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   Table of Contents - Current issue
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May-June 2019
Volume 36 | Issue 3
Page Nos. 181-274

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EDITORIAL  

Endobronchial metastasis: The challenge continues Highly accessed article p. 181
Neeraj Gupta
DOI:10.4103/lungindia.lungindia_84_19  PMID:31031334
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ORIGINAL ARTICLES Top

New combined assessment of chronic obstructive pulmonary disease: Utilization, pitfalls, and association with spirometry Highly accessed article p. 183
Ruchi Dua, Ranjeeta Kumari, Vivek Yadav, Mayur Ranjan, Subodh Kumar, Mayank Mishra, Suryakant Tripathi
DOI:10.4103/lungindia.lungindia_163_18  PMID:31031335
Introduction: Classification of chronic obstructive pulmonary (COPD) disease has changed from being solely based on spirometric variables to combined assessment including symptom scores and history of exacerbations/ hospitalizations. There is both lack of awareness regarding change in its assessment as well as underutilization due to time constraints and seeming complexity. Moreover, treatment of COPD needs to be tailored according to the new combined assessment. Aims: Current study was planned to look at current stratification of patients according to new revised combined assessment (Global Initiative for Chronic Obstructive Lung Disease GOLD 2017) in comparison to old(GOLD 2011) as well as its incorporation in clinical practice. Co-relation between revised combined assessment and spirometric staging was also assessed. Methods: 418 consecutive COPD patients were enrolled, their dyspnea scores in terms of modified medical research council scale (mMRC), preceding history of hospitalization/ exacerbation over preceding one year and spirometric variables were recorded. Their stratification according to old and new classification recorded. Their past treatment records were reviewed and combined assessment if done recorded. Results: Substantial shift of categories is seen from C and D respectively to stage A and B on applying the new classification compared to old i.e more severe to less severe. Secondly, revised combined assessment is still highly underutilized. Revised combined assessment has positive co-relation with spirometry and post bronchodilator forced expiratory volume in 1 second(FEV1). Conclusions: Management of substantial number of stable COPD patients may need to be stepped down in accordance with revised combined assessment. There is a need to disseminate information regarding change in COPD classification and stress on its incorporation in our day-to day clinical practice. Revised combined assessment has positive co-relation with spirometry, stressing its utility even in peripheral centers without spirometry facilities.
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Exacerbation of chronic obstructive pulmonary diseases as a risk factor of the skeletal muscle dysfunction Highly accessed article p. 188
Vitalii Poberezhets, Yuriy Mostovoy, Hanna Demchuk
DOI:10.4103/lungindia.lungindia_185_18  PMID:31031336
Background: Exacerbation of Chronic Obstructive Pulmonary Disease (COPD) contributes to increased systemic inflammation, oxidative stress, hypoxia, hypercapnia and other risk factors of the skeletal muscle dysfunction. Aims and Objectives: This study aimed to determine whether the frequency of the COPD exacerbations promotes deterioration of the skeletal muscle dysfunction in patients with COPD and to figure out which characteristics of the muscles will reflect this changes. Materials and Methods: We examined 98 male COPD patients, mean age 60.4±11.2 years, GOLD groups B, C, D. To assess the degree of skeletal muscle dysfunction we used hand-grip strength, 6-minute walk test, bioelectrical impedance analysis. Quality of life was evaluated using St. George's respiratory questionnaire (SGRQ). Results: Increase in the frequency of COPD exacerbations was associated with the decrease in the 6-minute walk test distance (r= -0.214, P = 0.034) and with the rise of sarcopenia according to the results of bioelectrical impedance analysis – lower fat-free mass index (r = -0.201, P = 0.047). Frequency of COPD exacerbations had a weak correlation with the degree of the activity limitation component of SGRQ (r = 0.436, P < 0.001). Conclusions: COPD exacerbation plays an important role in progression of the skeletal muscle dysfunction. It decreases endurance of the skeletal muscles, diminishing their size, which manifests itself in reduced exercise tolerance. Increase in the frequency of the COPD exacerbations also worsens all components of the life quality.
