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   Table of Contents - Current issue
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January-February 2018
Volume 35 | Issue 1
Page Nos. 1-92

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EDITORIAL  

Molecular biology tools for precision medicine in managing lung cancer p. 1
PA Mahesh
DOI:10.4103/lungindia.lungindia_470_17  PMID:29319025
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ORIGINAL ARTICLES Top

Sequelae of pulmonary multidrug-resistant tuberculosis at the completion of treatment p. 4
Rupak Singla, Manashree Mallick, Parul Mrigpuri, Neeta Singla, Amitesh Gupta
DOI:10.4103/lungindia.lungindia_269_16  PMID:29319026
Background: Treatment of multidrug-resistant (MDR-TB) mainly focuses on bacteriological cure. However, only limited studies have evaluated the sequelae left after the completion of treatment among MDR-TB patients. Objective: To assess the persistent symptoms, radiological sequelae, pulmonary function impairment and quality of life at the completion of treatment among MDR-TB patients. Methods: Forty six MDR-TB patients were enrolled, who completed two years of treatment under programmatic management of Drug Resistant tuberculosis at a tertiary referral institute in Delhi, India. Detailed clinical history was taken. X-ray chest, 6 Minute Walk Test and pulmonary function tests were attempted in all patients. Quality of life was evaluated using Seattle obstructive lung disease questionnaire. Results: At the completion of MDR-TB treatment 95.7% patients had residual symptoms; 100% patients had residual bilateral chest x-ray abnormality with 82.6% patients showing far advanced disease. PFT was abnormal in 97.6% patients with mixed pattern being the commonest abnormality. Quality of Life was impaired with mean physical function of 46%. Conclusion: At the completion of MDR-TB treatment, significant numbers of patients are left with post treatment sequelae. The medical management and social support for these patients should be incorporated in the national programs.
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Comparison of diagnostic yield and safety profile of radial endobronchial ultrasound-guided bronchoscopic lung biopsy with computed tomography-guided percutaneous needle biopsy in evaluation of peripheral pulmonary lesions: A randomized controlled trial p. 9
Ayush Gupta, Jagdish Chander Suri, Dipak Bhattacharya, Manas Kamal Sen, Shibdas Chakrabarti, Abhijeet Singh, Tulsi Adhikari
DOI:10.4103/lungindia.lungindia_208_17  PMID:29319027
Background: Peripheral pulmonary lesions (PPLs) pose a diagnostic challenge, and the optimal investigation in many such cases remains unclear. Computed tomography (CT)-guided percutaneous needle biopsy (CT-PNB) has been the modality of choice for such lesions with a high diagnostic accuracy but with high rates of pneumothorax. Endobronchial ultrasound (EBUS) with a radial probe is an alternate diagnostic modality with increased diagnostic yield of bronchoscopy in the evaluation of PPL. We conducted a randomized controlled trial comparing the diagnostic accuracy and complication rates of radial EBUS with CT-guided lung biopsy for the evaluation of PPL. Methods: Fifty patients with PPL surrounded by lung parenchyma on all sides were randomly assigned to either radial EBUS or CT-PNB group (25 each). Results: Both groups had similar clinicoradiologic characteristics. The diagnostic accuracy of radial EBUS was comparable to CT-PNB with no statistically significant difference (72 vs. 84%; P = 0.306). However, the yield was significantly lower in right upper lobe lesions (20% vs. 83.3%; P = 0.03). CT-PNB group had significantly higher pneumothorax rates than radial EBUS (20% vs. 0%; P = 0.03). The lesions that were more than 2 cm, those with ultrasound feature of continuous hyperechoic margin around the lesion (P = 0.007), and the position of the ultrasound probe within the lesion (P < 0.001) were associated with a higher diagnostic yield with radial EBUS. Conclusion: Our findings suggest that radial EBUS is a safer investigation than CT-PNB with a comparable diagnostic accuracy for PPL not abutting the chest wall (CTRI/2017/02/007762).
