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ABSTRACTS FROM NAPCON 2013
Year : 2013  |  Volume : 30  |  Issue : 5  |  Page : 44-68  

Abstracts for Poster Presentation


Date of Web Publication11-Nov-2013

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How to cite this article:
. Abstracts for Poster Presentation. Lung India 2013;30, Suppl S1:44-68

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. Abstracts for Poster Presentation. Lung India [serial online] 2013 [cited 2019 Nov 20];30, Suppl S1:44-68. Available from: http://www.lungindia.com/text.asp?2013/30/5/44/121190

Case Reports

TB/ INFECTION

Disseminated tuberculosis manifesting as pulmonary, lymphnode and splenic abscess in an immunocompetent patient: A rare case report

Jally Vara Prasad, M. Sravan Kumar, M. G. Krishna Murthy, D. Dhanalakshmi, B. Ramana Prakash


Department of Pulmonary Medicine,

Kakatiya Medical College, Warangal,

Andhra Pradesh, India.

E-mail: varaprasadjally@yahoo.com

Background: Disseminated tuberculosis (TB) refers to involvement of two or more non-contiguous sites. Mycobacterial lymphadenitis comprises about 2% to 5% of all cases of TB. Disseminated mycobacterial lymphadenopathy is rare in non- Human immunodeficiency virus patients. Splenic TB is extremely rare and has no characteristic symptoms or abnormal imaging findings.

Case Report: An 18-years-old male, non-diabetic from low socioeconomic status, presented to out-patient department with recurrent fever, cough, left hypochondrial pain since 4 months and with no past history of TB. His further evaluation revealed right side stony dull note on chest, diminished breath sounds in infra-scapular region, mild splenomegaly, nodal enlargement in the right axilla and left supra-clavicular regions. Past 4 months X-rays mainly showed right mild pleural effusion and left sub-diaphragmatic pathology with progressive deterioration. His lab data were within normal limits, sputum acid fast bacilli (AFB) was negative and HIV was non-reactive. Computed tomography of chest and abdomen showed hepatomegaly with multiple splenic abscesses and few matted lymphnodes in peri-pancreatic area. Pleural fluid analysis showed exudative pattern. Excisional biopsy of left supraclavicular lymphnode showed granulomatous lesion. Ultrasonography guided splenic aspirate culture was AFB positive. The patient was started on anti-tubercular therapy (isoniazid, rifampicinn, pyrazinamide and ethambutol). Patient had symptomatic relief and his general condition was improved.

Conclusion:
This is one of the rare cases of disseminated TB (lymphnode, pleural involvement, splenic abscess) where diagnosis was achieved and confirmed by histopathology as well as culture.

Pancreatic tuberculosis presenting as a mass

Nitin S. Gadewad, Gyanshankar P. Mishra,

S. V. Ghorpade


Department of Pulmonary Medicine, Government Medical College, Nagpur, Maharashtra, India. E-mail: knits3@yahoo.co.in

Background: The incidence of isolated pancreatic tuberculosis is extremely rare. We report here a case of pancreatic tuberculosis which presented as a mass.

Case
Report: A 45-year-old married male, who was a chronic smoker, presented with pain in abdomen, low grade fever along with loss of appetite and weight since 3 months. Physical examination was unremarkable. Investigations revealed a raised erythrocyte sedimentation rate and a positive Mantoux test. Ultrasonography (USG) abdomen showed a hypoechoic lesion in the head and neck of pancreas which was confirmed on computed tomography scan of abdomen as a lobulated non-enhancing mass lesion of 5.3 cm × 3 cm size. There was no evidence of tuberculosis elsewhere in the body. USG guided fine needle aspiration cytology (FNAC) revealed caseating necrosis and positive acid fast bacilli stain. BACTEC culture of FNAC revealed mycobacterium tuberculosis complex. Patient was initiated on anti-tubercular chemotherapy under revised national tuberculosis control program anti-tubercular treatment category I regime, which was extended for 3 months. Patient symptomatically improved after completion of treatment and USG at the end of treatment revealed complete resolution of the mass.

Conclusion:
Tuberculosis should be included in the differential diagnosis of a pancreatic mass and confirmation of diagnosis by histopathological and microbiological methods needs to be done in today's era of evidence based medicine. Also, a good response to anti-tubercular chemotherapy can be expected in such cases thereby obviating the need for a major surgery with its accompanying morbidity.

Endobronchial tuberculosis presenting as malignancy

Shahid Patel, Girija Nair, Aparna Iyer, Abhay Uppe, T. K. Jayalakshmi, Lavina Mirchandani


Department of Pulmonary Medicine, Padmashree Dr. D. Y. Patil Hospital, Mumbai, Maharashtra, India. E-mail: patel_shahid@hotmail.com

Background: Endobronchial tuberculosis is defined as a specific inflammation of the tracheobronchial tree caused by the tubercle bacillus. There are seven subtypes according to the bronchoscopic findings: Actively caseating, edematous-hyperaemic, fibrostenotic, tumorous, granular, ulcerative and non-specific bronchitic type. It is a highly infectious disease and definitive diagnosis depends on culture of mycobacterium from bronchoscopic material.

Case
Report: A 45-year-old female was referred for evaluation of fitness for hysterectomy for dysfunctional uterine bleeding on account of chest X-ray findings. On enquiry she complained of dry cough, low-grade fever, dull-aching chest pain and loss of weight. The X-ray revealed a right upper zone inhomogeneous opacity with air bronchogram. High-resolution computed tomography was suggestive of collapse consolidation with bronchus cut-off sign in right upper lobe, of possible neoplastic etiology with associated multiple rounded discrete nodules. General examination revealed anemia. On respiratory system examination bronchial breath sounds in right infraclavicular area were present. A differential of primary lung malignancy versus secondary metastasis was made. The patient underwent bronchoscopy and a polypoidal white mass lesion was seen at the right upper lobe opening, occluding it. Bronchial wash and biopsy was done. The bronchoalveolar lavage came culture positive for Mycobacterium tuberculosis and the biopsy showed epitheliod granulomas and giant cells. The post bronchoscopy sputum sample showed acid fast bacilli. The patient was started on antitubercular treatment with steroids. 1 month post initiation of treatment the X-ray showed significant resolution.

Conclusion: Endobronchial tuberculosis poses a diagnostic challenge as it may mimic lung carcinoma.

Ethambutol induced optic neuritis leading to bilateral complete blindness in a 20-year-old woman under category-IV regimen for drug-resistant pulmonary tuberculosis

Gopalsing N. Solanke, Arun Kumar S. Roy,

R. Shyam Krishnan, M. Z. Patel


Department of TB and Respiratory Disease, New Civil Hospital Campus, Majura Gate, Surat, Gujarat, India. E-mail: drgopalsing0@gmail.com

Background: Category II (CAT-IV) regimen under revised national tuberculosis control program (RNTCP) has many drugs which may cause grave side effects. Ethambutol may cause reversible ocular toxicity though irreversible visual changes can occur. We report a case of rifampicin resistant tuberculosis, started on CAT-IV regimen under programmatic management of drug resistant tuberculosis under RNTCP who developed ethambutol induced bilateral optic neuritis resulting in progressive worsening of vision and eventually complete blindness.

Case
Report: A 20-year-old female with rifampicin resistant pulmonary tuberculosis presented to our institute with bilateral acute progressive painless visual loss after taking CAT-IV regimen for 15 days. Her therapy comprised of ethambutol 400 mg/day, kanamycin, levofloxacin, pyrazinamide, ethionamide, cycloserine and pyridoxine (16-26 weight band) according to the DOTS-plus guideline. We promptly stopped ethambutol as per the guidelines and an ophthalmologist and a neurologist were consulted. Magnetic resonance imaging brain with orbit was suggestive of changes of optic neuritis. No other co-morbidity was found. We put her on steroids. Despite starting her on steroids, in the next 14 days she continued to have progressive visual loss with bilateral loss of light perception and landed up in bilateral complete blindness. After 6 months follow-up she had no improvement.

Conclusion:
Ethambutol, especially in the CAT-IV regimen under RNTCP where the dose and duration is more, sometimes causes irreversible complete blindness. Proper patient education, tight weight based anti-tubercular therapy, routine visual assessment, testing prior to CAT-IV initiation and periodic follow-up during the course will help in early detection and prompt management of ocular morbidity.

Double mycobacterial infection in a young individual: A case report

Elen Ann Abraham, Babaji Ghewade, Satyadeo Choubey


Department of Pulmonary Medicine, Datta Meghe Institute of Medical Sciences (Deemed University), Wardha, Maharashtra, India. E-mail: elenann153@hotmail.com

Background: Both leprosy and tuberculosis have been prevalent in India since ancient times. Leprosy especially the multibacillary one leads to depressed cell mediated immunity which may either reactivate the latent tubercular infection or make the person susceptible for new infection.

Case
Report: A 25-year-old male presented with complaints of cough with expectoration for 2 months; low grade fever, loss of appetite, loss of weight for 1 month; skin lesions over bilateral legs and arms for 1 month duration. Complete blood count was within normal limits and Human immunodeficiency virus was non-reactive while erythrocyte sedimentation rate (ESR) was 104 mm and sputum acid fast bacilli (AFB) was positive (2+) on 2 consecutive day's samples. Multiple well to ill-defined erythematous and hyperpigmented scaly plaques on upper limb, lower limb, trunk and face were present. Bilateral thickening of the greater auricular nerve, bilateral ulnar nerve, right radial cutaneous nerve and bilateral lateral popliteal nerve and patchy loss of hot and cold sensation on bilateral upper limb was present. Chest X-ray showed bilateral parenchymal infiltrates. Split skin smear from ear lobe and skin patch showed AFB. Skin punch biopsy histopathology showed lepromatous leprosy.

Conclusion:
Reduced inducible chemokine ligand-2 (CCL2) and TNF-alpha response in lepromatous leprosy contributes to unrestricted growth and dissemination of tubercular bacilli. In every case of leprosy, it should be mandatory to screen for active tuberculosis to avoid rifampicin monotherapy and cross resistance.

Miliary-endobronchial tuberculosis-lung malignancy: A rare coexistence

Elen Ann Abraham, Babaji Ghewade,

Mukesh Kumar Sharma, Satyadeo Choubey


Department of Pulmonary Medicine, Datta Meghe Institute of Medical Sciences (Deemed University), Wardha, Maharashtra, India. E-mail: elenann153@hotmail.com

Background: There are evidences on possible association between tuberculosis (TB) and subsequent risk of developing lung cancer in particular, adenocarcinoma. We are reporting a rare case of lung malignancy co-existing with miliary and endobronchial tuberculosis.

Case
Report: A 43-year-old male presented with hemoptysis of 6 months, shortness of breath and left sided chest pain of 1 month duration. No past history of TB or any comorbidity was present. Complete blood count was within normal limits, Human immunodeficiency virus was non-reactive and sputum acid fast bacilli was negative while erythrocyte sedimentation rate was 84 mm. Computed tomography of chest showed diffusely scattered multiple small nodules on all lung fields. Well defined soft tissue attenuation mass with irregular speculated margins was seen in left lower lobe. Fiberoptic bronchoscopy showed erythematous and whitish patches along with mucosal edema in lingular and lower lobe bronchus of left side along with narrowing of anterior and lateral basal segments of lower lobe bronchus. A diagnosis of edematous hyperemic type endobronchial TB was made. Bronchial biopsy showed histopathological features of tuberculosis. Bronchial brush smear showed mucin secreting adenocarcinoma. Ultrasonography guided fine needle aspiration cytology of chest lesion also showed mucin secreting adenocarcinoma.

Conclusion:
Tuberculosis and lung malignancy may co-exist within the same pulmonary lesion as well as in separate lesions. Lung malignancy may occur in long standing or chronic TB and is well reported e.g., occurrence of cancer in tubercular scar. But in the present case both pathologies were present together.

A case report of parotid tuberculosis in a middle aged female patient with good response to anti-tubercular treatment

U. Sharma, S. Chaurvedi, S. Jain, A. Kharate, S. Avashia, S. Bhargava


Department of Respiratory Medicine, MGM Medical College and MY Hospital, Indore, Madhya Pradesh, India. E-mail: ujjwalsharma004@gmail.com

Background: Tuberculosis of the parotid gland is a rare condition. We describe a case of tuberculosis of left parotid gland in a 24-year-old female patient. Diagnosis was made by early suspicion and confirmed by demonstration of epitheloid granulomas on fine needle aspiration cytology (FNAC).

Case
Report: 24-years-old female presented with swelling of right parotid region for the last 1 year. The swelling was slow-growing and painful. History of fever was present. No history of cough, hemoptysis and difficulty in swallowing was present. There was no past history of tuberculosis in the patient or the family. On examination, there was a single swelling present in the right parotid region of size 6 cm × 5 cm, extending just below the pinna. The swelling was round with ill-defined borders and mild tenderness. Local temperature was not raised. On FNAC examination of the swelling, epitheloid cells and salivary ductal and acinar cells were present. Ziehl Neelsen staining was negative. Mantoux test was highly positive (induration of 15 mm × 18 mm). Erythrocyte sedimentation rate was raised. Chest X-ray was normal. Sputum examination was negative for acid fast bacilli. Antitubercular drugs were given. The swelling completely resolved after 4 months of treatment. Patient was followed-up for 4 months period and there was no recurrence.

Conclusion: Although rare, tuberculosis should be kept in mind and considered in the differential diagnosis of any patient presenting with a solitary tumor in the parotid gland.

A case of extensive renal tuberculosis

A. Raghavender Reddy, K. Satish Chandra, C. N. Prasad, B. Shrikanth


Department of Pulmonary Medicine, Prathima Medical College, Nugnur, Karimanagar. E-mail: raghu.annela@gmail.com

Background: Renal tuberculosis is a rare entity now-a-days. It forms 27% of all extrapulmonary tuberculosis. Ureteric involvement is seen in 2-7% of renal tuberculosis. Bilateral involvement of ureters is very rare.

Case Report: A young male presented with pyrexia, cough and left loin pain. Ultrasonography abdomen and computed tomography abdomen showed bilateral pyelonephritis with a hydronephrosis on right side and abscess noted in the left kidney and contracted bladder. Right ureteric stricture was noted in upper and lower one third and left ureteric stricture on lower one third with renal abscess on retrograde pyelography. Bilateral percutaneous nephrolithotomy under local anesthesia was done and pus was drained from left kidney which showed acid fast bacilli (AFB) stain and AFB culture positivity. Patient was started on antitubercular therapy and showed clinical improvement on follow-up.

Conclusion: Bilateral ureteric stricture due to tuberculosis is a rare entity.

Tubercular elbow joint sinovitis coexisting with inguinal lymphadenopathy: A rare case presentation

Kamal Deep, A. P. Kansal, Naresh Kumar, Kalpesh Patel


Department of Pulmonary Medicine, Govt. Medical College, Patiala, Punjab, India. E-mail: kdeep.kamal@gmail.com

Background: Tuberculous arthritis and tenosynovitis of the elbow joint are relatively rare as compared with other joints. Making an early diagnosis is often difficult and treatment is therefore frequently delayed. Synovial thickening of the radiohumeral segment of the articulation can be normally felt, particularly if the synovium is involved.

