosis Unit Puducherry, Puducherry, India. E-mail: agnuspanicker@gmail.com
Background and Aim: Tuberculosis is one of the most common causes of death in the world. Drug resistance has become more common in previously treated patients, who were treated irregularly or with improper regimens and doses. Previous TB treatment is an important risk factor for developing DR-TB. So goal of this study is to look the clinico-microbiological profile, treatment outcomes, and follow-up of patients who were registered for DRTB and IRL at Puducherry tuberculosis unit.
Materials and Methods: This study included 73 patients who were treated for drug-resistant tuberculosis at DRTB/IRL during 2014-2020. Their clinical condition, microbiological parameters, drug resistance pattern, laboratory profiles, and radiological results were taken into consideration. Patients with favourable and unfavourable outcomes (completed treatment, cured, failed) were followed up using random sampling method. Patients followed up at home or in hospital and their current clinical findings, sputum smear status, and radiological data were recorded.
Results: 73 patients were included with mean age of 43.83±15.20 years. Treatment outcomes of patients as follows: 57 patients cured (78.08%), from the cured patients 16% were died during follow up period, 1.4 % completed treatment, 4.1% died before completing the treatment, 4.1% were lost to follow up and 2.7% had treatment failure.
Conclusion: Treatment success outcomes occurred more than 3/4th of cases, which is higher than the WHO of at least 75% success rate. There were 16% patients who died during the follow up period of study, which resulted an unfavourable outcomes.
Study to assess effectiveness of shorter regimen among multi-drug resistant tuberculosis patients at a rural tertiary care centre of Northern India
Background: The burden of multidrug-resistant (MDR) tuberculosis (TB) is increasing and threatening worldwide. An estimated 480,000 people developed MDR-TB globally in 2014. However, only an estimated 26% (123,000 people) were notified and even fewer (111 000, ∼23%). The number of MDR/ Rifampicin Resistant TB cases in India is 124000(9.1/lakh), Considering the effectiveness of shorter regimen for the treatment of MDR-TB patients we have planned this study to assess the effectiveness of shorter regimen among MDR-TB patients at rural tertiary care centre of North India.
Methods: A hospital based prospective, longitudinal study of a moxifloxacin based directly observed regimen was done between January 2020 to June 2021. The treatment given of 4-6 months of intensive phase and 5 month continuation phase. Patients were monitored using liquid culture after treatment completion.
Results: This study reveals that 76% patients were cured and 24% patients failed to cure, among all the patients. Treatment outcome was found significantly associated with smoking and previous history of ATT as inadequately treated (P < 0.05).
Conclusion: Mean age of study participants was 31±15.11 years with 59% were male and 41% were female. Most common age group was 18-45 years with 72% patients. Treatment outcome was negatively associated with smoking and previous inadequate treatment for tuberculosis. Most common adverse effect observed was Gastro-Intestinal intolerance.
Rifampicin and isoniazid induced thrombocytopenia with anaemia
V. Sai Krishna Rao, Induri Bala Mamatha Reddy, A. Vinay Kumar, C. H. Praveen Kumar
Department of Pulmonary Medicine, Chalmeda Anandrao Institute of Medical Sciences, Karimnagar, Telangana, India. E-mail: vsaikrishnarao2274@gmail.com
Background: ATT forms the mainstay of treatment of pulmonary tuberculosis. However, these drugs cause rare but serious side effects,RIFAMPICIN is the most studied drug to cause thrombocytopenia and agranulocytosis but isoniazid induced thrombocytopenia are rare.
Case Study: A 24yr old male patient presented to ER with complaints of bleeding from nose, blood in stool and rash all over the body since 3days.He was on CAT 1 ATT for sputum positive pul TB since 3months,presented with thrombocytopenia, ATT was immediately withheld and was investigated for cause of anemia and thrombocytopenia, thrombocyte suspension was given until a normal thrombocyte count was obtained, After several start-stop trails, first R AND H were identified as the possible cause of thrombocytopenia and were removed from regimen. The patient is treated with altered regimen of ATT drugs.
Discussion: ATT induced thrombocytopenia and anaemia are rare and serious side effects of anti TB drugs. Drug induced thrombocytopenia is a frequent condition. George et al collected case reports and defined the 4 standard criteria to explain the association between the drugs and thrombocytopenia.
Conclusion: Although (H) induced thrombocytopenia has been defined previously there have been very few cases reported so far to knowledge but early identification of the offending drug can prevent serious complications and save lives.
Laryngeal TB: a rare case presentation with endobronchial TB in antibiotic era
V. Sai Krishna Rao, Induri Bala Mamatha Reddy, A. Vinay Kumar, C. H. Praveen Kumar
Department of Pulmonology, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, Telangana, India. E-mail: vsaikrishnarao2274@gmail.com
Background: Before the availability of anti TB treatment, laryngeal involvement was considered as a grave prognostic sign suggestive of severe disease and was seen in nearly one third of cases. Post availability of anti TB treatment the incidence of laryngeal TB has reduced to less than 1%.
Case Study: A 51years old male came to OPD with complaints of fever, cough, loss of appetite and weight since 3months and change in voice,hoarseness of voice, odynophagia since 10days and he was investigated with Chest X Ray, Hrct Thorax, Blood Investigations, Ent Examination, Sputum Examination And Bronchoscopy Was Done.
Discussion: Laryngeal TB classically develops due to bronchogenic spread which is frequent in sputum smear positive pulmonary TB and most commonly involves the posterior glottis. This results in localized edema, grauloma, or ulcerations. Incidence of laryngeal TB mostly seen in 40s and 50s and age ranging from 25yrs to 75yrs.Apical TB with laryngeal involvement though rare can be managed with anti TB treatment.
Conclusion: Laryngeal TB is less common in comparison to Laryngeal TB secondary to Pulmonary TB with early diagnosis the response to treatment is satisfactory.
Interesting case of nocardiosis mimicking TB
S. v. Jagmohan
E-mail: drjagmohan99@gmail.com
Background: Nocardia is a gram-positive, weakly acid-fast, filamentous bacteria belonging to Actinomycetes. Currently about 30 species of Nocardia have been described which can cause disease in humans. Among them, Nocardia asteroides is responsible for about 70% of the infections Nocardiosis occurs most commonly inimmunocompromised patients.
Nocardiosis primarily effects lungs (75–80%) and the other organs that can be effected are brain, skin and rarely kidney and liver.
CASE REPORT: A 42-year-old male presented with fever, productive cough with episodes of hemoptysis and breathlessness from one week and altered sensorium and tremors since 3 days. He was a chronic alcoholic, with history of binge drinking from 1 month and stopped since 3 days. He did not have any other significant past, personal or drug history. On examination, he was conscious but drowsy. He was febrile with body temperature of 1020F, pulse rate was 124beats/min, respiratory rate was 28 cycles/min and Blood pressure was 114/70mmHg. His O2 saturation was 88%. On systemic examinations, fine crepitations were heard in all the areas of right lung. Other systems examinationwas unremarkable. His blood investigations revealed TLC-17,250cell/mm3. Other investigations (Hb, platelet count, RBS, RFT, LFT, FBS, PPBS, HbA1C) were normal. VCTC was negative. Chest x-ray showed non-homogenous opacities, infiltrations and two thin walled cavities in right lung upper and middle zone.
Differential diagnosis of community acquired pneumonia or pulmonary tuberculosis in alcohol withdrawl state was made and patient was started on Inj. Linezolid (600mg bid), Inj.meropenem (1g tid) and bronchodilators. 4hrs after admission, patient became tachypneic and his oxygen saturation was not maintained on oxygen face mask. Then patient was intubated and kept on ventilator. Despite broad-spectrum antimicrobial therapy, patient’s condition was deteriorating.
ATT was planned to start but several sputum samples collected and tested for the presence of acid-fast bacilli, were negative. Sputum for Gene Xpert was also negative. Sputum Gram stain revealed Gram positive thin branching filaments. Modified Ziehl-Neelsen staining showed branching Acid fast bacilli consistent with the morphology of Nocardia species (Figure 3). Culture and sensitivity of tracheal aspirate identified the organism as Nocardia. Tablet Cotrimoxazole (160/800mg DS tablets bd) was added to meropenem. Patient improved clinically and radiologically and was discharged after 15 days and advised to continue Cotrimoxazole for 9 months. Patient is coming for follow up and is doing well.
cxr showed right upper mid and lower zone opacity with cavity
Sputum Gram stain revealed Gram Modified Ziehl Neelson staining showed positive branching filaments branching Acid fast bacilli.
Conclusion: Pulmonary nocardiosis, though a well recognized entity, is often missed due to its clinic radiological similarities with tuberculosis. Our report emphasizes that a high level of clinical suspicion is required in patients without risk factors. In a patient with pneumonia if the lung infection responds poorly to antimicrobial therapy for community acquired pneumonia, pulmonary nocardiosis should be considered and a careful search for evidence of the organism is necessary.
Adverse events reported by patients with HIV/TB coinfection and taking both ATT and Haart
Dennis Simon1, Jayant B. Chauhan2
1Department of Pulmonary Medicine, Baroda Medical College, Vadodara, Gujarat, India, 2Department of Pulmonary Medicine, Baroda Medical College, Vadodara, Gujarat, India. E-mail: dennis.k.simon@gmail.com
Background: TB is the most common and serious opportunistic infection in HIV positive patients and the initial manifestation of AIDS in 50% of cases in developing countries. This research aims to analyse the adverse events reported by patients with HIV/TB coinfection and taking both ATT and HAART and to determine the sociodemographic and clinical profiles.
Methods: This was a time bound study done in a tertiary hospital. All HIV TB coinfected patients (>18 years) on ATT and HAART were included in the study. Patients were examined for any drug reactions and blood examination was done and followed up every 3 months for six months.
Results: A total of 50 TB/HIV co-infected patients were taken for the study.
• Mean age of the patients was 38 years (25-50years).
• 82% were male.
• BMI of around 18 is more prone to have tuberculosis. (62%)
• Drivers and urban group were commonly affected. (44%)
• Abdominal (70%), neurological and dermatological complaints were seen most commonly after ART initiation.
• Most common chest Xray findings were infiltrates in upper zone followed by lower zone.
• TB IRIS seen in 6% of the patients.
• Zidovudine and Rifampicin are the drugs causing haemolysis.
• Tenofovir, Protease Inhibitors and Rifampicin are the nephrotoxic drugs.
• Nevirapine, efavirenz, Ritonavir, Rifampicin, Isoniazid, pyrazinamide are the hepatotoxic drugs
• Streptomycin caused SNHL in two patients
Conclusion: Improvements in both ATT and ART drugs is needed to shorten the duration of TB treatment, with no drug-drug interactions, and very minimal toxicities so that treatment for both diseases can be optimized.
A case of 52-year-old male with pulmonary multiple cysts and cavities caused by aspergillus species and disappeared with the anti-fungal agent
Simon Dennis
Department of Pulmonary Medicine, Government Medical College, Vadodara, Gujarat, India. E-mail: dennis.k.simon@gmail.com
Case History: A 52-year-old male who had past history of asthma for 10 years admitted to our hospital. He had complained productive cough with brown plugs and slight fever for a month followed by blood in sputum for 7 days.
Diagnosis: HB 8g/dl;
Total count: 20,000/cumm;
Blood eosinophils: 10% on differential count;
Absolute eosinophil count: 2500 IU/ml
Sputum for smear and Gene X- pert: MTB not detected
Aspergillus specific IG E: 81 IU/ML
Stool routine examination: No parasites, ova, or cyst
C ANCA: Negative
Imaging: Chest radiographs reveal a solid round mass within a cavity in the right upper lung field and few pulmonary infiltrates. HRCT Thorax showed features suggestive of aspergilloma; Multiple cysts, cavities and central bronchiectasis were also found.
Sputum for fungal culture: Aspergillus Fumigatus
Others: positive precipitin reaction for aspergillus
He was diagnosed with possible ABPA, and the mycetoma may be pulmonary aspergillosis.
Haemostatic drugs like ethamsylate were given intravenously 250mg thrice daily for 10 days; Proper bed rest was given. Haemoptysis subsided after that. He had administrated antifungal agent, Tab Itraconazole 200 mg twice daily continuously for 6 months.
Discussion: Aspergillus infection usually, results from saprophytic growth within pre-existing cavities. Controversially, in this case, multiple cysts and cavities may be caused by aspergillus infection, which is extremely rare. We suppose that cysts and cavities might be formed by the check valve mechanisms.
Outcome: Multiple cysts and cavities were all disappeared and the patient responded very well and there were no further episodes of haemoptysis too.
A rare case of pulmonary artery pseudoaneurysm with pulmonary AV fistula
A. S. Madhurima, P. L. Meshram, V. V. Pujari, R. R. Hegde
Department of Pulmonary Medicine, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India. E-mail: asmadhurima@gmail.com
Background: Rasmussen’s aneurysm is an inflammatory pseudo–aneurysmal dilatation of a branch of pulmonary artery adjacent to a tuberculous cavity which if ruptures, though uncommon, can cause life threatening massive hemoptysis.
Case Study: A 57-year old male with DM presented with productive cough since 1 month and hemoptysis since 5 days around 50ml daily. No history of pulmonary tuberculosis or other illnesses. CT pulmonary artery angiogram showed large pseudoaneurysm with AV fistula arising from the right lateral basal segmental artery, 3.3x5.6x4.9cm, causing compression of the adjacent bronchus and collapse consolidation of the adjacent lung. Aberrant origin of the right subclavian artery from the aortic arch and Bovine aortic arch and few enlarged partially necrotic lymph nodes in paratracheal and para esophageal regions were also noted. This was suspected to be secondary to infective etiology ?Rasmussen’s aneurysm ?Mycotic aneurysm. Patient underwent pulmonary artery pseudoaneurysm embolization with vascular plug. Patient was started on first line anti-Tuberculosis Treatment along with antibiotics and was also advised for right lower lobectomy and AV fistula excision.
Discussion: Rasmussen’s aneurysm occurs from progressive weakening of the wall from adjacent cavitatory tuberculosis and granulation tissue and fibrin subsequently replaces the tunica adventitia and media, causing thinning of arterial wall, pseudoaneurysm formation and subsequent rupture and hemorrhage.
Conclusion: Life-threatening massive hemoptysis can arise from a pseudoaneurysm of pulmonary artery or its branches contiguous to a tuberculous cavity. Such pathology should be differentiated from a bronchial source of bleeding by urgent CTA and may require emergency endovascular management techniques.
Clinical characteristics, prognostic indicators and treatment outcomes of patients on shorter Mdr regimen in Coimbatore, Tamil Nadu: A retrospective study
K. Jeswyn Robert, S. Keerthivasan, R. Vani, T. Pudhumalar, V. Arunchandar
Department of Thoracic Medicine, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India. E-mail: jeswynrobert@yahoo.in
Background: The global incidence of MDR-TB is 3.4% in new cases and 18% in previously treated cases. However, information about management and clinical outcomes of patients on shorter MDR regimen is scarce and hence the need for this study.
Methodology: This is a 3-year retrospective cohort study of 129 patients on shorter MDR drug regimen registered in Coimbatore district. Patients demographic details, BMI, comorbid status, HIV status and other clinic-social characteristics data were taken.Clinical outcomes were cured, died, lost to follow up, treatment completed, treatment failure, Treatment regimen change. Association between clinical outcomes and factors associated were studied and analyzed.
Results: Among 129 patients, majority were male, age group between 41-60 years. The outcome was-52 patients got cured, 27 patients died, 19 patients treatment completed, 19 patients lost to follow up, 5 patients had treatment failure, and treatment regimen was changed in 7 patients. There were no significant difference in outcomes with BMI, Rural vs Urban, Old Vs new case. Cured rates were significant among non-smokers, non-alcoholic, non-hypertensive patients. Death rate was significant among smokers. Treatment completed was significant among non-smokers, non-alcoholic.
Conclusion: Better outcomes in Patients on shorter MDR drug regimen is seen among non-smokers, non-alcoholics, non-diabetics and non-hypertensive patients.
A rare case of Mac breast abscess in an immunocompetent female
C. Bavithrra, P. L. Meshram, V. V. Pujari, R. R. Hegde
Department of Pulmonary medicine, Grant Government Medical College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India. E-mail: bavithrra.muthu@gmail.com
Background: Mycobacterium avium complex (MAC) is a ubiquitous pathogen, widely distributed in the environment including water, soil and animals. It is an uncommonly encountered clinical pathogen, primarily causing pulmonary infections in patients with underlying lung disease or disseminated disease in immunocompromised hosts. Sporadically, extra-pulmonary infections have been documented of the liver, spleen, skin, soft tissue and lymph nodes. Breast abscess due to MAC in an immunocompetent patient has not been reported yet.
Case Study: A 40 year old female presented with complaints of pain and swelling initially in the left breast, later in right side also, with no co morbidities, married, multipara, with regular cycles. Ultrasound of breast was suggestive of bilateral duct ectasia with intra ductal echogenic masses with thick walled abscess. Pus aspirate culture showed growth of Mycobacterium intracellulare susceptible to Amikacin, Clarithromycin, Linezolid, Imipenem. She is being treated with Clarithromycin, Rifampicin, Ethambutol and Amikacin. Patient was evaluated for other immunocompromised states like anemia, chronic kidney and Liver disorders.CD4 count was also done. All reports were normal.
Discussion: It is important to consider rare infections also such as MAC in immunocompetent patients, regardless of symptoms and the severity.
Conclusion: Rare infection if timely diagnosed, will lead to effective treatment and cure.
Study of pattern of rifampicin susceptibility diagnosed through CBNAAT in microbiologically confirmed cases of pulmonary tuberculosis
Rahul V. Laiya, Sateesh Patel, Rajiv Paliwal, Nimit Khara, Dhavalkumar Prajapati
Department of Respiratory Medicine, Pramukhswami Medical College, Karamsad, Gujarat, India. E-mail: rahulahir4438@gmail.com
Background: Emergence of drug resistance and development of multidrug-resistant tuberculosis has become a significant obstacle for tuberculosis (TB) control. As rifampicin-resistance is an important indicator for drug-resistant-TB, rapid diagnosis of tuberculosis and detection of rifampicin-resistance are essential for knowing the magnitude of problem and early management of drug-resistance-TB. Cartridge-based-nucleic-acid-amplification-test (CBNAAT) is an essential investigation which help us in early diagnosis and treatment of tuberculosis patient according to rifampicin-susceptibility.
Methods: Total 297 microbiologically confirmed cases of pulmonary tuberculosis registered for treatment under RNTCP (now NTEP) during study period were included and their sputum reports were evaluated for study.
Results: We had enrolled 297 patients who were microbiologically confirmed cases of pulmonary-tuberculosis. Majority of patients were in the age group of 18-30 years (37.4%) and predominant were male (62.3%). About 90 (30.3%) patients were previously treated under NTEP, out of them 65 patients had completed treatment and rest 25 patients were defaulter. Amongst 297 patients, 7.08% patients had concurrent seropositive-illness(HIV-positive). AFB was detected in sputum microscopy in 263 patients (88.55%). According to the Sputum CBNAAT result, 15(5.05%) patients were resistant to rifampicin. Among rifampicin-resistance cases 60% were in age group of 18-30 years and 93.3% had past history of tuberculosis out of which 78.8% had defaulted treatment in past which statistically significant (p-value:<0.05).
