P1
Diagnosis of Pulmonary Thrombo-embolism in Respiratory Intensive Care Unit
O. JHA, R. GUPTA, D. TALWAR
Pulmonary Medicine and Critical Care, Metro Center for Respiratory Diseases, Noida, UP (India)
OBJECTIVES: CT-pulmonary-angiography/VQ-scan (CTPA/VQS) and compression ultrasonography (CUS) are
currently standard diagnostic methods for PTE and DVT respectively. Role of D-dimer as screening tool is not
objectively assessed for RICU patients with pulmonary and other co-morbidities where dyspnoea is common
presentation at admission and they are at high risk to develop PTE due to immobility prior to and after admission
in the RICU. Due to patients respiratory condition it may not be possible to do definitive tests on all patients and
many times due to waxing and waning nature of respiratory symptoms repeating them may not be feasible in
same patient many times. In current study using CTPA/VQS as gold standard we have analyzed the reliability of Ddimer and CUS positivity in evaluation of PTE in respiratory intensive care unit (RICU).
METHODS: All patients with respiratory and other co-morbidities with clinical suspicion of PTE (Well’s score > 6)
and undergone CTPA and/or VQS were screened. The Study includes data from 41 patients (mean age 54.7В±14.99)
who had undergone CT-PA/VQS, CUS and D-dimer within 24-hour of interval. D-dimer and CUS results for
CTPA/VQS positive and negative patients were compared.
RESULTS: The Demographics of CTPA/VQS positive (n=21) and negative (n=20) groups are comparable (Mean age
52.3В±15.00 vs. 57.2В±14.95; p=0.305). Both group had similar prevalence of COPD (30%). Higher prevalence of
other respiratory co-morbidities is found in CTPA negative group. D-dimer levels (3303В±2472 vs. 2337В±2341;
p=0.217), positivity of CUS (22% vs. 17%, p=0.763) and adjusted D-dimer (90% vs. 80%; p=0.412) of the two groups
was not significantly different.
CONCLUSIONS: D-dimer or CUS are not useful guide for evaluation of PTE in RICU setting in patients with
respiratory co-morbidities. Therefore there is need for low threshold for definitive tests (CTPA/VQS) to reliably
diagnose PTE cases in RICU patients in differential diagnosis of dyspnoea.
Physiological basis of Acid Base Disorders
P2
DR. RAJIV GOYAL M.D. , (M.R.C.P.U.K.), CHAIRMAN AND HEAD
CENTRE FOR RESPIRATORY DISEASE, JAIPUR GOLDEN HOSPITAL, NEW DELHI
The internal metabolic environment of the human body is in a constant state of flux with complex checks and
balances which keep its chemical constituents within a narrow �normal’ range. Despite the enormous load of acid
due to catabolic activities the internal milieu is tightly controlled and the H+ ion concentration therefore the pH is
kept within normal limits. The body is able to do this with help of certain buffer systems which are able to nullify
the effect of the additional acid load. Various disease states or organ malfunctions due to extrinsic stresses like
poisoning tend to induce changes in the metabolic environment by making it more acidic or alkaline. These are
resisted by compensatory mechanisms which are primarily mediated through the lungs and the kidneys. Before we
understand the physiological basis of these acid base disorders it is necessary to define few basic terms.
P3
IMMEDIATE ECHOCARDIOGRAPHIC ASSESSMENT OF PAP IN PATIENTS ADMITTED WITH EXACERBATION OF COPD
IN RICU
Kuldeep Saini, Deepak Talwar
Metro Centre for Respiratory Diseases, Noida, India
Objectives: PH is a well established complication of COPD, develops from disease related deranged structurefunction relationship of lungs. This study correlates PAP assessed by immediate echocardiography in Indian
patients admitted with acute exacerbation of COPD with severity of COPD (spirometry) ,severity and duration of
current exacerbation of COPD
Methods: PAP (systolic & mean) assessed by immediate echocardiography in 64 patients admitted with COPD with
acute exacerbation as per GOLD 2013 Guidelines at Metro Centre for Respiratory diseases were retrospectively
analyzed for their clinical symptoms, assessment of severity in the last one year’s using SPSS software.
Results: Mean age 64.90+10.12 yrs and 15 (23.5%) were females. sPAP correlated with Pred post bronchodilator
FEV1 % (r=-0.321** ,p=0.010), severity of COPD (commonly seen C & D) (r=0.339** ,p=0.006), duration and
severity of current exacerbation (r=0.215, p=0.088) and (r=0.067,p=0.596) respectively.
Conclusions: PAP correlated with severity of COPD, not with severity and duration of current exacerbation of
COPD in this study.
Clinical implications: As COPD is a progressive disease, investigations like PFT and serial Echocardiography should
be done to assess the progression and complications of associated PH. However repeat Echocardiography, once
exacerbation has resolved is likely to give valuable information regarding PAP.
P4
Diagnosing bacterial peritonitis made easy by use of leukocyte esterase dipsticks
VIPIN GOYAL1, KIRAN CHUGH2, YUTHIKA AGRAWAL2,
1. Department of Chest and TB, S.H.K.M. Govt Medical College, Nalhar, Mewat, Haryana.
2. Departments of Biochemistry, PGIMS, Rohtak, Haryana, India
Introduction:
Spontaneous bacterial peritonitis (SBP) requires rapid diagnosis for the initiation of antibiotics. Its diagnosis is
usually based on manual examination of ascitic fluid (AF) having long reporting time. AF infection is diagnosed
when the fluid polymorphonuclear leukocyte (PMNL) concentration ≥ 250 cells/mm3.
Aims and objectives:
Aim was to evaluate the diagnostic utility of leukocyte esterase (LE) reagent strip for rapid diagnosis of SBP in
patients who underwent abdominal paracentesis and to calculate the sensitivity, specificity, positive, and negative
predictive values.
Materials and Methods:
The study was carried out on 103 patients with ascites. Cell count of AF as determined by colorimetric scale of
Multistix 10 SG reagent strip was compared with counting chamber method (PMNL count ≥ 250 cells/mm3 was
considered positive).
Results and Observations:
Of the 103 patients SBP was diagnosed in 20 patients, 83 patients were negative for SBP by manual cell count. AF
culture was positive in 55% (11) of these cases. The sensitivity and specificity of the LE test for detecting
neutrocytic SBP taking grade 2 as cut off were 95% and 96.4% respectively, with a positive predictive value of
86.4% and a negative predictive value of 98.8%. Diagnostic accuracy of LE test was 96.1%.
Conclusion:
There was a good correlation between the reagent strip result and PMNL count. In India, till date only two studies
have been published on the use of LE reagent strip in AF. It is a very sensitive and specific method for the prompt
detection of elevated PMNL count, and represents a convenient, inexpensive, simple, and bedside method for
diagnosis of SBP. A negative LE test result excludes SBP with a high degree of certainty.
P5
Comparison of Idiopathic Pulmonary fibrosis patients with and without pulmonary hypertension
Ashik.K, Suhail.N, Abdul Nazar.T, Lisha.P.V, Irshad.K
Department of Pulmonology MES medical college Perinthalmanna, Kerala, India
Background: Studies evaluating of phenotypic characteristics of IPF have not been reported in this region.
Pulmonary hypertension (PH) may develop as an unrecognized complication of IPF leading to worse prognosis.
There is debate on whether PH in IPF develops in end stage disease or as separate phenotypic entity
Aim: To compare the clinical and radiological profile of IPF patients with and without PH
Materials and methods:
Study design: Observational study
Inclusion criteria
IPF diagnosed according to the revised ATS/ERS/JRS/ALAT diagnostic criteria
Exclusion criteria
Patients with LV disease , IPF during exacerbation
Methods: All patients diagnosed as IPF were included. PH assessed using 2D-ECHOcardiography. Functional status
assessment was done by 6-MWT, PFT, ABG. A scoring system was used to grade fibrosis in HRCT Thorax
Results: A total of 24 IPF patients are included (15 males, 9 females). 8 patients had PH (6M, 2F). Mean age in PH
group was 73.12 and in non-PH group was 60.44 (P value 0.004). Patients with PH had Grade 3MMRC dyspnoea or
above (P value 0.001).Mean 6MWT distance of patients with PH was 42.5 and without PH was 172.5mtrs (P value
<0.001).Mean HRCT fibrosis score in patients with and without PH was 218.75.
Conclusion: PH in IPF shows a significant association with advanced age at presentation. Reduced 6MWT distance
correlates with presence of PH. Higher MMRC dyspnoea grade are seen in those with PH. HRCT fibrosis score
doesn’t show any significant association with PH
Clinical implication: PH is a significant worse prognostic factor in IPF. This study helps in identifying factors
associated with PH so that such patients can be identified early and given appropriate care
P6
Case report of cryptogenic organizing pneumonia (cop).
SUJIT REDDY CHINTHALA, SATISH CHANDRA, SUDHEER, CN PRASAD
Prathima Institute of Medical Sciences, Karimnagar, Telangana
OBJECTIVES: To report a case of cryptogenic organizing pneumonia presenting with fever, dyspnea and acute
respiratory failure. Cryptogenic organizing pneumonia is a clinical entity of unknown etiology. A prevalence of 6 to
7 per 100,000 admissions has been reported.
METHODS: A 60 year male, nonsmoker, presented to our hospital with fever, dry cough, breathlessness grade IV
(modified MMRC), progressing over 4 weeks. His PaO2 of 58.0 mm Hg, SpO2 of 79% on room air. Chest X-ray s/o
bilateral patchy alveolar airspace consolidation. HRCT chest s/o: Patchy ground-glass opacities in a subpleural and
peribronchovascular distribution, bilateral basal airspace consolidation, small nodular opacities measuring 1-10
mm in diameter,noted,which is suggestive of COP.Transbronchial lung biopsy was performed which showed
features consistent with COP. Patient improved with initial NIV support, intravenous steroids later maintained on
oral steroids,presently on a gradual tailoff.
RESULTS: Histopathological examination revealed anastomosing plugs (�buds’) of granulation tissue, the Masson
bodies, that fill bronchiolar and extend into the alveolar ducts and spaces.
CONCLUSION: Patients presenting with acute or subacute features of fever and dyspnoea with above imaging
features should be evaluated for possibility of COP, simultaneously excluding various infective etiologies.
P7
Diagnostic value of transbronchial lung biopsy in diffuse lung disease
Praveen BS, George Albert D’souza, Priya Ramachandran, Uma Devraj,
Department of Pulmonary Medicine, St Johns medical college, Bangalore, India
OBJECTIVE:
To understand the diagnostic value of transbronchial lung biopsy in diffuse lung disease.
METHODS:
A retrospective review of our records was done between june 2012 to july 2014. A total of 57 TBLB were
performed. All cases were reviewed for diagnostic yields.
RESULTS:
Adequate samples were obtained in 54/57 TBLBs (94.7%). In total 5/57 TBLBs (8.7%) yielded bronchial mucosa,
while 20/57 TBLBs (35.1%) showed chronic inflammation. Confirmed diagnosis was obtained in 34/57 patients; the
total positive diagnostic rate was 59.7%. Diseases included adenocarcinoma 8/57 (14%), Non-specific interstitial
pneumonia 5/57 (8.7%), Tuberculosis 6/57 (10.5%), Sarcoidosis 3/57 (5.3%), Usual interstitial pneumonia 2/57
(3.5%), Brochiolitis obliterans with organizing pneumonia 2/57 (3.5%), Hypersensitivity pneumonitis 1/57 (1.8%),
Small cell cancer 1/57(1.8%), silicosis 1/57(1.8%).
CONCLUSIONS:
Our experience substantiates previous reports of the value of transbronchial lung biopsy in diffuse lung disease
P8
Interstitial Lung Disease (Ild) In Rheumatoid Arthritis (Ra)-A Study Of forty seven cases.
S Bansal, D Talwar, S Joshi, R Gupta
Metro Hospital and Institution, MCRD, L-94 sec 11, Noida
OBJECTIVES
To evaluate Interstitial Lung Disease (ILD) in the patients with Rheumatoid Arthritis (RA) and to assess pulmonary
function tests and High Resolution Computed Tomography (HRCT) findings.
Methods
An unselected cohort of patients with a confirmed diagnosis of RA (satisfying the American College of
Rheumatology (ACR) criteria ) and known lung disease were identified (n =47 ) and evaluated for RA lung disease
activity and severity. Outcomes included abnormalities determined by the HRCT findings of the lung, forced vital
capacity (FVC) and diffusion capacity for carbon monoxide (DLco).
Results
Four major HRCT findings were observed, nodules (n=27; 57.4%), Ground glass haze (n=20; 42.5%), Pleural effusion
(n=12; 25.5%) and apical fibrobulla (n=10; 21%). Bronchiectasis was observed in 4 cases (8.7%) Dominant pattern
observed were UIP (n=7; 14.8%), OP (n=5; 10.6%), NSIP (n=3;6.3%), Mixed (n=8; 17%). FVC was reduced in 80%
(n=38) of patients in which 20 (42.5%) had mild, 15 (31.9%) had moderate and 3 (6.38%) had severe reduction in
FVC. DLco was normal in 12 (25.5%) cases where as 16 (34%) had mild, 18 (38.2%) had moderate and 1 (2%) had
severe reduction in diffusion capacity.
Conclusion
Pulmonary nodules are the most common pattern observed in our patients followed by ground glass haze. Pleural
effusion is seen in one forth of our patients with RA-ILD. UIP, OP, and NSIP interstitial pattern is observed in
decreasing frequency but mixed pattern is more commonly seen. Mild to moderate reduced FVC and DLco was
observed in more than 80% of our pts. Pulmonary complications in RA are directly related to the severity of
pleural, parenchymal and airway involvement. Our study emphasizes that all patients with RA should undergo
HRCT and PFT even with minimal respiratory symptoms so that more aggressive treatment can be justified in
otherwise stable patients.
P9
Title: A case of ILD with descending thoracic aorta aneurysm
Somnath Dash, K.V. Ramana Rao, Archana A.
GSL Medical College, rajamundry, Andhra Pradesh
A 46 year old female presented with shortness of breath and cough with expectoration since 2 months.She is
known hypertensive. she had history of amputation of distal phalynges due to gangrene. Patient is not a known
case of tuberculosis. On clinical examination she was found to have hypopigmented macules on scalp with bilateral
Velcro crackles on auscultation. On thorough investigations it was confirmed she was suffering from ILD with
dermatological involvement and aneurismal dilatation of descending thoracic aorta. Though ILD’S are
common,such presentation is rare and should be an eye opener to everyone.
P10
Title: A case of systemic sarcoidosis
Somnath dash, K.V.Ramana rao, Satish.B
GSL Medical college, Rajamundry, Andhra Pradesh
A 47 yr old male presented with dry cough and progressive dyspnoea. Patient is a known diabetic and
hypertensive. He underwent cholecysectomy and biopsy from liver was obtained. It was confirmed
histopathologically as non caseating granuloma. Chest Xray and CT revealed features of sarcoidosis. Such kind of
asymptomatic presentation needs early and effective diagnosis for better management.
P11
Unusual presentation of Desquamative interstitial pneumonia: A case report
Dr. Santhosh V G, Dr. G.S. Gaude, Dr. Jyothi Hattiholi
Dr. Santhosh V G, Postgraduate in Department of Pulmonary Medicine, KLE University’s Jawaharlal Nehru Medical
College, Belgaum, Karnataka
Desquamative interstitial pneumonia (DIP) is a rare disease which was reported by Liebow et al. in 1965. We
hereby report a case of 46 year old male, nonsmoker with diagnosis of DIP and peripheral gangrene of fingers.
Patient had presented with history of cough, repeated episodes of hypoglycemia and peripheral cyanosis of fingers
involving both upper and lower limbs. Past history revealed, he was working in iron factory for last 25 years. Chest
radiography showed the presence of non-homogenous opacity with air bronchogram in the left upper and mid
zone. Patient was treated with appropriate antibiotic coverage and other supportive treatment. Repeat chest
radiography after 5 days showed no improvement and peripheral cyanosis persisted inspite of normal arterial
blood po2. CT scan of thorax showed non homogeneous opacity with air bronchogram in left upper lobe.
Bronchoscopy was normal and bronchialveolar lavage (BAL) fluid was negative for malignant cells and AFB. CT
guided biopsy of lung was done, which showed alveoli filled with proteinaceous contents with plenty of
macrophages containing brown pigment and fibrosis of interstitial tissue which was suggestive of DIP. He was
treated with steroids and supportive medication. Repeat chest radiograph showed radiological improvement with
good resolution. However peripheral cyanosis progressed to developed gangrene of fingers of both lower and
upper limbs. The color Doppler study of arteries and venous system showed thrombus in the left cephalic and
subclavian vein, while other arteries and vessels had no evidence of thrombus. Patient was discharged and
continued on oral steroids and oral anticoagulants.
Key words: Desquamative interstitial pneumonia, gangrene, CT guided biopsy.
P12
NITROFURANTOIN – INDUCED PULMONARY FIBROSIS: CASE REPORT
GIFTY MG, KISKU KH, MADHUSMITA M
Department of Pulmonary Medicine, Pondicherry Institute of Medical Sciences, Puducherry-605014
Introduction
Nitrofurantoin is a commonly used drug in the treatment and prevention of urinary tract infections. Many adverse
effects of nitrofurantoin have been documented, including aplastic anemia, polyneuritis, and liver and pulmonary
toxicity.
Case presentation
We describe the clinical history and the autopsy findings in a 60-year-old man with Interstitial Lung Disease of
unknown etiology. He had a history of recurrent urinary tract infections, treated with nitrofurantoin for four
months. He came to our hospital with progressively worsening breathlessness for 1 month. He was in respiratory
failure and oxygen dependent and progressively worsened in spite of treatment with steroids and perfenidone. He
finally died of respiratory insufficiency.
At autopsy there were features of organizing pneumonia. With the microscopic pattern bronchiolitis obliterans
organizing pneumonia and the history of long-term nitrofurantoin use, we concluded that this was a drug induced
pulmonary toxicity.
Conclusion
This case shows that the use of nitrofurantoin may cause severe pulmonary disease. Patients with long-term use of
nitrofurantoin should be monitored regularly for adverse pulmonary effects.
P13
A case series of connective tissue diseases in interstitial lung disease (CTD –ILD).
K.V.V. Vijaya kumar, T.Suresh babu, K. Venkataramana, A.Prem kumar
Government Hospital for Chest & Communicable diseases (GHCCD), Andhra Medical College, Visakhapatnam, AP,
India.
Introduction: The connective tissue diseases (CTDs) are a group of inflammatory, immune-mediated disorders in
which a failure of self-tolerance leads to autoimmunity and subsequent tissue injury. Involvement of the
respiratory system, particularly interstitial lung disease (ILD), is common and is an important contributor to
morbidity and mortality. The radiographic findings and histopathologic appearances of ILD among the CTDs closely
resembles idiopathic interstitial pneumonias. However, close examination of radiographs, pathologic tissue and
collagen profile may offer clues to a diagnosis of underlying CTD. Corticosteroids and immunosuppressive agents
are often used.
Case Reports: Here, we present 3 cases of CTD –ILDs in which two were females and 1 male. Two were aged more
than 70 years. Collagen profile of these patients confirmed the diagnosis of dermatomyositis in one case (Ro- 52
recombinant positive, increased CPK) , mixed connective tissue disorder in one case ( sRNP positive) , and
rheumatoid arthritis in one case ( raised RF , anti CCP and CRP ). 2D ECHO in two patients showed moderate PAH
and one case showed mild PAH. Among the three patients, dermatomyositis patient was died because of pneumomediastinum and due to vasculitis flare up. Another 2 patients were managed uneventfully for the present.
Conclusion: Lung disease is a common manifestation of the CTDs and may be a presenting feature. Subclinical
disease is common. Clinically apparent disease is often slowly progressive but may present in an acute fashion,
contributing to high morbidity and mortality. The diagnosis of idiopathic ILD should never be made without a
careful clinical search for evidence of CTD.
P14
Correlation of GAP risk assessment system in Idiopathic Pulmonary Fibrosis at a tertiary care center
UNNATI DESAI, VINAYA KARKHANIS, JYOTSNA M JOSHI
Department of Pulmonary Medicine, T.N.M.C. & B.Y.L. Nair Hospital, Mumbai
Objective
Idiopathic pulmonary fibrosis(IPF) is a progressive IIP with poor prognosis. The GAP risk assessment system,
consisting of the GAP index and staging system, is a clinical prediction tool that estimates prognosis in patients
with IPF. We studied the correlation of GAP risk assessment system in IPF.
Material & Methods
An observational study was conducted at a tertiary care center on 37 patients with IPF diagnosed on basis of
clinico-radiology and lung biopsy wherever required. Clinical characteristics, comorbidities, GAP score and GAP
stage were noted at baseline. The survival of patients at one, two and three years was enquired for telephonically.
Results
Total thirty-seven IPF patients consisted of seventeen men and twenty women. There were eight smokers all men.
31(84%) of these patients had associated comorbidities. Twelve patients had baseline six-minute-walk-distance
(6MWD) less than 207meters of which nine (75%) died at 3year follow-up. All patients with pulmonary
hypertension died at 3 year follow-up. At one, two, three years follow-up 17(46%), 22(60%), 23(62%) patients died
respectively. Patients classified into stages of GAP I, II, III consisted of 5, 17, 15 respectively. Of the GAP I patients
20% died at 1 year, 40% died by 2year & 3year. Of the GAP II patients 35% died at 1 year, 47% died by 2year &
3year. Of the GAP III patients 67%, 80%, 87% died at follow-up 1year, 2year and 3year respectively.
Conclusion
The mortality in our IPF patients as per GAP staging system was higher than noted in IPF cohorts internationally.
Delayed diagnoses, comorbidities, lower 6 MWD; presence of pulmonary hypertension could be the reasons,
necessitating their incorporation into future IPF staging systems.
P15
SEMIRIGID THORACOSCOPY: INITIAL EXPERIENCE FROM TERTIARY CARE CENTRE
ELAKYA.V, VENGADA KRISHNARAJ.S.P, ALLWYN VIJAY, SRIDHAR.R, KRISHNARAJASEKAR.O.R, CHANDRASEKAR.C
Government Hospital of Thoracic Medicine & Stanley Medical College
Objective: To assess the indications, efficacy and safety of semirigid thoracoscopy
Methods: Retrospective non randomized cohort study. Study population: All cases subjected to thoracoscopy
during March 2014 – august 2014. Technique: Semirigid thoracoscopy under conscious sedation and local
anaesthesia. Variables like age, sex, indication, adhesion, loculations, visceral peel, no of biopsies, diagnosis,
quantity of fluid, colour of pleural fluid were assessed. Site of study – Govt Hospital Of Thoracic Medicine,Chennai.
Results: Total number of cases is 45 - 38 cases male and 7 cases female.Mean age is 45.Indications noted were
empyema(22%), undiagnosed pleural effusion(31%) , non expanding lung(33%), hemorrhagic effusion(11%) and
lung biopsy(2%). 18 % of cases were diagnosed as malignancy and rest were due to benign causes. 4 out of 5 cases
of hemorrhagic effusion was malignancy.6 out of 10 cases of empyema were successfully drained.4 required
decortications. Lung biopsy in a case of ILD shows hypersensitivity pneumonitis. Visceral peel was present in 47%
of study population with high incidence (73%) in non expanding lung group. Prolonged air leak and visceral peel
were main reasons for non expanding lung group.
Conclusion:Semi rigid thoracoscopy is relatively easy to use and efficient in management of pleural diseases .It is
safe with minimal complications
P16
ROLE OF FIBREOPTIC BRONCHOSCOPY IN SMEAR NEGATIVE RE-TREATMENT PULMONARY TUBERCULOSIS
NAVANEETHA KRISHNAN, G. ALLWYN VIJAY, S.P. VENGADA KRISHNARAJ, R.SRIDHAR, O.R. KRISHNA
RAJASEKHAR, C. CHANDRA SEKAR
BACK GROUND: Diagnosis of sputum smear –negative retreatment pulmonary tuberculosis patients can be
challenging and many patients being put on anti-tubercular treatment empirically, leading many time to
avoidable risk of drug toxicity, particularly retreatment cases. Fibreoptic bronchoscopy may provide a confirmative
and early diagnosis in such patients.
AIMS: To assess the role of fibreoptic bronchoscopy in the sputum smear – negative Retreatment pulmonary
tuberculosis and compare the pre FOB sputum for LPA with FOB wash AFB culture by LJ medium.
MATIERIALS AND METHODS: This is prospective study. It was conducted on 52, clinically and radio logically
suspected sputum smear –negative Retreatment Pulmonary Tuberculosis patients attending Government Hospital
of Thoracic Medicine, Tambaram, Sanatorium. Fibreoptic bronchoscopy was performed. Bronchial wash and brush
sent for AFB smear and malignant cytology. Bronchial wash for AFB culture by LJ medium, post FOB sputum for
AFB smear. All patients in this study given pre bronchoscopy sputum for LPA.
P18
Yield of Thoracoscopy in Undiagnosed Exudative Pleural Effusions
VIKAS MARWAH, AK RAJPUT, IM PANDEY, YADVIR GARG
Army Hospital (R&R), Delhi Cantt, India
An undiagnosed pleural effusion is often a difficult medical problem that needs histopathologic study for a
definitive aetiological diagnosis.
BACKGROUND AND AIMS:
Medical thoracoscopy has received renewed interest in the recent past for diagnostic as well as therapeutic uses.
In this study, we describe our experience with thoracoscopy for undiagnosed pleural effusions.
METHODS:
In a retrospective analysis of thoracoscopic procedures, we performed between August 2013 and Aug 2014, yield
of thoracoscopic pleural biopsy for achieving a diagnosis in undiagnosed pleural effusions, defined as pleural
effusions with adenosine deaminase (ADA) levels less than 40 IU/L and negative pleural fluid cytology for
malignancy on three occasions was evaluated.
RESULTS:
A total of 34 patients (25 males and 9 females; mean age years) underwent thoracoscopy. Overall diagnostic yield
of thoracoscopic pleural biopsy was 97.05% in patients with undiagnosed pleural effusions. Malignancy was
diagnosed in 21 patients, tuberculosis was found in 09 patients, 03 patients had non-specific inflammation, and
was non-diagnostic in 01 patient. There were no major complications, only four patients had minor complication
like subcutaneous emphysema (three patients) and prolonged air leak (one patient).
Histologic diagnosis
Prevalence
Malignant pleural effusion
21 (61.74%)
Granulomatous lesion
09 (26.47%)
Chronic non- specific inflammation
03 (8.82%)
Non diagnostic
01 (2.94%)
CONCLUSIONS:
Pleuroscopy is a safe, simple, and valuable tool in the diagnosis of undiagnosed exudative pleural effusion with
minimal complication rates. In a tertiary care centre, thoracoscopy has shown more malignant pleural effusions
than tuberculous signifying a changing trend.
P19
Bedside pleurodesis and digital suction device
S Khandelwal, K Ali, N Agarwal, A Z Khan
Department of Minimally Invasive and Robotic Thoracic Surgery
Medanta The Medicity, Gurgaon
Objectives: We present our experience of facilitation of conservation management of air leaks and malignant
TM
pleural effusion by bedside pleurodesis due to use of Thopaz digital suction suction device thus avoiding surgery
and general anesthesia for very sick patients.
Methods: 52 patients unfit for general anaesthesia underwent bedside Talc pleurodesis for prolonged air leak or
malignant pleural effusion. Talc slurry with lignocaine was introduced via the drain and digital suction was applied
at 2 Kpas for 48 to 72 hours
Results: 48/ 52 patients underwent successful talc pleurodesis due to complete lung expansion. 8/48 patients
needed 2 doses of talc over 4 days. Early mobilisation was facilitated by portable digital suction device. 2/ 52
patients had small localised apical pneumothorax with no clinical significance. 4 patients with tuberculosis were
put on a flutter bag and discharged home. Drain was removed at follow up.
All patients had successful conservative management of clinical problem.
Referral rates have increased from Cardiac surgery, oncology, pulmonology and urology departments specifically
seeking medela digital suction device.
TM
Conclusion: Use of Thopaz digital suction device facilitates early expansion of lung and thus aiding in successful
bedside talc pleurodesis in very sick patients who are unfit for general anaesthesia
P20
Avoidance of surgery in secondary pneumothorax using digital suction device
S Khandelwal, K Ali, N Agarwal, A Z Khan
Department of Minimally Invasive and Robotic Thoracic Surgery
Medanta The Medicity, Gurgaon
Objective: We present our experience of facilitation of conservation management patients with secondary
TM
pneumothorax with air leaks by bedside pleurodesis due to use of Thopaz digital suction device thus avoiding
surgery and general anesthesia for very sick patients
Methods: 18 patients with secondary pneumothorax with ICD with prolonged air leak, who were unfit for general
anaesthesia, underwent bedside Talc pleurodesis. Talc slurry with lignocaine was introduced via the drain and
digital suction was applied at 2 Kpas for 48 to 72 hours.
Results: 13/18 patients underwent successful talc pleurodesis due to complete lung expansion. 2/18 patients
needed 2 doses of talc over 4 days. Early mobilisation was facilitated by portable digital suction device. 2/ 18
patients had small localised apical pneumothorax with no clinical significance. 1 patient with tuberculosis was put
on a flutter bag and discharged home. Drain was removed at follow up. All patients had successful conservative
management of clinical problem.
TM
Conclusion: Use of Thopaz digital suction device facilitates early expansion of lung and thus aiding in successful
bedside talc pleurodesis in very sick patients who are unfit for general anaesthesia
P21
Unusual Endobronchial Foreign Bodies
1
1
1
2
2
3
S Khandelwal , K Ali , N Agarwal , S Khanna , A Sharma , T Piplani , A Z Khan
1
1
Department of Minimally Invasive and Robotic Thoracic Surgery
2
Department of Anesthesiology
3
Department of Radiology
Medanta The Medicity, Gurgaon
Objective: We set out to present our experience of extracting unusual endobronchial foreign bodies.
Methods: A total of 11 cases were diagnosed roentogenographically and bronchoscopically at our hospital. These
patients consisted of 10 men and 1 woman with a mean age of 48.5 years (range 10 to 77 years). Symptoms on
presenting were usually cough, sputum, or chest pain. Three patients were not aware that they had aspirated a
foreign body. Rigid bronchoscopy and retrieval of foreign body was performed in all the cases.
Results: The articles removed were betelnut, peanuts, denture, antihypertensive tablet, plastic button, coin, pen
spring. There were no severe complications during or after the endoscopic removal of the foreign bodies.
Conclusion: In conclusion, rigid bronchoscopy is useful for the diagnosis and treatment of endobronchial foreign
bodies.
P22
Robotic & VATS Lobectomy for post tuberculosis Aspergilloma
1
1
1
2
2
3
S Khandelwal , Kamran Ali , N Agarwal , S Khanna , A Sharma , T Piplani , A Z Khan
1
1
Department of Minimally Invasive and Robotic Thoracic Surgery
2
Department of Anesthesiology
3
Department of Radiology
Medanta The Medicity, Gurgaon
Objective: We present a video of our experience of Robotic & VATS Resection of Aspergilloma using a DaVinci 4
Arm robot. We also demonstrate a novel intraoperative technique to prevent spillage of aspergilloma into the
normal lung.
Methods: Between January 2012 to September 2014, 18 patients underwent surgical resection of Aspergilloma CT
scan demonstrated an aspergilloma.
4 arm DaVinci Robot was used to perform the surgery. Intubation was done with double lumen tube into the nonoperative bronchus with the patient in a lateral position with affected side down to prevent spillage. A Fogarty’s
catheter was also introduced into the affected side (operative side). Fissure and hilum were exposed and
structures were stapled with endostaplers.
Results: Age group was 35 to 78 years (mean 48 years). 12 males and 6 females. Patients received antituberculous
drugs for at least 6 weeks. Voriconozole was given 2 weeks prior and continued for 3 months postop.
3 cases of robotics needed completion by VATS. 2 needed conversion to open due to bleeding and frozen hilum.
Mean operative time was 188 minutes. Mean blood loss was 558 mls. 6 patients received blood transfusion. Chest
X-ray showed complete lung expansion.
One patient died with multi organ failure and fungal septicaemia on day 25.
Conclusion: Robotic and VATS Resection of Lung is technically possible with good clinical outcomes. Robotics
allows 3D visualization and 360 degree movement of endowrist. It gives good and accurate mobilization of
adhesions. Addition of anesthetic techniques like lateral double lumen intubation, Fogarty catheter prevent
spillage of aspergilloma into normal lung. In the background of tuberculosis, where the general feeling across the
country is that VATS is not possible we have not only done these very complex cases by VATS but shown clinical
efficacy of resection by robotic thoracic surgery.
P23
VATS Decortication: The Indian experience
1
1
1
2
2
3
S Khandelwal , Kamran Ali , N Agarwal , S Khanna , A Sharma , T Piplani , A Z Khan
1
1
Department of Minimally Invasive and Robotic Thoracic Surgery
2
Department of Anesthesiology
3
Department of Radiology
Medanta The Medicity, Gurgaon
Objective: A retrospective case matched analysis of clinical outcomes of VATS drainage of empyema and
decortication of patients with tuberculous and non-tuberculous empyema.
Methods: 180 patients with empyema presented for surgical treatment over a four year period. The diagnosis
confirmed on CT scan included simple and loculated early and late stage empyema with or without cortices. All
patients underwent VATS drainage of empyema and decortication to enable full expansion of trapped lung. Group
A consisted of 90 patients with tuberculous empyema and group B had 90 patients with non tuberculous
empyema. Postoperatively patients had intrapleural antibiotic washouts till drain fluid was culture negative.
Samples were sent for cultures, AFB cultures, histopathology, ADA analysis and TB PCR. Clinical and radiological
data was collected to show clinical outcomes at discharge and subsequent follow-ups. Data was analyzed using
SPSS 16.0 software.
Results: Group A & group B had similar demographics with relation to age, gender, duration of illness, clinical
comorbidities. The age distribution in group A was 8-82 and group B was 14-80 years
Both groups had two conversion to open surgery (p<0.235).
All patients had good post operative outcomes. Percentage improvement in chest X-rays was 96% in both groups
(p<0.235) and 100% at 3 months. Both groups had negative Intrapleural cultures at discharge (p<0.234). One
patient in group A with Giant Bullous disease underwent lung volume reduction surgery. He subsequently had
prolonged air leak requiring indwelling drain. There was no statistical difference in hospital stay (mean 5 days,
p<0.325).
Conclusion: VATS does have a role in the surgical management of patients with tuberculosis empyema. Besides
slightly longer operative time, the clinical outcomes are just as good as patients with pyogenic empyema. Presence
of suspected tuberculosis is not a contraindication for VATS decortication.
P26
Unusual presentation of anterior mediastinal mass - a case report
Srilata P. Naik, Jayaraj B S, Mahesh P A, Chaya S K.
JSS Medical College, Mysore, Karnataka, India
Introduction
Approximately half of all mediastinal lesions are asymptomatic and are detected on chest radiographs taken for
unrelated reasons. The absence of symptoms suggests that a lesion is benign, whereas the presence of symptoms
suggests malignancy. In adults, 48 to 62 percent of lesions are symptomatic, whereas the percentage of
symptomatic lesions is higher in children (58 to 78%). The most common symptoms are cardiorespiratory – in
particular, chest pain and cough. Other manifestations are heaviness in the chest, dysphagia, dyspnea, hemoptysis,
signs of superior vena caval obstruction with facial swelling, and cyanosis. Recurrent respiratory infections are a
common complaint.
Case Report
A 28 year old female presented with multiple pigmented papules and macules over the extremities and
inflammatory papules over the back with severe itching. She had no respiratory symptoms other than mild cough.
The skin lesions were confirmed to be Prurigo nodularis on biopsy. Chest radiograph and CT thorax showed an
anterior mediastinal mass enclosing the superior vena cava and right main bronchus. Mini thoracotomy and biopsy
confirmed Hodgkin’s lymphoma (nodular sclerosing type). Patient showed good response to standard
chemotherapy.
Conclusion
High degree of clinical suspicion is required as anterior mediastinal mass may have paucity of clinical symptoms at
presentation. Early diagnosis may help in improving the prognosis.
P27
Tracheal Lymphoma
YUNUS.A.S, R.NARASIMHAN, N.GEETHA, UMAMAHESHWAR.C
Department of Respiratory Medicine and Pathology
Apollo Hospital, Chennai, Tamil Nadu,
Primary pulmonary Non-Hodgkin’s Lymphoma (NHL), also known as Bronchial Associated Lymphoid tissue(BALT)
lymphoma, is a rare extra-nodal lymphoma. They account for very small percentage of all lung malignancies. We
describe a case of a 73 year old male who presented with exertional dyspnea and foreign body sensation in throat
with a normal chest radiograph. Until date very few cases of BALT lymphoma involving the trachea have been
described.
CASE REPORT
A 73 year old Indian male, non smoker, diabetic and hypertensive presented with exertional dyspnea and foreign
body sensation in throat since 4 months to the outpatient department. Auscultation revealed bilateral inspiratory
rhonchi. He was found to have a subglottic growth on Indirect Laryngoscopy. Chest Radiograph was essentially
normal. Computed Tomograph (CT) scan neck and thorax revealed a circumferential mural thickening with
intraluminal mass and narrowing involving the left lateral, anterior and posterior wall of the trachea with multiple
nodules extending up to the primary bronchus on either side. Bronchoscopy revealed a polypoidal endotracheal
rd
mass in the upper 1/3 of the trachea. Multiple endobrochial biopsies were taken from the mass and tissue sent
for histopathology. Histopathology of the bronchial tissue showed dense aggregates of the lymphoid cells with
fibrinous material within the pseudostrattified respiratory epithelium suggestive of Lymphoma. Further
Immunohistochemistry analysis was done and B Cell BALT lymphoma confirmed. Patient was started on
Therapeutic Radiotherapy. Patient underwent repeat scan which showed reduction in the size of the mass and
clinical improvement.
CONCLUSION:
Tracheal BALT lymphomas have an indolent behavior. The lesions are commonly missed on chest radiographs
unless we have a high index of suspicion
P28
High Dose Rate Endobronchial Brachytherapy for Palliative Treatment of Lung Cancer – A Case Report
Muhammed Aslam N K , Rajeev Ram , Achuthan V , Manoj D K ,Rajani M
Pariyaram medical colleg , kannur , india
Introduction
High-dose-rate endobronchial brachytherapy (HDREB) is used in the treatment of endobronchial lung cancer for
the main purpose of symptom relief.
Case Report
76 year old male ex-smoker presented with 1 month history of exertional dyspnea .His chest X-ray revealed left
perihilar homogenous opacity. CECT Thorax showed infiltrating mass (7cm) in left hilum with mediastinal invasion
reaching up to 1.5 cm from carinal angle. Flexible video bronchoscopy showed proliferative growth partially
occluding the distal end of left main bronchus. Histopathology of bronchial biopsy showed squamous cell
carcinoma. Radiation oncology consultation done and posted for HDREB. An afterloading polyethylene catheter
passed through the bronchoscope. With Iridium -192 , a dose of 10 Gray was delivered using remote after loading
device. Repeat bronchoscopy done after 6 week showed significant reduction in size of mass. Patient got
symptomatic relief and now he is on 6 cycles of chemotherapy.
Conclusion
HDREB is an excellent modality for palliating malignant airway obstruction resulting in quality of life improvement,
with a good tolerance, patient compliance, and low rate of severe complications
P29
Utility of fibreoptic bronchoscopy in a case of left lung collapse with Guillain Barre Syndrome and 5 months of
amennorhea
1
2
3
4
5
Dr P P JAIN , Dr A S PANDEY , Dr D A MODH , Dr H V DESAI , Dr S R Ghadiya
Introduction
Lung collapse due to thick mucus plug impaction in a mechanically ventilated patient with GBS is a difficult clinical
sequel to manage. Involvement of respiratory muscles in GBS hampers cough reflex and muco-ciliary clearance
causing formation and accumulation of mucous plugs, which may result in life threatening complications.
Case Report
This case report highlights the importance of flexible fibre-optic bronchoscopy in consonance with Nacetylcysteine and Mesna (Sodium 2-mercaptoethanesulfonate) in the extraction of thick mucus plug from lungs.
We had a 20-year-old female patient with GBS and 5 months of amenorrhea (pregnant patient) on invasive
ventilator referred to us for left lung collapse. The Bronchoscopy findings were suggestive of impacted thick mucus
plug in the left main bronchus with circumferential narrowing. Suction was applied after the instillation of Nacetylcysteine and Mesna. The procedure took 40 minutes and the O2 saturation was successfully maintained
above 90%. Post bronchoscopy, the left lung expanded and arterial blood gas analysis showed marked
improvement.
Conclusion
Prompt and timely intervention for lung collapse is required to manage patients of GBS with respiratory
complications with pregnancy. Risk versus benefit ratio must be evaluated and hypoxia should be avoided to
improve maternal and foetal outcome. Use of Mesna and N-acetylcysteine enhances mucus plug breakdown and
helps in reverting collapse thereby, improving the prognosis of the patient.
P30
PREVALENCE OF LUNG CANCER IN A RELATIVELY NONSMOKING POPULATION VISITING CHEST & TB HOSPITAL,
AMRITSAR
B. MALHOTRA, N. PANDHI, N.C. KAJAL, R. PRABHUDESAI, C.L. NAGARAJA
CHEST AND TB HOSPITAL, AMRITSAR
Prevalence Of Lung Cancer In a Relatively Nonsmoking Population Visiting Chest And TB Hospital , Amritsar.B.
MALHOTRA, N. PANDHI, N.C. KAJAL, R. PRABHUDESAI, C.L. NAGARAJAChest and TB hospital, Amritsar-Punjab,
India.OBJECTIVESLung cancer is the most common cancer worldwide. Smoking is the most common risk factor in
development of lung cancer. In patients who develop lung cancer without a smoking history, potential
environmental or inherited causes of lung cancer are unclear. In Punjab, majority of the population is nonsmoking
due to religious prohibitions and also smoking is banned by law in public places and institutions. Inspite of this we
are getting quite a lot of lung cancer cases.METHODSThis study included 50 patients with proven diagnosis of lung
cancer. They were divided into 2 groups-smokers and nonsmokers. They were compared according to their
demographic characters like age, sex, occupation, smoking history, clinicoradiological findings and
histopathology.RESULTSIn our study of 50 patients, 48% were smokers whereas 52% were non-smokers. Mean age
of smokers was 62.25 years and that of nonsmokers was 56.15 years. All smokers were males. Amongst
nonsmokers 46% were males and rest was females. 92% of the smokers exclusively smoked beedies whereas 8%
smoked both cigarettes and beedies. 88% of the smokers had smoking index >300. Most smokers were labourers
by occupation (50%) whereas 61% of the nonsmokers were unemployed. Most common symptom in smokers was
cough (41%) whereas nonsmokers presented with cough and breathlessness (42%). Most common examination
and radiological finding in both smokers and nonsmokers was mass lesion. Most predominant histological type in
smokers was squamous cell carcinoma(75%) and in nonsmokers was adenocarcinoma(69%).CONCLUSIONSFrom
this study we have concluded that lung cancer is equally prevalent in both smokers and nonsmokers. Most
smokers were males presented with squamous cell carcinoma whereas majority of the nonsmokers were females
and presented at an earlier age than smokers with adenocarcinoma as the predominant histological type. Factors
leading to increased incidence of lung cancer in nonsmokers need to be further evaluated.
P31
MISDIAGNOSED CASE OF BRONCHIAL CARCINOID PRESENTING WITH REFRACTORY DYSPNOEA AND WHEEZE – A
RARE CASE REPORT
S Meher ,P Dutta, R Manjhi, S Pothal
V.S.S MEDICAL COLLEGE BURLA
MISDIAGNOSED CASE OF BRONCHIAL CARCINOID PRESENTING WITH REFRACTORY DYSPNOEA AND WHEEZE – A
RARE CASE REPORT
S Meher, P Dutta, R Manjhi, S Pothal
Department of Pulmonary Medicine,V S S Medical College ,Burla ,Odisha, India
BACKGROUND: Bronchial Carcinoid is a neuroendocrine tumour and constitutes 20-25% of all carcinoid tumours.
They usually present with recurrent haemoptysis but can sometimes present as refractory wheeze and
breathlessness.