Case Report:
A 28-year-old male presented to us with chief complaints of pain and discharge from sinus in the left elbow joint, fever on and off from 8 month. On examination, the patient had swelling at level of left elbow with discharging sinus on the back of elbow. The patient was not able to flex the arm due to spasm of muscles. The patient also had swelling in inguinal area of about 5 × 5 cm size, soft in consistency. Pus around 5 ml was aspirated from inguinal swelling. Acid fast bacilli was positive in pus from both sites. X-ray of elbow joint showed that bones were not involved. The patient was started on revised national tuberculosis control programme category I to which he responded well.

Conclusion:
Tuberculosis of the elbow, like pyogenic arthritis, is characteristically a mono-articular disease, although multifocal osteoarticular tuberculosis does occur. The diagnosis depends on the recognition of M. tuberculosis on either histologic study or culture, or, ideally, both. Juxta-articular osteoporosis and swelling of soft tissue are the earliest roentgenographic changes observed when involvement of a joint occurs. A high level of clinical vigilance is needed to make an early diagnosis of tuberculous synovitis.

Presentation of a combination of laryngeal carcinoma associated with pulmonary tuberculosis

R. Ramakrishna, Bhanu Naik, G. Nageswara Rao, M. Venu, Jayabharat Reddy


Department of Pulmonology, Katuri Medical College, Guntur, Andhra Pradesh, India. E-mail: Ramakrishna45@yahoo.co.in

Background: Tuberculosis and carcinoma may present as mass lesions but their coexistence may pose a problem in diagnosis.

Case
Report: A 65-year-old male patient presented to Katuri Medical College OPD with symptoms of cough with expectoration, fever, loss of weight of 3 months and hoarseness of voice. Patient was treated by an ear-nose-throat (ENT) surgeon for hoarseness and laryngeal obstruction 10 days before. Lower tracheostomy was done to overcome the obstruction. Endoscopic biopsy was attempted by the ENT surgeon two times for the subglottic laryngeal mass and the result was negative for malignancy. Routine chest X-ray revealed bilateral upper zone infiltrative lesions suggestive of tuberculosis. Computed tomography of neck and chest revealed soft tissue mass lesion involving right true vocal cord, glottis area and aryepiglottic fold. Bronchoscopically entire area of false vocal cords and aryepiglottic folds were oedematous in continuation with supraglottic mass. Sputum as well as bronchial washing was positive for acid fast bacilli. As patient did not improve with antitubercular treatment (ATT), a repeat contrast enhanced computed tomography of neck was done after 2 weeks to assess the vascularity of lesion and suitability for biopsy. It showed an increase in the size of the mass lesion. We did percutaneous fine needle aspiration cytology with help of radiologist. The pathology report revealed a squamous cell carcinoma with secondary infection. Patient was referred to oncology on ATT.

Conclusion:
Physicians should be aware that combinations do exist and should not be ignored in the interest of the patient.

A case of secondary haemophagocytic lymphohistiocytosis caused by tuberculosis

U. Maheswar Chandrakantham, R. Narasimhan, K. Anand Babu, Mamta Soni


Department of Respiratory Medicine, Apollo Hospital, Chennai, Tamil Nadu, India. E-mail: chandrakanthmahesh@gmail.com.

Background: Haemophagocytic lymphohistiocytosis (HLH) is a rare hyper inflammatory syndrome characterized by abnormal and uncontrolled activation of macrophages leading to phagocytosis of mature blood cells. It may be inherited or may be secondary to infections, haematological malignancies or rheumatological diseases.

Case Report: Hereby we reported a case of 31-year-old gentleman who came with history of receiving antitubercular treatment (ATT) for last 3 months for fine needle aspiration cytology (FNAC) proven tuberculosis of right supraclavicular lymph nodes without any significant improvement noticed in his systemic symptoms. On further evaluation, he was found to have pancytopenia, splenomegaly and radiological features of right upper lobe collapse with mediastinal adenopathy on computed tomography scan of chest. Re-work-up showed necrotizing granulomatous inflammation of the endobronchial biopsy of the mass lesion obstructing right upper lobe bronchus as well as acid fast bacilli were visualized on FNAC of right supraclavicular lymph node. Bone marrow biopsy revealed hemophagocytosis which is characteristic for HLH. A quick response was noticed with the addition of oral steroid to ATT in a dose of 1 mg/kg, which was tapered over a period of 8 weeks. Follow-up after 8 weeks period showed significant clinco-radiological improvement.

Conclusion:
Even though the HLH caused by tuberculous infection is rare and fatal, the strong suspicion of HLH and early initiation of appropriate treatment can reduce the mortality significantly.

Enigmatic presentation of pulmonary tuberculosis: Acute pulmonary embolism

Pankaj Gupta, Savita Jindal, Nalin T. Shah, Kusum V. Shah


Department of Pulmonary Medicine, BJMC, Ahmedabad, Gujarat, India. E-mail: pankajkmrgpt4u@gmail.com

Background: Pulmonary tuberculosis is prevalent in developing countries but its thrombogenic potential is less well studied.

Case
Report: A 27-year-old dentist presented with dyspnea on exertion, cough with expectoration of acute onset. His chest X-ray was normal. He underwent computed tomography pulmonary angiography which confirmed pulmonary embolism with small parenchymal opacity with early cavitation and perifocal ground glass opacity in right lower lobe suggestive of septic emboli with mediastinal lymphadenopathy. Patient was thrombolysed with tenecteplase. Lower limb venous Doppler was normal. Patient's coagulation profile was normal. Serum angiotensin converting enzyme levels were within normal limits. Multidetector row computed tomography (MDCT) of neck and axilla showed bilateral level II lymph nodes. MDCT abdomen and pelvis was normal. 2D-echocardiography showed severe pulmonary arterial hypertension and right ventricular dysfunction. After hemodynamic stabilization with antiplatelet drugs, patient was provisionally diagnosed as sarcoidosis and discharged with steroids. Thereafter, patient again presented with dry cough and dyspnea on exertion after 2 months. Bronchoscopy was done which revealed normal bronchial orifices and bronchial mucosa but there was external compression from subcarinal lymph node. Transbronchial needle aspiration was suggestive of chronic inflammatory changes. Bronchoalveolar lavage culture (including C/S for acid fast bacilli) and cytology were negative. Mantoux test was positive. Interferon-gamma release assays was also highly positive. Patient improved with anti-tubercular treatment.

Conclusion:
One should try to find out the illnesses associated with pulmonary embolism.

Limited Wegener's granulomatosis with pulmonary tuberculosis

R. Sumithra, Hariprasad D. Ranganathan, N. Meenakshi


Department of Thoracic Medicine, Madras Medical College, Chennai, Tamil Nadu, India. E-mail: sunilmithrar@gmail.com

Background: Wegener's granulomatosis (WG) is a multi-systemic disease characterized by a small and medium vessel, necrotizing granulomatous vasculitis affecting predominantly the lower and upper respiratory tract, lung and kidneys. The prevalence of the disease is about 3 persons per 100,000 people; equally in both sexes. The German pathologist Friedrich Wegener first described the disease in 1936. In limited WG may be restricted to respiratory system.

Case Report: 43-year-old female patient admitted with complaints of haemoptysis, breathlessness, chest pain without history of fever, loss of appetite, loss of weight and contact with pulmonary tuberculosis, or prior antitubercular treatment (ATT). Chest X-ray showed bilateral multiple nodular opacities with cavity and computed tomography of chest showed bilateral multiple sub-pleural nodules and cavitary lesions. Pneumorrhachis3-anti-neutrophil cytoplasmic antibody positive, p-ANCA positive, sputum acid fast bacilli was positive. Ultrasonography abdomen and contrast enhanced computed tomography of abdomen showed only simple renal cortical cyst. We started category-I ATT for this patient and planned to start immunosuppresive drugs after lung biopsy report.

Conclusion:
Tuberculosis and WG are difficult to differentiate. In both cases, the main clinical finding includes hemoptysis. Radiological presentation can be the same in both diseases. Sometimes, patients with WG have been mistakenly treated for pulmonary tuberculosis.

Tubercular chest wall abscess in human immunodeficiency virus: A case report

V. Elakya, R. Sridhar, O. R. Krishnarajasekhar, C. Chandrasekar


Department of T.B. and Respiratory Diseases, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India. E-mail: uryazhs@yahoo.co.in

Background: Tuberculosis and Human immunodeficiency virus (HIV) are diseases of major public health importance. HIV has played a significant role in modification of natural history of tuberculosis.

Case
Report: A 45-years-old male patient admitted in our ward with complaints of chest wall swelling and cough for 2 weeks. Patient had completed 6 months of category I anti-tuberculous treatment in March 2013. Patient was found to be HIV positive. His CD4 count was only 3. On examination, soft swelling of 10 cm × 12 cm was seen in right mammary area suggestive of abscess. 50 ml of pus was aspirated. Pus revealed acid fast bacilli 3+. Further investigations showed pancytopenia. Blood transfusion was given. Chest X-ray showed haziness in right upper and mid zone. Lateral X-ray showed soft tissue swelling anterior to sternum. Magnetic resonance imaging chest was taken and non-dependent drainage of pus was done. Patient was started on category II antitubercular treatment and antiretroviral therapy. Patient improved and swelling subsided.

Conclusion:
HIV may lead to varied manifestations of tuberculosis.

An interesting case of pancoast tumor caused by adenocarcinoma of lung in HIV-II patient

G. Nageswara Rao, M. Venu, Bhanu Naik, Jayabharath Reddy, R. Ramakrishna


Department of Pulmonology, Katuri Medical College,

Guntur, Andhra Pradesh, India.

E-mail: ramakrishna45@yahoo.co.in

Background: Pancoast tumor also known as superior sulcus tumor is commonly caused by squamous cell carcinoma of lung. Here we present a case of pancoast tumor caused by adenocarcinoma in a Human immunodeficiency virus (HIV)-II patient.

Case Report: A 60-year-old male presented with symptoms of dry cough, pain over right shoulder and arm and weight loss since 4 month. On clinical examination, he was found to have partial ptosis of right eye, enopthalmos, miosis, ipsilateral anhydrosis and grade-III clubbing of fingers. He was pale, emaciated, ill-built and chronic heavy smoker. Supra scapular fossa was full and tender on right side. His blood profile showed moderate degree of anemia and surprisingly found to be positive for HIV-II antibodies. This was further confirmed by ELISA. Sputum acid fast bacilli (AFB) was negative on two samples. High-resolution computed tomography showed a 6 cm × 5 cm size homogenous non-enhancing mass with destruction of posterior ends of first and second ribs. Ultrasonography abdomen shows hepatomegaly with no evidence of free fluid or any metastatic foci. Flexible bronchoscopy showed extrinsic compression on the right upper lobe bronchus. No endoluminal growth was seen and bronchial washings were negative for malignant cytology and AFB. Ultrasound guided fine needle aspiration cytology of mass lesion histologically was consistent with adenocarcinoma. He responded well to thoracic radiotherapy and chemotherapy with Cisplatin plus etoposide.

Conclusion:
Adenocarcinomas may also present with symptoms of Horner's syndrome. In unresectable cases, locally advanced stages concurrent chemoradiotherapy is helpful. Routine antiretroviral drugs are ineffective in HIV-II patients.

Unusual presentation of aspergillus lung disease

Pradeep S. Goudar, Lavina Mirchandani, Aparna Iyer, Girija Nair, T. K. Jayalakshmi, Abhay Uppe


Department of Pulmonary Medicine, Padmashree Dr. D. Y. Patil Hospital, Mumbai, Maharastra, India. E-mail: pradeepsgoudar6543@icloud.com

Background: Aspergillus species are ubiquitous fungi and cause a spectrum of diseases. Infection is acquired by inhalation of airborne spores. In cases of pneumonia not responding to antibiotics the possibility of aspergillus lung infection should be considered and appropriate investigations done.

Case 1: A 28-year-old female, immunocompetent, presented with complaints of fever, cough and dyspnoea since 15 days. X-ray chest showed right lower zone consolidation. HRCT showed consolidation with perilesional ground glass appearance and nodular lesions. Patient had no improvement after antibiotics. Bronchoscopy was done and washings showed Aspergillus niger. Patient responded clinically and radiologically to Itraconazole.

Case 2: A 28-year-old male with occupational exposure to dust and fungi, with childhood asthma presented with X-ray chest showing bilateral abscess. Patient was asymptomatic on presentation. HRCT confirmed X-ray findings. Serum IgE were elevated and skin prick test for aspergillus was positive. Sputum sent for culture grew Aspergillus niger. There was complete resolution of abscesses following initiation of antifungal and steroids.

Case 3: A 32-year-old female with persistent allergic rhinitis and wheeze was referred for left upper zone consolidation. The patient had been misdiagnosed as tuberculosis and had received treatment for it. HRCT confirmed left upper lobe mucus impaction with finger in glove appearance. Serum IgE and specific IgE to aspergillus fumigatus were elevated. Sputum grew candida. Complete resolution was observed following treatment.

Conclusion: Case 1 fits into the criteria for probable invasive aspergillosis as per EORTC/MSG consensus while Case 2 and 3 fit into the criteria for allergic bronchopulmonary aspergillosis as per Rosenberg Patterson criteria. The radiological presentation in Case 2 was uncommon and so were the fungi isolated in Case 2, 3.

A case of recurrent lower respiratory tract infection: Common variable immunodeficiency

V. S. Hariprasad, R. Manju, M. K. Panigrahi, Pratap Upadhya


Department of Pulmonary Medicine, JIPMER,

Puducherry, India. E-mail: hariprasadkalpakam@yahoo.com

Background: Common variable immunodeficiency is a primary immunodeficiency disorder characterized by impaired B-cell differentiation with defective immunoglobulin production. It is most prevalent form of severe antibody deficiency affecting both children and adults. Variable refers to the heterogeneous clinical manifestations of this disorder which include recurrent infections, chronic lung disease, autoimmune disorders, gastrointestinal diseases and heightened susceptibility to lymphoma.

Case Report: A 34-year-old male agricultural laborer from a low socioeconomic status presented with complaints of cough with expectoration and breathlessness of 10 days duration. History of recurrent respiratory illness since childhood was present and he had repeated hospitalizations for the same. Patient also had recurrent diarrheal episodes, recurrent CSOM and polyarthritis. He was retroviral negative. Computed tomography chest showed features of lower lobe bronchiectasis with active infection. Upper gastrointestinal endoscopy was normal. A possibility of underlying immunosuppression was considered. Serum immunoglobulins were measured. Reduced serum immunoglobulins (IgE, IgG and IgM) were noted. A diagnosis of common variable immunodeficiency was made. Since this disease is known to have autosomal dominant inheritance, his 8 month old girl was screened for serum immunoglobulin levels and she also had reduced immunoglobulin levels.