Conclusion: Patients with past history of tuberculosis are at high risk of developing MDR. Rifampicin-resistance cases are more prevalent in male, younger age and treatment defaulter in our study.
Clinical, radiological and bacteriological profile of lung abscess
Kovvada Aswini, A. Ayyappa
Department of Pulmonary Medicine, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India. E-mail: aswinikovvada@gmail.com,
Background: The incidence, mortality and morbidity of lung abscess was high in the pre-antibiotic era but with the advent of powerful antibiotics there is fall in both. With the emerging antibiotic resistance and change in the trends of bacteriological profile causing lung abscess, it is the need of time to reevaluate lung abscess profile.
Aim: The study aimed to determine the clinical, radiological and bacteriological profile of lung abscess.
Methodology: The study was a retrospective study conducted in the department of pulmonary medicine, Andhra medical college, Visakhapatnam during October 2020 to October 2021. Demographic, clinical, radiological, bacteriological, antibiotic sensitivity and treatment data were collected from the hospital (GHCCD) data and analysed.
Results: 92 adult cases of lung abscess were included, and with a male to female ratio of 6.6:1. The most common predisposing factor was an unhygienic oral cavity in 28% of cases with alcohol ingestion being the most important risk factor in 22% of cases. The most common organism found in lung abscess cases was Klebsiella pneumoniae, and they were sensitive to ceftazidime.
Conclusion: Our study shows that Klebsiella pneumoniae should be considered an important pathogen in community-acquired lung abscesses and all the available parameters should be used in treating lung abscess cases so that there is good outcome.
Massive hemoptysis in a patient with pulmonary aspergilloma and type 2 diabetis mellitus and chronic renal failure on anti tubercular treatment – Managed surgically
Kovvada Aswini, A. Ayyappa
Department of Pulmonary Medicine, Andhra Medial College, Visakhapatnam, Andhra Pradesh, India. E-mail: aswinikovvada@gmail.com
Background: Life threatening hemoptysis in patients with pulmonary aspergilloma should be managed by surgical resection but may have poor prognosis.
Case Study: A 52year old male patient with past history of type 2 diabetis mellitus and chronic renal failure and using Anti tubercular treatment since3 months presented with chronic hemoptysis. Clinical presentation and workup revealed a left lung Aspergilloma, with chest x ray and CT chest showing thick walled cavitory lesion with intracavitory soft tissue mural nodule on the upper lobe of left lung and FNAC showing Aspergillus. In view of recurrent and massive hemoptysis patient was referred to CT surgery department and underwent thoracotomy with left superior lobectomy. Histopathological examination of specimen showed hyphae with septa. The patient had postoperatively controlled pleural effusions.
Discussion: Type 2 diabetis mellitus and chronic renal failure are risk factors for Aspergillus infection because of the immunocompromised state when chronic hyperglycemia and hyperuricemia occur. Pulmonary Aspergilloma has poor prognosis after surgery. Removing aspergilloma of the lung cavity and maintaining blood glucose and urea levels can provide good prognosis.
Conclusion: Pulmonary Aspergilloma that involves only one lung lobe has a good prognosis after surgery.
Diagnostic role of gastric aspiration in sputum negative pulmonary tuberculosis among adults
Yesha V. Patel, Jigna Dave
Department of Respiratory Medicine, Government Medical College, Bhavnagar, Gujarat, India. E-mail: yeshakakak@gmail.com
Background: Tuberculosis is a major cause of ill health, one of the top 10 causes of death worldwide and the leading cause of death from a single infectious agent. Faster reduction in TB incidence and death requires prompt diagnosis using highly sensitive diagnostic tests including Drug Resistant TB in country. Gastric aspiration has been applied in pediatric population for suspect TB cases. These study was carried to find diagnostic role of Gastric aspirate in adults.
Methods: Retrospective study conducted at Government Medical College Bhavnagar from May 2019 to November 2021. 230 Patients taken in the study were classified into: 1. Those who have sputum production with radiologically active lesion but sputum smear negative for AFB.
2. Those patients who have neurological deficits and very sick patients who cannot bring out sputum.
3. Those who have a radiological significant lesion without sputum production. Patients were kept NBM overnight before the procedure. Evaluation of gastric aspirate fluid was done by AFB smear and CBNAAT method.
| Result | Positive | Negative | Yield (%) |
|---|---|---|---|
| Gastric aspirate AFB smear | 34 | 196 | 14.78 |
| Gastric aspirate CBNAAT | 74 | 156 | 32 |
AFB: Acid fast bacilli; CBNAAT: Cartridge based nucleic acid amplification test
Results
| Gastric aspirate | CBNAAT positive | CBNAAT negative | Total |
|---|---|---|---|
| AFB smear positive | 34 | 0 | 34 |
| AFB smear negative | 40 | 156 | 196 |
| Total | 74 | 156 | 230 |
AFB: Acid fast bacilli; CBNAAT: Cartridge based nucleic acid amplification test
Conclusion: Microbiological confirmation should always be done to ensure correct diagnosis; all effort must be made to get appropriate clinical specimens from affected site. Gastric aspirate can be used as simple tool in diagnosis of pulmonary tuberculosis in patients as outpatient procedure who cannot bring out adequate sputum for examination.
Comparison of radiographic findings between drug sensitive and drug resistant tuberculosis in a tertiary care hospital
Mrinmoy Chakraborty
Department of Respiratoty Medicine, RGKMCH, Kolkata, West Bengal, India. E-mail: drmrinmoychakraborty@gmail.com
Background: Imaging has a big role in tuberculosis(TB) diagnosis and radiography is preferable because it can point out the morphology of lesions such as cavity consolidation, pleural effusion and fibosis. We aim to compare the radiographic findings in multidrug resistant tb(MDR-TB) and in drug sensitive TB(DS-TB) cases.
Methodology: A prospective study wERE performed in the OPD and the ward of the department of RESPIRATORY MEDICINE on the basis of radiographic findings among the patients of MDR-TB and DS-TB giving consent and meeting the inclusion criteria. The data were analysed by using proper statistical methods.
Results: Radiological findings show there was sinificant association between DRTB with consolidations, cavities, bronchiectasis, calcification and miliary shadows In DSTB we found significant association with infiltrates, consolidations, pleural thickening and with pleural effusion.In DSTB we found significant association with unilateral and upper lobar predominence. DRTB patients show significant association with bilateral,middle and lower lobar involvement.
Conclusion: We can conclude that characteristic radiogrphic findings may help differentiate between drug sensitive and drug resistant tuberculosis. The presence of DRTB as detected on CT scan or CXR may help the use of appropriate therapy for infected patients before obtaining a definite diagnosis based on bacteriology. Although presence of cavities, bronchiectasis, miliary shadows do not mean drug resistance but may suggest possibilities of drug resistant tuberculosis
Pseudomonas aeruginosa: Case of septic pulmonary embolism and oro-naso-pharyngeal lesions
Dilsha Parveen
JNMC, AMU, Aligarh, Uttar Pradesh, India. E-mail: bsdilshaparveen94@gmail.com
Background: Septic pulmonary embolism is an uncommon but serious disease in which septic thrombi are mobilised from an infectious nidus and transported in vascular system of lungs. Methicilline-Sensitive Staphylococcus aureus and Methicilline-Resistant Staphylococcus aureus are most common causating organism of SPE. Here we report a case of SPE with oro-naso-pharyngeal lesion due to pseudomonas.
Case Study: A 45 year old man with newly diagnosed uncontrolled diabetes mellitus, ex-smoker, on steroids for presented to hospital with high grade fever, cough expectoration, chest pain, oral and lip ulcers and nasal black crusting lasting 10-12 days. Chest x-ray revealed bilateral nodular opacities. Chest computed tomography revealed multiple randomly distributed cavitary nodules with few air-fluid level. Sputum for AFB and KOH negative. Fungal c/s negative. Vasculitis and cancer ruled out. Blood c/s, sputum c/s and nasal swab c/s all suggestive of Pseudomonas aeruginosa. Treated with broad-spectrum antibiotics, but patient landed into DIC and expired.
Discussion: In this case diagnosis of SPE based on fever, blood culture, multiple nodules on chest CT and oro-naso-pharyngeal lesions as predisposing infectious sites. Risk factors are immunosuppressed state and uncontrolled diabetes mellitus. Management of Pseudomonas infection is challenging due to poor prognosis and antimicrobial resistance.
Conclusion: We report case of septic pulmonary embolism associated with oro-naso-pharyngeal lesions caused by Pseudomonas aeruginosa in immunosuppressed and uncontrolled diabetic patient. Patient did not respond to antibiotic therapy, landed into DIC and expired.
Sensitivity of Genexpert ultra in the diagnosis of extra pulmonary tuberculosis
R. Anand, C. Chandrasekar, M. Koushik Muthu Raja, T. Dhanasekar
Department of Respiratory Medicine, SRIHER, Chennai, Tamil Nadu, India. E-mail: dranandrajendran1994@gmail.com
Background: TB is one of the leading causes of death from a single infectious agent, with an estimated 10 million new cases and 1.5 million deaths in 2020. Diagnosis of EPTB remains challenging and newer diagnostic modalities like GeneXpert Ultra helps in improved detection rates in these Paucibacillary Conditions which in turn helps in early initiation of ATT.
Objectives: To evaluate the sensitivity of GeneXpert Ultra in the diagnosis of extra pulmonary tuberculosis
Methodology: This is a prospective and observational study conducted at the Department of Respiratory medicine, SRIHER. Laboratory Data were taken along with Extrapulmonary sample analysis for MGIT Culture, GeneXpert and GeneXpert Ultra.
Results: Majority of the patients had pleural tuberculosis followed by lymph node tuberculosis. Among the study population, GeneXpert ultra was positive in 38 out of 52 patients compared to other diagnostic methods such as GeneXpert which was positive 23 patients with AFB smear and culture positivity constitutes about 13 and 14 out of 52 patients.
Conclusion: Our study was a pilot study with very limited population and has an excellent sensitivity around 100 % in GeneXpert ultra-compared with 86% in GeneXpert. The improved molecular chemistry of Ultra enabled detection of even the trace category that constitutes a substantial number of cases. Nevertheless, negative Ultra tests cannot rule out tuberculosis.
A prospective cohort study on treatment outcome and drug resistant profile of isoniazid mono-resistant pulmonary patients in Madurai District
G. Anand Raja, P. Dhamodharan, Senthil Kumar, B. Rajesh Kumar, R. Hariprasad, R. Prabhakaran
Department of Respiratory Medicine, Madurai Medical College, Madurai, Tamil Nadu, India. E-mail: rgk.anand@gmail.com
Introduction: The global prevalence of INH Mono-resistant TB is 7.4% among new TB patients and 11.4% among previously treated TB patients. As per NDRS 2014-2016, any Isoniazid resistance is 11.06% and 25.09% and INH mono-resistance is 3.85% and 7.61% among new and previously treated patients, respectively. INH mono-resistance is much more common than RR TB, with majority of the patients detected with primary mono resistance.
Objective: To measure the outcome and the impact of comorbidities in the outcome of Isoniazid Mono-resistant PTB patients who were treated with H Mono Poly regimen.
Methods: Microbiologically confirmed Isoniazid Mono-resistant PTB patients were evaluated and followed up as per PMDT Guidelines.
Results: Of the 79 patients enrolled, KatG mutation was seen in 48(61%) patients and InhA mutation was seen in 27(34%) patients and InhA and KatG was seen in 4(5%) patients. 60(76%) patients were detected with primary monoresistance whereas 19(24%) patients were previously treated PTB patients. Positive treatment outcomes were seen in 70(88.6%) patients, and Negative treatment outcomes were seen in 9(11.39%) patients. CKD and history of previous treatment to TB was associated with statistically significant poor treatment outcomes.
Conclusion: As per Drug resistance profile studied, the commonest mutation found was Kat G. Though Kat G resistance is associated with High level of resistance, there was no statistically significant difference in the treatment outcomes of those patients. Hence to achieve better outcome emphasis should be on improving treatment adherence, treatment of adverse events, comorbidities and close follow up.
Atypical presentation of pulmonary hydatid cyst
Nayantara Sudhakar, Alamelu Haran, S. Mamatha, G. Anish
Department of Pulmonary Medicine, Vydehi Institute of Medical Sciences and Research Centre, Bengaluru, Karnataka, India. E-mail: nayantara_nayan@yahoo.co.in
Background and Objectives: Isolated Pulmonary involvement in hydatidosis is rare and is associated with several complications which if left untreated, results in higher morbidity and mortality.Early diagnosis (which includes radiology & serological testing), is essential for diagnosis, predicting prognosis and proposing further plan of management, which involves both medical and surgical intervention. This case report is an example of a rare presentation of Pulmonary hydatid cyst.
Case Presentation: A 32 year old male presented to Pulmonary Medicine Department with complaints of Productive Cough, Left sided chest pain, haemoptysis from 10 months. Clinical examination was within normal limits. Routine investigations were normal.Ultrasound abdomen revealed no sonological abnormality.CECT thorax showed a wedge shaped cystic lesion with septations, air foci with a calcified wall and nodules in the anterior segment of left upper lobe. For further evaluation of haemoptysis, bronchoscopy was done, which revealed a white mobile glistening endobronchial mass, consistent with ruptured hydatid cyst in the left upper lobe anterior segment. Examination of BAL fluid, revealed the presence of hooklets and scolices. Biopsy report showed features consistent with hydatid cyst wall. Patient was referred to a CTVS surgeon for lobectomy.
Conclusion: This case was an atypical presentation of pulmonary hydatid cyst in the form isolated pulmonary involvement, location of lesion and radiological features.Detailed evaluation is required for definitive management of every case.
Mycotic aneurysm: A rare presentation of severe hemoptysis
Pratyakcha Rai, Zuber Ahmad, Imrana Masood, Ummul Baneen
TB and Respiratory Diseases. E-mail: raipratyakcha26@gmail.com
Background:
• Pulmonary artery aneurysm (PAA) is a rare abnormality of the pulmonary vasculature with very few reports being described in literature.
• Several etiologies are implicated in PAA such as infection, malignancy, congenital heart disease, or vasculitis.
• Patients may present with dyspnea, chest pain, cough, pulmonary hypertension, right ventricular failure and hemoptysis.
Case Study: A 65 year old diabetic male admitted with dysnea and cough (taking steroids for same)
• Fever & hemoptysis × 10 days
• Weight loss 8 kg × 8 months
• Sputum c/s revealed P. aeruginosa
• On Echo several septic thromboembolism present. On CTPA, a saccular structure with enhancement charactertics equal to those of adjacent pulmonary arteries in the right upper lobe of lung.
Discussion: The differentials for this case could be Tuberculosis, Malignancy, Bronchiectasis and mycotic aneurysm. Pulmonary mycotic artery aneurysm (PAA) is a dilated arterial wall due to infection.
• Risk factors are trauma, antecedent infection or septic embolization.
• Pathogenesis in this case could be endovascular seeding, contiguous spread from adjacent consolidation.
• Mortality in PAA is commonly (~50%) due to massive hemoptysis.
• Clinical, serological & radiological diagnosis is required to diagnose this case.
• Surgical interventions as embolotherapy, aneuresectomy, pneumonectomy, lobectomy are required in cases of recurrent, uncontrolled hemoptysis.
Conclusion: PAA is a rare case detected on CT and should be intervened surgically.
To assess the clinical profile of suspected/proven cases of tubercular cervical lymphadenitis and role of molecular tests (Cbnaat) in diagnosis
Prathyusha Alakunta, Nitin Gaikwad, Mahavir S. Bagrecha
Department of Respiratory Medicine, Dr. D. Y. Patil Medical College and Research Centre, Pune, Maharashtra, India. E-mail: prathyusharaj27@gmail.com
Background: Tuberculous lymphadenitis (TL) will be the initial differential diagnosis in a patient with the enlarged lymph node in developing countries like India. Fine needle aspiration cytology (FNAC) and Ziehl Neelsen (ZN) smears were lacking both sensitivity and specificity in detecting Tuberculosis. The goal of the present study is to see how well the CBNAAT (Cartridge Based Nucleic Acid Amplification Test) performed in detecting MTB and RIF resistance directly from a TB suspected lymph node tissue.
Aim: The present study aimed at a detailed clinical profile evaluation and also to assess the role of CBNAAT in the diagnosis of suspected/proven cases of tubercular cervical lymphadenitis to significantly improve the accuracy and rapid diagnosis of Tuberculous lymphadenitis.
Methods: Study was conducted in Dr Dy Patil medical college which included 100 suspected/proven cases of TB Cervical lymphadenopathy(TBLN),a detailed clinical history and evaluation was carried out, all patients underwent FNAC and excisional biopsy was done in inconclusive cases of FNAC and detailed analysis was done.
Results: Fever was the most common symptom followed by loss of appetite/weight, Jugular group of lymph nodes are most commonly involved. FNAC-CBNAAT had a good sensitivity(74.29%) and also specificity(68.18%), whereas excisional biopsy had a very good sensitivity(94.4%) and specificity(100%) in inconclusive cases of FNAC.
Conclusion: CBNAAT has a high sensitivity and specificity, allowing it to be used to better diagnose, manage, and treat suspected TBLN patients. Excisional biopsy should be considered of all inconclusive/negative reports in patients who are strong suspects of tubercular lymphadenopathy particularly in endemic countries like India.
ABPA exacerbation and PTB co-infection: A diagnostic conundrum
Vinnie Sarah Ch Sangma, Surabhi Jaggi, Deepak Aggarwal, Mandeep Kaur Sodhi
Department of Pulmonary Medicine, GMCH-32, Chandigarh, India. E-mail: vinnie.sangma@gmail.com
Background: ABPA is a complex immunological pulmonary disorder caused by hypersensitivity to antigenic products released by Aspergillus fumigatus colonizing the tracheobronchial tree in bronchial asthma and cystic fibrosis patients. ABPA is often misdiagnosed as tuberculosis caused by Mycobacterium tuberculosis in a high TB burden country like India but rarely co-infection is seen.
Case Presentation: Here we report a 48 year old male suffering from Childhood Bronchial Asthma with diagnosed and treated ABPA in remission (2019). He presented with dyspnoea, wheezing and cough for a week in 2021.The total IgE was raised (1802 IU/ml) and found to be >50% from the previous baseline (85.6 IU/ml). Serial chest x-rays revealed fleeting opacities. Thus he was diagnosed as ABPA exacerbation (ISHAM-ABPA working group criteria) and started on oral itraconazole and prednisolone and followed up. Despite adequate treatment he continually deteriorated and after 2 months he was admitted with increased dyspnea. CECT chest revealed multifocal ill-defined confluent cavitatory patches of consolidation with air fluid levels. Sputum examination was inconclusive. Bronchoscopy was done and BAL AFB stain was positive. Anti-tubercular treatment was started with continuation of the treatment for ABPA. On follow up marked clinical and radiological improvement were noted after the completion of 6 months.
Conclusion: Very few cases of co-infection of both the diseases have been reported so far although the occurrence of ABPA in other structural lung diseases including scars of old healed pulmonary tuberculosis is known in literature.