CASE REPORT: We report a case of 59 year male patient, teacher by occupation, presenting with gradually
progressive dyspnoea over two years and occasional cough with scanty mucoid expectoration. He was a smoker
since last 30 years, smoking 4-5 cigarettes per day. He was clinically diagnosed to have COPD and was put on
inhalational formoterol and budesonide (800 microgram/day) along with inhalational tiotropium. On clinical
examination, there was tachycardia, tachypnoea, SpO 2 93% at room air. Auscultation of chest revealed diminished
vesicular breath sound and wheeze on left hemithorax. Spirometry demonstrated a restrictive pattern. ECG
revealed right axis deviation with first degree heart block. On chest X-Ray, left lung was found to be more
radiolucent in comparison to right. CT scan of thorax revealed a near complete cut off of left main bronchus due to
intraluminal soft tissue mass with parenchymal infiltrate in the left upper and lower lobe without evidence of
lymphadenopathy. Flexible bronchoscopy showed a tumour in the left main bronchus and biopsy was taken.
Histology revealed uniform polygonal cells suggestive of bronchial carcinoid. Immunohistochemistry indicated
neuroendocrine differentiation of tumour cells with cytoplasmic positivity for Cytokeratin, Chromogranin A and
Synaptophysin. Hence, a diagnosis of typical carcinoid tumour was established. Subsequently the patient was
referred to thoracic surgeon and left pneumonectomy was performed.
CONCLUSION: Though carcinoid is an uncommon tumour of respiratory system, its possibility should be kept in
mind in cases of refractory asthma or COPD.
P32
P33
A Rare Case Of Tracheal Tumour
A.M KHOJA, K S K GOUD, R.K JALAN, D L JAIN
Department of Respiratory Medicine, Ruby Hall Clinic, Pune, Maharashtra, India
BACKGROUND:
Primary tracheal tumours either benign or malignant account upto less than 0.1% of all tumours. Benign tumours
are usually misdiagnosed as asthma or COPD and are usually diagnosed late. On contrary because of the rapid
growth and hemoptysis malignant tumours are usually diagnosed a little early. Here we report a case of squamous
cell carcinoma of trachea which was being treated as bronchial asthma for 6 months. The main objective of
reporting this case is to always keep a suspicion of tracheal tumour when an elderly male being treated for chronic
airway diseases does not respond to the treatment.
METHODS:
A 63 yr old male patient, nonsmoker, presented to us with complaints of severe orthopnea and cough since 6
months. Physical examination revealed severe stridor and wheeze. He was being treated as bronchial asthma with
no improvement in symptoms. HRCT showed an enhancing mid-tracheal mass lesion with collapse consolidation of
right lower lobe. Flexible bronchoscopy showed a lobulated mass arising from left lateral wall in the mid trachea,
5cm away from the carina, blocking almost 90% lumen with mucopurulent secretions in right main bronchus.
Electrocautery and snare was used to excise the whole mass and APC coagulation was done. Mass was sent for
HPE.
Histopathological examination showed moderately differentiated Squamous cell carcinoma. Post-resection PET-CT
was done which showed uptake only in tracheal wall suggestive of residual mass, No distant metastasis.
CONCLUSION:
Primary Tracheal tumours are very rare and slow growing and hence the diagnosis is often made very late. Mostly
they are treated either as asthma or COPD. The most common tracheal tumour being squamous cell carcinoma
followed by adenoid cystic carcinoma.The initial management in acute setting includes relieving the symptoms by
resection of mass. Modern techniques for tracheal surgery include laryngotracheal, tracheal, or carinal resection
combined with radiotherapy and have shown good outcome.
P34
P35
Lung adenocarcinoma in 32 year old male
Dr. P.M. Anbu Maran, Dr. B. Rajagopalan, Dr. T. Dhanasekar, Dr. Koushik Muthu Raja
Lung Cancer is a rare disease in patients under 35 years of age. It typically occurs in older patients with a history of
tobacco use. This case concerns a 32 year old male with no history of tobacco use who complaints of hoarseness of
voice, chest pain, dry cough, breathlessness grade II and loss of weight and appetite for two weeks. Chest x ray
showed left sided massive pleural effusion. Computerized tomography showed massive left sided pleural effusion
with complete collapse of left lung with numerous enhancing lobulated nodules in the left pleura. Patient
underwent left sided thoracentesis. Pleural fluid cytology suggestive of polymorphous cellular infiltrates with
atypical cells. Biopsy of left hilar mass showing features suggestive of adenocarcinoma. Unfortunately, despite
aggressive therapy, the patient’s disease progressed and he died within one week following chemotherapy. In this
paper we hope to illustrate the unique challenges in diagnosing and treating young patients with lung cancer.
P36
Title: Two cases presenting with common respiratory symptoms but uncommon diagnosis
S K SAMANTA, S BARMAN, J JOSEPH
FORTIS HOSPITAL, KOLKATA, INDIA
CASE 1
A 20 year female
п‚· Right sided chest pain for 2 month
п‚· Low grade intermittent fever for 15 days
п‚· progressive SOB for 1 year with increasing severity for last 15 days
EXAMINATION:
п‚· Features of right sided pleural effusion with tracheal displacement to right
п‚· Sternal percussion - dull
INVESTIGATION:
• Pleural fluid: hemorrhagic, exudative lymphocytic, low ADA, Malignant cells ~ negative
• Pleural biopsy ~ chronic inflammatory cells.
• Serum alfa fetoprotein and beta-HCG ~ normal
FURTHER EVENTS:
• ICTD for severe SOB with drainage of 4.6 liters of fluid over 9 days.
• Right antero-lateral thoracotomy
“Large mediastinal mass adherent to right lung, pericardium, chest wall, diaphragm with thickened
pleura”.
HISTOPATHOLOGY:
• “Tumor with nests, cords, trabeculae of Polygonal cells with round oval nuclei, prominent nucleoli, Mitotic
figures seen”.
IMMUNOHISTOCHEMISTRY:
• Expressing Cytokeratin, EMA, CK7,P63,TTF-1 and immunonegative for HMB-45, S-100 protein, CD-20.
FINAL DIAGNOSIS:
Malignant clear cell tumor of the lung with a Myoepithelial phenotype
CASE 2:
A 45 year old, male smoker
• Exertional SOB for 1 year
• dull aching chest pain for 6 months
• Low grade intermittent fever for 1 month
EXAMINATION:
• Dull percussion note left hemithorax with ↓ Vesicular breath sound & ↓ Vocal resonance
CHEST RADIOLOGY:
Large heterogenous SOL in whole left hemithorax
TRU-CUT BIOPSY:
• Tumour cells are bland, monomorphic, hardly any mitotic activity, arranged in vague fascicles, stroma is
markedly collagenous & contain hyalinized vessels”.
IMMUNOHISTOCHEMISTRY:
• CD 34 positive, negative for Cytokeratin, EMA, S-100 protein.
THORACOTOMY:
Well circumscribed, encapsulated lobulated mass measuring 19 x 13 x 10 cm attached to pleura by a
pedicle with part of lung tissue adherent to it.
HISTOPATHOLOGY:
• compatible with solitary fibrous tumour of pleura
FINAL DIAGNOSIS:
• Solitary Fibrous Tumor of Pleura with intraparenchymal extension
CONCLUSION: Sometimes common symptoms can be presentation of rare diseases
•
P37
CASE OF TRACT CARCINOMA
Dr.s.trivedi, Dr.m.pawar, Dr.madhuri.g, Dr.s.singh
Objectives: To evaluate a 60 yr old female patient, operated case of Ca breast 20 yrs back for metastasis.she
presented with left sided chest pain, progressive breathlessness, swelling in lateral chest wall and back.
Methods: 1) Thorough history taking revealed Ca breast 20 yrs back, h/o massive pleural effusion on left drained
via icd 4 months back, 1 month h/o swellings in lateral chest wall & back.2) examination revealed dull note on
percussion on left side, icd scar, swellings in chest wall.3) cxr & CT scan thorax to visualize mass.4) usg abdomen to
r/o metastasis.5) FNAC of swellings.
Results:1) CT scan revealed pleural effusion left & pleural based mass.2)usg abdomen showed no metastasis.3)
FNAC of both swellings showed highly cellular picture consisting of poorly differentiated malignant cells with
convoluted nuclei s/o metastasis from Ca breast.
Conclusion: case of tract carcinoma at intercostal tube drainage & pleural fluid aspiration site due to metastasis
from old operated Ca breast..
P38
Multiple small nodule and medistinal lymph node with minimal pleural effussion cause tubercular misdiagnose as
Ca lung
Author-Harendra yadav-1 A Agrawal-2 A Jaiswal-3 R K Diwan-4 a Srivastava-5
1-senior resident NITRD Delhi 2-junior resident NITRD Delhi 3-Senior chest physician NITRD 4-Senior thorasic
surgeon NITRD Delhi 5-Senior pathologist CHS Diagnostics Delhi
Introduction- Pulmonary tuberculosis is a common disease in India. India is the highest TB burden country in the
world, accounting for one fifth of the global incidence-an estimated 1.9 million cases annually. Tuberculosis has a
lots of presentation. It can present like pleural effusion, mediastinal lymph node, pulmonary nodule, sputum
positive pulmonary tuberculosis. In India most of the time lung cancer is misdiagnosed as pulmonary tuberculosis.
But in some cases like multiple pulmonary nodules is misdiagnosed as Ca lung. Lung carcinoma is rare under 40
years of age.
Case description- A 40 year old female came to our department with the chief complaint of low grade fever from 7
days and left side chest pain from 5 days. Chest x-ray was done outside and it showed left sided costophragnic
angle blunting. USG guided pleural fluid was aspirated and sent for biochemistry and cytology. It was lymphocytic
predominant but cytology revealed adenocarcinoma. Further investigation was done like USG whole abdomen,
mammography, PAP smear, transvaginal USG and CT scan thorax. But these investigations were normal. After that
PET scan was done and it revealed multiple small nodules in left upper lobe with mediastinal lymph node. Open
lung biopsy was done and sent for histopathology. It showed multiple necrotizing granulomas. Patient is not having
previous history of antitubercular treatment and registered under DOTS category-1.
Discussion- Tuberculosis is one of the deadliest disease in the world. Extra-pulmonary tuberculosis is common
among children and women. Pulmonary tuberculosis is common adults and elderly. Multiple small nodule is a rare
presentation of pulmonary tuberculosis. It is missed on chest x-ray. It is diagnosed on HRCT scan. For
histopathology VATS guided biopsy or open lung biopsy should be done. There are lots of diseases which can
present multiple lung nodules like sarcoidosis, silicosis, military tuberculosis, lung mets. Most common cause of
multiple pulmonary nodule is lung metastasis.
Conclusion-HRCT scan of thorax is the basic investigation for diagnosis of multiple pulmonary nodule. For
histopathology VATS guided biopsy or open lung biopsy can be done.
Key words- Pulmonary TB, Adenocarcinoma, Multiple nodule
P39
TOPIC NAME:- Posterior mediastinal mass presenting as paraparesis
DR IBRAHIM SIDDIQUE,DR.LAVINA MIRCHANDANI,DR JAYALAKSHMI T.K,DR GIRIJA NAIR,DR ABHAY UPPE,DR
APARNA IYER
INSTITUTION:-DR DY PATIL HOSPITAL AND RESEARCH CENTRE NERUL, NAVI MUMBAI
ADDRESS:-102 LAKE VIEW APARTMENT OPP BANDRA LAKE STATION ROAD BANDRA [W] MUMBAI 50
EMAIL ID:-SIDDIQUEMOHAMEDIBRAHIM@GMAIL.COM
Schwannoma are slowly growing , benign nerve sheath tumours that rarely cause symptoms and are usually
detected on routine radiographic imaging
Ten percent schwannomas grow across the adjacent intervertebral foramen and extend across the spinal clumn in
an hour glass or dumbbell shape .Thus
Spinal dumbbell schwannoma is a rare disorder having incidencebeing 3.75 per 10 million.
п‚—
We report a case of a 27 years old male who came with progressive weakness in lower limb leading to
paraplegia over a period of one month .A chest X-ray done as routine evaluation revealed a posterior
mediastinal mass confirmed by taking lateral chest x-ray. Hence MRI of spine was done which revealed
hour glass or dumbbell shaped tumour.FNAC done showed spindle cell neoplasm confirming
schwannoma. Complete surgical resection of tumour was done within 3 days of diagnosis Thus
radiography is a vital diagnostic tool in the detection of these silent tumours and early diagnosis and
complete surgical resection gives excellent prognosis
P40
Title – Non Hodgkin’s Lymphoma presenting as a chest wall mass
Authors – DR ABHIJIT AHUJA, DR SINDHU KAMATH, DR JAYALAKSHMI TK, DR LAVINA MIRCHANDANI, DR MUGDHA
BHIDE, DR APARNA IYER, DR ABHAY UPPE, DR GIRIJA NAIR
Institution- D Y Patil Hospital & Research Centre, Nerul, Navi Mumbai
BackgroundMalignant lymphoma presenting as a chest wall mass is not common.
1
Lymphoma comprises 2% of primary chest wall tumors & is mutually an extension of mediastinal disease.
Only 5% of Non-Hodgkin’s Lymphoma present in Anterior Mediastinum.
Most commonly seen are large, irregular, anterior & superior mediastinal masses.
Associated with large pleural effusions, pericardial effusions, pulmonary parenchymal changes.
Prevalence of anterior mediastinal mass is more in adults (65%) as compared to children (28%)
Case reportA 47 year old Male, Farmer, addicted to Tobacco chewing ВЅ packet/ day for 40 years , without any co-morbidities
came in OPD with complains of tender swelling over chest wall, breathlessness, chest pain, cough & low grade
fever since 2 months. Local examination of the swelling revealed the size being 5x2x1cm, shape was irregular,
tender, mobile, skin over the mass was tense & not warm on touch. Respiratory system examination revealed
reduced breath sounds, left infrascapularly. Chest X-ray showed left sided CP angle blunting with homogenous
opacity in the left lower lobe, silhouetting with left heart border & diaphragm. High Resolution Computed
Tomography showed a large lobulated heterogeneously enhancing lesion in the anterior mediastinum –
prevascular compartment extending to superior mediastinum. USG guided biopsy revealed Non Hodgkins
Lymphoma. Patient was referred to Onco surgery for further management.
Conclusion –
This case is a rare presentation of Non Hodgkins Lymphoma presenting as a chest wall mass.
Reference:
1
Annuls of thoracic surgery 2006 April: 81(4): 1214 - 1218
P41
Bronchial carcinoid:Rare cause of Hemoptysis. A case report
Vishal CHOPRA, Don Gregory MASCARENHAS, Aditi, Ashrafjit CHAHAL, Prabhleen KAUR, Shiyas MOHAMMED
Department of Chest & Tuberculosis(TB), Govt medical college, Patiala , Punjab
Introduction: Carcinoids are neuroendocrine tumours. General prognosis for patients with this neoplasm is quite
favorable if diagnosed early.
Case report: A 32 year old male, manual labourer by occupation presented with recurrent episodes of cough, right
sided pleuritic chest pain and blood in sputum off and on for last 8 years. He had receive anti-tuberculosis therapy
twice based on Chest X-ray findings.Respiratory system examination revealed impaired percussion note in right
infrascapular and infra-axillary area along with diminished breath sounds as well as vocal resonance in the same
areas.PA view chest X-ray revealed homogenous opacity in right lower lung field with elevated right hemidiaphragm and a positive silhouette sign with right heart border. Sputum for AFB was negative. Contrast enhanced
computed tomography of chest performed, showing collapse of right middle and lower lobes with minimal pleural
effusion on the same side and non-significant mediastinal lymphadenopathy. Bronchoscopy revealed a well
defined mass in right main bronchus. Biopsy on histopathological examination suggested a diagnosis of carcinoid
tumour.
Discussion: Carcinoids are most commonly found in the small intestine (26%), respiratory system (25%) and
appendix (19%).The severity and variety of symptoms depend on the size of the carcinoid pulmonary tumor and
the production of hormones. Bronchial carcinoids are mostly located centrally and produce symptoms and signs of
bronchial obstruction such as localized wheeze, non-resolving recurrent pneumonitis, cough, chest pain, and fever.
Most of these symptoms were present in our case.The primary and most effective treatment for all pulmonary
carcinoid tumors is surgical resection.
Conclusion: Due to the lack of characteristic symptoms, diagnosis of pulmonary carcinoid is delayed.
Pulmonologists should be vigilant to suspect carcinoid in cases of lobar collapse. Earlier the diagnosis is made,
more are the chances for radical treatment and hence favourable prognosis and outcome.
P42
A study on lung cancer in smokers and non smokers in a tertiary care center
Verma A,Shamim S,Mitra S
Department Of Pulmonary Medicine, Calcutta National Medical College,Kolkata
Objective:
To study the epidemiology , clinical and radiological profile of lung cancer patients with comparison
parameters among smoker and non smoker lung cancer.
of these
Methods:
Study was undertaken among admitted lung cancer patients in a medical college of Kolkata during the period Sept
2013 – Aug 2014. 160 lung cancer patients with smoking habits and 14 lung cancer patients without h/o smoking
were admitted during the study period. To facilitate comparison between profile of smoker and non smokers 30
patients with lung cancer were selected randomly from the smoker group .Thus the sample size is 44; smokers -30
and non smoker 14.
Results:
Overall non smokers were only 8% among the total lung cancer patients admitted .
Mean age( 59 В± 8.86) of smoker lung cancer is significantly high(p<.05) than that of non smoker(54.21 В± 13.82)
.Male preponderance noted among smokers(96%) and non smokers are mostly female(71.4%).commonest
occupation is skilled work (60%) in smoker lung cancer and home making (71.4%) in non smoker lung cancer.
Cough(63%), dyspnoea(47%) haemoptysis(57%) and wheeze(23%) were common symptoms in smokers with lung
cancer whereas cough(93%), dyspnoea(43%), hemoptysis(43%) were common in non smokers .Smokers with lung
cancer radiologically presented with pleural effusion(46.7%), collapse(30%), mass lesion(30%)and Mediastinal
lymph nodes(53%) whereas nonsmokers presented with pleural effusion(57%) collapse(14.3%) mass
lesion(35.7%) and mediastinal lymph node(21.4%). Histologically Squamous cell ca(63.3%) is prevalent significantly
among smokers whereas Non small ca(57.2%) were significantly prevalent among non smokers.
Conclusion:
1) Prevalence of non smoker lung cancer is very low in our cohort of patients
2) Smoker and non smoke lung cancer are different in several aspects in epidemiological clinical and
radiological perspective .
Commonest histological type in smokers with lung cancer is squamous cell ca and in non smokers it is nonsmall
cell ca
P43
Concurrence of Lung Malignancy and Tuberculosis – A case report
DR.B.NITHILAVALLI, DR.K.ANUPAMA MURTHY, DR.R.KARTHIKEYAN
DEPT OF RESPIRATORY
nithila76@gmail.com
MEDICINE,
PSG
IMS&R,
COIMBATORE,
TAMILNADU,
INDIA;
97906-51384;
Abstract:
A 54 year old male presented with productive cough, right sided pleuritic chest pain and streaky
hemoptysis of one month duration.
On examination he was hemodynamically stable. General examination revealed a right supraclavicular
lymph node of 2.0 x 1.0 cm. CXR showed right lower zone non- homogeneous opacity. Sputum for acid-fast bacilli
was negative. Bronchoscopy revealed no endobronchial lesions and broncho-alveolar lavage was inconclusive.
FNAC of the lymph node was suggestive of granulomatous lymphadenitis, CT-Thorax revealed a heterogenous
enhancing irregular lesion of 3.0 x 1.0 cm in right lower lobe with minimal effusion. A possibility of malignant lesion
with an ipsilateral cervical node metastasis was considered. Since the patient was not willing for invasive
procedures, excision biopsy of the lymph node was done. Biopsy revealed granulomatous inflammation s/o
tuberculosis and was negative for malignancy. Patient was initiated on anti-tuberculous treatment. During review
CXR revealed increasing right pleural fluid. Pleural fluid cytology revealed atypical cells suspicious of malignancy.
VATS biopsy of the right lower lobe lesion was done and it revealed adenocarcinoma lung with infiltration into
pleura-stage IV lung malignancy.
Patient was initiated on chemotherapy and ATT continued. This case has been reported for the
concurrent existence of tuberculosis and malignancy in the same patient.
Discussion:
Clinical diagnosis of co-existing tuberculosis and malignancy is often challenging. Lymphadenitis of various
etiologies causes a delay in diagnosis in malignancy patients; it may also lead to overstaging in the TNM system.
This case also highlights the need of exploring pleural and parenchymal lung opacity in spite of biopsy proven
lymphadenitis.
Conclusion:
The clinicians need to be aware of the protean manifestations of tuberculosis and malignancy and
maintain a high index of suspicion for simultaneous and / or misleading presentations.
P44
A CASE REPORT ON BRONCHOALVEOLAR CARCINOMA PRESENTING AS NON-RESOLVING CONSOLIDATION
GIFTY MG, KISKU KH, MADHUSMITA M
Department of Pulmonary Medicine
Bronchoalveolar carcinoma presenting as non-resolving consolidation is an uncommon presentation. The typical
presentation of bronchoalveolar carcinoma is asymptomatic (solitary nodule) and remains without symptoms even
as disease disseminates. We report a case of bronchoalveolar carcinoma presenting as non-resolving consolidation
in a 45 year female with productive cough (bronchorrhoea), exertional breathlessness and physical examination
revealing the features of left lower lobe consolidation on x-ray chest, with subsequent CT of the chest and biopsy
revealed bronchoalveolar carcinoma. Patient had a good performance score and was managed conservatively
P45
SPINDLE CELL SARCOMA OF THE LUNG: CLINICAL, RADIOLOGICAL AND HISTOPATHOLOGICAL
THREE CASES
FEATURES OF
ANANTHA R, SANTOSHAM R, MADHUSMITA M, KISKU KH
DEPARTMENT OF PULMONARY MEDICINE
The frequency and clinical features of lung spindle cell carcinoma (SpCC) are unknown. Hence we retrospectively
reviewed the records of 45 patients with lung cancer over 3 years and re-examined the clinical, radiological and
histopathological features of three patients of Spindle Cell Sarcoma. Thus the incidence of SpCC was 6.6% of all
lung malignancies in our hospital. All three patients were females and non-smokers. The age of the patients was
34, 43 and 56 years. The SpCC was initially detected by routine chest X-ray examination in all cases. Two were
peripheral tumors and one was a central tumour with total lung collapse. One patient had a surgical resection
other two cases were treated by chemotherapy. The survival period was 7 and 16 months for two patients. One
patient for whom surgical resection was done is still under our follow up 15 months after surgery. Histologically, all
the three SpCC consisted of only malignant spindle cells with hyperchromatic nuclei and mitotic figures.
These results suggest that SpCC of the lung shows no differentiation. In summary, the present study showed the
frequency (6.6%) of SpCC of the lung of all lung malignancies. Clinical features of the three SpCC are described
P46
Present trend of carcinoma lung in our hospital setup
AJIT.H
Institution..vydehi institute of medical sciences and research centre bangalore Karnataka india
Objective-Lung cancer is most commonly diagnosed major cancer in the world and it is the most common cause of
mortality in both males and females.Recently there is a change in histopathological presentation of lung carcinoma
among males and females in western world based on change in trend of cigarette smoking.
Present study is conducted to study the recent change in trend of Histopathological presentation of lung cancers in
Adult male and female.
Methods-Prospective study of lung carcinoma was conducted by using histopathological diagnosis.Weanalysed
patients coming to our hospital (vydehi institute of medical sciences and research centre)for the period of 2 years
(from august 2012 to august 2014).Correlation was done between age, sex and histopathology.Results were
analysed using chisquare test and logistic regression analysis.
RESULTS-During this period of 2 years 40 lung cancer patients were diagnosed in the department of pulmonary
medicine (vydehi institute of medical sciences and research centre, Bangalore). Out of 40 patients small cell
carcinoma was detected in 10% of patients, squamous cell carcinoma 45% of patients and adenocarcinoma 35%
out of which 22.5% were males and 12.5% of females , and large cell carcinoma were found in 10% patients.all
female patients(5/40 i.e., 12.5% ) had adenocarcinoma.
Conclusions-In our hospital setup we found squamous cell carcinoma is predominant type of lung cancer among
males.But adenocarcinoma is showing raising trend.
P47
Epidemiology & clinicoradiological profile of lung cancer patients presenting in a tertiary care centre
AP KANSAL ,Nancy GARG, Don Gregory MASCARENHAS, Shiyas MOHAMMED, Kiran.N, Anand Kumar BANSAL
Department of Chest & TB, GMC, Patiala, Punjab
Introduction: Lung cancer has varied patterns in its epidemiology and histology.
Objective: To study the epidemiological , clinicoradiological & histological pattern of lung cancer presenting to our
department over one year period.
Method & Materials : 67 patients suspected of lung cancer on symptomatology & Chest Xray(CXR) were subjected
to sputum examination, CT Scan of chest, followed by interventions like FNAC of the lesions and bronchoscopy to
prove the diagnosis .
Results : In our study of 67 patients, 53 were males, 14 were females. Median age was 59. 9 years, youngest being
26 years & oldest 95 years. All 14 females were non-smokers but had exposure to biomass fuel. Among males, 20
were non-smokers & 33 smokers. Chief complaint was cough in 60 cases(89%) ,breathlessness in 12 cases(18%)
,loss of appetite/weight in all cases. 18 patients were put on AntiTubercular Treatment(ATT),merely on basis of
CXR (89%) or pleural effusion(11%).
CXR had varied presentations ,most common being pleural effusion(22.4%) , unilateral homogenous
opacity(21%),and hilar enlargement(12%). Most common findings in CT chest were peripheral mass(34.3%), central
mass(20.9%), consolidation(15%), pleural effusion(11.95%),bilateral nodules(5.97%), Cannonball secondaries in 2
cases, SOL , Pancoast tumour & Lymphangitis carcinomatosis in 1 case each. Histological patterns included poorly
differentiated NSCLC in 29 cases(45.3%).,squamous cell carcinoma(SCC) in 28 cases(43.8%), adenocarcinoma in 5
cases(7.8%), large cell carcinoma & mesothelioma in one case each. Most of the patients were in stage 3 or stage 4
lung cancer.
Conclusion: Lung cancer has equally high incidence among non-smokers , SCC still being most common histological
variant. Patients shouldn’t be put on ATT merely on CXR basis without microbiological/histological evidence.
P48
P49
Abstract : TITLE : - “ The Changing Face of TBNA ”
Transition From Conventional TBNA (c-TBNA) TO EBUS-TBNA With ROSE
Retrospective Analysis of 150 cases from a tertiary care hospital in New Delhi, India.
AUTHORS:- Nafees Ahmad KHAN, Nevin Kishore, Ajay LALL, Ashish JAIN, Vikas MITTAL, Jaya KUMAR, Nitin DAYAL,
Amit SINGH, Akansha SHARMA,
Objectives :- To retrospectively analyze the diagnostic efficacy of EBUS-TBNA with ROSE compared to that of
conventional TBNA done by the same operators in our department over a 18 month period .
Material and methods : A retrospective analysis of case records of 150 consecutive patients with mediastinal or
hilar lymphadeopathy who underwent TBNA were included of which the first 75 cases were done by
conventional TBNA method and 75 cases were done by EBUS TBNA with ROSE
Results were compared in terms of diagnostic efficacy, no of lymph node stations punctured, no of total punctures
per patient, representative and non representative samples and final diagnosis.
Results: - 150 cases records were analyzed - 75 (c-TBNA ) and 75 (EBUS- TBNA with ROSE )
Commonest LN station in both groups was 4R ( 52 % in c-TBNA and 50 % in EBUS –TBNA
Percentage of Representative samples was 47 % (137/292) c-TBNA vs 68 % ( 183/269) EBUS –TBNA
No of Diagnostic Punctures was 36% (106/292 ) c-TBNA vs 53% (144/269) EBUS –TBNA
Diagnostic yield was 72 % (54/75) c-TBNA vs 95 % (71/75 ) EBUS-TBNA
Conclusion :1- Starting an EBUS programme at our hospital improved the diagnostic efficacy of FNA of Mediastinal and
Hilar LN from 72 % (c-TBNA ) to 95 % (EBUS TBNA with ROSE)
2- Total no of punctures in both groups was comparable ( 292 vs 269 )
3- Percentage of Representative samples was higher in the EBUS Group ( 68 % vs 47 % )
4- The most common diagnosis was granulomatous inflammation in both the groups.
P50
A RARE VARIETY OF LUNG CARCINOMA IN A FEMALE MIMICKING MASSIVE PLEURAL EFFUSION
Prof. ATIN DEY, Dr. PALASH NANDAN DHARA, Dr. SAYANTAN SAHA
R.G.KAR MEDICAL COLLEGE & HOSPITAL
A 40 years old housewife presented with gradually progressing right sided chest pain for one year, increasing
dyspnoea for 4 months and weight loss of four kgs. in last two months. The clinical findings & CXR was suggestive
of right-sided massive pleural effusion. Computed tomography (CT) scan of the thorax showed a large patchily
enhancing mixed density lesion having both solid & cystic component involving Rt. Lung, with minimal pleural
effusion. CT-guided tru-cut biopsy from the mass revealed Spindle cell neoplasm. However, on
immunohistochemistry tumour cells
P51
Comparison of Diagnostic yield of fiberoptic bronchoscopic procedures in the evaluation of bronchogenic
carcinoma
Mahendra KUMAR, Sanjay GEHLOT, Mahesh MAHICH, Baname WAANBAH, Ravi PANWAR
Department of Respiratory Medicine,
R.N.T. Medical College (Udaipur, Rajasthan)
Objective: Aim of the study was to assess the diagnostic yield of bronchial washing, brushing, biopsy, and TBNA in
bronchogenic carcinoma.
Design: Retrospective analysis.
Method:-Present study was carried out in 100 cases of bronchogenic carcinoma, proved either by Bronchial
washing, brushing, biopsy or TBNA. Bronchoscopy was done by flexible fiber-optic video bronchoscope at 280
bedded TB & Chest hospital, Bari attached with R.N.T medical College, Udaipur.
Results: Out of 100 cases, 80 were of central lesion in which diagnostic yield of endobronchial biopsy was highest
i.e. 92.5% , followed by brushing (75%) and washings (65%) respectively.In peripheral lesion (20 cases) , yield of
bronchial brushing was higher than washings. TBNA (Trans-bronchial needle aspiration) was done in 18 patients
and were found positive in 77.77%.
Conclusion: The overall diagnostic yield of flexible bronchoscopy procedures can be increased if conventional
TBNA performed together.
P52
A rare case of broncholithiasis: Removal by flexible video bronchoscopy
Mahendra KUMAR, Ananda DATTA, Ravi PANWAR, Mahesh MAHICH, Baname W.D. WAANBAH, Hemant SHARMA
Department of Respiratory Medicine, R.N.T. Medical college, Udaipur
Background: Broncholithiasis is a rare medical condition that needs to be considered in the differential diagnosis of
bronchial obstruction. Broncholiths originate from calcified material in peribronchial lymph nodes eroding into the
tracheobronchial tree. Flexible bronchoscopy plays an important role in the diagnosis of broncholithiasis, but its
therapeutic application is still controversial. We report a case of broncholith removal with the help of flexible video
bronchoscope without any complications.
Case report: A 45 year old male, farmer, chronic smoker was admitted with the complaint of cough with
hemoptysis and low grade fever, off and on since 8 months. He had similar episodes in past and was diagnosed
previously as a case of recurrent left upper lobe pneumonia. He never received antitubercular treatment. Clubbing
was the only finding in the general physical examination. Chest auscultation revealed diminished breath sound
over left infraclavicular region. AFB smear and malignant cytology of sputum were negative. Gram’s and KOH
stain revealed no pathogenic organism. Mantoux test was 4 mm. Chest x-ray showed left upper and mid zone
homogenous opacity with calcified lesions with bilateral hilaradenopathy. CT thorax showed calcified density in
lingular bronchus. Flexible video bronchoscopy revealed a loosely attached greyish white broncholith in the
lingular segment. We successfully removed broncholith with a toothed forceps. Patient was stable and had no
episodes of hemoptysis after the procedure.
Discussion: Usually rigid bronchoscopy with Nd-YAG laser photocoagulation or cryotherapy is used for safe
removal of broncholiths. Flexible bronchoscopy can be a promising tool in removal of broncholiths that are not
incarcerated in the bronchial wall.
P53
A rare case of cavitating primary adenocarcinoma of lung
M.L. VED, Mahendra KUMAR, Ravi PANWAR, Ananda DATTA, Baname W.D. WAANBAH, Mahesh MAHICH, Sanjay
GEHLOT
Department of respiratory medicine, RNT medical college, Udaipur
Background: Adenocarcinoma is one of the most common histologic types of lung cancer which rarely cavitates.
We report a case of cavitating primary adenocarcinoma.
Case report: A 65 year old male, contractor, chronic smoker was admitted with complaint of dry cough, low grade
fever for last six months with occasional streaky haemoptysis. He was having dull aching pain on back of chest in
right side. Physical examination revealed pallor and clubbing. Tenderness was present over right interscapular
region. Diminished breath sound was present over same region on auscultation. Other system examinations
revealed no abnormality. Routine blood test showed microcytic hypochromic anemia. Biochemical tests were
normal. Chest x-ray showed peripheral cavitating mass lesion eroding posterior part of ribs in the right mid zone.
Smear and culture of induced sputum did not reveal any pathogen. CECT chest revealed right upper posterior
pleural based cavitating mass lesion of size 5.9Г—4.9 cm with posterior rib erosion. USG guided FNAC was suggestive
of adenocarcinoma. Bronchoscopic study was inconclusive. Transthoracic tru-cut biopsy was performed.
Histopathological examination and immunohistochemistry for EGFR & TTF-1 confirmed the diagnosis. Patient was
then referred to the oncology department.
Discussion: Overexpression of epidermal growth factor present in neoplastic cells cause rapid tumor growth that
exceeds blood supply, favoring central necrosis and cavity formation. This case is interesting because cavitating
primary adenocarcinoma of lung is rare.
P54
Pancoast tumour – a case report
DR.VEENA REDDY VANKAYALA, Prof. Pradyut waghray ; Dr. A.V.N.Koteswara Rao ; Dr.Venkateswara Reddy
Tummuru ; Dr. Sowmya ; Dr. Chetan Rao ,Dr.Harish , Dr.Rikin; Dr. Aditya ;Dr. Krishna Chaitanya ,
Prof Ramakrishna Reddy.G *, Dr.Chandrakanth Reddy^
Dept of Pulmonary Medicine, S.V.S Medical College, Mahabubnagar, Telangana.
Introduction: Pancoast tumour , also called pulmonary sulcus tumour or superior sulcus tumour is a tumour of
pulmonary apex. They account for less than 5% of all bronchogenic carcinomas. It is a type of lung cancer defined
primarily by its location situated at the top end of either the right or left lung . Clinically patient presents with the
characteristic symptoms of severe pain in the shoulder radiating toward the axilla and/or scapula and along the
ulnar distribution of the upper arm, atrophy of hand and arm muscles and obstruction of the subclavian vein
resulting in edema of the upper arm , horners syndrome.
Case report :
65 yr old male patient came to pulmonary medicine op with complaints of giddiness, and left sided pleuritic chest
pain from 2 months ,radiating to left hand , absence of sweating on left side of face. General examination showed
clubbing and wasting of hypothenar muscles. Opththalmological examination showed horners syndrome with
reverse ptosis. X ray chest showed a mass with 1st and 2nd rib erosions. CECT chest showed a contrast enhancing
mass with first 2 rib erosions.pt was diagnosed as having pancoast tumour. CT guided biopsy showed
adenocarcinoma of lung. patient was referred to oncologist for further management.
P55
A rare case of cardiac angiosarcoma of right atrium with pulmonary metastases
*
Dr.G.AMBERNATH, Dr.Sai P Haranath, Dr.Meenakshi Swain , Dr.Manasa, Dr. Baisakhi Chandra
Dept of Pulmonary Medicine, Apollo Hospitals, Hyderabad, Telangana
* Dept of Pathology, Apollo Hospitals, Hyderabad, Telangana
BACK GROUND
primary malignant cardiac tumors are extremely rare but their associated mortality is very high. Cardiac
angiosarcoma, originates from mesenchymal tissue and endothelial subepicardium. Although angiosarcmoa
constitutes 31% of all malignant cardiac tumors, it is rare and prompted us to report this case.The diagnosis of
angiosarcoma is often delayed because early signs may be absent and generic. Indicative symptoms of potential
cardiac disease are exertional dyspnoea, chest pain, cough, syncope, arrhythmias, pericardial effusion leading to
tamponade and pleural effusion which occur late in the progression of angiosarcoma. Right atrial presentation is
the most common and the most difficult to diagnose.
CASE DETAILS
A 30 year old male from Tanzania presented to our hospital with complaints of chest pain since four months ,
cough, haemoptysis ,shortness of breath & diminished vision in the left eye since admission.Chest radiograph
showed marked cardiomegaly with right atrium (RA) & right ventricle (RV) enlargement. Echocardiography
showed large hollow cystic mass attached to RA & RV. MRI chest with contrast showed irregular mass in the right
lateral wall with pedunculated & nodular areas in the RA anterior wall .PET-CT showed metabolically active
skeletal & bilateral lung lesions suggestive of metastases and non-avid RA lesion possibly angiosarcoma arising
from RA with pulmonary, skeletal & hemorrhagic brain metastases. Pulmonary metastasectomy by video assisted
thoracoscopic surgery showed lung parenchyma with multiple tiny tumor nodules suggestive of angiosarcoma &
multiple nodules in favour of metastasis. Immune-histochemistry showed CD31 & CD34 positive tumor cells.The
patient has been treated with chemotherapy & radiation and has a good quality of life for the last 6 months .
P56
A rare case report of Low Grade Fibromixoid sarcoma in Anterior Mediastinum
*
#
Dr.Q.H.Ansari, Dr. Meenakshi Swain ,Dr.Avinash Dal , Dr.G.AMBERNATH
Dept of Pulmonary Medicine, Apollo Hospitals, Hyderabad, TS
Dept of CTVS, Apollo Hospitals, Hyderabad, TS
* Dept of Pathology, Apollo Hospitals, Hyderabad, TS
BACK GROUND
Low Grade Fibro Mixoid Sarcoma (LGFMS) is a rare neoplasm commonly affecting young adults and typically
arising in the somatic soft tissue of the proximal extremities. Its occurrence with in the thorasic cavity in the
anterior mediastinum is exceedingly rare.
CASE DETAILS
A 52 year old woman, presented to OPD with c/o cough with expectoration since 10 days. On evaluation, CXR PA &
lateral view showed well defined soft tissue dense shadow with convex outer margin not silhouting the cardiac
border in the anterior mediastinum in the hilar and supra hilar region. CECT chest showed well defined round mass
lesion in anterior mediastinum measuring 45 x 52 mm with moderate degree of non-homogenous enhancement &
necrotic areas on post contrast study. FNAB showed non specific bland spindle cells. PET CT scan whole body did
not reveal any distant metastasis. Wide local excision of the mass lesion was done through median sternotomy and
sent for histology for definitive diagnosis and on HPE showed hyalinised tumor cells arranged in loosely cellular
mixoid and collagen rich areas and are composed of spindle to stellate cells, features consistent with LGFMS.
Patient was treated with radiation to prevent recurrence. After surgery and radiotherapy,patient was
asymptomatic and leading a good quality of life for the last two months.
P57
A rare case of extraskeletal Ewings sarcoma originating from the parietal pleura
Dr.HARISH KUMAR G.,Prof.Pradyut Waghray,Dr.ANV Koteshwar rao,Dr.Venkateswara Reddy.T,Dr.Veena
,Dr.chetan Rao,Dr.sowmya,
Department of pulmonary Medicine,Svs Medical College,Mahbubnagar,Telangana
Introduction: Extra skeletal Ewing Sarcoma (EES) is a rare entity which predominantly occurs in adolescents and
young adults. It usually arises from the soft tissues of the trunk or the extremities,the most frequent sites of
occurrence are the chestwall, the para vertebral region and the lower extremities. EES is associated with reciprocal
translocation between chromosomes 11 and 22.
The case report:A 16years old male patient who presented to the ER with complaints of fever,right sided
hypochondriac pain,shortness of breath since 10days
Physical examination revealed tenderness at right hypochondriac region on palpation,dull note felt on percussion
on right infrascapular, infra-axillary area and decreased breath sounds on rigt infrascapular and infra-axillary area
Cxr,suggestive of Right sided homogeneous opacity silhoutting right dome of diaphragm with oblitreration of right
costophrenic and cardiophrenic angle
Ultrasound suggestive of irregular heterogenously hyperechoic lesion measuring 4*5 cms noted in the right pleural
space arising from supradiaphragmatic region taking no flow on color doppler with moderate pleural effusion
CT chest suggestive of irregular heperdense region noted in the pleural space arising from parietal pleura
obscuring the daiphragm in its superior aspect and causing erosion of adjacent rib with moderate collection of
pleural fluid
Pleural fluid analysis: Exudative effusion and negative for malignant cells
Pleural Biopsy using Abraham’s needle: Pleural based mass suggestive of pleural ewings sarcoma
CT guided biopsy of mass: Suggestive of pleural ewings sarcoma
Conclusion: As a conclusion EES should be considered in the differential
Diagnosis of any patients but especially in adolescents or young adults, with a soft tissue mass of the trunk or the
extremities, though it is a rarest possibility
P58
A rare case report of Secondary Pulmonary Amyloidosis.
G.NageswarRao, M.Venu, R. Ramakrishna, B.Surya kumari, N.Balakrishna.
Department of Pulmonary medicine, Katuri Medical College & Hospital, Guntur-17, India.
Introduction:
Amyloidosis is a systemic disease caused by extracellular deposition of insoluble fibrillar proteins. It can be
idiopathic (primary form) or associated with various inflammatory, hereditary, or neoplastic diseases (secondary
form). Pulmonary amyloidosis may be part of a widespread process that involves many organs, or it may be
localized to the airways and lung parenchyma.
Case scenario:
A 40 year old female presented with a two months history of progressive dyspnoea, productive cough, and
weight loss. She suffered from several episodes of respiratory infection in preceding months that improved after
antibiotic therapy. She had a past history of military tuberculosis treated well ten years ago. She was not a
hypertensive and diabetic.
Upon admission, physical examination showed an ill looking patient who was thin and pale. Her blood
pressure was 100/70 mmHg, her pulse 100 beats/min, respiratory rate was 26 breaths/min and pulse oxymetry
saturation was 94%.There was cervical lymphadenopathy. Chest auscultation revealed diffusely scattered crackles
and polyphonic rhonchi bilaterally. A physical examination of the heart and abdomen revealed no abnormal
findings. Routine blood investigation showed moderate anaemia and elvated serum creatinine (1.8mg%). She was
non-reactive for HIV, HBV and HBC. Her sputum for acid-fast bacilli and fungi was negative. A chest radiograph and
computed tomography (CT) on the thorax showed multiple calcified nodular opacities of varying sizes with
irregular contours, and were diffusely and bilaterally distributed. Spirometry demonstrated a moderate
restriction. Arterial blood gas analysis was normal. Echocardiography revealed a normal ejection fraction with no
myocardial or valvular abnormalities. Bronchoscopy showed no abnormalities and bronchial washings disclosed
only chronic inflammatory changes. CT guided transthoracic core needle biopsy and excisional biopsy of cervical
lymph nodes was done. Biopsy sections examined under light microscopy showed intense eosinophilic material.
The diagnosis of amyloidosis was confirmed by the presence classical green birefringence in congo red stained
sections viewed under polarized light. This was further fortified by immunohistochemistry positive for serum
amyloid A protein.
Conclusion:
Secondary amyloidosis is a rare systemic complication of pulmonary Koch’s. Tuberculosis is still the most
common cause of secondary amyloidosis (AA form) followed by chronic suppurative lung diseases in developing
countries. Several cytokine like IL-1, IL-6 and TNF-О± stimulate hepatic synthesis of serum amyloid A precursor
during tuberculosis inflammation. It should be considered in the differential diagnosis of calcified pulmonary
nodules due to malignancy, baritosis, alveolar lithiasis and granulomatous diseases.