Conclusion: A detailed past history of patient presenting with respiratory infections is important. A diagnosis of common variable immunodeficiency should be suspected in any patient presenting with infections at multiple sites in the past.

Unusual cause of right upper lobe mass

R. G. Gomathi, T. Dhanasekar, K. Sreedevi, P. Durai Kannan


Department of Chest Medicine and TB, Sri Ramachandra Medical Centre, Porur, Chennai, Tamil Nadu, India. E-mail: drgomathi22@yahoo.com

Background: Nocardiosis is an infrequent but potentially serious pulmonary infection caused by a soil borne filamentous bacteria belonging to the genus Nocardia. The organism infects both immunocompromised and immunocompetent individuals. The apparent rarity of the disease is probably due to failure to recognize the clinical manifestations and findings of pulmonary nocardiosis. Usually pulmonary nocardiosis presents as cavitatory nodules and consolidation.

Case Report: 67-year-old male, a known case of diabetes, was admitted with complaints of fever and non-productive cough for a period of 2 weeks. His chest X-ray revealed homogenous opacity in right upper zone. Sputum was negative for acid fast bacilli. Computed tomography scan of chest showed right upper lobe mass with spiculated margins suggestive of malignancy. Initial computed tomography guided biopsy done was inconclusive. Fibreoptic bronchoscopy with bronchoalveolar lavage revealed filamentous gram positive, acid-fast bacteria suggestive of Nocardia species, which was confirmed by bacterial culture for Nocardia species. Patient showed a dramatic improvement with cotrimoxazole therapy given for 6 weeks. Chest X-ray done at the end of 6 weeks showed complete resolution of right upper zone lesion.

Conclusion: The case mentioned above is rare form of presentation of pulmonary nocardiosis.

Chronic necrotizing fungal pneumonia presenting as a lung mass: A rare entity

R. Jackin, M. Madhusmita, K. H. Kisku, G. V. Renu


Department of Pulmonary Medicine, Pondicherry Institute of Medical Sciences, Puducherry, India. E-mail: drjackinmoses@gmail.com

Background: Chronic necrotizing aspergillosis is characterized by tissue necrosis and destruction with granulation tissue formation almost similar to reactivation of tuberculosis. This disease process generally does not erode into the blood vessels. It is commonly associated with mild immunosuppression and in patients with pre-existing lung disease. Common presentations include chronic cough and sputum production in an immunocompromised patient but reports of hemoptysis has been well documented.

Case Report: We present a 38-year-old female recently diagnosed as rheumatoid arthritis and on immunosuppressive agents came with chief complaints of hemoptysis, cough with expectoration since 30 days. Patient did not have any pre-existing pulmonary ailment. Patient, on evaluation, was found to have a mass lesion which was seen encroaching on the mediastinum. A computed tomography guided biopsy was done which revealed tissue necrosis with fungal elements having acute angle branching. Patient was diagnosed as chronic necrotizing pulmonary aspergillosis and given a course of anti-fungal drug. Patient is currently doing well and is on regular follow-up in our hospital.

Conclusion: Chronic necrotizing aspergillosis itself may present as a mass lesion other than that due to associated aspergilloma.

A rare presentation of actinomycosis

C. Anil Kumar, R. Narasimhan, Manish K. Sharma, K. Anand Babu


Department of Respiratory Medicine, Apollo Hospitals, Chennai, Tamil Nadu, India. E-mail: dr.ch.anilkumar@gmail.com

Background: Pulmonary actinomycosis is caused by gram positive, anaerobic, non-spore-forming bacteria belonging to family Actinomyceataceae. It is a rare and challenging diagnosis, often confused with malignancy or chronic suppurative lung disease. The most common form of actinomycosis is cervicofacial type which attributes to 50% whereas the pulmonary actinomycosis contributes to 15%.

Case
Report: We report a case of a 55-year-old lady who presented with dry cough associated with chest pain since 3 months and occasional hemoptysis. Chest X-ray showed right hilar opacity. Computed tomography of the chest showed obstructed superior segmental bronchus of the right lower lobe (RLL) with distal consolidation. Fibreoptic bronchoscopy showed necrotic tissue completely occluding RLL common basal segment with endobronchial irregularity. Narrow band imaging did not show any abnormal vascularity. Histopathological examination showed features consistent with actinomycosis. She was treated with 4 weeks course of benzyl penicillin and subsequently changed to oral pencillin derivatives.

Conclusions:
Pulmonary actinomycosis should be considered as a differential for persistent pulmonary shadows. Early diagnosis would obviate unnecessary surgery of a highly treatable disease with good prognosis.

CRITICAL CARE

A case of pneumonia with weaning difficulty

C. Ramanjula Reddy, Raj B. Singh, Manish K. Sharma


Department of Respiratory Medicine, Apollo Hospitals Chennai, Tamil Nadu, India. E-mail: doctorramanjulareddy@gmail.com

Background: Neuromuscular problems are frequent complications in patients requiring prolonged intensive care unit (ICU) stay. Critical illness, more precisely defined as the systemic inflammatory response syndrome, occurs in 20-50% of patients who have been on mechanical ventilation for more than 1 week in an intensive care unit.

Case
Report: Here we report a case of a 70-year-old lady, a known diabetic and hypertensive, admitted with type1 respiratory failure secondary to multilobar pneumonia. Gradually her oxygen status improved and radiological clearance of parenchymal opacities was achieved but she continued to require prolonged ventilatory support. This was found to be due to neuromuscular weakness preventing weaning from the ventilator. Nerve conduction study (NCS) showed bilateral sensory-motar neuropathy predominantly of lower limbs which raised suspicion of probable critical illness myopathy (CIM) and critical illness polyneuropathy (CIP). CNS causes of weakness were ruled out with imaging studies of brain which showed only age related changes. CIP and CIM are common complications of critical illness seen in ICU and present with muscle weakness and failure to wean from the ventilator. CIP and CIM are difficult to distinguish from each other on pure clinical grounds. NCS, electromyogram and muscle biopsy are necessary to confirm the diagnosis.

Conclusion:
Prognosis of this condition depends on the severity of the underlying illness, duration of ventilatory support, the age of the patient and early diagnosis. Early institution of physiotherapy, appropriate nutritional support and strict glycemic control played a major role in recovery and favored outcome in this patient.

Myotonic dystrophy presenting as hypercapnic respiratory failure

Ajmal Khan, Alok Nath, Zia Hashim, Jeetendra Kumar Patra


Department of Pulmonary Medicine, Sanjay Gandhi Postgraduate Institute of Medical Sciences, Lucknow, Uttar Pradesh, India. E-mail: drajmal13@gmail.com

Background: Myotonic dystrophy is an inherited multisystemic disease with chronic, slowly progressing and highly variable course, characterized by muscle wasting, cataracts, conduction defects, endocrine changes and myotonia. Respiratory failure at presentation is rare.

Case Report: A 30-years-old male with known diabetes mellitus and hypertension presented with high grade fever for 5 days associated with severe breathlessness and generalized weakness. He also had history suggestive of mental retardation with similar neurological complaint in the sibling. On examination, bilateral basal crepitations were present. Arterial blood gas analysis showed type II respiratory failure. Electrocardiogram findings were suggestive of left bundle branch block however 2D-ECHO was normal. Neurological examination was suggestive of myotonic dystrophy which was confirmed by electromyogram, nerve conduction velocity and cytosine-thymine-guanine (CTG) repeats on mutational analysis. Chest X-ray and CT-angiogram was normal. Polysomnography revealed apnoea hypopnoea index -30 with predominant central apneas. Reduced diaphragmatic excursion was evident on fluoroscopy. A final diagnosis of myotonic dystrophy Type I with Type II respiratory failure was made. He was managed by supplemental oxygen and non-invasive ventilation and optimization of medical management.

Conclusion: Respiratory failure is a life-threatening complication of myotonic dystrophy. It is caused by abnormal expansion of CTG repeats. Although diaphragmatic weakness is the predominant mechanism of respiratory failure, altered regulation of breathing has also been suggested. Respiratory failure at presentation in myotonic dystrophy is uncommon, high index of suspicion and precise diagnosis and management is crucial.

ASTHMA

ABPA without asthma: A case series

A. P. Kansal, Komaldeep Kaur, Kalpesh B. Patel, Don Gregory Mascarenhas


Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India. E-mail: drkalpeshpatel@hotmail.com

Background: The prevalence of allergic bronchopulmonary aspergillosis (ABPA) in asthma clinics is reported to be around 13%. We are reporting cases of ABPA having no history of asthma.

Case 1: A 19-year-old female patient presented with complaints of fever, cough with expectoration and hemoptysis, was on antitubercular therapy since 5 months with no significant improvement of symptoms. Chest radiograph showed a cavitory lesion on right side, sputum for acid fast bacilli (AFB) was negative. Patient was further investigated and diagnosis of ABPA was confirmed. Patient was started on deflazacort 30 mg daily along with oral antifungal therapy. Subsequent follow-up showed reduction in cavitory lesion with resolving symptoms.

Case 2: A 49-year-old male patient presented with complaints of cough, breathlessness, chest pain, low-grade fever and chest radiograph showing right upper zone involvement. Sputum for AFB was repeatedly negative. Chest computed tomography scan showed bronchiectatic changes. On index of suspicion, skin prick test was performed which was strongly positive, along with raised total IgE and specific IgE and IgG for A. fumigatus, thus diagnosis of ABPA was established. Patient responded well to corticosteroid therapy.

Case 3: A 30-year-old male presented with cough, chest pain having lower zone involvement on chest skiagram was also diagnosed as ABPA and showed improvement with corticosteroids and antifungal therapy.

Conclusion:
As ABPA is very rarely diagnosed in patients without a history of asthma. The possibility of ABPA should be kept in mind even if there is no asthma present.

Aerospace: A rare case of pneumoracchis with spontaneous subcutaneous emphysema after an exacerbation of bronchial asthma

M. Madhusmita, K. H. Kisku, D. Phansalkar


Department of Pulmonary Medicine, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India. E-mail : drmadhusmita1@gmail.com

Background: Pneumorrhachis (PR), the presence of intraspinal air, is an exceptional but eminent radiographic finding, secondary to different etiologies and possible pathways of air entry into the spinal canal. Intraspinal air is usually found isolated not only in the cervical, thoracic and less frequently, the lumbosacral regions but can also be located in the entire spinal canal. PR usually represents an asymptomatic epiphenomenon but can also be symptomatic by itself as well as by its underlying pathology. The latter, although often severe, might be concealed and has to be examined carefully to enable adequate patient treatment.

Case
Report: We present a 17-year-old boy who was admitted with a diagnosis of exacerbation of bronchial asthma. He was a diagnosed case of bronchial asthma 2 years back but was not on regular treatment. On examination he was found to have palpable crepitus around the neck and anterior chest wall. computed tomography chest revealed multiple pockets of subcutaneous emphysema, pneumomediastinum and penumoracchis. He improved on conservative management.

Conclusion:
The pathogenesis and aetiologies of PR are multifold and can be a diagnostic challenge.

SMOKING

Case report on vanishing lung syndrome

Hardikkumar V. Desai, Milan Jiyani, Sunil Amin, Parul Vadgama


Department of Pulmonary Medicine, Surat Municipal Institute of Medical Education and Research, Surat, Gujarat, India. E-mail: hardikdesai3288@yahoo.in

Background: Vanishing lung syndrome is defined as large bullae involving at least one-third of hemithorax mostly in upper lobes. It usually occurs in young men with a history of smoking and marijuana abuse. Its progressive nature may cause exercise intolerance, worsening dyspnea and occasionally spontaneous pneumothorax. Surgical resection in form of bullectomy is the treatment of choice.

Case Report: A 22-year-old young male with history of tobacco smoking (7 pack years), tobacco chewing (7 years) and marijuana abuse (5 years), shopkeeper presented to us with breathlessness at rest and dry cough since 5 days. On physical examination, he was tachypnoeic and right side of chest was hyper resonant with absent breath sounds. X-ray chest was suggestive of large bulla on right side with collapse of right lung. Contrast enhanced computed tomography confirmed the findings of chest X-ray. His alpha 1 antitrypsin was normal. Spirometry was suggestive of restrictive defect. We subjected the patient to right side bullectomy. The post-operative chest radiograph showed complete expansion of the right lung and a significant improvement in post-operative spirometry.

Conclusion: Smoking and marijuana abuse are found to result in vanishing lung syndrome. The patient commonly presents with chest pain and progressive dyspnea. The computed tomography thorax should be done to confirm bullous lung disease. Asymptomatic bullae should be managed conservatively with reassurance, advice to stop smoking and avoiding strenuous activities. Symptomatic patient with progressive dyspnea should undergo surgery in form of bullectomy.

LUNG CANCER

Anterior mediastinal mass: A case of thymoma

M. Kavitha Devi, Bency Koickal Thomas, S. Yuvrajan


Department of Pulmonary Medicine, Sri Manakula Vinayagar Medical College and Hospital Kalitheerthalkuppam, Madagadipet, Puducherry, India. E-mail: kavimohanraj@gmail.com

Background: Thymoma, the most common neoplasm of the anterior mediastinum, originates within the epithelial cells of the thymus.

Case Report: We hereby present a case of 52-year-old male presented to out-patient department with a history of dry cough, wheezing and breathlessness for past 6 months. General and chest examination were within normal limits and routine blood investigations revealed no abnormality. Chest radiography showed a well defined homogenous opaque shadow obscuring the right heart border near the hilum. Contrast enhanced Chest computed tomography (CT) revealed a well defined ovoid hypodense mass of size 4.4 cm × 8.0 cm × 5.0 cm in the anterior mediastinum. Following which CT guided fine needle aspiration cytology was done which showed highly cellular smear composed of cohesive clusters and sheets of ovoid to spindle thymic epithelial cells with distinct cell borders and moderate cytoplasm. The cells were admixed with reactive lymphocytes. The above features were suggestive of benign thymoma.

Conclusion: Thymoma is a common neoplasm of the anterior mediastinum but high index of suspicion is needed to diagnose it early.

Bronchial carcinoid: A rare cause of recurrent pneumonia in adolescence

Dheeraj Rao Ch, Rameshwara Kumar, Rajesh Palvai, Pragati, Kalyan Kumar, Nirupama Devi Raju Ch, A. Sathya Prasad


Department of Pulmonary Medicine, Mamatha General Hospital, Khammam District, Andhra pradesh, India. E-mail: kalyankambampati@gmail.com

Background: Carcinoid tumours are neuroendocrine tumours that occur mainly in intestines, in middle aged populations. Bronchial carcinoid affects 2 persons/million population per year and represents 1-2% of all lung malignancies. Lung malignancies are generally rare in adolescence and usually bronchial adenomas are more common.

Case Report: We report a case of 16-years-old male who presented with fever, productive cough, breathlessness and streaky haemoptysis since 10 days. Patient had 2 episodes of similar complaints in the past 1 year where symptoms were resolved with antibiotics. Chest X-ray showed atelectasis of few segments of right lower lobe. Computed tomography (CT) thorax showed right lower lobe atelectasis with consolidation. Fibreoptic bronchoscopy revealed a pinkish glistening polypoidal mass in right intermediate bronchus. Biopsy was not possible as it was bleeding. Patient was referred to CT surgeon and underwent right lower lobe bronchus sleeve resection surgery. Histopathology of mass was confirmatory of bronchial carcinoid.

