Background: Bronchial artery embolization (BAE) is an established, safe, and effective procedure for the treatment of hemoptysis but long-term outcomes of the BAE have never been investigated before. Objectives: To retrospectively analyze long-term outcomes of the BAE. Materials and Methods: A retrospective chart analysis was done from the hospital central database for all patients undergoing the BAE over a consecutive 14-year period (January 2000-February 2014). A total of 58 patients were identified from the database. Eight patients were excluded due to the lack of follow-up. Data such as patient demographics, reason for hemoptysis, medical imaging results, bronchoscopy findings, recurrence rates, and morbidity/mortality rates after the BAE were collected. Results: Eighty three embolizations were performed in 50 patients. The median follow-up was of 2.2 years. Cystic fibrosis (CF) bronchiectasis was the most common etiology (21/50), followed by non-CF bronchiectasis (9/50). Cavitary lung disease occurred in 12/50 patients, an additional 4/50 had cancer (primary lung and metastatic), and one patient had antineutrophil cytoplasmic antibody (ANCA) vasculitis. In three patients the etiology was unknown. Postprocedural complications occurred in 5/83 (6%) patients, two patients with two major complications - stroke (one) and paraplegia (one) - and three patients with minor complications - chest pain (two) and bronchial artery dissection (one). A total of 15/50 patients died during the follow-up. Three patients died of hemoptysis, and the remaining deaths were unrelated to the procedure or hemoptysis. Twenty four patients had recurrent hemoptysis. A Kaplan-Meier analysis revealed an excellent long-term survival that was 85% at 10 years. Conclusions: The BAE is a safe and effective procedure with excellent overall long-term survival.

Background: Aspergillus fumigatus is a saprophytic fungus which colonizes in the cavitary lesions in the lungs. In our part of the world, where tuberculosis is endemic, the healed tubercular cavities form a good nidus for this fungus. The fungus forms a fungal ball or aspergilloma within the cavity, which erodes the walls of the cavity and causes hemoptysis by erosion of the bronchial vessels. Hemoptysis is the main symptom. Antifungal agents are not useful against the fungal ball. Surgery in the form of lobectomy is the primary treatment. Surgery for aspergilloma is known to be risky because of intra-pleural adhesions, obliteration of the interlobar fissures, massive hemorrhage during dissection and poor pulmonary reserve of the patient due to the underlying disease. Materials and Methods: Clinical presentation, radiological investigations, operative techniques, postoperative outcome, and follow-up of 24 cases of pulmonary aspergilloma treated surgically were studied prospectively between August 2010 and July 2013 at IPGMER and SSKM Hospital, Kolkata. Results: There were 15 male (62.5%) and 9 female (37.5%) patients. Mean age of the study population was 34.54 years. All the patients had complex aspergilloma. Tuberculosis was the underlying disease in 22 patients (91%). Hemoptysis was the main symptom in 79.16% cases. Chest X-ray was the first investigation, which gave a clue to the diagnosis. Computed tomography scan was diagnostic in all cases. Lobectomy was done in 16 patients (66.67%). There was one mortality and the overall complication was 33.33%. The average follow-up period was 21.65 months, during which there was no mortality and no recurrence of hemoptysis in these patients. Conclusions: Though surgery for aspergilloma is considered to be risky, excision of the cavity along with the involved lobe can be done with acceptable morbidity and mortality to provide the patient complete cure and symptom-free survival.

Background: Falling asleep behind the wheel is one of the most relevant consequences of obstructive sleep apnea (OSA). We created a new screening questionnaire, named the Driver Sleepiness Score (DSS), aiming to assess sleepiness in drivers with suspected OSA. The primary aim of our study was to evaluate sleepiness in drivers with a suspicion of OSA by the DSS in order to assess its correlation with the apnea-hypopnea index (AHI), oxygen desaturation index (ODI), and total sleep time with oxyhemoglobin saturation below 90% (TST90). We also aimed to assess the diagnostic accuracy of DSS for three different cutoffs of AHI (AHI = 5, AHI = 15, AHI = 30), which allow stratification of the severity of OSA. Materials and Methods: Seventy-three driving patients at risk for OSA participated in the study. DSS and the Epworth Sleepiness Scale (ESS) were both administered in operator-dependent modality and in randomized sequence. Results: The DSS showed higher accuracy in screening patients with mild OSA [area under curve (AUC): 0.88 vs 0.74] and moderate OSA (AUC: 0.88 vs 0.79), whereas ESS showed higher accuracy in screening patients with severe OSA (AUC: 0.91 vs 0.78). A DSS score ≥ 7 is the optimal cutoff for distinguishing true positives from false positives for the presence of OSA and for its different severity levels. The administration of both questionnaires increases the accuracy for the detection of all OSA severity levels. Conclusions: If validated, DSS may qualify as a new screening tool specifically for drivers with the suspicion of having OSA, in combination with the ESS.