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Nonadherence to treatment and quality of life among patients with chronic obstructive pulmonary disease p. 193
Shorouk Mohsen, Fadia Zaki Hanafy, Aya Ahmed Fathy, Abdel-Hady El-Gilany
DOI:10.4103/lungindia.lungindia_340_18  PMID:31031337
Objectives: Chronic obstructive pulmonary disease (COPD) is one of the most common respiratory diseases. Assessment of medication nonadherence and quality of life (QOL) is important in such chronic diseases. The aim of the study was to describe treatment nonadherence and QOL of COPD patients and their associated factors. Materials and Methods: A cross-sectional study was performed in Mansoura Chest Hospital on 133 already diagnosed inpatient cases of COPD from March to August 2017. Data were collected using two validated questionnaires, Morisky Medication Adherence Scale to assess medication adherence and St George's Respiratory Questionnaire for COPD patients (SGRQ-c) to assess QOL. Results: About 45% of studied group were nonadherent to prescribed medications. Logistic regression analysis showed that duration of disease is the only independent risk factor for nonadherence. The scores on SGRQ-c indicated sever QOL affection in COPD. SGRQ-c scores show significant impairment with the presence of comorbidities, hospital admission, and frequency of exacerbations. Conclusions: Nonadherence to treatment was affected mainly by the duration of disease. QOL impairment in COPD is influenced by broad range of factors suggesting the importance of QOL assessment in those patients. No association was found between nonadherence to treatment and QOL.
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Flexible bronchoscopy-guided vocal cord biopsy under conscious sedation: An option to surgical biopsy in special situations p. 199
Ravindra M Mehta, Abhinav Singla, Pavankumar Biraris, Sheelu Srinivas, Lakshmipriya Srinivasan
DOI:10.4103/lungindia.lungindia_326_18  PMID:31031338
Introduction: Vocal cord (VC) biopsies are usually performed with rigid laryngoscopy under general anesthesia (GA). In patients with comorbidities such as cardiovascular or pulmonary disease, the risk of GA is high, with morbidity and potential mortality. We describe VC biopsy (VCB) in such a high-risk cohort, done safely and successfully with flexible bronchoscopy-VCB (FB-VCB) and conscious sedation. Methods: FB-VCB was done in two groups of patients – the first at high risk for GA due to comorbidities and the second group where VC lesions were found incidentally in the course of FB done for other reasons. FB was done with local anesthesia and conscious sedation, and the VC lesion was identified. Flexible forceps were introduced through the working channel of the bronchoscope, and the lesions were carefully sampled. Results: FB-VCB was performed in 15 patients (14 males and 1 female) with a mean age of 60.7 ± 12.1 years. Of these 15 patients, 6 patients were poor candidates for GA due to comorbidities and 9 patients had incidental VC lesions found during bronchoscopy. A diagnosis was made in 14/15 (93.3%) patients. Complications included a mild ooze and hoarseness of voice for a few days, which did not require any intervention. Conclusion: We report one of the few series of patients with VC biopsies done with FB (FB-VCB) under conscious sedation, without significant complications. It is safe and useful in high-risk patients who are poor candidates for GA, with a good diagnostic yield.
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A single-center experience of pediatric foreign-body aspiration: A retrospective 4-year case series p. 202
Mustafa Erman Dorterler, Osman Hakan Kocaman, Tansel Gunendi, Mehmet Emin Boleken
DOI:10.4103/lungindia.lungindia_69_18  PMID:31031339
Introduction: Foreign body aspirations (FBA) in children are serious life-threatening clinical conditions that require immediate intervention. In this study, it was aimed to retrospectively investigate the demographic features, clinical diagnosis and treatment methods of children admitted to our clinic due to FBA. Materials and Methods: The study included 86 children aged <16 years, diagnosed with tracheobronchial foreign body aspiration (FBA) between January 2013 and December 2017. All patients with two-way chest radiography were examined for foreign body aspiration diagnosis. In case of suspicion of diagnosis, low-dose multi-slice chest CT was taken. In cases of FBA diagnosis, rigid bronchoscopy was performed under sevoflurane and propofol anaesthesia supported by controlled ventilation. Evaluation was made of the patient demographic characteristics, type and localization of the foreign body removed with bronchoscopy and operation-related complications. Results: The mean age of the patients with FBA diagnosis was 3.17 years and 55.8% (n = 48) of the patients were male. The most commonly aspirated foreign body was nuts (peanut and hazelnut) (70%) and the most common finding on the chest radiographs was obstructive emphysema, determined on 51% of the patients. Bronchoscopy revealed that the foreign body was in the right main bronchus and left main bronchus in 41%. Conclusion: The main treatment for FBA is prevention. However, in patients applied with bronchoscopy for FBA, controlled ventilation and appropriate general anesthesia should be generally used. Early bronchoscopic intervention with safe anesthesia and controlled ventilation support will improve the success rates in FBA cases.