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Comparison of oral montelukast with oral ozagrel in acute asthma: A randomized, double-blind, placebo-controlled study p. 16
Rahul Magazine, Vyshak Uddur Surendra, Bharti Chogtu
DOI:10.4103/lungindia.lungindia_226_17  PMID:29319028
Background: The need for more effective management of acute asthma has led to research on drugs which are otherwise approved for use in chronic asthma. Objective: To study and compare the effects of oral montelukast with oral ozagrel in acute asthma. Materials and Methods: One hundred and twenty patients with acute asthma were recruited for the study. Out of 120 study patients, forty each were randomized into placebo, montelukast, and ozagrel groups. After the first dose of the drug or placebo was administered, peak expiratory flow rate (PEFR), number of rescue medications and also vital signs were noted at 6 h, 12 h, 24 h, 48 h, and at discharge. In addition, same recordings were done on the morning (8 a.m. – 10 a.m.) following admission. The difference in mean PEFR of each group at above-mentioned time points was the primary endpoint whereas need for rescue medications the secondary end-point. Results: The respective mean PEFR recordings of the placebo, montelukast, and ozagrel groups at various time points were as follows: at 6 h (235.19 ± 3.18, 242.86 ± 3.26, 228.18 ± 3.25); at 12 h (254.37 ± 5.23, 265.62 ± 5.38, 242.99 ± 5.36); at 24 h (267.46 ± 7.41, 291.39 ± 7.61, 268.14 ± 7.58); and at 48 h (277.99 ± 7.35, 303.22 ± 7.56, 285.27 ± 7.53); and discharge (301.94 ± 7.07, 317.32 ± 7.27, 298.99 ± 7.23). The mean PEFR between the treatment groups were not statistically significant (P = 0.102). The mean PEFR in the three groups at 8–10 a.m. following admission was 257.60 ± 5.52, 264.23 ± 5.98, and 249.94 ± 5.96; P = 0.266. Total number of rescue doses needed were 7, 4, and 13, respectively (P = 0.67). Conclusion: Montelukast or ozagrel when added to the standard treatment of acute asthma does not result in any additional benefit.
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Clinical and pulmonary functions profiling of patients with chronic obstructive pulmonary disease experiencing frequent acute exacerbations p. 21
Prem Parkash Gupta, Manjunath B Govidagoudar, Rohtas Yadav, Dipti Agarwal
DOI:10.4103/lungindia.lungindia_528_16  PMID:29319029
Purpose: The present study aimed at clinical and pulmonary functions profiling of patients with chronic obstructive pulmonary disease (COPD) to anticipate future exacerbations. Methods: The study included 80 COPD patients; 40 patients had ≥2 acute exacerbations during preceding 1 year (frequent exacerbation [FECOPD] group) and 40 patients had <2 acute exacerbations during preceding 1 year (infrequent exacerbation [I-FECOPD] group). Clinical profile, sputum microbiology, blood gas analysis, spirometric indices, and diffusion capacity (transfer test) variables were assessed. Groups' comparison was performed using an independent t-test for numeric scale parameters and Chi-square test for nominal parameters. Pearson's and Spearman's correlation coefficients were derived for numeric scale parameters and numeric nominal parameters, respectively. Multinomial logistic regression analysis was done using SPSS software. Results: FECOPD group contained younger patients than in I-FECOPD group although the difference was not statistically significant. There was no significant difference between two groups regarding smoking pack-years and duration of illness. FECOPD group had significantly more expectoration score and Modified Medical Research Council dyspnea scores. Cough score and wheeze score did not differ significantly between two groups. More patients in FECOPD group (12/40 vs. 4/40) had lower airway bacterial colonization. Arterial blood gas parameters were more deranged in FECOPD group. Spirometric indices (forced expiratory volume during 1st s) as well as transfer test (both diffusing capacity for carbon monoxide and transfer coefficient of the lung values) were significantly reduced in FECOPD group. Conclusions: The patients in FECOPD group had clinical, spirometric, and transfer test profiling suggestive of a severe COPD phenotype, the recognition will help in predicting future exacerbations and a better management.