Background: Antisynthetase syndrome (AS) is an uncommon and under-recognised connective tissue disease characterized by the presence of antibodies to anti-aminoacyl t-RNA synthetase along with features of interstitial lung disease (ILD), myositis and arthritis. The aim of the current study is to describe our experience with management of AS. Materials and Methods: This was a 2-year (2013-2014) retrospective analysis of patients diagnosed with anti-Jo-1-related AS. The presence of anti-Jo-1 antibody was tested by the immunoblot assay. All patients underwent high-resolution computed tomography of the chest, transthoracic echocardiography and evaluation for inflammatory myositis. Transbronchial lung biopsies and muscle biopsies were obtained when clinically indicated. Results: Nine patients (mean age: 43.8 years) were diagnosed with anti-Jo-1-related AS. The median duration of symptoms before diagnosis of AS was 6 months. All patients were negative for antinuclear antibodies by indirect immunofluorescence. The prevalence of ILD, myositis and arthritis at presentation was 100%, 77.8% and 55.6%, respectively. The most common ILD pattern was non-specific interstitial pneumonia (n = 6) followed by organizing pneumonia (n = 2) and usual interstitial pneumonia (n = 1). ILD was the sole manifestation in two patients and was subclinical in two patients. Six patients had pleuropericardial effusions, three patients had pulmonary artery hypertension and two patients had venous thromboembolism. Eight of the nine patients improved after treatment with steroids and other immunosuppressants. Conclusion: Antisynthetase syndrome is an important and a treatable cause of ILD. Strong clinical suspicion is needed to achieve an early diagnosis.

Background: Emergence of drug resistance has complicated the treatment of tuberculosis (TB). WHO reports India to be one among 27 “high burden” multidrug-resistant (MDR) TB countries. Objective: To diagnose TB and detect drug resistance of mycobacterial isolates in acid-fast bacilli (AFB) smear negative HIV reactive patients (Group A) and compare them with HIV seropositive AFB smear positive (Group B) and HIV-seronegative AFB positive cases (Group C). Materials and Methods: Clinical specimens collected in all groups were processed as per the standard protocol except blood, which was processed by lysis centrifugation technique. They were then inoculated with Lowenstein-Jensen media and the isolates obtained were subjected to drug susceptibility test (DST) by proportion method and genotype MTBDR plus assay. Results: In Group A, 162 patients were included. Of the 443 clinical samples collected, 76 mycobacterial strains were obtained from 67 (41%) patients. Of these, 50 (65.8%) were sensitive to all drugs and 26 (34.2%) resistant to one or more anti-tubercular drugs. Antibiogram of Group A when compared with Group B and C showed that the MDR rate 6.6%, 6.7% and 8% respectively) did not differ much; but resistance to at least single drug was (26 [34.2%], 3 [10%], and 8 [16%]), respectively. Conclusion: Our study suggests that HIV has no influence on the anti-tubercular resistance pattern, but increased MDR rate along with HIV in high TB burden setting stresses the need for early diagnosis and DST in providing proper regimens and improve prognosis.