P60
An Atypical Presentation of Pulmonary Embolism
M.M. MODI, R.K. JALAN
Department of Respiratory Medicine, Ruby Hall Clinic, Pune, Maharashtra, India
OBJECTIVES :
Pulmonary Embolism is the most common preventable cause of death in the world. Post-operative deep vein
thrombosis from the pelvic veins is the most common cause. Cardiac Atrial myxomas are an extremely rare cause
for pulmonary embolism. 75% of myxomas are located in left atrium. Right atrial myxomas are extremely rare. We
report a rare case of pulmonary embolism due to fragmentation of an atrial myxoma in an usual location in right
atrium. The main objective of reporting this case is to consider such diagnosis when all other common causes of
pulmonary embolism are ruled out as timely surgical resection is the treatment of choice to prevent fatal
consequences such as sudden death.
METHODS :
34 yrs old male patient, smoker, presented with history of right sided chest pain and breathlessness since 15 days
.Chest X- Ray - Right pleural effusion and Right lower lobe consolidation. Diagnostic thoracentesis - Exudative
pleural effusion. Patient was diagnosed as having syn-pneumonic effusion and started on antibiotics . After 21 days
of treatment repeat chest x- ray showed no reduction in pleural effusion and consolidation. Patient was referred to
us for further management. HRCT- Thorax with Pulmonary Angiography - Dense calcific plaque in right descending
artery. 2- D Echo - Large mobile mass measuring 3.9 X 1.6 cm in Right atrium, prolapsing across mitral valve .
Cardiac MRI - Mass in right atrium with heterogenous contrast uptake. Mid- Sternotomy and CP bypass showed a
freely floating mass in the right atrium with 2 attachments , one near anterior lip of coronary sinus and other just
above the opening of IVC into RA.
Mass was completely excised and sent for HPE - Stellate cells surrounded by abundant loose myxoid stroma with
areas of infarction- consistent with Atrial Myxoma.
CONCLUSION :
Right atrium is a very rare site for atrial myxomas, which can rarely cause fragmentation and lead to pulmonary
embolism.
P61
ABSTRACT
Successful Non- Surgical Management Of Acquired Benign Tracheo- Esophageal Fistula
A.M. KHOJA , R.K. JALAN, D.L. JAIN, K.A. PATIL, KSK GOUD, B. SIDDESH
Department of Respiratory Medicine, Ruby Hall Clinic, Pune, Maharashtra, India
INTRODUCTION :
Tracheo-esophageal fistula (TEF) are a rare entity which can either be congenital or acquired. Acquired TEF are
seen in adults and are most commonly due to malignancy. Benign TEF are rare and are most commonly attributed
to post intubation injuries. Till date,surgical correction for management of benign TEF has been most commonly
employed. Tracheal stenting with self expanding metallic stent (SEMS) has been mostly reserved for palliative
management of malignant TEF. Here, we report a case of benign TEF caused due to high tracheostomy cuff
pressure which was successfully managed non – surgically by tracheal stenting.
METHODS :
54 yrs old male patient with history of Road traffic accident and subsequent Diffuse axonal injury was admitted in
the hospital since 2 months . He underwent tracheostomy 45 days ago and had Ryle’s tube in situ since 2 months.
He was referred to us with complaints of regurgitation of Ryle’s tube feeds and purulent secretions through the
tracheostomy site since 10 days. Examination and X- ray findings were suggestive of aspiration pneumonitis. He
was posted for bronchoscopy which showed a large trachea-esophageal fistula in the upper part of the trachea. As
the patient was unfit for surgical closure of the fistula due to poor neurologic status, he underwent tracheal
stenting with a SEMS for closure of the fistula.
CONCLUSION :
Benign TEF is a rare entity and can be successfully managed by non – surgical interventions like tracheal stenting
A case report on pulmonary alveolar microlithiasis
P62
Suman Kumar Jagaty, Pravati Dutta, Rekha Manjhi, Sudarsan Pothal,
Madhumita Nayak, Paresh Chandra Mohanta
Department of pulmonary medicine, VSS Medical College, Burla, Odisha, India.
Background: Pulmonary alveolar microlithiasis is a rare inborn error of calcium metabolism with unknown
etiology and familial association in which concretions composed of calcium and phosphorus collect in alveolar
spaces.
Case Report: A 42 year old male non smoker weaver presenting with 6 months history of fever,cough with mild
expectoration and dyspnea on exertion was diagnosed as miliary tuberculosis by a local physician for which he
was taking antitubercular treatment.His general physical examination was unremarkable with vitals being
normal.Respiratory system examination revealed bilateral fine inspiratory crackles in axillary area.His laboratory
parameters and Pulmonary function test were normal and sputum was negative for acid fast bacilli.Chest X-ray
shows bilateral diffuse micronodular shadows (sand-storm pattern) predominant in middle and lower
zones.Presence of diffuse calcified micronodular opacities with lower lobe and subpleural predominance and
septal thickening on high resolution computed tomography of chest confirmed the diagnosis of Pulmonary
alveolar microlithiasis.
Conclusion: Pulmonary alveolar microlithiasis being a rare disease with unknown etiology has burdened the
patient with unnecessary doses of anti-tubercular treatment because of its resemblance to miliary tuberculosis
on chest X-ray.Patients due to delayed diagnosis ultimately progress to end stage lung disease necessitating lung
transplantation. So attempt for earlier diagnosis and finding the etiology is all that needed.
P63
Title: Kartagener Syndrome
Subject: Abstract for poster presentation about a case of Kartagener Syndrome
Presenter: Dr.M.Sharanya G.S.L.Medical College, Rajahmundry,A.P.
Objective: To discuss the signs, symptoms, clinical evaluation, diagnostic investigations and
Kartagener Syndrome
treatment aspects of
Methods: A 20 year old female came to the Pulmonology O.P. with a complaint of cough with mucoid
expectoration , breathlessness and common cold like symptoms since 3 months. Patient claimed to have had a
history of similar illness recurrently since childhood.
Result: Investigative workup revealed that the patient had Situs inversus , Bilateral Brocheichtasis and Chronic para
-sinusistis. The patient was diagnosed to have Kartagener Syndrome.
Conclusion: The frequency of Kartagener syndrome is 1 case per 32,000 live births. Situs inversus occurs randomly
in half the patients with primary ciliary dyskinesia; therefore, for every patient with Kartagener syndrome, another
patient has primary ciliary dyskinesia but not situs inversus.
Hence I would like to present a poster for representation of the basic text of the summary, with the use of figures,
graphs and tables, as well as references, so to facilitate visual communication about Kartagener Syndrome.
P64
A rare cause for stridor in an elderly male
Dr.Madhusudhan.Y, Dr Vishnu Sharma.M, Basavaraj.S.
A.J.Institute of Medical Science, NH-66 , Kuntikana, Mangalore ,Karnataka- India 575004 madhu4788@gmail.com
INTRODUCTION:
Stridor is most often due to upper airway obstruction. Any intra thoracic lesion leading to tracheal obstruction can be a
rare cause for stridor.
CASE REPORT
An 80 year old male patient presented with progressive dysphagia since 3months, hoarseness of voice since 4 weeks
and noisy difficulty in breathing (stridor) since 10 days. He had loss of weight and appetite. He had no chest pain,
cough, sputum, hemoptysis or fever. He had no neurological symptoms. He was a chronic smoker.
ENT examination showed left vocal cord palsy. No other local abnormalities were seen in the throat. Respiratory
system examination was normal. Chest X-ray did not reveal any obvious lesion which could account for stridor.
Contrast enhanced CT scan of chest revealed soft tissue density shadow in upper part of esophagus at the level of D1 –
D4 vertebra. Fat plane around trachea and esophagus was lost and the lesion was seen invading the trachea from
posterior aspect narrowing the tracheal lumen. Upper GI scopy showed a fleshy growth in the upper end of esophagus
and biopsy from the lesion was taken. Biopsy revealed moderately differentiated squamous cell carcinoma.
Bronchoscopy showed a lesion invading the trachea from posterior aspect occluding the tracheal lumen almost
completely which lead to stridor.
CONCLUSION:
Consider and evaluate for intra thoracic causes for stridor when ENT evaluation is normal. Carcinoma in the upper end
of esophagus can invade the trachea and can lead to stridor.
P65
A rare presentation of spontaneous acquired diaphragmatic hernia – case report.
B.Bhushan, N.C.Kajal, A.Gupta, S.Gupta
TB and Chest Department, Government Medical College, Amritsar
Background
Diaphragmatic hernias represent a weakness that can evolve into a localized defect, allowing abdominal structures
to protrude. Spontaneous diaphragmatic rupture is one of the rarest thoracoabdominal emergencies, and is harder
to detect in patients without visceral damage. A sceptical approach is key to the diagnosis of this condition.
Case Report
A forty-six year old male patient presented with chest pain on left side and dyspepsia for the past two months,
associated with few episodes of vomiting. Chest radiograph showed lesion mimicking a cavity in the left lower zone
overlying cardiac shadow with a surrounding area of collapse(Figure 1). Initially, he had presented to a general
practitioner, where he was misdiagnosed as a case of pulmonary tuberculosis and was prescribed anti-tubercular
drug treatment The findings led to a provisional diagnosis of spontaneous acquired diaphragmatic hernia, which
was later confirmed on contrast enhanced tomography scan. Patient was referred to the cardiothoracic surgery
department.
Conclusion
The presentation of diaphragmatic rupture is often a result of herniation of abdominal contents into thorax.
Spontaneous Diaphragmatic Rupture (SDR) describes the rupture of the diaphragm due to increasing pressure in the
abdominal cavity and chest wall without any direct trauma. It is difficult to diagnose SDR in the absence of visceral
organ injury or herniation. The diagnosis may be delayed by a few days or even several years as the symptoms are
non-specific. Diagnostic procedures for traumatic diaphragmatic ruptures include: chest x-ray, CT scan, ultrasound,
Magnetic Resonance Imaging (MRI), Upper GI contrast studies, laparoscopy and thoracoscopy. However chest x-ray
has only a diagnostic accuracy for diaphragm injuries of just 25-50%. The management of SDR is surgical.
P66
Early stages of scleroderma- A case report
Dr.N.Snigdha,Dr.N.Gopi chand,Dr.D.sudeena,Dr. C. Suma latha
Siddhartha medical college, Vijayawada, Andhra Pradesh, India.
ABSTRACT
Introduction: Scleroderma or systemic sclerosis (SSc) is a clinically heterogeneous, multi-system autoimmune
disorder characterized by endothelial dysfunction, dysregulation of fibroblasts resulting in excessive production of
collagen and autoantibody formation with profound abnormalities of the immune system.Incidence of
scleroderma is about 9-19 per million populations. Pulmonary involvement like Interstitial Lung Disease(ILD) and
Pulmonary arterial hypertension(PAH) are common and occurs in all SSc subsets. Progression of lung disease in
SSc is variable and difficult to predict.
Case Report: A 30 year old female home-maker presented with shortness of breath and dry cough since 3
months.On general examination she has pallor, skin showed shiny ,light hide bound skin over extensor aspect of
forearm and front of legs. Salt and pepper pigmentation over both ears, microstomia, digital pitting scars are
seen. Respiratory examination reveals bilateral normal vesicular breath sounds with basal fine end inspiratory
crepitations. Chest X-ray PA view,2-D Echo are normal, Electrocardiography shows sinus tachycardia. High
Resolution computed Tomography shows peripheral ground glass pattern in basal segments and bilateral lower
zones which is consistent with nonspecific interstitial pneumonia(NSIP). Spirometry showed restrictive pattern.
Complete hemogram shows microcytic hypochromic anemia. She is positive for serum antinuclear antibodies , anti
scl70 antibody and negative for anticentromere antibody. Endoscopy shows erosive antral gastritis. Barium
swallow shows delayed filling of barium in lower 1/3 of esophagus. Liver Function Test’s and Renal Function Test’s
are within normal limits. She is diagnosed to have diffuse type of systemic sclerosis.
Discussion: PAH and ILD are most common pulmonary manifestations in Systemic sclerosis, with ILD of NSIP more
commonly associated with diffuse subset.PAH can occur in these patients secondary to ILD. Early diagnosis would
enable us to prevent progression to severe forms of pulmonary fibrosis. However the outcome may vary. Steroids
and antineoplastic drugs like cyclophosphamide , methotrexate, mycophenolate remain main stay of treatment.
Anti-fibrotic drugs like D-penicillamine have a role.PAH is managed on drugs like sildenafil or bosentan.
P67
Unusual presentation of Right sided Bochdalek Hernia in an adult
Ravi Bhaskar, Alok Chandra, Tariq Mahmood, Rajneesh Shrivastav, Neha Agrawal
Moti Lal Nehru Medical College and Swaroop Rani Nehru Hospital, Allahabad, India
Introduction: Bochdalek hernia is a type of congenital diaphragmatic hernia resulting from failure of closure of
th
posterior pleuro- peritoneal membrane by 8 week of gestation. It primarily manifests in neonates and infants. It is
rare in adults and accounts for about 0.17% to 6% of all diaphragmatic hernias. As 80%-90% occur on left side,
right sided presentation is exceedingly rare in an adult with only about 20 cases reported in literature.
Case presentation: A 24 year old male presented with gradual onset breathlessness on exertion for 3 months and
pain over epigastrium for 1 day. Patient was non-smoker. General and systemic examinations were within normal
limits. On auscultation, air entry was decreased on right side of chest. Chest X-Ray PA view(fig 1) revealed that
right diaphragm was exceptionally high. USG abdomen showed epigastric location of right kidney with eventration
of right hemidiaphragm. Barium follow-through showed that hepatic flexure of large bowel loops and ileal loops
were higher up in position under the right dome of diaphragm. CECT Thorax and Abdomen(fig 2) confirmed the
presence of small bowel, right colon, right kidney and right lobe of liver in thoracic cavity causing mass effect on
right lung. Patient underwent short lateral thoracotomy and herniated organs were moved back to abdominal
cavity and defect was closed. Postoperative course was uneventful and patient had no symptoms on follow up.
Conclusion: Bochdalek hernia occurs in about 1 in 2,200 to 12,500 live births and is a rare finding in adults. Right
sided hernias are rare because right pleuroperitoneal cavity closes earlier and liver buttresses the diaphragm.
P68
INTRAPULMONARY SOLITARY FIBROUS TUMOR OF LUNG PRESENTING AS PANCOAST TUMOR.
Dr VIPUL KUMAR, Dr K B GUPTA, Dr RITU AGGARWAL
Pt BD Sharma Post Graduate Institute of Medical Sciences
INTRODUCTION
Intrathoracic solitary fibrous tumors (SFT) are the rare mesenchymal tumors, commonly arising from the pleura.
Inward tumor growth into the lung parenchyma is infrequent while totally intra-pulmonary localized fibrous
tumors without histological continuity with visceral pleura have been described rarely. These tumors are three
times more likely to arise from visceral than parietal pleura with variable morphological presentation.
CLINICAL DETAILS
45 year old female presented with right side chest pain since two months. CECT revealed hypo dense mass lesion
of size 58mm x 66mm x 61mm in apical and posterior segment of right upper lobe showing heterogeneous
enhancement with central non-enhancing or necrotic area. CT guided biopsy of the lesion revealed replacement of
normal lung parenchyma by haphazardly distributed fibroblast like cells embedded in matrix of variable density
with low mitotic activity. On immunohistochemistry, tumor cells were positive for CD34, vementin and negative for
cytokeratin, smooth muscle antigen consistent with the diagnosis of SFT.
DISCUSSION
SFTs account for 8% of benign intrathoracic tumors and 10% of pleural tumors. Most of the patients are
asymptomatic and lesion is detected incidentally on routine chest radiograph. The diagnosis is usually made
histopathologically either by CT guided lung biopsy or surgical resection. As these lack distinctive histological
features, immunohistochemical examination is very important for their diagnosis. Although CD34 is expressed by
various cell types such as hematopoietic progenitor cells and mesenchymal tumor cells, its detection along with
vimentin and absence of cytokeratin in cells from a pleural tumor excludes the diagnosis of mesothelioma and of
most other pleural tumors such as carcinomas, fibrous histiocytomas, fibromatosis, fibrosarcomas, and synovial
sarcomas. The treatment of choice is surgical resection either through VATS or open thoracotomy depending on
the size.
P69
CATAMENIAL HAEMOPTYSIS
Dr.MOUNIKA.V*, Dr. H.V.PRASAD MALLA **, Dr.P.SUBBARAO***,
DEPARTMENT OF PULMONARY MEDICINE, KONASEMA INSTITUTE OF MEDICAL SCIENCES &RESEARCH
FOUNDATION, CHAITANYANAGAR, NH-214,AMALAPURAM, ANDHRA PRADESH-533201.
BACKGROUND: The monthly periodicity of the symptoms led to the coining of �’CATAMENIAL”( In Greekmonthly).Thoracic endometriosis can involve the lung parenchyma causing catamenial haemoptysis or it may
involve the pleura causing pneumothorax. We present a case of catamenial haemoptysis associated with pelvic
endometriosis.
CASE REPORT: A 25 yr old multiparous women was presented with recurrent episodes of haemoptysis at the time
of menstruation since 6 years. She had no fever, cough, weight loss, family H/O TB. Physical Examination was
unremarkable. Her chest radiography was normal and microscopy for mycobacterium tuberculosis was negative.
nd
Mantoux test 20 mm induration with BCG scar present. CT scan of chest was carried out on the 2 day of
menstruation with normal study. Fibre optic bronchoscopy showed normal endobronchial appearences.
Considering the history of haemoptysis during menstrual periods, pulmonary endometriosis was diagnosed.
DISCUSSION:
Endometriosis is a common gynecologic disorder with peak prevalence between 30 to 45 years of age. Only 10 25% of women with endometriosis are presenting with gynecological symptoms. It is most commonly found in
pelvis and only rarely in sites such as umbilicus or lungs. Pulmonary endometriosis gives rise to symptom of
catamenial haemoptysis.
The etiology of pulmonary endometriosis is unknown, but the theories of haematogenous spread and coelomic
metaplasia are plausible. The diagnosis is often presumptive, based on clinical history of cyclical haemoptysis at
the time of menstruation. Other diagnostic aids include endometriotic plaques on bronchial washings and
endometrial tissue on lung biopsy. Imaging technique of choice is CT scan of chest during days of menstruation and
in mid cycle.
P70
Hereditary Hemorrhagic Telangiectasia presenting as recurrent Haemoptysis
Dr.Rajesh Kumar B, Dr.S.V.Ghorpade, Dr.Vinit Niranjane, Dr.Gyan S Mishra.
Dept. Of Pulmonary Medicine, Govt. Medical College, Nagpur, Maharashtra.
Introduction: Osler-Weber-Rendu syndrome is a rare hereditary, autosomal dominant disease characterized by a
local angiodysplasia. Patients usually have nasal and gastrointestinal bleeding and characteristic mucocutaneous
telangiectasia associated with Arteriovenous malformations in the viscera commonly lungs, brain and liver.
Case report: 48yrs old male patient presented with recurrent haemoptysis, had recurrent epistaxis in past and
operated for brain abscess previously. He also had multiple cutaneous telangiectasias in face, chest and hands.
During evaluation CT Thorax and CT Pulmonary Angiogram were done, which showed multiple pulmonary A-V
Malformations bilaterally.
Discussion: Epistaxis caused by spontaneous bleeding from nasal mucosal telangiectasia is the most common
manifestation of this disease; about 80% of the patients have recurrent epistaxis. Cutaneous manifestations are
macular telangiectasia, which affect the face, lips, nose, tongue, ears, hands, upper body and feet. Pulmonary A-V
malformations caused by direct communication between the pulmonary vein and artery by means of a thin-walled
aneurism. They are usually multiple and bilateral, common in lower lobes, the treatment of choice is embolization
of vessels. Cerebral manifestations like Brain abscesses, Ischemic strokes, Bacterial encephalitis may occur due to
pulmonary A-V malformations. Cerebral malformations occur in about 28% cases. Gastrointestinal tract bleeding is
caused by mucosal telangiectasia in GIT. Liver involvement may cause congestive heart failure, hepatic
encephalopathy, and portal hypertension with oesophageal varicose veins. Our patient fulfilled three criteria for
the diagnosis of HHT. Pulmonary A-V Malformations were occluded by multiple Coil Embolization. After Coil
Embolization, his Orthodeoxia improved dramatically.
Conclusion: Hereditary hemorrhagic telangiectasia should be suspected in a case of recurrent haemoptysis.
Awareness must be created about this disorder and its genetic nature to enhance early diagnosis and appropriate
management. Diagnostic facilities for this disorder should be made available at specialised centres in India.
Atypical presentation of achalasia cardia
P71
B S Behera, P Dutta, R Manjhi, S Pothal
Department of Pulmonary Medicine,V S S Medical College ,Burla ,Odisha, India
Background:- Achalasia is defined as failure of organised peristalsis in esophagus and failure of relaxatiuon at the
level of lower esophageal spincter. It is a disease of unknown etiology.
Case report:- A 62 yr old male presented with history of low grade fever and cough for the past one year. No
history of hemoptysis. He had history of dysphasia, regurgitation or vomiting. These symptoms were mild so he
consulted either a local physicain and sometimes was on some home remedies, but his symptoms were not relived
on medications. He is non diabetic and non hypertensive. His physical examination was normal. On examination of
respiratory system tubular bronchial breath sound was found over left mammary, upper interscapular& lower
interscapular areas. His laboratory parameters showed a raised TLC count with rest of the blood parameters were
within normal limits. Chest X-ray showed widening of mediastinum with a patch of consolidation in the left upper
zone. CT scan of chest revealed a dilated and tortous bowel loop with a dilated loop of esophagus in thorax with
hiatus containing food particles with consolidation of the left upper zone. Barium swallow was performed which
showed a dilated and tortous esophagus. On Upper GI endoscopy the diagnosis of achalasis cardia was confirmed.
His respiratory symptoms subsided with antibiotics there was also radiological improvement of the consolidation.
He was referred to cardiothoracic department for further management.
Conclusion:- Achalasia remains an elusive diagnosis. The diagnosis is often delayed in asymptomatic patients as in
the present case.
AN UNUSUAL CASE OF MILIARY INFILTRATES
P72
Dr.HAJI, Dr.KRISHNAMOORTHY,Dr.SANGAMITRA,Dr.MATHAN,Dr.RAHMAN,Dr.JEYAKUMAR
DEPARTMENT OF THORACIC MEDICINE,
TIRUNELVELI GOVT MEDICAL COLLEGE AND HOSPITAL,TIRUNELVELI(TAMILNADU)
ABSTRACT:
Carcinomatosis is described as a condition in which multiple carcinomas develop simultaneously, usually after
dissemination from a primary source. They are forms of metastasis and whether they spread in a general manner
or in a defined pattern, they will still be a form of disseminated cancer. Miliary carcinomatosis is similar to military
tuberculosis in terms of their radiographic appearance. They are characterized by a pattern of metastases which
are not only nodular but also small in sizes.Usually presents late .We have described a 59 year old Female a case
of military carcinomatosis whose primary was papillary carcinoma of thyroid.Her thyroid had been removed and
was started on palliative chemoradiation.
P73
Ascending aortic aneurysm with left lung atelectasis
P74
Dr.Dishan.Y, Dr.Yuvarajan S, Dr.Bency Koickal Thomas
Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India
ABSTRACT
Pulmonary atelectasis may be caused by endobronchiallesions or by extrinsic compression of the bronchus.
However, lung collapse due to compression from a thoracic aneurysm is uncommon.
We report a 52 yr old male patient who has pulmonary atelectasis due to an extrinsic compression from the
ascending thoracic aortic aneurysm. He came with complaints of breathlessness for past 1 year. He was a non
smoker and non alcoholic. On examination of chest ,breath sounds reduced on left side of chest. Chest xray
showed enlarged cardiac shadow with left sided volume loss, following which 2D echo was done which showed
right atrium and right ventricle enlargement with moderate pulmonary artery hypertension and aortic aneurysm
with bicuspid aortic valve. CT thorax showed dilated ascending aorta and anomalous left brachiocephalic vein,
joined with left atrium directly and compression of pulmonary trunk between ascending aneurysm and anomalies
vein. Also narrowing of left main bronchus by left pulmonary artery and anomalous vein. Apical segment
atelectasis with patchy hyperinflation was also noted in left lung. Bronchoscopy showed carina shifted to left side
with narrowing of left main bronchus. No evidence of endobronchial obstruction at the level of left main bronchus.
Patient was referred to CTVS for the opinion regarding definitive surgical management.
P75
A rare anterior mediastinal paraganglioma-a case report.
Anandeswari P, Ramesh.P.M, Chitrakumar.A. Gangadharan.V
Govt. Kilpauk Medical College&GTHTM,Chennai, Tamil Nadu, India.
Case report: 40 yrs. male, pest controller, presented with hoarseness of voice-5 years, weight loss, breathlessness3 months. He was chronic smoker and alcoholic-20 years. On examination there were dilated veins over left
anterior chest wall. Examination of respiratory system revealed normal breath sounds with occasional wheeze with
impaired to dull note over the left infraclavicular and left mammary region. His blood counts were normal. Chest X
Ray PA view revealed a large well circumscribed homogenous opacity with left border abutting the lateral chest
wall and right border extending up to right mid clavicular line. Left lateral view revealed obliteration of retrosternal
space. Echo revealed moderate pericardial effusion. CT Chest revealed a well-defined hyper dense lesion in
anterior mediastinum extending from lower neck to anterior pericardium abutting the anterior chest wall
compressing and displacing trachea and vascular structures. CT guided biopsy revealed nests of small round to oval
cells separated by richly vascular thin stromal cells separated by dysmorphic stroma with focal calcification.
Neuron specific enolase was strongly positive suggestive of paraganglioma. Immunohistochemical markers showed
weak to moderate activity of synaptophysin and chromagranin. Patient was discharged and referred to surgical
oncology department for further management.
Discussion: Paraganglioma are rare, highly vascular, extra adrenal neuroendocrine tumors. First described by Von
Haller in 1743 involving various body sites(Abdomen-85%, Thorax-12%, Head&Neck-3%). <1% seen in
mediastinum. Anterior mediastinal paraganglioma arise from paraganglias associated with parasympathetic
system located in head and neck and extends into anterior mediastinum. They are asymptomatic, seen in older
people, identified incidentally and serve chemoreceptor function. Diagnosis is usually made by biopsy and
immunohistochemistry. So far only about 34 cases have been reported in the literature. Ours is another interesting
case presented for its rare incidence.
P76
ABSTRACT
Early Detection Of The Rare Entity Pulmonary Alveolar Proteinosis
M.M MODI,B.SIDDESH, R.K JALAN, K S K GOUD.
Department of Medicine, Ruby Hall Clinic, Pune, Maharashtra, India
300
OBJECTIVES: 142
Pulmonary alveolar proteinosis (PAP) is a rare syndrome characterized by pulmonary surfactant accumulation with
in the alveolar spaces with a reported prevalence of 0.1 per 100000. It occurs in an individual with distinct clinical
forms of which primary (idiopathic) represents the vast majority of cases, secondary form due to underlying lung
infections, haematological malignancies and inhalation of mineral dusts and insecticides, congenital form due to
mutations in the genes encoding for the granulocyte- macrophage colony stimulating factor receptor and very few
with surfactant gene mutations.
Here we report a case of secondary PAP who was successfully treated with total lung lavage which is accepted as
the most effective treatment for advanced cases. The main objective of presenting this is to increase awareness
regarding this rare disease as early detection and prompt treatment increases the survival where if delayed leads
to death.
METHODS: 99
A 30 year old male patient, smoker, presented with complaints of productive cough with whitish expectoration
along with breathlesness on exertion from 3 months and fever on and off from 8 days. Patient had history of
working in blast mines and fertilizer Company. On ausculatation the patient had fine inspiratory crepitations all
over lung fields. Chest X ray showed bilateral reticulo- nodular shadows. HRCT Thorax showed crazy paving pattern
along with ground glass opacities and reticulo- nodular shadows. Bronchoscopy with transbronchial lung biopsy
was done which was consistent with PAP. Patient had pneumothorax post biopsy for which intercostal drain was
inserted.
lavage patient was put on invasive ventilation. he developed ventilator associated pneumonia and died due to
sepsis.
CONCLUSION: 28
PAP is a rare entity which can be confused with many conditions. Early diagnosis and appropriate treatment
improves the life expectancy and quality of life of such patients.
P77
P78
A CASE OF TRACHEOESOPHAGEAL FISTULA PRESENTING WITH RECURRENT LRTI’S
P.sireesha,G.P.vignan kumar
Postgraduate,department of pulmonary medicine,narayana medical college,Nellore,Andhra Pradesh
INTRODUCTION:Tracheoesophageal fistula (TOF) is a congenital or acquired communication between trachea and
oesophagus.These can often lead to severe and fatal pulmonary complications.Among the acquired
causes,malignancy is the most common cause of tracheoseophageal fistula.The second most common cause is the
endotracheal cuff related trauma.
CASE REPORT:Here we report a case of 45 yr old male who presented with increased cough on
foodintake,breathlessness and recurrent LRTI’S.Past history of insecticide poisoning with prolonged intubation was
present.Investigated with routine laboratory tests.CBP was normal.Chest xray showed a pneumonic patch.Furthur
work out with bronchoscopy revealed a Tracheoseophageal fistula.case was planned for surgical repair of the
fistula.
P79
Title abstract for oster presentation: Skin associated lymphoid tumour
Name of author: Saurabh P borgaonkar
Dr vasantrao pawar medical college , nashik. india
A 28/M ,case of pleural effusion on cat 1 since 1 month. Pleural fluid was exudative and also was on oral steroids.
Presented to us with fever,cough with white frothy sputum ,dyspnea , oedema over hand ,arm . Pleural tapping
was done , it was exudative with ADA 29.cytology negative for malignancy. TLC Venous doppler was done for right
arm suggestive of thrombus in axillary vein and brachilal vein. USG suggestive of multiple LN with
splenomegaly.CECT thorax shows mediastnal widening with right pleural effusion. Supraclavicular LN biopsy
suggestive of monotonous population of lymphoid cells. Biopsy could not be done due to deranged PT INR.
Meanwhile his oedema increased and neck vein engorged,odema on face and periorbital region.he developed
reddish skin papule on face and chest ,biopsy was done suggestive of monotonous population of atypical lymphoid
cell suggestive of SALT. Skin biopsy Block was sent for IHC but unfortunately patient succumbed. ADA are sensitive
and specific for diagnosis TB pleurisy. Incidence of thrombosis is 6.5% with NHL and 4.5% for HL. Incidence of
pleural effusion with NHL is between 6 to 50% and with HL is 7 to 21%.
Result lymphoma presenting with pleural effusion then developing into thrombosis.
Conclusion not every exudative pleural effusion is tubercular.
P80
Kikuchi Fujimoto disease--a case report
P81
Dhamodharan P, Chella Raja C, Chitrakumar.A. Gangadharan V
Govt. Kilpauk Medical College&GTHTM, Chennai, TN , India
Case report: 13 year old female from villupuram district in Tamil Nadu presented with swelling over the left side of
neck -1 month, fever, headache and projectile vomiting - 1 week. On examination she was febrile and anemic.
Examination of cardiovascular and respiratory system were normal. There were multiple, mobile, tender, firm
lymph nodes over left side of neck each measuring 2 x1.5 cms. X ray and CT of chest-Normal. USG abdomen and CT
abdomen-Normal. CT Neck revealed multiple enhancing bulky lymph nodes with central areas of necrosis over
both submandibular, deep cervical, left posterior cervical, left supraclavicular and left retroclavicular areas. MRI
Brain revealed features suggestive of raised ICT. CSF analysis suggested chronic inflammatory pathology. Excision
biopsy of node reported as necrotizing lymphadenitis with immunohistochemistry positive for CD3+, CD43+, CD8+
and CD68+ suggesting Kikuchi. After 6 months she developed node on same side and it was also confirmed as
Kikuchi’s disease by biopsy and immunohistochemistry.
Discussion: Kikuchi-Fujimoto’s disease is a benign self limiting cervical lymphadenitis with fever and other
constitutional symptoms. It should be differentiated from lymphoma, tuberculosis and SLE which presents with
multisystem and multinodal involvement. It was first described in Japan by Dr Kikuchi in 1972 and independently
by Y. Fujimoto. The mean age of was between 20-30 yrs and occurs predominantly in young female due to
nonspecific, hyper immune reaction to a variety of infections, physical, chemical and neoplastic agents.
Confirmation is done by histopathological examination of excision biopsy showing expansion of the paracortex
with phagocytic histiocytes and immunohistochemistry showing positive for CD3, MAC 387, CD68, CD43, CD45RO,
CD8, CD4,CD11b and CD11c. Treatment involves supportive, NSAIDS and corticosteroids. Since then only 23 cases
have been reported and ours is a very rare and interesting case and hence we are presenting it.
P82
IDIOPATHIC CD4 LYMPHOCYTOPENIA
P.ANAND K.RAJARAJAN, S.P.VENGADAKRISHNARAJ, G.ALLWINVIJAY, R.SRIDHAR, O.R.KRISHNARAJASEKHAR,
C.CHANDRASEKAR
STANLEY MEDICAL COLLEGE
Introduction
Idiopathic CD4 lymphocytopenia(ICL) is defined by CDC as a clinical condition in patients with depressed numbers
of circulating CD4 T lymphocytes (<300 cells/Ојl or <20% of total T cells) at a minimum of two separate time points
at least 6 weeks apart, with no laboratory evidence of infection with human HIV-1 or HIV-2, and the absence of any
defined immunodeficiency or therapy associated with depressed levels of CD4 T cells.
Case Report
A 28 Years male admitted with C/o Cough with sputum – 3 months, Breathlessness - 15 days , left sided
chest pain, No other significant positive history. On general examination, he is pallor. With no clubbing, no
generalised lymphadenopathy, Vitals are stable. Respiratory system examination revealed normal vesicular breath
sounds on both sides, with decreased breath sounds on both infrascapular regions.
пЃЅ
Investigations : CBC – Hb - 7 .6 g,WBC- 8,700 / cu mm DC - Neutrophils – 84.4% Lymphocytes –
13.3 % Mixed - 2.3 % . HIV 1& 2 – non reactive ,HBsAg - negative , HCV - negative,Mantoux – 0
mm, Sputum AFB – negative. X-ray revealed bilateral pleural effusion.Pleural Fluid Analysis showed AFB –
Positive .ATT was started.
пЃЅ
Since the patient condition did not improve despite ATT and Since lymphocyte count is very low, CD4
count was done and it came as 186 cells/cu.mm. Patient gradually showed improvement. His CD4 count
after 6 weeks was 205 cells/cu.mm
ICL in an immunocompetent adult is very rare. ICL patients are susceptible for various opportunistic infections.
Cryptococcal infections were the most prevalent infections in ICL patients (26.6%), followed by mycobacterial
infections (17%), candidal infections (16.2%), and VZV infections (13.1%). Because of sustained CD4 T lymphocyte
depletion, the lack of serological evidence of HIV infection, and the absence of any immunodeficiency or
immunosuppresive therapy associated with T cell depletion, our patient met the existing criteria for ICL.
Conclusion
In treating patients with tuberculosis who are slow to respond, complete hematological workup may be necessary
to find out conditions like idiopathic lymphocytopenia.
P83
TITLE:
LONG TERM FOLLOW UP OF A CASE OF PULMONARY ALVEOALAR MICROLITHIASIS (PAM): A CASE REPORT
Author 1:
SHIVALINGASWAMY SALIMATH
rd
3 year Post graduate
Department of Pulmonary Medicine
JSS Medical College Hospital, Mysore
Author 2:
DR. JAYARAJ B S
Professor and Head
Department of Pulmonary medicine
JSS Medical College Hospital, Mysore
Author 3:
DR. MAHESH P A
Professor
Department of Pulmonary medicine
JSS Medical College Hospital, Mysore
INTRODUCTION:
PAM is a rare disease of unknown pathogenesis, characterized by widespread laminated calcospherites in alveolar
spaces. PAM is an autosomal recessive disease caused by mutations of SLC34A2 gene, encoding a sodium
phosphate cotransporter. There is a need for long term progression and survival data in India.
CASE REPORT:
We present an 8 year follow-up of a 52 year old female with pulmonary alveoalar microlithiasis.
Patient presented with exertional dyspnoea and cough in 2006. Chest radiograph had typical “sandstorm
appearance”. HRCT showed diffuse infiltrates and “Black pleura sign”. BAL showed microliths and BAL cytology
showed multiple calcospherites.
COURSE OF DISEASE OVER 8 YEARS:
The progression of various clinical, radiological, spirometric and biochemical parameters are presented.
She underwent BAL 6 times in initial 2 years and clinically improved for 6 years. Last two years showed progressive
deterioration in clinical, spirometric and radiologic parameters with corpulmonale.
FOLLOW UP:
Patient
2006
2008
2010
2012
2014
characteristics:
Dyspnoea
3
1
2
3
3
(MMRC grade)
FVC in litres
(%Pred)
FEV1 in litres
(%Pred)
FEF25-75 in litres
1.93(66)
1.50(59.6)
1.43(62.4)
1.20(50.2)
1.05(46)
1.28(59.6)
0.97(45.3)
0.97(50.2)
0.77(38.2)
0.64(34)
1.03(36.4)
0.57(20.7)
0.58(22.0)
0.42(16)
0.29(12)
(%Pred)
+2
Serum Ca
(mg/dl)
Chest X-Ray
(Zones)
Pulmonary artery
systolic pressure
(mmHg)
9.8
9.0
8.8
9.0
9.5
4
4
5
6
6
15
18
30
48
55
Conclusion:
Further studies are necessary to identify markers for progression and better treatment modalities to delay the
progression of the disease.
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Pulmonary Thromboembolism - A Rare Combo!!!
1
Dr.Javid Abdullah , Prof.Dr.Meenakshi, Dr.Subramanian, Dr.Vishwambhar, Chettinad Health Institute,
Kelambakkam, Chennai.
Background:
Most cases of pulmonary embolism occur as a result of thrombus originating in the lower extremity. Many patients
who develop venous thromboembolism are found to have an inherited risk factor due to abnormal levels of or
functional abnormalities in coagulation factors.
Case Report:
34 year old male presented with sudden onset chest pain and breathlessness, family history negative for PTE and
DVT. Blood investigations revealed elevated D dimer and aPTT. CT Pulmonary angiography revealed a saddle
shaped non enhancing, intraluminal filling defect noted in the bifurcation of main pulmonary artery, extending to
superior and inferior pulmonary artery branches in both sides. Doppler study showed a thrombus in short
saphenous vein. Further workup revealed Antithrombin III deficiency -49.1% (normal- 83-128%), lupus
anticoagulant 1(screen) -93.2 s (normal- 28-48 s), lupus anticoagulant 2 (confirm)-64.6 s (normal 28-40 s). Ratio
(LA1/LA2) - 1.44 (>2 - strong presence, 1.5-2 -moderate presence,1.3-1.5- weak presence, < 1.3 normal).
Homocysteine-22Вµmol/L(normal-3.7-13.9Вµmol/L) Anticardiolipin Ab-negative, protein C & S - normal. Factor V
leiden assay normal. Thereby establishing a diagnosis of pulmonary thromboembolism with multiple etiological
factors
DISCUSSION
Hereditary antithrombin deficiency is estimated to occur in about 1 in 2,000 to 3,000 individuals with PTE. Several
studies have shown a good relation between homocysteinemia and thrombovascular disease. Antiphospholipid
antibodies (APLA) have been reported in 2-5% of the general population. Combination of these 3 etiological
factors has not been commonly reported.
CONCLUSION
Co existence of hyperhomocystinemia, antithrombin deficiency and lupus antibody (APLA) in pulmonary
thromboembolism is a rare entity. This case is reported for its rarity.
P85
MEDIASTIASTINAL MASS PRESENTING AS THYMIC CARCINOID
Dr.AVINASH R GANDHARE, Dr.S.V.GHORPADE Dr.S.H.MESHRAM, Dr.V.NIRANJANE, Dr.G.MISHRA, Dr.P.GHOLAP
GOVERNMENT MEDICAL COLLEGE AND HOSPITAL, NAGPUR
Introduction - Thymic carcinoids are unusual and rare tumors, and prognosis is difficult to predict. We hereby
report a rare case of primary neuroendocrine carcinoma of the thymus which had an aggressive behavior and
patient died within 6 months.
Case Reports- A 45 yrs. old married female farmer was admitted with complaints of breathlessness for 3 months,
multiple joints pain for 3 months, generalized weakness for 3 months and retrosternal chest pain for 1 month. Xray chest showed mass in left hemithorax. Computed tomography scan (CT scan) thorax revealed mass in left
hemithorax which appeared to arise from superior mediastinum. CT scan guided fine needle aspiration cytology
(FNAC) from the mediatinal mass revealed small cell neuroendocrine tumors. CT scan guided biopsy showed
neuroendocrine carcinoma with possibility of thymic carcinoid. Patient was advised surgical excision for which
patient was unwilling. Patient was then started on chemotherapy vincristine, doxorubicin and cyclophosphamide.
Discussion- Neuroendocrine neoplasms of the mediastinum form part of a family of tumors characterized by
genotypic, immunophenotypic and functional properties of neuroendocrine differentiation. Such tumors comprise
lesions derived from; elements within the thymus, paraganglionic nests, misplaced embryonal structures within
the mediastinum and rarely from aorticopulmonary or aorticosympathetic paraganglia or from ectopic or
supernumerary parathyroid glands.
Neuroendocrine Carcinomas of the thymus may be asymptomatic or have signs and symptoms of rapidly growing
mediastinal mass. One third of patients may have endocrine symptoms, Multiple Endocrine Neoplasia (MEN) -type
1 syndrome, polyarthropathy, proximal myopathy, peripheral neuropathy, hyperparathyroidism, inappropriate
antidiuretic hormone secretion, Eaton-Lambert syndrome, and hypertrophic osteoarthropathy. They are not
associated with myasthenia gravis, hypogammaglobulinemia, or the carcinoid syndrome
Conclusion- Primary neuroendocrine tumors of the thymus are rare aggressive tumors associated with poor
survival. Surgical resection of the tumor remains the treatment of choice because the experience with adjuvant
therapy has been unsatisfactory.
P86
AETIOLOGY OF HEMOPTYSIS IN PATIENTS PRESENTING IN DEPARTMENT OF PULMONARY MEDICINE, MEDICAL
COLLEGE HOSPITAL, THIRUVANANTHAPURAM.
Dr Smitha P.S, Dr Anithakumari .K, Dr Ronald Win , Dr Sanjeev Nair
INTRODUCTION
Hemoptysis is defined as coughing up of blood originating from the lungs or tracheobronchial tree. The material
and amount produced varies from mere blood streaking of expectorated sputum to massive volumes of pure blood
.Massive hemoptysis has been variably defined according to the volume ,but Bronchiectasis, pneumonia and
malignancy are the main causes of hemoptysis. The frequency of each disease as a cause of hemoptysis varies in
different series, according to the geographical areas implies a life threatening process requiring immediate
evaluation and treatment.
AIM OF STUDY
To determine the proportion of patients presenting with different aetiologies of hemoptysis in Department of
Pulmonary Medicine in Medical College Hospital, Thiruvananthapuram for a period from February 2013 to august
2014.
MATERIAL AND METHODOLOGY
Study design-Descriptive study.
Study Period-From February 2013 to August 2015.
Assessment include sputum AFB, Sputum Cytology, Chest X-ray, CT chest, Bronchoscopy.
All patients were advised to do sputum AFB and chest X ray, if diagnosis was uncertain
CT chest and bronchoscopy with tissue diagnosis was done .All patients are assessed for one month after discharge
from hospital.
RESULTS AND DISCUSSION
Total 265 cases of hemoptysis were analysed. Till now, analysis had shown Post TB bronchiectasis – 26.79%,
Pneumonia—20.37%, Bronchiectasis—13.58% Malignancy—13.58%, Smearpositive pulmonary TB—9.43%,
Aspergilloma—3.39%, c/c bronchitis --3.37%, ABPA—4%, lung abcess 2% and other causes –3.57%.
Massive hemoptysis was present in 11 patients and main etiology was post TB bronchiectasis.
Bronchial artery embolisation done in 12 patients
Lobectomy was done electively in one patient. There were death of 5 patients while in IP care due to massive
hemoptysis.
Is inhaled budesonide useful in bronchiectasis?
1
P87
2
S K Singaraju , E P Chelluri .
1.
Resident, Post-graduate department of Pulmonary medicine, Shadan Institute of Medical Sciences &
Research Centre, Hyderabad, Andhra Pradesh.
Phone number: +918897565555
Email: drsaiskrishna@yahoo.com
2.
