Background: Mycobacterium can develop drug resistance (DR) by mutation of its existing gene. However, the existence of DR without mutation shows the need to look for an alternative mechanism such as the role of efflux pumps. In this study, we examined the effect of efflux pump inhibitors on isoniazid (INH) susceptibility in clinical isolates of Mycobacterium tuberculosis (Mtb). Materials and Methods: Resazurin microtiter assay was used to examine the effect of efflux pump inhibitors on minimum inhibitory concentration (MIC) levels of INH in eighteen Mtb clinical isolates. Results: The observed reduction in INH-MIC was 2–16-fold in INH-resistant isolates with katG and inhA gene mutations, 2–8-fold in INH-resistant isolates without mutation and 2–4-fold in INH-sensitive isolates. The MIC reduction by verapamil (VER) was observed in 83% isolates, by carbonyl cyanide m-chlorophenylhydrazone (CCCP) 61% isolates, by chloropromazine (CPZ) 61% isolates, by reserpine (RES) in 61% isolates and by 2,4-dinitro phenol (DNP) in 55% isolates. Interpretation and Conclusions: The results obtained in this study confirm that MIC of INH decreased in the presence of efflux pump inhibitors (VER, CCCP, CPZ, DNP, RES) in clinical isolates of Mtb and that the inhibition of efflux pumps by the efflux pump inhibitors can enhance the clinical effect of a drug. The results showed that these efflux pump inhibitors are active against both drug susceptible and drug resistant isolates, indicating that the effect of efflux pump inhibitors is not dependent on the mutational profile of the isolate. We observed in this study that VER was the most effective efflux pump inhibitor.

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India accounts for the highest number of incident tuberculosis (TB) cases globally. Hence, to impact the TB incidence world over, there is an urgent need to address and accelerate TB control activities in the country. Nearly, half of the TB patients first seek TB care in private sector. However, the participation of private practitioners (PPs) has been patchy in TB prevention and care and distrust exists between public and private sector. PPs usually have varied diagnostic and treatment practices that are inadequate and amplify the risk of drug resistance. Hence, their regulation and involvement as key stakeholders are important in TB prevention and care in India if we are to achieve TB control at global level. However, there remain certain barriers and gaps, which are preventing their upscaling. The current paper aims to discuss the status of private sector involvement in TB prevention and care in India. The paper also discusses the strategies and initiatives taken by the government in this regard as evidence shows that the involvement of private sector in co-opting directly observed treatment short-course (DOTS) helps to enhance case finding and treatment outcomes; it improves the accessibility of quality TB care with greater geographic coverage. Besides public-private mix, DOTS has been found more cost-effective and reduces financial burden of patients. The paper also offers to present some more solutions both at policy and program level for upscaling the engagement of PPs in the national TB control program.

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Introduction: Multidrug-resistant Pseudomonas aeruginosa (MDR-PA) is an important and growing issue in the care of patients with cystic fibrosis (CF), and a major cause of morbidity and mortality. Objective: The objective of the study was to describe the frequency of MDR-PA recovered from the lower respiratory samples of pediatric and adult CF patients, and its antibiotic resistance pattern to commonly used antimicrobial agents including β-lactams, aminoglycosides, and fluoroquinolones. Materials and Methods: The lower respiratory isolates of P. aeruginosa were obtained from inpatients and outpatients CF clinics from a tertiary care teaching hospital for the period from October 2014 to September 2015. The identification and antimicrobial susceptibility for all the isolates were performed by using the BD Phoenix™ and E-test in compliance with Clinical and Laboratory Standards Institute (CLSI) guidelines. Results: A total of 61 P. aeruginosa samples were isolated from thirty CF patients from twenty families. Twelve sputum samples were positive for MDR-PA (seven nonmucoid and five mucoid isolates) from five CF patients (five families) with moderate-to-very severe lung disease given MDR-PA frequency of 19.7%. The median age of the study group was 20 (range 10–30) years. Three CF patients were on chronic inhaled tobramycin and two on nebulized colistin. The antimicrobial patterns of isolates MDR-PA showed the highest rate of resistance toward each gentamycin, amikacin, and cefepime (100%), followed by 91.7% to ciprofloxacin, 75% to tobramycin, 58.3% to meropenem, and 50% to piperacillin-tazobactam. None of the isolates were resistant to colistin during the study period. Conclusion: The study results emphasize that the emergence of a significant problem in the clinical isolates of P. aeruginosa in CF patients that dictate appropriate attention to the antibiotic management after proper surveillance.