A case report of rare RSV superinfection in diagnosed case of lung carcinoma on chemotherapy
Devang S. Boxa, Bina H. Modi, Kamlesh G. Vithalani
Department of Pulmonary Medicine P.D.U. Civil Hospital, Rajkot, Gujarat, India. E-mail: devangboxa96@gmail.com
Background: A 58 year old, male patient,chronic smoker, farmer by occupation known case of chronic obstructive pulmonary disease (COPD) since 2 months and hypertension since 2 years with metastatic squamous cell carcinoma of lung on chemotherapy referred from private hospital to our department with breathlessness, dry cough and bilateral chest pain since 4-5 days.
Objective: To Highlight RSV Superinfection In Lung Carcinoma Case.
Methods: Patient was on chemotherapy for metastatic squamous cell carcinoma of lung. Then he developed above mentioned symptoms and patient’s throat swab was taken for RTPCR in which all possible respiratory pathogens had tested among which Human RSV (type a and b) was detected.
Results: To which, according to antibiotic sensitivity report, intravenous and oral antibiotics administered. Although being dangerous superinfection, eventually patient improved clinically and haematologically and got discharged.
Conclusion: Timely intervention is necessary to avoid the chance of superinfection in lung carcinoma patients due to immunocompromised state.
New onset sarcoidosis in a patient recovered from coronavirus-19 Pnemonia – A case report
Himanshu Saini
Department of Pulmonology, Max Superspeciality Hospital, Saket, New Delhi, India. E-mail: hsainiprivate@gmail.com
Sarcoidosis is a systemic multisystem inflammatory disorder of unknown etiology characterized by the presence of non-caseating granulomas. Despite its long history, this disease remains enigmatic. Unidentified etiology and the multisystemic nature of the disease have made it more complex.In this case report we describe two patient with new-onset, biopsy confirmed sarcoidosis in the setting of COVID-19 pneumonia and we propose that the noncaseating granulomas in this case are due to sarcoid immune reaction to SARS-CoV-2. Earlier one case of sarcoidal granulomas mimicking scar sarcoidosis in a patient diagnosed with COVID-19 has been reported and one case of dermatologic manifestation, biopsy confirmed sarcoid-like reaction in the setting of COVID-19 pneumonia has been reported.
Rare causes of mediastinal mass in immuno-competent adults – A report of two cases
Mohan Venkatesh Pulle, Harsh Vardhan Puri, Belal Bin Asaf, Arvind Kumar
DNBE Thoracic Surgery Fellow. E-mail: mananparikh91@gmail.com
Multiple etiological factors are known for a mediastinal mass. Lymphadenopathy due to several causes, neoplasms and various cystic mass lesions contribute to a major percentage. However, fungal infection presenting as a mediastinal mass is rarely reported. Invasive fungal infections are encountered often in immunosuppressive conditions. But, herein we present two cases of mediastinal masses in young immune-competent adult hosts.
Case 1: A 28-year gentleman, with history of cough and exertional dyspnoea, who was found to have a mediastinal mass on CECT Chest associated with right lower lobar consolidation and pleural effusion. He was evaluated elsewhere, where TBLB was done which was suggestive of granulomatous inflammation (AFB – ve). He was started on Anti-Tubercular Therapy, but without improvement. In that condition, he was referred to us and we planned mediastinal mass biopsy. Thoracotomy & biopsy of the mediastinal lesion was done, which proved it to be mucormycosis.
Case 2: A 29 years young gentleman, presented with progressively worsening dysphagia, was evaluated with a CECT Chest, which showed mediastinal mass. EBUS FNAC was initially attempted, but failed to provide anything conclusive. A VATS Biopsy was then done, which was reported as invasive aspergillosis.
Both these patients were treated with antifungals and showed clinical as well as radiological disease resolution. In Endemic areas empirical treatment of mediastinal adenopathy with anti tubercular drugs is a common practice. The Gold standard is to obtain enough tissue to achieve a correct diagnosis. In conclusion, Mediastinal lymphadenopathy due to fungal infections are rare and merit further study.
Cutaneous tuberculosis masquerading as malignancy: A rare case report
Sudhini Sreeja Reddy, M. Narender, Sree Swathi, Ganapathy
Department of Pulmonary Medicine, Osmania Medical College, Hyderabad, Telangana, India. E-mail: sreejapulmo@gmail.com
Background: Cutaneous tuberculosis occurs rarely in spite of high and increasing prevalence of tuberculosis world wide.it is reported as <1% of all cases of tb. Diagnosis is difficult as it resembles many dermatological diseases.
Case Study: A 75year female presented with a single, large swelling over left cheek since 4months, complaining of discharge of pus since 15days. On examination, a single, well-defined, size 10x10cm, erythematous swelling, firm to hard in consistency present over left malar region with surface telangiectasis, central crusting, skin is non pinchable, not fixed to underlying structures. nasal mucosa is normal, deviated left nasal fold. chest x-ray is normal, Mantoux test was positive, Dermascopy revealed arborizing vessels, punch biopsy showed keratin plugging in epidermis, dermis showed necrotizing granulomas with plasma cells, epitheloid histiocytes and Langhan’s cells around blood vessels, adnexa extending into subcutis. The patient was managed with Anti-tuberculous drugs for 6 months.
Conclusion: Some forms of cutaneous TB indicates an immunocompromised state or severe underlying infection that may be fatal, lupus vulgaris can be complicated by development of squamous cell carcinoma or other skin cancers in the scar 25-30yrs later in up to 10% patients.
Radiological pattern of pulmonary tuberculosis in HIV patients and its correlation with CD4 cell counts
M. P. Krishnadas, Thomas George, O. K. Mani, Sanjeev Nair, C. P. Murali, Elizabeth Mathai, Parvathy Rajendran, C. R. Kiran
Department of Pulmonary Medicine, Government Medical College, Thrissur, Kerala, India. E-mail: das302867@gmail.com
Background: Tuberculosis, is an ancient disease continues to remain even today as a major public health problems in developing world. HIV infected individuals co-infected with mycobacterium tuberculosis have an increases annual risk of 5-15% for developing active tuberculosis.
Aim:
1. To study the radiological presentation of pulmonary tuberculosis in HIV Patients.
2. To study the radiological presentation of tuberculosis in HIV infection in relation to CD4 cell count.
Methods:Informed consent excluding their personal details is taken from the patients.Their blood reports and microbiological status will be checked, chest x ray and CD4 cell counts are collected and later the results are analysed.
Results: This study showed that 42.5% patients have CD4 cell counts between 150 and 300.And 20% patients have involvement of middle / lower lobe. We observed that predominant radiological pattern of pulmonary tuberculosis in HIV positive patients was pulmonary infiltrates which was in 57.8% patients. In patients with CD4 counts <200 we found that most common radiological pattern was infiltrates, miliary pattern and fibrosis. And on the other hand normal x ray, infiltrates, pneumothorax,mediastinal lymphadenopathy and cavity was seen in patients with CD4 >200.
Discussion: In a south Indian study by Mahesha Padyana et al (1) found that in patients with CD4 <200 most common patterns infiltration (39%) followed by consolidation (30%) and cavity in 11%. And lymphadenopathy. In patients with CD4 >200, infiltrates (37.5%) followed by cavity (25%) and miliary 25%. Bilateral 68.5%, mid and lower zones or all zones involvement commonly seen.
Conclusion: In our study, most common radiological presentation of tuberculosis was parenchymal infiltration. In CD4 <200 group infiltrates, miliary pattern and fibrosis predominant. In CD4 >200 normal xray, infiltrates, pneumothorax, mediastinal lymphadenopathy and cavity predominant.
Tongue tuberculosis – A rare entity
R. Soorya, Mahaboob Khan, Dhanalakshmi, Rajesh Palvai
Department of Pulmonary Medicine, Osmania Medical College, Hyderabad, Telangana, India. E-mail: soorya29ramesh@gmail.com
Background: Oral cavity is an uncommon site of involvement of Tuberculosis. In oral cavity, tongue accounts for nearly half the cases.
Case Study: A 64 year old male presented with complaints of difficulty in swallowing, hoarseness of voice, ulcer over tongue, loss of appetite and loss of weight. Biopsy revealed pseudo epithelial hyperplasia that was mistaken for malignancy. PET CT revealed hypermetabolic fibro cavitary disease which raised the suspicion of tuberculosis and sputum for AFB was done which turned positive and to rule out possibility of malignancy of tongue repeat biopsy of the tongue ulcer was done which showed granulomas with caseous necrosis and diagnosed as tongue tuberculosis and started on antituberculous chemotherapy and patient improved.
Discussion: Tuberculosis of oral cavity even as secondary form is uncommon
Conclusion: Tuberculosis should always be a differential diagnosis in a case of ulcer of tongue and deeper biopsies are advised for ulcers of tongue as superficial biopsy may not reveal the etiology due to epithelial hyperplasia.
Rare presentation of pulmonary hydatid cyst in left upper lobe: A case report
S. Suja Lekshmi, M. Narender, Anita Bhalla, T. Srinivas
Department of Pulmonary Medicine, Osmania Medical College, Hyderabad, Telangana, India. E-mail: sujasachu93@gmail.com
Background: Hydatid disease is a parasitic infection caused by echinococcus granulosus. Thoracic hydatid cysts are rare even in endemic areas. 60 % cases affect right lung and 80% cases occur in lower lobes.
Case Study: A 30 year old female presented with left sided chest pain, shortness of breath and cough with expectoration. Examination findings and chest X ray were suggestive of left upper lobe mass. CT chest revealed cystic mass lesion suspicious of hydatid. Ultrasound abdomen was normal. Pre operatively patient was medically treated with albendazole. Pericystectomy and capitonage was done. On follow up patient had symptomatic and radiological improvement.
Discussion: Hydatid disease is a zoonotic parasitic disease with global existence. Though it can involve any organ, liver and lungs are the most commonly involved organ. Patients remain asymptomatic for a longer period as the cyst grows slowly. Diagnosis is usually based on radiology supported by serological testing. Surgery is the treatment of choice of pulmonary hydatid cyst but in inoperable cases or in cases where surgery is contraindicated, medical therapy with benzimidazoles compounds may be tried.
Conclusion: Though hydatid disease of lung is common in lower lobes, it can occur in upper lobes also.Timely surgery along with medical management can cure the disesase thereby preventing the complications.
Pulmonary tuberculosis and malignancy coexisting and masquerading each other
Tamsha Rajkumar
Osmania Medical College, Hyderabad, Telangana, India. E-mail: trajukumar7@gmail.com
Introduction: Tuberculosis and lung cancer are common diseases that cause substantial morbidity and mortality worldwide. Although the two rarely occur together, a relationship has been established between them.
Case Report: A 60 year old male presented with left sided chest pain, shortness of breath and cough with expectoration. Examination findings and chest radiography were suggestive of left upper lobe cavity. CT chest revealed large cavitory lesion with irregular nodular wall thickening. Patient was diagnosed as sputum AFB and CBNAAT positive tuberculosis. Further in view of thick walled cavity and suspicion of malignancy, sputum for malignant cells was sent which showed presence atypical cells. Bronchoscopy was done and patient found to have squamous cell carcinoma.
Discussion: Pathogenesis of coexisting tuberculosis and lung cancer remains controversial. Tuberculosis and lung cancer are able to mimic each other sometimes with clinical and radiological features. Both diseases are independent of each other and develop simultaneously or sequentially.
Conclusion: Differentiation of lung tuberculosis from neoplasm, according to the clinical and radiological findings can be challenging. In the changing scenario tuberculosis can coexist with malignancy as well. When CT shows irregular thick walled cavity even if it is a case of tuberculosis, malignancy could not be ruled out in such instances. Hence bronchoscopy is advisable in such cases for diagnosis of coexisting malignancy.
A cross sectional study on correlation of computed tomography and spirometry in PTB sequalae
S. Suja Lekshmi, M. Narender, T. Srinivas, E. Raju
Department of Pulmonary Medicine, Osmania Medical College, Hyderabad, Telangana, India. E-mail: sujasachu93@gmail.com
Background: PTB is often under appreciated as a cause of chronic lung disease.
Objectives: To find the correlation of CT chest with dyspnoea and spirometry in patients with post tubercular sequalae.
Methodology: CT scoring and spirometry was done in 50 patients with PTB sequalae.
Results: CT chest showed 80% cases with fibrosis ( score of 1 in 12%, 2 in 28%, 3 in 20%, 4 in 10%, 5 in 4%, 6 in 6%), 48% cases with cavity ( score of 1 in 10%, 2 in 18%, 3 in 6%, 4 in 6%, 6 in 6%, 8 in 2%), 66% with bronchiectasis ( score of 1 in 10%, 2 in 26%, 3 in 12%, 4 in 10%, 5 in 6%, 6 in 2%), 18% with nodules ( score of 1 in 6%, 2 in 12%), 8% with consolidation ( score of 1 in 4%, 2 in 2%, 4 in 2%), 12% with aspergilloma ( score of 1 in 4%, 2 in 4%, 4 in 4%). On Spirometry 40% cases had obstructive pattern,24% had mixed pattern and 10% had restrictive pattern,where as 26% had normal pattern.The total morphological score and total lung score has got a statistically significant correlation with the grades of dyspnoea and the ventilatory defect.
Conclusion: CT and spirometry can be used in the routine evaluation of post tuberculosis cases.
A cross sectional study on comparison of drug resistance pattern in HIV and non-HIV pulmonary tuberculosis patients
R. Soorya, Mahaboob Khan, Dhanalakshmi, Rajesh Palvai
Department of Pulmonary Medicine, Osmania Medical College, Hyderabad, Telangana, India. E-mail: soorya29ramesh@gmail.com
Background: HIV and MDR-TB are deadlier combination. Even though the impact of HIV infection on MDR-TB is of great public health importance, their relationship is not yet fully understood.
Objectives: To compare the drug resistance pattern of pulmonary tuberculosis in HIV and non-HIV individuals.
Methodology: 60 patients with drug resistance pulmonary tuberculosis (40 non-HIV and 20 HIV patients) were categorised based on their gene Xpert and LPA reports and analysis of data was done using SPSS.
Results: In non- HIV group- INH monoresistance- 9 (22.5%), rifampicin monoresistance –9(22.5%), MDR- 8(20%), MDR with FQ -6 (15%), XDR – 4 (10%), and others (RIF+ FQ, INH+FQ(2), INH +FQ+SLID)-4 (10%).
In HIV group- INH monoresistance- 5 (25%), rifampicin monoresistance -4(20%), MDR- 4(20%), MDR with FQ -3 (15%), XDR – 2 (10%), and others (RIF+ FQ, INH + FQ)-2 (10%)
There is no significant difference between HIV and non- HIV group in the pattern of drug resistant tuberculosis.
Conclusion: Even though association of HIV and MDR TB was not established in the study, keeping in mind high prevalence of HIV-TB coinfection monitoring of drug resistance should be given utmost importance to improve outcome and success of national strategic plan.
Chylous ascites with tuberculosis
Ravi Apoorva, Vijayakumar
Department of Respiratory medicine, Shri B. M. Patil Medical College, Hospital and Research Centre, Vijayapura, Karnataka, India. E-mail: apoorvaraaavi@gmail.com
Background: Chylous ascites is a challenging manifestation with several underlying pathologies. While malignancy accounts for majority of cases in developed countries, in developing countries like India, tuberculosis (TB) must be suspected as the etiologic factor.
Case Study: A 56-year-old male with Type 2 Diabetes mellitus with diabetic nephropathy presented with recurrent hydropneumothorax which was treated with ICD insertion. Pleural fluid analysis was suggestive of extrapulmonary TB and the patient was subsequently started on anti-tubercular therapy (ATT). During the course of illness, he developed gross ascites, chylous in nature. Ascitic fluid analysis revealed to be of tuberculous etiology for which ATT was sufficient. Gradually, patient responded well to treatment with resolution of his symptoms.
Discussion: Tuberculosis has consumed millions of people each year. It also involves the gastrointestinal system and is the sixth most frequent site of extra-pulmonary involvement. One manifestation of abdominal tuberculosis is ascites. Etiologies of chylous ascites vary across different parts of the world, tuberculosis and filariasis accounting for a majority of cases in India.
Conclusion: Among patients with diagnosed pulmonary or extra-pulmonary TB, tuberculosis should be kept as an important differential diagnosis for chyloascites, especially in developing countries, so as to avoid delay in diagnosis and initiate appropriate treatment at the earliest.
Study of tuberculosis diagnosis and treatment in COVID 19 pandemic
Sarath Bhrungi, Girija Nair, Shahid Patel, Karan Singhal, Harshitha Degapoodi
Department of Pulmonary Medicine, DY Patil University School of Medicine, Nerul, Navi Mumbai, Maharashtra, India. E-mail:drsarathbhrungi@gmail.com
Background: TB and COVID 19 have similar presentation. This study Aims to identify the problems and difficulties faced by TB patients during COVID 19 pandemic and Lockdown.
Methods: A 35 Questionnaire based study where a total of 100 diagnosed TB cases in DOTS OPD were asked regarding the difficulties faced by TB patients for Diagnosis of TB and starting treatment, and also the ease of availability of consultation, anti TB drugs, Investigations and counselling during the period of pandemic and lockdown.
Results: Out of 100 patients diagnosed with TB, 42% were COVID 19 suspects, 38% had symptoms for <1month which helped in early diagnosis of TB. 6% patients had symptoms for > 6 months. 27% patients faced problems getting diagnosed, of which 51.8% had travel difficulty, 29.6 % - financial, 18.5 % - lack of health care access, 19% of the patients had no access to high protein diet during lockdown. 31% of patients had side effects due to AKT, Vomiting 74%, 16% Itching, 9.6% Joint pains. 57% patients required admission. All patients were satisfied about counselling regarding disease and treatment course. Patients reported for follow up after 6.7 days on average.
Conclusion: TB patients faced difficulties during COVID 19 pandemic.
A study on pharmacokinetics of modified ATT regimen in chronic kidney disease
S. Dhivyabharathi, A. Mahilmaran
E-mail: drdhivyaselvam95@gmail.com
Background: Current guidelines recommends dosage adjustments of first line anti-TB drugs according to renal function for Tuberculosis patients with chronic kidney disease. However, its therapeutic efficacy is unknown.
Objective: This study was done to measure pharmacokinetic values of anti TB drugs of pulmonary TB patients with CKD who were treated according to the recommended guidelines.
Methods: We prospectively enrolled cases of Microbiologically confirmed Pulmonary TB patients whom were started on Modified ATT regimen based on renal function.We measured Pharmacokinetic levels of isoniazid, rifampicin and pyrazinamide in 3 different categories of Modified ATT regimen namely HR full dose with Z-half No E, ZE-half dose daily and ZE –full dose alternate days in this study.
Results: Mean Cmax levels of H, R & Z were 3.57, 12.38 & 24.91 respectively.The Minimum C max of H obtained in 9 patients(30%) among 3 categories of Modified ATT Regimen namely Z-Half No E, ZE Full dose Alternate and ZE Half dose daily were 1.2mcg/ml(n=3,10%),2.7mcg/ml(n=5,16.6%) & 1.7 mcg/ml (n=1,3.3%)respectively.
The Minimum C max of R obtained in 6 patients(20%) among 3 categories namely Z-Half No E,ZE Full dose Alternate and ZE Half dose daily were 6.7 mcg/ml(n=2,6.6%),8.5 mcg/ml & 6.2 mcg/ml (n=4,13.3%) respectively.