Head, Post-graduate department of Pulmonary medicine, Shadan Institute of Medical Sciences &
Research Centre, Hyderabad, Andhra Pradesh.
Address for the correspondence:ceprasad@hotmail.com
Background. Role of inhaled steroids in bronchiectasis is controversial. None of the previous studies examined
effect of inhaled corticosteroids on post bronchodilator reversibility in bronchiectatic patients. Effect of inhaled
budesonide 400 mcg/day on ventilatory functions of 23 consecutive bronchiectatic patients was studied.
Subjects and Methods: Bronchiectasis was diagnosed by clinical & imaging criteria. Randomized into two groups.
Study group (n=12) inhaled budesonide 400 mcg/day through spacer while Controls (n=11) received placebo
inhaler. Both groups received amoxicillin & physiotherapy. Spirometry was performed at 7-day intervals at the
same hour of the day. FEV1, FVC, PEFR, FEF 25-75% and “salbutamol reversibility” were tested as per ATS
guidelines. Percent change in FEV1, FVC, PEFR, FEF 25-75% and FEV1 reversibility at 0,7,14, and 21 day were
analyzed by Student “t” test.
Results:
Study group
Time
FEV1
FVC
FEV1 “Reversibility”
Day O
1.58+/- 0.67
1.94+/-0.97
8.18+/-7.3
Day 7
1.59+/-0.74
1.94+/-0.80
11.27+/-11.63
Day 14
1.61+/-0.8
2.07+/-0.93
11.79+/-15.48
Day 21
1.66+/-0.76
2.12+/-0.87
6.44+/-4.95
Control group
Day 0
1.28+/-0.48
1.45+/-0.65
5.92+/-8.93
Day 7
1.35+/-0.45
1.63+/-0.65
4.75+/-3.79
Day 14
1.38+/-0.5
1.72+/-0.72
4.82+/-5.90
Day 21
1.48+/-0.46
1.79+/-0.78
3.33+/-5.46
No statistically significant change between study and control groups.
Conclusion:
The present small study, though the results are not statistically
significant, shows a trend of improved
“reversibility” of FEV1 in the budesonide treated bronchiectatic subjects.
P88
Tracheal diverticulum : a rare cause of chronic cough
1
2
3
4
S D GABHALE , S JAIN , N JOSHI , S P AGNIHOTRI
DEPT. OF RESPRATORY DISEASES AND TUBERCULOSIS, INSTITUTE OF RESPIRATORY DISEASES, S.M.S. MEDICAL
COLLEGE, JAIPUR, RAJASTHAN
Introduction :
Tracheal diverticulum is a rarely encountered entity, It is an out pouching of tracheal wall progressing as an air
filled paratracheal cyst. Most cases are asymptomatic, however they can act as a reservoir for secretions with
secondary chronic infections of the tracheobrochial tree. We herein report a case of tracheal diverticula that
presented with chronic cough.
Case report :
A 40 year old female nonsmoker presented with recurrent cough since 1 year. atient had no improvement on
antituberculosis treatment. Chest x-ray revealed left lower lobe consolidation, CT chest revealed left lower lobe
atelectasis. Fiber optic bronchoscopy showed an opening in left posterior wall of trachea, air bubbles and
secretions were coming from opening. Barrium contrast study of the case showed no oesophageal communication.
Diagnosis of tracheal diverticulum was made causing recurrent respiratory infection.
Conclusion :
This malformation is a rare anomaly with two types, the congenital and the acquired one. It must be included into
the differential diagnosis of recurrent respiratory infection.computed tomography scans (with thin section and
reconstructed images) seem the proper imaging. Bronchoscopy can also visualize the diverticulum although
sometimes the connection with trachea can't be detected. Most cases are asymptomatic and need no special
treatment. A possible danger of repeated respiratory infections and insufficient intubation and/or ventilation must
be in mind.
P89
A case of systemic sclerosis with atypical chest presentation
Dr. K.NAGA CHAITANYA , Dr. S.V. PRASAD , Dr. T.V. RAJIV
MNR MEDICAL COLLEGE AND HOSPITAL
BACKGROUND – Systemic sclerosis is a relatively uncommon condition with an average annual incidence of 6-12
patients per million population. The disease is most prevalent between 30 and 50 years of age with female
preponderance(7:1).
Systemic sclerosis is characterized by progressive fibrosis of skin and multiple organs. Parenchymal lung
involvement is very common in these patients , lung fibrosis being the most common pattern of abnormality.
This current case is unique in that a male patient with cavities in the lung is unusual in Systemic sclerosis.
CASE REPORT - A 48-year-old man came to Pulmonary medicine OPD , with the complaints of breathlessness ,
cough , haemoptysis, generalised weakness since 6 months. He was diagnosed earlier as a case of Bronchial
asthma and later as PTB and was started on ATT since 10 days.
On examination, his skin was smooth, shiny, thick, hard and hidebound with pigmentary alteration of 'salt and
pepper' appearance on limbs, and trunk . Hands and fingers appeared tight and digital ischaemia was present
(atrophy, ulceration )
Examination of the respiratory system showed restriction of chest movement and reduced expansibility of chest
wall on right side. Decreased Vesicular breath sounds and Crepitations are present on right side of chest .
After corroborative investigations the positive findings were:TLC 18000cells/mm3. CUE – albumin +. CXR - showed
cavities in right lung . Bronchoscopy – showed mucus plug in right intermediate bronchus. BAL –NAD.CT-CHEST
showed cavities in right UL, consolidation with cavities in right LL . Serology was non-reactive (negative ANA,
Antitopoisomerase antibody, Anticentromere antibody ). Upper GI endoscopy – Sliding hernia, erosive
gastritis.ECG – sinus tachycardia. 2decho – mild PAH.
DISCUSSION Systemic sclerosis is a systemic and complex collagen vascular disease of unknown etiology
The AMERICAN COLLEGE OF RHEUMATOLOGY (ACR) criteria for the diagnosis of systemic sclerosis.
One major criteria / two or more minor criteria for diagnosis.
п‚—
п‚—
Major criterion : Proximal scleroderma
Minor
: 1.Sclerodactyly
2.Digital pitting scars/loss of substance from the finger pad
3.Bibasilar pulmonary fibrosis
Serologic specificity of the disease is the presence of ANA ,directed against cellular nuclear enzymes, like DNA
topoisomerase -1 (anti –Topo 1 ) and RNA polymerase, as well as centromeric proteins (anticentromere Ab) .
Antitopoisomerase antibody is positive in 20-70% of cases.
In this case though the serology was negative as he fulfilled one major and two minor criterias , we diagnosed him
as a case of Systemic sclerosis.
Pulmonary fibrosis is the most common radiographic finding, present in 20%–65% of patients.The histologic
pattern is of usual interstitial pneumonia.
CONCLUSION
It is an unusual presentation because of its rare occurrence in male and presentation as cavities in lung. This case
highlights the wide variety of presentations in connective tissue disorders and importance of thorough
investigation in connective tissue diseases
P90
A rare case of haemoptysis with Pulmonary artery thrombosis
Dr Subash Immanuel G , , Dr Richa Gupta, Dr D J Christopher
Christian Medical College, Vellore, Tamil Nadu, India
Hughes Stovin syndrome (HSS) is a rare and life threatening disorder characterized by pulmonary artery aneurysm
(PAA) and thrombosis. So far, less than 30 cases have been reported in literature.
We report a case of Hughes Stovin syndrome presented with haemoptysis, pulmonary artery aneurysm and
thrombosis.
A 19 year old male presented with complaints of cough, dyspnoea with intermittent haemoptysis of 4 months
duration. His general and systemic examination was unremarkable. His routine blood examination was normal.
Connective tissue disease, vasculitis work up and sputum AFB smear were negative. Radiology revealed normal
chest x-ray; however, CT pulmonary angiogram (CTPA) showed pulmonary artery aneurysm with intra mural
thrombus in bilateral lobar and segmental pulmonary arteries.
With above investigations, differential diagnosis of Behcet’s disease and Hughes Stovin syndrome were
considered. Our patient had no complaints of oral or genital ulcers and Pathergy test was negative. His
ophthalmology examination was normal and HLA B51 was negative which ruled out the possibility of Behcets
disease. He was diagnosed to have Hughes Stovin syndrome and improved on treatment with Immunosuppressant
and corticosteroids.
Hughes Stovin syndrome was first described in 1959 as a combination of deep venous thrombosis, cerebral venous
sinus thrombosis and PAA . It is considered to be a variant of Behcets disease. Diagnosis is made on the basis of
clinical history and imaging studies for detection of PAA. Initial management of HSS involves corticosteroids and
immunosuppressive drugs. Anti-coagulants are contraindicated due to risk of life threatening rupture of aneurysm.
Surgical resections may be the option in patients with localised aneurysm.
We conclude that in young patients with haemoptysis and normal initial work up, CTPA and Doppler studies should
be considered to look for rarer causes like HSS which if left undiagnosed can be potentially life threatening due to
aneurysmal rupture.
Aortic aneurysm – a rare cause of ortner’s syndrome
P91
DR. JYOTI PATNAIK, DR. H.K.SETHY, DR. T. MOHANTY,
PRADHAN, DR. B.P.TRILOCHAN, Dr. BIJAYA KUMAR MEHER
DR. G.PANDA, DR.M.R.DASH, DR. S.
Department of pulmonary medicine, scb medical college & hospital,cuttack, Odisha,India
OBJECTIVE: To study the cause of hoarseness of voice in a 60yr old male
METHODS: detailed history, physical examination, routine blood test, chest x-ray, bronchoscopy, HRCT Thorax,
echocardiography, CT-angiography
RESULTS: A 60yr old man presented with hoarseness of voice and was found to have left vocal cord paralysis and a
medistinal widening on chest X-ray. Fibre optic laryngoscopy & bronchoscopy showed absent movement of left
vocal cord. A HRCT scan of thorax and CT Angio Aortogram revealed fusiform aneurysmal dilatation of the arch of
aorta possibly compressing left recurrent laryngeal nerve.
ortner’s syndrome or cardio-vocal syndrome
CONCLUSIONS: Hoarseness of voice is a very common condition and
underlying causes vary from reversible benign causes to life-threatening malignancies. Unilateral recurrent
laryngeal nerve injury is most commonly caused by surgical trauma or a malignant tumor. Ortner’s syndrome is a
rare disorder characterised by left recurrent laryngeal nerve palsy secondary to a cardiovascular cause. Cardiovocal
syndrome was originally described in 1897 by Nobert Ortner in three patients with severe MS. He explained that
hoarseness was caused by compression of the left recurrent laryngeal nerve by the enlarged left atrium. Later it
has been encountered with other mediastinal structures causing mass effect and in many cardiac conditions for
example, congenital heart diseases, mitral valve disorders, ventricular and aortic aneurysms, atrial enlargement
and in iatrogenic conditions. Chest radiograph is usually ordered as the first imaging study which can give hints of
the underlying condition and direct further studies. CT is useful for evaluating the mediastinum and especially the
aortopulmonary region.
P92
Title: Tracheobronchopathia osteochondroplastica (TO) – only case series from India
Dr. Jebin Roger S, Dr. Prince James, Dr. Richa Gupta, Dr. D.J Christopher
Christian Medical College, Vellore
Introduction: Tracheobronchopathia osteochondroplastica (TO) is a rare benign disease of unknown etiology
characterized by cartilaginous or bony outgrowths in the tracheobronchial tree. We present first and largest case
series of 8 cases of TO from India.
Case Presentation: Out of 13,700 bronchoscopies done from year 2004 to 2014 at Christian Medical College ,
Vellore , India, we diagnosed 8 cases of TO. Male to Female ratio was 6:2 with a mean age of 48 years (range 2958 years) at the time of diagnosis. The most common symptoms were cough (100%), dyspnea (50%) and
hemoptysis (43%). CT thorax showed multiple beaded calcified nodules in the tracheobronchial tree in 7 cases.
Bronchoscopy showed diagnostic typical appearance of multiple irregular hard nodules in trachea, sparing the
posterior membranous wall. In 6 cases, bilateral main bronchi were also studded with TO nodules. Bronchoscopic
biopsy of these nodules gives hard gritty feeling of cutting hard structure. Bronchoscopic biopsies showed
calcifications, cartilage and lamellar bone formation in respiratory mucosa. In one patient, TO presented as right
upper lobe endobronchial growth, for which she underwent right upper lobectomy. Out of 8 cases, one patient
also had active TB and received ATT. The rest of the patients were put on symptomatic treatment.
Discussion: Bronchoscopy remains the gold standard for identifying TO with typical findings of multiple irregular
nodules in tracheobronchial tree, sparing the posterior wall of trachea. Though the course of disease remains
benign, some cases may present with airway obstruction, post-obstructive pneumonia, atelectasis, and difficult
intubation. The treatment of TO varies from symptomatic management, endobronchial treatments to operative
debulking surgeries depending on the severity of airway obstruction.
Conclusion: TO is a rare benign disease and Bronchoscopy is the most important tool to detect TO. Awareness of
the condition among physicians is important to identify this rare disorder of the tracheobronchial tree.
P93
Bilateral Congenital Cystic Adenomatoid Malformation with Tuberculosis in an adolescent: a rare presentation
DR. J. PATNAIK, DR. H.K. SETHY, DR. T. MOHANTY, DR. G. PANDA, DR. M.R. DASH, DR. S. PRADHAN, DR. BP
TRILOCHAN, DR. DIBYA PRAKASH ACHARYA
Dept. of Pulmonary Medicine, SCB Medical College, Cuttack, Odisha.
Introduction
Congenital cystic adenomatoid malformation (CCAM) of the lung is a rare developmental anomaly of tracheobronchial tree beyond terminal bronchioles. Incidence 1 in 25,000в€ј30,000 pregnancies. The lesion is usually
unilateral. Most cases are diagnosed antenatally or in neonates/infants who present with severe respiratory
distress or pulmonary infections. Occasionally, CCAM remains unrecognized until adolescence or adulthood.
Recurrent bacterial infections are frequent feature of CCAM.
Case Summary
A 14 year old female presented with the complains of Fever for 4months low grade, intermittent, with evening rise
of temperature, not a/w chills, rigor. Cough for 4months with scanty mucoid expectoration. Chest examination
revealed diminished breath sounds at left anterior chest. Sputum for AFB- negative. Chest x ray showed nonhomogenous opacity over left hemithorax. Patient was started on Anti Tubercular Therapy CAT I DOTS. She
improved with ATT. CXR PA View showed multiple cystic lesions; opacities in the previous radiograph had cleared.
HRCT Thorax :Left Lung showed multiple large cystic lesions, largest of size 14.4 * 6.6 cm Type I CCAM .Right Lung
showed multiple small cystic lesions largest size 1.2* 1 cm Type2 CCAM.A diagnosis of bilateral CCAM in
adolescent secondarily infected with Tuberculosis was hence made.
Discussion
CCAM is an abnormality characterised by a hamartomatous multicystic mass of pulmonary tissue with an abnormal
proliferation of bronchial structures.Type I CCAM most common includes multiple large cysts (>2 cm in diameter)
Type II CCAM has multiple small cysts, less than 2 cm in diameter.Type III CCAMs are a solid mass consisting
multiple adenomatoid microcysts, less than 0.5 cm in diameter. Radiograph: Multiple air filled cysts Diagnostic
method of choice is the HRCT. Lobectomy is the treatment of choice.
Unusual bilateral involvement Left Lung Type1 Right Lung type2 CCAM and Tubercular superadded infection in
adolescent makes it a rare presentation.
Spontaneous esophagopleural fistula:a rare case report
P94
DR J.PATNAIK,DR HK SETHY,DR T.MOHANTY,DR G PANDA,DR MR DASH,DR S.PRADHAN,DR BP TRILOCHAN
DR JYOTIRMAYA SAHOO.
Dept of Pulmonary medicine,SCB Medical college and hospital ,cuttack,Odisha.
INTRODUCTION:-Esophagorespiratory fistula (ERF) is an uncommon condition despite the anatomical proximity of
these structures.Malignany of esophagus,lung and mediastinum is recognized as the most common cause.Benign
ERF is very rare and may be due to trauma and infections.Here we report a rare case of spontaneous
esophagopleural fistula.
CASE REPORT:-A 34 year old male was admitted to scb medical college,cuttack,odisha complaining of right side
chest discomfort and regurgitation of food particles during feeding.He has known psychiatric(bipolar ) disorder
since last 7years on antipsychotic medications.He had no smoking history.No previous operative history.No
medical history like diabetes mellitus,hypertension,tuberculosis or hepatitis.On physical examination diminished
breath sound in right IAA,ISA and lower inter scapular area.Dull note on same area.Rest of the right hemithorax is
normal resonant note and normal breath sound.All routine investigations are WNL.Chest x ray revealed a
homogenous opacity with straight upper boarder in right lower zone.Diagnostic tap was dry.On usg thorax there
was minimal collection in right pleural space.On CT Thorax there was a suspicious connection between esophagus
and pleural space.On oral contrast administration the contrast moved to pleural space.On barium swallow study
barium passed into pleural space.On upper GI endoscopy there was fistulous opening in esophagus that connects
to right pleural space.So final diagnosis is Spontaneous esophagopleural fistula.Finally patient was operated
(closure of EPF and reconstruction of esophagus ) and patient is doing well now.
Tissue biopsy was taken and it was nontubercular.
DISCUSSION:-Spontaneous
esophagopleural fistula is a very rare condition.Spontaneous rupture of esophagus occurs due to sudden raise of
itraesophageal pressure .usual complains of patients are retrosternal chest pain and vomiting.On chest x ray
reveals as pleural effusion,hydropneumothorax or pneumothorax.CT thorax helps to find any mediastinal
involvement.Conservative management with ICT drainage of pleural space and finally definite surgery required.
P95
A RARE CASE OF LEFT UPPER LOBE LESION
AUTHORS – DR SANJEEV MEHTA, DR SWAPNIL THORVE, DR ANURATI MEHTA, DR KARISHMA BHATIA
CASE: 28 YEAR ASYMPTOMATIC FEMALE REFERRED FOR LEFT ZONE OPACITY PERSISTENT SINCE 5 YEARS.
INVESTIGATIONS: HRCT CHEST REVEALED LARGE, WELL ENCAPSULTED, LEFT UPPER LOBE MASS 7.1 x 4.5 CM WITH
ECTOPIC CALCIFICATION, INDENTING THE TRACHEA AND SUPERIOR MEDIATINAL STRUCTURES WITHOUT
INFILTRATING THEM. FNAC REVEALED LYMPHOID CELLLS. CT GUIDED BIOPSY REVELAED CASTELMAN’S DISEASE.
TREATMENT: COMPLETE SURGICAL EXCISION OF THE MASS. UNEVENTFUL RECOVERY. SURGICAL SPECIMEN
CONFIRMED THE DIAGNOSIS.
DISCUSSION: CASTLEMAN’S DISEASE OR ANGIOFOLLICULAR LYMPH NODE HYPERPLASIA IS A RARE DISORDER
CHARACTERISED BY BENIGN PROLIFERATION OF LYMPHOID TISSUE (CERTAIN B CELLS).
WHILE NOT OFFICIALLY A CANCER, OVERGROWTH OF LYMPOID CELLS RESEMBLES A LYMPHOMA. TWO CLINICAL
ENTITIES HAVE BEEN DESCRIBED, UNICENTRIC (CONFINED TO A SINGLE LYMPH NODE STATION) OR MULTICENTRIC
(GENERALISED, WITH MORE AGGRESSIVE CLINICAL COURSE, USUALLY WITH HIV INFECTION). FOUR
HISTOPATHOLOGICAL SUBTYPES HAVE BEEN DESCRIBED, HYALINE-VASCULAR, PLASMA CELL, PLAMABLASTIC AND
MIXED. PREOP DIAGNOSIS IS DIFFICULT AND FINAL SUBTYING IS USUALY ON THE POST OP SPECIMEN.
WHILE RADIATION, STEROIDS, ANTIVIRAL DRUGS, CHEMOTHERAPY AND IMMUNOTHERAPY ARE TREATMENT
OPTIONS, THE BEST CURE, IN UNICENTIRIC DISEASE, IS COMPLETE SURGICAL EXCISION.
OUR CASE IS IMPORTANT AS IT HIGHLIGHTS A RARE CONDITION THAT IS OFTEN MISSED OR CONFUSED WITH TB
OR LYPHOMA. HIGH INDEX OF SUSPICION AND AGGRESSIVE APPROACH TO MANAGEMENT IS NEEDED.
P96
Title: The oxidative stress determined through the levels of antioxidant enzymes and the effect of N-acetylcysteine
in aluminium phosphide poisoning.
MANISH GUTCH, AVINASH AGARWAL, ROTO ROBO, NIRDESH JAIN
Department of Internal medicine, King George’s medical university, Lucknow, India
ABSTRACT
Objectives: The primary objective of this study to determine the serum level of antioxidant enzymes and to
correlate them with outcome in patients of aluminium phosphide (ALP) poisoning and secondly, to evaluate the
effect of N-acetylcysteine (NAC) given along with supportive treatment of ALP poisoning.
Design: We conducted a cohort study in patients of ALP poisoning hospitalized at tertiary care center of NorthIndia. The treatment group and control group were enrolled during the study period of one year from May 2011 to
April 2012.
Interventions: The oxidative stress was evaluated in each subject by estimating the serum levels of the enzymes
viz. Catalase, superoxide dismutase (SOD) and Glutathione reductase (GR). The treatment group comprised of the
patients who were given NAC in addition to supportive treatment (magnesium sulphate and vasopressors, if
required), while in control group only supportive treatment was instituted. Primary end point of the study was the
survival of the patients.
Measurements and Results: The baseline catalase and SOD were reduced, however GR level was not reduced
rather was increasing with due time, and more so in treatment group. The baseline catalase (p =0.008) and SOD (p
<0.01) levels were higher among survivors than to Non-survivors. But, no association of outcome with baseline GR
levels (p =0.064), but the levels on day 1 was associated with outcome (p =0.017).Out of total, 31(67.4%) expired
and 15(32.6%) survived. Survival rate was 45.8% (11/24) in treatment group and 18.2% (4/22) in controls (p
=0.045). Among who expired, the mean duration of survival was 2.92В±0.40 days in test group and 1.82В±0.33 days
in control (p=.043).
Conclusions: This study suggests that the baseline level of catalase and SOD have reduced in ALP poisoning, but
baseline GR level has not suppressed, rather is increasing with due time, and more so in treatment group. NAC
along with supportive treatment has improved survival in ALP poisoning
P97
Pulmonary arteriovenous malformations with recurrent stroke late diagnosed but well managed!!!
N.D.Gondaliya, R.M.Kshatriya, N.V.Khara, R.P.Paliwal, S.N.Patel.
Dept of Respiratory Medicine, Pramukhswami Medical College, Karamsad 388325,Gujarat.
Introduction: PAVMs is an abnormal communication between the pulmonary artery and vein being congenital in
origin; it may be acquired in several conditions. Approximately 70% cases of PAVMs are associated with Hereditary
Hemorrhagic Telangiectasia(HHT). Presenting symptoms include dyspnea, easy fatiguability and rarely hemoptysis.
Approximately 4% to 12% develop complications like paradoxical embolism and stroke. Contrast enhanced
pulmonary angiography (CTPA) is the gold standard test. Treatment of choice is therapeutic embolization and lung
surgery. We report a case here as was managed as chronic obstructive pulmonary disease (COPD) for 5 years and
later diagnosed as PAVMs with stroke.
Case report: A 62 year female patient presented with exertional dyspnea and easy fatiguability for 5 years which
exacerbated since 10 days with inability to speak since 2 days. On examination cyanosis,clubbing and crepitations
were present over right lung. Neurological examination revealed Opercular syndrome (Trigemino-lingio-faciobuccal apraxia). She was on treatment for COPD for 5 years and had cerebrovascular stroke(Left frontal lobe) 3
years back. On investigatigating blood report showed hypoxemia and polycythemia. Where as chest X-ray showed
right lower zone opacity with CTPA showing complex pulmonary arterio-venous malformations in the right middle,
lower and left upper lobe largest being 12.1 mm. CT scan of brain suggested acute infarct in right temporal lobe.
Contrast echocardiography showed 'extracardiac right to left shunt'. Finally she was diagnosed as PAVMs with
paradoxical brain embolism. Angioembolization was done and anticoagulant therapy started with supportive
treatment and patient is better now.
Conclusion: Uncommon disorder like PAVMs can be misdiagnosed and managed as chronic obstructive
pulmoanary disease. So it is worth to investigate in detail in patients with unexplained hypoxia, cyanosis, clubbing
and recuurent stroke. For earlier diagnosis of PAVMs and better outcome, emphasis should be placed on a
multidisciplinary approach and inclusion in differential diagnosis.
P98
Prospective Study around Etiology of Mediastinal Lymphadenopathy using TBNA in a tertiary care center
A. Prabhu, R. Chawla
Indraprastha Apollo Hospital, New Delhi, India
Objectives:To find diagnostic yield in various etiology of mediastinal lymphadenopathy in a tertiary care center
Method:Following a meticulous,clinical and radiological assessment, bronchoscopic TBNA was performed in all
patients. Other procedures performed were Bronchial Biopsy and BAL.
Result:The most common etiology found in our study was Tuberculosis in 43 patients (41%) followed by
Granulomatous Inflammation, mostly Sarcoid, in 31 patients (29.5%). Lowest prevalence was for Lymphoma (found
in 1 patients only) – 1%. There were 7 (6.7%) cases of Malignancy and Fungal in 8 patients (7.6%). Our study could
not find the final diagnosis in 15 patients (14.3%) due to lack of conclusive evidence.
A sufficient specimen was obtained in 87 out of 105 patients and TBNA could establish a diagnosis in these cases.
Overall yield of TBNA was 82.86% and the diagnostic yield of TBNA was 68.57%. Coming to specific yields, highest
came from malignancy and lymphoma (100%) and lowest yield came from necrotizing/AFB (Tubercular etiology)
[58.1%]. Granulomatous Inflammation (Sarcoid) diagnosed patients gave a yield of 64.5% while patients diagnosed
with Fungal during TBNA gave a yield of 87.5%.
Conclusion: We recommend that TBNA is a reliable, safe and relatively cheap investigational method with good
diagnostic accuracy. Especially for endobronchial lesions, it may obviate the need for more invasive surgical
procedures. We also learnt multiple sampling of nodes, rapid onsite cytology method and optimizing interactions
at every step may prove to be most cost effective measures. EBUS TBNA is not very practical owing to high cost
especially in developing country like India. So the novel approach to be recommended is to first perform
conventional TBNA and refer only inconclusive cases for EBUS procedure.
P99
Effect of oral Zileuton in acute asthma – a prospective, randomized, double blinded study.
Shahul Hameed ABOOBACKAR, Rahul MAGAZINE, Bharti CHOGTU
Kasturba medical college, Manipal, Karnataka, India
Objective: 5- Lipoxygenase inhibitors are well established in the management of chronic asthma. However, very
little is known about their role in acute asthma. Our objective was to study the efficacy of oral Zileuton in acute
asthma.
Methods: We conducted a prospective, randomized, double blinded study whereby 80 patients aged 18 to 65
attending the outpatient department or emergency department under Pulmonary Medicine unit of Kasturba
Medical College, Manipal with a primary diagnosis of acute asthma were admitted and randomly assigned to
receive either 600 mg of oral Zileuton or placebo at enrolment and again after 12 hours, with twice daily
administration thereafter in addition to the standard therapy for acute asthma. The peak expiratory flow (PEF) was
measured at baseline, at 6 hours, 12 hours, 24 hours and 48 hours following administration of the study drug and
then at discharge. Additionally, PEF was measured between 8 – 10 am during the morning following admission.
The primary endpoint was the difference in PEF between the Zileuton and placebo groups at the various time
points following treatment. The secondary endpoint was the need for rescue medications by patients in each
group.
Results: Data of all 80 enrolled patients were analysed at the end of the study. It was found that patients receiving
Zileuton had significantly higher PEF values than patients receiving placebo (p = 0.007). The higher PEF values were
sustained over the entire hospital stay. Moreover, the need for rescue medications in the Zileuton group were
significantly lesser (p = 0.049) in comparison with the placebo group. No adverse effects were reported during the
study.
Conclusion: Additional administration of Zileuton results in greater improvement in lung functions in acute asthma
than that attained by current standard treatment.
P100
Asymptomatic Achalasia cardia presenting with bilateral bronchiectasis
Shahul Hameed ABOOBACKAR, Aswini Kumar MOHAPATRA, Manu Mohan K
Kasturba medical college, Manipal, Karnataka, India
Introduction: Achalasia is a disorder of oesophageal motility characterised by aperistalsis of oesophageal body, and
impaired relaxation of lower oesophageal sphincter. Most cases of Achalasia are symptomatic and usually present
with dysphagia, nasal regurgitations and heart burns. The oesophageal dysmotility can predispose to repeated
aspirations, resulting in recurrent pneumonias and bronchiectasis. We present a case of asymptomatic achalasia
cardia which presented initially as a pulmonary complication. Asymptomatic achalasia presenting with bilateral
bronchiectasis is extremely rare.
History and physical examination: A 25-year-old female, presented with chronic expectorative cough and
exertional shortness of breath since 10 years with recent aggravation. She had undergone multiple hospital
admissions for recurrent pneumonias in the past. There was no past history of pulmonary tuberculosis. General
physical examination was normal. Respiratory system examination revealed bilateral diffuse coarse crepitations.
Examination of other systems did not reveal any abnormality.
Investigations: Routine blood investigations were normal. Chest radiograph showed bilateral bronchiectatic
changes, predominantly over the right mid-zone and left lower zone. Sputum Ziehl-Neelsen staining for acid fast
bacilli was negative. High resolution computerised tomography (HRCT) of thorax revealed cystic bronchiectasis
involving right upper lobe and middle lobe segments, left lingular segments and anterior medial basal segment of
left lower lobe, along with dilatation of the entire extent of esophagus and smooth narrowing at gastroesophageal
junction. Upper gastrointestinal endoscopy showed inflammatory changes with minimal ulcerations along the
lower esophagus. Barium swallow study showed dilated thoracic oesophagus with narrowed gastroesophageal
junction. Oesophageal manometry showed high pressure at the level of lower oesophageal sphincter and
confirmed aperistalsis along the lower esophagus.
Management and outcome: She was offered surgical management (Heller’s myotomy), but she declined and her
symptoms persisted on follow up.
P102
Title : INSULINOMA PRESENTING AS ADULT-ONSET SEIZURE DISORDER
Name: Dr VENKATESH MALALI , Dr SHIVKUMAR B.G , Dr SHASHIKANTH M
Institution: JJM MEDICAL COLLEGE, DAVANGERE.
INTRODUCTION: Once diagnosed with a refractory seizure disorder, patients often receive aggressive and
escalating pharmacotherapy. Toxic and metabolic causes of seizures should always be considered as they are
potentially curable, and may be fatal if untreated .We describe a case of insulinoma who presented with recurrent
seizures.
METHOD: A 62 year old female presented to ED with H/o of generalised tonic clonic seizures. She was a known
epileptic since one year on multiple anticonvulsants.
On enquiry she gave H/o dizziness and excessive sweating prior to each seizure episodes and was mainly in
morning and before meals. Patient claims feeling better after meals. No significant past medical and family history
and denied addiction.
O/E -Patient was well built, drowsy, PR=80/min, BP=130/80 mm Hg, bilateral pupil 3-4 mm equally reactive to light.
Systemic examination was normal except drowsiness with no focal neurodeficits. Brain imaging and EEG including
routine hematological investigations were normal except RBS-38mg/dl. She was started on dextrose infusion and
anticonvulsant. During hospital stay she developed repeated hypoglycemia and seizure episodes. So she was
further investigated and evaluated for cause of hypoglycemia.
Investigations revealed FBS-30 mg/dl, S.insulin-6.96 uU/ml (normal < 6 uU/mL). Serum C-peptide-2.2ng/ml(normal
< 2 ng/mL),HbAlc-<4.CECT Abdomen was done suggestive of 1.5 cm enhancing mass at head-neck junction of
pancreas. So working diagnosis of pancreatic insulinoma with hypoglycaemic seizures was made. She underwent
enucleation of the nodule at higher centre and became asymptomatic. Histopathology revealed well differentiated
neuroendocrine tumour.
CONCLUSION: A high index of suspicion for a rare cause like insulinoma is warranted for non diabetic patients
presenting with intractable seizures with hypoglycemia not responding to anticonvulsant treatment, which is
amenable to complete cure.
P103
Unilateral hyperlucent lung: Common and uncommon causes presenting in the department of
pulmonary medicine at GMC, Patiala, from january 2014 till date .
VIDHU MITTAL , URVINDERPAL SINGH, ADITI, SUNIL KUMAR, MURLI
Department of Pulmonary Medicine, Govt. Medical College, Patiala,Punjab, India
Abstract:
Unilateral hyperlucency is described as darker appearance at one side due to increased X-ray
transmission. This radiologic appearance may be due to technical impropriety, chest wall abnormalities and
increased air volume and decreased pulmonary vascularization on that side. In diagnostic approach to
unilateral hyperlucency, soft tissues, lung volumes, air trapping existence, pulmonary vessels sizes and lung
hilum should be carefully evaluated.
Objectives:
1. To recognize a unilateral hyperlucent lung on chest radiography and computed tomography (CT).
2. To describe the common causes of a unilateral hyperlucent lung on chest radiography and CT and to
understand the pathophysiology of certain conditions.
3. To list an appropriate differential diagnosis in case of a unilateral hyperlucent lung and to provide a
targeted diagnosis when certain associated radiological signs are seen.
P104
DIAGNOSIS BY TRANSTHORACIC PERCUTANEOUS FNAC IN PERIPHERAL LUNG LESIONS.
Dr.Keyur Patel, Dr.Nasim Mondal, Dr. Savita Jindal, Dr. Nalin T. Shah,
Dr. Kusum V.Shah
Department of Pulmonary Medicine, BJMC, Ahmedabad, Gujarat- India.
INTRODUCTION:
Lung cancer is most commonly diagnosed cancer world wide Transthoracic Percutaneous FNAC of lung is rapid and
safe diagnostic tool.
AIM:
To Assess a role of Transthoracic Percutaneous FNAC and to determine the sensitivity and specificity of FNAC with
USG and CT guided aids in peripheral lung mass.
METHODS AND MATERIALS:
A study of 50 patients, conducted in Aug 2013 – Aug. 2014 in age group of 30-90 years in both the sex. The samples
were taken by the pathologist with the radiologist. At first, ultrasound was used. If lesion well visualized,
aspiration performed otherwise CT was chosen for image guidance.
RESULTS:
The FNAC were positive for malignancy in 27 (54%) cases, hemorrhagic aspiration 10(20%) cases, Suspicious of
malignancy in 6 (12%) cases, inflammatory infiltrate in 3 (6%) cases, inadequate aspirate in 3 (6%) cases,
granulomatous lesion in 1 (2%) cases. Most common malignancy was Adenocarcinoma (44.44%) followed by
squamous cell carcinoma (15%), Non-small cell carcinoma (15%), carcinoma (4%), small cell carcinoma (4%) Non
Hodkin’s Lymphoma (4%) and poorly differentiated 15% . Prevalence, sensitivity, specificity, positive predicted
value. Negative predicted value, and Accuracy observed 80%, 82.5%, 100%, 100%, 58.82% and 86% respectively.
The details of results will be discussed in study.
CONCLUSION:
Transthoracic FNAC for peripheral lung lesions is a safe and efficient method for cytological diagnosis. It has high
Sensitivity Specificity, Positive Predicted Value and Negative Predicted Value.
P105
Erasmus syndrome associated with broncholithiasis, bronchoesophageal fistula and active pulmonary
tuberculosis: A rare case report
Paulo Varghese Akkara, George Albert D’souza, Priya Ramachandran, Uma Devraj,
Department of Pulmonary Medicine, St Johns medical college
Background: Erasmus syndrome describes the association of generalised progressive systemic sclerosis following
exposure to silica with or without silicosis. Silicosis and progressive systemic sclerosis coexisting in the same
patient were published from western and Indian literature. We are reporting a case of 38-year-old female quarry
worker who developed silicosis and systemic sclerosis complicated by broncholithiasis, bronchoesophageal fistula
and active pulmonary tuberculosis. To our best of knowledge, this is the first case report of coexistence of Erasmus
syndrome with broncholithiasis, bronchoesophageal fistula and active pulmonary tuberculosis
Case Report: A 38-years-old female, quarry worker presented with history of fever, cough, and breathlessness of 3
months duration. All her symptoms worsened in the last 2 weeks and developed cough on swallowing.
Examination findings revealed thickening of skin and microstomia suggestive of scleroderma. Signs s/o right sided
lung fibrosis was also present. Her sputum was positive for acid fast bacilli (AFB). RA factor was negative and ANA
was positive. Skin biopsy consistent with scleroderma. CECT showed multiple calcific lymph nodes with fibrotic
changes, centrilobular nodules with tree in bud pattern along with reticular opacities consistent with ILD.
Bronchoscopy showed distorted bronchial anatomy and multiple broncholiths and fistulous opening. Barium study
showed the presence of bronchoesophageal fistulas. The patient was started on anti-tubercular therapy along with
management of scleroderma and oral feeds through nasogastric tube as patient refused any further invasive
management.
Conclusion: This is the first case report of coexistence of Erasmus syndrome with broncholithiasis,
bronchoesophageal fistula and active pulmonary tuberculosis
P106
TITLE- To Assess the Knowledge of RNTCP in Post Graduate Students
AUTHOR(S) –Dr Aparna Iyer, Dr Bhumika Madhav , Dr Girija Nair, Dr Abhay Uppe, Dr Jayalakshmi T.K, Dr Lavina
Mirchandani, Dr Mugdha Bhide
INSTITUTION-Dr D.Y.Patil Hospital and Research Centre, Sector 5 , Nerul, Navi Mumbai - 400706. Maharashtra .
Background-Causes of MDR/XDR Tuberculosis are improper regimen, inadequate treatment and Default. RNTCP
has protocol on evidence based regimens which intend to cope with these difficulties and ensure proper
management.Awareness regarding the need for doctor to imply the RNTCP protocol needs to be ensured for
success of the programme. PG students are the future of a country's medical care system; hence awareness should
be created at an early stage.
Aim- Evaluation of sensitisation and awareness regarding RNTCP protocol among PG students.
Method-PG students who attended the RNTCP sensitisation programme were subjected to a set of questionnaire
to assess their knowledge.
Result-Following were the most common answers.
Awareness in Students
Percentage
Aware of RNTCP
100%
Source- Study Course/Sensitisation /Television
60%/30%/10%
advertisement
RNTCP Categories
50%
Category III was scraped off
36%
Category IV/V existed
40%
Category1 Regimen
70%
Category2 Regimen
46%
Definition of MDR Tuberculosis
66%
Definition of XDR Tuberculosis
46%
Diagnosis of MDR Tuberculosis
55%
Diagnosis of XDR Tuberculosis
46%
Persistent cough> 2 weeks for AFB examination
26%
HIV- TB National Programme
16%
Dots Principle:-Common Answer-Early Detection, Prevents Relapse, Free of Cost
Rare Answer-Ensures compliance
HIV-TB Co infection- Common Answer- Anti Koch Treatment should be started 2 weeks prior to antiretroviral
Treatment
Awareness Score Card –100% students said they benefited from the sensitization programme.
Conclusion- Regular Intradepartmental RNTCP sensitisation programme will create better awareness among PG
students about the RNTCP protocols, hence reducing the rate of MDR / XDR tuberculosis.
P107
Clinical Audit of a Community Respiratory Centre in Bangladesh
Kamrun Nahar, GM Monsur HABIB,
President, Primary Care Respiratory Group, Khulna, Bangladesh
A clear shifting of respiratory diseases from communicable to non-communicable (NCD) sector is observed during
last decade in the developing countries of South East Asia. Asthma, COPD, Allergic Rhinitis, Bronchiectasis etc are
imposing huge burden on primary care health service in Bangladesh where these respiratory NCDs are well
managed. Aim of this study is to examine the power of primary care respiratory service by analyzing a clinical audit
of a CRC in Bangladesh.
Method: We have selected one of the 15 CRCs in the southern part of Bangladesh under the GARD-WHO
recognized project “Better Breathing Bangladesh”. We analyzed clinical audit report of CRC to examine the power
of service for improvement of respiratory NCDs. Study period was from 19 September 2013 to 19 September 2014.
Result: A total of 4366 patient was registered and all the medical records were saved in software “Doctors Guide”
in the CRC. The distribution of disease was: Asthma 2736, Allergic Rhinitis 263, High probability of Asthma 335
(symptom based diagnosis, not confirmed reversible airway obstruction due to age i.e. under-7 children), transient
BHR 108, UACS 45, COPD 499, bronchiectasis 17, Chronic Bronchitis 13 and others 350. Co-morbidities are also
recorded in the audit among them, GERD, AR, ACOS, Pregnancy, Rheumatoid Arthritis, visual, hearing and cognitive
impairment are also recorded to set up the target of care for the coming year in the centre.
Conclusion: Respiratory NCDs are common in South East Asia and its care need to invest all the efforts to primary
care rather than secondary or tertiary care health service. Primary care respiratory services should be updated and
empowered for the better service through continuous clinical audit and developing appropriate Clinical Practice
Guidelines (CPG).
P108
RARE CASE OF ALVEOLAR MICROLITHIASIS
R A S KUSHWAHA, RAJIV GARG, SANTOSH KUMAR, S K VERMA, ASHWINI KUMAR MISHRA, NEHA KAPOOR.
Pulmonary alveolar microlithiasis (PAM) is an uncommon chronic disease characterized by calcifications within
the alveoli and a paucity of symptoms in contrast to the imaging findings. It occurs sporadically and it is
regarded as an autosomal recessive lung disease. A 21 years old male, Non Smoker, presented to us with chief
complaints of non progressive exertional breathlesness since childhood. He had no other significant history and
no abnormality was detected on physical examination. Chest X Ray PA view showed bilateral diffuse nodular
shadows more on lower lung fields. Spirometry was suggestive of restrictive lung disease. CT Thorax showed
bilateral multiple fine nodular lesions with basal predominance, intra and interlobular septal thickening in both
lung fields. Foci of calcification noted in both lung fields, pericardium and mediastinal pleura. There was clinicoradiological dissociation as the patient was quite asymptomatic despite significant radiological findings. A
HRUSG of the scrotum was done which revealed calcification of the testes. Hence,a provisional diagnosis of
pulmonary alveolar microlithiasis was made. Pulmonary alveolar microlithiasis (PAM) is a rare disease of
unknown etiology characterized by the widespread intra-alveolar deposition of laminated calcispherites in the
lung. Most patients are between the ages 30 to 50 years at the time of diagnosis. It is often diagnosed
incidentally following a chest radiograph. The aetiology and pathogenesis are obscure. Technitium 99 scan is
diagnostic. Most patients remain symptom-free for many years despite extensive radiological changes. There is
a striking contrast between the paucity of signs and symptoms and the marked radiographic features. Patients
eventually develop dyspnoea on exertion that limits their physical activity. Eventually respiratory failure and
corpulmonale supervene. Survival of 10-20 years is characteristic. So far no reversible treatment of this disorder
is known. We report this rare and interesting disorder in an asymptomatic young adult.
P109
Acute onset rapidly progressive multisystem Granulomatosis with polyangiitis(Wegener’s Granulomatosis)
requiring plasmaphersis
JAIN R.S., MATHUR R.S., KADAM S.J.
Abstract
Granulomatosis with polyangiitis (Wegener’s Granulomatosis) is a rare idiopathic autoimmune multisystem
vasculitis characterised by necrotising granulomatous inflammation and pauci-immune vasculitis involving small
and medium size blood vessels.
Here we present a case of a 21 year old male who had a 4 day history of cough, fever and haemoptysis followed by
epistaxis. Granulomatosis with polyangiitis was diagnosed by CT guided lung biopsy and p-anca being positive.
Patient had a rapid progressive involvement of renal system in spite of giving pulse cyclophosphamide and oral
steroids. Renal biopsy showed focal necrotising glomerulonephritis with crescents. Patient required plasmaphersis
to which he responded.
