Background and Aims: Allergic bronchopulmonary aspergillosis (ABPA) is an immunological disorder caused by hypersensitivity against Aspergillus fumigatus. The pathogenesis of ABPA remains unknown. Few studies have investigated the role of environmental factors in pathogenesis of ABPA. Herein, we investigate the role of environmental factors in ABPA. Materials and Methods: In this prospective case-control study, consecutive patients with asthma (Aspergillus sensitized and unsensitized) and ABPA were investigated using a standardized questionnaire to enquire into their demographic characteristics, clinical details, exposure to organic matter and living conditions (home environment, presence of moisture in the walls, and others). Asthma severity and control was assessed using the 2002 The Global Initiative for Asthma (GINA) recommendations and asthma control test, respectively. Results: During the study period, 202 subjects of asthma (103 and 99 Aspergillus unsensitized and sensitized asthma, respectively) and 101 ABPA with a mean (SD) age of 35.3 (14.7) years were included. The baseline characteristics were similar in the two groups except for a higher prevalence of severe persistent asthma in the ABPA group (79% vs. 44%, P = 0.0001). No significant differences in environmental factors were noted in the ABPA population compared to asthmatic patients except for a higher rural residence in ABPA (47% vs. 66%, P = 0.007). Conclusions: The study found no significant environmental differences in ABPA compared to asthmatic patients. It is likely that environmental factors are not the primary pathogenetic factors in causation of ABPA.

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Anaplastic thyroid cancer presenting as bilateral malignant pleural effusion is rarely reported. We present a case who presented solely with respiratory symptoms and subsequently found to be having bilateral malignant pleural effusion secondary to anaplastic thyroid cancer.

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Two patients presented to us with very similar clinical and radiological presentation of huge hydatid cysts in the lung and liver. The first patient was an 11-year-old female child and the second one was a 9-year-old male child. The clinical features in both were breathlessness on exertion, pain abdomen, and abdominal distension. Chest Roentgenogram along with computed tomogram of the chest and abdomen revealed presence of thin-walled homogenous large cysts, one in the right lung and two in the liver, in both the cases. Although the liver cysts were of larger size and occupying most of the right lobe of the liver and part of the left lobe, liver function tests were normal. All three cysts were enucleated in the same sitting by a combined thoracic and abdominal approach (thoracotomy followed by laparotomy). After enucleation of the cyst, capitonnage of the cavity in the lung was done and the liver cavities were filled with omentum to prevent collection of fluid and abscess formation. Both patients recovered well, although the second patient required abdominal drain for a long period of 1 month for bile leakage which decreased gradually and eventually stopped.

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Hydatid disease has a wide geographic distribution around the world. In human, the liver is the most commonly affected organ, followed by the lungs. Intrathoracic extrapulmonary locations are generally the mediastinum, pleura, pericardium and chest wall. Pleural involvement usually follows the rupture of a pulmonary or hepatic cyst inside the pleural space causing secondary pleural hydatidosis. We report four cases of patients who were referred to our hospital for management of pleural hydatid disease as a complication of intrapulmonary echinococcosis.

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Mucous gland adenoma of the lung is an uncommon benign tumor that histologically resembles the mucus-secreting component of tracheobronchial gland. The majority arises within the main, lobar, or segmental bronchi but parenchymal involvement had also been reported. We herein present a case of mucous gland adenoma arising from the left lower lobe bronchus. The 32-year-old female presented with massive hemoptysis, productive cough, and dyspnoea and was clinically misdiagnosed as tuberculosis. Radiology proved to be inconclusive. This case highlights the importance of a complete lung work up in patients presenting with signs of respiratory tract infections.

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A synovial sarcoma (SS) is a rare form of cancer which usually occurs near the joints of the arm, neck, or leg, but has been documented in most human tissues and organs, including the brain, prostate, and heart. Primary pulmonary SS is an extremely rare tumor. We report a case of primary SS of lung who presented with severe chest pain and a large right lung mass with right-sided pleural effusion in computed tomography (CT) scan of thorax. The diagnosis was made on the basis of CT-guided core biopsy and immunohistochemistry. On immunohistochemistry, tumor cell expressed epithelial membrane antigen, bcl 2, Vimentin and smooth muscle actin and were immunonegative for S100 and cytokeratin. So, the final diagnosis was primary SS.

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Detection of skeletal metastasis in patients with lung cancer is important from management point of view. We report the bone scan finding in a patient with non-small cell lung carcinoma showing isolated abnormal tracer in femur and having a characteristic appearance in computed tomography, highlighting the importance of bone scan in patients with bronchogenic carcinoma.