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Efficacy of gefitinib in epidermal growth factor receptor-activating mutation-positive nonsmall cell lung cancer: Does exon 19 deletion differ from exon 21 mutation? p. 27
Amit Joshi, Vijay Patil, Vanita Noronha, Anuradha Chougule, Atanu Bhattacharjee, Rajiv Kumar, Supriya Goud, Sucheta More, Anant Ramaswamy, Ashay Karpe, Nikhil Pande, Arun Chandrasekharan, Alok Goel, Vikas Talreja, Abhishek Mahajan, Amit Janu, Nilendu Purandare, Kumar Prabhash
DOI:10.4103/lungindia.lungindia_201_17  PMID:29319030
Background: This study was designed to evaluate the differential effect of epidermal growth factor receptor (EGFR) mutation status (exon 19 vs. 21) on progression-free survival (PFS) and overall survival (OS) in treatment-naïve advanced EGFR mutation-positive nonsmall cell lung cancer (NSCLC) treated with gefitinib as first-line agent. Methods: This was a post hoc analysis of EGFR-mutated (exon 19 and 21) advanced-stage (Stage IIIB or IV), chemotherapy-naive NSCLC patients treated with gefitinib as first line in a phase 3 randomized study. Patients were treated with gefitinib 250 mg daily. Patients underwent axial imaging for response assessment on D42, D84, D126, and subsequently every 2 months till progression. Responding or stable patients were treated until progression or unacceptable toxicity. SPSS was used for statistical analysis. Kaplan–Meier method was used for survival estimation and log-rank test for comparison. Cox proportion hazard model was used for multivariate analysis. Results: One hundred and forty-one patients were eligible for analysis, of which 78 were males and 63 were females. A total of 127 patients (90.1%) were ECOG 0–1 while 14 patients (9.1%) were ECOG >1. Exon 21 mutation was present in 65 patients (46.1%) and exon 19 mutation in 76 patients (53.9%). One hundred and thirty-three of 141 patients were evaluable for response. Response rate of patients having exon 19 mutation was 72.9% (51 patients, n = 70) while it was 55.6% in patients having exon 21 mutation (35 patients, n = 63) (P = 0.046). Median PFS in exon 19-mutated patients was 9.3 months (95% confidence interval [CI] 6.832–11.768) compared to 7.8 months (95% CI 5.543–10.0) (P = 0.699) in exon 21-mutated patients. The median OS in exon 19-mutated patients was 19.8 months (95% CI 16.8–22.7), and it was 16.5 months (95% CI 10.9–22.1) in exon 21-mutated patients (P = 0.215). Conclusion: There were no differential outcomes in the Indian patients of advanced-stage NSCLC with exon 19 and 21 EGFR mutations treated with gefitinib.
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Association of comorbid anxiety and depression with chronic obstructive pulmonary disease p. 31
Ruchi Dua, Anindya Das, Abhishek Kumar, Sandeep Kumar, Mayank Mishra, Kapil Sharma
DOI:10.4103/lungindia.lungindia_537_16  PMID:29319031
Background: Chronic obstructive pulmonary disease (COPD) is a disease with known systemic manifestations including psychiatric comorbidities most commonly being depression and/or anxiety. Studies regarding the association of these psychiatric comorbidities in terms of symptom scores, spirometric variables, and hospitalizations among patients of COPD are lacking, especially in India. Materials and Methods: One hundred and twenty-eight patients of COPD attending the Outpatient Department of AIIMS Rishikesh, and fulfilling inclusion criteria were screened by Hospital Anxiety and Depression Scale, and those who scored above the cutoff underwent psychiatric evaluation using the International Classification of Diseases, Tenth Edition Diagnostic Criteria for Research for confirmation of their diagnosis. All patients were then evaluated by physician-administered questionnaire for symptom scores by Modified Medical Research Council Scale (mMRC) for dyspnea, Hindi-validated Clinical COPD Questionnaire (CCQ), and for functional capacity by 6-min walk distance (6MWD) according to the American Thoracic Society Guidelines. All patients also underwent spirometric evaluation, and postbronchodilator forced expiratory volume in 1 s (FEV1), BODE index (body mass index [BMI], postbronchodilator FEV1, mMRC for dyspnea, 6MWD) and a history of hospitalization/exacerbations over the past 1 year was also obtained. Comparison of symptom scores, functional capacity in terms of 6MWD, history of exacerbations or hospitalizations over preceding 1 year and BODE index between patients of COPD with or without anxiety and/or depression was done. Results: COPD patients with comorbid anxiety and/or depression had higher dyspnea scores and CCQ scores though the proportion of current smokers, BMI, history of hospitalization over the past 1 year, FEV1, and BODE index was not statistically significant between the two groups. Conclusions: Depression is a common comorbidity and leads to higher symptom scores as well as poorer quality of life among COPD patients.