The Minimum C max of Z obtained in 7 patients(23.3%) among 3 categories namely Z-Half No E, ZE Full Alternate and ZE Half dose daily were 15.8 mcg/ml(n=3,10%),21.8 mcg/ml&9.3 mcg/ml(n=4,13.3%) respectively.
Conclusion: Thus, this study clarified that the renal function based dosage adjustments of Pyrazinamide were also attaining the therapeutic drug concentration level.
Prevalence of fluoroquinolone resistance in MDR patients
Pratyakcha Rai, Zuber Ahmed, Imrana Masood
Department of TB and Chest Diseases, JNMCH, AMU, Aligarh, Uttar Pradesh, India. E-mail: raipratyakcha26@gmail.com
Background: The emergence and spread of FQ Resistant strains of M.TB poses a serious threat to TB control. The mutation in gyrA, gyrB loci, marRAB and SoXRS loci are the mechanism of resistance development. The annual India TB report shows 27.4% of 2nd line LPA report testing FQ drug resistance.
Methods: Normal routine investigations with sputum and involved areas specimens were sent for AFB, CBNAAT and LPA in a time period of 2 years.
Results: A total of 662 MDR patients were enrolled of which 212 were FQ resistant on 2nd LPA report. 59.20 % of FQ resistant cases were in the age group 16-29 Approximately 48 % and 22.4 % of FQ resistant patients had a history of exposure to drug sensitive and MDR patients respectively.
Conclusion: The prevalence of FQ resistance is increasing recorded 33.3% which has increased from the previous records. There are still hidden cases misdiagnosed as a case of drug sensitive TB having underlying FQ resistance.
Takotsubo cardiomyopathy in tuberculosis patient
Tushar Sahasrabudhe, Mahavir Bagrecha, Sona Mohan
Department of Respiratory Medicine, Dr. D. Y. Patil Medical College and Hospital, Dr. D. Y. Patil University, Pimpri, Pune, Maharashtra, India. E-mail: sona.mohan12@gmail.com
Introduction: Takotsubo cardiomyopathy (TTC) is an acute syndrome characterized by reversible ventricular dysfunction in the absence of significant coronary artery disease.
Case Report: 15 years old female diagnosed as sputum smear positive pulmonary tuberculosis (outside) was started on Antitubercular drugs, as her symptoms worsened; she was admitted for further management. On admission her pulse rate: 150beats/minute, BP: 100/90mmhg, Blood Investigation and other parameters were normal, ECG- sinus tachycardia, Troponin I – negative, 2D echo: LVEF-60%, mild pericardial effusion and was continued on Antitubercular treatment and other supportive management. After 14 days of admission, due to persistent sinus tachycardia, repeat ECG: sinus tachycardia with ST segment depression, repeat Troponin I :129, repeat 2D Echo showing apical, apico-septal, mid-septal, apico-antero-lateral, mid-antero-lateral segments are akinetic, dilated LV, mild pericardial effusion, LVEF – 25%.
Discussion: Revised Mayo Clinic diagnostic criteria for TTC diagnosis includes Transient dyskinesis of LV midsegments,Regional wall motion abnormalities beyond a single epicardial vascular distribution,Absence of obstructive coronary artery disease or acute plaque rupture,New electrocardiographic abnormalities or modest troponin elevation,Absence of pheochromocytoma and myocarditis. In our patient, all 5 criteria were met.
Conclusion: We report a rare case of Takotsubo cardiomyopathy accompanied by pulmonary tuberculosis suggesting that pulmonary tuberculosis may be a cause of Takotsubo cardiomyopathy.
Isolated pulmonary cryptococosis
Sonal, Raj Kumar, Sonam Spalgais
Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, New Delhi, India. E-mail: sonal94150@gmail.com
Background: Cryptococcosis is an opportunistic fungal infection usually found in immunocompromised patients; particularly prevalent in those with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) and usually in disseminated form. Patients of isolated pulmonary cryptococcosis present with non-specific clinical signs and symptoms.The rarity of this entity makes it difficult to recognize and diagnose.
Case Study: We present a case of a 67-year-old male with recently diagnosed diabetes, who presented with the complaints cough for 3 months, breathlessness for1 month and hemoptysis for 10 days prior to admission. The X ray chest showed homogenous opacity in left upper zone with normal routine blood and sputum investigations. His CT chest showed left upper lobe non resolving dense consolidation. Bronchoscopy was normal and BAL showed growth of Cryptococcus neoformans. To confirm diagnosis we did the CT guided biopsy of lesion and it showed granulomatous inflammation with staining positive of Cryptococcus. Fungal cultures of sputum and blood were negative. MRI brian was normal. There was no other evidence of disseminated cryptococcal disease. Antifungal treatment with oral fluconazole was started. The patient is on regular follow up and completed 6week therapy till date and the plan is to complete a six- to twelve-month course of therapy.
Conclusion: Isolated pulmonary Cryptococcal disease is a rare entity with difficult to diagnose due to non-specific clinical presentation. Non resolving lung lesion should investigate for all possible causes including rare infections despite granuloma on biopsy for proper management.
Rasmussen’s aneurysm: A forgotten scar
Soumya Swaroop Dash, G. N. Srivastava, Mohit Bhatia
Department of TB and Respiratory Diseases, Institute of Medical Sciences, BHU, Varanasi, Uttar Pradesh, India. E-mail: soumyaswaroop24@gmail.com
Background: Rasmussen’s aneurysm is an inflammatory pseudo-aneurysmal dilatation of branches of pulmonary artery adjacent to a tuberculous cavity. Massive hemoptysis from the rupture of a Rasmussen’s aneurysm is an uncommon yet life threatening complication of cavitary tuberculosis.
Case Study: 35 years male non-smoker presented with complaints of cough and massive hemoptysis since 7 days with 80ml per episode and 4-5 episodes per day. He had history of tuberculosis and treated with antitubercular therapy in 2010 later diagnosed with multi drug resistant tuberculosis in 2015 and treated till 2018. On examination pallor was present and bronchial breathe sounds heard on right side. Routine investigations revealed anemia. Sputum bacterial and fungal culture- negative, AFB- positive.
CECT Thorax: Large thick walled cavity with hypodense content mixed with air foci in right upper and middle lobes with ground glass opacification in right middle lobe and fluid attenuating collection adjacent to right upper lobe. Bronchoscopy showed no active sites of bleeding. CTPA revealed pseudoaneurysm arising from right pulmonary artery. He was treated with antifibrinolytics, PRBC was transfused and referred for pulmonary artery embolisation.
Discussion: Massive hemoptysis in TB can be caused due to bronchiectasis, aspergilloma or vascular complications of which 90% arise from bronchial artery. Rasmussen’s aneurysm is a rare cause of massive hemoptysis arising from the pulmonary artery found in 5% of cases.
Conclusion: The disease rarity hinders its suspicion, so early investigation and diagnosis is a must to explore the therapeutic options and save the life of a patient.
Paecilomyces lilanicus co-Infection with tuberculosis - A rare entity
K. Rasmitha, Mahaboob Khan, Dhanalaxmi, Rajesh Palvai
E-mail: rasmitha9@gmail.com
Introduction: Paecilomyces lilanicus is an extremely rare emerging fungus that rarely causes invasive pulmonary infection, with cases sporadically reported in immuno compromised patients.
Case Presentation: A 19 year old female had complaints of dry cough, fever, easy fatigue, loss of appetite & weight. Her chest x ray revealed bilateral lower zone consolidations. Patient was started on ATT. Patient developed left sided pneumothorax. Tube thoracostomy was performed and later patient was subjected for bronchoscopy. Bronchial wash was sent for analysis. Bronchial wash was not only positive for MTB but Paecilomyces lilanicus was grown in all 4 fungal culture bottles. Patient completed full course of ATT for 6 months & 2 weeks of oral voriconazole. After 2 months patient was free of symptoms & chest CT after 6 months showed marked improvement.
Conclusion: This case confirms co infection of pulmonary tuberculosis & paecilomyces lilanicus which was never reported before. We believe that tuberculosis is serving as an immuno compromised state in this patient. We also believe this case highlights the importance of paecilomyces lilanicus as an emerging infection and can be used for early & prompt diagnosis in future.
Pulmonary tuberculosis in elderly - Varying shades yet same
Tarun Tiwari, Mayank Vats, Deepti Rathi, Ankur Gupta
E-mail: drtaruntiwariofficial@gmail.com
Background: Pulmonary tuberculosis among elderly is often diagnosed late due to fewer symptoms and most of the cardinal symptoms such as malaise, fever, cough and progressive weight loss are often attributed to advancing age by patients and seeking medical advice late.
Objectives: This study was planned to confirm various aspects related to Pulmonary tuberculosis among elderly.
Methods: 104 patients of more than 65 years of age, newly diagnosed cases of Pulmonary tuberculosis were included in this study and compared with 100 cases of newly diagnosed cases of Pulmonary tuberculosis in 18-45 year age group.
Results: At the time of presentation, elderly Pulmonary tuberculosis cases in comparison to younger control group had far more advanced disease radiologically( 30.7 % as compared to 22 % cases). Radiological distribution, however was similar in both the groups. Elderly Pulmonary tuberculosis cases had radiological disease in upper and mid zones in 53.8 % cases and mid and lower zone in 21.1 % cases, respectively. In comparison to younger age groups extrapulmonary tuberculosis is more common among elderly and Pleural effusion, abdominal tuberculosis, miliary tuberculosis being commoner among elderly patients whereas Tuberculous lymphadenopathy and Potts spine was less common in elderly patients.
Conclusion: In order to arrive at a diagnosis it is necessary that one must go into the detailed history of symptoms, the order of occurrence and their duration as physical signs may be minimal in uncomplicated pulmonary tuberculosis cases. Thus, Pulmonary Tuberculosis has got a variable clinico radiological presentation in elderly patients and there should be a high index of suspicion for pulmonary tuberculosis while investigating and treating elderly patients presenting with respiratory symptoms.
A case of sarcoidosis presenting with unilateral pleural effusion – A rare finding
Aido Moyong, K. G. Vithalani, Bina Modi
P.D.U Govt. Medical College, Rajkot, Gujarat, India. E-mail: aidomoyong2019@gmail.com
Background: Sarcoidosis is a chronic granulomatous condition of unknown etiology having multisystem involvement with a varied clinical presentation and is a diagnosis of exclusion. Pulmonary involvement is common with parenchymal involvement and bilateral hilar lymphadenopathy but rarely with unilateral pleural effusion. we describe such a case in the following report.A 75 year old male ceramic worker ex smoker presented to our department with complaints of cough with copious expectoration,fever, anorexia with discolouration of skin for over 2 months with aggravated complaints since past 8 days.
Methods: Left pleural tapping was done and reports suggestive of a transudative picture patient had a palpable left supraclavicular node and was worked up accordingly with sputum, blood reports and imaging studies where sputum for AFB was negative and sputum CBNAAT was negative,chest x-ray revealed bilateral hilar lymphadenopathy. Patient had bilateral subcentrimetric lymph nodes on ultrasonography of neck and CECT thorax suggestive of sarcoidosis more likely than neoplastic etiology. Serum ACE levels were normal. Bronchoscopy guided biopsy of lung lesion revealed non caseous granulomatous lesion.
Results: A diagnosis of Sarcoidosis with lymphangitic spread was made. Both TB and SARCOIDOSIS share remarkable similarities clinically and radiologically and diagnosis becomes an enigma. In India, the prevalence of Sarcoid is 10-12 per 1000 new registrations yearly and diagnosis requires appropriate clinical, radiological and histopathological correlation. Corticosteroids remained the mainstay of treatment with other supportive medications.
Conclusion: Diagnosing Sarcoid in high TB burden countries pose a significant challenge. However it is now increased with availability of diagnostic modalities and negating the later remains important because of its high prevalence.
Unusual emergency presentation of MDR-Tb
Hina Afreen, Mohammed Hidayath Hussain
Department of Pulmonary Medicine. E-mail: hina_2412@yahoo.com
Background: Tuberculosis is a serious contagious major health problem at both national and international level. Spontaneous pneumothorax complicating pulmonary tuberculosis is a well-recognized complication and is a medical emergency but is scantily reported in the literature. This may account for the limited information on its epidemiology. Patients are often treated without treating the underlying cause.
Case Study: Single case study.
Discussion: Pulmonary tuberculosis has repeatedly described as frequent cause of Secondary Spontaneous pneumothorax. The frequency of secondary spontaneous pneumothorax complicating the course of TB has been studied little, figures range from 0.6-1.4%. These figures, although appearing to be very low, can be important if we keep in mind the 9.5 million new cases that the WHO reports are produced in the world every year. 80% of these occur in developing countries.
Inspite of TB being frequent cause of secondary pneumothorax, very few series, with very few patients, have been reported. The frequency of presentation, the clinical therapeutic management & prognosis of these patients have been poorly studied.
Conclusion: Pulmonary tuberculosis may present as spontaneous pneumothorax with acute severe dyspnea and may be missed with a catastrophic outcome. Although presentation may be confused with that of the other causes of acute dyspnea, a high index of suspicion, thorough history and careful examination clinches the diagnosis and the response to treatment is often rewarding. Morbidity and mortality from this curable disease is thus reduced.
Spectrum of Aspergillus infections in post TB patients
K. S. Sravani, G. N. Srivastava
Department of Pulmonary Medicine. E-mail: sravani11.kanchi@gmail.com
Background: Fungal colonisation of airways in Post TB patients, can lead to a spectrum of diseases based on the immune response of the host. Allergic Bronchopulmonary Aspergillosis, Aspergillus Tracheobronchitis, Chronic Pulmonary Aspergillosis (Aspergillus nodule, Aspergilloma, Chronic Cavitary Pulmonary Aspergillosis (CCPA), Chronic Fibrotic Aspergillosis (CFPA), Subacute Invasive Aspergillosis (SAIA)) and Invasive Pulmonary Aspergillosis (IPA) are the diseases of this spectrum.
Methods: A cross sectional observational study was conducted over 100 patients of post TB lung diseases like fibrosis, bronchiectasis, fibro-cavitary disease and obstructive airway disease. Clinico-microbiological profile was studied to make an observation of the individual diseases of the spectrum of Aspergillus infections.
Results: Of the 100 patients who were studied, 63 met the inclusion criteria. 41 (65%) were men, and 21 (33.3%) were Diabetics. Chronic pulmonary Aspergillosis (CPA) 34 (53.9%) was the most common manifestation followed by Allergic bronchopulmonary Aspergillosis 14 (22.2%). 8 (12.6%) had simple colonisation of fungal hyphae without disease and Invasive pulmonary Aspergillosis was seen in 7 (11.1%). Among the 34 CPA patients, CCPA was seen in 12 (35.2%), CFPA 8 (23.5%), SAIA 6 (17.6%), simple Aspergilloma 6 (17.6%) and Aspergillus nodule in only 2 (5.8%) patients.
Conclusion: Chronic pulmonary Aspergillosis was the most common disease from Aspergillus among Post TB patients. Diabetes was associated to invasive forms of Aspergillosis, Invasive Pulmonary aspergillosis (IPA) and subacute invasive pulmonary aspergillosis (SAIA).
A prospective study evaluationg the diagnostic accuracy of GeneXpert Ultra and AFB smear with TB MGIT culture as the gold standard for pulmonary and extra pulmonary tuberculosis in a tertiary care centre
Iram Syed, Amita Nene, P. S. Tampi
Department of Pulmonary Medicine, Bombay Hospital, Mumbai, Maharashtra, India. E-mail: iram.syed94@gmail.com
Background: This study was undertaken to evaluate the sensitivity of GeneXpert Ultra and AFB smear as compared to the gold standard MGIT culture for detection of MTB in pulmonary and extra pulmonary specimens.
Methodology: During the study period, June 2019-May 2021, 100 cases were prospectively evaluated which had MTB complex growth on MGIT culture. The results were compared with AFB smear microscopy and GeneXpert Ultra.
Results: 58 samples were pulmonary TB and 42 were extrapulmonary TB.
In the study, AFB smear had an overall sensitivity of 50% with sensitivity of 68.9% in pulmonary TB and 23.8% in extra pulmonary TB.
The sensitivity of GeneXpert Ultra overall was 93% with a sensitivity of 98.5% in pulmonary specimens and 85.7% sensitivity in extrapulmonary specimens.
The sensitivity of GeneXpert Ultra on smear positive samples, pulmonary as well as extrapulmonary was 100%. The sensitivity of Ultra on smear negative TB is 86%, with a higher sensitivity of 95% in pulmonary TB as compared to 81% in extrapulmonary TB.
The most common extrapulmonary TB was lymph node TB in which the sensitivity of GeneXpert Ultra was 87.5%, followed by spinal TB in which the sensitivity was 70%. The sensitivity of GeneXpert Ultra on pleural TB was 77.8% and on CNS TB was 100%.
Conclusion: GeneXpert Ultra is a rapid and highly sensitive test for tuberculosis case detection and simultaneous detection of rifampicin resistance. Our study confirms that GeneXpert Ultra will help in early diagnosis of paucibacillary TB, TB-HIVcoinfection, paediatric TB and extrapulmonary TB.
Clinical and microbiological analysis of pulmonary infections in chronic kidney disease patients on haemodialysis – a prospective study
Iram Syed, Praveen Waghmare, Amita Nene, P. S. Tampi
Department of Pulmonary Medicine, Bombay Hospital, Mumbai, Maharashtra, India. E-mail: iram.syed94@gmail.com
Background: Analysis of clinical characteristics, common pathogenic bacteria and their antibiotic susceptibility in chronic kidney disease(CKD) patients on hemodialysis has become increasingly important for treatment and prognosis of lung infections.
Methodology: The present prospective study investigated the pathogen distribution and drug resistance of lung infections in hemodialysis patients. 125 hemodialysis patients with pulmonary infection were analyzed.
Results: In our study, the most affected age group was 61-80 years and majority patient’s samples (sputum/BAL) were positive for pathogenic organisms. Out of 91 patients with positive pathogens, 76 (83.5%) showed bacterial growth (13.6% grampositive; 47.2% gramnegative) and 15 were positive for fungi (12%). The most common isolated pathogen was Klebsiella pneumoniae. The results of the drug sensitivity test suggested that Gram-negative bacilli had low resistance rates to piperacillin-tazobactam, imipenem and amikacin, while Gram-positive cocci had a low resistance rate to vancomycin. All resistance rates of the pathogens to other common antimicrobials were >50%. Among fungal species, Candida albicans and Aspergillus were isolated. The resistance rate for candida to fluconazole was more than 50% and for other antifungal drugs such as Itraconazole, Amphotericin B, Caspofungin was less than 50%.
Conclusion: We conclude that lung infections in hemodialysis patients were largely caused by gramnegative bacteria and were often multidrug resistant. Results of this study demonstrate that microbiological examination of sputum/BAL sample should be performed as early as possible and effective antimicrobial agent should be chosen according to drug sensitivity results to improve outcome of this vulnerable population.
A rare case of zygomycetes presenting as thick walled cavity in non COVID patient during COVID pandemic
S. Nikhila, M. Narender, Sree Swathy, B. Ganapathy Reddy
Department of Pulmonary Medicine, Osmania Medical College, Hyderabad, Telangana, India. E-mail: nikhila.samalas@gmail.com
Background: Mucormycetes was previously called as zygomycetes which causes mucormycosis/zygomycosis Pulmonary Mucormycosis is a relatively uncommon but an important opportunistic fungal infection in immunocompromised person. The main risk factors are diabetes mellitus, hematologic malignancies and organ transplantation. It is the second most common form of mucormycosis, accounting for more than 30% of infections. This form has a high mortality (40%-76%).