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Pulmonary alveolar proteinosis (PAP) is an orphan disease characterized by the accumulation of excess of surfactant within alveoli and bronchioles. The primary form of PAP (P-PAP; also referred to as idiopathic or autoimmune) is the most common form. It is mediated through a circulating neutralizing antibody against granulocyte-macrophage colony-stimulating factor. Secondary PAP (S-PAP) can be induced by a host of inciting agents and is far more liable to progress to terminal respiratory failure. We describe a rare case of S-PAP occurring in a renal transplant recipient due to mycophenolate and cyclosporine combination-therapy, which resolved spontaneously following withdrawal of these drugs.

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Allergic bronchopulmonary aspergillosis (ABPA) is an immune-mediated inflammatory disease caused by hypersensitivity to Aspergillus fumigatus. A wide spectrum of plain radiographic appearances has been described in ABPA, though none are pathognomonic of ABPA. The common radiological abnormalities encountered are fleeting pulmonary opacities, bronchiectasis, and mucoid impaction. Uncommon radiological findings encountered in ABPA include pulmonary masses, perihilar opacities simulating hilar adenopathy, and pleural effusions. However, miliary nodules as a radiological presentation of ABPA are very rare and only one case has been reported in literature. It is often misdiagnosed and mismanaged as tuberculosis; thus, the clinician should be vigilant enough to diagnose this very rare entity.

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Roseomonas are nonfermenting opportunistic Gram-negative bacilli belonging to the newly established genus of Roseomonas. The clinical experience with the species is limited and is difficult to diagnose because of limited expertise and lack of commercially available identification kits with any of the automated systems. This is a first ever reported case of secondary bacterial infection due to Roseomonas genomospecies 6 in a patient of pulmonary tuberculosis from the Indian subcontinent.

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Pulmonary alveolar microlithiasis (PAM) is a very rare diffuse chronic lung disease characterized by deposition of small spherules of calcium phosphate within the alveolar cavity. The disease is usually seen from birth up to 40 years of age and is usually diagnosed incidentally during radiography of the chest for other reasons. Most of patients are asymptomatic or having very mild symptoms and the majority of patients either have normal or restrictive pulmonary function test. Clinically, the course of the disease is different; it remains static in few patients or it may progress to pulmonary fibrosis, respiratory failure and cor pulmonale in others. In this case report, we present a 55-year-old man who presented with moderate shortness of breath which has progressed from mild symptoms with in the previous years. His chest high-resolution CT scan showed diffusely scattered, ill-defined little shadowy micronodules which involve the left lung; lingula and left lower lobe in particular. A lung biopsy confirmed the diagnosis of PAM. He was followed up for 1 year with treatment by steroid and alendronate, and no progression was noticed in fact improvement in pulmonary function test noticed. This is the first case report of PAM in Kurdistan.

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Selective IgM deficiency is a rare primary immunodeficiency defined as isolated low levels of IgM. It presents with recurrent infections and has been described as first presenting in adulthood with recurrent respiratory tract infections. Unlike its better known counterpart of IgA deficiency, this particular immunodeficiency is often overlooked. We present a case of selective IgM deficiency who presented with recurrent respiratory infections.

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Background: Endobronchial involvement is frequently absent in many patients with bronchogenic carcinoma. Malignant involvement may be confined to lymph nodes/peribronchial locations only or may be present along with endobronchial lesions. Transbronchial needle aspiration (TBNA) is a flexible bronchoscopic technique which can be employed to obtain tissue samples from mediastinal lymph nodes or peribronchial locations. Although a safe and cost effective bronchoscopic modality, it is frequently underutilized owing to concerns regarding its diagnostic utility and safety. Herein, we describe our experience over 1 year on the diagnostic utility of TBNA without rapid on-site evaluation (ROSE) in patients with suspected diagnosis of lung cancer. Materials and Methods: We retrospectively reviewed the cases in which conventional TBNA-without ROSE was performed for suspected lung cancer, between January 2012 and December 2012. Each lymph node station from which aspiration was performed was sampled thrice and smears were prepared on slides which were later examined by a cytopathologist. Results: Twenty-six cases were retrieved in which conventional TBNA without ROSE for suspected lung cancer with mediastinal involvement was performed during the study period. Adequate lymph node sampling could be achieved in 57.7% cases. Conventional TBNA was diagnostic in 11 out of the 26 (42.3%) patients. The diagnostic yield improved to 73.3% in patients in whom an adequate lymph nodal sample could be obtained. TBNA was the sole diagnostic sample in six (54.5%) patients. Alternative diagnoses (sarcoidosis and tuberculosis) were obtained in two patients. Conclusion: Conventional TBNA without ROSE is a safe and efficacious flexible bronchoscopic procedure which should be performed routinely from bronchoscopically accessible locations in patients with a suspected diagnosis of lung cancer.