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Study of inflammatory markers and BODE index in chronic obstructive pulmonary disease p. 37
Priti Lokesh Meshram, Shivprasad N Shinde, Nagsen N Ramraje, Rohit R Hegde
DOI:10.4103/lungindia.lungindia_46_17  PMID:29319032
Introduction: Chronic obstructive pulmonary disease (COPD) is a common preventable and treatable disease characterized by progressive airflow limitation and associated with enhanced chronic inflammatory response of the airways to a variety of noxious stimuli. The current concept of COPD, however, extends beyond the respiratory system to include a variety of extrapulmonary manifestations which includes raised inflammatory markers. Methods: This was a single, center observational open-labeled case–controlled study which included fifty patients of diagnosed COPD and 50 age- and gender-matched controls. All patients were evaluated by detailed history taking, pulmonary function test, 6-min walk test, and calculation of BODE scores. Levels of serum inflammatory markers such as cortisol, tumor necrosis factor alpha, interleukin-6 (IL-6), lactate dehydrogenase, and C-reactive protein were estimated using standard quality equipments. Observations: Majority of the patients in the study and control groups were males and were aged above 40 years. Thirty-eight of the fifty COPD patients had BODE scores of more than 3. All the studied inflammatory markers were significantly higher in the COPD group as compared to the control group. Of all the studied markers, only IL-6 showed a significant correlation with BODE index, i.e., higher IL-6 values were associated with higher BODE scores. No correlation was seen between the other markers and BODE scores. Conclusions: Our data suggest that IL-6 is a biomarker that correlates with BODE score. IL-6 as a target for therapy in COPD needs to be further studied. Follow-up studies are needed to validate findings.
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SYSTEMATIC REVIEW Top

Primary cavitary sarcoidosis: A case report, systematic review, and proposal of new diagnostic criteria p. 41
Ajay Handa, Sahajal Dhooria, Inderpaul Singh Sehgal, Ritesh Agarwal
DOI:10.4103/lungindia.lungindia_225_17  PMID:29319033
Primary cavitary sarcoidosis (PCS) is a rare form of pulmonary sarcoidosis. In this report, we present a case of a 47-year-old male patient with PCS who was initially treated as pulmonary tuberculosis. We also systematically review the literature on PCS and propose a new classification for this entity.
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CASE REPORTS Top

The mimic of tracheal carcinoid in elderly female p. 47
Parth Rali, Namrata Jasani, Hammad Arshad, Jianwu Xie, Marvin Balaan
DOI:10.4103/0970-2113.221726  PMID:29319034
We present a case of a glomus tumor of trachea in an elderly female who presented with a mass originating from the posterior trachea. She underwent rigid bronchoscopy with tumor debulking combined with laser therapy. Frozen section initially suggested carcinoid tumor but later turned out to be a glomus tumor. She improved with additional laser therapy. We present her clinical course and a literature review on glomus tumor.
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A rare case of bronchial elastosis: An unusual presentation of an unexpandable lung p. 50
Raghav Gupta, Hassan Patail, Mohammad R Al-Ajam
DOI:10.4103/lungindia.lungindia_31_17  PMID:29319035
Endobronchial obstruction is a known cause of an unexpandable lung. Endobronchial lesions are usually malignant, however benign cause like hemartoma, lipoma, amyloidosis and neuroendocrine tumors are known. We, hereby present the rare cause of bronchial elastosis presenting as right lower lobe lung collapse.