History: A 40 years old male, diabetic presented with cough with expectoration and fever since 1 month. Chest x-ray and CT chest revealed right upper lobe thick walled cavity.
Evaluation: Patient was investigated for sputum analysis for Acid Fast Bacill, Gene-Xpert,bacterial and fungal culture sensitivity which were inconclusive. Later Bronchoscopy was done which revealed right upper lobe bronchus corrugated mucosa present,B3 segment obstructed by mass lesion which bleeds on touch,bronchial brushings and washings and biopsy taken.Bronchial brushings and washings showed negative for culture sensitivity while bronchial biopsy revealed chronic inflammation with necrosis and ulcerations showing fungal eliments consistent with zygomycetes. Thus the diagnosis of pulmonary mucormycosis was retained and treatment with amphotericin B was started.
Conclusion: Pulmonary mucormycosis is a rare but emerging fungal infection with a high mortality rate. Proper and immediate treatment can significantly improve the prognosis.
Adverse drug reaction in treatment of multidrug resistant tuberculosis in a tertiary care centre
Saurabh Mandilwar, Ganesh Dhangar, Tejas Deshpande, Snehal Jadhav
Department of Pulmonary Medicine, H B T Medical College and Dr. R N Cooper Hospital, Juhu, Mumbai, Maharashtra, India. E-mail: saurabhmandilwar@gmail.com
Background: India has the highest burden of Tuberculosis and Drug resistant TB in the world. The WHO Global TB report 2021 estimates that India contributes 27% (2.6 million) and 25% (49679) of TB and Multidrug resistant TB (MDR-TB) respectively. The treatment of MDR-TB is highly challenging mainly due to the potential adverse drug reaction (ADR) associated with the second line drugs.
Aim: The study aims to determine the frequency of side effects of the drugs in patients of MDR-TB.
Methods: A prospective observational descriptive study was conducted among confirmed Pulmonary and Extra pulmonary MDR-TB patients. Total 40 newly diagnosed MDR TB patients between June 2021 and November 2021 attending our OPD were enrolled in the study. ADR during the treatment were recognized and confirmed with appropriate laboratory investigations.
Results: Among 40 patients 70% have completed 3 months of treatment and developed ADR noticed i.e. Peripheral neuropathy was seen in 15, GI disturbances/ nausea and vomiting in 10, arthralgia in 9, visual disturbances in 4, headache in 3, hepatitis in 2, convulsions in 1, hearing loss QTc prolongation in ECG in 1, renal impairment in 1, oral ulcers 1, giddiness in 1, skin rashes in 1
Conclusions: 25% patients had ADR requiring change or stoppage of drugs and 75% patients were successfully managed despite occurrence of adverse drug reactions. MDR TB can be cured and successfully managed despite of occurrence of minor or major ADR with appropriate combination of drugs, timely intervention and aggressive strategy.
Role of light emitting diode fluroscent microscopy and catridge based nucleic acid amplification test in presumptive tb patients with negative zn staining technique
Sandhya Balasundaram, M. G. Krishnamoorthy P. Eshwaramma
Department of Respiratory Medicine Gandhi Medical College and Hospital, Secunderabad, Telangana, India. E-mail: sandhyabalasundrm17@gmail.com
Introduction: Presumptive tuberculosis is defined as patient presenting with cough with expectoration > 2weeks, fever, weight loss, night sweats, hemoptysis and associated with changes in chest radiograph.
Aim: To study the role of light emitting diode fluroscent microscopy and catridge based nucleic acid amplification test in presumptive patients negative by ziehl neelson staining technique.
Objectives:
1. To make sputum collection technique standardized one, to identify missed cases.
2. To study the efficacy of LED microscopy and CBNAAT in comparison to ZN staining technique and to know rifampicin sensitivity.
Methodology: This is a prospective cross sectional study conducted on 100 presumptive TB patients with negative ZN staining technique. The detailed history was taken and clinical examination was done. the blood samples were collected for routine investigations. The sputum samples were further subjected to LED microscopy and CBNAAT. And following results were obtained.
Results: In the following study, out of 100 patients, 74 (74%) were males, 26(26%) were females. Hemoptysis was present in 21% of the patients while 79% did not report it. Smoking was present in 39% of the patients, 61% did not have the habit.54% of the patients had diabetes while 46% did not have it.
The sensitivity and specificity of CBNAAT is 100% and 88.64% respectively. The PPV and NPV of CBNAAT is 54.55% and 100% in the study conducted.
Conclusion: CBNAAT is superior than LED microscopy and ZN staining technique and additionally gives rifampicin sensitivity. So it helps in case detection and starting of early treatment, thereby decreasing the burden of the disease.
A rare case of nasal tuberculosis
Rahul Jain, Rajendra Saugat, Gunjan Soni, Manak Gujrani
E-mail: aolrahul28@gmail.com
Background: Tuberculosis can involve almost every organ in the body.Tuberculosis of nose, nasopharynx and para nasal sinuses is extremely rare even in countries where the incidence of tuberculosis is very high.
Case Study: A 38-year-old immunocompetent female patient presented with shortness of breath, nasal congestion, occasional epistaxis and left sided facial swelling for last 6 weeks. Her ESR was 45 mm/h, MT was 16mm, RFT and LFT were normal. Her two consecutive sputum smear were negative for AFB. X-ray chest was normal, X-ray of the para nasal sinuses showed increased soft-tissue density and mucosal thickening in left maxillary antrum. The CECT of the para nasal sinuses showed ill defined soft tissue attenuation area measuring approx. 29*25*35 mm in left maxilla. Patient referred for endoscopic sinus surgery followed by Caldwell luc procedure and excision of mass. Biosy of nasal mass revealed epitheliod cell granuloma along with multinucleated langhans giant cells, areas of casseous necrosis consistent with tubercular inflammation. Patient was referred for DOTS.
Discussion: Nasal tuberculosis is rare even in developing countries like India. Nasal tuberculosis commonly occurs in females and the median age of occurrence is mid 40 years. Nasal tuberculosis is usually unilateral as in our case, but in one-third cases it is bilateral.
Conclusion: We believe that though nasal tuberculosis is a rare clinical entity, it should be considered as one of the differential diagnosis of patients with granulomatous lesion of the nose. High degree of suspicion is the key to diagnose the disease.
Breaking the mold with newer diagnostic tools- A case series
Pooja Bajaj, H. J. Gayathri Devi, S. Devi Mounika, Karthik Kumar
Department of Respiratory Medicine, MS Ramaiah Medical College, Bengaluru, Karnataka, India. E-mail: poojabajaj26@gmail.com
Objectives: Aspergillus is a ubiquitous mold, which causes a wide spectrum of illnesses. Pulmonary disease is caused mainly by Aspergillus fumigatus. Pulmonary aspergillosis is a common infection in the immunocompromised, but it is also seen in patients with chronic debilitating diseases who require corticosteroids and/or immunosuppressive therapy. The aim of this work was to focus on the diagnosis of invasive pulmonary aspergillosis (IPA), with the use of a relatively new test, Galactomannan assay.
Methods: We report a case series of 6 patients with suspected fungal infection over the course of 2020-2021. The diagnosis of IPA was obtained by use of galactomannan assay. Patients underwent routine sputum examination, and when indicated, bronchoscopy. Sputum and/or BAL fungal cultures were negative for all patients.
Results: The patients mean age was 48.3±12 years. The most common clinical presentation was cough with expectoration. Comorbidities included past history of pulmonary tuberculosis (1), severe COVID-19(1), HIV infection (1), chronic kidney disease (1) and diabetes mellitus (2). Galactomannan levels were obtained in BAL in five patients, and serum in one patient. All patients were given voriconazole. Outcome was favourable in all patients.
Conclusion: Galactomannan is a polysaccharide cell wall component of Aspergillus species which is released during fungal growth. ELISA is capable of detecting galactomannan levels at concentrations as low as 0.5ng/mL. It is a non- invasive test with high specificity that can be used both for diagnosis as well as for monitoring of patients. Serum galactomannan levels, though diagnostic, become positive later in the disease. BAL galactomannan provides an early diagnosis.
Significance of interleukin 27 in the diagnosis of tubercular pleural effusions
Pravalika Vahini, Kandi Subhakar
Kamineni Academy of Medical Sciences and Research Center, Hyderabad, Telangana, India. E-mail: drpravalika072@gmail.com
Background: Tuberculous pleural effusion (TPE) is a second most common extrapulmonary manifestation of tuberculosis. TPEs are caused by delayed-type hypersensitivity to tuberculin-like antigens entering the pleural space after rupture of subpleural caseous foci. Interleukin-27(IL-27), a recently discovered heterodimeric cytokine, member of the IL-12 cytokines family, has been found to be involved in TPE and is mainly produced by active antigen-presenting cells under the stimulation of pathogen-associated molecular patterns binding to toll-like receptors and may provide a clue to the diagnosis.
Objectives: To compare the efficacy of IL-27 with ADA levels in diagnosing TPE. Diagnostic efficacy of IL-27 in differentiating TPE from Non-TPE.
Methods: Data was collected from 80 patients presenting to the Respiratory Medicine Department of KAMSRC with Pleural Effusions. All patients underwent necessary testing including serum, sputum and pleural fluid tests along with pleural biopsy.
Results: Out of 80 patients, 34/40 patients with TB Pleural effusions had ADA levels >40U/L with a sensitivity and specificity of 85% and 90% respectively. 38/40 patients with TB pleural effusions had a P.F IL-27 >1500ng/L With a sensitivity and specificity of 95% each.
Conclusion: Pleural fluid IL-27 is a new and better non-invasive biomarker in the diagnosis of TB pleural effusions when compared to ADA. IL-27 assessment can minimize the complications associated with pleural biopsy which is an invasive procedure.
Efficacy of CBNAAT in comparison with line probe assay and liquid culture in the evaluation of tubercular lymph node abscess
Sutrave Sumeeth, M. G. Krishna Murthy, P. Eshwaramma, G. Ramulu
E-mail: sumeethstrv29@gmail.com
Background: One of the world’s largest TB burden lies in India. TB can affect any organ or tissue. Most commonly involved extrapulmonary site is the lymphnode. The conventional methods include cytology, culture and AFB stain. LPA is molecular method to detect resistance to first line and second line ATT drugs. CBNAAT, also detects the presence of TB bacilli and Rifampicin sensitivity but in a very short time.
Aim and Objectives: This study aims to determine the efficacy of CBNAAT in comparison with LPA and liquid culture in the evaluation of lymph node abscess. The objectives are to evaluate the frequency of drug resistance patterns.
Methods: 50 cases with features of LN abscess on FNAC presenting at Gandhi hospital, secunderabad were included in the study. Each case was assessed with history, physical examination and investigations consisting of AFB stain, culture, LPA and CBNAAT.
Results: The diagnostic accuracy of CBNAAT was 86% whereas culture and LPA had 78% and 88% respectively. AFB stain showed an accuracy of 58%. Rifampicin sensitivity was detected in 96%.
Conclusion: CBNAAT is a better diagnostic option as it is equally efficacious when compared to LPA and Liquid culture in TBLN abscess. It also helps in clinical management by detecting Rifampicin sensitivity. It is a rapid, has minimal contamination risk, is not a biological hazard, and easy to use with minimal technical training.
Incidence of tuberculosis in people living with HIV before and after implementation of isoniazid prophylaxis therapy in west Godavari District, Andhra Pradesh
P. C. Naveen, B. Neeharika, P. Yugandhar
Department of Pulmonology, ASRAMS, Eluru, Andhra Pradesh, India. E-mail: dr.naveen999@gmail.com
Background: India has high burden of both TB and HIV and faces second highest burden of HIV associated TB. Tuberculosis is one of the most common opportunistic infections and leading cause of death among people living with HIV (PLHIV). Isoniazid Prophylaxis Therapy (IPT) is recommended as an important strategy for prevention of TB among PLHIV and is therefore a key public intervention for TB prevention in PLHIV.
Objective: To estimate the incidence of tuberculosis in PLHIV before and after implementation of IPT.
Methods: Study was conducted for a period of 3 months (15-09-2021 to 15-12-2021) among PLHIV, West Godavari district, A.P. Data was collected from four Anti-Retroviral Therapy (ART) centres namely Eluru, Bhimavaram, Tadepalligudem, Tanuku and was compared with that of 2017. Results were expressed in the form of percentages and frequencies.
Results: In the year 2017, before implementation of IPT, incidence of TB in PLHIV in West Godavari district was found to be 2.66 %. Whereas in 2021 that is after full implementation of IPT, incidence of TB in PLHIV is found to be 1.74%. Most of the TB cases after implementation of IPT were drug sensitive TB (95.64%). H mono/poly resistant TB was 1.24%. Rifampicin resistant TB was 3.12%.
Conclusion: PLHIV are in contact with health services and it is an opportunity to provide prophylaxis and encourage adherence. IPT is found to be effective in reducing the incidence of tuberculosis in PLHIV and sets a platform for the success of Tuberculosis Preventive Treatment in other target populations.
Diagnostic yield of bronchoalveolar lavage in sputum smear negative and sputum cbnaat negative presumptive pulmonary tuberculosis
Divyanjali, M. Sravan Kumar, Phani Kumar
Kakatiya Medical College, Warangal, Telangana, India.
Introduction: Tuberculosis is one of the most common chronic infections globally, especially in developing countries like India and is a leading cause of morbidity and mortality. Therefore, early diagnosis, and microbiological confirmation of pulmonary TB is important to break the chain of transmission.
Methodology: It was an observational study conducted among 56 cases of presumptive tuberculosis whose sputum were negative on sputum AFB and CBNAAT. Cases with relative or absolute contraindication for bronchoscopy were excluded from study,BAL was collected and sent for analysis.
Results: Mean age of study subjects was 50-69 years of age, majority were males 55.4% and 21.5% had past history of tuberculosis. Most common findings on chest X-ray was in non homogenous opacity (57%), cavities(14.3%). BAL AFB was positive in 19.6%, BAL culture was positive in 28.6% BAL.BAL sent for CBNAAT testing detected 46.4% mycobacterial TB, 11.5% mycobacterial TB with Rif resistance. 10 had past history diabetes,10 out of 7 diabetics were positive for tuberculosis in BAL.BAL cytology for malignant cells was positive in 4%. Sensitivity of BAL AFB-50%,Specificity-92.5%,PPV-72.7%,NPV-82.2%,Accuracy-80.4%.sensitivity for BAL CBNAAT-81.3%,specificity-65%,PPV-48.1%,NPV-89.7%,Accuracy-69.6%.
Conclusion: Fibreoptic bronchoscopy is useful investigation in establishing accurate and early diagnosis of lower respiratory tract infections.
A case of fungal pneumonia in immunocompetent patient in nonendemic area
M. Gayathri, Ramulu, Veena, P. Eshwaramma, M. G. Krishna Murthy
Department of Respiratory Medicine, Gandhi Medical College and Hospital, Secunderabad, Telangana, India. E-mail: gayathri.m2012@gmail.com
Introduction: Cryptococcal pneumonia is predominantly seen in immunosuppressed individuals and rarely in immunocompetent population. We report a case of middle age male with Cryptococcal pneumonia.
History: A 45-year-old male farmer by occupation presented with shortness of breath for 2months, cough with sputum for 2 months associated with streaky hemoptysis, fever on and off for 1month, loss of appetite for 1 month, no history of SARS CoV 2, no h/o long term steroid usage and immunosuppression (HIV, malignancy) no significant family history.
Presentation: Spo2- 98%RA, Blood pressure and pulse rate were normal. Examination reveaed Decreased breath sounds in left infra scapular area. Rest systemic examination was normal.
Diagnosis: HIV, HBsAg were negative, Sputum Gram stain, KOH mount, culture was
negative, Sputum CBNAAT was negative. Chest x-ray s/o non homogenous opacity in left
mid zone. CT chest s/o Consolidation in superior segment of left lower lobe. Patient
underwent FOB in view of hemoptysis. Bronchial washings cytology was negative,
CBNAAT was negative, Fungal culture s/o Cryptococcus neoformans sensitive to
amphotericin B and Flucytosine.
Management: Microbiology based treatment with Amphotericin B and fluconazole.
Clinical Implications: Any evidence of a cavitating nodule on CT in a patient presenting with cough & sob, a fungal infection is suspected irrespective of immune status and endemicity.
A study on role of pao2/fio2, total leucocyte count in predicting outcomes in community acquired pneumonia with respiratory failure
M. Gayathri, P. Eshwaramma, M. G. Krishna Murthy
Gandhi Medical College and Hospital, Secunderabad, Telangana, India. E-mail: gayathri.m2012@gmail.com,
Introduction: Community-acquired pneumonia (CAP) is one of the most common serious infective diseases accounting for nearly 1% of all medical admissions and is an important cause of mortality and morbidity worldwide.
Aims and Objectives: To assess the role of Pao2/Fio2, Total Leucocyte count in predicting the outcomes in Community Acquired Pneumonia with Respiratory failure.
1. To measure Pao2/Fio2 and Total leucocyte count in Community acquired pneumonia with respiratory failure.
2. To measure Absolute neutrophil count, Absolute lymphocyte count and its ratio.
3. To correlate Pao2/Fio2, Total Leucocyte count and Neutrophil Lymphocyte ratio in Community Acquired pneumonia with respiratory failure.
Methodology: This is a prospective observational study in 44 cases of community acquired pneumonia with respiratory failure conducted in dept. of Respiratory Medicine, Gandhi Hospital, Secunderabad. Blood samples as well as clinical data were collected in a well-designed proforma from all the patients. ABG analysis was done with 5 litres of oxygen for analysis at the time of admission.
Results: The mean Pao2/Fio2 was higher in survivors compared to non survivors (192.27 and 156.41 respectively). The mean Neutrophil-Lymphocyte Ratio was lower in survivors compared to non survivors (6.86 and 12.11 respectively).
Conclusion: It is suggested that Neutrophil-Lymphocyte Count Ratio (NLCR) and Pao2/Fio2 can be done in patients with CAP along with other severity scores to assess the prognosis and to consider treatment options.
Mysterious multiple pulmonary nodules: A case report
M. Yasar Arafat
Department of Respiratory Medicine. E-mail: dryasarphc@gmail.com
Background: The pulmonologist are faced with incidental radiographic findings of pulmonary nodules and deciding how to manage these findings is very important as the differential diagnosis of lung nodule is broad like neoplasms or infections or immune-mediated diseases etc.
Case Study: A 56-year-old female presented with complaint of sever pain over the back side of the lower part of chest on both side, which were pleuritic in nature since one month. Had history of wheezing for which she took methylprednisolone tablets for 3 years. On examination tenderness over right infra scapular region and on auscultation bilateral basal crackles heard. Blood investigations and chest x ray were normal. Her HRCT chest showed multiple soft tissue density nodules in right middle and lower lobe and lingular segment of left upper lobe. Multiple pleural based consolidation in bilateral basal segments. BAL for CBNAAT detected Mycobacterium with no Rifampicin resistance. ATT was started and she improved symptomatically.