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Background: Treatment of multidrug-resistant tuberculosis (MDR-TB) requires the use of expensive and toxic second-line anti-tubercular drugs which are given for a longer duration. Adverse drug reactions (ADRs) of second-line antitubercular drugs affect compliance and thereby treatment outcome. We set out to analyze ADRs and treatment outcome of MDR-TB patients receiving directly observed treatments plus therapy. Materials and Methods: A retrospective study of registered MDR-TB cases at district tuberculosis center during 2010–2014 was performed. Data regarding sociodemographic profile, diagnosis, and treatment as well as ADRs were recorded and evaluated. ADRs were evaluated for causality, severity assessment, management aspects, and impact on treatment outcome. Results: In total 147 ADRs were reported among 72 cases. Most commonly observed ADRs were gastrointestinal (24.5%) followed by self reported weakness (21.23%), psychological (14.38%), joint pain (14.38%), and respiratory symptoms. Discontinuation of the drugs due to ADRs was required in 36 (24.48%) events. ADRs were significantly associated with nontreatment adherence and defaulter outcome. Cure rate was higher in MDR-TB cases with ADRs (59.72%) than MDR-TB cases without ADRs (30.18%). Conclusion: Attention needs to be paid for timely recognition and treatment of ADR with minimum modification of treatment regimen. Equal attention should be paid to MDR-TB without ADR cases to raise over all cure rate.

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Background: Food allergy occurs in a significant portion of pediatric asthma. Various cells and their mediators/cytokines play a pivotal role in orchestrating the airway inflammatory response in asthma. Objective: To study the cutaneous hypersensitivity, Th1, Th2, and Th17 response of pediatric population with asthma and genetic predisposition to atopy, by determining total immunoglobulin E (IgE) level in response to various food allergens. Materials and Methods: Fifty asthmatic children with a history of worsening symptoms by various food allergens (study group) and twenty healthy children (control group) were included. Food allergy was assessed through skin prick test (SPT) of various food allergens. Total serum IgE level was measured by sandwich ELISA, and T-cell (Th1, Th2, and Th17)-dependent cytokines were measured by flow cytometry. Results: All 50 asthmatic children in the study group showed SPT positivity against various food allergens (rice = 17; banana, fish and groundnut = 10; wheat = 9; milk and orange = 7; egg = 6; and mango = 4). The average total IgE level in the study group was 316.8 ± 189.8 IU/mL. A significant positive correlation of total IgE with interleukin 17 (IL-17) (r = 0.796; P < 0.0001), IL-13 (r = 0.383; P = 0.01), and IL-4 (r = 0.263; P = 0.043) level was noted. A significant negative correlation of total IgE was noted with interferon gamma (r = −0.5823; P < 0.0001) and IL-10 (r = −0.4474; P < 0.001) level and the duration of breastfeeding (r = −0.31, P = 0.03). Conclusions: The present study found a positive correlation between total serum IgE level and Th2, Th17 cytokines in a pediatric population with asthma. A significant negative correlation was found between the duration of breastfeeding and the cytokines.

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Objectives: Data about long-term mortality of Indian patients following acute exacerbation of chronic obstructive pulmonary disease (AECOPD) are scant. We set out to study the 2-year mortality in north Indian patients following discharge after AECOPD. Materials and Methods: One hundred and fifty-one (96 male) patients admitted for AECOPD and discharged were followed for 2 years at 3, 6, 12, 18, and 24 months for mortality. Statistical analysis was performed to identify risk factors associated with mortality. Results: Sixty (39.7%) of the 151 recruited died during the 24 months of follow-up, 30 (19.8%) at 3-month, 43 (28.5%) at 6-month, 49 (32.4%) at 1-year, 55 (36.4%) at 18-month, and 60 (39.7%) at 2 years. There was no mortality in Global Initiative for Chronic Obstructive Lung Disease (GOLD) Stage I (0 of 6 cases), whereas it was 12.3% (n = 8 of 65 patients) in GOLD Stage II, 41.7% (n = 15 of 36 cases), in GOLD Stage III, and 84.1% (n = 37 of 4 cases), of patients with GOLD Stage IV. Mortality was associated with 6-min walk distance, oxygen saturation, low body mass index, history of congestive heart failure, and St. George Respiratory Questionnaire score. Conclusion: Indian patients discharged after AECOPD have a high 2-year mortality. Measures to reduce the frequency of exacerbations need to be routinely adopted in patients with COPD.

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Synovial sarcoma of lung is a very rare tumor accounting for 0.5% of all primary lung malignancy. It presents clinically with cough, chest pain, shortness of breath, or hemoptysis, with a mass lesion on X-ray and computerized tomography scan. Diagnosis is made by histopathology and immunohistochemistry. Here, we report a case of 48-year-old male, who presented with right-sided chest pain, cough with blood-tinged sputum, and found to have primary pulmonary synovial sarcoma of lung.

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A 26-year-old smoker male presented with a history of sudden onset dyspnea and right-sided chest pain. Chest radiograph revealed large right-sided pneumothorax which was managed with tube thoracostomy. High-resolution computed tomography thorax revealed multiple lung cysts, and for a definite diagnosis, a video-assisted thoracoscopic surgery-guided lung biopsy was performed followed by pleurodesis. This clinicopathologic conference discusses the clinical and radiological differential diagnoses, utility of lung biopsy, and management options for patients with such a clinical presentation.