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Background: The prevalence of vitamin D deficiency in critically ill patients has been reported to be as high as 80%. There is insufficient data regarding the relationship between 25-hydroxyvitamin D [25(OH) D] levels and outcomes in medical intensive care unit (MICU). The goal of this study was to evaluate the prevalence of 25(OH) D deficiency in MICU and its relationship with outcomes. Subjects and Methods: This was a retrospective study in a MICU of a teaching medical college hospital of Eastern India. All patients admitted to MICU, who had levels of 25(OH) D available, were included in the study. The discriminative powers of admission and lowest 25(OH) D values regarding day-30 mortality were evaluated by producing receiver operating curves (ROC). Binary end points were analyzed by means of a Fisher's exact test. Continuous variables were compared by using unpaired t-tests, Welch's tests, or Wilcoxon ranksum tests. All odds ratios and their corresponding 95% confidence intervals were calculated according to the profile-likelihood method. The time from inclusion to death in the two groups was compared with the use of the log-rank test, and the results are presented as Kaplan-Meier curves. Hazard ratios for death from hypo 25(OH) D were calculated by logistic regression model. All P values were 2-tailed and P < 0.05 was considered statistically significant. Results: Of the 300 patients admitted during the study period, 25(OH) D levels were available in 152 patients (50.6%). Of these 152 patients, 15 patients (9.8%) had 25(OH) D insufficiency (20-29.9 ng/dL), 79 (51.9%) had 25(OH) D deficiency (0-19.9 ng/dL), and the levels were normal (>30 ng/dl) in 58 (38.2%) patients. Most of the patients with deficient 25(OH) D levels were females (P < 0.05). Higher mortality (P = 0.01), increased length of MICU stay, and prolonged ventilation were observed in patients with 25(OH) D deficiency. Conclusions: Patients with 25(OH) D deficiency in MICU have increased hospital mortality, longer mechanical ventilation, and longer MICU stay.

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Background and Objective: Low bone mass (osteopenia and osteoporosis) is one of the effects associated with chronic obstructive pulmonary disease (COPD). There is very little data from Saudi Arabia on COPD and low bone mass. This retrospective study was done to assess the prevalence of osteoporosis and osteopenia in COPD patients attending King Fahd Hospital of the University (KFHU), Alkhobar. Patients and Methods: After obtaining the ethical approval from the research committee, all patients seen between at the King Fahd Hospital of the University between January 2010 and December 2012 were included. The inclusion criteria included a follow up of a minimum 2 years, and the Medical Records should have the details of forced expiratory volume in one second (FEV ₁ ), blood bone profile and bone biomarkers and dual-energy X-ray absorptiometry (DEXA) scan. Patients were labeled as osteopenia if the T score was -<1 to <-2.5 and osteoporosis of <-2.5 as per the WHO definition of osteopenia and osteoporosis. Results: Seventy-three patients were being followed in the clinics and 49 patients satisfied the inclusion criteria. The average age was 60.6 ± 10.47 years; males were 43 and females 6. Three (6.1%) were normal and the remaining 46 (93.9%) were with low bone mass. Thirty-two (65.3%) were osteoporotic and 14 (28.57%) were osteopenic. The average duration of COPD was 4.5 ± 6.2 years. Majority (n = 36, 73.4%) of patients were in the Global Initiative for COPD (GOLD) class II and III. FEV ₁ was significantly lower in the patients with low bone mass 1.66 ± 0.60 versus 3.61 ± 0.58 (P < 0.001). Conclusions: Our study shows that over 90% of Saudi Arabian patients with COPD suffer from osteopenia and osteoporosis and unfortunately they remain under-diagnosed and undertreated.