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Patient characteristics and outcomes of a home mechanical ventilation program in a developing country p. 207
Narongkorn Saiphoklang, Apichart Kanitsap, Pitchayapa Ruchiwit, Pattarin Pirompanich, Thiti Sricharoenchai, Christopher B Cooper
DOI:10.4103/lungindia.lungindia_219_18  PMID:31031340
Background: There are limited data on home mechanical ventilation (HMV) in developing countries. This study aimed to describe the patient characteristics, feasibility, and outcomes of an HMV program at a university hospital in Thailand. Materials and Methods: Data were collected on all patients who were discharged with HMV between October 2014 and August 2015 at Thammasat University Hospital. Results: Twelve patients (eight men and four women) underwent HMV. They were aged 71.5 ± 17.6 years; mean ± standard deviation. Indications for HMV were 6 neurologic diseases (4 amyotrophic lateral sclerosis, 1 multiple system atrophy, and 1 stroke), 2 chronic obstructive pulmonary disease (COPD), 1 tracheomalacia, and 3 combined neurologic diseases and respiratory diseases (2 stroke and COPD, 1 stroke and tracheomalacia). The duration of follow-up was 799.5 ± 780.5 days. The ratio of family income to cost of HMV usage was 77.2:1 ± 5.5:1. All patients had tracheostomies. Modes of HMV were biphasic positive airway pressure (66.7%), pressure-controlled ventilation (16.7%), pressure-support ventilation (8.3%), and volume-controlled ventilation (8.3%). Complications occurred in ten patients (83.3%), including tracheobronchitis (20 events) and ventilator-associated pneumonia (12 events). Overall mortality was 41.7% (5/12 patients), including two patients who died due to ventilator-associated pneumonia. There were no instances of ventilator malfunction. Conclusions: HMV is feasible for patients with neurological diseases and COPD in a developing country. The relatively high rate of complications indicates the need for more comprehensive clinical services for chronic ventilator-dependent patients in this setting.
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Endobronchial metastasis from extrathoracic malignancies: A clinicopathological study of 11 cases p. 212
Monika Breta, Sudheer Arava, Karan Madan, Ashok Singh, Deepali Jain, Randeep Guleria
DOI:10.4103/lungindia.lungindia_438_17  PMID:31031341
Introduction: Endobronchial metastases are uncommon. It accounts for 2-28%. Most common tumors that metastasis to the endobronchial site are breast, renal, endometrial and colon carcinomas. They have to be identified properly because they present poor prognosis and different treatment modalities when compared to that of primary lung carcinomas. Materials and Methods: We studied a total of 11 retrospective cases of Endobronchial metastasis. Detailed clinic pathological and radiological findings were analyzed along with a detailed Immunohistochemical workup and Endobronchial findings. Results: Mean age of presentation was 55 years with female predominance (Male to female ratio was 1:1.2). Most common tumors encountered were carcinoma breast (3), colorectal carcinomas (2), renal cell carcinoma (2) followed by one each from carcinoma endometrium, cervix and thyroid. Common symptom was cough followed by dyspnea. Exophytic endobronchial growth was common with right main bronchus being the common site. Conclusion: Endobronchial metastasis occurs in various types of malignancies. It should always be differentiated from primary lung carcinomas as they carries poor prognosis and different treatment protocol when compared to that of primary lung tumors.