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Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a minimally invasive and efficacious diagnostic modality for lung cancer staging and evaluation of undiagnosed mediastinal lymphadenopathy. Procedure-related complications are uncommon. We herein report an infrequently described phenomenon following EBUS-TBNA in which two patients developed nodular granulation tissue at the tracheobronchial puncture site. On systematic review, we found description of such phenomena by terminologies such as endobronchial inflammatory polyp, granuloma, and endobronchial mass. The endobronchial inflammatory polyp has been one of the most commonly used terminologies for these; but in most cases, the classical features of an inflammatory polyp are lacking. We propose the term, tracheobronchial puncture-site nodular reaction (TPNR) with further classification into granulomatous and nongranulomatous subtypes, for standardized reporting of such reactions following transbronchial needle aspiration procedures. Knowledge of this entity and standardized nomenclature shall help in better characterization of the outcomes and risk factors for the occurrence of these reactions.

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Erdheim–Chester disease is a rare non-Langerhans cell histiocytic disorder. It is primarily a disease of the long bones. Pulmonary involvement in systemic disease is detected in about half the reported cases. Isolated lung involvement is extremely rare with no clear recommendations for treatment. A 52-year-old caucasian male was evaluated for 1.9 cm × 1.6 cm spiculated nodule in the right upper lobe. Pulmonary function testing and bronchoscopy with endobronchial ultrasound, transbronchial biopsy, and microbiology were inconclusive. Positron emission tomography–computed tomography (PET-CT) was significant for the avidity in same lung nodule along with mediastinal and hilar adenopathy but no bone involvement. Wedge resection with histopathology and immunohistochemistry reported a fibrohistiocytic infiltrate in bronchovascular distribution which was positive for CD68 and negative for CD1A, S100, and BRAF V600E mutation. Magnetic resonance imaging brain ruled out central nervous system involvement. The rarity of the condition along with the complex pathology makes it difficult to diagnose and hence intervene appropriately.

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Bronchopulmonary sequestration is a rare anomaly of the lung which is characterized by the presence of a mass of lung tissue which has no connection with the normal bronchopulmonary tree. Sequestration is of two types - intralobar and extralobar, of which intralobar is the more common one. Patients typically present with recurrent hemoptysis, which at times can be massive or with recurrent respiratory tract infections. This case is being presented to highlight the radiological as well as the intraoperative appearance of this rare anomaly.

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Background: The audio signal in the conventionally accepted protocol of shuttle walk test (SWT) is not well-understood by the patients and modification of the audio signal may improve the performance of the test. Objectives: The aim of this study is to study the validity and reliability of an audio signal modified SWT, called the Singla-Richa modified SWT (SWT_SR), in healthy normal adults. Patients and Methods: In SWT_SR, the audio signal was modified with the addition of reverse counting to it. A total of 54 healthy normal adults underwent conventional SWT (CSWT) at one instance and two times SWT_SRon the same day. The validity was assessed by comparing outcomes of the SWT_SRto outcomes of CSWT using the Pearson correlation coefficient and Bland–Altman plot. Test-retest reliability of SWT_SRwas assessed using the intraclass correlation coefficient (ICC). The acceptability of the modified test in comparison to the conventional test was assessed using Likert scale. Results: The distance walked (mean ± standard deviation) in the CSWT and SWT_SRtest was 853.33 ± 217.33 m and 857.22 ± 219.56 m, respectively (Pearson correlation coefficient - 0.98; P < 0.001) indicating SWT_SRto be a valid test. The SWT_SRwas found to be a reliable test with ICC of 0.98 (95% confidence interval: 0.97–0.99). The acceptability of SWT_SRwas significantly higher than CSWT. Conclusions: The SWT_SRwith modified audio signal with reverse counting is a reliable as well as a valid test when compared with CSWT in healthy normal adults. It better understood by subjects compared to CSWT.

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Lung cancer during pregnancy is a rare condition. We report a case of 28-year-old nonsmoker female, who was admitted to our hospital with massive left pleural effusion in the 21^st week of gestation. Chest radiograph showed total left hemithorax opacity with contralateral mediastinal deviation. Pleural biopsy and cytological examination of pleural fluid revealed adenocarcinoma invasion with positive epidermal growth factor receptor mutation status. Cesarean section was performed at 32 weeks of pregnancy, and targeted therapy was given to this patient after delivery. Computed tomography of the thorax showed a mass lesion in the left hemithorax with liver metastases. Unfortunately, the patient died 10 days after delivery.

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Severe hypokalemia presents with significant muscle weakness and involvement of respiratory muscles. Bedside ultrasonography of the diaphragm is emerging as a noninvasive bedside tool for diagnosis and followup of diaphragmatic dysfunction due to various causes. Here, we present a case of diaphragmatic dysfunction due to severe hypokalemia. The patient presented with acute onset quadriparesis that rapidly improved with correction of hypokalemia. The clinical and laboratory parameters correlated well with the findings of diaphragm ultrasound, both initially and after correction of hypokalemia.

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