P110
A CASE REPORT OF CONGENITAL PULMONARY AIRWAY MALFORMATION
DR NALINI GHANATE, DR.A.SATHYA PRASAD, DR.PRASHANTHY, DR.VIJAY, DR.SUBBA RAO
MAMATA MEDICAL COLLEGE AND HOSPITAL, KHAMMAM
Introduction: Congenital pulmonary airway malformation (CPAM), previously known as congenital cystic
adenomatoid malformation (CCAM), is a rare developmental anomaly of the lower respiratory tract with a
reported incidence between 1:25,000 and 1:35,000.It is a multi-cystic mass of segmental lung tissue with abnormal
bronchial proliferation and is considered part of the spectrum of bronchopulmonary foregut malformations. We
report a case of CPAM in a 6year old child with recurrent infections.
Case report: A 6-year-old boy born of secondary consanguineous marriage presented with high grade fever and
cough with expectoration of 15 days duration. Past history revealed admission in NICU at birth for respiratory
distress and similar complaints at the age of four. Physical examination revealed decreased breath sounds and end
inspiratory crackles in right upper part of chest. Finger clubbing was absent. Laboratory investigations showed
anemia and neutrophilic leukocytosis. Mantoux test was negative. A chest radiograph showed multiple cystic
lesions in the right upper lobe. Computed tomography (CT) showed organized multiple cystic changes with
surrounding consolidation in the right upper lobe. He was treated with antibiotics and referred to pediatric
surgeon. Surgical resection was done and biopsy revealed congenital pulmonary airway malformation.
Conclusion: Early recognition and surgical intervention of CPAM is essential in view of complications like recurrent
infections and bronchogenic carcinoma. It is usually diagnosed in fetal or neonatal life. Serial ultrasonographic
evaluation, fetal lung mass size, and fetal echocardiography are needed for management of antenatally detected
cases .We report this case for its rarity.
P112
Primary pulmonary hypoplasia masquerading as cystic bronchiectasis in an adult.
K.V.V. Vijaya kumar, K. Preethi, Ch.R.N. Bhushan Rao,
K.Venkataramana,
Government Hospital for Chest & Communicable diseases (GHCCD) , Andhra Medical College,
Visakhapatnam,AP,India.
Introduction : Primary pulmonary hypoplasia is an intrinsic defect in the process of lung development
with an incidence of 1-2 cases for 12000 live births. Congenital anomalies are increasingly diagnosed
in the adulthood as they mimic other thoracic pathology or remain asymptomatic in the childhood.
We report a case of right sided primary pulmonary hypoplasia masquerading as cystic bronchiectasis.
Case report : A 30 year old nonsmoker male patient presented with complaints of cough ,
expectoration which is more on left lateral position , shortness of breath and right sided chest pain of
1 month duration. He had similar complaints since 16 years and was being treated under the
provisional diagnosis of right total lung cystic bronchiectasis of congenital etiology. Chest examination
revealed loss of lung volume with diminished breath sounds and coarse crepitations on right side.
Chest radiograph showed cystic changes and ipsilateral mediastinal shift on right side with
compensatory hyperinflation on left side. Spirometry showed severe obstructive and severe
restrictive abnormality. HRCT chest showed multiple thin and thick walled intercommunicating cystic
areas connected to lobar bronchi which had decreased calibre on the right side. 2D ECHO showed
situs solitus with dextro position of heart. Bronchoscopy revealed multiple blind pouches at the
distal end of right main bronchus with narrowing of lumen of right lobar bronchi. CTPA showed small
calibre of right main pulmonary artery (16mm) , lobar and segmental arteries than left side.
Conclusion : Prognosis depends on integrity of remaining lung and presence of associated congenital
malformations. Pulmonary hypoplasia should be kept in mind as a differential diagnosis in cases of
congenital cystic brochiectasis.
P113
Myth and Truth of Patient Satisfaction Surveys in Teaching hospital
AP KANSAL, Kiran N, Nancy GARG, Kamal Deep, Sudesh Kumari, Varinder SINGH Bamrah
Department Of Chest & TB, GMC, Patiala, Punjab
Introduction: The primary goal of hospital is to provide best possible health care to patients. Where it is the right
of every patient to demand best possible care, it is the duty of every staff member of the hospital to deliver
optimum efforts to the entire satisfaction of the patient and its assessment will give us an opportunity to find
loopholes in our services and future ratification.Measuring and reporting of impartial patient satisfaction survey is
major issue .
Method & Materials:The patients admitted over year were randomly selected in three groups,one group was
interviewed by health professional or hospital staff, one by volunteers, and third was by patient satisfaction
questionnaire. Patient satisfaction is assessed regarding the outpatient department services, waiting time,
facilities, and perception about the performance of staff, appointment system, behavior and knowledge of staff,
cleanliness and any other suggestions of patients.
Observations Out of 3342 patients admitted in year in department, 2978 agreed for survey and average scores in
three groups are shown in graph.
It is seen survey becomes partial when hospital staff interviews, while similar results are observed with
questionnaire or when third person like independent body or volunteers are used to assess.
Conclusion: Patient satisfaction survey in country like India with limited literacy is best done with help of
volunteers or independent body which make it less partial and more realistic
P114
Right lower zone opacity on chest Xray: Rule out eventration of diaphragm
AP KANSAL, Don Gregory MASCARENHAS, Prabhleen KAUR, Shiyas MOHAMMED, Nancy GARG, Anand Kumar
BANSAL
Department of Chest & TB, GMC, Patiala, Punjab
Introduction: Eventration of diaphragm is characterised by elevation of right or left leaf of diaphragm abnormally
high into the chest. Usually its congenital, rarely can be acquired. Left side eventration is more common than right
sided.Asymptomatic cases are managed conservatively. We report three cases of right lower zone opacities on
chest Xray(CXR), which eventually proved to b cases of eventration of diaphragm.
Case series:
Case1: 80 year old non-smoker male presented to us with dry cough for two weeks, right sided chest pain for
3days.there was no h/o ATT or trauma in the past.GPE was unremarkable. On chest examination, trachea was
central. Chest movements were reduced on right ISA, IAA,IMA. Breath sounds as well as Vocal Fremitus/Vocal
Resonance were reduced in corresponding areas.CXR showed RLZ opacity. Right lateral Xray showed raised right
hemidiaphragm. Lab investigations & ECG were normal. Fluoroscopy showed reduced movement of right
hemidiaphragm .sniff test showed no paradoxical movement. CECT chest proved it to b a case of eventration.
Case 2: 65 year old female presented to us with generalised weakness & exertional dyspnoea. GPE was
unremarkable. On chest examination, trachea was central. Chest movements were reduced on right ISA, IAA,IMA.
Breath sounds as well as Vocal Fremitus/Vocal Resonance were reduced in corresponding areas.CXR showed RLZ
opacity. Right lateral Xray showed raised posterior end of right hemidiaphragm. Fluoroscopy, sniff test & CECT
chest proved it to b a case of eventration
P115
Title : Genetic Dissection of Birt Hogg Dube' syndrome in an Indian family
1
2
2
Authors: Anindita Ray , Suman Paul , Susmita Kundu , Bidyut Roy
1, *
1
Address: Human genetics Unit, Indian Statistical Institute, 203 B.T. Road, Kolkata 700108
2
R. G Kar Medical College & Hospital, Kolkata - 700004
*corresponding author, Bidyut Roy, email:broy@isical.ac.in
1
Anindita Ray,anindita.2486@gmail.com
Introduction and Objectives: Birt Hogg Dube' syndrome (BHDS,MIM 135150) is a rare genetic disorder which
follows autosomal dominant mode of inheritance with incomplete penetrance. BHDS may predispose to three type
of manifestations - kidney neoplasms, cutaneous fibrofolliculomas and/or lung cysts or pneumothorax,. It is a
monogenic disorder, mapped to a gene encoding a 579 amino acid protein – Folliculin (FLCN) at chromosome
17p11.2. We encountered a family, in Kolkata, with spontaneous pneumothorax and lung cysts in two members of
the family but absence of skin lesions and renal tumors. Genetic studies were performed in the 8 individuals of a 3
generation family from Kolkata, India.
Methods: Genomic DNA was isolated from venous blood from all 8 individuals of the family. Bidirectional DNA
sequencing of all 14 exons of FLCN gene was done to identify mutations. Also high-resolution CT scan was
performed in 4 individuals (two of them with pneumothorax and two phenotypically normal individuals) of the
family.
Results: Genetic analysis revealed presence of a heterozygous “C nucleotide” deletion in the hypermutable polycytosine (poly-C) tract in exon 11 leading to a possible truncated protein. This mutation was found in two affected
members along with 4 other members with no lung or renal complications in the family. CT scan for the
phenotypically normal member (age: 28yrs) of the family but having this mutation, revealed presence of
paracardiac lung cysts without any symptoms of BHD. We also checked for this mutation in 14 healthy unrelated
control individuals but none of these controls carried this mutation.
Conclusion: Our results confirmed presence of deletion mutation in poly C8 tract at exon 11 which is a mutational
hot-spot for patients with BHDS. This study gives the first genomic insight in an Indian family with BHDS,
correlating the mutation hotspot with radiological findings.
P116
Thymomic myasthenia gravis with solely bul bar invol vement- a rare case report.
S.harikrishnan, A.sundararaj aperumal, A.mahilmaran, D.ranganathan.,
Institute of thoracic medicine, madras medical college, Chennai, Tamilnadu, Indi a.
Introduction:
Overall incidence of thymoma is approximately 0.15/10,0000/yr. Thymoma is usually a rare begin tumor from
anteri or mediastinum. About 1/3rd of cases were di gnosed during myastheni a evaluation.1/3rd during
asymptomatic mass evaluation,1/3rd as obstructi ve features.Myasthenia gravis is the common paraneoplastic
syndrome associated with thymoma.Ocular weakness is most typical usual present ation with or without limb
invol vement,while early or isolat edoropharnygeal or limb weakness is less common.
Case report :
40 yr old male manual labour, evaluated in otol aryngol ogy for dysarthria for past 3 months,reffered to
pulmonol ogy for abnormal chest X-ray fi ndi ng- medi astinal wideni ng.patient had nasal speech and gave
history of recurrent nasal regurgitation,occasional dysphagia and dry cough with no ocular or limb weakness
symptoms. Necessary investigations were done.CECT chest confi rmed anterior medi astinal mass.CT gui ded
FNAC was done- reported as thymoma with metaplastic squamous cells.Neurophysician opi nion obtained reported as decremental response in repeated nerve stimulation test which confi rmed Myastheni a
gravis.Patient referred to surgery with consent. Cardiothoracic surgeon
staged the tumor as stage-I thymoma during surgery . Histopathol ogical examinati on of resected tumour shows
type-B2 thymoma(WHO classification) without evi dence of malignancy.
Conclusion:
Thymoma is a rar e tumor but its association with myasthenia gravis is well reported. Main stay of
treatment of thymoma is surgical removal.if it is associated with myasthenia gravis surgery should be elective
with adequate preoperative assessment such as avoidance of immunosuppressive drugs, adequate respiratory
function, in which FVC > 2 liter is mandatory or else plasmapheresis/IVIg shoul d be carried out. We report end
this case because despite of being a manual laborer by occupation patient had a rare presentation of only bulbar
involvement without ocular and limb muscular involvement.
P117
P118
Pediatric mucoepidermoid carcinoma
DR. MEHTA N, Dr. SHETH V, DR.RAMI K, DR.GHANCHI F,
DR.CHATTERJEE I
Shri M.P.Shah Government medical college, Jamnagar, India
8 year old male child was referred to chest medicine department for recurrent respiratory tract infections
for 2 year needing frequent treatment with antibiotics and decongestives. He had also been given short course
Anti TB treatment for the same complaints.
On Examination: At time of consultation He was afebrile, had quite breathing, but was pale and
underweight and had no chest symptoms .Auscultation revealed less aerated right lower chest. There was neither
digital clubbing nor any chest deformity. Other systemic examination was unremarkable. Except 10 gm/dl Hb his
hematological, microbiological and biochemical reports were normal. His Chest X ray(PA view) [Figure 1] showed
well outlined homogenous right lower zone opacity obliterating right dome and right cardiac border with spared
right costophrenic angle. Similar opacity with varying size was present in the previous Chest X rays. He was
suspected to have right intermediate bronchus occluding pathology with collapse of middle lobe and lower lobe
and
recurrent post obstruction infection. FOB(fiberoptic broncho scopy) revealed intermediate bronchus
occluding, smooth surfaced tumor, that on CT scan was found infiltrating adjoining lung parenchyma. FOB guided
biopsy was negative for carcinoma and carcinoid. He was advised surgical treatment and underwent bilobectomy.
The tumor turned out to be Mucoepidermoid Carcinoma. Post operatively he has been asymptomatic and doing
well after 9 months.
Conclusion: Recurrent RTIs with variable response to anti infective measures and iso-positioned chest
opacity is an alarming state of bronchus occluding pathology and endoscopic examination clubbed with CT
scan are irreplaceable definitive diagnostic tools, directing further timely management.
Pneumonic Carcinoma
P119
DR. SHETH V, DR.RAMI K, DR.UDACHANKER G, DR.GHANCHI F, DR CHATTERJEE I
Shri M.P.Shah Government Medical College, Jamnagar, India
60 year old lady was referred to chest medicine department for recurrent intermittent cough, trivial hemoptysis
and transient spells of fever for 7 years.
On Examination: On evaluation she reported to have mucoid expectoration and feeling short of breath on brisk
walk for last one year. At time examination her resting pulse, respiratory rate, body temperature and blood
pressure were normal. She had audible crepitation on left lung field. She did not have digital clubbing or enlarged
lymphnodes. Her sputum microbiology and cytology reports were inconclusive while hematological, biochemical
and urine analysis were normal. HIV, ANA, CEA were negative. Her chest X-rays(PA view) (Figure 1) showed
progressive multicentric pneumonic shadows left lung in right middle zone and left mid zone lower zone. Her
breast examination and abdominal sonology were normal. She was suspected to have Broncho Alveolar Carcinoma
(BAC) with remote possibility of immunogenic inflammatory pneumonia and was further evaluated by HRCT chest
and FOB(fiberoptic bronchoscopy) At bronchoscopy frothy secretion was found oozing from left bronchi and right
upper lobe bronchus. However BAL, and transbronchial biopsy from left lower lobe were non diagnostic. For
further confirmation Trans thoracic lung biopsy from left upper lobe was carried out. Histopathological
examination of biopsy sample confirmed BAC.
Conclusion:
Slowly progressive multicentric pneumonic shadows with recurrent chest symptoms and variable response to antiinfectives is a suspect scenario of BAC especially in non smokers. High index of suspicion and timely further
evaluation with interventional investigations can lead to specific diagnosis.
Figure 1: Chest X rays(PA view)showed progressive multicentric shadow
P120
A rare case report on pulmonary langerhan’s cell histiocytosis or histiocytosis x
DR.ADITYA REDDY. VANGALA, Prof. Pradyut waghray**, Dr.A.N.V.Koteswara rao**, Dr.v.veena**, Dr. Chetan**,
Dr. Sowmya **, Dr. Harish **, Dr. Rikin**, Dr. Krishna chaitanya**.
prof. k.p.a.chandrashekhar #
prof. ramakrishna reddy gaddam^
п‚·
п‚·
п‚·
** dept of pulmonary medicine,s.v.s.medical college, mahabubnagar,a.p
# dept of pathology, s.v.s.medical college, mahabubnagar,a.p
^ dept of radiology, s.v.s.medical college, mahabubnagar,a.p
We report a case of pulmonary langerhans cell histiocytosis in a 57 yr old male chronic smoker presented with 1
month h/o productive cough,chest discomfort ,joint pains & dyspnea gr-3. And he reported coughing up a few
mouthfuls of blood over the previous 10-15 days. Chest radiography revealed cystic changes and nodules in the
mid and lower zones with infiltrations. BAL,Endobronchial biopsy unremarkable. Trucut lung biopsy proved.
18 F-FDG PET in Benign Pulmonary Diseases
P121
KETAKI UTPAT, MAKARESH YADAV, VINAYA KARKHANIS, SANDIP BASU, JYOTSNA M JOSHI
Department of Pulmonary Medicine, T.N.M.C.& B.Y.L. Nair Hospital, Mumbai
Objective
18 F-Fluorodeoxyglucose (FDG)-positron emission tomography (PET) is emerging as an important non-invasive
investigation in benign conditions. We studied its utility in the diagnosis and monitoring of various benign
pulmonary diseases.
Materials and methods
An observational study was conducted on 47 consecutive patients with benign lung diseases.FDG PET scan was
performed at baseline and repeated after therapy in necessary cases. The findings of FDG scan were correlated
with clinical, histopathological and radiological findings.
Results
47 patients of benign pulmonary diseases were included in the study. Pulmonary tuberculosis(16), tuberculous
mediastinal lymphadenopathy (5),sarcoidosis (9)- type 1(1), type 2(3) and type 3(5), IIPs (9)-IPF (5) and NSIP (4), CTD
related ILD (1), alveolar proteinosis (1), silicotuberculosis (2), tropical pulmonary eosinophilia (2), pleural hydatid disease
(1), diffuse panbronchiolitis (DPB (1). All patients showed increased FDG uptake in areas showing lesion on HRCT.
Additional uptake was noted in 2 patients. Repeat FDG scan after treatment showed improvement in all patients which
was consistent with clinico radiologic and/or spirometry findings.Findings of FDG PET scan in patients of pulmonary
tuberculosis matched well with microbiological findings in all but 2 patients. 4 patients with mediastinal
lymphadenopathy showed favourable response on FDG PET on antituberculous therapy. All ILD patients had bilateral
low grade FDG uptake. Unusual intense FDG uptake was seen in 2 cases in areas of honeycombing. Comparison of FDGPET scans with clinic-radiological correlation in silicosis, DPB and hydatidosis showed consistent findings at baseline and
after therapy.
Conclusion
FDG-PET scan can be used as an important adjunct non invasive investigation in diagnosing and monitoring of
various non-malignant lung conditions by assessing metabolic disease activity along with microbiology and
computed tomography.
P122
Traumatic Diaphragmatic Hernia
Dr.Rajeshwari, Dr.K.RameshKumar I/C Professor Department of Pulmonary Medicine
Govt. General and Chest Hospital, Hyderabad
OBJECTIVES: The estimated rate of occurrence of congenital diaphragmatic hernia varies from 1:2000 to 1:4000
live births. Though thousands of such cases are reported during infancy, few reports describe adult patients
diagnosed with Bochdalek hernia. Usually, these hernias become evident during the neonatal period, through
symptoms and signs of respiratory distress. However the most frequent symptoms found in adult patients are
slight respiratory and digestive symptoms. It is also possible for these hernias to be asymptomatic. Here we report
a case of mild dyspnea within a traumatic posterolateral diaphragmatic hernia. Evaluation of 50 years old male
with one month history of shortness of breath without any previous respiratory complaints.
METHODS: A 50-year-old male patient was admitted to our department with a one month history of slight
dyspnea. The discomfort was greatly obvious after heavy physical work, but could be alleviated by taking a rest. he
denied having other symptoms such as chest pain, abdominal pain, dysphagia, vomiting, and dyspepsia. There was
history of penetrating trauma and surgery. Upon physical examination we inspected nothing characteristic except
the remarkable decrease of breathing sounds and increased bowel sounds in the left hemithorax. Computed
tomography(CT) Chest showed herniation of stomach, splenic flexure and peritoneal fat in left hemithorax. Defect
of about 65 cm was seen in the left diaphragm
RESULTS: Sputum for gram stain, culture and sensitivity and sputum for AFB: No growth found. Blood group: “o”
positive. Ultrasound Abdomen Nothing abnormality detected. HIV: Non reactive. Ultrasound chest radio opacity
which seen in radiograph is not appreciated on ultra sound. PFT moderate restriction. No significant
brochodilation.
CONCLUSION: For Bochdalek hernias, correct diagnosis and early treatment is significant to avoid the occurrence
of serious complications.
P123
Familial Spontaneous pneumothorax and lung cysts in an Indian family associated with Folliculin gene mutation.
AUTHORS: S. PAUL, A. RAY, B. ROY.
INSTITUTION: R.G Kar Medical College, Kolkata- 700004, India; Indian Statistical Institute , 203 ,Barrackpore trunk
road ,Kolkata – 700108; Indian Statistical Institute , 203, Barrackpore trunk road, Kolkata – 700108.
Approximately 10% patients of spontaneous pneumothorax have positive family history. Birt–Hogg–Dube
syndrome (BHD) is one of the cause of familial pneumothorax. BHD syndrome is associated with hamartomas of
skin, renal cancer and spontaneous pneumothorax. However there have been reports of isolated spontaneous
pneumothorax and lung cysts in patients of BHD syndrome in the absence of other manifestations . Mutation in
Folliculin gene (FLCN) on chromosome 17 has been reported to cause BHD syndrome.
A 32 year old non-smoker female presented with left sided spontaneous pneumothorax . Her sister had
previously suffered from recurrent pneumothorax (twice). High Resolution CT (HRCT) scan of chest of both the
sisters revealed multiple lung cysts. We decided to evaluate these patients of familial pneumothorax and identify
any genetic basis for their disease.
After getting informed consent , genetic study of the FLCN gene was performed in 7 family members. We
subsequently screened willing family members by HRCT scan of chest for any lung abnormality. One of the sibling
of the index patient did not wish to participate in the study.
Physical examination and abdominal CT scan was done to rule out any skin and renal involvement. Genetic
sequencing revealed Cytosine - deletion mutation in hypermutable region of exon 11 of FLCN gene in the index
case, her 3 siblings, her mother and her son. HRCT scan of the patient’s brother showed lung cysts whereas her son
had normal lungs.
For cystic lung disease with an undetermined etiology, or familial pneumothorax, it is necessary to consider the
possibility of BHD syndrome. Pulmonologists should be aware that BHD syndrome can occur as an isolated
phenotype with pulmonary involvement.
P124
A rare case report of churg-strauss syndrome and loefflers syndrome in the same patient
Dr.J.SOWMYA , Prof.Pradyut waghray, Dr.A.V.N.Koteswar Rao, Dr.K.Surender Reddy , Dr.Venkateswara reddy T,
Dr.Veena, Dr.Harish, Dr.Chetan, Dr.Aditya, Dr.Krishna Chaitanya, Dr.Rikin
Dept of Pulmonary Medicine, SVS medical college, Mahbubnagar,TS
BACK GROUND
Churg-strauss syndrome is a systemic disorder characterized by asthma, transient pulmonary infiltrates, hyper
eosinophilia and small vessel vasulitis.It is also called “allergic angitis and granulomatosis or eosinophilic
granulomatosis”. It may involve multiple organ systems including lungs, heart, skin, GIT, nervous system
Loefflers syndrome is characterized by migrating lung infiltrates and by eosinophilia.Diagnosis is based on the
radiographic picture and eosinophilia.it is most likely an allergic reaction in the lung to foreign antigen mainly
parasites.
CASE SCENARIO
A 40 yr old male patient came to the OPD with the complaints of cough with sputum, SOB ,fever since 3 months
,pain abdomen since 1 month, headache since 15 days. On general examination skin lesions were seen. Chest x ray
PA view showed bilateral migratory pulmonary infiltrtates. CBP showed increased WBC count with eosinophilic
predominance of 64%, AEC,IgE were elevated. Stool for ova and cyst showed large number of stongyloides ,
giardia lambia larvae. Sputum and BAL for cytology showed increased number of eosinophils .Skin biopsy showed
eosinophilic predominant small vessel vasculitis with granulomas. P-ANCA is elevated. Patient responded well with
corticosteroids, albendazole and Diethyl carbamazine.
P124
LAM PRESENTING AS PNEUMOTHORAX COMPLICATED BY ACINETOBACTER SPECIES - A RARE CASE REPORT
AUTHOR NAME-SWAPNIL CHAUDHARI
GUIDED BY- BABAJI GHEWADE
ABSTRACT-
18 year old female presented with complaints of Breathlessness & Cough with mucoid expectoration – 3 months
Patient was started on Cat I DOTS from PHC on September 2013 based on chest X- Ray (Sputum for AFB –
Negative) , but no symptomatic relief was present
She got admitted under us on November 2011 with complaints of Fever & Breathlessness-15 days, Right sided
chest pain – 2 days
Clinical examination and chest x-ray suggestive of RIGHT SIDED PNEUMOTHORAX & Consolidation in Left mid &
th
lower zone & ICD Tube was inserted in the 4 intercostal space in mid – axillary line.
п‚· Hb-10, TLC-14000(P-86%,L-10%,E-3%M-1%)
 LFT & KFT – WNL
п‚· Sputum Culture & Sensitivity- No growth of pathogenic organisms (2 mucopurulent samples)- Negative
for AFB
 ELISA & HBsAg– Non Reactive
п‚· ABG was suggestive of Type I Respiratory Failure
п‚· Pleural fluid ADA-32, Culture & sensitivity- No growth seen , occasional RBCs seen, Triglyceride-31 mg/dl,
Cytology- suggestive of Acute Mixed Leucocytic Exudation
п‚· HRCT thorax- Bilateral Ground Glass Opacities With Air Bronchogram & Reticular Thickening In
Interstitium with right sided pneumothorax
 Serum LDH – 1135 IU/L (200-400)
 ANA – 10.2 (< 20 u/l)
 Serum calcium – 7.9 mg/dL
п‚· SerumACE-Negative
 24 hour urinary protein – 0.5 g
 BAL culture & sensitivity – Growth of Acinetobacter species
 BAL Cytology – Benign epithelial cells in inflammatory & hemorrhagic background
п‚· TBLB was suggestive of Type II pneumocyte proliferation & hemorrhage, smooth muscle proliferation
around airways most likely possibility is Resolving Adult Respiratory Distress Syndrome
P125
Title: Dysphagia and dysarthria with cavitary lung lesions: A Case Report
Satyajeet SAHOO, Subhra MITRA
Calcutta national medical college & hospital, Kolkata, India
th
th
CASE: Lesions affecting the posterior parapharyngeal space involving the 9 to 12 cranial nerves with Horner
syndrome is called Villaret’s syndrome. Etiologies include parotid gland tumor, nasopharyngeal tumors,
parapharyngeal abscess and aneurysms of internal carotid artery. We report this case of 42 year immunecompetent housewife presenting with high grade fever, headache and neck pain for 25 days with inability to take
food and difficulty in speech for 10 days. She was admitted in a local hospital 20 days back, where she was
diagnosed meningitis and put on intravenous antibiotics. During the previous hospitalization she developed cough
and dyspnoea with CXR showing bilateral pleural effusions and patchy opacities in lower zones. There were no
2
complaints of haemoptysis or chest pain. On examination she had decreased appetite with BMI of 15 kg/m . She
was dysarthric, dysphagic and febrile. Her respiratory rate was 26/min with scattered crepitations. Horner’s
syndrome was noticed on right side. CNS examination showed right lateral rectus paralysis and lower motor
th
th
th
th
neuron palsy of 9 , 10 , 11 and 12 cranial nerves bilaterally. Meningeal signs were absent. She was put on ryle’s
tube feeding and intravenous antibiotics. MRI brain revealed prevertebral (upper cervical) abscess. Sputum for
Gram stain and culture showed growth of Staphylococcus aureus. CECT thorax showed minimal bilateral pleural
effusion and multiple bilateral nodules with cavitations in some of them. A week later she had become afebrile,
her neck pain had subsided, she was taking soft diet and put off ryle’s tube. She is under follow-up with some
improvement in speech, though her tongue remains atrophic and weak.
DISCUSSION: We present this case of staphylococcal abscess of prevertebral space complicated with Villaret’s
syndrome with hematogenous spread to lungs which presented to our department with unusual features of
dysphagia and dysarthria with multiple cavitating lesions and bilateral pleural effusions.
P126
Title: Invasive pulmonary aspergillosis (IPA) in liver transplant recipient(LTR) – a case
report.
R CHOPRA, A TAKALE, V PANDHARKAR
Grant Medical Foundation’s Ruby Hall Clinic, Pune, Maharashtra, India
Objectives:
IPA post liver transplant is a devasting complication with high mortality(40-90%) despite newer antifungal agents.
Rapid and reliable diagnosis may improve the outcome. This is an interesting case, with late onset IPA in a LTR
being presented.
Methods(case report):
A 45 years old, post HCV liver cirrhosis, underwent liver transplant in 2011 and now presented in 2014 with cough,
fever and haemoptysis since 2 wks prior. He has been on steroids and cyclosporine based immunosuppressive
drugs. CXR and CT scan showed macronodules, consolidation, cavity, halo and crescent signs.
WBC count and renal functions were normal. BAL showed branching hyphae and culture grew green colonies of A.
fumigates. Galactomanan index was high. IPA diagnosis was confirmed. Treated with incremental doses of
liposomal Amphotericin B(total 2.5 gms) followed by oral Voriconazole. Clinical and CT scan resolution was
satisfactory.
Results(discussion):
With changed epidemiology and better immunosuppressive drugs, late onset IPA in post liver transplant is
reported frequently. Our patient developed IPA as late as 3 yrs after liver transplantation. Characteristics CT scan
findings in IPA patients, cavity and patchy consolidation, halo and crescent signs, were present and this also
described in retrospective analysis of 2150 liver transplant cases. Though mortality is high, some trials documented
better survival with combination antifungal treatment with liposomal Amphotericin and Voriconazole. Our patient
received liposomal Amphotericin followed by Voriconazole with good result.
Conclusion:
IPA is uncommon but severe complication in LTR and has high mortality. Quick diagnosis of IPA with typical CT scan
findings and culture was made in our patient. Results with liposomal Amphotericin and Voriconazole were
satisfactory.
P127
P128
A Rare Encounter With Hemoptysis
Dr. Natraj. M, Dr. N. Meenakshi, Dr. S. Subramanian, Dr. Thirunavukarasu,
Chettinad Hospital And Research Institute, Rajiv Gandhi Salai, Kelambakkam, Chennai
Introduction
Rhinosporidiosis is a chronic granulomatous disorder caused by Rhinosporidium seebri. Molecular biological
techniques have more recently demonstrated that this organism is an aquatic protistan parasite. It is grouped
under the class Mesomycetozoea. This disease is endemic in Sri Lanka and India, predominantly South India.
Case Report
Here we present a case report of a 70 years old male patient who presented with multiple episodes of hemoptysis
for one month duration (10 – 15 ml per episode, frank blood), progressive dyspnea, cough with expectoration
(mucoid, not foul smelling ) associated with loss of weight and appetite for the last one month. Patient is a known
smoker for more than 40 years. Patient was a bus driver by occupation. Chest X ray PA view and CT thorax for the
patient were normal. Routine blood investigations revealed no significant abnormality. Initial nasal examination
revealed only congested turbinates and deviated nasal septum but Direct Nasal Endoscopy revealed reddish
granular mass seen occupying right nasopharynx. The mass was surgically removed. Histopathology report was
consistent with the diagnosis of rhinosporidiosis. Patient was asymptomatic after surgery.
An Unsusal Cause of Fungal Pneumonia.
S.dharmic, V.suryanarayana, M.harish
Sree balaji medical college and hospital,Chennai,india
P129
A 65 year old female, known asthmatic on steroids intermittently, with no other co-morbidity presented with
fever, breathlessness and cough with mucoid expectoration of ten days duration. Bilateral crepts were heard in
auscultation. She was maintaining saturating well in room air. Blood investigations revealed leucocytosis with
neutrophilic predominance. CT chest showed multiple patchy consolidations of the right upper, middle and lower
lobes with ground glass appearance and enlarged mediastinal lymph nodes. Work up for retrovirus and
tuberculosis was negative. Sputum for KOH mount was negative. Sputum showed gram negative bacterial growth
and she was started on antibiotics. Meanwhile patient went for Type II respiratory failure and was intubated
followed by tracheostomy in view of prolonged ventilator support.
In spite of high end antibiotics, weaning off the ventilator was not possible. Bronchoscopy showed pus along with
flakes in the right lateral basal bronchus. Bronchial wash sample grew Curvularia species. Fluconazole 150mg OD
was added. Serial imaging of the chest showed resolution of the consolidation. She was weaned off the ventilator
and was comfortable on room air.
Discussion: The genus Curvularia (filamentous fungi) contains some 35 species which are mostly subtropical and
tropical plant parasites. Three ubiquitous species have been recovered from human infections, principally from
cases of mycotic keratitis; C. lunata, C. pallescens and C. geniculata. Clinical manifestations of phaeohyphomycosis
include sinusitis, endocarditis, peritonitis and disseminated infection.
Pneumonia caused by Curvularia in an immune competent patient is very rare and if diagnosed and treated early,
will respond well to first line drugs like azoles. This case report highlights a unilateral fungal pneumonia with
dramatic clinical improvement post treatment once the rare causative organism was identified.
P130
Progressive allergic fungal rhinosinusitis with stable lingular bronchiectasis
1
2
3
1
Sindhoora Rawul , Prasad E Chelluri , SK Sistla , Fahad Aleem , Sai Singaraju
1
Background: Allergic fungal rhinosinusitis with or without asthma has been mentioned in literature. Criteria for
diagnosis have been proposed without a consensus. We report one such case in a 59 year old lady with recurrent
rhinopulmonary allergy with progressive nasal and sinus disease since year 2006 and stable non-progressive
lingular bronchiectasis.
Methods:Clinical assessment, Imaging(X-ray,CT:PNS,Chest,Brain),Echocardiogram,Spirometry,EEG, Eosinophil
count,Serum Chemistry (VitaminD,Calcium,Thyroid, Immunology), Specific IgE, Total IgE,Sputum examination, FESS
in June2013,histopathology of nasal mucosa. Patient refused skin prick test and bronchoscopy.
Results: On examination: postnasal drip, crackles in the left infraaxillary and paracardiac areas. CT PNS: left side
turbinate hypertrophy,maxillary sinusitis with polyps, CT chest: left lingular segmental bronchiectasis with patch
of consolidation, eosinophil count increased(24%), total IgE: 4574 IU (Lab Normal 400 IU), Specific IgE to
aspergillus,candida markedly increased, Echocardiogram normal,Spirometry:mild airflow obstruction without any
moderate or severe episodes since 4years,Histopathology:profuse eosinophilic infiltraton, no bony changes, no
fungal elements,Sputum examination revealed fungal elements,CT brain normal,EEG: temporal lobe epilepsy.
Conclusion: A case of fungal rhinosinusitis with turbinate hypertrophy, maxillary polyps, high eosinophil counts and
total IgE with highly elevated specific IgE to aspergillus and candida, mild airflow obstruction with reversibility and
lingular bronchiectasis is presented. The unusual feature being stable lung disease while rhinosinusitis was
progressive.
Treatment: Nasal, inhaled, oral steroids, bronchodilators and Itraconazole
Clinical implications: Any patient of rhinosinusitis with or without asthma should be screened by tests of allergy
and lung function for early diagnosis of allergic fungal disease.
P131
An unusual case of invasive Aspergillus pseudomembranous and obstructive
involvement of lung parenchyma in a immunocompetent patient.
tracheobronchitis without
Dr Ramesh S.Pal, Dr Sonam Spalgais, Dr Amit Kumar, Dr U C Ojha
department of pulmonary medicine esi pgimsr basaidarapur new delhi india
A 19 years aged young female presented with cough, mild expectoration since 3 month and life threatening
hemoptysis since 1 week. She was non diabetic, not suffering from any chronic illness, not on any cytotoxic and
immunosuppressive drugs.Immune status was evaluated in terms of HIV status, hepatitis B, IgA, IgG, C3,C4
complement components and were found normal. CECT thorax revealed segmental collapse of left lower lobe.
Videobronchoscopy showed tiny nodules in trachea and left lower lobe bronchi. Dark brown intra luminal thready
material was visualized and taken out in piecemeal. Direct smear KOH preparation shows fungal elements. Biopsy
from nodules shows chronic non specific inflammation. Repeated sputum KOH preparation also showed fungal
elements and culture revealed Aspergillus flavus. Serum Galactomannan was positive. Thus a conclusion is made of
Invasive Apergillus Tracheobronchitis. Patient received intravenous Voriconazole for one month than switchover to
oral Voriconazole for next two months. Her hemoptysis was stopped and improved clinically and radiologically.
Repeat Serum Galactomannan become insignificant.
Discussion
The finding of Aspergillus spp. in respiratory tract samples in critically ill patients should not be routinely discarded
as colonisation, even in presumably immunocompetent hosts like the case mentioned above. However risk factors
for the development of invasive aspergillosis in critically ill patients include neutropenia, haematological
malignancy and immunosuppressive treatment. But, invasive disease can occur in the absence of these risk factors.
Figure1
Vediobronchoscopic view of left lower lobe showing luminal obstruction
Figure 2
Vediobronchoscopic view of left lower lobe showing brown thready structure protruding through lumen
Figure3
Bronchial wash from left lower lobe showing brownish sediment
P132
SOUVENIER in the ICD BAG
Dr Kumar Utsav, IInd Year Resident, BJMC, Ahmedabad
Dr Savita Jindal, Asst. Professor, BJMC, Ahmedabad
BACKGROUND: Pleural effusion is common in INDIA. The importance of this case study is how a clinician can be
easily misled by Age of the patient, past AKT, when clinically symptoms are not prominent.
CASE HISTORY: An 80 year old male patient presents to O.P.D. with chief complaints of Breathlessness slowly
progressive over the period of 2 years. Cough with expectoration over a period of 2 years, Generalised weakness
over 5 days. Pt has a past history of AKT and has been a smoker but left smoking since 10 years. CXR: Massive U/L
pleural effusion, An ICD was placed in situ. Pleural fluid assessment was not leading anywhere, neither were
Pleuroscopy and CECT Thorax
RESULTS: Incidentally, one day patient mentioned something crawling in ICD BAG. It was a full grown worm of
A.Lumbricoides. It was extracted from ICD BAG& sent for MICROBIOLOGICAL assessment. Pt was given Tab
Albendazole 400mgSTAT. 2 days later stool R/M and parasitic examination was sent for, came negative for
ova/cysts/eggs. Tab Prednisolone (5mg) 5-0-5 was started. Pt was regularly followed up, was healthy, lost to follow
up at 6 months.
CLINICAL IMPLICATIONS: Seeing the age and presentation of patient, correlating with Past history of the patient
one can easily make a mistake of presuming above case to be tuberculosis induced pleural effusion or malignant
effusion, but like every lock has a different key, every case is to be looked OBJECTIVELY. This is perhaps rare case
with uncommon presentation of parasitic infestation where a fully grown worm is roaming freely in pleural cavity.
P133
Isolated pulmonary cystic lesion? Always suspect hydatidosis.
D.N.Prajapati, R.M.Kshatriya, N.V.Khara, R.P.Paliwal, S.N.Patel
department of respiratory medicine, pramukhswami medical college, karamsad
388325, gujarat, india.
Introduction: Hydatidosis is caused by echinococcus granulosus. Humans may
be infected incidentally as intermediate host by accidental consumption of soil,
water or food contaminated by fecal matter of an infected animal. Lung is the 2
most commonly affected organ following liver. The symptoms depend on the
size and site of the lesion. There are very few reported cases of isolated lung
hydatidosis. For hydatidosis, serology and imaging are diagnostic tools. Surgical
removal and/or chemotherapy are the mainstay of treatment. Here we discuss a
case of persistent left lower lobe lesion with history of operated left breast
carcinoma.
Case report: A 36 years old female presented with 1 month history of cough
with yellow expectoration, dyspnea and left sided chest pain, with history of
trace hemoptysis before 1 month. Patient was a known case of infiltrating ductal
carcinoma of left breast operated before 3 years and had cystic lesion in left
lower lobe of lung confirmed on CT scan. Physical examination revealed
dullness to percussion and diminished breath sounds over left lower chest.
Blood reports showed eosinophilia with normal leukocytes. Chest radiograph
was interpreted to have a left lower zone round opacity (possibly metastatic)
which was increased in size as compared to previous x-rays and on ultrasound
it was found to be a cystic lesion with fluid collection. So diagnostic fluid
aspiration was performed and surprisingly hooklets of ecchinococcus were
found on microscopy. Abdominal ultrasound was nomal including liver. Patient
was referred for surgical intervention and underwent left lower lobectomy. There
were no complications in the postoperative period and no recurrence of the
disease.
Conclusion: Pulmonary hydatidosis should always be considered as a
differential diagnosis when dealing with a cystic lesion on radiology in our
country.
P134
Co-existence of ABPA and aspergilloma in same individual: a rare entity.
URVINDERPAL SINGH, VIDHU MITTAL, ADITI, SUNIL KUMAR.
Government Medical College, Patiala,Punjab,India.
ABSTRACT
Coexistence of allergic bronchopulmonary aspergillosis (ABPA), a hypersensitivity disorder to Aspergillus
antigen, and aspergilloma, in same individual is of rare occurrence. Aspergilloma is a fungus ball caused by
saprophytic overgrowth of Aspergillus species in a cavitatory or cystic lung disease. However, tissue necrosis and
invasion of blood vessels does not occur. We hereby present a case of a 42 years old male who was diagnosed as a
case of ABPA with co-existing aspergilloma.
P135
Clinicoradiological and laboratory profile of Allergic bronchopulmonary aspergillosis ( ABPA) patients presenting
to a tertiary care centre
AP KANSAL, Kiran.N, Shiyas MOHAMMED, Don Gregory MASCARENHAS, Nancy GARG, Hardik JAIN
Department Of Chest & TB, GMC, Patiala , Punjab
Introduction: ABPA is an idiopathic inflammatory lung disease characterized by an allergic inflammatory response
to the colonization of Aspergillus or other fungi in the lung.
Objective: To study the clinicoradiological and laboratory profile of ABPA patients presenting to our department
from August 2013 to July 2014.
Method & Materials : Patients diagnosed as ABPA based on Rosenberg Patterson criteria were retrospectively
studied and analysed.
Results: In our study of 61 patients, 35(57.3%) were males, 26(42.7%) were females. Median age was 32.8 years,
youngest being 7 years & oldest 84 years. Cough was the commonest presenting complaint present in 57(94.4%)
followed by breathlessness in 51(83.6%), haemoptysis in 8(13%) patients. History of asthma was present in
44(72.1%) patients. History of anti tuberculosis treatment was present in 11(18%) patients, all of them being
prescribed ATT in the peripheral health centres merely on the basis of Chest X-ray(CXR).
Fleeting opacities was present in chest X-rays in 14(22.9%) patients.On HRCT, 54(84.5%) patients has central
bronchiectasis , consolidation/mucus plugs in 4(6.5%) and normal in 3(4.9%) patients. Total and specific IgE
against aspergillus antigen was high in all 61 patients.
Discussion : 70% of ABPA patients have a history of asthma.Keeping a high suspicion and evaluating on the lines of
ABPA is necessary in bronchial asthma patients especially when they are poorly controlled on regular asthma
treatment. CXR lesions are nonspecific when serial X-rays are unavailable. Patients shouldn’t be put on ATT merely
on CXR basis without being properly evaluated for ABPA especially in asthma patients .






P136
BILATERAL HYTADID CYST OF THE LUNG
Dr. RJESWARI G, Dr.RAMESH KUMAR, Dr. SARTAJ HUSSAIN
Department of Pulmonary Medicine, Osmania Medical College, Hyderadad
A 17 years girl presented with the chief complaints of
Cough with expectoration - 3 months
Shortness of breath
- 3 months
L side chest pain
- 3 months
Past history - Relatively healthy without any co-morbidities
Treatment history – no history of worm infestations, no history of handling pets.
Cough with expectoration, sputum moderate in quantity, mucoid,non foul smelling, aggravated on lying
down to left side, no diurnal variation
Shortness of breath, gradual in onset ,progressive, aggravated on lying down to left side, no history of
orthopnea
Left sided chest pain, dull aching in nature, no history of radiation of pain, increases on lying to left side
No history of wheeze or hemoptysis
History of sputum being salty 15 days ago

On examination Vitals – stable; upper respiratory tract – normal; examination of chest
Inspection: deviation of trachea to the right side; Palpation : TVF decreased over the L hemi thorax.
P137
A rare case report of disseminated
cryptococcosis in immunocompetent host
*
Dr.G.AMBERNATH, Dr. Ajit Vigg, Dr.S.Gourishankar, Dr.S.V.N.Anuradha*
Dept of Pulmonary Medicine, Apollo Hospitals, Hyderabad, TS
*Dept of Pathology, Apollo Hospitals, Hyderabad, TS
BACK GROUND
Cryptococcosis is a defining opportunistic infecton for AIDS, and is the second most common AIDS defining illness.