Discussion: In our case, she had atypical presentations of PTB both clinically and radiologically. She was immunocompromised(steroid misuse). There many cases of TB where radiological findings are not typical of tuberculosis and may mimic a number of other diseases like lung metastases in our case. A tree-in-bud appearance and cavitation are known to be typical findings on CT; however, TB may also present as a pulmonary nodule that resembles pulmonary carcinoma.
Conclusion: The immunocompromised patients may have atypical presentations of PTB both clinically and radiologically.
A rare case presentation of pancreatic tuberculosis mimicking pancreatic mass
Sutrave Sumeeth, M. G. Krishna Murthy, G. Ramulu, V. Veena
E-mail: sumeethstrv29@gmail.com
Introduction: Tuberculosis is a leading public health problem, with India bearing one of the highest TB burden in the world. There is parallel increase in the cases of extra pulmonary TB along with rising burden of pulmonary TB. Despite the high prevalence of TB in developing countries, primary pancreatic TB is extremely rare, as pancreas is protected biologically due to presence of pancreatic enzymes that interfere with seeding of MTB.
Case Report: 75 year male patient, with no comorbidities and no significant past history, came to OPD with complaints of loss of weight since 3 months, hiccups from 45 days, epigastric pain since 10 days and yellowish discolouration of eyes since 10 days. Investigations revealed obstructive jaundice with elevated lipases and amylases. CBP, ESR, serology and CXR were unremarkable.USG abdomen showed gastric antral thickening.UGI Endoscopy was done and it revealed polypoid ulcerated growth in periampullary area with mild luminal narrowing and a growth infiltrating proximal to ampulla suspecting pancreatic carcinoma with duodenal infiltration. Biopsy was taken which revealed well defined epitheloid cell granuloma, necrosis,giant cells and dense lymphohistiocytic infiltrates – suggestive of Tubercular inflammation. Patient was started on anti tubercular therapy and there was significant reduction in clinical symptoms during the course of therapy.
Conclusion: Pancreatic mass in a patient from high prevalence of TB or in an immunocompromised patient, pancreatic tuberculosis should be considered. Direct HPE is the best test for confirmative diagnosis of pancreatic tuberculosis.
A comparative study on the sensitivity and specificity of pleural fluid cbnaat versus pleural fluid lymphocyte neutrophil ratio in a diagnosed case of pulmonary tuberculosis
Indraneel Bose
Department of Respiratory Medicine. E-mail: indraneel2992@gmail.com
Background: Tubercular Pleural effusion are one of most common causes of exudative pleural effusion in India.In a tubercular pleural effusion when lymphocyte:neutrophil ratio(L:N) more than equals to 0.75 is used in combination with ADA,the sensitivity,specificity,positive predictive value,negative predictive value for identification of TB were reported 88%,95%,88% and 92% respectively.CBNAAT had relatively low sensitivity(62%) compared to other pleural fluid markers but high specificity(98%) for diagnosing TB.
Methods: All sputum positive(CBNAAT or AFB) pulomnary TB patients with pleural effusion attented NRS Hospital during 15th December 2019 till 30th November 2021 were taken as study population.Excluded from the study are---patients with <12 years age,Malignant Pleural Effusion and those unwilling to give consent for study.After effusion analysis,statistical data were entered into a Microsoft excel spread sheet and then analyzed by SPSS and Graph Pad Prism version 5.p-Value less than equals to 0.05 were considered statistically significant.
Results: In Pleural fluid CBNAAT detected group,38.9% patients had L:N Ratio 0.5-0.6,50% patients 0.6-0.75 and 11.1% had >0.75.Pleural fluid CBNAAT detected patients had ADA < 35 in 5.6%,35-40 in 5.6%,40-45 in 16.7% and >45 in 72.2%.
Conclusion: Association of Pleural Fluid ADA vs CBNAAT as well as Pleural Fluid L:N Ratio vs CBNAAT were not statistically significant.CBNAAT though found negative,patients with ADA>40IU/L with Lymphocytic effusion(though L:N Ratio may not be >0.75) to be considered tubercular.
Association of nutritional status with severity of pulmonary impairment after tuberculosis
Lokesh Kumar Lalwani, Pawan Kumar Singh, Sanjay Gupta, Rupak Singla
E-mail: l.lalwani05@gmail.com
Background: Management of Pulmonary Tuberculosis is largely limited to the bacteriological cure, but there is little information about the role of nutritional status on severity of pulmonary impairment after tuberculosis (PIAT) and the effect of PIAT severity on quality of life and exercise tolerance.
Methods: A total of 150 adult PIAT patients with any chest complaints presenting to the outpatient department were enrolled prospectively and sequentially. The severity of PIAT was assessed by spirometry. Socio-economic status, the severity of dyspnea, nutritional status, quality of life and exercise tolerance were also assessed.
Objectives: The severity of PIAT was correlated with nutritional status and clinical features.
Results: Out of 150 enrolled patients, 19 (12.67%) had no impairment, 28 (18.7%) had mild impairment, 39 (26.0%) had a moderate impairment and 64 (42.7%) had severe impairment based on the value of FEV1 on spirometry. Patients with lower-socio-economic status tend to have a poorer nutritional status which was associated with increased severity of PIAT. Dyspnea severity was assessed using the MRC scale and found to be significantly worse in patients with severe impairment (p<0.01) and BMI is inversely associated with the same. 39/63 undernourished patients had severe PIAT. Half of the patients with adjusted FFMI of less than 16 kg/m2 had severe PIAT suggestive of positive and strong correlation. Quality of life score and exercise intolerance were significantly decreased with increasing severity of pulmonary impairment after tuberculosis (p<0.001).
Conclusion: Patients with severe PIAT tend to have poorer nutritional status and severe PIAT is associated with decreased exercise tolerance and poor quality of life.
A case of disseminated hydatid cyst of liver and lung- seropositive echinococcosis
S. Dhanalakshmi
Institute of Thoracic Medicine, Madras Medical College, Chennai, Tamil Nadu, India. E-mail: dhanapulmo1995@gmail.com
Introduction: Hydatid disease is a parasitic infection caused by Echinococcus granulosus (EG), characterized by cystic lesions in the liver, lungs, and rarely in other parts of the body. Lungs and liver are the most frequent sites involved. Simultaneous lung and liver cysts are observed in less than 10% of the cases.
Case Report: A 44 year old male presented with complaints of abdominal pain and fever for two month and breathlessness for one month.Patient was complaining left sided chest pain on and off for past 15 days. He was admitted and evaluated for diagnosis and treatment.There was no significant finding on general examination On systemic examination,there was decreased breath sounds on left lower hemithorax and mild epigastric with right hypochondrial tenderness.Chest X-ray revealed a round and we’ll defined mass in the left lung base and USG abdomen shows 9× 9.8 cm heteroechoic lesion in 7th segment of Right lobe of liver.MRcholangiopancreatogram showed enlarged liver and a heterogenous intensity lesion involving segment 4,7,8 segment.The lesion shows solid cystic component with well defined capsule and similar intensity lesion involving the left lower lobe measuring 8.8x10 cm also visualized.Ultrasound guided cystic fluid was aspirated from the liver and sent for latex agglutination test found to be POSITIVE. Patient was given T.albendazole and treated surgically.
Conclusion: Hydatid cysts can be treated by surgical or medical intervention. Surgical resection is the cornerstone for the treatment of hydatid cyst of lung and and is useful for the patient where cysts cause compression due to their large size. However,medical therapy is indicated in patients with primary liver or lung cysts that are inoperable, patients with cysts in two or more organs and peritoneal cysts.
An interesting case of complex multiloculated right sided tuberculous empyema
Francis Ankita, Jayamol
Department of Respiratory Medicine, Sree Balaji Medical College and Hospital, Chrompet, Chennai, Tamil Nadu, India. E-mail: francisanki833@gmail.com
Background: Empyema thoracis is defined as, a collection of pus in the pleural space, between the visceral and parietal pleura. Empyema causes significant morbidity and mortality. Pleural empyema can be subdivided into 3 stages: exudative, multiloculated, and organizing. Clinical outcomes of Tubercular empyema are worse compared to those of non-tubercular empyema, because of protracted illness, presence of concomitant fibrocavitary lesions, high bacillary load, development of bronchopleural fistulae (BPF), and requirement for complicated surgeries.
Case Presentation: A 33 year old female presented with productive cough for 2 weeks with mucoid expectoration and malaise. On lung auscultation, reduced breath sounds were present over right infrascapular and infra axillary area. Chest X ray revealed right sided loculated pleural effusion for which USG thoracocentesis was performed, thick purulent pus was aspirated and sent for pleural fluid analysis. Pleural fluid reports were indicative of exudative pleural effusion, most likely TB. Patient was started on IV antibiotics and was planned for CECT Scan [Figure 1] which revealed right loculated empyema with split pleura sign.
Patient underwent Thoracoscopy which revealed nodularity [Figure 2] with septation throughout the pleura, pleural biopsy sample was taken after which thick pus was drained and ICD inserted. Anti-tubercular therapy was started. Patient improved symptomatically.
Discussion: The procedure of medical thoracoscopy in early management of multiloculated pleural empyema is safe, efficient and cost effective in developing countries where thoracic surgery facility is scarce.
Conclusion: In the absence of clear septation, antibiotics plus simple drainage of pleural fluid is often sufficient treatment, whereas clear septation often requires more invasive treatment.
Determinants for drug resistance in tuberculosis patients from perspective of patients
Hareesh Pathak, Lokendra Dave, Sourabh Pandey
Department of Respiratory Medicine. E-mail: harishpathak92@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/50km ) 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) Dept of Respiratory Medicine, GMC,BHOPAL.
Results: In our study non-compliance to ATT drug intake on previous treatment, adverse drug reaction on previous treatment and mental health issues on previous treatment have statistically significant positive association interpreting as, with the ascent of these factors, incidence of MDR Tb will also increase. (p value <0.05)
Whereas unobserved treatment and socioeconomic burden do not have any significant correlation but still possess risk factor in development of MDR TB.(p value >0.05)
Conclusion:
1. Possible Factors related to patients which may lead to development DRTB mainly comprise of those which make them uncomfortable to drugs or poor counseling so such patients should be proper counseled about drug compliance and its adverse effects. Also there are patients who are regular defaulters or go into depression due to medications and social stigma such patients should be properly counseled and some government programmes be made up for their betterment and rehabilitation. Also such patients should be treated after hospitalizing them for longer duration in order to ensure compliance and avoid spread of infection in society.
Not just a complication, can be an initial presentation in COVID 19 A case report
Georgin Shaji, B. Archana Ponnathota Vindhya, Aleena Mariam Mathew
Department of Pulmonary Medicine. E-mail: georginshaji@gmail.com
Background: The coronavirus disease 2019 (COVID-19) infection caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is sweeping across the Globe and may be complicated with a wide range of secondary bacterial and fungal co-infections during the course of illness. Here we report a case of severe COVID 19 patient co-infected with pulmonary aspergillosis.
Case Study: A 56 year old male patient presented with cough, dyspnea and generalized weakness since 3 days, streaky hemoptysis since a day,with uncontrolled diabetes mellitus of HBA1c8.2% and RAT positive covid-19 illness. HRCT thorax was done which showed diffuse, dense ill-defined ground glass oapacities with air bronchograms involving all the segments of bilateral lower lobes and periphery of upper lobes with CORADS 5 Category and CT severity score - 16/25. Also noted reversed halo sign in right upper lobe, hence possibility of angioinvasive fungal infections (Mucormycosis/ aspergillosis) was considered.Patient was treated with Covid-19 guidelines as per Government of Karnataka. Also started with oral Posaconazole in view of CT findings. His general condition continued to deteriorate and despite all the efforts he succumbed to the illness within 28hours after admission. After taking written informed consent from the patient’s attenders, we went ahead doing transthoracic biopsy from right upper lobe after his death which showed pulmonary aspergillosis.
Discussion: Covid 19 associated pulmonary aspergillosis is commonly seen in immunocompromised individuals including uncontrolled diabetes mellitus, chemotherapy, hematological and other malignancies,organ transplantation, and corticosteroid therapy.
Conclusion: Our case report highlights the fact that COVID 19 infection may expose the patients to a greater risk of developing opportunistic co-infections even at presentation which may lead to worse outcomes.
The effect of adverse drug reactions on prolongation of treatment in patients of tuberculosis
Manjari, Archana, Kolla Vinod, Vindhya
Department of Pulmonary Medicine, Rajarajeshwari Medical College and Hospital, Bengaluru, Karnataka, India. E-mail: manjarirajagopalan@yahoo.com
Background: Tuberculosis remains one of the biggest healthcare challenges of the world with effective diagnosis and management being more essential now than before with the emergence of drug resistant strains. Pill burden and longer duration of treatment has been an important limitation in effective tubercular treatment. This study aims to highlight the correlation between prolonged duration of treatment in those patients with adverse drug reactions during the treatment period.
Aim: To assess the effect of adverse drug reactions on duration of treatment in patients with tuberculosis on fixed dose combination of antitubercular therapy
Methods: 150 Patients with drug sensitive tuberculosis were enrolled. Patients were followed up for the period of treatment and drug reactions noted. Descriptive statistical analysis was used.
Results: We studied 150 patients with tuberculosis. 24 out of 150 had prolonged treatment duration with 18 in whom drug reactions had occurred. The association between occurrence of adverse drug events and prolongation of treatment duration was found to be significant (p value of 0.0001).
Conclusion: This study shows direct correlation between occurrence of adverse drug reactions and prolonged treatment duration. This highlights the need to address adverse drug reactions thereby increasing adherence and limiting treatment duration.
Clinical and epidemiological profile of tubercular cervical lymphadenitis – a hospital based observational study
Praveen, Vishnukanth, Dharm Prakash Dwivedi
Department of Pulmonary Medicine JIPMER, Puducherry, India. E-mail: pppraveenbittu@gmail.com
Background: The commonest form of extrapulmonary tuberculosis is tubercular cervical lymphadenitis, or scrofula. Tuberculosis continues to be the biggest health problem in developing countries with enormous social and economic implications. TB is one of the most common cause of death particularly due to infectious agent worldwide in adults. India have the highest burden of TB.. Cervical lymph nodes are the most common lymph nodes affected by this disease—classically termed as “scrofula”. The word ‘scrofula’ comes from
Methods: A hospital based descriptive study was conducted among 35 of newly diagnosed cervical tubercular lymphadenitis referred to DOTS centre of department of pulmonary medicine JIPMER. Patients aged 10 and above who is started on treatment from 2020 will be followd up for 1year,6months during treatment and 6months after treatment
Results: Of 35 participants, 62.9% were females and the median age of the participants was 30years,out ofare,8% are non resolving lymph nodes, for 8% extension of treatment done after excision biopsy showed caseating granulomatous lesions and CBNAAT detected MTB with no refampicin resistance,2% showed allergy to ATT.
Conclusion: From this study,it has been concluded there is high incidence of tubercular cervical lymphadenitis in patients with enlarged lymph nodes in developing country like India. Even after improvement in economy and DOTS program there is decline in pulmonary tuberculosis but there is increase in incidence of extra pulmonary tuberculosis
Rare presentation of miliary tuberculosis with tuberculoma with right pleural effusion
D. Shiva Kumar, M. Sravan Kumar, P. Ravi
Kakatiya Medical College, Warangal, Telangana, India. E-mail: shivadharavath32@gmail.com
Background: Miliary tuberculosis results from the lymphohematogenous spread of the tubercle bacilli to the vascular beds in the lungs and other organs. Diagnosis is made by clinical judgment and chest X-ray showing miliary mottling of the lung fields. Another imaging study like computed tomography imaging of the lungs and abdomen can also be supportive in diagnosing miliary tuberculosis.
Case Study: A 35 yrs male came with cough with expectoration (1month), fever (1month), breathlessness (20 days), headache, drowsiness. Chest X-ray shows small nodular opacities present in bilateral middle and lower zones along with right Cp angle blunting - miliary tuberculosis with right pleural effusion. HRCT CHEST shows Diffuse Miliary opacities scattered in all segments of lungs. MRI BRAIN with Contrast - Multiple tiny foci T1/FLAIR hyper density noted in bilateral parietal and left occipital lobe S/o tuberculoma. Patient started ATT and corticosteroids and other symptomatic drugs. Patient improved both clinically and radiologically.
Discussion: Miliary tuberculosis results from the hematogenous spread of the tubercle bacilli resulting in tiny discrete foci of the size of millet seeds which are distributed uniformly in the lungs and other organs and common among the immunocompromised individuals and 8% in the immunocompetent individuals. Our patient presentation was suggestive of miliary tuberculosis with atypical manifestations in the form of right sided pleural effusion and tuberculoma.
Conclusion: This case highlights the atypical presentation of miliary tuberculosis with tuberculoma with right pleural effusion.
Unusual presentation of tabes pulmonali as diffuse cystic lung disease
Anvesha Tummala, T. Pramod Kumar, G. Nalini, G. Sravan, V. Karthik
Department of Pulmonary Medicine, Osmania Medical College, Hyderabad, Telangana, India. E-mail: anveshatummala@gmail.com
Introduction: Tuberculosis (TB) continues to be a major public health problem throughout the world, more so in developing countries and India in particular. Patients with pulmonary tuberculosis present a wide range of CT findings, including airspace or interstitial nodules, the tree-in-bud pattern, consolidations, cavitation, fibrosis, bronchial wall thickening, lymph node enlargement, and pleural effusion. However, cystic changes associated with pulmonary tuberculosis have very rarely (8-9cases) been reported, and are among the rarest presentations of this common disease.
History: A 25 years old female, non-smoker presented to emergency department with sudden onset of dyspnoea and right sided chest pain. Chest x-ray revealed right sided pneumothorax with collapsed lung. So, tube thoracostomy was done.
Evaluation: Patient was advised ATT by clinician in view of clinically diagnosed pulmonary tuberculosis (bilateral multiple micronodular opacities on CT chest). But patient discontinued after 4 months of treatment. There was no significant family history. Viral markers were negative. After few days, patient developed pneumothorax on left side. Repeat CT chest and abdomen revealed cystic changes replacing nodular opacities in bilateral lungs and simple renal cysts. Anti-nuclear antibody profile was normal. Bronchial washing for CD1Ag was negative. Histopathological examination of video assisted thoracoscopy guided biopsy revealed respiratory epithelial cells. After the follow up of 1month, patient developed splenic abscess. Pus for gene-xpert detected MTB indicating inadequate treatment with ATT as a cause for abdominal TB.
Conclusion: Even though fibrocystic changes are common, bilateral diffuse cystic disease is an unusual presentation of TB and has varied response to treatment.
A study of safety, efficacy and outcomes of shorter course mdr regimen at nodal DRTB Centre SNMC Agra
Vipin Kumar, Santosh Kumar, Gajendra Vikram Singh, Sachin Krgupta
E-mail vpin.kmar2407@gmail.com
Background: TB is a communicable disease that is a major cause of ill health and one of the leading causes of death worldwide. The therapy of MDR-TB using shorter course regimen is crucial and essential to explore, as it has the potential to increase the success rate of MDR-TB treatment.
Methods: The proposed study was a hospital based, without control group prospective study,in cohort of DRTB patients conducted at Nodal DRTB Centre, SNMC Agra. 180 MDR-TB patients registered under the short course.