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REVIEW ARTICLE Top

Pneumococcal disease burden from an Indian perspective: Need for its prevention in pulmonology practice p. 216
Parvaiz A Koul, Sudhir Chaudhari, Ramesh Chokhani, D Christopher, Raja Dhar, Kumar Doshi, A Ghoshal, SK Luhadiya, Ashok Mahashur, Ravindra Mehta, Amita Nene, Md Rahman, Rajesh Swarnakar
DOI:10.4103/lungindia.lungindia_497_18  PMID:31031342
Globally, pneumococcal diseases are a significant public health concern. They are preventable and frequently occur among older adults. Major risk factors for the disease are extremes of age, alcohol intake, smoking, air pollution, and comorbid conditions (diabetes, chronic obstructive pulmonary disease, chronic kidney disease, liver disease, and heart disease). Risk factors, coupled with limited disease-burden data and the emergence of antibiotics resistance, are hindering the effective management of the disease in older adults. Various global guidelines recommend pneumococcal vaccines for the prevention of pneumococcal diseases, as they reduce disease burden, hospitalization, and mortality rates among patients with comorbid conditions. Besides being an integral part of childhood immunization, these vaccines are advocated by various Indian healthcare bodies/groups for older and younger adults with certain medical conditions. The article presents an overview of the closed-door discussion by the Indian pulmonary experts on the scientific evidence and clinical practice followed for the prevention of pneumococcal disease in India.
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CASE REPORTS Top

Barber's neck manipulation causing bilateral diaphragmatic paralysis and type-2 respiratory failure p. 226
Ashish Kumar Prakash, Anand Jaiswal, Sandeep Mittal, Poulomi Chatterjee, Sameer Kotalwar, Bornalli Datta
DOI:10.4103/lungindia.lungindia_90_18  PMID:31031343
This is a case report of an unusual cause of bilateral diaphragmatic palsy. A 54-year-old gentleman, presented to us with exertional dyspnea and chest heaviness for the past 6 months which had increased in the last 6 days. Dyspnea increased on lying down. He was diagnosed as pneumonia on the basis of X-ray and chest CT scan, received treatment for the same and responded to the therapy. However, breathlessness and hypercapnia persisted. He had unexplained hypercapnia for which extensive investigations were carried out. Neurological and cardiac assessments were essentially normal. On revisit clinical examination, he was found to have paradoxical diaphragmatic movement with respiration. Ultrasound of chest detected no diaphragmatic movement. Detailed history elicited that patient was fond of neck massage and neck cracking wherein his barber would bend his neck with jerk to either side after a haircut.After considering all possible etiologies; we concluded that it was a case of diaphragm palsy induced by barber neck manipulation, leading to Type-2 respiratory failure. The fact that the vital clues to the diagnosis were elicited by detailed history and thorough examination reinforces that history and clinical examination for doctors shall remain a very important tool for clinical diagnosis.
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Pulmonary amyloidosis: A case series p. 229
Anil Kumar Gandham, AR Gayathri, L Sundararajan
DOI:10.4103/lungindia.lungindia_205_18  PMID:31031344
Amyloidosis is a spectrum of diseases, in which various proteins which are usual components of plasma are deposited as insoluble beta-pleated sheets extracellularly, disrupting function of various organs. Amyloid light-chain amyloidosis occurs due to the deposition of proteins, derived from immunoglobulin light chains, routinely manifesting with multisystem involvement. Pulmonary involvement is seen in about 50% of cases. Three common patterns of pulmonary amyloidosis on computed tomography (CT) chest are tracheobronchial, nodular parenchymal, and diffuse alveolar septal variety. We hereby report two cases of pulmonary amyloidosis, one being a case of diffuse alveolar septal pulmonary amyloidosis, which is an extremely rare pattern of involvement, with a very poor prognosis, and the other one being tracheobronchial pattern of involvement, which usually results due to the localized deposition of amyloid in the tracheobronchial tree. Knowledge about pulmonary amyloidosis is important due to its poor prognosis and nonspecific findings in CT chest.
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Subglottic hemangioma masquerading as croup and treated successfully with oral propranolol p. 233
Prawin Kumar, Darwin Kaushal, Pawan Kumar Garg, Neeraj Gupta, Jagdish Prasad Goyal
DOI:10.4103/lungindia.lungindia_200_18  PMID:31031345
Subglottic hemangioma (SGH) is a rare and potentially life-threatening condition of the airway. A 3-month-old girl presented with croup which improved only partially with nebulized adrenaline and intramuscular dexamethasone. An upper airway endoscopy revealed the diagnosed of SGH. Oral propranolol was started, and following that, there was a dramatic response within 48-h of therapy, and complete remission after 1 year of therapy.