The distribution of Cryptococcus neoformans is worldwide and it is mostly seen in soil. Cryptococcosis is believed
to be acquired by inhalation of the infectious propagule basidiospore from the environment. Pulmonary
cryptococcosis with dissemination to brain in immunocompetent host is rare, which prompted us to report this
case as a poster presentation.
CASE SCENARIO
A 59 year old gentleman,presented to ER in a state of altered sensorium, shortness of breath of grade II MMRC
scale, low grade, intermittent fever associated with chills, cold and dry cough for the past 10 days and had a brief
exposure to pigeon bird droppings over a period of 1month prior to development of these symptoms.Was a known
3
hypertensive,not a diabetic and also not on any immunosuppresants.TLC counts 26,000 cells/mm ,ESR 30mm at
first hour. CXR PA view showed RLL consolidation. CT scan chest with contrast evidenced soft tissue density
lesion in the antero-lateral segment of right middle lobe suggestive of segmental consolidation. BAL on PAS stain
showed budding yeast cells of Cryptococcus in mucinous background. CT guided biopsy of lung tissue from RML on
HPE showed necrotic tissue and encapsulated budding yeast cells with morphological features consistent with
Cryptococcus.MRI of brain with contrast study showed evidence two descrete large irregular thick walled ring
enhancing lesions in rt capsulo-ganglionoic area with significant peri-lesional edema causing midline shift. patient
responded well to amphotericin-flucytosin combination therapy followed by oral fluconazole for six months.
Patient on repeat MRI brain and CT chest showed significant resolution at four months.
P138
Association of serum vitamin-D concentrations with pulmonary disorders: Tuberculosis, COPD and Bronchial
Asthma.
GAYATHRI B, SUJATHA R, NEHA GHALIB
PSG Institute of Medical Sciences and Research, Coimbatore, India.
Objectives:
Vitamin-D is classically associated with bone and mineral metabolism, but the identification of vitamin-D receptor
(VDR) in many human cells suggests a role for vitamin-D in extra-skeletal diseases. Several cross-sectional studies
have associated lower vitamin-D status and decreased lung function. The present study was designed to find out
the association of serum vitamin-D concentration with pulmonary disorders like Tuberculosis, COPD and Bronchial
Asthma.
Methods:
A retrospective data collection of serum vitamin-D concentrations was performed between September 2013March 2014, for the patients attending the out-patient and in-patient clinics of PSG hospitals, out of which vitaminD levels of patients having the diagnosis of Tuberculosis, COPD and Bronchial Asthma were segregated and
analysed. Serum 25-OH Vitamin-D levels were measured by electrochemiluminescence. Normal serum reference
interval was 30-70ng/mL. The objective of the study was to determine the vitamin-D status in patients with these
pulmonary diseases. Vitamin-D levels of 20 - <30ng/mL was classified as vitamin-D insufficiency and levels
<20ng/mL were classified as vitamin-D deficiency(VDD). VDD was further classified based on Lips classification as
mild (10-<20ng/mL), moderate (5-<10ng/mL) and severe (<5ng/mL).
Results:
The mean age of the study group was 62.85В±15.64 years. Of the total 28 pulmonary cases, 12 (43%) had severe
vitamin-D deficiency, 2 (7%) had moderate deficiency, 5 (18%) had mild deficiency. Among the 14 tuberculosis
patients, (36%) 5 patients had severe vitamin-D deficiency. There were also 5 severe vitamin-D deficiency cases
among the 10 respiratory failure cases.
Conclusion:
Vitamin-D improves lung function by regulating inflammation, inducing anti-microbial peptides and its action on
muscle. Vitamin-D deficiency has been associated with lowered lung function in COPD and Bronchial Asthma, and
also in tuberculosis infections.
The reduced levels of serum 25-OH Vitamin-D in pulmonary diseases suggest optimization of serum vitamin-D
levels to improve the lung function among the general population.
P139
Title: A study on bode index as a predictor of severity in patients with Chronic Obstructive Pulmonary Disease.
Author: Dr. Manik Mahajan
Co-authors: Dr. Stani Francis(Prof & Head), Dr. Arti Shah(Asso. Prof),
Dr. Parth Shah (Asst. Prof).
Designation: 2nd Year Resident, Respiratory Medicine
Institute: Department Of Respiratory Medicine, SBKS Medical College & Research institute, Piparia, Vadodara.
Introduction:
Chronic Obstructive Pulmonary Disease (COPD) as defined by the Global initiative for chronic obstructive lung
disease is a disease state characterized by airflow limitation that is not fully reversible. According to WHO, COPD
was the 6th major cause of death in 1990 and is estimated to be the 3rd major cause by 2020. The present study
has been undertaken to determine the factors other than the lung function that affect the outcome in COPD
patients. The original BODE index ,body-mass index (B), degree of airflow obstruction (O) , dyspnea (D), exercise
capacity (E), measured by the six-minute–walk test, is a simple multidimensional grading system which is superior
to FEV1 alone for prediction of mortality and hospitalization rates among COPD patients.
Aims & Objectives:
To study the outcome of COPD patients by using BODE Index.
Method:
It is prospective observational study.
Total 50 adult patients with symptoms suggestive of COPD and who attended respiratory medicine department,
SBKS & MIRC were included.
The study was done to evaluate the BODE index as a predictor of hospitalization and severity in patients with
COPD.
Results: A total 50 COPD patients were enrolled in the study. 17 patients who had mild COPD with (BODE score
between 0 – 2). 16 patients had moderate (BODE score of 3 – 5) and 17 patients had severe COPD (BODE score
more than or equal to 6). The average age of participants in the study was 56.01yrs. Among the COPD patients,
BODE index was found to increase with age. The average BMI of the patients in this study was 21.58kg/m2. The
BMI was found to be significantly lower in patients with COPD.
Conclusion: BODE index is reliable method to predict hospitalization and the severity in patients with COPD and
which is relatively inexpensive.
Keywords: COPD; BODE Index
P140
Integrated Dose Counters: Technical Aspects and Functional Specifications
1
2
2
1
V NAIK , G MALHOTRA , K ROTE , DR J GOGTAY
1 Medical Services, Cipla Ltd., Mumbai, India
2 R&D Centre
Introduction
Currently there is no accurate test whereby the patient can estimate the number of doses remaining in a
pressurized metered dose inhaler (pMDI). As a result patients may underuse or overuse the pMDIs thereby
increasing the cost or the risk of not receiving the correct dose, respectively.
Cipla’s dose counter is integrated into the pMDI and shows the number of puffs remaining in the inhaler with its
use. It has been designed to satisfy the USFDA’s guidance on “integrated dose counters”, as well as meeting the
needs of patients and physicians.
Design Features
The dose counter is integrated with the canister thus maintaining count integrity while minimizing interference
with airflow and aerosol generation. No additional force is required to use a pMDI with a dose counter.
The counter starts slightly above label claim doses in order to take care of doses lost in priming and re-priming. The
last 40 doses are in red color, indicating the need to obtain a new pMDI, at position “0” the user knows that the
device is empty. However the pMDI is functional even beyond this point thus confirming with US FDAs guidance
that even partially therapeutic dose could be lifesaving.
Accuracy
Accuracy of count is a critical parameter and Cipla’s dose counter includes delivery of a dose without the possibility
of jamming the valve and displacement-driven design which eliminates the possibility of under-counting.
In vitro tests
Robustness has been confirmed by various in vitro studies including temperature cycling (hot, cold), drop testing,
transportation, contamination analysis, robustness testing, counting accuracy, and actuation force analysis.
Conclusion
Cipla’s dose indicator potentially provides reassurance and adds confidence on the usage of pMDIs, thus improving
adherence to treatment and enhancing the effectiveness of aerosol drug delivery by pMDIs.
P141
Profile of sensitivity to pollen allergens in the bronchial asthma patients attending a tertiary care hospital in Jaipur,
India by skin prick testing
1
2
R SEHAJPAL , S KOOLWAL
INSTITUTE OF RESPIRATORY DISEASES, SMS MEDICAL COLLEGE, JAIPUR
Objective : To determine the profile of sensitivity to pollen allergens in the bronchial asthma patients attending a
tertiary care hospital in Jaipur, India by skin prick testing .
Methods: Skin test reactivity for 20 pollen allergens was studied by skin prick testing, using buffer saline as
negative control and histamine phosphatase as positive control in 100 stable bronchial asthma patients ..
Immediate cutaneous responses were recorded at 20 minute after allergen challenge. Pollen antigens were
selected based on the local aerobiological calendar.
Results :Fifty seven percent of the patients had a significant positive reaction( >+2). 57.7% of the males and 56.3 %
of the females were found to be allergic to pollens.Pollen allergy was more common in urban population(64%)and
in the occupational groups it was common in office job workers (66.6%), shopkeepers(66.6%)and students(60.7%)
.Family history was positive in 40% of the patients. .Twenty three percent of the patients had positive reaction to
single pollen , 17 % to two pollens and 24% to three or more pollen.Tree pollen were the most common allergen in
the study population and among them Holoptelea integrifolia was the commonest pollen .Amaranthus spinosus
was the commonest weed pollen and Pennisetum typhoides was the commonest grass pollen having significant
positive reaction by SPT.
Conclusion: Airborne pollens are important causal factor of allergic diseases such as asthma . Therefore
identification of these pollens is important. Knowledge of profile of sensitivity may be useful to clinicians
managing patients suffering from respiratory allergies and allergen‑specific immunotherapy could be a viable
option for these patients.
P142
Understanding perception of COPD among doctors at different specialty levels in India: a face-to-face survey
Dr. ISHPREET KAUR, Dr. BHUMIKA AGGARWAL, Dr. JAIDEEP GOGTAY
Cipla Ltd., Mumbai, India (for all three authors)
Objective:
COPD in India remains highly under-recognized and under-treated despite high prevalence and diagnosis usually
does not occur until loss of significant lung function. This survey aimed to identify the existing barriers to an early
and proper diagnosis and treatment of COPD in India by exploring the attitudes, beliefs, and knowledge of Indian
doctors w.r.t. COPD.
Methods:
A cross-sectional study involving data collation through a questionnaire and face-to face interviews was conducted
in 91 randomly selected physicians (primary care physicians & internal medicine specialists) and pulmonologists
from 8 Indian cities.
Results
The response rate to the written questionnaire was 59.34% (54 out of 91). Majority of the doctors (57.4%)
reported that COPD patients usually visit them at severe stages. Lung function testing is not routinely performed
and diagnosis is largely symptom and history based - 44% physicians denied performing spirometry to make a
diagnosis of COPD. About 35% of physicians believed that COPD occurs only in smokers.
The most commonly reported challenges to diagnosis of COPD were a) spirometry related- access (22.22%),
interpretation (27.77%), patients’ unwillingness (44.44%), affordability issues (29.62%); b) doctor relatedinadequate training on COPD diagnosis (11.11% ) and c) patient related-lack of awareness about the disease.
Doctors’ perceived barriers to the treatment of COPD included difficulty in explaining COPD to patients (38.88%)
and poor compliance to treatment (42.59%).
Conclusion:
Lack of awareness about COPD, its symptoms and its implications contribute significantly in preventing people at
risk from reaching out to doctors. Inadequate use of or access to spirometry and the belief that COPD is a smoker’s
disease are important barriers to diagnosis. A large scale study will help to further understand the physician and
patient perceptions. Educational and awareness programs are needed both for doctors and patients to help
address the awareness-gap, under-diagnosis and under-treatment associated with COPD.
P143
Inspiratory flow rates using In-check Oral in patients of obstructive airway diseases in Indian population
DR. ISHPREET KAUR, DR. JAIDEEP GOGTAY, DR. BARDAPURKAR SUHAS,
DR. BARNALI BHATTACHARYA, DR. S. RAJU, DR. SHAILESH JAIN
Introduction:
The patient’s inspiratory flow has to be adeqaute to activate the dry powder inhaler or breath-actuated inhaler
and to guarantee optimal pulmonary drug deposition. Peak inspiratory flows (PIFs) are dependent on the patient's
inhalation effort and device resistance. Optimal inspiratory flow rates may not be achieved in few patients,
-1
especially in children or elderly COPD patients. PIFs >60 l.min are generally accepted to be the optimal flows for
-1
most of the devices, while PIFs < 30 l.min are believed to be insufficient.
Methods:
The present study measured PIF rates in patients (n=178) with asthma including children and with COPD
including elderly. PIF was measured using the In-Check Oral (Clement Clarke International Ltd, Harlow, UK). The
highest value of the three attempts was recorded.
Results:
-1
-1
The mean (В± SD) PIF was 201.89 (В±82.74) l.min and 134.78 (В±61.85) l.min in patients with asthma (n=132; mean
age=35.88 years) and COPD (n=46; mean age=64.54 years), respectively. Paediatric (≤12 years) asthma (n=22,
mean age=7.98) and severe COPD patients (n=34, mean age=64.41) demonstrated a mean (В± SD) PIF of 124.54
-1
-1
(В±50.68) l.min and 124.70 (В±60.46) l.min , respectively; these subgroups representing two ends of the spectrum
-1
with the lowest PIF values. The lowest PIF recorded was 40 l.min in 3 patients (2 elderly severe COPD patients and
1 paediatric asthma patient). PIF correlated positively with FEV1% (r=0.53). PIF showed a strong positive correlation
with age till 12 years (r=0.60) while for 13 to 84 years it showed a moderate negative correlation (r= -0.50). PIF
correlated positively with height (r=0.51) and negatively with severity of asthma and COPD.
Conclusion:
The present study demonstrates the ability across all age groups, including children and elderly patients, to
generate sufficient inspiratory flow, irrespective of the severity of asthma or COPD.
P144
Abstract
Title –ECG and ECHO correlation in COPD patients in Tertiary health care centre.
Authors-Dr Nikhilesh Pasari, Dr Ashok Bajpai, Dr Bhupendra Jain.
Sri Aurobindo Institute Of Medical Sciences & PG Institute Indore,India
Objective-To observe correlation in ECG and ECHO findings with COPD severity.
Methods- A prospective study of 80 patients( pts) over a period of 7 months Jan 2014 to July 2014 are recruited at
Sri Aurobindo Institute Of Medical Sciences Indore in Dept of Pulmonary Medicine and detailed history, clinical
evaluation,spirometry,2D Echo & ECG obtained.
COPD severity is categorized based on GOLD Guidelines and data were analysed by Fisher’s Exact Test and p<0.05
considered significant.
Results-We found that maximum number of pts was of grade 2 (42.50%) among which significant association
between presence of P pulmonale and COPD grading was observed. ECG changes (P pulmonale) were observed.
Grade 1 COPD 0% pt. was having P pulmonale while in
Grade 4 91.66% ,pts were having the same. (P<0.001)
Signifiacant association with echo findings was observed that maximum Grade 4 COPD pts were having moderate
PAH. (P<0.007) while Cor pulmonale was present in 50% of cases in grade 4 COPD ( p<0.005)
Conclusion-Stages of COPD is significantly proportional to ECG changes
consider as a non invasive and easily available screening tool.
P145
& Echo findings in COPD pts.&
A rare cause for Hypercapnic respiratory failure
Dr Janso KOLLANUR, Dr Vishnu SHARMA M., Dr.Alka BHAT, Dr Harsha D. S.
Department of Respiratory Medicine, A. J. Institute of Medical Sciences, Kuntikana, Mangalore, 575004.
INTRODUCTION
Hypercapnic respiratory failure can be a manifestation of neuromuscular weakness due to various causes.
CASE REPORT
A 55 year old female presented with breathlessness of 8 months duration increased since 1 week. There was no
history suggestive of asthma or COPD neither did she give any occupational exposure. Thyroidectomy was done 12
years back and she was on thyroxine 100mcg daily.
On examination she was conscious, oriented, had pulse rate of 96/min, respiratory rate of 32/min and oxygen
saturation of 82% with room air. Chest examination revealed normal vesicular breath sounds with bilateral basal
crepitations and few scattered rhonchi. Thyroid function tests were within normal limits. Chest x-ray showed
bilateral basal infiltrates. ABG showed metabolic alkalosis with hypercapnic respiratory failure.
Despite adequate bronchodilators, antibiotics and NIV, patient did not improve. She developed focal seizures one
day after admission. On further enquiry patient gave history of 3 episodes of seizures 3 months back. CT head was
normal. Nerve conduction study showed mild asymmetrical sensory motor axonal peripheral neuropathy. Serum
calcium level was 4.4mg/dl. Vitamin D3 level was 13.65ng/ml, parathormone level was 139.7pg/ml and urine
calcium was 4.1mg/dl. A diagnosis of Post thyroidectomy hypothyroidism, hypocalcaemia with
pseudohypoparathyoidism with hypercapnic respiratory failure secondary to hypocalcaemia was made. She made
uneventful recovery with calcium supplementation and other supportive treatment.
CONCLUSION
This case report aims to highlight the fact that neuromuscular weakness secondary to electrolyte imbalance can
lead to Hypercapnic respiratory failure and should be considered in differential diagnosis of causes for Hypercapnic
respiratory failure.
Effect of oral montelukast in acute asthma
1
B CHOGTU*, S HAMEED , R MAGAZINE
P146
1
1
Department of Pharmacology, Department of Pulmonary Medicine , Kasturba Medical College, Manipal University,
Manipal, Karnataka-576104, India
Objectives: Montelukast is used in prophylaxis of asthma. Studies have shown that it has a beneficial effect in
asthma exacerbations. Hence, the study was done to evaluate the effect of oral montelukast as an add on therapy
in patient with acute severe asthma
Methodology: It was a randomised, prospective study conducted in department of Pulmonary Medicine. After
obtaining Institutional Ethics Committee clearance, the patients presenting to emergency triage from September
2012 to March 2014 with a primary diagnosis of acute exacerbation of asthma requiring hospitalisation, were
included in the study. Informed consent was taken from the patients prior to inclusion. History, physical
examination and laboratory investigations were recorded as per the proforma. Baseline peak expiratory flow rate
(PEFR) was measured. All patients received standard treatment for asthma exacerbation and were randomised
into 2 groups. Patients in group1 and group 2 received a placebo tablet and oral montelukast 10mg respectively at
baseline. The investigational medications were continued once daily till the patient was discharged from the
hospital. Nebulised salbutamol 2.5 mg was given as rescue medication. PEFR values, details of rescue medication
and vital signs were recorded at 6 hours, 12 hours, 24 hours and 48 hours of drug or placebo administration and at
discharge. The data was analyzed using SPSS software v20.0.
Results: Of the total enrolled patients, 50 were randomized to placebo group and 40 patients to the montelukast
group. Repeated measures ANOVA was used to compare the mean change in PEFR. The values at the various time
points between the two groups were not statistically significant (p=0.189). However, the patients in the
montelukast group required significantly lesser number of rescue medications than the placebo group (p=0.049).
Conclusion: Montelukast decreases the need for rescue medication in acute severe asthma.
P147
Title: Co-relation between risk factors of asthma and severity of the disease.
Author: Dr. Rahul PANDYA.
Co-authors: Dr. Stani FRANCIS, Dr. Arti SHAH, Dr. Parth SHAH.
Introduction: Asthma is a major cause of chronic morbidity and mortality throughout the world and asthma’s
prevalence has increased considerably over past 20 years, mostly young adults. Globally asthma affected 235 to
330 million people in 2011, out of which 70-80% patients belong to developing countries. India has an estimated
15-20 million asthmatics, with prevalence rising more in recent decades. Worldwide, the economic costs
associated with asthma exceed those of
TB and HIV/AIDS combined.
Aims & Objectives: To analyse the pattern of asthmatics in terms of environmental factors, indoor environment,
ETS (Environmental Tobacco Smoke), occupational exposure, obesity, socio-economical status and correlate them
with severity of their asthma.
Methods: It is a prospective, observational type of study. 50 diagnosed patients of asthma were included in the
study and their detailed clinical history was taken. Severity of the asthma was calculated based on frequency of
asthma attacks, PFT values and FEV reversibility.
Result: Out of 50 patients, the severity of asthma was as below:
Co-existing allergic conditions were found in 30 asthmatics, while 40 had exposure to indoor or outdoor triggers.
Conclusion: Severity of asthma was more with sedentary life-style, lower socio-economical status, occupational
triggers, and indoor environmental triggers. Asthma was severe in smokers and ever-smokers. Presence of coexisting other allergic conditions resulted in poor prognosis of asthma.
P148
Effect of Inhaled Anticholinergic Drugs on Intraocular pressure In Chronic Obstructive pulmonary disease
patients
YADAV PRASHANT, CHAUDHRI SUDHIR, KUMAR ANAND, VERMA SANJAY, KUMAR AVDHESH
GSVM Medical College, Kanpur, Uttar Pradesh, India
Objective: The objective of this study is to know the effect of inhaled anticholinergics (Tiotropium/ Ipratropium
bromide) on intraocular pressure in COPD patients and to evaluate their safety in potential glaucoma patients.
Glaucoma is frequently seen in patients with chronic bronchitis who require treatment with nebulized Beta2
agonists and ipratropium due to accidental instillation in eyes. Significance of anti cholinergic drugs used as
inhalers by Chronic Obstructive Pulmonary Disease (COPD) causing raised intraocular pressure is unknown.
Methods: Initially 132 patients were included. 14 patients were excluded because on initial examination they had
hyper mature senile cataract. 10 patients were excluded because they were not co-operative with the study
protocol. Included patients were divided into 70 patients (study group) who received Ipratropium or Tiotropium
with formetrol and fluticasone as Metered dose Inhaler (pMDI) and 38 patients(control group) took formetrol with
fluticasone without ipratropium / tiotropium. General ophthalmic examination, and Gonioscopy was done as pretreatment. Intra-ocular pressure measurement done in all patients before starting treatment, 2 hours after first
dose and thereafter weekly for four weeks.
Results: Out of 108 patients, 73 were males and 35 were females. Mean age of patients was 64 years. Out of 70
patients (study group) 13 showed increase in intraocular pressure (IOP), 57 did not show any change. The
maximum increment was 4mmHg. In Control group 33 out of 38 did not show any change in IOP, only 05 showed
increment
of
IOP.
The
maximum
increment
was
2
mmHg.
Conclusion: The inhaled anticholinergics all by Metered Dose Inhalers did not lead to any significant change in
st
nd
rd
th
intraocular pressure (IOP) after 2 hours, 1 , 2 , 3 and at 4 week of starting treatment. All values of intraocular
pressure are within normal clinical range.
P149
Correlation of spirometry with impulse oscillometry, body plethysmography and DLCO
VANJARE N, KODGULE R, RASAM S, BHOSALE S, SALVI S
Chest Research Foundation, Pune, India
Background: Spirometry, Impulse Oscillometry (IOS), Body Plethysmography (BP) and DLCO are tools that measure
different aspects of lung function. However, there is inadequate knowledge about the correlation between the
parameters measured by these tests.
Aim: To study the correlation of spirometry indices with values measured by IOS, BP and DLCO.
Methods: In this ongoing study 4 healthy, 9 asthma and 10 COPD patients underwent IOS, BP, spirometry and
DLCO according to the international guidelines. Correlations between values obtained by IOS (R5, R20, and R5-20),
BP (sGawtot, sGaweff, RV, TLC), spirometry (FEV1, FVC, FEF25-75%) and DLCO were analyzed using Pearsons’s
correlation.
Results: R5, R5-20 and DLCO correlated with FEV1 (r=-0.55, -0.61 and 0.87, all p<0.05) suggesting that small airway
resistance increased and DLCO decreased linearly with reduction in FEV1. The correlation of FEV1 was highest with
sGawtot and sGaweff (r=0.96, p<0.01 for both). FVC correlated with all the measured parameters suggesting that
FVC is reflective of overall lung function (all p<0.05). Small airway parameter FEF25-75% correlated best with
sGawtot and sGaweff (r=0.911 and 0.914, both p<0.01) and also correlated with R5 and R5-20 (r=-0.5 and p<0.05
for both). Neither FEV1 nor FEF25-75 correlated with R20 (p>0.05). sGawtot and sGaweff correlated best with
FEF25% (r=0.95, p<0.01 for both).
Conclusion: sGaw reflects more distal airways than R5 and R5-20. FEV1 majorly reflects small airway obstruction
and FVC is a measure of overall lung function. DLCO decreases linearly as FEV1 decreases.
P150
Can Impulse Oscillometry and Body Plethysmography differentiate response to two salbutamol doses?
VANJARE N, KODGULE R, RASAM S, BHOSALE S, SALVI S
Chest Research Foundation, Pune, India
Background: Impulse Oscillometry (IOS) and Body Plethysmography (BP) are more sensitive in differentiating
between mean percentage responses to sequentially increasing bronchodilator doses. However, whether IOS and
BP can differentiate bronchodilator response between single doses of different strengths of bronchodilator is not
known.
Aim: To study the effect of 100 and 400 mcg of salbutamol on Impulse Oscillometry and Body Plethysmography
parameters?
Methods: In this ongoing study, 9 asthma and 10 COPD patients were randomized to receive either 100 mcg or 400
mcg of inhaled salbutamol in a cross-over manner. Impulse Oscillometry to study resistances at 5 Hz, 20 Hz and 520 Hz (R5, R20 and R5-20), body plethysmography to study specific airway conductances -sGawtot and sGaweff
and spirometry to study FEV1 and FEF25-75 was done before and 30 min after drug administration. Within group
changes were analyzed by paired t-test and the within-group changes were analyzed using independent t-test and
ANCOVA.
Results &Conclusion: R5, R20, R5-20 and FEF25-75% showed maximum differentiation between two doses. All
parameters showed significant change after bronchodilation with 100 and 400 mcg of salbutamol (Table 1)
Table 1: Mean percent change (MPC) in asthma &COPD
Mean percent change (MPC) in asthma
MPC
Parameters
100 mcg
FEV1
26.8
FEF25-75%
39.69
sGawtot
52.03
sGaweff
59.81
R5
-18.28
R20
-7.6
R5-20
-23.72
Mean percent change (MPC) in COPD
MPC
Parameters
100 mcg
FEV1
16.31
FEF25-75%
7.9
sGawtot
43.25
sGaweff
46.82
R5
-9.2
R20
-16.31
R5-20
-19.41
P151
Std
dev
17.35
48.71
26.6
23.86
34.06
19.29
59.61
MPC
400 mcg
30.63
71.18
40.36
50.7
-26.86
-18.44
-30.96
Std.
dev
19.83
38.94
90.65
6.25
36.84
17.09
74.98
Std
dev
13.5
16.27
21.48
30.18
21.33
15.73
23.76
MPC
400 mcg
14.07
18.92
50.4
49.65
-14.78
-10.37
-22.67
Std.
dev
15.82
33.48
51.08
51.26
17.03
16.55
23.94
В®
Confidence, usability, preference, satisfaction and errors with use of Revolizer : A single dose dry powder inhaler
(SDDPI) for patients with obstructive airway disease (OAD).
1
1
1
2
2
SK RAJAN , S SHRIVASTAVA , I BUBNA , SP JADHAV , PV LONDHE , JA GOGTAY
1
2
2
Bhatia General Hospital, Mumbai, India, Cipla Ltd. Mumbai, India
Objective: Optimal management of obstructive airway disease depends on adequate drug delivery to the airways. The
choice of device therefore becomes pertinent. Ease of use should be given careful consideration when prescribing a
device to patients. The objective of this study was to assess the confidence, usability, preference, satisfaction and
В®
errors associated with the use of Revolizer , a single dose dry powder inhaler (SDDPI) in India.
Methods: 100 participants [50 healthy and 50 with obstructive airway disease (OAD)] of 18 years and above were
enrolled in the study. At visit 1, the technique of using the device was explained and demonstrated twice by the
investigator. Participants then repeated the procedure until they achieved three consecutive correct attempts. At visit
2 (two days later), participants made a single attempt before receiving demonstration from the investigator. They then
repeated the steps until three consecutive correct attempts were made. At both visits, time taken to achieve three
consecutive correct attempts was noted. The number and type of errors were recorded. The participants were asked to
answer a questionnaire at both visits.
Results: 100 participants (54 women, 46 men) with a mean (SD) age of 42 (+14) years were enrolled in the study. The
mean time taken for three consecutive correct attempts at visit 1 was 3.75 (2.10) minutes and at visit 2 was 3.07 (1.32)
minutes (p<0.001). Patients who made critical errors were 38 and 28, while non critical errors were 49 and 38 at two
visits respectively. Most of these were device independent. Out of 48 patients who were using an inhaler device, 78%
В®
preferred Revolizer over their current device.
В®
Conclusion: Revolizer , a SDDPI is easy to use and scores high on confidence, preference and satisfaction in patients
with OAD.
P152
Usability, confidence, preference, satisfaction and errors with the use of spacers: a combined analysis of results from
three studies
1
2
3
3
S SALVI , S RAJAN , SP JADHAV , PV LONDHE J GOGTAY
1
2
3
3
Chest Research Foundation, Pune India, Bhatia General Hospital Mumbai, India, Cipla Ltd., Mumbai, India
Objectives: Errors with the use of pressurized metered-dose inhalers (pMDIs) reduces lung deposition and increases the
local and systemic side effects. The use of a spacer reduces these errors. The objectives of these studies were to assess
the usability, confidence, preference and satisfaction with the use of three spacers (Zerostat, Zerostat V and Zerostat VT)
in three different but identically designed studies.
Methods: The three studies were open-labelled, prospective and single center conducted in healthy volunteer and
patients with mild asthma and COPD. The study consisted two visits. In these two study visits , the patients were trained
to use the device at visit 1 and again at visit 2, and the average time taken for three consecutive correct attempts was
reported (primary endpoint). The secondary endpoints included number and type of errors (critical and non-critical), and
scores on usability, confidence, preference, and satisfaction questionnaires.
Results: A total of 90 participants (30 participants per study, 1:1 healthy volunteers: patients with asthma/COPD)
completed these studies. The average time taken for three consecutive correct attempts in patients with asthma/COPD in
the three studies decreased at visit 2 (2.99, 4.65 and 1.91 minutes) from visit 1 (3.58, 4.99 and 2.23 minutes),
respectively. The critical and non-critical errors also decreased at visit 2 from visit 1. Overall reduction in the scores at
visit 2 was also observed on the usability, confidence, preference and satisfaction questionnaires.
Conclusion: Zerostat, Zerostat V and Zerostat VT spacers are easy to learn, understand and operate. This highlights the
fact that the spacer devices can be recommended for all patients finding difficulty in using a pMDI.
P153
Evaluation of efficacy and safety profile of Fluticasone/ Formoterol (FF) combination versus
Budesonide/Formoterol (BF) combination administered through a pressurized Metered Dose Inhaler (pMDI) in
patients with moderate to severe persistent asthma- : A randomized controlled trial.
A BALKI1; S DALAL2; A SINGH3; S BARDAPURKAR4; S BALAMURUGAN5; B SINGH6; R MEHTA7; SURYAKANT8; S
BHARGAVA9; B TRIVEDI10; A ARYA11; S PAPINWAR12; S CHANDRATRE 13; B MUTHA14; K PODDAR15; P.
PHOPALE16; A VAIDYA 16; J GOGTAY16.
1Chest Care Hospital, Nagpur, India; 2Ashray Chest Center, Vadodara, India; 3Asthma Bhavan, Jaipur, India;
4Shree Nursing Home, Aurangabad, India; 5Dr.Balamurugan's Chest Clinic, Chennai, India; 6Surya Chest
Foundation, Lucknow, India; 7Dr. Mehta's Allergy, Asthma Care And Research Center, Indore, India; 8Research
Department, India; 9Gyanpushp Research Center For Chest And Allergy Diseases, Indore, India; 10Nashik Health
Care And Research Centre, Nashik, India; 11Center For Chest Diseases, Delhi, India; 12 Dr. Papinwar Hospital,
Aurangabad, India; 13Shatabdi Super Speciality Hospital, Nashik, India; 14Mutha Hospital, Nashik, India;
15Chest, Asthma And Allergy Clinic, Kolkatta, India; 16Cipla Ltd India.
Objective:
Combination of an inhaled corticosteroid (ICS) and long-acting beta agonist has become the mainstay of
treatment of asthma when not controlled by ICS alone. A number of combination inhalers are already available,
but there is scarce data on the combination of FF in a single inhaler. Hence, this study was conducted to evaluate
efficacy and safety of FF 125/6 mcg pMDI combination versus BF 200/6 mcg pMDI combination in patients with
moderate to severe persistent asthma.
Method:
This was a double blind, prospective, active controlled, parallel group, multicenter study, with a 2-4 weeks runin period during which patients received budesonide 100 mcg, 2 puffs twice daily. 232 patients, symptomatic
with ICS alone, were randomized to receive either of the active treatments at a dose of 2 puffs twice daily for
12 weeks.. Levosalbutamol was provided as rescue medication. Spirometry and subject diary assessments were
performed at 2, 4, 8, and 12 weeks. Adverse events (AE) were assessed at all visits.
Results:
232 patients (117 - FF and 115 - BF group) were enrolled, out of which 59% were males and average age was 41
years. Both FF and BF produced a statistically significant improvement within group in mPEFR from baseline to
12 weeks (48.07L/min and 49.03 L/min respectively (p<0.005) and the difference between the two groups was
not significant (p>0.005) (difference of -0.96 L/min, 95% CI: -2.38L to 0.46L). Improvement was observed from
baseline in FEV1, evening PEFR, nighttime symptoms and rescue medication within both group at all treatment
visits. BF reduced day time symptom scores over FF (p=0.0326). There was no difference observed in frequency
of AE.
Conclusion:
This study showed comparable efficacy and safety data of FF to BF in terms of primary & secondary endpoints.
P154
Comparison of a novel fixed dose combination (FDC) of nebulized formoterol/budesonide with pMDI
formoterol/budesonide FDC in patients with severe to very severe COPD
S SALVI1; H PANDYA2; A GHOSAL3; R DHAR4; S WALANJ5; N BOYILLA6; V DESHMUKH7; B TAYADE8; V NANGIA9;
S JADHAV10; P PHOPALE10; A VAIDYA10; J GOGTAY10
1Chest Research Foundation Pune, India; 2Sheth LG Hospital and AMC Met Medical College, Ahmedabad, India;
3National Allergy Asthma Bronchitis Institute Kolkata, India; 4Fortis Hospital Kolkata India; 5Ethika Clinical
Research Center Kalwa India; 6Axon Hospitals Hyderabad India; 7Nagpur Chest Centre Nagpur India; 8NKP Salve
Institute Of Medical Sciences & Lata Mangeshkar Hospital, Nagpur India; 9Fortis Flt. Lt. Rajan Dhall Hospital New
Delhi India; 10Cipla Ltd., India.
Objective:
To evaluate efficacy, safety and tolerability of 20 mcg/1mg of FB neb with 6/200 mcg of FB pMDI in patients
with severe to very severe COPD
Method:
In this open-label, prospective, active-controlled, parallel group, 6 weeks, multicentre study, patients were
randomised (2:1) after 2 weeks of run-in period to receive either FB neb or FB pMDI, with a non-static spacer,
twice daily for 6 weeks. Combination of ipratropium 40 Вµg & levosalbutamol 50 Вµg, 2 puffs, thrice daily was
provided in run in period. Levosalbutamol 50 Вµg pMDI was provided as rescue medication.Primary efficacy
parameter was difference in mean change in trough FEV1 at the end of 6 weeks. Others included FVC, FEF25-75
and subject diary assessment at the end 2, 4 and 6 weeks.
Results:
113 patients (96.43% males) were randomized, with a mean age 62 В± 9.11 years. Data of 94 patients with a
mean baseline post bronchodilator (PB) FEV1% predicted 35.91% with reversibility 10.44% was analyzed. At the
end of 6 weeks, the difference in the change in trough FEV1 between FB neb and FB pMDI was not significant (30
ml, 95% CI (-0.05L, 0.11L) (p=0.42)). Similar results were seen for PB FEV1, FVC and FEF25-75. There was a trend
towards significance in the PB FEF25-75 at week 6 vs baseline in FB neb group (p=0.05) but not in the FB pMDI
group. Use of rescue medication and adverse events were similar in both groups..
Conclusion:
FB neb is as efficacious, safe and well tolerated as FB pMDI and can serve as an alternative treatment option in
patients with severe to very severe COPD who are unable to use handled inhalers.
P155
TITLE: D-dimer level in acute exacerbation of COPD.
AUTHOR: P.PERIWAL, A.K SINHA, K. SAINI, D.TALWAR
INSTITUTION: Pulmonary Medicine and critical care, Metro centre for respiratory diseases, Noida, Uttar Pradesh, India.
INTRODUCTION: Acute exacerbations of COPD are associated with increased airway inflammation, causing imbalance in
the endothelial- coagulation system, resulting in a potential prothrombotic stimulus. D-dimer is a marker of fibrin
turnover but is also used as a predictor of pulmonary thromboembolism (PTE) in the absence of sepsis and trauma. It is
elevated in a number of inflammatory conditions including acute exacerbations of COPD.
METHODS: D-dimer levels of 27 consecutive known cases of COPD with acute exacerbations admitted in Respiratory ICU
were evaluated, their values were adjusted for age (defined as age * 10 in patients 50 years or older) and statistical
analysis of the data was done.
RESULTS: Of the 27 patients admitted with acute exacerbation of COPD, 66.66% were male and 33.33% were female. The
mean age of the admitted patients was 66.81+/-9.8 years. The mean D-dimer level in these patients was 3107.9 +/2882.7 ng/ml. 26 patients were >= 50 yrs of age. The mean age-adjusted D-dimer cutoff was 675.7+/-91.8 ng/ml. All
these patients underwent MDCT thorax and that revealed no evidence of PTE or pneumonia.
CONCLUSION: D-dimer level is elevated upto 4.6 times in acute excacerbations of COPD and is not a useful screening test
for PTE.
CLINICAL IMPLICATION: D-dimer cannot be used as a screening tool for pulmonary embolism in COPD with acute
exacerbation. Futher studies are required to evaluate the D-dimer cutoff value that can be used to screen PTE in the
patients of COPD exacerbation.
P156
TITLE: - Adequacy of inhaler technique in COPD & asthma patients attending a tertiary care hospital in Navi
Mumbai.
AUTHORS: - Dr. Akanksha Das, Dr. Jayalakshmi T.K., Dr. Girija Nair, Dr. Lavina
Michandani, Dr. Mugdha Bhide.
OBJECTIVES: - Chronic obstructive pulmonary disease (COPD) & asthma are major concerns to health care system.
Improper inhaler device used (Metered dose inhaler/ Dry powder inhaler) is one of the major causes associated
with inadequate control of the disease. This study was performed to evaluate the inhaler technique among
patients and to investigate factors associated with improper use and whether age or gender was associated with
poor inhaler technique.
Methods:- A cross-sectional study of all patients who visited chest out- patient department with asthma or COPD
over a 6 months period in a tertiary care hospital in Navi Mumbai. Information was collected about demographic
data and inhaler technique was assessed using a standard checklist.
Results: - There were 107 patients, 71 with asthma and 36 with COPD. Inhaler techniques of 95% of patients were
found to be inadequate in some form or the other as per check- list Of all the patients interviewed, only about
60% of patients recalled, that demonstration was done by doctors or other health care professionals. Twelve
percent were instructed by pharmacists and remaining followed their friend’s or relative’s suggestions along with
insert literature.
Conclusion: - The inhaler technique is inadequate among most patients. On every visit patient’s inhaler technique
should be observed and adequate suggestions should be given to correct any deficiencies.
P157
An Observational Study Of Risk Factors For Hospitalization Of Chronic Obstructive Pulmonary Disease
Exacerbation And Their Outcome
DR. S. BARMAN, DR. S. K. SAMANTA, DR. A. DATTA, DR. P. BISWAS
Department of Pulmonary Medicine, Fortis Hospitals Kolkata
Objectives
By 2020 chronic obstructive pulmonary disease will be fifth leading cause of disability and third leading cause of
death worldwide. By 2030, fourth leading cause of death. If risk factors of hospital admission can be identified
preventive measures can be taken to affect outcome and reduce the economic burden. This study aimed to study
risk factors associated with acute exacerbation, study the quality of life and evaluate the ultimate outcome of
these patients.
Method
Using a preformed structured questionnaire; relevant blood parameters including C-reactive potein, Pulse
oxymeter, Spirometry, Echocardiography, arterial blood gas analysis to assess risk of exacerbations and outcomein
last one year.
Results
Of 60 patients included in study, majority are above 60 years (56.6%) with male predominance (80%) and 17
patients (28.3%) died during hospitalization. Advancing age (p value < 0.001), smoking status (p value < 0.001),
duration of symptoms (p value < 0.004), FEV1 (GOLD grade p value < 0.001), past hospitalization (value < 0.018),
Body mass index(p value < 0.005), Dyspnea scale (p value < 0.001) were statistically significant relating to
exacerbations whereas sex is found to be statistically insignificant (p value 0.857).
Conclusion
Identification of risk factors of exacerbation helps respiratory specialists to extend their expertise to broader
diagnostic and treatment. But the study has limitation of hospital based Barkesonian bias.
P158
Number of pack year smoked increases frequency of COPD exacerbation per year
Mohit Bhatia, J.K.Samaria, Ganeshee Lal Sharma
Department of TB chest and respiratory diseases S.S. hospital IMS BHU Varanasi.
Objective:
Smoking is the most important risk factor involved in pathogenesis of COPD. Quantification of the risk due to
smoking has done in form of pack per year (1). We investigate effect of increase quantity of risk factor (pack years)
on the frequency of COPD exacerbation per year.
Method:
We evaluated 50 patients of COPD and classify them in 4 groups according to number of pack year smoked.
Group- 1(o pack years, the non-smokers), group-2 (1-10 pack years), group-3(11-20 pack years), and group-4 (>20
pack years). We excluded group-1 from our study as some of non-smokers had other risk factors like exposure to
biomass fuel etc. which are difficult to quantify. We obtain record of total number of exacerbation of COPD in last
one year for all the patients included in study. Obtained data was analysed statistically.
Results:
In our study we found that mean value for group-2 was 0.12 (with standard deviation of + 0.35), for group-3 it was
1.25(with standard deviation of + 1.0) and in case of group-4 it was 1.55(with standard deviation of + 1.5). Number
of pack per year has significant positive correlation with frequency of COPD exacerbation per year (f-value= 4.203,
p-value= 0.024).
Conclusion:
As the numbers of pack year smoked increases risk of exacerbation of COPD increases.
References:
1.Cigarette Calculator - American Cancer Society www.cancer.org › Stay Healthy › Tools and Calculators ›
Calculators
P159
Agreement between the spirometry criteria and peak expiratory flow rate criteria in diagnosing bronchial
asthma – a prospective observational study
Rishabh Priyadarshi, Seshadri Varadarajan, Suganya, A Suresh
Sundaram Medical Foundation, Chennai
Objective:
To compare the spirometry criteria (post bronchodilator reversibility of 200 ml plus 12% in FEV1 and/or FVC –
GINA & ATA/ERS) and peak expiratory flow rate criteria (post bronchodilator reversibility of 60 L/mt or 20% - GINA
2013) in diagnosing bronchial asthma.
Study period: October 2013 to July 2014
Materials and Methods:
The spirometry (Ganshorn spirometer) reports of all patients during the above period were collected. Peak flow
recording (pre and post bronchodilator) using Wright’s peak flow meter, was done additionally during the
spirometry tests and was mentioned in the reports.
The reports of those patients who showed positive bronchodilator response in PEFR (GINA) and those with
significant FEV1 (GINA &ATS/ERS) and/or FVC (GINA &ATS/ERS) reversibility were isolated. The sensitivity and
specificity of PEFR method in diagnosing asthma was calculated in comparison with the spirometry method.
Results:
There were 258 spirometry reports during the above period and all the reports had the documentation of pre and
post peak expiratory flow rates (PEFR) measured simultaneously. Sixty six out of 258 reports showed positive
bronchodilator response in FEV1 and/or FVC, which means 66 (25.6%) patients’ reports were consistent with the
diagnosis of asthma. PEFR reversibility was seen in 33 (12.8%) patients’ reports. Twenty one out of 33 PEFR
positive patients were also positive for spirometry criteria (FEV1 and/or FVC reversibility) and the remaining twelve
patients were positive for PEFR criteria alone.
FEV1 and/or FVC positive (DISEASE)
FEV1 and/or FVC negative
(DISEASE)
PEFR positive (TEST)
21
12
PEFR negative (TEST)
45
180
PEFR in comparison with spirometry as a gold standard showed,
Sensitivity: 31.8%
Specificity: 93.75%
Positive predictive value: 63.6%
Negative predictive value: 80%
Though the PEFR reversibility has a good specificity, it seems to have a poor sensitivity in diagnosing asthma.