Results: In our study we found that in the study period out of 420 registered TB patients 180 were registered under shorter course DRTB regimen. Maximum number of males were in 21–30-year age group followed by ≤20 year and 31-40 year. Similarly, females also were maximum in age group 21-30 followed by ≤20-year year. Only 50% patients were aware of their suspected contacts. Majority of patients had duration of illness between 1 month to 12 month. Most common findings in Chest X-ray was Unilateral lesion followed by Bilateral lesions. Overall, 5% patients claimed to be defaulted due to Adverse drug reactions.12%completed their treatment. 20% patients shifted to all oral longer regimen.
Conclusion: Most common cause of DRTB is failure of previous regimen. Adverse drug reactions are the most common cause to default.
Fever with lung nodules on chest radiograph: A diagnostic dilemma
S. V. Agarwal1, S. S. Yadav1, M. L. Gupta2
1Department of Medicine, Santokba Durlabhji Memorial Hospital CUM Medical Research Institute, Jaipur, Rajasthan, India, 2Department of Pulmonary Medicine, Santokba Durlabhji Memorial Hospital CUM Medical Research Institute, Jaipur, Rajasthan, India. E-mail: svinayak.agarwal8@gmail.com
Respiratory clinician usually encounters patients with history of fever along with chest radiograph having bilateral lung nodules. In endemic areas like India usually tuberculosis is considered as the initial diagnosis. A falsely ascribed diagnosis may prove unfortunate as the underlying diagnosis is left unaddressed and the burden is amplified by avoidable potential side effects of anti-tuberculosis drugs. We encountered a 30-year-old male patient with a rare cause of fever along with bilateral lung nodules. Details of the case will be further discussed.
Comparative analysis of total serum proteins, albumin/globulin ratio and albumin to alpha-2 globulin ratio in patients of TB, TB with HIV coinfection and healthy controls
Kamaldeep Singh, Surinder Pal Singh, Mahesh Gupta
Department of Pulmonary Medicine, GMC Patiala, Punjab, India. E-mail: kamaldeep19931994@gmail.com
BACKGROUND
Tuberculosis is one of the leading causes of morbidity and mortality.. In chronic infectious TB disease, the albumin shows a decrease while globulin content shows an increase leading to low Albumin to Globulin (A/G) ratio and albumin to alpha-2 globulin ratios. Several studies of HIV-infected individuals have determined that hypoalbuminemia (defined as a serum albumin concentration of <35 g/L) is associated with more rapid progression to AIDS and accentuated mortality rate. Scientific literature also suggests that monitoring the serum albumin concentrations may have a greater impact on clinical management and treatment of HIV infection. This present study is designed to evaluate the levels of total serum proteins along with serum albumin-globulin ratio in individuals suffering from pulmonary tuberculosis alone and co-infected with HIV. Our study also aims at corelating these levels with disease severity and whether anti-tubercular therapy has any effect on these biomarkers
METHODS
RESULTS
The serum albumin globulin ratio was significantly decreased in pulmonary TB and TB with HIV co infection. The ratio showed complete reversal in patients of TB-HIV coinfection.
CONCLUSION
Both albumin/globulin ratio and albumin/alpha-2globulin ratio are markers of severe disease in TB and TB-HIV coinfection and emphasize the need of protein supplementation in patients of Tb and TB-HIV coinfection.
A study to assess the relationship between nutritional status and disease severity in patients of pulmonary Tb, copd, & bronchial asthma
Rahul Suri, Kranti Garg, Vishal Chopra, Rishabh Deshwal
Department of Pulmonary Medicine, GMC Patiala, Punjab, India. E-mail: prince199029@gmail.com
Background: The co-relation between malnutrition and active TB has been based on various observational studies.Malnutrition is associated with risk of relapse and low treatment response rates of TB. In general population, diets rich in fruits and vegetables is seen having low risk of lung function decline and asthma.It has also been seen that asthma is difficult to control in obese patients.it has also been observed that obese and overweight children have higher risk of development of bronchial asthma as compared to normal weight individuals.Majority of COPD patients have malnourished or under nourished state known as pulmonary cachexia syndrome and is associated with a decline in functional status and unfavorable prognosis.The present study was done to assess nutritional status of patients with Pulmonary Tb, bronchial asthma and COPD and to co-relate nutritional status with disease severity in these patients.
Methods: this is a cross sectional study done in 50 patients each of sputum AFB positive pulmonary TB, bronchial asthma and COPD. These patients underwent anthropometric measurements alongside biochemical parameters (i.e Hb, S. albumin) and 24 hour calorie intake(via oral questionnaire). The nutritional status was co-related inter-disease as well as with disease severity.
Results: There is a significant difference seen in all the three groups of patients for BMI with lowest BMI seen in TB patients.Tb patients were found to have a significantly lower Waist-Hip Ratio as compared to COPD (p=0.041) patients.Tb patients were found to have a significantly lower MUAC as compared to Asthma (p<0.001) or COPD (p<0.001) patients.More than 3/4th of TB patients had anaemia which was significantly higher than Asthma and COPD patients (p<0.001).both COPD (p=0.004) and TB (<0.001) patients had a significantly lower calorie intake as compared to Asthma patients.
Conclusion: patients with TB had more severe malnutrition as compared to asthma and COPD. Asthma patients had prevalence of obesity with more waist/hip ratio. The 24 hour calorie intake was significantly lower in patients of Pulmonary TB and COPD as compared to bronchial asthma suggesting the disease related cachexia and need of nutritional supplementation.
A rare case of MDR PTB with primary bedaquiline resistance in the society
Dnyaneshwar V. Dhobale, P. L. Meshram, V. V. Pujari, R. R. Hegde
Grant Government Medical College Mumbai, Maharashtra, India. E-mail: dhobale75@gmail.com
Background: XDR-TB is defined as resistance to at least isoniazid,rifampicin plus any of fluoroquinolones and any one of the second-line injectable anti-TB drug. A single case of primary BDQ-resistance is reported from Taiwan,Alver till date. BDQ is diarylquinoline which targets mycobacterial ATP synthase. It is bactericidal drug with mean terminal t1/2 of 5.5months.
Case Study: A 22-year old male with no comorbidities presented with cough and constitutional symptoms of tuberculosis since 2 months. He had history of MDR-PTB in May 2017, for which he was treated with kanamycin-based regimen for 21 months. His followup cultures of 15m,18m and 21m were positive and no clinical improvement. After gap of 3months patient reported to hospital and he was started on capreomycin-based regimen from June 2019. As sputum cultures of 21m and 24m were negative and he showed clinical improvement, AKT was stopped in May 2021. Patient again became symptomatic for which he was evaluated. As sputum smear and culture was positive, phenotypic-DST was done, which showed Resistance to Bedaquiline,Levofloxacin,Moxifloxacin, Ethionamide, Ethambutol, Clofazimine,PAS,Pyrazinamide,Rifampicin,Isoniazid and sensitivity to Linezolid,Amikacin,Kanamycin and Capreomycin.Patient was started on delaminid,amikacin,cycloserine,linezolid.
Discussion: BDQ is part of all oral longer regimen in treatment of DR-TB. It is group A drug as per WHO Consolidated Guidelines for TB. Primary BDQ-resistance raises concern in DR-TB control programme. Early recognition of BDQ-resistance is important to achieve better treatment outcome and prevent spread of BDQ-resistance.
Conclusion: Primary BDQ-resistance is important concern in management of DR-TB. Early detection and management of BDQ-resistance is core in preventing spread of BDQ-resistance.
Study on drug induced liver injury among drug sensitive tb patients who is on fixed drug combination of anti-tb drugs in a tertiary care centre
S. Ramyadevi, S. Aravind, P. Arulkumaran, P. M. Ramesh
Government Thiruvotteswarar Hospital of Thoracic Medicine, Govt Kilpauk Medical College, Chennai, Tamil Nadu, India. E-mail: ramyadevi.dinesh01@gmail.com
Background: Tuberculosis caused by susceptible mycobacterium tuberculosis strains is effectively treated by the fixed drug combination of anti TB drugs. However, most anti TB drugs are known to induce hepatotoxicity which may limit their adherence and hence lead to the development of mycobacterial drug resistance
Aims and Objectives: The aim of this study was to assess the incidence of FDC induced hepatotoxicity, associated risk factors and outcome among drug sensitive tuberculosis patients in a tertiary care centre.
Materials and Methods: This is a study done among new PTB and EPTB patients started on 4 fixed drug combination of anti TB drugs. After enrolling in to the study, blood samples taken from all the patients and asked to repeat after 1 week of starting 4 FDC. Those with Drug induced liver injury were admitted and details regarding associated risk factors collected. Rechallenging of non hepatotoxic drugs done and did further follow up of patients.
Results: There were 77(13.8%) cases of ATT-associated Drug induced liver injury among 557 patients diagnosed with active TB between FEBRUARY 2021 to JULY 2021.Among 77, 46(59.7%) male and 31(40.2%) female, > 40 years- 57(74%), alcoholic – 31(40.2%), GI disorder- 18(23.3%), viral markers- 3(3.8%). Rechallenging of non hepato toxic drugs done for all the patients then Regimen restarted for 16(20.7% among DILI, 2.8% among 557) and change of regimen needed for 61(79.2% among DILI, 10.9% among 557). The outcome of the study is among 557, treatment completed - 290(52%) on treatment- 200(35.9%) lost follow up- 35(6.2%) died – 38(6.8%). Among 61(regimen changed), treatment completed- 32(52.4%) on treatment- 20(32.7%) lost follow up- 5(8.1%) died- 4(6.5%). Among 16(regimen restart), treatment completed – 9(56.25%) on treatment – 5 (31.25%) lost follow up – 1(6.2%) died – 1(6.2%)
Conclusion: There is a significant increase in drug induced liver injury among drug sensitive tuberculosis patients started on 4 fixed drug combination of anti-tuberculosis drugs. Risk factors like age >40yrs, chronic alcoholic, higher baseline LFT and GI disorders are more prone to develop drug induced liver injury. Hence LFT can be added as preliminary routine test for Drug sensitive TB patients and follow up LFT should be done after starting 4 fixed drug combination of Anti TB drugs.
Pulmonary artery pseudoaneurysm in a covid survivor
R. Awatansh, Tripathi, Radhika Banka
E-mail: tripathiawatansh@gmail.com
Introduction: Pseudoaneurysm of the pulmonary artery (PAP) is a rare cause of hemoptysis with a wide array of aetiologies. This case report discusses our clinical experience of PAP associated with pulmonary mucormycosis (PM) in a COVID survivor.
Case Report: A 58-year-old gentleman presented with a 1-week history of high-grade fever and progressive dry cough. Four weeks before his presentation, he was treated for mildly symptomatic COVID-19 infection with unusually high doses of steroids. On admission, a chest x-ray and CT chest showed a cavitatory lesion in the right lower lobe. He underwent a FOB with BAL and endobronchial biopsy, which were inconclusive. On day 5 of his hospital admission, he had an episode of massive hemoptysis leading to hemodynamic instability. CT showed an increase in the size of the cavity and a pulmonary angiogram showed the descending segmental branch of the right pulmonary artery traversing through the consolidative cavitating lesion with focal dilatation of the same measuring up to 1.5 x 1.9 cm. Consistent hemostasis couldn’t be achieved after gluing an interlock coiling of pseudoaneurysm, hence he underwent video-assisted thoracic surgery for right lower lobectomy and stump ligation of the right lobar pulmonary artery. Lobectomy specimen on histopathology revealed large areas of necrosis with aseptate fungal hyphae. He responded well to antifungal therapy during follow on 4th week post discharge.
Conclusion: Mucormycosis is characterized by angioinvasion, vessel thrombosis, and subsequent tissue thrombosis. Pseudoaneurysm formation is rarely seen in PM and can be associated with fatal hemoptysis. Irrational use of systemic steroids in the management of COVID makes the patient more vulnerable to an otherwise rare disease.
Multiple cavities in lungs: A diagnostic dilemma
Mohammed Danish, Imrana Masood, Zuber Ahmed, Ummul Baneen
Department of Pulmonary Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, India. E-mail: danishtbrd@gmail.com
Background: Lung cavitation occurs in a variety of pathological processes that comprise of a wide spectrum of diseases, both infectious (Tuberculosis, Atypical Pneumonia, Cavitating bacterial pneumonias) and non-infectious (vasculitis, secondaries, Rheumatoid and sarcoid nodules).
Here we present a case of a 60 year old male who was a farmer by occupation, immunocompetent, and chronic smoker, who presented to our OPD, with complaints of yellowish discoloration of skin and eyes for the past 3 months, fever and cough for one and half months. Cough was associated with scanty expectoration, white to yellow in color, mucoid in consistency, non-foul smelling, not associated with haemoptysis. There was no history of previous ATT intake.
Discussion: The routine blood investigations, mantoux test, AEC count, urine examination, sputum examination, c-ANCA, p-ANCA, RA factor, bronchoscopy, etc. were done but showed no specific abnormality. Repetitive cultures from sputum and BAL came out to be sterile. Chest X ray and CT scan revealed only multiple cavities in lung parenchyma without any particular lobe predilection.
Despite extensive investigations, we could not establish a cause for the multiple cavities in lung.
Hence, the patient was started on empirical antibiotics and symptomatic treatment was given. The patient responded to our treatment and improved clinically after 10 days of treatment. Radiologically there was significant resolution of cavities in chest X-ray taken after 3 weeks.
Prostatic abscess complicating to septic pulmonary emboli
Vishnukanth Govindaraj, Vemuri Maheshbabu, Abhisekh Chandran, Jayabharati Palanivel
Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. E-mail: vishnu1429@yahoo.com
Background: Prostatic abscess is a complication of acute prostatitis and usually occurs in the 5th and 6th decades of life with immunocompromised status. Gram negative organism are the most commonly implicated. We herein describe a case of septic pulmonary emboli with origin from prostatic abscess.
Case Details: A 52 Year old diabetic with uncontrolled sugars presented to emergency medicine in view of breathlessness, cough with expectoration, dysuria and fever for 2 weeks. He was tachypneic and hypoxic on room air. Chest x ray and subsequent CT showed bilateral multiple cavities involving all lobes of the lung with left side effusion.a feeding vessel sign was also noted. His blood investigations showed leucocytosis of 23 000 counts /mm3 with peripheral smear showing toxic granules and normocytic normochromic anemia and a blood sugars of 520 mg/dl with no ketone bodies.urine routine showed plenty of pus cells with granular material. USG abdomen and pelvis showed complex hypoechoic collection with thick septations and few areas showing moving echoes seen posteroinferior top bladder suggesting a prostate abscess. Suprapubic cystostomy and transperineal pigtail insertion done for ruptured prostatic abscess. Blood culture,sputum culture and exudate culture from prostate yielded E.Coli which was sensitive to cefoperzone and sulbactam and amikacin. Anaerobic culture showed Bacteroides uniformis and caccae sensitive to cefoxitin,chloramphenicol and imipenem. He was treated with sensitive antibiotics, fluid replacement and insulin. He improved clinically and radiologically and was subsequently discharged.
Conclusion: The origin of septic emboli should be meticulously searched and can be present in rare sites like prostate.
Rare case of esophageal tuberculosis
KaranKumar Waghmare, P. L. Meshram, V. V. Pujari, R. R. Hegde
Grant Government Medical College Mumbai, Maharashtra, India. E-mail: karankumarw@gmail.com
Background: Esophageal Tuberculosis is a rare Extrapulmonary tuberculosis accounting only 2.8 % of all cases of Gastrointestinal Tuberculosis. which are total of 1-3% of all Tuberculosis cases. Oesophageal tb usually occurs as a result of direct spread from mediastinal nodes. Commonly presents as Dysphagia,retrosternal pain with constitional symptoms as mild grade Fever, loss of weight and appetite. If not treated can complicate as perforation, fistula formation, aspiration pneumonia, fatal hematemesis and esophageal strictures. Early initiation of AKT can decrease emergence of such complications.
Case Study: A 22-year old male with no comorbidities presented with dry cough,dysphagia,evening rise of fever with loss of weight since 1 month.
Blood investigations revealed raised TLC with lymphocytosis, with an elevated ESR. Patient tested negative for HIV,HbsAg,HCV.
Sputum CBNAAT - MTB Not Detected
On CXR patient had bilateral Hilar Lymphadenopathy.
On CT - Thorax - hilar Lymphadenopathy was confirmed with Normal lung parenchyma.
Esophageogastroduodenoscopy was done - longitudinal esophageal friable ulcers were seen,Biopsy taken.
Histopath was suggestive of granulomatous inflammation.
CBNAAT s/o MTB DETECTED LOW.
Patient was started on AKT 4FDC.
On 2 monthly f/u Dysphagia was resolved along with all other complains.
Conclusion: Along with conventional symptoms, Dysphagia is also common presenting complain in oesophageal tuberculosis. CB-NAAT along with histopathology is mainstay for diagnosis. Early starting of AKT remains best management and for preventing complications
The utility of tuberculosis whole genome sequencing in complete drug resistance profiling
Amrutraj Zade1, Sanchi Shah1, Anirvan Chatterjee1, Chaitali Nikam2
1Haystack Analytics Pvt. Ltd., 2Thyrocare Technologies Limited. E-mail: amrutraj@haystackanalytics.in
Background: The epidemiology of tuberculosis (TB) is a dilemma today. With an increasing option of treatment choices, the specter of drug resistance (DR) is also rising. Newer drugs offer a much-needed option in patients who have highly resistant TB. Today’s methods of identifying DR, however, are limited. Several national and international authorities now recommend the use of whole-genome sequencing for TB drug profiling.
Methods: TB whole-genome sequencing (WGS) was performed for over 500 samples. The data was analyzed using the OmegaTB genomic analysis. DR of newer drugs or unique profiles that would not be identified easily through current testing methods were identified and further described.
Results: Among these samples, the profiles of samples that show resistance to newer drugs or unique patterns are showcased to exemplify samples that would not be easily identified through standard diagnostic profiles.
Conclusion: WGS is inherently comprehensive. It is a single-test solution for the complete profiling of TB. It can identify drug-resistance conferring mutations even to newer drugs. As evidence for newer mutations grows, this test can be used to identify those as well. Several countries have shown the benefits of using TB WGS. We demonstrate its utility in an Indian context.
An observational study to assess the Treatment outcome and adverse effect profile of patients of Multidrug Resistant Pulmonary Tuberculosis put on shorter regimen under PMDT 2019
Sandeep Kumar, Darshan Kumar Bajaj
E-mail: rkumarjkl@gmail.com
Tuberculosis (TB) is an ancient human disease caused by Mycobacterium tuberculosis which mainly affects the lungs and thereby pulmonary manifestations are the most common way of presentation. Mycobacterium tuberculosis is a pathogen that infects humans with no reported environmental reservoir as such but it has mastered the art to survive and persisted through the human generations from ancient times till date. Drug resistant Tuberculosis has been known from the time anti-TB drugs were first introduced. The era of modern effectively treatable tuberculosis began in 1952 and it was since then that various drug resistant strains started coming into light for which arose the need of both treatment and control programs. In 2016, World Health Organization guidelines conditionally recommended standardised shorter 9–12-month regimens for multidrug-resistant (MDR) tuberculosis (TB) treatment. We conducted a prospective study of a shorter standardised MDR-TB regimen in Tertiary centre
Objective:
• To assess the clinical outcome in patient of Multidrug Resistant Pulmonary Tuberculosis taking shorter injectable regimen.
• To assess the radiological outcome of patient of Multidrug Resistant Pulmonary Tuberculosis put on shorter regimen.