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Atypical carcinoid tumor of the lung: A rare entity p. 236
Rajiv Garg, Rahul Kumar, Pradyumn Singh, Silpa Kshetrimayum
DOI:10.4103/lungindia.lungindia_111_16  PMID:31031346
Carcinoids account for approximately 2% of all lung tumors, and the atypical carcinoids (ACs) are much rarer than typical carcinoid. Here, we report a rare case of AC tumor of the lung. A 50-year-old female patient presented with left-sided chest pain for 1 year, cough for 6 months, and loss of appetite for 6 months. Contrast-enhanced computed tomography scan of the thorax revealed an ill-defined heterogeneously enhancing soft-tissue attenuation lesion in the mediastinum following which transthoracic biopsy was done. Histomorphology and immunohistochemistry were consistent with AC, a neuroendocrine tumor. Combination chemotherapy consisting of cisplatin and etoposide was administered as initial chemotherapy.
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COMMENTARY Top

The great smog of Delhi p. 239
Mausumi Basu
DOI:10.4103/lungindia.lungindia_363_18  PMID:31031347
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NEWER TECHNIQUES Top

Cryoprobe transbronchial lung biopsy with flexible bronchoscope using Arndt endobronchial blocker p. 241
Karan Madan, Saurabh Mittal, Vijay Hadda, Anant Mohan
DOI:10.4103/lungindia.lungindia_35_18  PMID:31031348
Cryoprobe transbronchial lung biopsy (TBLB)/transbronchial lung cryobiopsy (TBLC) is increasingly being described as an alternative to surgical lung biopsy and provides larger lung biopsy samples as compared with conventional TBLB in patients with diffuse parenchymal lung diseases. The technique for cryoprobe TBLB procedure has not yet been standardized, and various authors describe different modalities. However, the use of an artificial airway (rigid bronchoscope or endotracheal tube) is preferred for airway protection. In addition, the use of an occlusion balloon provides safety to prevent excessive bleeding. The exclusive use of rigid bronchoscopy may limit the widespread adoption of this diagnostic modality. We describe a method to perform cryoprobe TBLB with exclusive use of a flexible bronchoscope and utilization of Arndt endobronchial blocker as an occlusion balloon. The procedure was performed in two patients under moderate conscious sedation. Adequate lung biopsies were obtained in both the cases without any complications. This modality may allow safe performance of cryoprobe TBLB with a flexible bronchoscope. Herein, we describe the technical and procedural considerations of this modality.
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NEW HORIZON Top

Host genetics and tuberculosis: Theory of genetic polymorphism and tuberculosis p. 244
PP Aravindan
DOI:10.4103/lungindia.lungindia_146_15  PMID:31031349
Background and Objective: Tuberculosis (TB), the leading cause of morbidity and mortality by a single infectious agent, Mycobacterium tuberculosis, is still a major health problem in the world. To date, many studies have shown evidence of association between host genetic polymorphisms and TB susceptibility, including chemokine (C-C motif) ligand 2 (CCL-2)/monocyte chemoattractant protein1 (MCP-1), natural resistance-associated macrophage protein 1 (NRAMP-1)/solute carrier protein 11A1 (SLC11A1), Immunity-related GTPase family M protein (IRGMI), interleukin (IL)-8, toll-like receptor (TLR), and nucleotide-binding oligomerization domain containing protein-2 (NOD-2) genes. Most of these genes participate in immune response, and their polymorphism can alter immunity and lead to genetic susceptibility to TB. Materials and Methods: This is a special article compiled with reference to various case-control studies, meta-analysis, and other research work on different genes and TB. The genes selected and a number of studies from different countries and ethnic groups for this article are shown below. The genes selected for the study are: NRAMP-1 (SLC11 A1), Vitamin D receptor, low molecular weight polypeptide/transporter with antigen processing, CCL-2/MCP-1, IRGM-1, IL-1, IL-8, IL-10, IL-12, TLR, NOD-2, human leukocyte antigen, mannose-binding lectin, major histocompatibility complex, tumor necrosis factor, P2X 7, epiregulin, SP110, and interferon gamma (IFN-gamma). Results: Genetic polymorphisms in different genes showed variable levels of significance in relation to TB. All these were proved by the researchers using appropriate statistical methods and tools. Conclusions: Based on different research works across the world, there is sufficient evidence to prove that TB is a genetically primed and determined infectious disease caused by M. tuberculosis and the genetic polymorphism is the mechanism that leads to progression from infection to TB disease. Why only 10–15% of the people infected with M. tuberculosis progress toward TB disease has continued to be an unresolved debate. Hence, for provoking thoughts and encouraging more research in the field of genetics and TB I formulated hypothesis and algorithms, and theory. Genetic susceptibility to TB has been substantiated based on the extensive literature review and the research findings that are well narrated.