Conclusion: The possibility of bronchial carcinoid in adolescene as a cause of recurrent pneumonia cannot be ruled out. Early intervention can prevent further complications as it has malignant potential and can lead to carcinoid syndrome.

Non-Hodgkins lymphomas presenting as anterior mediastinal mass: A case series

K. Sateesh Chandra, P. Subba Rao, Ch. R. N. Bhushan Rao, V. Surya Kumari


Govt. Hospital for Chest and Communicable Diseases, Chinnawaltair, Visakhapatnam, Andhra Pradesh, India. E-mail: dr.sateeshchandra@yahoo.in

Introduction: Non-Hodgkins lymphomas (NHL) are a heterogeneous group of lymphoproliferative disorders originating in B-lymphocytes, T-lymphocytes or natural killer cells, usually presenting as peripheral lymphnode enlargement, may also present as a mediastinal mass.

Materials and Methods: Here in, we report three patients presenting with mediastinal widening and pleural effusion on chest X-ray who were admitted and investigated. Routine investigations including pleural fluid analysis and pleural fluid adenosine deaminase (ADA) were done in all patients. Contrast enhanced computed tomography of thorax, fine needle aspiration cytology (FNAC) of lymphnode, FNAC/biopsy of mediastinal mass with image guidance, peripheral smear were done as indicated in order to arrive at a diagnosis.

Results: In all the three cases, non-Hodgkins lymphoma was found to be the cause of mediastinal widening and pleural fluid had lymphocyte predominance with high ADA levels, mean ADA level being 280 U/L.

Conclusion: Lymphomas should be kept in mind while evaluating a case of mediastinal mass as they are aggressive tumors but have excellent response to chemotherapy hence early diagnosis carries a good prognosis. Although high ADA levels in lymphocytic rich effusions are usually suggestive of tuberculous pleurisy, non-tuberculous effusions like lymphomas may also exceed the diagnostic cutoff for tuberculosis.

Diffuse large B-cell lymphoma presenting as multiple pulmonary nodules and gastric ulcer in a patient with HIV infection on highly active anti-retroviral therapy

T. Angel Miraclin, Ravikar Ralph, Manika Alexander, Thambu David


Department of Medicine, Christian Medical College Hospital, Vellore, India. E-mail: angel_miraclin@yahoo.com

Background: The increased survival rates in patients with human immunodeficiency virus infection following the introduction of highly active antiretroviral therapy and prophylaxis against various opportunistic pathogens have increased the occurrence of non-infectious complications of human immunodeficiency virus (HIV) infection. The occurrence of intermediate and high grade non-Hodgkin's lymphoma is 60% higher in immunocompromised host than that in the general population. Diffuse large B-cell lymphoma (DLBCL) is the most common histological subtype of non-Hodgkin's Lymphomas, 40% of them among the immunocompromised present with extranodal disease involving skin, gastrointestinal tract. Diffuse large cell lymphoma presenting as pulmonary metastases as an initial presentation is a rare entity.

Case
Report: We present a case of 40-year-old lady, a known patient with HIV infection, on highly active antiretroviral therapy for 2 years who presented with pyrexia of unknown origin associated with dry cough and progressive breathing difficulty. Her chest radiography revealed multiple pulmonary nodules. On further evaluation, it was diagnosed as gastric DLBCL with pulmonary metastasis.

Conclusion:
Pulmonary manifestations in HIV infection is usually secondary to various opportunistic infections, however the possibility of malignancy especially acquired immunodeficiency syndrome associated lymphoma should be considered especially when patients present with HIV infection on prolonged highly active retroviral therapy.

Pulmonary lymphoma mimicking a metastasis: A case report

R. Manju, G. Vishnukanth, Pratap Upadhya, Aniruddha Udupa


Department of Pulmonary Medicine, JIPMER, Puducherry, India. E-mail: mail2 manju22@gmail.com

Background: Primary T-cell lymphoma is a rare entity which constitutes <1% of non-Hodgkin's lymphoma in general and 3-4% of extranodal Non-Hodgkins lymphomas. Clinically, these patients present with non-specific symptoms and radiologically mimic bronchogenic carcinoma.

Case Report: A 62-year-old male never smoker presented with complaints of dyspnea on exertion and dry cough of 2 months duration. No other significant history obtained. General examination was unremarkable. Respiratory system examination revealed signs of bilateral mild pleural effusion. Pleural fluid cytology reported as suggestive of hematolymphoid malignancy. Contrast-enhanced computed tomography of chest showed right middle and lower lobe mass with bilateral diffuse multiple pulmonary nodules with bilateral pleural effusion. Peripheral blood smear showed leukocytosis with atypical lymphoid cells. Bone marrow biopsy showed features suggestive of acute lymphoblastic leukemia. Ultrasound-guided lung biopsy showed infiltration by T-cell non-Hodgkin's lymphoma.

Conclusion: Primary T-cell lymphoma, though rare, has a relatively good prognosis. An early detection is crucial in treating these patients.

Pulmonary tuberculosis versus bronchial carcinoid: Coexistence leading to a diagnostic delay

Shivanshu Raj Goyal, Uday Kiran, D. Srinath, A. D. Nageswari


Department of Pulmonary Medicine, SRM Medical College Hospital and Research Centre, Kattankulathur, Tamil Nadu, India. E-mail: shivanshu.goyal@gmail.com

Background: Carcinoid tumors are classified as typical or atypical according to histopathological criteria. But data suggests that it is impossible to differentiate between the two. When the tuberculosis and carcinoid have simultaneous occurrence, diagnosis is often delayed as one condition masks the other.

Case Report: We report a rare case of a young female with sputum positive pulmonary tuberculosis followed for 7 years and had taken three full courses of anti-tuberculosis medications. Finally, on resection a bronchial carcinoid of the right lung was found. The patient was treated with right sided pneumonectomy without chemotherapy. Post-operative period was uneventful and is being followed-up regularly.

Conclusion: The above case report reveals varied presentations of carcinoid and also how it remains undiagnosed even after many years of follow-up. Furthermore, the overall prognosis after surgical resection is good and chemotherapy is not required if there is no evidence of metastases and local recurrence if any can be managed with surgery.

Basaloid carcinoma of the lung: An uncommon morphologic entity

J. Thanka, M. Arunan, B. Rajagopalan,

S. Shanmuga Priya, Lawrence D. Cruze, S. Rajendiran


Department of Pathology, Sri Ramachandra Medical College and Research Institute, Chennai, Tamil Nadu, India. E-mail: drjthanka@yahoo.com

Background: Basaloid carcinoma (BC) of the lung is a rare primary neoplasm first described in 1992. It is an aggressive subtype of non-small cell lung cancer. We report a patient with lung BC, initially diagnosed as poorly differentiated carcinoma on biopsy.

Case Report: 62-year-old male, a smoker who abstained from smoking for the past 6 years was evaluated for cough and difficulty in breathing of 1 month duration. Computed tomography (CT) thorax showed a well defined nodule in the superior segment of the left lower lobe suggestive of bronchogenic carcinoma. CT guided tru-cut biopsy was performed. Haemotoxylin and eosin and immunohistochemistry of the biopsy was that of a poorly differentiated adenocarcinoma. Left lower lobectomy sample was sent for histopathology. Tumor was measuring 4 cm × 3 cm ×2 cm. Microscopically, the tumor showed lobular growth pattern of small to medium sized tumor cells, with moderately hyper chromatic nuclei, without nucleoli, scant cytoplasm, high mitotic rate and peripheral palisading with central necrosis. The diagnosis of BC of lung was rendered.

Conclusion: We are presenting this tumor to highlight and recognize the unique histological features of this rare subtype. World Health Organization recently classified BC as a separate entity since the prognosis is poor with a median survival rate of only 22 months for Stage I and II disease. This diagnosis was established in the resection specimen in our case and tru-cut biopsy did not give the accurate subtype of this tumor, perhaps because of the sampling error.

Liposarcoma of mediastinum

A. M. Khoja, Omkar Kajale, A. Yannawar, C. Patel, S. Garde, D. Jain


Department of Pulmonary Medicine, Ruby Hall Clinic, Pune, Maharashtra, India. E-mail: kajale.omkar.ok@gmail.com

Introduction : Liposarcoma is a tumor that arises from fat tissue. It occurs in lower limb or in abdomen. Because liposarcoma may grow in surrounding tissue or organ, it is considered as a malignant tumor.

Aim: Liposarcoma is the second most common cause of all soft tissue sarcomas. Annual incidence is 2.5 cases per million populations. 5 year survival rate of high-grade liposarcoma is less than 50%. Lungs and liver are the most common sites of metastasis.

Case 1: A 60-years-old male non-smoker presented with complains of fever, breathlessness, chest pain and dry cough since 1 month. Chest X-ray and computed tomography (CT) scan of thorax showed homogenous opacity in right hilar region and a large pearl shape mass lesion arising from right thoracic wall, respectively. Transbronchial needle aspiration and CT guided biopsy showed low grade spindle cell sarcoma. Patient was treated with surgical removal of mass. Spindle cell liposarcoma was confirmed on immunohistochemistry.

Case 2: A 31-year-old female presented with complains of dyspnea, productive cough of 3 months, odynophagia of 15 days, low grade fever of 3 days, right sided chest pain and weight loss of 4 kg in last 3 months. Chest X-ray showed right sided homogenous opacity. High-resolution computed tomography of thorax showed a mass lesion in retrocrural region. Bronchoscopy showed extrinsic compression on right lower lobe bronchus. CT guided biopsy showed spindle cell liposarcoma. Patient was treated with surgical resection of mass and pharmacotherapy.

Conclusion:
Liposarcoma is an under-recognized neoplasm and to be considered in the differential diagnosis of lung neoplasms.

Mediastinal mass: A report of two cases

M. R. Nedunchezhian, Nancy Glory, D. Ranganathan, N. Meenakshi


Department of Thoracic Medicine, Madras Medical College, Chennai, Tamil Nadu, India. E-mail: nchezhian21@gmail.com

Background: Thymic cysts represent 1% to 2% of anterior mediastinal masses usually present as incidental mass in antero-superior mediastinum. It may be unilocular [congenital] or multilocular [acquired], age group affected is 20-50 years and has excellent prognosis. Acute lymphoblastic leukemia, commonest hematological malignancy, is characterized by excess lymphoblasts and is diagnosed by: History, physical examination, complete blood count and bone marrow study and usually manifest as generalised weakness, fever, bone pain, skin bruising, splenomegaly and lymphadenopathy. It has good prognosis in age group 2-10 years. It rarely presents as mediastinal mass and if so, it has poor prognosis.

Case 1: 18-year-old female presented with complaints of cough with expectoration and neck swelling for 2 years. Chest X-ray and computed tomography (CT) chest showed anterior mediastinal mass and thoracotomy was done. Histopathological examination revealed thymic cyst.

Case 2: A 17-year-old female presented with complaints of facial puffiness and breathlessness since 3 days and features of superior vena cava obstruction with left massive pleural effusion. Chest X-ray and CT chest showed heterogeneous density lesion involving anterior, middle and posterior mediastinum. Fine needle aspiration cytology of mediastinal mass was suggestive of lymphoma. Bone marrow aspiration showed features suggestive of acute lymphoblastic leukemia.

Conclusion: Thymic cyst is a rare cause of anterior mediastinal mass and it has excellent prognosis. Acute lymphoblastic leukemia also can present as mediastinal mass.

Spindle cell sarcoma of the lung: A rare entity

R. Santosham, K. H. Kisku, K. V. Krishnan, M. Phansalkar


Department of Pulmonary Medicine, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry, India. E-mail : drsantoshamdm@gmail.com

Background: Primary sarcomas of the thorax are rare. The diagnosis is established only after sarcoma like primary lung malignancies and metastatic diseases have been excluded. Primary sarcomas of the thorax are classified according to their histologic features and constitute a large group of tumors that occur in the lung, mediastinum, pleura and chest wall.

Case Report: Here we present a 37-year-old lady who had a mass in the left lung which was an incidental finding on her chest X-ray. Following which a contrast enhanced computed tomography (CT) thorax was done which showed a contrast enhancing well circumscribed mass in left lung 8.4 cm × 6.3 cm in size. A bronchoscopy was done and a pedunculated mass was seen in the anterior segment of left upper lobe bronchus which bled profusely on touch and a biopsy was not possible. She was then taken for CT guided biopsy which showed spindle cell sarcoma. A surgical resection was planned. She was taken up for left upper lobe lobectomy and her histopathology showed spindle cell sarcoma with possibility of synovial sarcoma. She is being treated with chemotherapy and is under follow-up.

Conclusion: We have presented this case here because of rarity of the tumor and its ambiguous presentation.

Lung cancer misdiagnosed as sputum negative pulmonary tuberculosis

Kalyan Kumar Kambampati, A. Sathya Prasad, C. H. Raju, Rameshwara Kumar Mosali, Palvai Rajesh Kumar, Dheeraj, Pragati, Nirupama


Department of Pulmonary Medicine, Mamatha General Hospital, Khammam District, Andhra Pradesh, India. E-mail: kalyankambampati@gmail.com

Background: Though India is the second most populous country in the world, it has more tuberculosis cases annually than any other country. World Health Organization estimates, lung to be the leading cause of mortality due to cancer in males in India. Higher prevalence of tuberculosis and overlap of its clinical presentation and radiological features with lung cancer creates a scenario where a significant number of early lung cancer patients may get wrongly labeled as tuberculosis.

Case Report: A 45-year-old male with history of 12 pack years of smoking presented with complaints of cough with expectoration, breathlessness and weight loss for past 3 months, chest X-ray had shown consolidation of right upper lobe and right middle lobe, his early morning sputum samples was negative for acid fast bacilli (AFB). For the same complaints, patient had multiple consultations with 3 physicians and took antitubercular treatment for 2 months in spite of sputum smear negativity. As patient did not improve with the therapy, he consulted out-patient department of pulmonary medicine at MGH, Khammam. Contrast enhanced computed tomography thorax showed right upper lobe and right middle lobe consolidation with bilateral diffuse ground glass opacities with possibility of pulmonary tuberculosis or bronchogenic carcinoma. Bronchoscopy revealed no abnormality, bronchial washings and brushings were negative for AFB and malignant cells. Ultrasound-guided TNAC proved to be intermediate cell type of small cell carcinoma.

Conclusion: Even in endemic areas, every lung opacity is not pulmonary tuberculosis. Clinicians must be cautious before labeling a case as sputum smear negative pulmonary tuberculosis.