Introduction: The prevalence of asthma in Jaipur district of Rajasthan was reported as 0.96% in an earlier survey. It was far below the national average of 2.38%. It was reasoned then that this could be due to under diagnosis of asthma in the Jaipur population. Material and Methods: A resurvey of the symptomatics, not diagnosed as asthma at time of the original survey was, therefore, undertaken. The resurvey data were analysed and those who now fulfilled the twin criteria for diagnosis of asthma, as used in the original survey, were diagnosed as having asthma. The original data of these newly diagnosed asthma patients were reanalyzed in search for an alternative diagnostic criterion. Results: Of the 382 symptomatics, 344 (90%) could be resurveyed and of them, 85 now fulfilled the twin diagnostic criteria for asthma. The reanalysis of the original survey data of these patients revealed that presence of shortness of breath (SOB) had the highest sensitivity, the presence of allergic symptoms in self or the family had the highest specificity and the presence of wheezing had the highest odds ratio (OR) for diagnosing asthma. Further, the OR for diagnosing asthma increased further and was highest with the presence of SOB and 2 additional symptoms. With the use of the “symptom criteria” for diagnosis of asthma i.e. the presence of SOB with 2 additional symptoms, it would have been possible to diagnose majority of the missed cases at the time of the original survey itself. Conclusions: Based on this study data it can be concluded that (a) the twin criteria for diagnosing asthma as used in earlier surveys led to under diagnosis of asthma and (b) the use of symptom criteria alone effectively checks the problem of under diagnosis of asthma. The symptom criteria are being suggested as an alternative method for use in future epidemiological surveys on asthma.

Purpose: Physical inactivity in Indians is leading to an increase in noncommunicable disorders at an early age in life. Early identification and quantification of the lack of physical activity using simple and reliable exercise testing is the need of the hour. The incremental shuttle walk test (ISWT) is an externally paced walk test widely used for the evaluation of exercise capacity. Currently the normative values available for clinical reference are generated from Western populations. Hence, the study was conducted to find normative values for the ISWT in healthy Indian adults (17-75 years). Materials and Methods: A convenience sample of 862 subjects was recruited after ethical approval was obtained. All subjects were divided into groups as per age and gender. For age, the grouping was as follows: Group 1: Young adulthood (17-40 years), group 2: Middle adulthood (40-65 years), and group 3: Old adulthood (>65 years). The ISWT was performed as per standard protocol by Sally Singh. Results: The average distance walked were 709.2m,556.4m and 441.3m in females and 807.9 m, 639.6 m and 478.2 m in males in the three respective age groups. Stepwise regression analysis revealed age and gender as key variables correlating with incremental shuttle walk distance (ISWD). The derived predictive equations for males and females may be given as follows: 740.351 - (5.676 × age) + (99.007 × gender). Conclusion: Reference values were generated for healthy Indian adults. Physiological response to the ISWT was shown to be affected by gender and increasing age. Easily measurable variables explained 68% of the variance seen in the test, making the reference equation a relevant part of the evaluation of the ISWT.

Introduction: Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory disease affecting the airways, leading to significant morbidity and mortality throughout the world. There is a need to have a holistic evaluation of COPD patients, other than just measuring the level of obstruction as performed by spirometry. High resolution computed tomography (HRCT) scan of thorax partly fulfills this requirement. Materials and Methods: Fifty patients of COPD (confirmed on spirometry as per the GOLD guidelines 2014 guidelines) were enrolled, out of which 35 patients got a HRCT done. Complete clinical evaluation was done. The Philips computer program for lung densitometry was used with these limits (−800/−1, 024 Hounsfield unit [HU]) to calculate densities, after validating densitometry values with phantoms. We established the area with a free hand drawing of the region of interest, then we established limits (in HUs) and the computer program calculated the attenuation as mean lung density (MLD) of the lower and upper lobes. Results: There was a significant correlation between smoking index and anteroposterior tracheal diameter (P = 0.036). Tracheal index was found to be decreasing with increasing disease severity which was statistically significant (P = 0.037). Mean upper lobe MLD was −839.27 HU, mean lower lobe MLD was −834.91 HU and the mean MLD was −837.08 HU. The lower lobes MLD were found to be decreasing with increasing disease severity. A mild linear correlation of pre forced expiratory volume in the first second (FEV1) was observed with lower lobe and total average MLD while a mild linear correlation of Post-FEV1 was observed with both coronal (P = 0.042) and sagittal (P = 0.001) lower lobes MLD. In addition, there was a linear correlation between both pre (P = 0.050) and post (P = 0.024) FEV1/forced vital capacity with sagittal lower lobe MLD. A predictive model can be derived to quantify obstruction severity (FEV1). Conclusion: HRCT may be an important additional tool in the holistic evaluation of COPD. HRCT can well be correlated with the spirometric and clinical features and the level of obstruction can be indirectly derived from it by measuring the MLD.