Hence further testing with spirometry would still be required for the confirmation of asthma in patients with
absence of PEFR reversibility.
Conclusion:
Peak expiratory flow rate (PEFR) measurement, though a simple method in a resource limited setting, is a doubtful
parameter in asthma diagnosis.
P160
FeNO and serum IgE do not correlate with asthma assessment tests in Indian untreated severe asthma patients
Authors: Mayuri Johari, Deepak Talwar
Metro Centre for Respiratory Diseases, Noida, India
Objectives: Severe asthma patients demonstrate chronic inflammatory changes in the airway , severity being
ascertained by assessment scores. FeNO and Serum IgE are well-establisehd markers of atopic inflammation. This
study correlates FeNO and total serum IgE with asthma assessment scores in 50 adult untreated Indian patients
with severe asthma. Smokers and ex-smokers were excluded from the study.
Methods: 50 untreated patents of asthma satisfying the latest WHO criteria for adult severe asthma, attending
outpatient clinic of Metro Centre for Respiratory diseases were retrospectively analyzed for their clinical
symptoms, assessment scores and atopic biomarkers in the last two years using SPSS software.
Results: Severity assessment of asthma was done with asthma control test (ACT) in 34 patients and asthma control
questionnaire (ACQ) in 16 patients, and FeNO and Serum total IgE done in all patients included in the study. The
mean ACT score was 13.44 + 3.71and mean ACQ score of 3.07 + 1.59. The mean FeNO was 62.09 + 52.96 parts per
billion(ppb) and the mean IgE value was 540.54 + 705.12 IU/ml. The cut-off value for FeNO to be considered as
raised was 50ppb and 168 IU/ml for serum total IgE. There was inverse relationship of FeNO and Serum total IgE
with Asthma control test(ACT) and Asthma Control Questionnaire(ACQ)(p>0.05)
Conclusions: FeNO and serum total IgE do not correlate with ACT and ACQ scores in adult severe asthma patients.
Clinical implications: Severe asthma, caused by varied etiologies, may be atopic or non-atopic phenotype. Western
studies show improvement in the assessment scores and atopic biomarkers corticosteroid treatment. However, in
view of lack of data in severe untreated asthma, studies are required to correlate these variables in this subset of
population.
P161
FeNO and serum IgE do not inter-correlate in untreated severe asthma in adult Indian patients.
Authors: Mayuri Johari, Deepak Talwar
Metro Centre for Respiratory Diseases, Noida, India
Objectives: Both serum IgE and FeNO are biomarkers of atopic inflammation, which is a hallmark of asthmatic
airways. This study inter-correlates FeNO and total serum IgE in 50 adult untreated Indian patients with severe
asthma. Patients with a history of smoking were excluded from the study.
Methods: 50 untreated patents of asthma satisfying the latest WHO criteria for adult severe asthma, attending
outpatient clinic of Metro Centre for Respiratory diseases were retrospectively analyzed for their clinical
symptoms, assessment scores and atopic biomarkers in the last two years using SPSS software.
Results: FeNO and Serum total IgE were done in all patients included in the study. The mean FEV1 was1.85 + 0.67
liters and FeNO was 62.09 + 52.96 parts per billion(ppb) with a mean IgE value was 540.54 + 705.12 IU/ml.
According to the standard cut-off values, FeNO was raised in 23 patients (more than 50ppb), 13 patients had
borderline raised values (between 25 to 50 ppb) and 12 patients showed normal values (less than 25 ppb). Total
serum IgE was raised in 36 patients (more than 168 IU/ml) and normal in remaining 14 patients with a mean of
79.57 IU/ml. FeNO and total serum IgE showed negligible inter-correlation (r= 0.02, p>0.05).
Conclusions: FeNO and serum total IgE do not inter-correlate in adult untreated severe asthma patients.
Clinical implications: While both serum IgE and FeNO are markers of atopic inflammation, studies show conflicting
data between the two variables. This could be due to varied etiologies of severe asthma including atopic or nonatopic phenotypes. However, in view of limited data in severe untreated asthma, studies are required to correlate
these variables in this subset of population.
P162
To determine the prevalence pattern of aeroallergens in patients of Bronchial Asthma and Allergic Rhinitis
reporting to a tertiary care centre in western UP.
A Jain, M Saluja, S Singh, S Kumar, S R Yadav
Subharti Medical College, Meerut, India
Allergens have been associated with diseases such as BA (Bronchial Asthma) and AR (Allergic Rhinitis) which are of
most concern, among the patients visiting the chest physicians. Exposure to various aeroallergens has direct
impact on pathogenesis as well as outcome of BA and AR. Allergens responsible for respiratory allergies (BA & AR)
are found to be different from place to place as echoed in various Indian and international studies. This study is
being done in Meerut district of western province of Uttar Pradesh to find out the major prevailing aeroallergens
leading to respiratory distress.
Objective: To determine the prevalence pattern of aeroallergens in patients of BA and AR reporting to tertiary care
centreSubharti Medical College inwestern UP.
Methods: It is a prospective study in which a cohort of 20 patients were assessed who were diagnosed as a case of
BA or AR clinically or by pulmonary function test. These patients were subjected to skin prick test after taking
written and informed consent.
Results: Among the total cohort 13(65%) were females, 7(35%) males. In relation to age wise distribution
maximum patients were in age group 20-29 yrs(7 pts, 35%) and minimum in 60 yrs and above with 1 pt(5%). In
relation to disease status 11 had BA followed by 5 AR and 4 had mixed disease. Distribution of aeroallergens in
maximum positivity in age groups were observed as; pollens 46 (97%significant) in age group 30-39, fungi 17 (94.4
sig) in 0-19yrs, insects 15 (100% sig)in 20-29yrs & 30-39yrs, dusts 11 (100%sig) in 20-29yrs, dander 6 (100% sig) in
20-29 yrs, feathers and fabric 5 (83.3% sig) in 20-29yrs. House dust mite was found to be positive in 70%(sig) of the
total cohort group with maximum in 20-29yrs.
Conclusion: The study concludes that most of the patients allergic belong to female gender. High allergenicity was
observed in BA. Most of the patients had polysensitisation and the age group most vulnerable was 20-29yrs.
Education of patient regarding avoidance of allergens help in reduction of symptoms and morbidity and increasing
the overall health status.
P163
RevolizerВ®: The Next Generation Novel Single Dose Dry Powder Inhaler
1
2
2
2
1
V Naik , G Malhotra , P Rege , V Mhapsekar , B Aggarwal , J Gogtay
1
1 Medical Services and
2 R & D Centre, Cipla Ltd, Mumbai, India
Introduction
Dry powder inhalers (DPIs) are breath-actuated devices which do not require propellants and eliminate the need
for co-ordination and cold-freon effect associated with the use of metered dose inhalers. The RevolizerВ® - a novel,
single dose DPI, is the result of a development program to address the critical requirements of an ideal inhalation
device. It was developed using computational fluid dynamics simulation and enables visual, gustatory and acoustic
feedback mechanism to assure patients of having taken their medication correctly. It is designed to be used with
dry-powder capsule formulations and is currently available in India, Sri Lanka, Nepal, UAE, Dominican Republic,
Lebanon, and South Africa.
Performance of the Revolizer
Revolizer shows a high drug deposition at flow rates of 30, 45 and 60 L/min. The Revolizer has medium airflow
resistance and uses an optimized dispersion system to ensure effective de-agglomeration of the inhalation
powder. Revolizer gets activated at inspiratory flow rates of approximately 44 L/min.
Design features of the Revolizer
The long and narrow mouthpiece of the Revolizer leads to a straight air path and a laminar exiting airflow while
creating turbulence in the tubular capsule chamber, thus facilitating easier evacuation of the drug particles at all
angles of holding the device. The design of the capsule chamber and the baffles inside ensure maximum drug
delivery to the lungs. The transparent medication chamber provides visual confirmation, the vibration sound of the
capsule whirring in the chamber gives an audio feedback, and the taste of the lactose (excipient) confirms dose
inhalation.
Conclusion
The Revolizer has been designed to achieve optimal efficacy and to deliver doses consistently with minimal
instruction. It can be used for delivering a variety of inhaled medications including bronchodilators, corticosteroids
and their combinations.
P164
Severity, risk factors and comorbid conditions in newly diagnosed smoking and non-smoking COPD patients:the
SCOPEstudy
Dr R. Kacker1,Dr A. Dalal2, Dr R. Palaniappan3
1.Dr Rajeev Kacker - Sr Consultant Pulmonary, Critical Care & Sleep Medicine, Regency Hospital,India
2.Dr AlpaDalal - HOD Pulmonology, Jupiter Hospital, India
3.Dr Ramanathan Palaniappan -Prof & HOD, Department of Pulmonary Medicine, Peelamedu
SamanaiduGovindarajulu Hospitals,India
Objective:
Survey of newly diagnosed COPD PatiEnts (SCOPE)in India,to gain insights on theirhealth status.
Method:
This survey conductedin7 cities of Indiainvolved 47 pulmonologists, who recordedsymptoms, risk factors, lung
function, previous respiratory ailments, inhaler use, history of exacerbations, hospitalizations, comorbid
conditions and COPD assessment test (CAT) score for consecutive newly diagnosed COPD patients.
Results:
Data was obtained on 247 newly diagnosed COPD subjects, mean age (В± SD) 59.91 (В± 11.53) years, majority 209
(84.6%) males with 75.7%reportingcurrent or past history of smoking.
Of the non-smokers, 24.29% reported biomass exposure.
Average FEV1% predicted was 50.30 (В± 18.96) and average FEV1/FVC% was 60.38 (В± 20.30), indicating a higher
degree of airflow limitation. Cough (97.57%), dyspnea (95.45%), sputum (92.41%) were the most common
symptoms followed by wheezing (82.51%) and chest tightness (85.59%). Average CAT score (В± SD) was 21.26 (В±
7.68). Approximately 31%, 28% and 22% of all patients reported biomass exposure, living close to highway/
industrial areas and occupational exposure (cotton mills/ chemicals industry etc.), respectively.
History of respiratory ailments included asthma (29.96%), tuberculosis (15.38%) and allergic rhinitis (5.73%). 45.9%
patients were using inhalers, of whom 67.44% did not have a good inhaler technique and 59.77% reported poor
compliance with therapy.
On an average, there were 1.96 exacerbations and 0.79 hospitalizations in the last 1 year. Hypertension, diabetes
mellitus, osteoporosis, depression was reported in 33.2%, 17.81%, 7.69% and 6.88% of the COPD patients.
There was no significant difference between symptoms, clinical presentation, co-morbidities, number of
exacerbations and CAT assessment in smokers and non-smokers.
Conclusion:
The SCOPE survey highlightsthat newly diagnosed COPD patients attending a chest physician’s clinic in India, are at
an advanced stage of COPD with comorbid conditions. Many of themare non-smokers showing symptoms, comorbidities and exacerbation frequencysimilar tosmokers.
P165
Clinical effectiveness of anticholinergic tiotropium bromide as an add on therapy in patient with severe bronchial
asthma: A randomized control trial.
Dr. Santhosh V G, Dr. G.S. Gaude, Dr. Jyothi Hattiholi, Postgraduate in Department of Pulmonary Medicine, KLE
University’s Jawaharlal Nehru Medical College, Belgaum, Karnataka
Introduction: Some patients with severe asthma remain symptomatic despite maximum recommended treatment.
Tiotropium bromide, a long acting inhaled anticholinergic agent might be used as an effective bronchodilator in
such patients.
Aim: To evaluate clinical effectiveness of anticholinergic tiotropium bromide as an add on therapy to the usual
standard therapy in severe Asthma patients.
Methodology: In a randomized single blinded study involving 60 patients, aged more than 18 years with severe
Asthma, the patients were randomized into two groups. The study group received addition of 18mcg of Tiotropium
once daily, while both the groups were continued on standard therapy as per GINA guidelines. Improvement in
lung function test, clinical symptom and quality of life by mini asthma quality of life questionnaire (AQLQ) were
monitored at 4, 8 and 12 weeks.
Results: A total of 30 patients were included in each group. Baseline characteristics were identical in both the
groups with a mean age of 41.5В±11.87 years. At 12 weeks, the mean (В±SD) change in FEV1, FVC and PEFR from
baseline was greater in Tiotropium group as compared to the control group, with a difference of 0.71В±0.36 L (pЛ‚
0.001), 0.75В±0.40 L (p
AQLQ was statically better in the Tiotropium group (p˂ 0.001). There was no difference in the number of
exacerbations during the study period between the two groups. No serious adverse events were noted with the
use of Tiotropium.
Conclusion: The addition of once-daily Tiotropium to severe asthma treatment, including a high-dose inhaled
corticosteroid plus a long-acting ОІ2-agonist, significantly improves lung function and quality of life in patients with
inadequately controlled, severe asthma.
Pulmonary Function test in patients of Allergic Rhinitis
P166
Jinesh Shah, Ajay Akkara, Stani Akkara
Smt. B. K. Shah Medical Institute and Research Centre
Introduction: It is a known fact that there is a close relationship between allergic rhinitis (AR) and bronchial
asthma (BA). However very rarely do pulmonologists and ENT surgeons cross refer patients or look for signs of
concomitant disease, especially in the absence of symptoms or complaints in a given patient. Aim: To find the
status of pulmonary function in patients of allergic rhinitis. Materials and methods: All patients of allergic rhinitis
presenting to our institute were investigated for pulmonary functions tests (PFT) over and above their routine
work up and treatment. The findings of PFT were collected, tabulated and analysed. Results and Discussion: A
total of 20 cases were included in the study during the three month period of the study. Majority of the cases were
female and the commonest age group of presentation was in the fourth decade of life. Only 6 of the cases had
normal PFT. 2 of the cases had a history consummate with BA and manifested as severe obstructive and restrictive
disease. Rest of the cases had varying degrees of obstruction and restriction on PFT. These results were as per
contemporary literature. Conclusion: All cases of allergic rhinitis should also undergo work up for BA to detect sub
clinical and pre clinical stages of the disease.
P167
Clinical profile of diseases causing chronic airflow obstruction in a tertiary care centre in India
AUTHORS: SS GUPTA, A SRIVASTAVA, S TRIPATHI
Department of Pulmonary Medicine, Era’s Lucknow Medical College & Hospital, Lucknow, India
OBJECTIVES: To evaluate the profile of patients with chronic airflow obstruction with an aim to establish a causeeffect relationship between various disorders vis-a-vis chronic airflow obstruction.
MATERIALS AND METHODS: A total of 100 OPD and in-patients from the Department of Pulmonary Medicine with
chronic airway obstructive disorders were included. Demographic profiles and environmental and occupational
exposures were noted. Clinical features and spirometry results were used to confirm the diagnosis.
RESULTS: Majority of patients had COPD (68%) followed by bronchial asthma (19%) and bronchiectasis (13%).
Major etiology of COPD and bronchiectasis was smoking (70.6% and 53.8% respectively). Age of bronchial asthma
patients was lowest (29.74В±4.78 years), followed by those suffering from COPD (non-smokers) (55.00В±10.67
years), bronchiectasis (58.46В±9.02 years) and COPD (60.67В±6.64 years). Majority of patients of COPD due to
smoking (100%) were males. COPD owing to non-smoking reasons was more common in females who were
exposed to biomass fuel smoke. A total of 11 (55%) COPD (non-smokers) patients had a history of ATT intake. No
significant association between occupation and different types of chronic airflow obstruction (CAO) was observed.
Pulmonary functions were significantly more impaired in bronchial asthma patients as compared to other groups.
CONCLUSION: In this study, COPD was the most common chronic airway obstructive disorder. Risk of CAO was
higher in smokers or those having exposure to biomass fuel smoke. Pulmonary functions of patients with different
types of CAO showed a different trend
P168
A study of pulmonary function assessment in patients with allergic rhinitis.
Authors -ANUSHANALAMOTHU, B.VIDYASAGAR, B.P.RAJESH, B.J.ARUN
DEPARTMENT OF PULMONARY MEDICINE,
Institute :J.J.M.M.C, DAVANGERE, KARNATAKA, INDIA
ABSTRACT:
Objectives: a)To assess the pulmonary functions of patients with allergic rhinitis. b) To demonstrate the
presence of airflow obstruction and post-bronchodilator reversibility and to correlate with severity of allergic
rhinitis in these patients.
Material and methods: 50 patients presenting with allergic rhinitis over a duration of 1year (from Dec 2012- Dec
2013) were enrolled in our study .All the patients were evaluated with complete history, clinical examination,
blood investigations, spirometry (FVC,FEV1,FEV1/FVC,FEV25-75%) pre and post bronchodilator inhalation. The
degree of airflow obstruction and reversibility were assessed and correlated with severity of allergic rhinitis.
Results: : In our study of 50 patients with AR- obstructive flow pattern was observed in most of the patients27(54%) with reversibility in 17(63%). Among the patients with obstruction(n=27) - small airway obstruction with
reversibility was demonstrated in 10(37%) patients and large air way obstruction with reversibility in 7(26%)
patients. Majority of the patients presented with moderate-severe AR-34(68%)vs mild AR-16(32%).). Lower airway
obstruction was more frequent 19(56%) in patients with moderate- severe AR(n=34) compared to patients with
mild AR(n=16) - 8(50%).The mean baseline FEV1(% predicted)was 74.14В±20.42% and it tend to decrease with
severity of AR(P<0.004).The mean baseline FEF25-75%(%predicted)-54.76В±24.64 and the flow rates tends to
decrease with severity of AR(P<0.01).
Conclusions: According to our study the prevalence of asthma in patients with allergic rhinitis was high. Small
airway obstruction was found to be predominant and there was significant post-bronchodilator reversibility.The
flow rates tend to decrease with severity of AR. Asthma and allergic rhinitis should not be treated as two seperate
clinical entities. Patients with allergic rhinitis should be evaluated for lower airway obstruction to initiate a safe
and effective combined treatment strategy for both upper and lower airway.
P169
ISOLATED PULMONARY MUCORMYCOSIS PRESENTING AS FATAL SEVERE ASTHMA
SANTOSHAM R, ANANTHA R KISKU KH, MADHUSMITA M
Department of Pulmonary Medicine, Pondicherry Institute of Medical Sciences, Puducherry-605014
Pulmonary mucormycosis is an uncommon disease caused by zygomycetes. It occurs predominantly in
immunocompromised host. Isolated pulmonary mucormycosis is extremely rare. We report a case of pulmonary
mucormycosis presenting as acute severe asthma and consolidation with no other site of involvement and
underlying risk factors
We report a 30 year old female who presented with altered sensorium – 1 day, wheeze, breathlessness and fever
for 10 days. Her chest xray showed non homogenous opacity in the right lower zone. She was a known asthmatic
not on regular treatment. She had no other comorbidities. She was found to have CO2 narcosis and was treated as
acute severe asthma with ventillatory support. She died of respiratory insufficiency and her post mortem lung
biopsy showed mucormycosis
P170
IS COPD THE BREEDING GROUND FOR PULMONARY TUBERCULOSIS ?
AP KANSAL, Kamal Deep, Prabhleen KAUR, Shiyas MOHAMMED, Anand Kumar BANSAL, Varinder SINGH Bamrah
Department Of Chest & TB, GMC, Patiala, Punjab
INTRODUCTION : Both chronic obstructive pulmonary disease (COPD) and tuberculosis (TB) primarily affect the
lungs and are major causes of morbidity and mortality worldwide. COPD and TB have common risk factors such as
smoking, low socioeconomic status and dysregulation of host defence functions. COPD is a prevalent co-morbid
condition, especially in elderly with TB but in contrast to other diseases known to increase the risk of TB
AIM AND OBJECTIVES: To study Profile of Geriatric Patients having Pulmonary tuberculosis and COPD and their co
relation .
METHOD AND MATERIALS: This study was conducted on 500 geriatric patients with different respiratory problems
presenting in Department of Tuberculosis and Respiratory Diseases, Govt. Medical College, Patiala. This was a
performa based study. A proforma was used to seek biodata, clinical history and relevant investigations. All the
cases were subjected to detailed physical examination and specific investigations and final diagnosis was made.
Newly diagnosed Pulmonary tuberculosis were checked for history of COPD, smoking and corticosteroid use .
RESULTS : This study shows 372 (74.4%) males and 128 (25.6%) with different respiratory problem.243 were
smokers or have smoked in past.116 were having COPD. 147 cases were diagnosed to have pulmonary tuberculosis
, 124 males and 23 females. Out of 147 cases of pulmonary tuberculosis 79 had history of smoking, 15 had history
of biomass fuel exposure, 58 had history of inhaled ICS use with mean duration of use 4В±3.2 and 54 were
previously diagnosed as COPD.
CONCLUSION: Keeping a high suspicion and regularly monitoring for the development of pulmonary TB in COPD
patients are necessary,as majority are receiving oral corticosteroids and have history of smoking.
P171
Intranasal Fluticasone vs Oral Montelukast in the management of NasoBronchial Allergy
Dr Apar JINDAL, Dr Meenakshi N., Dr Subramanian S.
Department of Respiratory Medicine, Chettinad Hospital and Research Institute, Kelambakkam, Chennai, India
Introduction:
Both asthma and rhinitis are considered to be inflammatory disorders of the airway as per the “one airway
hypothesis”. Thus it follows that a therapeutic approach targeting one site may significantly improve the other.
Aim:
To compare intranasal fluticasone and oral montelukast for - symptom control of asthma and allergic rhinitis (nasal
and non nasal), reduction in acute exacerbations and adverse effect profile.
Methodology:
120 Patients of Bronchial Asthma (GINA) and concomitant Allergic Rhinitis (ARIA) in the age group of 15 to 65 years
were randomized into 2 groups receiving intranasal fluticasone propionate 200mcg and oral montelukast 10mg
respectively, for a period of 60 days, and neither of the drugs for the following 30 days. During study period
Asthma was treated with fluticasone/salmeterol 125/50 mcg via Metered Dose Inhaler for all patients. At each visit
(Day 0, 30, 60 and 90) asthma and allergic rhinitis control was evaluated by symptom score questionnaire.
Results:
The baseline characteristics were comparable in both the groups. There was better asthma control in the
fluticasone group at Day 60(p = 0.001) and 90 (p = 0.041). At day 60 the control of nasal and non-nasal symptoms
of allergic rhinitis was better in fluticasone group (difference of mean -2.324, p = 0.000 & -1.369, p = 0.028
respectively). There were more adverse effects noted with Montelukast, most common being headache and GI
disturbances (18.9% and 13.2% respectively). Adverse effects with fluticasone were nasal irritation (9.3%) and
throat irritation (7.1%). At day 60 the Odds Ratio for Acute Exacerbation of Asthma for fluticasone versus
montelukast was found to be 0.325(p = 0.098).
Conclusion:
The present study demonstrates the superior efficacy and better safety profile of intranasal fluticasone Propionate
over oral montelukast, in control of Asthma and Allergic Rhinitis symptoms in patients with Nasobronchial Allergy.
P172
Title- BODE index as a prognostic tool in COPD patients.
Authors- Dr Kapil Jangid,Dr Ravi Dosi ,Dr Ravindra Chordia ,Dr Ashok Bajpai , Dr Satish Motiwale.
Sri Aurobindo Institute of Medical science & PG Institute Indore, India
Objective: - We hypothesize that BODE index is good prognostic tool in COPD patients.
Methods: 100 pt over 2 year period at Sri Aurobindo Institute of Medical science indore in department of
pulmonary medicine recruited in study and demographics, clinical evaluation, spirometry, peripheral oxygen
saturation, body composition, 6-minute walking distance, dyspnea, and quality of life measurements were
obtained and BODE score is calculated at 0 month (baseline) and after 1 yr of follow up of 51 patients.
3 groups as per BODE score severity were made & patient were followed accordingly. P <0.05 considerd significant
& paired t test applied.
ResultsBaseline of BODE 1 - 19 pts (patients) were in BODE 1
2 pts worsen to BODE 2
0 pt was in BODE 3
Baseline of BODE 2 - 7 pts were in BODE1
10 pts worsen to BODE 2
1 pt was in BODE 3
(p <0.001)
Baseline of BODE 3 - 0 pt was in BODE 1
5 pts improved to BODE 2
7 pts remain in BODE 3
We obtain that 6 min walk distance significantly improved in BODE 2 & BODE 3 (p < 0.003 & p<0.012)
FEV1 was not significant with either of BODE index. Patients addicted to both smoking and alcohol were more
decrease in 6MWD (P 0.136) also decline in FEV1 (P 0.866).
Conclusion- BODE index strongly determine prognosis of COPD patients and be should consider as a surrogate
marker in assessment of COPD patients as compared to FEV1.
P174
AIRWAY HYPERRESPONSIVENESS IN CHRONIC ASTHMATICS
Dr. Jenam Mehta, Dr. J M Phadtare, Dr. N N Ramraje
Department of Pulmonary Medicine, Grant Government Medical College, Mumbai-8
ABSTRACT
50 mild to moderate asthmatic patients were assessed for airway hyper responsiveness by direct method using
graded concentrations of histamine.The youngest was 18 years, the oldest 51 years ,the mean age being 34
years.44% were males and 56% females. Bronchial challenge tests were positive in 90% of mild to moderate
asthmatic patients. 62% of the asthmatics had an associated nasobronchial allergy as documented by X ray PNS.
There was significant linear correlation of PC20 levels with FEV1, .There was no significant correlation of PC 20 levels
with serum Ig E levels.
P175
CONSOLIDATED REPORT OF THE PULMONARY FUNCTION TEST CHECK UP CAMPS FOR MUMBAI TRAFFIC POLICE
JAIN S., MOHANTY K.C., BENDRE S.S., SAI H., BALAKRISHNAN R.
K. J. SOMAIYA MEDICAL COLLEGE & RESEARCH CENTRE, MUMBAI
INTRODUCTION-URBANISATION IS ASSOCIATED WITH AN ENORMOUS INCREASE IN VEHICULAR TRAFFIC EMITTING
EXHAUST AND POLLUTION OF THE ATMOSPHERE.SO2,NO2,CO,SUSPENDED PARTICLE PLAYS A KEY ROLE IN
OVERALL ATMOSPHERIC POLLUTION AND MOTOR VEHICLE EMISSION CONSTITUE THE MOST SIGNIFICANT
SOURCE OF ULTRAPARTICLE IN AN URBAN ENVIRONMENT.TRAFFIC POLICE ALL EXPOSED TO POLLUTANT MORE
THEN 8 HRS AS OCCUPATIONAL HAZARDAIM- DETERMINE THE PULMONARY FUNCTION TEST OF TRAFFIC POLICE
PERSONALMETHOD-MEDICAL CHECK UP WAS DONE ON 1455 TRAFFIC POLICE PERSONNEL AT 12 MULTI
SPECIALITY MEDICAL CHECK UP WITH CO-OPERATION OF ADDITIONAL COMMISSIONER OF POLICE DRAWING THE
POLICEMEN FROM EASTERN,WESTERN SUBURB,CENTRALMUMBAI, .PFT WAS CARRIED OUT AS A PART OF
COMPLETE MEDICAL CHECK-UP RESULTS ARE AS FOLLOWSRESULT-OF 1455 POLICEMEN ALL PERFORMED THE
PFT. 210 (15%) WERE FEMALES AND 145(10%) WERE SMOKERS. 250(17%) HAD AIRWAY OBSTRUCTION, OF
WHICH 204(14%) HAD MILD OBSTRUCTION,45(3%)HAD MODERATE OBSTRUCTION AND ONE POLICEMAN HAD
SEVERE AIRWAY OBSTRUCTION . MACHING INDIAN STANDARDS OF SPIROMETRY. NO POLICEMAN
DEMONSTRATED RESTRICTIVE PATTERN. AVERAGE DURATION OF WORKING HOURS WAS 8 HOURS PER
DAY.CONCLUSION-OUR RESULT SUGGEST THAT EVEN AFTER EXPOSURE TO ENVIROMENTAL POLLUTION PFT
CHANGES WERE NOT MUCH AS EXPECTED .MOST OF THEM HAD MILD AIRWAY OBSTRUCTION WHICH CAN BE
CONTROLLED BY BREATHING EXCERCISE AND USING FACIAL MASK. INTRODUCTION OF UNLEADED PETROL, LOW
SULPHUR DIOXIDE CONTENT DIESEL AND IMPLEMENTATION OF BHARAT III EMISION NORMS HAS PROBABLY
PLAYED A MAJOR ROLE IN PREVENTING DEVELOPMENT OF ABNORMAL LUNG FUNCTION.
P176
ROLE OF SPUTUM EOSINOPHILS CORRELATION WITH SPIROMETRY DURING ACUTE EXACERBATION AND
REMISSION IN BRONCHIAL ASTHMA AND COPD
P.RAVI
KMC
OBJECTIVES:-The presence of eosinophilia has been considered typical asthmatic inflammation where as
neutrophils,macrophages and lymphocytes are the most significant inflammatory cells found in the airways of
patients with COPD.The aim of the present study is to compare the eosinophils in sputum of pts with asthma and
COPD.
MATERIALS AND METHODS:-30 pts presenting with airway disorders were prospectively studied in the year 20122014 they were evaluated with spirometry and sputum for eosinophil count during exacerbation and remission.
RESULT:-Out of 30 pts, 20 were COPD and 10 were bronchial asthma.In the bronchial asthma group 9 out of 10 had
sputum eosinophilia(90%) and 1 pt didn’t. (Mean level during exacerbation- 13.2).In remission 8 pts had sputum
eosinophilia 2 pts didn’t.(Mean level - 3.8). In the COPD group out of 20, 18 had sputum eosinophilia and 2 pts
didn’t.(Mean level in COPD exacerbation-9.8),during remission 3 patients had sputum eosinophilia,17 pts
didn’t.(Mean level during remission -1.5).
CONCLUSION:-There was no difference in the occurrence of sputum eosinophilia during exacerbation in bronchial
asthma and COPD.But mean level of eosinophilia is more in asthma than COPD.During remission sputum
eosinophilia was more common in asthma than COPD
P177
CONSOLIDATED REPORT OF THE PULMONARY FUNCTION TEST CHECK UP CAMPS FOR MUMBAI TRAFFIC POLICE
JAIN S., MOHANTY K.C., BENDRE S.S., SAI H., BALAKRISHNAN R.
K. J. SOMAIYA MEDICAL COLLEGE & RESEARCH CENTRE, MUMBAI
INTRODUCTION-URBANISATION IS ASSOCIATED WITH AN ENORMOUS INCREASE IN VEHICULAR TRAFFIC EMITTING
EXHAUST AND POLLUTION OF THE ATMOSPHERE.SO2,NO2,CO,SUSPENDED PARTICLE PLAYS A KEY ROLE IN
OVERALL ATMOSPHERIC POLLUTION AND MOTOR VEHICLE EMISSION CONSTITUE THE MOST SIGNIFICANT
SOURCE OF ULTRAPARTICLE IN AN URBAN ENVIRONMENT.TRAFFIC POLICE ALL EXPOSED TO POLLUTANT MORE
THEN 8 HRS AS OCCUPATIONAL HAZARDAIM- DETERMINE THE PULMONARY FUNCTION TEST OF TRAFFIC POLICE
PERSONALMETHOD-MEDICAL CHECK UP WAS DONE ON 1455 TRAFFIC POLICE PERSONNEL AT 12 MULTI
SPECIALITY MEDICAL CHECK UP WITH CO-OPERATION OF ADDITIONAL COMMISSIONER OF POLICE DRAWING THE
POLICEMEN FROM EASTERN,WESTERN SUBURB,CENTRALMUMBAI, .PFT WAS CARRIED OUT AS A PART OF
COMPLETE MEDICAL CHECK-UP RESULTS ARE AS FOLLOWSRESULT-OF 1455 POLICEMEN ALL PERFORMED THE
PFT. 210 (15%) WERE FEMALES AND 145 (10%) WERE SMOKERS. 250 (17%) HAD AIRWAY OBSTRUCTION, OF
WHICH 204(14%) HAD MILD OBSTRUCTION, 45 (3%) HAD MODERATE OBSTRUCTION AND ONE POLICEMAN HAD
SEVERE AIRWAY OBSTRUCTION. MACHING INDIAN STANDARDS OF SPIROMETRY. NO POLICEMAN
DEMONSTRATED RESTRICTIVE PATTERN. AVERAGE DURATION OF WORKING HOURS WAS 8 HOURS PER
DAY.CONCLUSION-OUR RESULT SUGGEST THAT EVEN AFTER EXPOSURE TO ENVIROMENTAL POLLUTION PFT
CHANGES WERE NOT MUCH AS EXPECTED .MOST OF THEM HAD MILD AIRWAY OBSTRUCTION WHICH CAN BE
CONTROLLED BY BREATHING EXCERCISE AND USING FACIAL MASK. INTRODUCTION OF UNLEADED PETROL, LOW
SULPHUR DIOXIDE CONTENT DIESEL AND IMPLEMENTATION OF BHARAT III EMISION NORMS HAS PROBABLY
PLAYED A MAJOR ROLE IN PREVENTING DEVELOPMENT OF ABNORMAL LUNG FUNCTION.
P178
Triple drug therapy in patients with COPD: a survey of prescription practices in India
DR A HASAN1, DR P PRABHUDESAI2
1Deccan College of Medical Sciences and Care Institute of Medical Sciences, Hyderabad, India
2Lilavati Hospital & Research Center, Mumbai, India
Objective:
Recent guidelines recommend the use of triple therapy (Long acting ОІ2 agonists [LABA] + long acting muscarinic
antagonists [LAMA] + inhaled corticosteroids [ICS]) in patients with advanced chronic obstructive pulmonary
disease (COPD). Triple drug therapy finds a place in the prescribing practices of physicians in India, especially in the
moderate and severe stages of COPD. This survey was designed to understand the ground realities of COPD
practice in India in terms of triple drug therapy.
Methods:
The data for this survey was obtained through a questionnaire from those respiratory physicians across India who
routinely manage COPD patients.
Results:
Two hundred respiratory physicians participating in the survey reported that on an average COPD patients
comprised 26.1% of all their patients. According to the survey, 35% [95% CI: 31.3 - 39.8] of patients with COPD
were receiving the three drugs in combination. A concurrent administration of [ICS+LABA] fixed dose combination
and LAMA was the most preferred line of treatment by respiratory physicians for prescribing triple drug therapy in
patients with COPD. Eighty percent of the physicians agreed that using triple drug combination in a single inhaler
could simplify therapy (especially for patients with comorbidities), improve compliance, reduce overall cost of
therapy and improve efficacy. 48.7% of those physicians who did not prescribe the three drugs in a single inhaler
admitted to lack of data about the combination as the primary factor for reluctance to prescribe the combination.
Patients with severe (51%) or moderate to severe (39%) COPD were more likely to be prescribed triple drug
therapy.
Conclusion:
This survey provides insight into the fact that respiratory physicians in India frequently employ triple therapy
comprising LABA, LAMA and ICS in patients with COPD. They also acknowledged that using triple therapy in a single
inhaler helps improve efficacy, compliance and simplifies treatment regimen.
P179
Title
COPD-6 a screening device to detect obstructive airways disease in patients with respiratory symptoms from a
primary care centre in India.
AUTHORS
1.
2.
3.
4.
Dr Shobhit Bansal MBBS (Presenting Author); Metro Hospitals & Heart Institute; L-94, Sector-11, Noida,
Delhi NCR, India-201301.
Dr. Vidya Nair, MD; Metro hospital & heart Institute; L-94, Sector-11, Noida, Delhi NCR, India-201301.
Mr. Abhijit Vaidya, MSc, abhijit.vaidya@cipla.com; MSc; Medical Service (Clinical Research Division), CIPLA
Ltd., Mumbai Central, Mumbai, Maharashtra, India-400008.
Dr. Deepak Talwar , dtlung@hotmail.com, MD; Metro Hospitals & Heart Institute; L-94, Sector-11, Noida,
Delhi NCR, India-201301.
INTRODUCTION AND BACKGROUND
Despite rising mortality and health care costs COPD and asthma remains the most undiagnosed diseases due to
lack of required infrastructure in primary care hospitals.
AIMS AND OBJECTIVES
To evaluate clinical equivalence in terms of sensitivity, specificity and reliability of COPD-6 device in comparison
with pneumotach spirometer in detecting patients with obstructive airway disease with respiratory symptoms.
Methods
This was a descriptive, cross-over, prospective study which included 60 participants. Screening was done
sequentially with COPD-6 device and pneumotach spirometer. The validity and specificity of the COPD-6 device in
detecting obstruction was determined using standard formulas, and the sensitivity, specificity, positive predictive
value (PPV) and negative predictive value (NPV), were calculated. We also estimated the area under the ROC
(Receiver-Operating Characteristic) curve of the FEV 1/FEV6 ratio (measured with the COPD-6) in the discrimination
of the obstruction, using the FEV1/FVC <0.7 quotient obtained with spirometry as the gold standard.
Results
There were 29 participants detected to have obstructive airway disease. The kappa index was 0.66 when an
FEV1/FEV6 cut-off point of <0.7 was used as gold standard. The ROC AUC was 0.88. To detect obstruction, if the cutoff point of FEV1/FEV6 for COPD-6 was <0.70, the sensitivity, specificity, PPV and NPV were, 65.5%, 93.5%, 90.5%
and 74.4% respectively. For a cut-off point of <0.76, they were 76.9%, 95.2%, 96.8% and 69%, respectively.
Conclusion
COPD-6 is a moderately accurate device to detect airway obstruction in patient with respiratory symptoms.
Greater accuracy is observed when cut-off point is 0.76.
P180
Bird Fancier’s Lung - usefulness of ImmunoCAP
technology to measure IgG precipitating antibodies
against avian antigens
Authors and affiliations:
S KHAN, S R CHOWDHURY, S GHOSH, A SENGUPTA, B GHOSH and S
RAMASUBBAN
Department of Allergy & Immunology, Apollo Gleneagles Hospital, Kolkata, India
Department of Pulmonary Medicine, Apollo Gleneagles Hospital, Kolkata, India
Department of Intensive Care Unit, Apollo Gleneagles Hospital, Kolkata, India
OBJECTIVES: Bird fancier's lung is a hypersensitivity pneumonitis (HSP) involving the
pulmonary interstitia in response to avian droppings or antigens on bird feathers. There is
little data on the usefulness of serum specific IgG antibodies and whether a cut-off value
can be determined at different stages of the disease.
METHODS: A retrospective analysis was done on suspected HSP patients with data
collected from radiologic analyses, absolute eosinophil count, total IgE levels and avian
specific IgG antibodies using ImmunoCAP (Thermo Fisher Scientific) with Ge91 (pigeon
serum, feathers and droppings). Six-point calibration was done using ImmunoCAP IgG
calibrators and serum analyzed at 1 in 100 dilution. Different cut-off levels of Avian
Precipitins IgG were analyzed including negative and positive predictive values. The
current cut-off for significant exposure determined from previous studies is 10 mgA/L.
RESULTS:
23 patients (10 males, 13 females) with a mean age of 49.9 years (range 20-66 years)
between June 2013 to May 2014 were studied. Dyspnea and cough were present in 100%
of patients. Mean absolute eosinophil count was 277 (n=11) and mean total IgE was 877
kU/L (range 40-2810, n=7). Specific IgE to Aspergillus fumigatus done in 6 patients were
negative (range 0.03-0.28 kUA/L, manufacturer recommended cut-off 0.35). Eleven
patients (47.8%) had high values of avian precipitins from 30.3 to >200 mgA/L, of which 6
patients in the acute phase with extensive honey combing on HRCT had very high levels
at >200 mgA/L. Five patients had levels in the intermediate range 30.3-68.1 mgA/L, of
which only one patient did not have significant changes on HRCT. 12 patients without
significant lung involvement had mean (В± SD) value at 16.74(В± 8.34) mgA/L. Cut-off value
at 10mgA/L would yield sensitivity (Se) at 100% but very low specificity (Sp) at 16.67%;
cut-off value 20mgA/L, Se 100% Sp 58.33; and at 30mgA/L Se 100% Sp 91.67% PPV
91.67 NPV 100%.
CONCLUSIONS:
Use of the ImmunoCAP Ge91 avian precipitin technology proved helpful to clinicians and
we recommend a higher cut-off at 30mgA/L with concomitant HRCT findings to determine
significant antigen exposure. Patients with acute HSP had levels >200 mgA/L. The actual
cut-off of avian precipitins for subacute and chronic stages of the disease remains to be
determined.
P181
Use of ImmunoCAP technology to measure Aspergillus
fumigatus specific IgE and IgG precipitating antibodies (precipitins)
in the management of ABPA
Authors and affiliations:
S KHAN, S R CHOWDHURY, S GHOSH, A SENGUPTA, B GHOSH, S RAMASUBBAN, D
Department of Allergy & Immunology, Apollo Gleneagles Hospital, Kolkata, India
Department of Pulmonary Medicine, Apollo Gleneagles Hospital, Kolkata, India
Department of Intensive Care Unit, Apollo Gleneagles Hospital, Kolkata, India
Department of Medicine, Apollo Gleneagles Hospital, Kolkata, India SEN
Objectives:
Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity pneumonitis in the lung
interstitium and terminal bronchioles induced by chronic exposure to moulds. We present our
experience in using the quantitative estimates of specific IgE and precipitating IgG antibodies
against Aspergillus fumigatus using the automated ImmunoCAP method (Thermo Fisher
Scientific) in the management of ABPA.
Methods:
A retrospective analyses was done on suspected ABPA patients who had total IgE (kU/L),
specific IgE and IgG against Aspergillus fumigatus (m3 IgE and m3 IgG) blood tests done
using ImmunoCAP (fluoroenzyme immunoassay), including skin prick tests on some patients.
Criteria for ABPA were assessed using the Patterson or Agarwal criteria. Normative data on
specific IgE level for sensitization to Aspergillus fumigatus were calculated on patients with
asthma without ABPA. Descriptive statistics and unpaired t-test was done using GraphPad
Prism software.
Results:
71 patients (39 males, 32 females) with average age 53.4 years (age range 9-94 years)
between June 2013 to May 2014 were evaluated for ABPA. 19 patients (26.7%) fulfilled
criteria for ABPA of which 11 had m3 IgG between 40-90 mgA/L, 5 between 90-200 mgA/L, 2
had >200 mgA/L and one patient with skin test positive to 3 Aspergillus species but low m3
IgG (18 mgA/L). The mean (SD) m3IgG value of the ABPA patients was 98.1 (56.38) as
compared with mean value of 58 patients with bronchiectasis but without ABPA 17.33 (SD
9.68) (p<0.0001, 95%CI 64.85 to 96.66). Mean m3 IgE in the 8 patients was 13.32 kUA/L (SD
22.77). Unpaired t-test to compare means between gender and m3 IgG (98.08 mgA/L vs
90.15 mgA/L) and m3 IgE were non-significant (p=0.77 and 0.47 respectively). Of 65
consecutive patients with asthma (without ABPA) as controls checked for sensitization to
Aspergillus fumigatus, 5 were sensitized (0.35-1.19 kUA/L) with mean total IgE 840.58 kU/L
(SD 1129.39).
Conclusions:
Around 8% of asthmatics were sensitized to Aspergillus fumigatus in our study. The cut-off
value of specific IgG against Aspergillus fumigatus at 40mgA/L for diagnosis of ABPA had
100% sensitivity but specificity is much higher when the cut-off is 90mgA/L. The diagnosis of
chronic pulmonary aspergillosis appears more plausible at levels between 40-90mgA/L.
Title- Life Threatening Occupational Hazards
P182
Author- Dr Nikhilesh pasari Dr Ashok Bajpai Dr B.Jain
Sri Aurobindo Institute Of Medical Sciences & PG Institute Indore, India
Toluene Inhalation is an important occupational health hazard in persons working in factories manufacturing
paint, pharmaceuticals& rubber .The present report describes an unusual case of toluene induced ALI threatening
life.
Key words:-Health, Lung injury, Toulene
REFERENCES
1) U.S Depart of labor occupational safety &Health Administration. Safety & Health topics; Toulene available
from:http://www.osha.gov/dts/chemicals/data/CH_272200.html.
2) Byrme A,Kirby, ZibinT,EnsmingerS.Psychiatric &Neurological effects of chronic solvent abuse. Can J Psychiatry
1991;36:735
P183
Effects of cotton dust exposure on the respiratory system in spinning mill workers
Santhosh C, nageswari A D, srinath D, rajalakshmi R, aishwarya R
SRM medical college hospital and research centre, chennai, india
Objective To estimate the prevalence of respiratory symptoms and to evaluate the pulmonary function changes in spinning
mill and textile workers
Method The study was conducted in the spinning mills in and around Tirupur district in Tamilnadu, at their workplace itself.