Pulmonary metastasis (metastatic phyllodes) presenting as whole lung mass: A rare case report

J. Venugopal, S. Vinod Kumar, Srinivas Banoth,

R. Manju, G. Vishnukanth


Department of Respiratory Medicine, PSG Institute of Medical Sciences and Research, Coimbatore, Tamil Nadu, India. E-mail: venu_0984@yahoo.co.in

Background: Phyllodes tumor accounts for 0.5% of all breast malignancies. 25% of malignant phyllodes give rise to hematogenous metastasis. The commonest sites are lungs, soft tissue, bone, pleura. Pulmonary metastasis usually presents as multiple nodular lesion.

Case Report: 45-year-old lady presented with swelling over right breast for 1 month. On examination 10 cm × 10 cm firm mass was found which was not fixed to any underlying structure. Excision biopsy (mastectomy) was reported as phyllodes tumor. After 2½ years, patient presented with breathlessness and left sided chest pain. On examination, breath sounds were diminished and impaired note felt over the left hemithorax. Chest X-ray showed homogenous opacity occupying entire left side with mediastinal shift to the opposite side. Based on the above findings patient was diagnosed as left sided malignant pleural effusion and left side tube thorocostomy was done and referred to JIPMER as there was no drainage. At JIPMER sonography of the thorax revealed 15 cm × 14 cm large hypoechoeic mass in the left lung without any concomitant pleural effusion. Computed tomography thorax showed large mass lesion in the left lung with right lung nodular lesions. Biopsy of the left lung mass was suggestive of metastatic phyllodes without any native lung parenchyma.

Conclusion: Pulmonary metastasis in malignant phyllodes tumor and other sarcomas are common but rarely do they present as whole lung mass which mimicks massive pleural effusion on chest X-ray. Simple sonography guided biopsy will yield the diagnosis.

Cavitating malignancy with thrombus in the pulmonary artery

R. Anantha, K. H. Kisku, M. Phansalkar, D. Phansalkar


Department of Pulmonary Medicine, Pondicherry Institute of Medical Sciences, Kalapet, Puducherry. E-mail: beckans2004@gmail.com

Background: The causes of pulmonary cavities are many. Pulmonary cavities may be result of malignancy, infection, inflammation or be congenital. Both primary and metastatic lung tumors can present with cavitation. The cavitation arises from tumor necrosis in the majority of cases, but can also occur as a result of bacterial colonization or growth in the necrotic center of tumors.

Case Report: Here we present a 70-year-old male who was admitted with a provisional diagnosis of exacerbation of COPD with type II respiratory failure. He was a chronic smoker for more than 40 years and had no history of diabetes or hypertension. His chest X-ray showed a large thick walled cavity in the right lower zone. A contrast enhanced computed tomography thorax was done which revealed a large thrombus in the right pulmonary artery completely occluding the lower lobe branches and a thick wall cavity in the right lower lobe and multiple mediastinal nodes. A computed tomography guided biopsy from the cavity wall showed squamous cell carcinoma.

Conclusion: Our aim was to highlight this uncommon presentation of lung carcinoma. The cavity was produced by occlusion of the vessel supplying right lower lobe leading to its destruction.

BRONCHOSCOPY

Foreign body aspiration and its removal using fiberoptic bronchoscope

Caroline Simon, Ram B. Dessssoskar, Medha D. Bargaje, S. P. Rai


Department of Pulmonary Medicine, Bharati Vidyapeeth Deemed University Medical College and Hospital, Dhankawadi, Pune, India. E-mail: dr.carolinesimon@gmail.com

Case Report: A 13-year-old female patient came to our OPD in 2009, with complaints of recurrent episodes of fever, cough with mucopurulent expectoration and hemoptysis since few years. She also complained of breathlessness on exertion and right sided chest pain. She had earlier consulted with two chest physicians who had prescribed antibiotics, bronchodilators and mucolytics, but the symptoms still persisted. She was then put on antitubercular therapy for 1 year, in spite of her sputum acid fast bacilli smears being negative all throughout this time. She was also advised resectional surgery with a diagnosis of post-tubercular bronchiectasis, as she didn't respond to the given treatment. It was then that she came to our OPD for a third opinion. She was thoroughly investigated by us. A high-resolution computed tomography scan of the thorax with a virtual bronchoscopy was done which was suggestive of a sub-centimeter foreign body in the right bronchus intermedius with bronchiectasis in the anterior, posterior and medial basal segments of the right lower lobe with associated consolidation. On probing her further for a more detailed history, she then revealed that she had aspirated a Ludo token while playing with the neighborhood children. Fiberoptic bronchoscopy was then done and the foreign body removed. She has symptomatically improved and is now on regular follow-up in our department.

Conclusion: Foreign body should be suspected in patients with long term non-resolving consolidation.

ILD

Pulmonary Langerhan's cell histiocytosis: A rare cause of interstitial lung disease

Manoj Kumar Panigrahi, Saka Vinod Kumar, T. Pampa


Department of Pulmonary Medicine, All India Institute of Medical Sciences, Bhubaneswar, Odisha, India. E-mail: manoj_kp99@rediffmail.com

Background: Pulmonary Langerhan's cell histiocytosis (PLCH) is a rare disorder accounting for 5% of all biopsy-proven interstitial lung disease (ILD). This is almost always seen in adult smokers, white people and no genetic or familial predisposition has been found.

Case Report: A 62-year-old man, farmer and chronic smoker, presented with progressive breathlessness for 4 months and productive cough for 2 months. At admission he was tachypneic, hemodynamically stable with room air oxygen saturation 95%. Lung auscultation revealed bilateral diffuse coarse crackles and wheeze. Chest radiograph showed bilateral diffuse honeycombing interspersed with nodules suggesting ILD. High resolution computed tomography scan showed bilateral multiple bizarre cysts of variable sizes and nodules characteristic of PLCH. Bronchoalveolar fluid analysis revealed total cell count 320/cmm, histiocytes-72%, alveolar macrophages-22%, lymphocytes-2%, neutrophils-4% and staining showed Langerhan's cell with typical nuclear groove and kidney bean shaped nuclei, thus confirming the diagnosis. Sputum for acid fast bacilli and malignant cytology were repeatedly negative. Later, he developed high-adenosine deaminase (ADA) (75 U/L) and exudative lymphocyte predominance (100%) pleural effusion on right side followed by pneumothorax with large air leak. Subsequently his hospital course was stormy requiring continuous oxygen supplementation to maintain saturation, dyspnea and air leak persisted and he was discharged on request after explaining the prognosis.

Conclusion: The etiopathogenesis and prognosis of PLCH is still poorly understood. Majority of patients present with non-productive cough and dyspnea. The only reported pleural complication of PLCH is recurrent pneumothorax unlike our case who developed pleural effusion. PLCH should be considered as an etiology of ILD in all adult smokers. Whether high-ADA pleural effusion could be a feature in PLCH needs further confirmation.

Unusual causes of hypersensitivity pneumonitis: Two cases

K. Shanmugapriya, T. Dhanasekar, B. Hariprasad, T. Vijayalakshmi


Department of Chest Medicine and TB, Sri Ramachandra Medical Centre, Chennai, Tamil Nadu, India. E-mail: drvthanasekaraan@yahoo.com

Background: Hypersensitivity pneumonitis is a spectrum of interstitial, alveolar and bronchiolar lung disease resulting from immunologically induced inflammation in response to inhalation of a wide variety of different materials that are usually organic or low molecular weight chemical antigens (or haptens) that may lead to irreversible lung damage. The prevalence of hypersensitivity pneumonitis is quite variable in different populations, due to differing intensity, frequency and duration of inhalation exposure. We present two unusual causes of hypersensitivity pneumonitis due to hitherto unreported organic antigens.

Case 1: A 44-year-old male who worked in coir industry for 20 years, presented with progressive dyspnea and dry cough of 2 month's duration.

Case 2: A 62-year-old male, temple priest for the last 40 years, gave history of exposure to frankincense (sambrani) fumes. He presented with progressive exertional dyspnea of 3 month's duration.

In both patients, chest X-ray and high resolution computed tomography chest showed bilateral diffuse ground glass opacities with interstitial fibrosis in the upper lobes, suggestive of acute on chronic hypersensitivity pneumonitis. Their 6-min walk tests showed significant desaturation. Considering a diagnosis of hypersensitivity pneumonitis, they were started on oral steroids in tapering doses and were followed-up regularly at 6 monthly intervals. Both patients showed significant clinical and radiological resolution, paralleling progressive improvements in spirometry and exercise tolerance with steroids and change in occupation.

Conclusion: The improvement in clinical, radiological and spirometric courses in the two patients with oral steroids and occupational exposure was highly suggestive of the diagnosis of hypersensitivity pneumonitis due to exposure to organic antigens-coconut husk and frankincense fumes.

Rapid diagnosis and management of pulmonary alveolar proteinosis

V. Arun Babu, A. S. Natarajan, S. Subramanian


Department of Pulmonary Medicine, Chettinad Medical College, Kelambakkam, Chennai, Tamil Nadu, India. E-mail: arunbabu311@yahoo.co.in

Background: Pulmonary alveolar proteinosis (PAP) is a rare syndrome characterized by pulmonary surfactant accumulation within the alveolar spaces. It occurs with a reported prevalence of 0.1 per 100,000 individuals and in distinct clinical forms: Autoimmune (represents the vast majority of PAP cases), secondary (consequence of underlying disorders), congenital (caused by mutations in the genes encoding for the granulocyte-macrophage colony stimulating factor receptor) and PAP-like syndromes (associated with surfactant gene mutations). We report a case of rapid diagnosis and management of pulmonary alveolar proteinosis.

Case Report: A 30-year-old male patient construction worker by occupation, exposed to sand stone powder for 3 years, presented with complaints of breathlessness for 6 months and cough with mucopurulent expectoration for 1 week. Chest X-ray was done and showed alveolar opacities. Subsequently, computed tomography thorax was done and showed crazy paving pattern superimposed on ground glass haziness sparing the periphery. Bronchial washing showed gelatinous milky white secretion which was also positive for Periodic Acid Schiff clinched the diagnosis of pulmonary alveolar proteinosis. Whole lung lavage was done for both the lungs with which patient improved well and clearing of alveolar opacity noted on chest X-ray.

Conclusion: The PAP is rare but curious entity. The main underlying defect is dysregulated pulmonary surfactant metabolism.

A rare case of progressive scleroderma with cutaneous involvement and sputum positive pulmonary tuberculosis

Mayur Adalja, Stani Ajay, Arti Shah, Madhavi Gondha


Department of Respiratory Medicine, SBKS MI and RC, Sumandeep Vidyapeeth, Piparia, Vadodara, Gujarat, India. E-mail: nihar103@gmail.com


Background:
Scleroderma is a chronic systemic autoimmune disease of collagenous connective tissue characterized by fibrosis, vascular alterations and auto-antibodies. Tuberculosis is a disease caused by mycobacterium tuberculosis, mainly affecting the lungs. The co-existence of scleroderma and pulmonary tuberculosis is very rare and is being reported to be 0.26%. Patient having tuberculosis with scleroderma is very rare and fatal. Patients with very widespread skin and systemic involvement have a negative prognosis. People with scleroderma and tuberculosis have varied life expectancies and death occurs generally due to scleroderma.

Case Report: A 30-years-old Hindu male smoker came with complaints of difficulty in swallowing, generalized thickening, tightening and blackening of the skin since 6 months. He was known case of pulmonary Koch's, sputum acid fast bacilli 3 + positive, on Category I antitubercular treatment (ATT) since 4 months. Chest X-ray showed reticular pattern bilaterally. His collagen vascular disease profile was positive for scleroderma. Spirometry showed moderate restriction. Skin biopsy was suggestive of scleroderma. In our patient we continued ATT with oral steroids and cyclophosphamide. Patient improved symptomatically and was discharged with the same.

Conclusion: Timely intervention is necessary in tuberculosis and one should rule out other comorbid conditions for better prognosis. Treatment with proper antitubercular drugs, steroids, anti-fibrotic agents and other immunosuppressants gives better symptomatic relief.

Atypical presentation of sarcoidosis

Sandeep Rana, M. S. Barthwal, D. Bhattacharyya, C. D. S. Katoch


Department of Pulmonary Medicine, Armed Forces Medical College, Pune, Maharashtra, India. E-mail: drsandy97@gmail.com

Background: Sarcoidosis is a multisystem inflammatory disorder of unknown aetiology. Diagnosis of sarcoidosis is made by clinical, radiological and histopathological examination. Sometime because of rare atypical presentations like muscular sarcoidosis and extra thoracic lymphadenopathy it becomes extremely difficult to diagnose a case of sarcoidosis. We present a case with rare atypical presentation reported to our hospital.

Case Report: This 39-year-old patient presented with stiffness of muscles and inguinal lymph node enlargement to a peripheral hospital and diagnosed as pulmonary tuberculosis. He was started on antitubercular treatment but due to deterioration in symptoms and no improvement in general condition patient was transferred to our hospital for further evaluation. On further evaluation patient was diagnosed as a case of multisystem sarcoidosis involving muscles, skin, lungs and hepatosplenomegaly and treated with oral steroids. Patient responded remarkably to oral steroids and he is under follow-up.

Conclusion: Sarcoidosis may have atypical presentation and patient may be misdiagnosed with more common diseases like tuberculosis due to similarity in clinical and histopathological features. Patient should be extensively evaluated to find out the actual disease in case of suspicion of inaccurate diagnosis. To the best of our knowledge, till date in literature no case has been reported with atypical presentation of both inguinal lymphadenopathy and muscular sarcoidosis.

Pulmonary alveolar microlithiasis: A case report

G. Vishnukanth, R. Manju, Venugopal, S. Vinod Kumar


Department of Pulmonary Medicine, JIPMER, Puducherry, India. E-mail: vishnu1429@yahoo.com

Background: Pulmonary alveolar microlithiasis (PAM) is a rare condition characterized by diffuse bilateral filling of the alveoli by calcific concentrations, calcospherites.

Case Report: A 40-year-old male agricultural laborer, never smoker, presented with 10 months history of cough with expectoration and exertional breathlessness. He had completed 6 months of antitubercular treatment for the same 4 months back. His general physical examination was unremarkable and was not hypoxic at room air. Respiratory examination revealed fine crackles in the left axillary region. Chest X-ray revealed bilateral diffuse nodular lesions with translucent band in bilateral upper zones with a possibility of black pleura sign. Possibility of PAM was considered and was confirmed with high-resolution computed tomography chest. FOB was done and bronchial brushings and washings reported as numerous calcific concretions of alveolar macrophages. Periodic acid Schiff stain was negative. Percutaneous lung biopsy revealed numerous calcospherites which confirmed our diagnosis.

Conclusion: Though PAM is a rare entity, a high index of suspicion in cases where there is clinico-radiological dissociation may reduce the need for invasive procedures in a limited resource setting.

A case of mixed connective tissue disease with interstitial lung disease

Bency K. Thomas, S. Yuvarajan


Department of Pulmonary Medicine, Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India. E-mail: bencykthomas413@gmail.com

Background: Interstitial lung diseases are a diverse group of disorders characterized by varying degrees of fibrosis and inflammation of the lung parenchyma and the interstitium. Different interstitial lung diseases show specific age predilection.