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The use of adaptive intensity-modulated radiotherapy in the treatment of small-cell carcinoma lung refractory to chemotherapy in a patient with preexisting interstitial lung disease p. 54
Sarthak Tandon, Munish Gairola, Manoj Pal, Archana Aggarwal, Kanika Sharma, Ahmad Masroor Karimi, Avik Mandal, Rajiv Goyal, Ullas Batra, Inderjit Kaur
DOI:10.4103/lungindia.lungindia_93_17  PMID:29319036
This is a case report of a 60-year-old diabetic, hypertensive male with a good performance status and a history of bilateral interstitial lung disease with a left upper lobe lung mass diagnosed to be a Stage IIB mixed small-cell/squamous cell carcinoma which was refractory to carboplatin- and etoposide-based chemotherapy. The patient was then taken up for adaptive intensity-modulated radiotherapy with tighter margin under image guidance with a mid-treatment replanning done at 25#. Acute toxicities were assessed weekly and showed no Grade 3 or more reactions. Pulmonary function test showed no detrimental changes during or after radiation. Response assessment at 12 and 20 weeks showed a partial response with decrease in metabolic activity on serial scans.
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Ventilator-dependent pulmonary nocardiosis in a patient with chronic obstructive pulmonary disease p. 58
Stella Pak, Tarek Mansour, Yan Yatsynovich, Andrew Kobalka
DOI:10.4103/lungindia.lungindia_170_17  PMID:29319037
Nocardiosis is a rare infectious disease entity that mostly affects the lungs, brain, or skin of immunocompromised individuals. Recent reports of pulmonary nocardiosis (PN) in patients with chronic obstructive pulmonary disease (COPD) as the only risk factor suggest a possible association between nocardiosis and COPD. Herein, we present a case of ventilator-dependent PN in a patient with a moderate degree of COPD. A high level of suspicion for PN should be maintained when encountered with COPD patients complaining of symptoms of pneumonia and excessive thirst.
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Noninvasive ventilation–neurally adjusted ventilator assist for management of acute exacerbation of chronic obstructive pulmonary disease p. 62
Vijay Hadda, Tajamul Hussain Shah, Karan Madan, Anant Mohan, Gopi C Khilnani, Randeep Guleria
DOI:10.4103/lungindia.lungindia_97_17  PMID:29319038
Patient–ventilator asynchrony is common with noninvasive ventilation (NIV) used for management of acute exacerbation of chronic obstructive pulmonary disease (COPD). Neurally adjusted ventilator assist (NAVA) is a mode of ventilatory support which can minimize the patient–ventilator asynchrony. Delivering NIV with NAVA (NIV–NAVA) during acute exacerbation of COPD seems a logical approach and may be useful in reducing patient–ventilator asynchrony. However, there are no published reports which describe the use of NIV–NAVA for management of acute exacerbation of COPD. We describe the successful management of a 56-year-old gentleman presenting to the emergency department of our hospital with acute exacerbation of COPD with hypercapnic respiratory failure with NIV–NAVA.
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Anaplastic large cell lymphoma presenting as bilateral endobronchial tumor in a young boy p. 66
Abhijeet Dharmaji Sawant, Vijayraj S Patil, Pranjal M Gugalia, Rajiv Kumar, Sabita Jiwnani, George Karimundackal, CS Pramesh
DOI:10.4103/0970-2113.221727  PMID:29319039
A 15-year-old boy presented to us with a 4-month history of fever with worsening dyspnea since 1 month. His contrast-enhanced computed tomography scan of the thorax showed bilateral endobronchial lesions with complete collapse-consolidation of the left lung and partial collapse of the right lower lobe. His fiberoptic bronchoscopy guided biopsy had been reported in outside hospital as a neuroendocrine tumor. Due to worsening breathlessness, he had to be intubated. We repeated the endobronchial biopsy and combined with outside slides and blocks, was diagnosed to have an anaplastic lymphoma kinase-1 positive anaplastic large cell lymphoma (ALCL). We started the patient on chemotherapy to which he had a dramatic response radiologically and clinically. ALCL presenting as endobronchial mass is an extremely rare occurrence and it presenting with bilateral endobronchial masses has not been reported yet in literature. Pathologists and clinicians should be aware of this presentation as prompt diagnosis and treatment give promising results.