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CASE LETTERS Top

Conventional laryngoscopy as a rescue for fiber-optic-assisted tracheal intubation in a patient with perilaryngeal edema after rigid bronchoscopy: A case report p. 253
Rakesh Garg, Rudranil Nandi, Vijay Hadda, Anant Mohan
DOI:10.4103/lungindia.lungindia_251_17  PMID:31031350
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Mediastinal shift towards postpneumonectomy space in the early postoperative period and its management by simple technique of air insufflation p. 254
Vikas Deep Goyal, Shelly Rana
DOI:10.4103/lungindia.lungindia_199_14  PMID:31031351
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”St. Peregrine tumor” with synchronous primary renal cell carcinoma p. 256
Sameer Vaidya, Dipti Gothi, Mahismita Patro, Ram Babu Sah, Ritu Kulshreshtha
DOI:10.4103/lungindia.lungindia_413_18  PMID:31031352
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Mouse in the pleural cavity p. 259
Roopali Khanna, Neeraj Jain, Praveen K Goel, Sunil Kumar
DOI:10.4103/lungindia.lungindia_445_18  PMID:31031353
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Acute parenchymal lung involvement in a 68-year-old woman with systemic lupus erythematosus, anemia, and thrombocytopenia p. 261
Michela Dimitri, Vito Liotino, Silvano Dragonieri, Agnese Caringella, Luciana Labate, Pierluigi Carratu, Onofrio Resta
DOI:10.4103/lungindia.lungindia_400_18  PMID:31031354
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Rupture of occlusion balloon during transbronchial lung cryobiopsy p. 263
Saurabh Mittal, Vijay Hadda, Anant Mohan, Karan Madan
DOI:10.4103/lungindia.lungindia_152_18  PMID:31031355
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LETTERS TO EDITOR Top

Hemophagocytic lymphohistiocytosis complicating nontuberculous mycobacterial infection p. 266
Stuti Gupta, Arup Kumar Basu, Abhinav Guliani, Amit Dhamija
DOI:10.4103/lungindia.lungindia_451_18  PMID:31031356
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Inflammatory phenotypes of severe asthma in India p. 267
Angira Dasgupta, Vittal Ade, Jayeeta Dutta, Gautam Dasgupta
DOI:10.4103/lungindia.lungindia_502_18  PMID:31031357
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Diffuse tracheobronchial calcinosis in a geriatric patient with chronic kidney disease p. 269
Alper Alp, Levent Usta
DOI:10.4103/lungindia.lungindia_10_19  PMID:31031358
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Hydropneumothorax following diagnostic bronchoalveolar lavage: A rarest of rare complication p. 270
Laboni Sarkar, Sagnik Biswas, Animesh Ray, Sanjeev Sinha
DOI:10.4103/lungindia.lungindia_423_18  PMID:31031359
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Spontaneous pneumomediastinum complicated by pneumopericardium after a single use of inhaled methamphetamine p. 271
Namrata Paul, Rahul Vasudev, Sushant Nanavati, Vinod Kumar, Trina Pal, Julia Arena, Upamanyu Rampal, Chandra B Chandran
DOI:10.4103/lungindia.lungindia_98_18  PMID:31031360
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Lung hydatid cyst, an immunological process, not a pearl formation p. 273
Beuy Joob, Viroj Wiwanitkit
DOI:10.4103/lungindia.lungindia_94_19  PMID:31031361
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Ignotum per ignotius p. 274
Milind Baldi, Sahajal Dhooria, Ritesh Agarwal, Inderpaul Singh Sehgal
DOI:10.4103/lungindia.lungindia_134_19  PMID:31031362
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