Case Report: A 70-year-old retired school teacher presented with cough, breathlessness, body pain, multiple joint pain for past 1 year and complaints of difficulty in swallowing for 1 week. All these symptoms were of gradual in onset and progressive. On examination he had reduced intensity of breath sounds during auscultation with late inspiratory fine crackles were heard bilaterally in infra-axillary and infra-scapular areas. His diagnostic bronchoscopy showed anthracotic pigmentations in bronchial mucosa. A mixed pattern was seen in spirometry. computed tomography chest revealed bilateral mid and lower zone septal thickening with honey-comb pattern and minimal ground-glass opacities. The antinuclear antibody blot profile revealed a strong positivity for Antibodies to U1 ribonucleoproteins (anti-U1RNP) and anti-ribosomal P protein. Thus a diagnosis of mixed connective tissue disease (MCTD) with interstitial pneumonia and pulmonary fibrosis was made.

Conclusion: MCTD presents with overlapping features of systemic lupus erythematosus, scleroderma and polymyositis. The important clue to diagnose is ANA positivity with a predominant anti-U1RNP activity. Patients present with myalgia, cough and progressive breathlessness. If not treated in right time the patient may develop complete fibrosis of lungs. Corticosteroids, azathioprine, methotrexate, cyclophosphamide and NSAIDs are the mainstay of treatment.

Bilateral lung transplantation for idiopathic pulmonary fibrosis in Hermansky Pudlak syndrome

K. Anand Babu, Lakshmi Varadarajulu, K. Madhan Kumar, T. Sunder


Departments of Respiratory Medicine and Cardiothoracic Surgery, Apollo Hospitals, Chennai, Tamil Nadu, India. E-mail: sunder64@gmail.com

Background:  Hermansky-Pudlak syndrome More Details (HPS) is a rare autosomal recessive disorder which comprises of oculo-cutaneous albinism causing generalized hypopigmented skin lesions with defective vision and bleeding tendencies. Patients with most severe form of this syndrome develop pulmonary fibrosis and are associated with 80% mortality. We describe a young patient with HPS who had successful bilateral lung transplantation for usual interstitial pneumonia.

Case Report: 29-year-old male patient with end stage pulmonary fibrosis and oculocutanoeus albinism was on continuous oxygen support. Steroids, acetyl cysteine, pirfenidone had no effects. He underwent bilateral lung transplantation through a clam shell incision using cardiopulmonary bypass and a feeding jejunosotmy. Apart from a mild reperfusion injury on 1 st day which responded to conservative measure, he was extubated on the second post-operative day. He required platelet transfusions. He was commenced on immunosuppressive therapy. He developed gastroparesis with vomiting and hence had a gastrostomy. His nutrition improved and is currently maintaining saturations of 100% on room air.

Conclusion: Patients with the most severe form of HPS develop pulmonary fibrosis which has 80% mortality. Lung transplantation is the only option and has been reported once in 2005. Our patient is the second reported case of lung transplantation for this rare genetic disorder. Although bleeding diathesis is common in HPS, lung transplantation may be safely performed in these patients. Lung transplantation, as a treatment option, can be considered in patients with end stage pulmonary disease in our country with acceptable results.

PLEURAL DISEASE

Filariasis presenting as recurrent pleural effusion

M. Pragati, A. Satya Prasad, Ch. Raju, Rameshwara Kumar Mosali, Rajesh Palavi, Ch Dheeraj Rao, Kalyan Kumar Kambampati, A. Nirupama Devi


Department of Pulmonary Medicine, Mamatha General Hospital, Khammam District, Andhrapradesh, India. E-mail: kalyankambampati@gmail.com

Background: Filariasis is common in tropical countries and is endemic in India, but the finding of microfilaria in the pleural fluid is very rare. We report a case of filariasis presenting as recurrent pleural effusion. Until date very few cases have been reported in the medical literature, in which microfilaria was demonstrated in the pleural effusion.

Case Report: A 40-year-old male presented to us with the complaints of fever, cough, pain in the left side of the chest and shortness of breath since 20 days. On clinical examination, signs of left sided pleural effusion were present. Chest X-ray revealed left sided pleural effusion. Pleural tap was performed. Straw colored fluid was aspirated. Acid fast bacilli were not detected in the direct smears and in culture made from the fluid. Microscopic examination of fluid from centrifuged sediments showed microfilaria with lymphocytes and few reactive mesothelial cells. Microfilariae were detected in nocturnal peripheral blood smear and in aspirated material from lymph nodes.Ultrasound scan of scrotum showed dancing sign. He was treated with diethyl carbamazine citrtate (DEC) in dose of 6 mg/kg body weight for 21 days. As there was no improvement, second cycle of DEC of same dosage was given. Patient symptomatically improved and was discharged on request and was lost to follow-up. Later, on enquiry we came to know that patient expired.

Conclusion: In cases of recurrent effusion, tuberculosis and malignancy should be considered first, but a careful search for microfilaria in aspirated fluids may be quite rewarding.

Spontaneous chylothorax associated with primary congenital lymphedema: A rare case report

Priyadarsini Parida, Thitta Mohanty, Hemant Kumar Sethy, Jyoti Patnaik


Department of Pulmonary Medicine, SCB Medical College and Hospital, Cuttack, Odisha, India. E-mail: dr.priyadarshini14@gmail.com

Background: Generally chylothorax results from operative injury to thoracic duct or from neoplasm of the mediastinum or pleural cavity. Spontaneous chylothorax is an uncommon entity and its association with other lymphatic malformation has been rarely reported. We describe a unique case of primary lymphedema presenting with chylothorax.

Case Report: A 22-year-old female was admitted with progressive dyspnoea, left sided chest pain and dry cough. She had history of left arm and left leg swelling from infancy. Family history was unremarkable and her physical examination was normal except lymphedema. Chest X-ray showed massive left pleural effusion and thoracocentesis revealed it to be chylothorax. Ultrasonography and 2D-Echocardiography showed minimal pericardial effusion with normal systolic function. Lymphocintigraphy showed near total obstruction of lymphatic flow of both upper and lower limbs of left side with partial obstruction of thoracic duct drainage to superior vena cava. Chylothorax was initially drained with intercostal drainage and patient was kept on total parenteral nutrition for 3 weeks. After 3 weeks of conservative treatment, as daily drainage exceeded 500cc, patient was transferred to thoracic surgery unit where thoracoscopic ligation of thoracic duct was done and patient discharged after day 5. On follow-up, patient was doing well with no detectable sign of pleural effusion on chest X-ray.

Conclusion: We report a rare case of chylothorax with congenital lymphedema. To diagnose it, other etiologies must be ruled out and a complete investigation with lymphocintigraphy is mandatory. Treatment mainly depends on morphology of thoracic duct on lymphocintigraphy.

Massive recurrent pleural effusion in a 35-year-old non-smoking male

C. Raghavendra, K. Gowrinath


Department of Pulmonary Medicine, Narayana Medical College, Nellore, Andhra Pradesh, India. E-mail: drkgowrinath@yahoo.com


Background:
Massive pleural effusion is an unusual complication of pancreatitis due to leakage of pancreatic juice from pseudocyst or pancreatic duct leak in some cases. In acute pancreatitis, pleural effusions are usually minimal and self limiting.

Case Report: We report a case of massive pleural effusion due to acute pancreatitis in a 35-year-old non-smoking male who presented with exertional breathlessness of 10 days duration. Patient stopped alcohol use 1 year ago. Pleural effusion recurred within 3 days of therapeutic thoracocentesis done on two occasions. Pleural fluid showed 90% polymorphonuclear leucocytes and all cultures were negative. Ultrasound and contrast enhanced computed tomographic (CT) scan of abdomen showed bulky pancreas with a pseudocyst (7.1cm × 4.5 cm size) and ascites. Pleural fluid amylase was 2216 IU/L (normal range <150 IU/L) compared to its serum level of 1073 IU/L. In our case, presence of large recurrent pleural effusion, pancreatic pseudocyst and elevated pleural fluid amylase suggested communication between the pancreatic pseudocyst and the pleural cavity (Pancreaticopleuralfistula).

Conclusion: Acute pancreatitis is a rare cause of massive recurrent pleural effusion and initial abdominal ultrasound/CT is recommended in high risk individuals.

Pyopneumothorax of rare cause: A case report

Rahul Tyagi, M. S. Barthwal, D. Bhattacharyya, C. D. S. Katoch


Department of Pulmonary Medicine, Armed Forces Medical College, Pune, Maharashtra, India. E-mail: raw_haul4960@rediffmail.com


Background:
Rupture of pyriform sinus due to forced effort with closed glottis has been reported but is extremely rare. We report a case of rupture of pyriform sinus following episodes of vomiting with subsequent development of pyopneumothorax.

Case Report: A 42-year-old male presented with complaints of episodic vomiting followed by development of painful swelling of neck, pain and difficulty during swallowing and hoarseness of voice. Evaluation revealed a febrile patient (101 o F) with tachycardia (110/min), tachypnea (30/min), crepitus over neck and anterior chest wall on left side. Chest radiograph revealed a left sided hydropneumothorax. Urgent drainage of 1.5 L pus was done with a 36F intercostal tube. Broad spectrum injectable antibiotics were started and Ryle's tube was inserted for feeding. Computed tomography scan of neck and thorax revealed a leak along lateral wall of left pyriform sinus with visualization of contrast along lateral wall of pharynx, cervical esophagus and retropharyngeal space. Dense consolidation in posterior segment of left upper lobe and all segments of left lower lobe was noted. Patient improved with treatment and became afebrile. After 2 weeks intercostal drain was removed and oral antibiotics were started. Chest radiograph done at 4 weeks revealed left sided pleural thickening only. Ryle's tube was removed and gradual oral feed were started which were tolerated by patient with no recurrence of symptoms.

Conclusion: Spontaneous rupture of pharynx has been reported but is rare. Although surgical approach is preferred conventionally, conservative management is believed to be helpful in a select group of patients.

Pulmonary nocardiasis presenting as unilateral massive effusion in immunocompetant host: An unusal host response

A. P. Kansal, Gopal Chawla, Kamal Deep, Naresh Kumar


Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India. E-mail: dramritpalkansal@yahoo.co.in

Background: Pulmonary nocardiosis is an infrequent and severe infection due to Nocardia sp., microorganisms that may behave both as opportunists and as primary pathogens . The risk of pulmonary or disseminated disease is more in persons with deficient cell mediated immunity.

Case Report: A 38-year-old manual labourer presented with chief complaints of progressive breathlessness which increased from grade I to grade III over a period of 1 month, chest pain and mild dry cough for last 10 days. Chest X-ray revealed homogenous opacity on the left side pushing mediastinal structures to the other side. Contrast enhaced computed tomography chest showed left sided massive effusion with complete collapse of ipsilateral lung along with mediastinal lymphadenopathy. Intercostal chest tube drainage was done and around 6 litre of fluid was drained over a period of 6 days. The patient was non-reactive to human immunodeficiency virus, non-diabetic and was not on any other medication and there was no other finding suggestive of immunosupression. Liquid based cytology and May Gruenwald giemsa (MGG) smear of pleural fluid showed features of pleural effusion due to nocardiosis. The pleural fluid grew Nocardia after 2 weeks of culture on Sabourauds dextrose agar at 37°C. Patient was started on trimethoprim-sulfamethoxazole and oral steroids. The patient responded well to treatment.

Conclusion: Nocardiosis is an acute, sub-acute or chronic infectious disease that occurs in cutaneous, pulmonary and disseminated forms. Pulmonary nocardiasis occurs usually in form of pneumonitis and is mostly seen in immunocompromised patients. Pulmonary nocardiasis in form of massive unilateral pleural effusion in immunocompetant host without underlying pneumonitis is a rare condition

A rare complication of chronic empyema: A case report

M. Kasi, V. Sundar, D. Ranganathan, N. Meenakshi


Department of Thoracic Medicine, Madras Medical College, Chennai, Tamil Nadu, India. E-mail: paddy_2020@yahoo.com

Background: Mediastinitis with subsequent empyema or pyopneumothorax represents one of the most common complications of esophageal perforations. However, the reverse pathogenesis, i.e., perforation of esophagus caused by chronic empyema, occurs with sufficient rarity.

Case Report: A 38-year-old male chronic alcoholic was referred to us as a case of chronic empyema for the past 6 months. He had been treated with antitubercular treatment and antibiotics irregularly over the period of 6 months. On admission, emergency tube thoracostomy was done that drained 2 L of foul smelling pus. On 4 th day, he complained of finding food particles in the intercostal drainage tube. Emergency Computed tomography was taken with oral contrast which showed a fistulous connection between oesophagus and pleural space. Upper GI endoscopy revealed a fistulous opening in the middle one third of oesophagus. Patient was sent for surgical management.

Conclusion: One should keep in mind that chronic empyema may also lead to perforation of esophagus.

Occupational asbestosis exposure and malignant pleural mesothelioma: A case report

G. Sambasivarao, T. Suresh Babu, N. Usha rani


Guntur Medical College, Guntur, Andhra Pradesh, India. E-mail: gsgssrao@gmail.com

Background: Malignant pleural mesothelioma (MPM) is a rare primary tumour of pleura usually resulting from asbestos exposure. It represents less than 1% of all lung cancers and it is unfortunately associated with many diagnostic difficulties. We report a case of 65-year-old male who presented with left massive hemorrhagic pleural effusion which proved to be due to MPM.

Case Report: A 65-year-old male patient who worked as a labourer in H.S.L Vizag shipyard for 20 years, presented with left sided chest pain, breathlessness and cough for 2 months. Prior to our hospital admission he underwent diagnostic and therapeutic thoracocentesis several times. Routine blood investigations were normal. Chest X-ray revealed left massive pleural effusion. Pleural fluid analysis was negative for malignant cytology. Contrast enhanced computed tomography thorax revealed irregularly lobulated thickened pleura with a maximum thickness of 28 mm along chest wall and mediastinum and bilateral parietal pleural calcification. Since the patient's general condition was bad, a bedside closed pleural biopsy was done with Abram's needle and intercosta tube drainage was done later. Pleural biopsy and immunohistochemical (IHC) stains confirmed the diagnosis of MPM.

Conclusion: MPM is the most lethal complication of asbestos exposure. Very often there is a diagnostic delay due to lack of suspicion. Without adequate tissue it is also difficult to distinguish mesothelioma from lung adenocarcinoma. Pleural biopsy with IHC is the key to making diagnosis as in our case.

Filarial pleural effusion: An unusual case

Pravin Dumne, S. V. Ghorpade, S. H. Meshram


Department of Tuberculosis and Chest Disease, BJMC and SGH, Pune, Maharashtra, India. E-mail: dr_aaniket@yahoo.co.in

Background: Filariasis is a major public health problem in India. It mostly presents as asymptomatic microfileremia, acute adenolymphangitis, chronic lymphatic disease, chylothorax and cryptic form causing tropical pulmonary eosinophilia. Rarely, it causes serous pleural effusion and the finding of microfilaria in the pleural fluid is very rare. So far only 15 cases of filarial pleural effusion have been reported.