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Refractory bronchovascular pleuropulmonary mucormycosis: Case report and difficulties in management p. 70
M Manjunath, Deepak Prajapat, Rahul Kumar Sharma, Deepak Talwar
DOI:10.4103/lungindia.lungindia_535_16  PMID:29319040
Pulmonary mucormycosis is a life-threatening opportunistic fungal infection. It is considered as a disease of immunocompromised state and is rarely seen in immunocompetent patients. We here report a case of refractory bronchovascular pleuropulmonary mucormycosis, who despite early detection, optimal management with liposomal amphotericin B, and posaconazole therapy followed by surgery, progressed further and led to a fatal outcome. Dual antifungal therapy combined with surgery is the only definitive treatment option available in the literature. Many new therapeutic options for mucormycosis treatment have become available but none have shown promising results, and larger studies are required to assess their efficacy.
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Successful pulmonary thromboendarterectomy in a patient with sickle cell disease and associated resolution of a leg ulcer p. 73
Abhinav Agrawal, Rakesh Shah, Matthew D Bacchetta, Arunabh Talwar
DOI:10.4103/lungindia.lungindia_47_17  PMID:29319041
Pulmonary hypertension (PH) is a relatively frequent and severe complication of sickle cell disease (SCD). PH associated with SCD is classified as Group 5 PH. The exact pathogenesis of PH in SCD in not known. There are also very limited treatment options available at this time for such patients with Group 5 PH. Patients with SCD are predisposed to a hypercoagulable state and thus can also suffer from chronic thromboembolism. These patients can have associated chronic thromboembolic pulmonary hypertension (CTEPH), thus being classified as Group 4 PH. We present such a case of a patient with SCD diagnosed with severe PH who was found to have CTEPH and successfully underwent a thromboendarterectomy with resolution of his symptoms such as reduction of his oxygen requirements and healing of chronic leg ulcer. This case illustrates the importance of screening patients with SCD and elevated pulmonary artery pressures for CTEPH as this would offer possible treatment options such as pulmonary thromboendarterectomy and/or riociguat in this subset of patients.
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POSTGRADUATE EDUCATION DESK Top

Multidrug-resistant tuberculosis/rifampicin-resistant tuberculosis: Principles of management p. 78
Rajendra Prasad, Nikhil Gupta, Amitabh Banka
DOI:10.4103/lungindia.lungindia_98_17  PMID:29319042
Multidrug-resistant tuberculosis (MDR-TB)/rifampicin-resistant TB (RR-TB) is human-made problem and emerging due to poor management of TB and is a threat to control of TB. Early suspicion and diagnosis are important. Culture and drug susceptibility testing are gold standards, but newer molecular methods help in rapid diagnosis. Once diagnosed, prompt treatment should be started, preferably under direct observation. Treatment can be standardized or individualized. Conventional regimen takes up to 24 months but recently shorter regimen of up to 12 months was introduced in specific subset of MDR-TB/RR-TB patients. Management of MDR-TB/RR-TB is complicated, costlier, and challenging and is a concern for human health worldwide. It must be emphasized that optimal treatment of MDR-TB/RR-TB alone is not sufficient. Efforts must be made to ensure effective use of first- and second-line anti-TB drugs.
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RADIOLOGY QUIZ Top

Incidentally detected lung lesions in a patient with crohn's disease p. 82
Padmanabhan Arjun, Azharul Haque, Rahul Ramachandran
DOI:10.4103/lungindia.lungindia_91_17  PMID:29319043
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CASE LETTERS Top

Catastrophic antiphospholipid lung syndrome in young female with repeated abortions p. 85
Aliae Abd-Rabou Mohamed-Hussein, Hoda A Makhlouf, Sarrah M Hashem
DOI:10.4103/lungindia.lungindia_254_17  PMID:29319044
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Curious case of a black pleural effusion: Mediastinal teratoma presenting as massive pleural effusion p. 87
Subhra Mitra, Mridul Kumar Sarma, Anjan Kumar Das
DOI:10.4103/lungindia.lungindia_253_17  PMID:29319045
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Endobronchial lipoma with tuberculosis: A solitary coetaneousness p. 90
Sameer Bansal, Ketaki Utpat, Unnati Desai, Jyotsna M Joshi
DOI:10.4103/lungindia.lungindia_319_17  PMID:29319046
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LETTER TO EDITOR Top

Management of malignant pleural effusion with different pleural catheters p. 92
Sami Karapolat, Alaaddin Buran, Celal Tekinbas
DOI:10.4103/lungindia.lungindia_173_17  PMID:29319047
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