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Background: Chronic obstructive pulmonary disease (COPD) is a syndrome of progressive airflow limitation caused by the abnormal inflammatory reaction of the airway and lung parenchyma. Osteoporosis is one of the major extrapulmonary manifestations of COPD. The, prevalence of osteoporosis in COPD patients in Indian population is unknown. Objectives: To study the prevalence of osteoporosis in COPD and to define various risk factors associated with reduced bone mineral density (BMD) in COPD. Materials and Methods: The study was done in the department of Pulmonary Medicine of a tertiary care hospital. All the diagnosed cases of COPD according to the Global Initiative for Obstructive Lung Disease (GOLD) guidelines were included in this study. The present study was a prospective study in for a period of 1 year. A brief history of the patients was taken, especially regarding duration of illness, number of exacerbations in the past 3 years, smoking in pack years, and history of steroid use (both systemic and inhaled steroids) after which cumulative dose of steroids was calculated. Spirometry was done in all these patients to stage the severity of COPD according to GOLD criteria. DEXA scan of the lumbar spine was done using bone densitometer to determine osteoporosis. A world Health Organization (WHO) criterion for definition of osteoporosis was applied and patients with T-score of > –2.5 standard deviation (SD) were diagnosed to have osteoporosis, –1 SD to –2.5 SD were diagnosed to have osteopenia and < –1 SD as normal. Statistical analysis for association of COPD with osteoporosis was done using chi-square test. Risk factors for osteoporosis were identified by univariate and multivariate logistic regression analysis. Results: A total of 102 COPD patients were included in the study. Among these, 68 patients (66.6%) had osteoporosis and 20 patients (19.6%) had osteopenia. Majority (64.7%) of the patients who had osteoporosis had stage III and stage IV COPD disease. It was observed that as the severity grade of COPD increased, the risk of osteoporosis also increased. The bone mineral density (BMD) showed a significant difference among different stages of COPD. As the severity of the stage of COPD increased, BMD decreased. It was also observed that patients with lower body mass index (BMI) had higher prevalence of osteoporosis (37.3%) as compared to overweight patients. On univariate analysis, it was observed that risk factors for osteoporosis were female sex, higher number of exacerbations, BMI, and severity of COPD. After using multivariate logistic regression analysis, stage IV COPD (odds ratio (OR): 34.48, 95% confidence interval (CI): 1.59-1,000, P < 0.02), number of acute exacerbations >3 (OR: 30.3, 95% CI: 4.74-200, P < 0.01), and steroid cumulative dose >1,000 mg (OR: 7.35, 95% CI: 0.92-58.5, P < 0.04) were observed to be significant risk factors for osteoporosis in COPD patients. Conclusions: In the present study, the prevalence of osteoporosis was 66.6% and another 19.6% had osteopenia. As the severity of COPD increased, the risk of osteoporosis increased. GOLD stage III and stage IV patient had significantly lower BMD as compared to stage I and stage II of COPD disease. Stage IV COPD disease, use of oral or parenteral glucocorticoids, and repeated number of exacerbations were found to be independent risk factors for osteoporosis in COPD patients. Thus, high clinical suspicion and early diagnosis and treatment is required in the evaluation of osteoporosis in COPD patients so that the quality of life can be improved in these patients.

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Objective: PMBCL is a distinct type of nonhodgkins lymphoma with specific clinicopathological features. To clarify clinical features, treatment alternatives and outcomes, we evaluated 28 Arab patients treated with chemotherapy or radiotherapy between 2006 and 2011. Patients and Methods: PMBCL lymphoma patients identified according to WHO classification and treated at KCCC between 2006 and 2011 were included in this study. Demographic and clinical data are presented as means or medians. Overall survival was estimated using the Kaplan-Meier method. Survival rates were compared using the log-rank test. A P < 0.05 was considered significant. Results: The median age of the patients was 31 years and the male to female ratio was 2:1. Majority of the patients (75%) presented with stage I/II disease. Most had features of local extension like pleural effusion (18%) and SVCO (39%). Only 11% of the patients had bone marrow involvement at presentation. 96% of the patients required biopsy from the mediastinal mass either by image guided core biopsy (75%) or by surgical biopsy. Most patients were treated by RCHOP and involved field radiotherapy. Patients with positive PET scan after RCHOP chemotherapy received salvage chemotherapy and BEAM autologous marrow transplant. The five year OS for the entire group was 85% while the PFS was 73%. Patients who had PET scan for response evaluation had better OS [P = 0.013] and PFS [P = 0.039] when compared with those patients who received only radiotherapy based on CT scan evaluation. Conclusion: PMBCL is a specific lymphoma entity seen in the young with good survival. The role of PET scan for response evaluation and the type of consolidation therapy needs to be further clarified