Case Report: A 55-year-old male presented with high grade fever, dry cough, left sided pleuritic chest pain since 2 months. Radiograph of the chest was suggestive of left sided pleural effusion. On diagnostic thoracentesis, pleural fluid protein was 5.5 gm, sugar 99.5 mg, adenosine deaminase 29.6 U/l. Differential count showed 18% eosinophils. Pleural fluid cytology by cell block study was negative for malignant cells. Microscopy of the pleural fluid sediment showed active, motile microfilaria of Wuchereria bancrofti. Enzume linked immunosorbent assay was negative for human immunodeficiency virus (HIV1) and HIV2. Computed tomography of the thorax showed a malignant neoplastic lesion in left upper lobe with multiple pleuro-parenchymal metastases. Fine needle aspiration cytology was suggestive of squamous cell carcinoma of the lung. Pleural effusion resolved after a 3 week course of diethylcarbamazine. Then the patient was referred to the radiooncologist for the management of malignancy.

Conclusion : Microfilaria should be considered as a cause of eosinophilic pleural effusion in persons residing in endemic areas like India. A search for underlying immunosuppressive conditions especially malignancy should be undertaken in such patients.

OTHERS

Bronchogenic cyst

A. Raghukanth, M. Rajender, A. Vinay


Department of Pulmonary Medicine, Chalmeda Anad Rao Institue of Medical Sciences, Karimnagar, Andhra Pradesh, India. E-mail: raghukantharra@yahoo.com

Background: Mediastinal cysts constitute 20% of all mediastinal masses and bronchogenic cysts make up 60% of all mediastinal cysts. Bronchogenic cyst is a rare clinical entity that occurs due to abnormal development of the foregut. Bronchogenic cysts commonly occur at the tracheal carina. Though most bronchogenic cysts are asymptomatic, severe respiratory distress and compressive symptoms can occur.

Case Report: A 26-year-old female presented with complaints of fever, cough and breathlessness since 1 month. Routine investigations were normal except for the chest radiograph showing right paratracheal cystic lesion in the upper zone. She was managed symptomatically but later developed respiratory failure for which she needed ventilatory support. After extubation, she was advised computed tomography chest which showed a thin walled cystic lesion in the right anterosuperior mediastinum suggestive of bronchogenic cyst and small communication noted with lateral wall of trachea. She had tuberculoma in the right temporal region and was on anti-epileptics. We referred the patient to cardiothoracic surgery department for further management. Right postero-lateral thoracotomy was done and the cyst was excised and sent for histopathological examination. After 3 weeks, she developed severe breathlessness, which was not improved with symptomatic treatment. So, bronchoscopy was done which showed a subglottic stricture. It was treated with bronchoscopic balloon dilatation followed by stent placement after 2 weeks. Post-operative period was uneventful.

Conclusion: Majority of the bronchogenic cysts are asymptomatic. Few cases may lead to complications. Thus, surgical resection of all bronchogenic cysts is recommended.

An unusual presentation of pulmonary arterio-venous malformation during pregnancy

Manu Kurian Baby, K. Sreedevi, T. Dhanasekar, Vijayalakshmi Thanasekaraan


Department of Pulmonology Medicine, Sri Ramachandra University, Chennai, Tamil Nadu, India. E-mail: manubaby86@gmail.com

Background: Pulmonary arterio-venous malformations (PAVMs) usually remain silent, but can present with symptoms of dyspnea, platypnea and orthodeoxia. Pregnancy can act as an aggravating factor due to increase in overall blood volume. Only about 13 cases of PAVMs during pregnancy have been reported so far.

Case Report: 23-year-old primigravida in the second trimester of pregnancy presented to an outside hospital with complaints of shortness of breath and epistaxis for 2 weeks. She was subjected to chest radiography after abdominal shielding which revealed a right upper zone mass and a left side pleural effusion. Her sputum was negative for acid fast bacilli. Pleural aspiration was grossly hemorrhagic. She was started on antitubercular treatment. Her intrapartum period was uneventful following which she was referred to Sri Ramachandra hospital for further management. Computed tomography (CT) angiogram was done and showed pulmonary AVM measuring 2.0 cm × 1.9 cm in right upper lobe with feeding artery from pulmonary artery and draining vein through segmental branch of pulmonary vein. Another vascular malformation measuring 2.7 cm × 1.8 cm was visualized in anterior basal segment of left lower lobe with feeding artery from segmental branch of left pulmonary artery. CT brain and renal angiogram were all normal. Patient was advised embolization.

Conclusion: Computed tomography pulmonary angiogram is the gold standard for the diagnosis of PAVMs, but is risky during pregnancy. Echocardiogram can be a useful alternative. Once diagnosed, PAVMs must be managed by embolization or surgical resection.

A case of hemoptysis: Pulmonary sequestration with rare findings

Apar Jindal, Subramanian, Viswambhar, Ragulan, V. Arun Babu


Department of Pulmonary Medicine, Chettinad Hospital and Research Institute, Kelambakkam, Chennai, Tamil Nadu, India. E-mail: apji82@yahoo.com

Background: Pulmonary sequestration is a developmental disorder characterized by non-functioning abnormal pulmonary parenchyma that has no connection with the tracheobronchial tree and receives its blood supply from a systemic artery. Classically, it has been described in two forms, intralobar sequestration where the abnormal lung tissue lies within the normal lung visceral pleura and extralobar sequestration where the sequestered lung is totally separate and has its own pleural covering. The intralobar variety is found more commonly, has an equal sex distribution and a predilection for occurrence in the posterior basal segment of the left lower lobe.

Case Report: We describe here a 48-year-old female patient admitted to our hospital with complaints of recurrent hemoptysis for 1 year. The chest radiograph demonstrated a well-defined opacity in the right lower zone. A contrast enhanced computed tomography scan of the thorax showed a round heterogeneously enhancing mass with abundant peripheral vascularity of size 5.3 × 3.5 × 4.6 cm in right lower lobe lateral basal segment. 3D reconstruction imaging revealed an anomalous artery arising from the right renal artery supplying the mass and the venous drainage into the inferior pulmonary vein. Hence a diagnosis of right lower lobe intralobar sequestration was established.

Conclusion: The unusual findings in our case were the presence of sequestration in right lower lobe lateral basal segment, punctate calcification noted within the mass and an anomalous branch from right renal artery noted supplying the mass.

Cough making ground for syncope: A case report

Komaldeep Kaur, A. P. Kansal,

Don Gregory Mascarenhas, Kalpesh Patel


Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India. E-mail: bhatti.komal@gmail.com

Background: Syncope is defined as a transient loss of consciousness with subsequent spontaneous recovery, resulting from global cerebral hypoperfusion. Cough syncope refers to syncope upon coughing, the pathogenesis of which is unclear and probably multi-factorial. Cough syncope is a well-recognized but uncommon phenomenon. We present a case of 34-year-male having cough as a cause for his syncope.

Case Report: A 34-year-old male presented with a history of multiple episodes where he lost consciousness during or after cough along with jerky movements of body since 2 weeks. The syncopal events lasted for durations ranging from 30 s to about 1 min. All this was disturbing his routine life at home and at workplace. He was a chronic alcoholic. His weight was 97 kgs and body mass index was 32.4. During the attack, his systolic blood pressure fell down to 80, his face became congested and he lost his consciousness. The blood pressure returned to baseline as soon as the symptoms resolved. Symptomatic management of patient was done with cough suppressants and bronchodilators. Dietary and life style modification was advised to the patient. He was discharged a few days later for outpatient follow-up and is having no more syncopal attacks.

Conclusion: Cough syncope may result in serious problems such as traffic accidents and falls leading to brain and extremity injuries. Physicians should be aware of this easily recognizable cough induced syncope in all subjects admitted with syncope.

Haemoptysis: An unusual presentation

Lakshmi Sushmita Gaddam, Sunil Kumar,

Swathi Sanivaram, Bhargav Ram


Department of Pulmonology, Narayana Medical College, Nellore, Andhra Pradesh, India. E-mail: sushmita201286@gmail.com

Background: Aneurysm of the thoracic aorta is a serious form of disease because it may be fatal. The incidence of aneurysm of arch of aorta is 10.4/1,00,000 population. The clinical features of aneurysms are related to the location and extent of aneurysm. Hemoptysis as initial presentation of aneurysm of arch of aorta is rare.

Case Report: A 65-year-old male with 40 pack years of smoking, hypertension and ischemic heart disease presented to emergency department with history of 3 bouts of haemoptysis over a period of 3 h, each bout consisting of around 30-50 ml of blood. Patient was admitted and evaluated for bronchogenic carcinoma or mediastinal mass lesion provisionally as the chest X-ray showed widening of mediastinum. Computed tomography (CT) scan was deferred for initial 2 days in view of abnormal renal parameters and patient was managed conservatively. CT chest subsequently showed aneurysm of arch of aorta measuring 6.5 cm × 5.5 cm. Bronchoscopy was done to elicit cause of haemoptysis and erosion of left upper lobe bronchus with partial extrinsic compression was seen. Patient was referred to cardiothoracic surgeon for surgical management. Surgery was declined in view of poor general condition and advised medical management.

Conclusion: We report a case of aneurysm of arch of aorta which presented with hemoptysis.

Right paratracheal opacity on chest X-ray: An atypical presentation of achalasia cardia

A. P. Kansal, Gopal Chawla, Naresh Kumar, Komaldeep Kaur


Department of Pulmonary Medicine, Government Medical College, Patiala, Punjab, India. E-mail: dramritpalkansal@yahoo.co.in

Background: Achalasia is an esophageal motor disorder characterized by aperistalsis of the esophageal body and lack of relaxation of the lower sphincter in response to swallows. We present a case of achalasia in a 15yrs old female having mostly respiratory symptoms and atypical appearance as a right paratracheal opacity in her chest X-ray film.

Case Report: A 15-years-old girl presented with chief complaints of low grade fever, central chest pain, cough and vomiting associated with bouts of cough for 1 month. She was on antitubercular therapy (ATT) as her chest X-ray was showing right paratracheal opacity. But none of her symptoms got relieved. She used to regurgitate food particles within half an hour of ingestion and had bouts of cough. Contrast enhanced computed tomography chest and barium studies revealed smooth regular tapering of distal most part of esophagus at gastroesophageal junction giving bird beak appearance with proximal dilatation of esophagus suggesting achalasia cardia. ATT was stopped and the patient was put on medical treatment for achlasia and was referred to higher centre for surgical management of the disease.

Conclusion: Plain chest radiographs occasionally offer clues in the diagnosis of achalasia. A double mediastinal stripe is occasionally depicted. Other commonly observed radiological findings include, mediastinal widening, air-fluid levels, absence of gastric air bubble and complications such as aspiration pneumonia or a lung abscess. In patients with atypical presentation and findings, the diagnosis is often delayed.

Hemoptysis in a post pneumonectomy patient: A case report

K. Rajarajan, R. Sridhar, O. R. Krishnarajasekhar, C. Chandrasekar


Department of T.B. and Respiratory Diseases, Government Stanley Medical College and Hospital, Chennai, Tamil Nadu, India. E-mail: drkrr2010@gmail.com

Background: Postpneumonectomy complications are common and some of them could be serious leading to adverse outcome.

Case Report: A 27-year-male was admitted in our ward with complaints of recurrent hemoptysis of 5 years duration. Patient gave history of poliomyelitis at age of 2 years. Patient had repeated admissions for hemoptysis and had conservative treatment. Patient gave history of prior antitubercular treatment at age of 22 years. Clinical and radiological evaluation showed kyphoscoliosis, paraplegia and extensive fibrocavitary disease in left lung. Fibreoptic bronchoscopy was done and showed bleeding from left main bronchus. After discussion with cardiothoracic surgeon, patient underwent left pneumonectomy and was stable after the surgery. Five days later patient developed hemoptysis. Fibreoptic bronchoscopy excluded bleeding from the pneumonectomy stump. Multidetector computed tomography angiogram was done and it showed ill defined soft tissue adjacent to left hilum supplied by a twig arising from the descending thoracic aorta and tortuous vessels from internal mammary artery. The bleeding site was identified and bronchial artery embolization was done. Patient had complete recovery after the procedure. He is under regular follow-up.

Conclusion: Chest physian must be aware of some common and serious postpnemectomy complications.

A case report of Kartagener's syndrome in a 17-year-old female

C. Sumalata, N. Gopichand, D. Sudeena


Department of Pulmonary Medicine, Siddhartha Medical College, Vijayawada, Andhra Pradesh, India. E-mail: drsumachittiboyina@gmail.com

Background: Kartagener's syndrome is an autosomal recessive disorder characterised by classical triad of situs inversus, bronchiectasis and sinusitis. This syndrome is seen in 1 in 20000-1 in 60000 cases.

Case Report: A 17-year-old female student presented with recurrent cold and headache from the past 7 years. Last year she developed cough with expectoration. Her family history was not significant. On ear, nose and throat examination, she had tenderness over frontal sinus. Ear and throat examinations were normal. Clinical examination revealed apical impulse on right side at 5 th intercostal space 1inch lateral to mid axillary line. Heart sounds were prominent on the right side. Respiratory examination was normal. She was investigated with X-ray paranasal sinuses, chest X-ray, electrocardiography, high-resolution computed tomography, spirometry, sputum for acid-fast bacilli, bacterial culture sensitivity, saccharin test and 2D-Echocardiography. Chest X-ray revealed dextrocardia while electrocardiography and 2D-Echo supported it. X-ray paranasal sinuses showed features of sinusitis. High-resolution computed tomography showed bronchiectatic changes in mid zones and situs inversus. Spirometry showed borderline obstructive pattern. Sputum for acid-fast bacilli was negative and culture for pathogenic organisms remained sterile. Saccharin test was positive after 30 min.

Conclusion: As this syndrome is rare in females, fertility issues and hearing defects can be anticipated in due course of time hence thorough counseling should be made at the earliest. Early diagnosis and counseling will help the patients to take precautionary measures to prevent complications (i.e.,  Fallopian tube More Details blockage, conductive hearing defects, etc.) in future.

Fracture avulsion of right main bronchus with delayed presentation as right lung collapse

Anil Sontakke, B. O. Tayade


Department of Pulmonary Medicine, NKP Salve Institute of Medical Sciences and Research Centre, Nagpur, Maharashtra, India. E-mail: dranil777747@rediffmail.com

Background: Bronchial rupture due to blunt chest injuries accounts for less than 1% injuries. While treating a patient of trauma, it often goes unnoticed in emergency room. Strong clinical suspicion is required to diagnose bronchial rupture as early intervention can salvage the distal lung.

Case Report: We report a case of unusual lung collapse as a sequel of post traumatic bronchial stenosis of right main bronchus. We made diagnosis from past history traced back to history of blunt trauma to chest associated with lacerated wound in right side of neck 1 month prior to present compliant of progressive dyspnea. Bronchial fracture went unnoticed during previous admission to emergency room for trauma. We confirmed our diagnosis with help of bronchoscopy and computed tomography scan of thorax.