Background: Interstitial lung disease (ILD) is a type of pulmonary manifestation in patients with rheumatoid arthritis (RA). Mostly RA-ILD has no symptoms and is only diagnosed by clinical examination, pulmonary function test (PFT), and high-resolution computed tomography (HRCT); hence it seems that the diagnosis of pulmonary involvement in early stages of RA is of great importance. Therefore, we decided to answer this question whether the evaluation of RA patients without pulmonary symptoms using methods such as PFT and HRCT are justifiable and reasonable or not. Methods: We conducted a cross-sectional study in a referral rheumatology clinic in Razi hospital of Rasht, Iran. Forty-four consecutive patients, diagnosed with RA, were enrolled. Physical examination of the joints was performed by an rheumatologist. The activity of RA was evaluated in all patients by Disease Activity Score 28. An expert pulmonologist performed the respiratory examination in all participants. Then, all subjects were referred for chest X-ray, PFT, and HRCT of lungs. Results: Patients included in this study, 9 (20.45%) males and 35 (79.55%) females, were 21–73 years old and their mean age was 49 ± 13 years. Significant relation between PFT and respiratory complaints was observed (P = 0.016). PFT had significant relation with respiratory examinations (P = 0.009). Our results indicated a significant relation between disease activity rate and PFT (P = 0.038). While HRCT had any significant relation with above items. Conclusion: We concluded, using PFT in the respiratory assessment of RA patients can be limited to persons with high disease activity, respiratory complaints, and positive findings in the clinical respiratory examination.

Background: Chronic obstructive pulmonary disease (COPD) is a major cause of mortality and morbidity. It is the fourth leading cause of death worldwide. Acute exacerbations of COPD are common and are associated with worsening lung function and mortality. Objectives: To evaluate the prevalence of elevation of cTnI in patients admitted with acute exacerbation of COPD and to study its association with the need for ventilator support, duration of hospital stay, and in-hospital mortality. Methods: In a prospective design, 50 patients admitted to our hospital with acute exacerbation of COPD were included. cTnI was assayed in a blood sample obtained at admission and 24 h later. Levels above 0.017 µg/L were taken as positive. The following data were also recorded–demographic data, pattern of tobacco use, clinical symptoms and signs, comorbidities, Glasgow Coma Scale, arterial blood gas, electrocardiogram/two-dimensional echocardiography, chest X-ray, and peak expiratory flow rate. Results: Among the 50 patients, 4 were females, and 46 were males. cTnI was positive in 32% of patients with a mean value of 0.272. Patients with cTnI positive were taken as Group I and those with negative were included in Group II. Prevalence of comorbidities was higher in cTnI positive group, so was the duration of COPD. cTnI elevation correlated significantly with the need for ICU admission and ventilator support. No significant difference was found in the duration of ventilator support, hospital stay, and in-hospital mortality. Conclusion: cTnI is elevated in a significant subset of patients with acute exacerbation of COPD. Duration of their illness was longer, higher incidence of ischemic heart disease was also found in these patients. Patients with cTnI elevation are more likely to require ICU care and ventilator support. However, it did not predict in-hospital mortality. Thus, it can be used as a marker to identify high-risk patients during acute exacerbation of COPD.

Pulmonary arterial hypertension (PAH) is a debilitating condition leading to progressive decline in functional capacity. As a result, PAH can lead to psychological impairment that can impact the overall disease status. The medical community has developed several screening questionnaires in order to assess depression in their patients allowing physicians to be at the forefront of recognizing clinical depression. There is a suggestion that depression symptomatology is more prevalent in the PAH population. The aim of this article is to review the current thought process about diagnosis and management of depression in PAH patients.

Sarcoidosis and tuberculosis are granulomatous disorders that mimic each other both clinically and radiologically. Both can present with fever and pulmonary nodules and often require the performance of transbronchial lung biopsy (TBLB) for diagnosis. In recent studies, the flexible cryoprobe for carrying out TBLB has been found to be useful in the diagnosis of disorders diffusely involving the lung parenchyma. Here, we present the case of a 29-year-old man who presented with fever and cough and was found to have multiple small nodules in both lungs. TBLB with a flexible cryoprobe helped in differentiating between sarcoidosis and tuberculosis.