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Background: The prevalence of water pipe (WP) smoking was studied using a standard questionnaire. Pulmonary function tests were also compared between WP smokers and non-smokers. Materials and Methods: The prevalence of WP smoking was studied using a standard questionnaire. Pulmonary function tests including forced vital capacity (FVC), forced expiratory volume in one second (FEV1), maximal mid-expiratory flow (MMEF), peak expiratory flow (PEF), maximal expiratory flow at 75%, 50%, and 25% of the FVC (MEF75,50,25) were compared between WP smokers and non-smokers. Results: A total of 673 individuals including 372 males and 301 females were interviewed. The number of WP smokers was 58 (8.6%) including 24 males (6.5%) and 34 females (11.3%). All pulmonary functional test (PFT) values in WP smokers were lower as compared to the non-smokers (P < 0.05 to P < 0.001). The prevalence and severity of respiratory symptoms (RS) in WP smokers were higher than non-smokers (P < 0.05 to P < 0.001). There were negative correlations between PFT values and positive correlation between RS and duration, rate, as well as total smoking (duration X rate) (P < 0.05 to P < 0.001). Conclusion: In this study the prevalence of WP smoking in Mashhad city was evaluated for the first time. The results also showed a significant effect of WP smoking on PFT values and respiratory symptoms.

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Context: There is conflicting evidence of effect of diabetes on treatment of tuberculosis (TB). There is a need to investigate effect of diabetes on outcomes of TB treatment under field conditions in India. Aims: To compare treatment outcomes among TB patients with diabetes with those without diabetes. Setting and Design: Study was conducted in Cuddalore, Tamil Nadu, among patients registered with Revised National TB Control Programme. Prospective observational study design was used. Materials and Methods: Registered TB patients aged 30 and above were invited to participate in the study. Those who were not aware of their diabetic status were diagnosed using oral glucose tolerance test. A total of 89 diabetic and 120 non-diabetic patients were recruited in the study. They were followed up till the end of treatment and outcomes were recorded. Statistical Analysis Used: Treatment outcomes in the two groups were compared using bi-variate and multi-variate analysis. Results: Bi-variate (unadjusted) analysis showed similar treatment success rates in the two groups. But, the adjusted odds ratios for successful treatment among diabetic patients were significantly lower (0.191, 95% CI 0.04-0.90) for pulmonary TB patients and for smear positive pulmonary TB patients (odds ration 0.099, 0.013-0.761). Diabetes was found to be predictor for sputum positivity at end of treatment. Conclusions: Diabetes increases risk of poor treatment outcomes among pulmonary TB patients. The study highlights need of screening of TB patients for diabetes. There is need to see the effect of glycemic control on treatment outcomes among diabetics.

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Echinococcosis can involve any organ. The liver is the most common organ involved, followed by the lungs. Depending on the location of involvement it can have varied presentation. We describe a young adult presenting with chest pain secondary to a pulmonary giant hydatid cyst. A pulmonary hydatid cyst should be considered in the differential diagnosis of patients presenting with chest pain without conventional risk factors of coronary artery disease, especially in a tropical region.

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Introduction: Personalized medicine has facilitated improved management of non-small cell lung cancer (NSCLC) patients by identifying predictive and prognostic biomarkers for enhanced efficiency of detection and efficacy of treatment. This systematic review and survey assessed the patterns of biomarker usage, molecular testing techniques to diagnose patients with NSCLC in India and testing techniques recommended by cancer societies. Materials and Methods: Studies were retrieved from Embase, PubMed, and Cochrane databases for the last 12 years, using relevant search strategies as per the Cochrane methodology for systematic reviews. Outcomes of interest were biomarkers for NSCLC, patterns of biomarker testing, diagnostic methods, guidelines and cost of biomarker testing. Results: In all, 499 studies were identified for screening and 17 primary publications were included in the review. Epidermal growth factor receptor (EGFR) expression and epithelial markers (particularly cytokeratins (CK)) were the most commonly reported biomarkers (7/17) and immunohistochemical (IHC) staining was the most common technique for detection of biomarkers. The frequency of EGFR mutations was higher among women than men. Significantly elevated levels of CK-18 were observed in patients with squamous cell carcinoma and of CK-19 in patients with adenocarcinoma, squamous cell carcinoma, and NSCLC (P < 0.001). Prognostic or predictive role of cytokines and angiogenic markers as well as DNA expression were evaluated. The survey also showed that IHC was the most common technique for detection of biomarkers. Conclusions: This systematic review and survey provides valuable information on biomarker usage in the Indian population, and highlights the need for initiatives required for future biomarker testing in India.

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