Conclusion: Bronchial rupture is an uncommon chest injury and it may be undetected in initial few hours of injury. If a patient presents with history of blunt injury to chest, acute progressive dyspnea with/without haemoptysis and desaturation, subcutaneous emphysema, fracture rib on chest X-ray; bronchial rupture should be suspected in emergency room. Early intervention with bronchoscopic stent placement or bronchoplasty can salvage the distal lung.

Horseshoe lung: A unique presentation

P. Jagadeesh kumar, K. Surendra Menon, R. Pajanivel


Department of Pulmonary Medicine, Mahatma Gandhi Medical College and Research Institute, Pillayarkuppam, Puducherry, India. E-mail: jaggu2503@yahoo.com

Background: The "horseshoe" lung is a rare congenital anomaly, in which there is a partial fusion of the right and left lungs by an isthmus of pulmonary parenchyma which extends from right lung base across the midline posterior to pericardium and anterior to the aorta and oesophagus. Isthmus of horseshoe lung is of pulmonary parenchyma.

Case Report: 18-year-old male student, symptomatic since 10 years of age presented to our outpatient department with recurrent bouts of streaky hemoptysis and fever with evening rise of temperature not associated with chills and rigor. Patient had no history of chest pain, breathlessness, bleeding from other sites, no significant past respiratory illness and no history of trauma. Patient was investigated with total blood count, clotting time, bleeding time, prothrombin time and other biochemical tests were within normal limits while chest X-ray showed multiple thin walled retrocardiac cystic lesions. Patient was further evaluated with a high resolution computed tomography of chest and finally a bronchoscopic bronchogram helped us to come to a conclusion. Patient was then referred to a cardiothoracic vascular surgeon and patient underwent a thoracotomy and the horseshoe lung was excised. On review, patient was asymptomatic and a follow-up computed tomography showed no abnormalities.

Conclusion: This case has a combination of both horseshoe lung and sequestration features including communication with bronchus without pulmonary artery hypertension and other cardiovascular abnormalities which were dissimilar to scimitar syndrome. There are only 8 cases previously reported by Takahashi M and associates.

Radiological and bronchoscopy findings of tracheal diverticulum

Chintan S. Patel, Amir M. Khoja, Sanesh Garde, Dhiraj Jain, Omkar Kajale


Department of Pulmonary Medicine, Ruby Hall Clinic, Pune, Maharashtra, India. E-mail: drchintanspatel@gmail.com

Background: A tracheal diverticulum is a paratracheal air cyst representing an outpouching of the tracheal wall. Specifically, tracheal diverticulae are characterized by single or multiple outpouchings of the tracheal wall. Paratracheal air cyst, as an entity, was first describedby Rokitansky in 1838. Tracheal diverticula are rarely encountered and only a handful of cases have been described in the literature. They are most frequently found incidentally in postmortem examinations, reported in 1% of patients at autopsy series.

Case Report: We report a case of a tracheal diverticulum that was identified as part of a work-up for a worsening cough.The patient was a 56-year-old man who reported no significant medical history. He reported no history of smoking and denied taking any oral medications. He complained of chronic cough and repeated respiratory tract infection, for which no clear etiology had been established. Chest X-ray was normal and computed tomography showed a "paratracheal air cyst" which had no lung markings and there was no connection to the lungs or esophagus. A short connection to the trachea was identified on coronal images. These findings are typical of tracheal diverticula. The bronchoscopy evaluation was done which showed an opening in the right-posterior part of trachea 4 cm from the true vocal cords. He was managed conservatively with antibiotics and physiotherapy.

Conclusion: The diagnosis of tracheal diverticula is relatively straightforward and can be made radiographically. It is an air-filled tubular structure, most often found posterior and slightly to the right of the trachea and communicating with the trachea.

Pseudohemoptysis: A rare case report

Guruprasad Antin, B. Vidyasagar, B. J. Arun, B. P. Rajesh


Department of Pulmonary Medicine, JJM Medical College, Davangere, Karnataka, India. E-mail: guruantin2203@gmail.com

Background: Hemoptysis, a significant and alarming respiratory symptom, may rarely present as pseudohemoptysis.

Case Report: 37-year-old male patient presented with history of cough, hemoptysis since 2 weeks. Hemoptysis was scanty bright red in colour. He had past history of pulmonary tuberculosis (sputum positive) which was cured. Systemic examination showed signs of right upper lobe fibrosis. Other systems were normal on examination. Chest X-ray showed right upper zone fibrocavitation. Sputum for acid fast bacilli (AFB) was negative. Bronchoscopy showed right upper lobe inflammatory pathology (? post tubercular squealae). Bronchoalveolar lavage (BAL) fluid was negative for AFB. Cytology showed bronchial epithelial cells (57%), pigment laden macrophages (27%), neutrophils (19%) and no red blood cell (RBC). Malignant cytology was negative. Gram stain showed many Gram-negative bacilli. BAL culture was positive for Serratia Marcescens with a colony count >1 lakh colonies/ml. It was sensitive to piperacillin plus tazobactum, cotrimoxazole and moxifloxacin. Patient recovered with intravenous piperacillin plus tazobactum and moxifloxacin during the hospital stay. So called "Hemoptysis" stopped completely and he was discharged with oral cotrimoxazole for 14 days. Patient, when followed-up after 2 weeks, was symptomatically normal. Serratia Marcescens, a Gram-negative, rod-shaped bacterium at room temperature, produces red pigment 'prodigiosin.' Pseudohemoptysis is appearance of bright-reddish sputum without evidence of RBC.

Conclusion: This report describes a rare case of an opportunistic infection. All the cases of hemoptysis are not true hemoptysis and may rarely be mimicked by pigment producing Serratia Marcescens.

An unusual cause of massive hemoptysis

Yadvir Garg, A. K. Rajput, Vikas Marwah


Department of Pulmonary Medicine, Army Hospital (Research and Referral), Delhi Cantonment, India. E-mail: yadvir.garg@rediffmail.com

Background: Common causes of hemoptysis include disorders arising within the airways and the pulmonary parenchyma. Other causes described are cardiac, coagulopathies, trauma and vascular.

Case Report: 54-years-old male, post angioplasty (with a drug eluting stent), presented with acute chest pain, fever and progressively increasing hemoptysis. On examination, he was febrile (temperatue102°F). Rest of systemic examination was normal. Investigations revealed polymorphonuclear leukocytosis with neutrophilia. Electrocardiography and echocardiography did not reveal any abnormality. High-resolution computed tomography of chest showed patchy consolidation of left lingual lobe. Fibreoptic bronchoscopy revealed mucosal erosion with a flap at the entrance of left upper lobe bronchus on medial aspect with ongoing bleeding from site. Post contrast computed tomography of chest showed mycotic pseudoaneurysm arising from left anterior decending artery (LAD) in the vicinity of coronary stent with extravasation of contrast in lingular segment abutting mycotic aneurysm suggestive of communication between aneurysm and lung. Coronary angiography confirmed computed tomography findings. He was subjected to open heart surgery and LAD aneurysmectomy. Stent extraction and coronary artery bypass grafting with left internal mammary artery to LAD was done. After surgery patient improved symptomatically with cessation of hemoptysis and his fever subsided.Thereafter, he was continued on medical management in form of dual antiplatelet agents, antianginal and antihypertensive drugs.

Conclusion:
To the best of our knowledge, coronary artery aneurysm complicating as coronary artery fistula communicating with lung has never been reported in standard medical literature. Aim of presentation was to highlight this rare cause of hemoptysis and importance of bronchoscopy in diagnosis of hemoptysis.

A case of recurrent hydatidosis involving pleural cavity, posterior mediastinum and right pararenal space

K. Christi Sunira, A. Sundararajaperumal, A. Chithra Kumar, N. Meenakshi


Department of Thoracic Medicine, Madras Medical College, Chennai, Tamil Nadu, India. E-mail: drchristi_2011@yahoo.com

Background: Hydatid disease is a parasitic infestation caused by the canine tapeworm Echinococcus granulosus. It is world-wide in distribution and endemic in many countries especially cattle and sheep rearing areas. Lung is the second most common site involved after liver. Concominant liver with pulmonary involvement is found in 10-40% of cases. This operated case of hepatopleural hydatidosis was unique as he presented to us with recurrent hydatid cyst in the pleural cavity, posterior mediastinum and right pararenal space.

Case Report: A 51-year-old male, farmer by occupation, presented with complaints of abdominal distension and breathlessness of 10 days duration. History of dry cough was present. General and systemic examinations were within normal limits except for diminished breath sounds in the right infrascapular and infra-axillary areas and crackles in right interscapular and mammary area. Abdomen was distended and free fluid was present. No palpable organomegaly was seen. Chest X-ray revealed multiloculated cystic lesions in right upper zone and mid zone with blunting of right costophrenic angle. Ultrasonography of abdomen showed gross ascites. Contrast enhanced computed tomography chest and abdomen showed features of right pleural effusion with well-defined multiloculated non-enhacing fluid density lesions in right pleural cavity and posterior mediastinum compressing the left atrium and in right posterior pararenal space with gross ascites. 2D-ECHO showed 6 cm × 5 cm globular echolucent structure compressing left atrium from outside. No evidence of pericardial effusion was seen.

Conclusion: We present this case as it is a recurrent hydatid cyst with pleural, mediastinal and abdominal involvement.

Asymptomatic posttraumatic diaphragmatic hernia

N. Muthulakshmi, D. Nancy Glory , A. Chitra Kumar, N. Meenakshi


Department of Thoracic Medicine and Madras Medical College, Chennai, Tamil Nadu, India. E-mail: dr.lakshmi.naveen@gmail.com

Background: Diaphragmatic hernias can be divided into 2 categories: Congenital defects and acquired defects. Acquired diaphragmatic hernias stem from all types of trauma, with blunt forces accounting for the majority. In acute phase of trauma, abdominal approach is preferred. In latent phase of trauma, a transthoracic approach may be necessary because patients often have adhesions to intrathoracic organs.

Case Report: A 57-year-female patient was referred from master health check up for abnormal chest X-ay. Patient did not have any specific complaints. Chest X-ray showed homogenous opacity with cystic lucencies in right mid and lower zones and silhouetting of right hemidiaphragm. Differential diagnosis of mass lesion with necrosis or a diaphragmatic hernia was considered. CT chest showed diaphragmatic defect between two anterior crura and herniation of portions of ascending colon, transverse colon without evidence of obstruction and strangulation. History of blunt abdominal bull horn injury at 8 years of age was elicited retrospectively. Patient was referred for surgery, reduction of hernia and diaphragmatic hernia repair was done through transabdominal approach.

Conclusion: This case is presented for the long latent period and asymptomatic presentation.

Diagnosis of Swyer-James-McLeod syndrome in an adult

Ajoy Samuel Mammen, V. Sundar, D. Ranganathan, N. Meenakshi


Department of Thoracic Medicine and Madras Medical College, Chennai, Tamil Nadu, India. E-mail: ace.bac@gmail.com

Background: Swyer-James-McLeod syndrome or unilateral hyperlucent lung syndrome is a rare entity associated with postinfectious bronchiolitis obliterans occurring in childhood. Swyer-James-McLeod syndrome should be considered when unilateral hyperlucent lung is found on chest X-ray.

Case Report: A 50-year-old gentleman from Chennai got admitted with complaints of 3 year history of dyspnoea on exertion with recurrent pulmonary infections. Patient had history of exanthematous fever in childhood period. He was non-smoker and with no family history of asthma. Physical examination revealed rhonchi, heard over both lung fields. Chest X-ray showed hyperlucent right lung with pulmonary oligemia and small hilum. High-resolution computed tomography revealed airtrapping and bronchiectactic changes. CT pulmonary angiography showed decrease in size of the right pulmonary vessels and no evidence of any thromboembolism. Spirometry showed obstructive airway disease of moderate severity with significant reversibility. Fibreoptic bronchoscopy showed normal trachea and bronchial pattern. Based on the above findings, diagnosis of adult Swyer-James-McLeod syndrome was made.

Conclusion: We report this case because of its rarity and only few cases have been reported worldwide in adults presenting with Swyer-James-McLeod syndrome.

A rare presentation of Ortner's syndrome

A. S. Adaikkalavan, A. Sundarajaperumal, A. Chitra kumar, N. Meenakshi


Department of Thoracic Medicine and Madras Medical College, Chennai, Tamil Nadu, India. E-mail: adaiks85@gmail.com

Background: Ortner's or cardiovocal syndrome, a rare syndrome, refers to recurrent laryngeal nerve palsy from cardiovascular disease. It was first described by N. Ortner, an Austalian physician in 1987. Most common cause is dialated left atrium due to mitral stenosis but rare causes include pulmonary hypertension, thoracic aortic aneurysms and aberrant subclavian artery.

Case Report: A 55-year-old male from Chennai presented to us with complaints of hoarseness of voice, dry cough and exertional breathlessness for 2 months. He was a chronic smoker and agricultural worker by occupation. General physical and systemic examinations were unremarkable. Video laryngoscopy demonstrated left vocal cord palsy; chest X-ray showed left sided superior mediastinal widening. Contrast enhanced computed tomography chest confirmed aortic arch aneurysm with thrombus just distal to origin of left subclavian artery. Based on the above finding diagnosis of Ortner's syndrome was made.

Conclusion: We report a case of left vocal cord palsy due to aortic arch aneurysm because of its rarity and only few cases have been reported worldwide.

A case of chronic thromboembolic pulmonary hypertension

N. Suriyakala, K. S. Vijayachander,

A. Sundarajaperumal, Nancy Glory, A. Chitra Kumar, N. Meenakshi


Department of Thoracic Medicine, Madras Medical College, Chennai, Tamil Nadu, India. E-mail: drsurya.n.samy@gmail.com

Background: Chronic thrombo embolic pulmonary hypertension (CTEPH) is suspected when patient presents with progressive dyspnoea and exercise intolerance. Improvement following acute pulmonary embolism is usually sufficient to restore normal pulmonary hemodynamics. However, a minority of patients develop CTEPH following an acute pulmonary embolism. Though some studies report the incidence to be between 1% and 3%, it remains uncertain.

Case Report: A 35-year-old man presented with grade IV breathlessness with history of orthopnoea, recurrent haemoptysis and chest pain. He was treated as bronchial asthma for 2 years and also had two spells of antitubercular treatment which he had defaulted after 2 months. He was a smoker and alcoholic. Physical examination revealed bilateral pedal edema, split S2 and loud P2 over pulmonary area. Chest skiagram showed right lung oligemia with cardiomegaly. 2D-Echo showed dilated right atrium and right ventricle with d-shaped septum and a mean pulmonary artery diameter of 2.9 cm. Contrast enhanced CT chest revealed dilated right pulmonary artery, mosaic attenuation with areas of air trapping seen involving left upper lobe and posterobasal segment of the left lower lobe. His CT pulmonary angiography showed dilated main pulmonary artery, narrowing of right pulmonary artery with multiple filling defects in the right pulmonary artery.

Conclusion: This case is being presented for its rare occurrence and misleading symptoms.




 

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