Cryptosporidium parvum is an intracellular spore-forming protozoa which predominantly causes intestinal diseases. It causes severe and life-threatening diarrheal diseases in immunocompromised hosts and usually self-limiting disease in immunocompetent hosts. Extra-intestinal manifestations of cryptosporidium infection are very rare. Herein, we report a case of pulmonary cryptosporidiosis in a 35-yrs-old immunocompetent host, who presented with fever, cough and breathlessness which was soon followed by diarrhea and vomiting, had lung consolidation, and treated successfully with nitazoxanide.

We report two cases of solitary fibrous tumor of the pleura (SFTP). The first appeared in a young, new mother as a large mass in the upper lobe of the left lung that caused compression of lung parenchyma without significant respiratory symptoms but with polyarticular paraneoplastic syndrome; the other was documented by an occasional chest x-ray in a man affected by chronic obstructive pulmonary disease (COPD) as a small peripheral mass 4 years before and no longer controlled. Both patients underwent surgical resection with quick and full recovery. SFTP is a benign, slow growing neoplasm that is mostly localized. It appears in adult or elderly patients often with few symptoms. The computed tomography (CT) of the chest with contrast medium is important in order to see the shape of the mass and relationships with adjacent structures but only histology can provide the diagnosis. Surgery is the best treatment.

Literature on concurrent association of sarcoidosis with lymphoproliferative malignancies other than lymphoma e.g. multiple myeloma is meager. The rarity of the situation prompted us to report this patient who was a 51-year-old woman with a 2-years history of breathlessness, cough with expectoration, chest pain and backache. Initial evaluation revealed mild anemia, increased alkaline phosphatase with chest skiagram showing both lower zone non homogenous opacities with calcified hilar lymph nodes. CECT chest showed mediastinal with bilateral hilar lymphadenopathy, parenchymal fibrosis, traction bronchiectasis, ground glass opacities, septal and peribronchovascular thickening affecting mid and lower lung zones bilaterally. MRI Dorsolumbar spine was suggestive of marrow infiltrative disorder. EBUS FNA of intrathoracic nodes, EBB and TBLB confirmed sarcoidosis. PET CT revealed hyper metabolic activity in lung, multiple lymph nodes and lytic bone lesions. Serum protein electrophoresis and immunofixation revealed a monoclonal paraprotein, immunoglobulin IgG kappa type. Bone marrow biopsy revealed an increase in plasma cells (15%), but no granulomas. Diagnosis of Indolent or multiple myeloma with sarcoidosis was established. 12 cases of sarcoidosis and multiple myeloma have been reported in literature, and mostly preceding the onset of multiple myeloma by many years, in our case both were diagnosed concurrently.

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 multiple episodes of vomiting with subsequent development of pyopneumothorax.

Inflammatory myofibroblastic tumors (IMT) are uncommon neoplasms of the lung in adults. They constitute less than 1% of all lung neoplasms and usually present as parenchymal masses. Diagnosis requires a high index of suspicion. They are characterized by spindle-shaped tumor cells (fibroblasts/myofibroblasts) in a background of lymphoplasmacytic infiltrate. About 50% of the tumors harbor an ALK gene rearrangement. They have to be differentiated from inflammatory pseudotumors (IPT), which show increased number of IgG4 plasma cells on immunostaining and are negative for anaplastic lymphoma kinase (ALK) protein. Herein, we present a case of a 28-year old female who presented with hemoptysis and was diagnosed with an IMT of lung in the first trimester of pregnancy. We have not only reviewed the occurrence of IMT during pregnancy but also discuss the management options for IMT during pregnancy.

Blunt thoraco-abdominal trauma in collision injuries in road traffic accident (RTA) occasionally results in diaphragmatic injury and rupture besides other serious multisystem injuries. These diaphragmatic injuries (DI) frequently go undetected specially when occur on the right side. DI associated with hemothorax need insertion of intercostal tube drainage (ICTD). ICTD has never been reported to precipitate diaphragmatic rupture and hernia. We are reporting such a rare case for the first time in medical literature.

Toxoplasmosis is a severe opportunistic infection in patients infected with the human immunodeficiency virus (HIV). The lung is a major site of infection after the central nervous system. In this report we described two cases of pneumonia due to Toxoplasma gondii infection in HIV patients with antiretroviral therapy. Clinical and radiological abnormalities are not specific. Pulmonary toxoplasmosis should be considered in HIV-infected patients with late stage of HIV, CD4 count less than 100 cells/µl and a poor adherence to HAART.