• To assess the microbiologic conversion of patient of Multidrug Resistant Pulmonary Tuberculosis taking shorter injectable regimen.
• To study the adverse effect profile of patient of Multidrug Resistant Pulmonary Tuberculosis taking shorter injectable regimen.
Design :Prospective Observational Study of MDR- TB patients treated with a standardised 12 month regimen including gaitifloxacin, clofazimine, prothionamide,ethambutol, and pyrazinamide throughout, supplemented by kanamycin and isoniazid during an intensive phase of a minimum of 4 months.
Patients were enrolled on the basis of inclusion and exclusion criteria of shorter injectable regimen. Patients were followed at the end of intensive phase,extended intensive phase, and continuation phase and assesses clinically,radiologically,microbiologically.
Results: In our study,our patients were mainly belonged to the younger group ( 24 patients, age group 11-20 years ),and 35 (67%) patients were female, 23 (43%) patients out of 53 patients were successfully treated, while regimen was changed for 17(32%) patients,out of which 5 patients regimen changed due to serious adverse effect reaction and and 12 patients had additional resistance. 9 patients died during the treatment, 2 were lost to follow up. Grade 3 adverse event was noted in 8 patients (15%). None of the patients were seropositive. The most common radiologic finding was patchy consolidation (n=40, 75%). And most of them had single parenchymal lesion (n=32, 60%.) BMI of the patient of 28 (53 %) belong to the underweight category.
Conclusions: Overall success with a standardised shorter MDR-TB regimen was moderate with considerable treatment failure and amplification of fluoroquinolone resistance. When introducing standardised shorter regimens, baseline drug susceptibility testing and minimising missed doses are critical. High rates globally of pyrazinamide, ethambutol and ethionamide resistance raise questions of continued inclusion of these drugs in shorter regimens in the absence of drug susceptibility testing-confirmed susceptibility.
A rare presentation of pneumothorax in adolescent with lower lung field tuberculosis
Sayyeda Arshia Jabeen, Mohammed Hidayath Hussain
Shadan Institute of Medical Science, Affiliated to Kaloji Narayana University of Health Sciences, Hyderabad, Telangana, India. E-mail: s.arshima06@gmail.com
Background: Lower lung field TB is a primary pulmonary Tuberculosis M.C in adults. In areas of high tuberculosis transmission, this form of tuberculosis is seen in adolescence with impaired immunity which is extremely rare & secondary spontaneous pneumothorax is a well-known complication of pulmonary tuberculosis (TB), particularly in patients with advanced TB, but its presentation in adolescence is rare.
Case Report: A 18 yr female presented with complains of fever low grades since 1 month progressed to high grade since 2 days, cough with expectoration since 1 month, loss of appetite since 1 month,shortness of breath grade 2 MMRC since 5 days.
On examination she was febrile temp 102 F, RR was 20/min, SPO2 95% RA
Respiratory examination revealed bilateral coarse crepitation’s with increase vocal resonance in bilateral infrascapular & infraaxillary area
CXR revealed right side minimal pneumothorax with bilateral mid & lower zone consolidation which was of 7 days back.
Hrct was done which showed resolution of pneumothorax with left lower lobe consolidation & cavity with tree in bud appearance in right lower lobe. Thus the pneumothorax resolved on its own without any intervention.
Sputum CBNAAT was done which showed MTB detected with no resistance & was started on ATT.
Conclusion: The lower lung field tuberculosis is very uncommon in adolescence age group & leading to secondary spontaneous pneumothorax is an extremely rare complication.
Post-COVID pulmonary aspergillosis - A case report
Puja Kommanaboyina, B. Bhanu Rekha
Department of Respiratory Medicine Dr. Pinnamaneni Siddhartha Institute of Medical Sciences and Research Foundation, Dr. NTR University of Health sciences, Andhra Pradesh, India. E-mail: pujapuli56144@gmail.com
Introduction: Novel coronavirus disease started in December 2019 and declared pandemic on march 11 2020. Viral pneumonia increases patients susceptibility to bacterial and fungal infections and those who were admitted to ICU had a higher probability of infection.
Case Report: A 33yr old female came to the hospital with chief complaints of cough with expectoration associated with streaky haemoptysis and generalised weakness since 20 days. There was a h/o hospital admission for covid and patient was on NIV support. Patient was denovo diabetic. On examination pallor present and decreased breath sounds in bilateral infrascapular and infraaxillary areas.
Investigations: Chest X ray showed bilateral mid and lowerzone non-homogenous opacities. Sputum for AFB,CBNAAT and KOH were negative. Sputum culture & sensitivity showed streptococcus. HRCT chest was done which showed multiple cavitary lesions in bilateral lung fields. Bronchoscopy was done and washings showed branching septate hyphae on KOH mount suggestive of aspergillosis.
Patient was started on antifungals and symptomatic improvement was seen.
Conclusion: Pulmonary aspergillosis is a serious complication in postcovid patients and high index of clinical suspicion and focused diagnostic approach is essential for early diagnosis and treatment which may improve the outcome.
Caverno pleuro subcutaneous fistula with subcutaneous emphysema: a rare presentation of pulmonary tuberculosis
S. Madhan, S. Yuvarajan, R. Praveen, Antonious Maria Selvam, K. Prathaban
Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Puducherry, India. E-mail: madhan.s21@gmail.com
Introduction: Subcutaneous emphysema and pneumomediastinum occur frequently in critically ill patients in association with alveolar rupture, blunt or penetrating trauma, soft-tissue infections, or any condition that creates a gradient between intra-alveolar and perivascular interstitial pressures. Subcutaneous emphysema in a case of pulmonary tuberculosis may be present because of associated secondary spontaneous pneumothorax or may be iatrogenic following chest tube insertion for pleural pathology. Subcutaneous emphysema in a case of pulmonary tuberculosis in the absence of these conditions are sparsely reported. We report one such case of pulmonary tuberculosis that presented with subcutaneous emphysema without Pneumothorax.
Case Report: A 49-year-old male who is farmer by occupation presented with complaints of chest pain, radiating to back and jaws with swelling over the chest for past three days which progressed to involve whole chest, neck, arm and face over the next few days. There was history of low-grade fever and cough with expectoration for the past 1 month. On examination of the chest, Crepitus was present over the chest and neck on palpation. Cavernous type of breathing was present in left infraclavicular area. Chest X-ray revealed heterogenous opacity involving entire left hemithorax, few fibrotic strands along with cavity noted in left upper zone and subcutaneous emphysema noted in both hemithorax extending upto neck.Computed tomography (CT) of thorax showed diffuse subcutaneous emphysema and pneumomediastinum with multiple cavities in right upper lobe and middle lobe. Volume loss with cavity communicating with pleura and subcutaneous tissue noted in left hemithorax. Sputum examination was positive for Acid –fast Bacilli.
Patient was treated with high flow oxygen and anti-tubercular chemotherapy. Following which the subcutaneous emphysema gradually reduced and the patient improved both clinically and radiologically. He was discharged with the advice of anti-TB chemotherapy for 6 months.
Discussion: Presence of air in the subcutaneous layer of skin is called subcutaneous emphysema. When it is secondary to any surgical procedure, it is called surgical emphysema and when cause is unclear, it is called spontaneous subcutaneous emphysema. It may be observed in association with pneumothorax or pneumomediastinum as a result of pathological changes in the respiratory tract. Spontaneous pneumomediastinum has been reported in several forms of pulmonary tuberculosis like miliary, silico tuberculosis and cavitary tuberculosis. Spontaneous subcutaneous emphysema from caverno pleuro subcutaneous fistula is rare. In our case the CT scan revealed a communication of pulmonary cavity to the subcutaneous tissue (caverno pleuro soft tissue fistula). The cavity was probably under tension that allowed passage of bronchial air through a tear to create subcutaneous emphysema. Subcutaneous emphysema carries no particular risk of its own. Additional high flow oxygen helps to correct hypoxia and denitrification of the blood which hastens reabsorption of subcutaneous air. Subcutaneous emphysema may be manually reduced by multiple skin incisions at the level of thoracic inlet or placement of subcutaneous drain.
Multiple pulmonary aspergillomas caused by aspergillus niger
P. C. Naveen, B. Neeharika, P. Yugandhar
Department of Pulmonary Medicine, ASRAM, Eluru, Andhra Pradesh, India. E-mail: dr.naveen999@gmail.com
Background: Aspergilloma is saprophytic colonization of parenchymal lung cavity by aspergillus. It is also referred to as mycetoma or fungal ball. It consists of both dead and living mycelial elements,fibrin,mucus,debris,inflammatory cells.Most aspergillomas are caused by aspergillus.fumigatus but some especially in patients with diabetes mellitus, caused by aspergillus.niger.
Case Study: A 47 year old female presented with cough with scanty, mucoid expectoration, mild haemoptysis 5-6 episodes/day, dyspnea grade 2 mMRC- since 7 days.She had history of old pulmonary tuberculosis 20 years back, with no history of diabetes mellitus, bronchial asthma.On auscultation bilateral normal breath sounds,coarse crepts over left basal areas were heard.Active TB was excluded.Chest X-ray was suggestive of old TB sequelae.Movement of fungal balls within the cavities were appreciated by comparing chest CT scans taken in supine and prone positions.
Discussion: Haemoptysis is typical manifestation of aspergilloma seen in 50-90% of patients.Aspergilloma in this patient was diagnosed by aspergillus.niger isolates from fungal culture of bronchial wash.Definitive treatment of aspergilloma is surgical resection.As there are multiple aspergillomas in this patient, surgical resection was not preferred.Itraconazole 200 mg twice daily was administered orally for 6 months.Patient improved symptomatically.
Conclusion: In patients with history of cavitary lung disease, careful investigation should be carried out and fungal infection,especially aspergilloma should be taken into consideration. Aspergillus.niger as cause of aspergilloma should be taken into account.Itraconazole is found to be useful in symptomatic improvement of the patient.
Beware of TB amid COVID 19 pandemic
S. Carishma
SMS Hospital, Jaipur, Rajasthan, India. E-mail: carish.s.01@gmail.com
Background: Tubercolosis has a worrisome connection with novel corona virus.Lingering respiratory symptoms in people who have recovered from Covid could well be mistaken as residual issues of Covid or secondary bacterial infections,missing TB diagnosis totally.
Methods: A 28 year old female doctor by profession, initially asymptomatic tested Covid -19 positive as a part of contact tracing. On the 15th day, she developed fever,dry cough and fatigue which persisted even after taking symptomatic treatment.Repeat Covid testing was negative.HRCT chest was normal.Sputum CBNAAT was negative and other relevant blood investigations were normal. On examination she was febrile and matted subcentimetric right cervical lyphnodes(LN) were palpable.Excision Biopsy of cervical LN was done and report suggested Kikuchi’s disease.As a part of work up of Pyrexia of Unknown Origin,she undertwent 18-FDG PET whole body CT scan and showed mediastinal lymph node uptake(2R,4R LN station). Mediastinoscopic biopsy report showed tuberculosis and Gene Expert showed mycobacterium complex with Rifampicin resistance.
Results: Based on clinical,radiological and laboratory findings,MDR LN tuberculosis was diagnosed.Patient wad started on MDR TB regimen and symptoms got improved.
Conclusion: There is an increased likelihood of tuberculosis in post COVID patients due to many factors like lung inflammation,altered immunity and stress due to COVID,use of steroids and uncontrolled diabetes.Therefore active tuberculosis should be vigorously ruled out in any post covid patients with continuous fever.
Follow-up of MDR/RR tb patients on treatment withshorter regimen at nodal DRTB center, Kanpur
Arpita Kanaujia, Anand Kumar, Sudhir Chaudhri, Sanjay Verma, Avdhesh Kumar
Department of Respiratory Medicine, GSVM Medical College, Kanpur, Uttar Pradesh, India. E-mail: 199304appykanaujia@gmail.com
Background: Shorter regimen for MDR /RR resistant patients was started in 2018 by RNTCP based on WHO recommendation in 2016. As per NDRS survey Success rate with injectable shorter MDR-TB in 2018 & 2019 was 60% and 57% respectively.
Methods: This was a hospital based study on patients registered on shorter regimen for MDR TB. Patients was analyzed in terms of sputum conversion time, rate of sputum conversion. Outcome analysis at the end of therapy was done as per NTEP guidelines.
Results: Among 420 MDR TB patients, 213 enrolled on shorter regimen out of which 200 were included after getting consent. 40 patients were switched over to all over longer regimen and 53 either defaulted or died or not submitted sample. Out of 107 patients,75% were negative,8.4% were positive &14.9% didn’t submit sample at 3rd month. 54.3% were turned negative, 4.9% patients were positive and 39.5% didn’t submit sample on completion.
Out of 166, sputum culture was negative in 46.38% and 48.70% at the end of third and 6th month of therapy.
Out of 200 patients, 26.5% were cured, 12% completed treatment, 20% converted into all oral longer regimen (32 during IP & 8 during CP),12 % were lost to follow-up,26% died while 3% not evaluated.
Conclusion: Among 200 patients registered on shorter regimen,77 patients completed shorter regimen. Out of these 77, 53 were cured and 24 were treatment completed. Success rate of shorter regimen in our study after transfer of 40 patients to longer regimen would be 48.12% (77/160).
Case report of tubercular ankle bursitis
Dhruv Raj Singh, Rajendra Prasad
Department of Pulmonary Medicine, Era’s Lucknow Medical College and Hospital, Lucknow, Uttar Pradesh, India. E-mail: singh.dhruvraj17@gmail.com
Introduction: The joint of feet including ankle, talocalcaneal and mid-tarsal, Tenosynovitis, and bursitis arising from TB are rare, so isolated tubercular ankle bursitis is a rare presentation of extrapulmonary tuberculosis, might not be seen in all forms of tuberculosis affecting this joint. Radiological investigations can help in accurate, timely diagnosis for safe and definitive management. Chemotherapy remains the mainstay of treatment.
Case Study: A 14-year-old female patient, presented with pain ankle joint for 3 months and was misdiagnosed as arthritis and had received multiple courses of anti-inflammatory medication.
Discussion: X-Ray left ankle joint showed soft tissue swelling on the lateral aspect of the ankle and osteopenic changes. MRI was done of the left ankle joint showed the fluid collection in the ankle joint. USG guided aspiration of abscess done from the left ankle joint and send for Culture and CBNAAT. Mycobacterium Tuberculosis was detected. The patient was advised of Anti-tubercular treatment under DOTS Cat-1.
Conclusion: Osteoarticular tuberculosis of the Ankle Joint is a rare form of extrapulmonary TB. Early diagnosis and treatment are essential to prevent joint destruction. Adjuvant surgery is often required to establish the diagnosis and in the treatment of patients with deformity and destruction of articular cartilage owing to delayed presentation.
Chronic necrotising pulmonary aspergillosis
Aditi Maheshwari, Gunjan Soni, Manak Gujrani, Vijay Kachhawa
E-mail: maheshwariaditi213@gmail.com
Background: Aspergillus is saprophytic fungi found in soil, water, decomposing organic matter. Among aspergillus species, A.fumigatus is the most common pathogen. Pulmonary aspergillosis can occur in different forms depending on architecture of the lung, host immune status. These are: simple colonisation, saprophytic aspergillosis, hypersensitivity reaction, semi-invasive or chronic necrotizing pulmonary aspergillosis (CNPA) or invasive aspergillosis. Here we report a case of CNPA.
Case Report: A 60yr old female presented with complaints of chronic productive cough from last 4 years, on and off fever and chest pain since last 2 months. Patient had no history of asthma, cystic fibrosis, diabetes, pulmonary tuberculosis. Viral markers were negative. Patient had COPD due to biomass exposure. CECT chest reveled bilateral multiple cavities with fungal ball. TEC was normal. Serum total IgE, IgE and IgG for Aspergillus fumigatus were raised. FOB showed edematous and hyperemic left upper lobe bronchus with thick purulent secretions and Bronchoalveolar lavage was positive for aspergillus culture. Based on clinical and laboratory findings patient was diagnosed with CNPA.
Discussion: CNPA is characterized as insidious infection that leads to progressive cavitatory lung disease and chronic respiratory symptoms for more than one month. The spores of aspergillus are deposited in the host lungs, resulting in extensive and progressive lung damage with no vascular invasion or dissemination to other organs. CNPA does not require a preexisting cavity.
Conclusion: The diagnosis requires a high index of suspicion as prognosis depends on the promptness of treatment and on the nature of the underlying lung disease.
Tuberculosis - The master impersonator, two cases of pulmonary tuberculosis mimicking diffuse cystic lung disease
V. Vinay, Yasir Abdullah, Abhimanyu Garg, Amit Sharma
National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India. E-mail: docvinayv@gmail.com
Background: Multiple cystic lung diseases are a group of uncommon disorders that pose a diagnostic challenge to the physician. Cystic lung disease as the initial presentation of tuberculosis is atypical and very rare.
Case Presentation: We present two immunocompetent cases of pulmonary tuberculosis who presented with multiple cysts in the lung parenchyma. The diagnosis was confirmed by the transbronchial lung cryobiopsy in first case and by analysis of bronchoalveolar lavage fluid in the second. Both had spontaneous pneumothorax which was treated with chest drain and pleurodesis. Both showed an excellent response to Anti-tubercular therapy and steroids.
Discussion: TB with multiple lung cysts on presentation is less frequently reported. The pathogenesis of cyst formation in the lung due to TB is unclear, but few mechanisms are postulated: a) Interstitial air leakage due to tubercle rupture, b) Chronic granulomatous inflammation of bronchioles and caseating necrosis of the bronchiolar walls leading to dilated bronchioles by check-valve mechanism, c) Poor drainage of necrotic lung parenchyma along with bronchiolar obstruction. The extent and outcome are dicey while cysts are reversible in few cases.
Conclusion: Tuberculosis is a heterogeneous disease with a myriad clinical presentation. Cystic lung lesion as an initial presentation of PTB is rare and should be considered as a possible cause of acquired cystic lung disease in a high TB burden country like India. If diagnosed and treated on time, we can prevent complications and improve the outcome.
A rare case of Ovarian TB with elevated CA 125 levels mimicking ovarian cancer
Megha Mangal, Manmadha Rao
E-mail: meghasmangal1111@gmail.com
Introduction
Perioperative diagnosis of ovarian tb is often difficult d/t confusion with ovarian cancer. Female who present with ascites, adnexal mass, elevated CA125 are presumed to have ovarian cancer. This can lead to radical surgery with associated morbidity. Case Report- 27 F presented with abdominal pain and distension with no fever, weight loss. CA125 level was 426. Ct s/o left adnexal cystic lesion with abdominal and right supraclavicular lymph nodes, moderate ascites, peritoneal soft tissue densities. Mantoux negative, ascitic fluid cytology was lymphocytic with no malignant cells. Ovarian cancer was highly suspected. Explorative laparotomy with omental biopsy and left oopherectomy done. Frozen section showed granulomas with military granular deposit over omentum. She was started on ATT and is under regular follow up.Conclusion- CA125 levels lack specificity with elevated levels encountered in benign and malignant condition. There are few discriminative features s/o tb than ovarian ca as smooth peritoneal thickening and dirty omentum on Ct s/o tb compared to nodular thickening s/o cancer. Diagnostic laparoscopy/laparotomy should be performed with aid of frozen section in case of discrepancies.