The workers were asked to fill the modified ATS respiratory questionnaire along with necessary demographic data
followed by spirometry. Chest symptoms and spirometric variables for all workers were analyzed.
Results –
The study was conducted among 251 spinning mill workers. The median age group of the population was 21years
(minimum – 17, maximum – 63). The gender distribution of the population was 142 males and 109 females. Among
them 136 were local people and 115 were migrants from other states. Out of 251 workers, 18(7%) were in carding
department, 106(42%) in spinning, 64(26%) in cone winding, 20(8%) in simplex and 43(17%) were from other
departments such as machine cleaning, technical support, drawing, and supervising.
Out of 251, 73(29%) were having respiratory symptoms, among the symptomatic 40(55%) were having chest
tightness.
Among 251, 36(14%) were having obstruction in PFT (FEV1/FVC < 0.70), in which 20(19%) were working in spinning
department.
Out of 251, 114(45%) were having FEV1 <80%, among them 49(43%) were in spinning department.
Out of 251, 106(42%) were having FVC < 80%, in that 43(41%) were in spinning department.
Among 251, 208(83%) had PEF% < 80%, in that 116(56%) were in spinning department
ConclusionIn this study, chest tightness was the most prominent symptom which accounts for 55% of chest symptomatics.
Workers in spinning department were having more obstruction (19%), reduced FEV1% (43%), FVC (41%) and
reduced PEF% (56%) in spirometry.
Workers in the spinning department of textile mills require personal protective measures than those in other
departments to prevent respiratory ailments.
P184
PROFILE OF PATIENTS PUT ON INTERCOSTAL DRAINAGE TUBE(ICD) IN A TERTIARY CARE HOSPITAL
AP KANSAL , Prabhleen KAUR , Don Gregory MASCARENHAS, Shiyas MOHAMMED , Nancy GARG
Department Of Chest & TB,GMC, Patiala , Punjab
Introduction : Chest tubes are used in pneumothorax, hemothorax, empyema and malignant pleural effusion(MPE)
Method and materials : A retrospective study was done of patients put on ICD in our department between
November 2013 to july 2014
Results: Out of the 34 patients who were inserted a ICD, 27 were males and 7 were females .Youngest was a 17 yr
old and oldest being 84 yrs with a median age of 42.9yrs. Most common(M/C) indication was
hydropneumothorax(38%) followed by pneumothorax(26.4%), empyema(17.6%) MPE(8.8%).most common
underlying condition was pulmonary tuberculosis , both for hydropneumothorax and pneumothorax(56%)
accounting for 64.7% of cases, followed by COPD(14.7%), trauma(5.9%) and malignancy(5.9%). Majority of patients
were manual labourers(50%) .2 pts were smokers . 13 pts had taken att prior to ICD insertion .only 3 patients came
out to be sputum positive for AFB .3 patients had AFB detected in their pleural fluid, all three being cases of
empyema .16 had right sided involvement and 18 had left sided involvement . Duration for lung expansion on an
average was 5days for pneumothorax, & 7 days each for Hydropneumothorax(HPT) and empyema with the latter
two requiring streptokinase injection in some cases(33%) for complete lung expansion. Pleurodesis was
successfully done in 11 out of 12 cases using 1.5gm single dose tetracycline intrapleurally(92%)
Discussion: Tuberculosis is still the major cause of pneumothorax(SSP), HPT & empyema in our part of country. ICD
insertion causes quick resolution of fluid/air & decreases morbidity. Tetracycline is a very effective agent for
pleurodesis.
Silicotuberculosis : A case report
P185
AP KANSAL, Prabhleen KAUR , Don Gregory MASCARENHAS, Kamal Deep, Nancy GARG, Varinder SINGH Bamrah
Department Of Chest & TB, GMC, Patiala , Punjab
Introduction: Silicosis, the most prevalent disease of all the pneumoconioses is caused by inhalation of crystalline
silica particles. Tuberculosis is notorious to alter its course and outcome.
Case Report: A 55 year old chronic smoker male presented to us with progressive breathlessness and productive
cough for 3 months with loss of appetite for 1 month. There was no history of fever , chest pain or hemoptysis.He
was a chronic bidi smoker for 30 years(pack year=30). He was a marble grinder for the past 30 years. On chest
examination, patient had bilateral rhonchi. Chest xray revealed multiple dense nodular shadows in both the lung
fields. patient came sputum positive for acid fast bacilli. Pulmonary function tests showed obstructive pattern.
HRCT showed multiple centrilobular nodules along with pleural thickening and multiple calcified lymph nodes
along with cavitatory lesion and consolidation in the bilateral upper lobes .Based on the clinicoradiological features
and occupatinal exposure to silica , diagnosis of silicotuberculosis was made. Patient was put on anti tubercular
drugs for which he responded well clinically and radiologically.
Discussion: Silicosis is caused by prolonged exposure to silica dust. Silica particles absorb body iron and act as a
reservoir of iron. Mycobacteria are dependent on iron for growth and produce the iron chelators mucobactin.
Hence silica-exposed workers are at increased risk for tuberculosis and other mycobacterium-related diseases. TB
complicates silicosis and viceversa. Silicotuberculosis affects the parenchyma ,arteries and the veins. Synergistic
effect of silicosis and TB leads to proliferative fibrous reaction leading to end stage lung disease.
Conclusion: Active surveillance of the workers in industries causing silica exposure is required both preemployment and post-employment periods to reduce the morbidity and mortality of silicotuberculosis.
P186
Chronic hypersensitivity pneumonitis: a case series of 18 biopsy proven cases
SANTOSH JHA,ANKUR AGRAWAL,PRAHLAD PRABHUDESAI
Lilavati hospital and research centre,Mumbai,india.
Objectives: 1)To retrospectively analyse the clinical features, radiological findings, spirometry and biopsy results
of 18 patients of chronic hypersensitivity pneumonitis(HP)
2)to compare pre and post treatment spirometry findings in these patients.
Methods and materials: 18 cases of biopsy proven HP was retrospectively studied. history, spirometry and
radiological findings were analysed. therapy was instituted and post therapy spirometry was compared to pre
treatment finding.
Results : Mean age was 46.2yrs. Exposure to pigeons was there in 15 patients. Most common symptom on
presentation was dyspnea on exertion and dry cough. Most common radiological findin was reticulonodular
shadow on CXR and centrilobular nodules, interstitial thickening, ground glass opacity in chronic HP cases. Most
common spirometric finding was restriction and reduced DLCO. and most common histopathological findings
were multinucleated giant cells, ill defined granulomas. Post treatment spirometry was done after 1 years, which
showed no significant improvement or deterioration in lung functions.
Conclusion: Exposure to pigeons was most common etiological agent in our study, in 3 patients we couldnot find
any cause.there was no significant improvent in spirometric values despite treatment with steroids, although there
was symptomatic improvement. More studies are required for elusive disease.
P187
Bird Fancier Lung: Clinico-radiological presentation in 15 patients
MANDEEP SINGH, RAJ KUMAR, RAJENDRA PRASAD
National Centre for Respiratory Allergy, Asthma and Immunology
Vallabhbhai Patel Chest Institute, Delhi-110009, India
Category: for ICS - Dr. J. C. Kothari Young Scientist Award (3 Awards)
Objective: Bird fancier's lung (BFL) is a type of hypersensitivity pneumonitis occurring in response to avian
antigens. The diagnosis is based on a combination of clinical, radiological and biopsy characteristics. The present
study was planned to highlight the clinico-radiological presentation in cases of bird fancier's lung.
Methods: The present study is a retrospective analysis of cases of BFL diagnosed in a unit of Vallabhbhai Patel
Chest Institute from 2013-14. The diagnosis of BFL was made as per criteria laid down by Mark Schuyler and Yvon
Cormier. The clinico-radiological features of the subjects were analysed.
Results: There were a total of fifteen cases diagnosed with BFL during the study period comprising of twelve
females and three males with a mean age of 54.93 В± 14.21 years. All studied subjects gave significant history of
exposure to pigeons and were non smokers. The period of symptoms prior to presentation varied from 1-8 years.
The main symptoms on presentation were exertional breathlessness in 100% (15/15), cough in 93.3% (14/15). On
examination, crepitations were heard in all patients and 73.33% (11/15) patients desaturated on 6MWT.
Radiologically, diffuse centrilobular nodules, ground glassing- predominant in upper lobes, was each seen in 40%
(6/15) cases, fibrosis with or without traction bronchiectasis in 40% (6/15) cases, honeycombing in 13.3% (2/15)
cases. Pulmonary function testing showed mild obstruction in one, was completely normal in another case while in
the rest there was evidence of restrictive lung disease with reduced diffusion capacity in all except one case in
which it was normal. Bronchoscopy showed ill defined granulomas in 60% (9/15) cases and chronic interstitial
inflammation in all cases.
Conclusions: BFL can exhibit a wide range of radiological patterns and high index of suspicion must be maintained
and particular attention paid to detailed exposure history in every case of ILD.
P188
Role of Adenosine Deaminase in the Diagnosis of Tubercular Pleural Effusion
Mehta A, Rohatgi A
Prashant Mehta, PG, Deptt. of Medicine LHMC & SSKH Delhi
Introduction: TB is common in India. ADA has recently become a valuable tool in diagnosing Extrapulmonary TB as
definitive diagnosis of TB pleural effusion is difficult due to the low sensitivity and specificity of non invasive tests.
Objectives: This Study was undertaken to evaluate the role of ADA in the diagnosis of TB Pleural effusion where
diagnosis based on conventional Non- Invasive tests is difficult.
Methods: Patients with exudative Pleural effusions were taken for this study after relevant investigations. ADA
levels were estimated in Pleural fluid by Giusti’s method. ADA>40 U/L was considered diagnostic of TB. In addition
L/N ratio > 0.75 in fluid was considered an additional supportive evidence .
Results: 50 cases were analysed of which 36 had TB effusion(group I) and 14 due to other causes(Group II :Malignant- 5; CTD- 6; Hypothyroidism- 1; SynPneumonic- 1). Mean ADA was 134 U/L in Group I compared to 15.17
U/L in Group II. Sensitivity, Specificity, Positive Predictive Value and Negative Predictive Value of ADA in effusion
was 100%, 86%, 95% & 100% respectively. L/N ratio was >0.75 in Group I as against None in Group II. Of 36 cases
of TB effusion( Group I), 28 responded to ATT however the remaining were lost to follow up.
Conclusion: The performance of ADA in TB effusion is reasonably accurate and is hence a good diagnostic method
as it is simple, rapid, easily available with high sensitivity and specificity. However larger multicentric studies
would be advisable to further look into this.
P189
Massive right sided haemorrhagic pancreatic pleural effusions :Case Series
Dr. N. Snigdha , Dr.N.Gopichand ,Dr.D.Sudeena,Dr.C.Suma lata
Siddhartha Medical College, Vijayawada, Andhra Pradesh,India.
INTRODUCTION: Pleural effusion occurs as a complication of pancreatic disorders like Acute pancreatitis,
Pancreatic Abscess, Pseudocyst, Pancreatic malignancy,Chronic pancreatitis.It is usually bilateral but 22% account
for left ,10% right sided. Diagnosis is established by demonstrating high levels of pleural fluid amylase. Here we
present four different cases of right sided pancreatic pleural effusions.
CASE REPORTS
Case1: A 36 year old alcoholic male came with shortness of breath (SOB), cough and chest pain on right side.
Absent breath sounds present over right side. Chest X-Ray (CXR) PA views showed right massive pleural effusion.
Thoracocentesis revealed hemorrhagic fluid which showed elevated amylase-59740 U/l. Contrast CT chest and
abdomen showed pancreatic pseudocyst.
Case2:A 45 year male, alcoholic and smoker came with complaints of severe SOB.CXR PA view showed massive
right sided pleural effusion. On evaluation his serum amylase was 457 U/l, pleural fluid amylase was 14,830 U/l.
Pleural fluid was haemorrhagic and showed malignant cells on cytology. Contrast CT chest and abdomen along
with ultrasound abdomen confirmed malignancy involving head and neck of pancreas.
Case3:A 33 year male, alcoholic came with complaints of SOB.CXR PA view revealed massive right sided pleural
effusion. On evaluation pleural fluid is haemorrhagic pleural fluid amylase was 14,486 U/l. Ultrasound abdomen
and CT abdomen showed features of chronic pancreatitis.
Case4:A 38 year male presented with SOB. On evaluation he is found to be having massive right sided pleural
effusion that is haemorrhagic. Pleural fluid amylase was 38,365U/l. Ultrasound abdomen revealed pancreatic
pseudocyst.
Discussion: Pleuro-pulmonary complications secondary to pancreatic etiology are well known but rare. These
effusions are usually left sided but all the above 4 cases are right sided, heamorrhagic, showed elevated amylase
levels. Often the underlying pancreatic disease is missed due to lack of abdominal symptoms. The best modality for
diagnosis in these cases remains pleural fluid amylase. They often tend to recur after thoracocentesis.
P190
Rare cause for pneumothorax in a young male
Manjunath M, Vishnu SHARMA M, Alka BHAT, Harsha D S
Department of Respiratory Medicine, A. J. Institute of Medical Sciences & Research Centre, Kuntikana, Mangalore,
Karnataka.
INTRODUCTION
When a patient develops pneumothorax proper evaluation should be done to find the cause. Identifying the cause
will help to prevent recurrences and is essential to treat the underlying disease.
CASE REPORT
A 20 year male presented with complaints of sudden onset of dyspnea, left sided chest pain and cough with scanty
expectoration since 3 days. No other significant history. He had started smoking at the age of 15 years, daily
smoked two packs of cigarettes.
Clinical examination revealed features suggestive of left sided pneumothorax. Chest X ray showed Left sided
pneumothorax with bilateral reticulonodular and occasional cystic lesions in both lower zones. Intercostal tube
drain was inserted. Routine blood investigations were normal. Sputum AFB smear was negative. In view of
radiological findings patient was empirically started on anti tuberculosis treatment. On further work up with HRCT
showed features suggestive of Pulmonary Langerhans cells Histiocytosis with left sided pneumothorax. He had an
uneventful recovery.
He was discharged with advice of smoking cessation and oral prednisolone 40mg/day. He was asymptomatic on 6
month follow up and steroid was tapered and stopped after 6 months.
CONCLUSION
Pulmonary Langerhans Cell Histiocytosis should be considered as a cause for pneumothorax in young smokers
when chest radiography shows bilateral reticulo nodular or cystic changes. Complete work up with HRCT should be
done when cause of pneumothorax is uncertain.
CASE REPORT
P191
Massive right sided hemorrhagic pleural effusion in a patient of Acute Necrotizing Pancreatitis - A rare case of
Pancreatico-Pleural Fistula
BUDHRAJA AKSHAY, SHARMA KAPIL, TANDON SANJAY, MAQSOOD SHEEMA, JOSHI PRIYANKA, DAUSAGE CHIRAG
Peoples College of Medical Sciences & RC, Bhopal (M.P), India
ABSTRACT
Hemorrhagic pleural effusion in patients of acute pancreatitis is very rare and warrants the consideration for
diagnosis of pancreatico-pleural fistula. We report a case of 30 year old chronic alcoholic male with alcohol
dependance with acute presentation of severe epigastric pain and respiratory distress for last 2 days. He was being
managed conservatively from past 3 months for acute necrotizing pancreatitis. On examination he had tachypnea,
tachycardia and hypotension. Breath sounds were absent over the entire right hemithorax. Massive right sided
effusion was confirmed radiologically. Pleural fluid examination revealed blood clots, protein of 4.9gm%,
TLC=18000/mm3 with extensively hemorrhagic background. Pleural fluid AFB was negative and pleural fluid
cultures were sterile and cytology was unremarkable. Serum Amylase and lipase were 101/1592 U/L respectively.
Liver function test (LFT) were normal except Total protein of 4.9gm% and Albumin of 2.2 gm%. Serum Calcium was
6.7mg%. Pleural fluid amylase was 1500U/L. PT/INR was within normal limits. Patient was managed
prophylactically by pancreatic duct stenting even though ERCP failed to detect fistulous tract. After 30 days of
admission, patient made complete recovery and was discharged in good health. He was followed later for upper GI
endoscopy for removal of pancreatic duct stent. Pancreatico-pleural fistula is a clinico pathologico radiological
diagnosis requiring high index of suspicion and early MRCP(sensitivity-80%) to detect fistulous tract. ERCP may be
helpful in detecting fistulous tract but a failure rate of 32% is reported. Duct stenting facilitates early drainage of
pancreatic fluids and promote healing. Surgical closure of tract is reserved for resistant cases.
A misdiagnosed case of malignant pleural effusion
P192
Paresh Chandra Mohanta, Pravati Dutta, Rekha Manjhi, Sudarsan Pothal,
Madhumita Nayak,Sasmita Meher
Department of pulmonary medicine, VSS Medical College, Burla, Odisha, India
Background: Malignant pleural effusion was on of the leading cause of exudative pleural effusion.Carcinoma of
lung and breast and lymphoma accounts for 75% of malignant pleural effusion.In tuberculosis prevalent country
like India it is sometimes misdiagnosed as tubercular pleural effusion.
Case Report: A 70 year old smoker presented with chest pain for 1 month and breathlessness for 20 days.He was
managed as a case of tubercular pleural effusion and was put on ATT for past 3 months.He was not relieved of
his symptoms despite of 3 months of treatment.On clinical examination features of massive pleural effusion
with pallor and not associated with clubbing and lymphadenopathy.Routine blood investigations revealed a
raised blood urea and creatinine.Chest X-ray suggestive of massive left pleural effusion.Pleural fluid analysis
showed a low ADA,exudative fluid and its cytology report showed TLC-4300 cells,DC-N-1%,L-86%,mesothelial
cells 12%,macrophages 1% and enlarged cells with binucleate,trinucleate reactive/hyperplastic changes.CT
thorax shows solitary nodule left lower lobe.On flexible thoracoscopy showed pleural adhesions and multiple
pleural growth and biopsy from suspicious lesion revealed invasive squamous cell carcinoma.
Conclusion: This case illustrates that in an elderly smoker presenting with pleural effusion, our first suspicion
should be to rule out malignancy.
P193
An incidental finding of Pleural Lipomas:Case series
P.Ajoy kumar, C.Sumalata, N Gopichand, D.Sudeena
Department Of Pulmonology, Siddhartha Medical College, Vijayawada,A.P
Abstract
Introduction: Lipoma is a benign mesenchymatous tumour seen in subcutaneous parts of the body, its presence in
pleura is a rare entity.They are incidentally found on chest x-rays or Computed tomographies.Here we present two
case reports of pleural lipoma, which are of intrapleural variety.
Case reports: Case 1:A 65 year old female patient came to chest OP with complaints of cough and shortness of
breath.On examination she had decreased breath sounds and was dull on percussion on right infrascapular and
infra axillary region.She was then subjected to radiological investigations where a large intrapleural lipoma of 9.8
cm x11.2 size tumour was observed.Case2:A 80 year old man was referred to chest OP for a lesion on the right
lower zone.When he was subjected to a CT chest plain,it was found to be a intrapleural tumour of 6x7cm.
Discussion:Pleural lipoma are extremely rare. They are of two types(1)hour glass or dumb bell lipomas
(2)intrathoracic lipomas. According to their origin,they are calssified into various types endobronchial lipoma,
diaphragmatic lipoma. Most patients are asymptomatic.The occurrence of symptoms depend on the size of the
lipoma. Although the tumours were detected incidentally in a chest X-ray, CT scan has replaced conventional x-ray
and ultrasound scan for accurate detection of thoracic lipomas. CT allows a definitive diagnosis when it
demonstrates a homogeneous fat attenuation mass (-50 to -150 Hounsfield units, or HU) which formed obtuse
angles with the chest wall and displaced adjacent pulmonary parenchyma and vessels .Management includes
clinical and radiological follow up.Follow up is done to see for malignant changes so that surgical intervention can
be planned accordingly.
CT scan of case no 1
Chest x-ray of case 2
P194
RARE PRESENTATION OF PLEURAL MALIGNANT MESOTHELIOMA IN A PATIENT WITHOUT PRIOR EXPOSURE TO
ASBESTOS
DR.K.VIJAY KUMAR, Dr.A.Sathya Prasad, Dr.Ganesh Chandra,Subba rao, Prashanti, Nalini
MAMATA MEDICAL COLLEGE & HOSPITAL ,KHAMMAM
Background:
th
th
Most common primary tumor of pleura is malignant mesothelioma occurring commonly in age group of 5 -7
decade with male: female - 2.6:1 with exposure to asbestos constituting about >70% cause. spontaneous (non
asbestos exposure related) incidence 1/million/year. Here we present you one such rare case.
Case report: A 60 year old female Sandamma Kanakapudi came to OPD with c/o left sided pleuritic chest pain with
SOB on moderate exertion with occasional dry cough with decreased appetite and sleep of 40 days duration and a
non-smoker, non-alcoholic and agriculture labour by occupation without any exposure to any environmental risk
factor. Husband is also an agricultural labour who is non-smoker, non-alcoholic . Chest X-Ray PA view - Left U/L
lesion confined to pleura with shagging borders & blunting of Costophrenic angle .USG guided TTNA in Left ant
th
Axillary line 4 ICS - Revealed large epithelial cells with increased N/C ratio strongly suggestive of epithelial
malignancy. correlate accordingly . CTguided pleural biopsy done at MNJ cancer institute suggestive of epithelial
variant of Mesothelioma
Conclusion: Our case high lightens the fact that we should widen our horizon in decision making with such patient
in a country like India that can lead to early diagnosis resulting in better survival rate by effective treatment and
follow-up
P195
CASE REPORT
P196
Spontaneous Pneumothorax and Myocardial Infarction in Marfan Syndrome without Valvular Heart disease
SHEEMA MAQSOOD,KAPIL SHARMA,PRIYANKA JOSHI,ST NAGDEOTE,AKSHAY BUDHRAJA
Dept. of Pulmonary Medicine, Peoples College of Medical Sciences,Bhopal
ABSTRACT :
Marfan Syndrome is a heritable disorder of connective tissue mainly affecting skeletal, cardiovascular
and ocular systems. Lungs are rarely involved.We report a case of a 19 year old young adult with history of
progressive dyspnea along with cough with expectoration with features of Marfan Syndrome. He also had past
history of ATT for pulmonary tuberculosis with same features of Marfan Syndrome in other siblings also. On
general examination he was tall with long slender limbs (Dolicostenomilia), long fingers and toes (Arachinodactyly)
and protruded sternum with scoliosis. On respiratory examination bilateral breath sounds were decreased with
bilateral occasional crepts with tapping apex beat. Sputum for AFB was negative with HIV non reactive. During the
hospital stay he developed MI confirmed by raised troponin levels and spontaneous pneumothorax. Chest X-Ray
followed by CECT Thorax showed right upper lobe fibrosis with right lower lobe bronchiectetic changes along with
left sided hydropneumothorax. Pus was sent for AFB and DST was planned. Pus for AFB was positive. No valvular
involvement on 2D-ECHO Heart. Patient was planned for ICDT insertion but he expired. Case opens our eyes in
view that MI as such can be rare entity in Marfan syndrome but precipitating factors like chronic hypoxia in post
tubercular pleuroparenchymal fibrosis with acute development of spontaneous pneumothorax (Amjadi K, Alvarez
GG, Vanderhelst E,Velkeniers B, Lam M, et al: Chest 2007;132: 1140–1145.) can cause MI in marfan syndrome
which spares heart valves.
P197
A study of pleural fluid adenosine deaminase levels in tubercular and other exudative pleural effusions at a
tertiary care center in U.P.
A AGARWAL, A JAIN , L SINGH, R TANDON, A CHAWLA, A SINHA
Shri Ram Murti Smarak Institute of medical sciences, Bareilly, U.P., India
Objective –
To study pleural fluid adenosine deaminase (ADA) levels in tubercular and other exudative pleural effusions.
Methods –
A prospective study was designed at SRMS Institute of Medical Sciences, Bareilly, U.P. to evaluate the importance
of pleural fluid ADA level in the diagnosis of tubercular pleural effusion and differentiating it from other causes of
exudative pleural effusion.
Results –
A total of 232 cases of pleural effusion were evaluated, of which 169 (72.85%) were observed to be exudative
pleural effusion. Tuberculosis was diagnosed in 76 (45%) cases, malignancy in 32 (19%) cases and parapneumonic
effusion in 50 (29.6%) cases. 11 (6.5%) cases were found to be due to miscellaneous causes or remained
undiagnosed. Median В± SD values of ADA for tubercular pleural effusion, malignant pleural effusion and
parapneumonic effusion were 62.37 В± 22.63, 24.12 В± 10.88, and 34.55 В± 20.45 U/L respectively. Our study showed
that 68 (89.5%) out of 76 cases of tubercular pleural effusion had ADA ≥ 40 U/L and only 3 (9.3%) out of 32 cases of
malignant pleural effusion had ADA ≥ 40 U/L. For the diagnosis of tuberculosis the pleural fluid ADA ≥ 40 U/L
yielded 89.47% sensitivity and 72.04% specificity; the positive predictive value was found to be 72.34% and the
negative predictive value 89.33%.
Conclusion Pleural fluid ADA level can be used for differentiating tubercular effusions from other causes of non-tubercular
exudative effusion. Moreover, it can reduce the diagnostic need of pleural biopsy for the diagnosis of malignancy.
P198
A case of complicated parapneumonic effusion presenting as empyema necessitans
Dr. K.NAGA CHAITANYA , Dr. S.V. PRASAD , Dr. T.V. RAJIV
MNR MEDICAL COLLEGE AND HOSPITAL , Sangareddy , Telangana
BACKGROUND : Empyema necessitans is an extremely rare condition developing secondary to infection by
mycobacterium tuberculosis , staphylococcus , fusobacterium , actinomycosis . The following case report is of a
wrongly diagnosed and neglected parapneumonic effusion which went on to develop empyema necessitans
CASE REPORT : A 40 year old male presented with complaints of right sided chest pain , non productive cough and
dyspnea on exertion for 1 month and a swelling in the axilla and back over the right chest for 10 days. Patient had
no history of haemoptysis or fever. He was treated 2 months back with injectables for 10 days for productive
cough and fever. He had no history of contact with TB patient.
There was grade 3 clubbing bilaterally and no cervical lymphadenopathy. Chest examination showed 7 * 8 cm
swelling over the right chest extending from the back to the axilla. It was firm in consistency and mobile with
warmth and no tenderness. Skin over the swelling was smooth and had no discharging sinuses. There was no
palpable crepitus. Apart from the swelling ,the right hemithorax shows bulging with reduced respiratory
movements. Intercostal tenderness was present on palpation along with dull note on percussion in right
mammary, inter and infrascapular , infraaxillary areas. Absent breath sounds were present in the same areas.
Rest of the chest was normal Blood investigations revealed TLC = 13200 cells/mm3 , negative for HIV and ESR was
70 mm/1st hr. Chest xrays PA and lateral views revealed right sided moderate pleural effusion and adjacent soft
tissue swelling. USG revealed right loculated pleural collection which was aspirated. The aspirate was thick pus
with ADA of 80 IU/dl , LDH – 1200 IU/dl , proteins 5.6 gm/dl , glucose 60 mg/dl. CT scan chest confirmed
encapsulated pus in the right hemithorax and soft tissue swelling and no rib erosions. Soft tissue swelling was
treated by incision and drainage. Pus for culture was negative for any bacterial growth and for AFB stain patient
was posted for thoracoscopy and ICD was placed. Histopathology of pleural biopsy specimen revealed
granulomatous inflammation and epitheloid histocytes, lymphocytes and multinucleate giant cells. Culture was
positive for AFB.
DISCUSSION: Empyema necessitans is an extremely unusual complication of empyema seen only in
immunocompromised patients and in neglected TB empyemas. Although accounting only for 10 % of empyemas,
Mycobacterium tuberculosis is responsible for 75 % cases of empyema necessitans causing an overall mortality of
60 %
CONCLUSION: This case is being presented to highlight a rare condition and to emphasize on the fact that wrong
and delayed diagnosis of TB is still a major problem in our country leading to increased morbidity and mortality.
GOVT. MEDICAL COLLEGE, NAGPUR
P199
DEPARTMENT OF PULMONARY MEDICINE
Dr. Anuroop Shankar S., Dr.P.Gholap , Dr. S.H.Meshram, Dr.S.V.Ghorpade
A RARE PRESENTATION OF TENSION PNEUMATOCELE
ABSTRACT
INTRODUCTION
Pneumatocele are air filled lung cyst that occurs when bronchial injury or inflammation creates check valve
mechanism for air entry in to the lung parenchyma. Underlying causes include severe pneumonia, blunt thoracic
trauma, COPD, hydrocarbon ingestion with aspiration
CASE PRESENTATION
48 yrs old married farmer ,known case of type 2 DM ,presented with left side chest pain ,continous and gradually
progressing its severity ,shortness of breath , fever for 15 days and sudden onset of swelling over left side of
chest.chest Xray and CT scan revealed tensed pneumatocele herniated in to the subcutaneous plane of chest wall
.sputum revealed staph. Aureus. Condition was treated with CT Guided percutaneous catheter placement using a
pigtail catheter for decompression with good antibiotic cover.
DISCUSSION
Pulmonary pneumatocele are thin walled, air-filled cysts that develop within the lung parenchyma. They can be
single emphysematous lesion but can be multiple, thin walled cyst like cavities. Most often they occur as a
sequelae to acute pneumonia, commonly caused by staph.aureus. Complicated tension pneumatocele which is
herniating to subcutaneous plane of chest wall is rare. It may cause cardio respiratory compromise. So
decompression with pigtail insertion is necessary but it is difficult for this patient due to herniation. Patient
expired postoperatively due to cardio respiratory compromise.
CONCLUSION
A rare presentation of complicated tension pneumatocele herniating in to subcutaneous plane
P200
Diagnostic efficacy of biochemical parameters in differentiating transudative and exudative pleural effusion
Bhavya S, Department of Respiratory Medicine
Regional institute of Medical sciences, Imphal
Abstract :
Objectives: To study the diagnostic efficacy of absolute level of pleural fluid cholesterol,pleural fluid and serum
ratio of triglycerides and bilirubin in differentiating transudative and exudative pleural effusion
Methods: A cross sectional study conducted in the Department of Respiratory Medicine, RIMS ,Imphal included
fifty six cases of pleural effusion with definite clinical diagnosis were classified as transudates and exudates . The
pleural fluid cholesterol (pf CHOL), Pleural fluid/serum triglycerides ratio (pfTRIG/s TRIG), pleural fluid /serum
bilirubin ratio (p BIL/s BIL ) were compared with clinical diagnosis with regard to their usefulness for distinguishing
between pleural exudates and transudates
Results:A total of 56 patients withb effusion who were definitively diagnosed were included in the trial and
analyzed. Out of which 36 and 20 cases are exudative and transudative respectively. The Pchol levels
demonstrated a sensitivity of 89%, a specificity of 100%, The p/s TRIG ratio showed a sensitivity of 89, a specificity
of 100%, p/s BIL ratio had a sensitivity of 100% and specificity of 80%. Combination of any two criteria had a
sensitivity and specificity of 100%
Conclusion:The pleural cholesterol level ,the pleural/serum triglycerides and bilirubin ratio can be utilized as
unique and cost effective biomarkers in differentiating transudative and exudative pleural effusions.
P201
CLINICO-LABORATORY PROFILE OF NON-MALIGNANT EXUDATIVE PLEURAL EFFUSION IN A TERTIARY CARE
HOSPITAL
DR.M.D.VARUNN, DR.K.SURENDRA MENON, DR.R.PAJANIVEL
DEPARTMENT OF PULMONARY MEDICINE, MAHATMA GANDHI MEDICAL COLLEGE AND RESEARCH INSTITUTE
BACKGROUND: Pleural effusion remains the commonest pleural disease making a significant contribution to the
pulmonologists. It is always a systematic approach which helps in arriving at an etiological diagnosis.
OBJECTIVE: The study was designed to investigate the clinical and laboratory profile of non-malignant exudative
pleural effusions.
METHODS: Patients who were diagnosed to have pleural effusion over a period of 6 months (Jan-Jun, 2014) were
subjected to diagnostic pleurocentesis. Patients with pleural fluid protein of >3gms% were taken into study and
were analyzed retrospectively for symptoms, side of effusion and pleural fluid analysis of cell count, ADA, glucose
and culture. Cytology showing malignancies were excluded.
RESULTS: Out of the study population of 65 patients, cough (99%) and breathlessness (97%) were the commonest
presentation, followed by chest pain (80%) and constitutional symptoms (46%). Based on the clinical features and
radiology, 72% of patients had right-sided effusion. Tuberculosis was diagnosed in 44 patients, parapneumonic
effusion in 21 patients. 79% of patients diagnosed as tuberculosis had lymphocyte count of >80%. The mean ADA
in tuberculous pleural effusion was 68.83. Parapneumonic effusions had cell count of predominant polymorphs.
83% of the pleural fluids pyogenic cultures were sterile and the commonest organism in culture positive samples
(17%) were staphylococcus aureus, streptococcus pneumonia. Majority of the isolated organisms were sensitive to
piperacillin, ciprofloxacin, vancomycin, gentamycin and amikacin.
CONCLUSION: Pleural fluid differential cell counts are helpful in narrowing the differential diagnosis but none are
disease specific. High lymphocyte proportions (>80%) with high ADA occur most frequently in TB, neutrophilpredominant pleural effusions are associated with acute processes like parapneumonic effusions. The sensitivity
pattern from this study helped us with the empirical choice of antibiotics in cases of parapneumonic effusions.
Despite the high incidence of indeterminate diagnoses, the measurement of protein and cytological examination
must be ordered routinely which plays an important role in arriving at the diagnosis.
P202
Osteosarcoma presenting as multiple calcified metastases to lung and pleura: A rare case report
Dr. K. Rajendra Kumar, Dr. S. Raghu, Dr. CH. Hanumantha Rao.
Dept. Of pulmonary medicine, Govt. Fever Hospital / Guntur Medical College, Guntur, Andhra Pradesh, India.
Abstract:
Osteosarcoma is a most common primary bone tumor in children and adolescents, arising from primitive bone
forming mesenchymal cells. The lung is the most common site of metastasis of osteosarcoma. Here we report a
case of an 18years old male patient presenting with progressive breathlessness for last the 2months. Chest X-ray
suggestive of extensive pleural calcifications and bilateral parenchymal lesions with right sided moderate pleural
effusion. CT scan chest revealed multiple calcified metastatic nodules in both lungs and pleural calcification with
right side pleural effusion. On examinantion, we found bony mass of left humerus which is of 3 months duration,
punch biopsy of which revealed osteosarcoma. FNAC of pleural lesion is diagnostic of metastatic deposits.
Osteosarcoma presenting as multiple calcified metastasis to lung and pleura is very rare that too within very short
duration.
P203
Empyema secondary to submandibular gland abscess : a rare case report
K.BHARATH P.SWETHA K.SAILAJA H.N.SREEDHA RAO U.KIRAN KUMAR
Department of Pulmonary Medicine, Kurnool Medical College, Kurnool ,Andhra Pradesh,India
INTRODUCTION:Although empyema is frequently seen in general population,but this condition secondary to neck
space infection [submandibular gland abscess] and mediastinitis is rarely seen .Mortality in such conditions
reported to be 15 to 40% despite high antibiotic therapy and in some cases surgical intervention is required We
would like to report a case of empyema secondary to submandibular gland abcess here.
CASE REPORT: A 38yr male presented to us with dyspnea,fever,purulent discharge from mouth,difficulty in
swallowing both to solids and liquids since 15 days. History of large swelling in the left submandibular area with
severe pain,that gradually reduced after taking medication .On examination,a swelling of 2x2cm below the angle
of mandible noted, which was tender, freely mobile. A small fistula [1x1 cm] noted in left retromolar area with
purulent discharge draining from it
CXR revealed homogenous opacity left side with mediastinal shift to opposite side s/o pleural collection and CECT
neck showed enlarged left submandibular gland with air and fluid collections and abcess is extending into right
side of neck through pretracheal space causing erosion & thrombosis of right IJV and retropharangeal space. CECT
chest showed abcess is extending into anterior,posterior and middle mediastinum causing left empyema and
lung fields were normal. With this imaging findings we suspect empyema secondary to submandibular infection.
Pus was drained from left pleural cavity and patient is kept on broad spectrum higher antibiotics.The patient
responded well with complete expansion of lung and reduction of submandibular swelling
CONCLUSIONS : The term descending necrotising mediastinitis implies the infection started from a head and neck
source, here from submandibular gland and extending into mediastinum. Infection from cervical region can spread
to pleural spaces and anterior mediastinum through pretracheal space, middle mediastinum through carotid
space, posterior mediastinum through retropharangeal or prevertebral spaces
P204
Carcinoma Breast related Metastatic Pleural Effusion –
A Thoracoscopic Evaluation.
CHETAN B PATIL, RAKESH C GUPTA, RAMAKANT DIXIT, NEERAJ GUPTA, A GUPTA, P. PACHAR
Department of Respiratory Medicine, J.L.N Medical College, Ajmer.
Objective: Carcinoma Breast is one of the common malignancies that metastasize to lungs and pleura, here we
evaluated four cases of Carcinoma breast that presented with recurrent massive pleural effusion, which showed
metastasis to the pleura, diagnosed by thoracoscopy.
Method: Carcinoma breast cases that presented to our centre with recurrent pleural effusion within a year of
diagnosis, treated by surgery alone or with multimodal therapy. Pleural effusion in these cases remained
undiagnosed even after routine initial workup & pleural fluid cytology negative for malignant cells on three
occasions. We performed thoracoscopy after informed consent, Thoracoscopic appearances of the pleura were
recorded and pleural biopsy was sent for histopathological analysis.
Results: All the four cases of Carcinoma Breast that presented with massive pleural effusion had hemorrhagic
pleural fluid with hematocrit less than 50% of peripheral blood. Thoracoscopic view revealed edematous pleurae,
grossly studded with multiple nodules of varying sizes forming grape like pattern which were hyperaemic and
bleeds on touch, nodularity was seen even on the diaphragmatic pleura which is rarely involved in metastatic
adenocarcinoma lung. Thin fibrinous adhesions were also noted. Pleural biopsy revealed metastatic deposits from
the primary carcinoma breast.
Conclusion: Thoracoscopy should be considered in all cases of undiagnosed pleural effusion with background
history of Ca Breast without any evidence of local recurrence or pulmonary metastasis.
A RARE CASE OF DRUG INDUCED CHYLOTHORAX
P205
BACK ROUND:DASATINIB IS USED AS A THERAPY FOR IMATINIB RESISTANT CHRONIC MYELOID LUEKEMIA.
INITIALLY APPROVED STANDARD DOSE OF DASATINIB 70MG TWICE DAILY PRODUCES VARIOUS SIDE EFFECTS LIKE
ANAEMIA,HYPERTENSION,PERIPHERAL EDEMA ,DRY COUGH ,DYSPNEA, PLEURAL AND PERICARDIAL EFFUSIONS .
METHODS: I REPORT MY EXPERIENCE IN MANAGING A CHRONIC MYELOID LEUKEMIA PATIENT - FOLLOWING
IMATINIB FAILURE ,WAS TREATED WITH DASATINIB AT 140 MG DAILY FOR 3 MONTHS,DEVELOPED CHYLOTHORAX
AS A COMPICATION.
RESULTS: MY PATIENT IS TREATED FOR CHRONIC MYLOID LEUKEMIA WITH DASATINIB 140 MG DAILY WHO
DEVELOPED CHYLOUS PLEURAL EFFUSION. THE PATIENT WAS MANAGED BY THERAPEUTIC PLEURAL TAPPING,
REDUCED DOSE OF DASATINIB AND DIURECTICS. CHYLOTHORAX RESOLVED.
CONCLUSION:IN CONCLUSION ,CHYLOUS PLEURAL EFFUSION IS A RARE COMPLICATION OF DASATINIB .
MANAGEMENT SHOULD BE DISCONTINUING DASATINIB / DOSE REDUCTION OF DASATINIB/ ALTERNATIVE
CHEMOTHERAPEUTIC DRUGS WITH DIURETICS OR STEROIDS. HENCE, PATIENTS ON DASATINIB SHOULD BE MADE
CLOSE FOLLOW UP TO MONITER THEIR SIDE EFFECTS AND FOR INITIATION OF PROMPT TREATMENT.
Giant solitary fibrous tumour of the pleura
P206
GAURAV GUPTA, RISHABH RAJ, SUSHEEL BINDROO
Dept. of respiratory medicine, jaslok hospital and research centre, mumbai, India
Solitary fibrous tumour of the pleura is a rare primary pleural neoplasm. They usually arise from visceral pleura but
may also arise from parietal pleural. These tumours are usually asymptomatic and are incidentally detected.
Sometimes they may be associated with chest pain, shortness of breath and cough. Majority of these neoplasms
are benign and surgical excision provides excellent results.
Here we are discussing a rare case who presented to us with complaints of breathlessness on exertion and loss of
weight since one year. Also he was having frequent episodes of hypoglycemia since one month though he was a
known case of diabetes mellitus. Chest Xray showed a homogenous mass occupying left hemithorax. Usg guided
biopsy was done and a diagnosis of solitary fibrous tumor was made. Associated multiple episodes of
hypoglycemia were present (Doegge potter syndrome) which is seen in 5% of patients with solitary fibrous tumor.
P207
TitleMetastatic alveolar rabdomyosarcoma presented as massive pleural effusion.
Authors- M N BHAKARE, G P GODBOLE, A DIWAN, N H BHAKARE, M KULKARNI. Smt. Kashibai Navale medical
college & general hospital, Pune Maharashtra, India.
IntroductionRabdomyosarcoma is the commonest soft tissue sarcoma of adolescence. The tumor commonly occurs in the soft
tissues of the head & neck, genitourinary & extremities. Alveolar rabdomyosarcoma presenting as massive pleural
effusion is extremely rare and presents diagnostic challenges, especialy in resource limited centers.
Rabdomyosarcoma is an aggressive tumor with poor prognosis especially when diagnosed late.
Case presentation We present a case of 14 years female who was presented to us with left side massive pleural effusion, which was
primarily diagnosed as tuberculosis & started with antituberculous treatment at another center. But after CT
thorax & left axillary lymph node biopsy diagnosis was revised as metastatic rabdomyosarcoma with unknown
primary. Ascites developed within 2 weeks of admission.The bone scan showed no evidence of any skeletal
metastases. Due to unavailability, PET scan could not be done. Metastatic malignant cells were seen in both pleural
fluid & ascitic fluid. The patient failed to respond to chemotherapy & succumbed to the disease.
ConclusionThough very rare, alveolar rabdomyosarcoma may be present as massive pleural effusion. Usually bone metastases
are common, which were absent in our patient. So massive pleural effusion in teen aged patient should be
investigated properly. We think this case will add knowledge for diagnosing alveolar rabdomyosarcoma.
P208
Title: Profile of patients underwent inter-costal drainage in a medical college hospital
R Bansal, PK Sharma
Dr. Rajendra Prasad Government Medical College, Kangra at Tanda (HP) 176001
Objective: To study the profile of patients underwent Inter Costal Drainage (ICD) procedure by the author
Methods: Information of all the patients underwent ICD was recorded on an approved proforma. The data was
analysed keeping objectives in mind.
Result: A total of 101 patients were treated with ICD over the study period of 18 months by the author. Only 2
were females, 60 and 76 years old. Average age of male patients was 48.11В± 15.86 years. Maximum 29% patients
were within 50-59 years of age.
Duration of ICD in place: Mean duration В± 1SD of ICD in place was 23.84В±38.33 days; Mode duration = 6 days;
Median duration = 14 days with a range of 2-251 days
Presenting complaints: Only Chest pain 19% and only shortness of breath (SOB) 15%. Chest pain with or without
other complaints 43%, SOB with or without other complaints 36%, fever with or without other complaints 13%,
cough with or without other complaints 6%, incidental 3%, leakage from previous tube site 2% and 1 case was
iatrogenic.
Provisional diagnosis: Pneumothorax 48% (Primary spontaneous 24%, Secondary spontaneous 23% and iatrogenic
1%), Pleural Effusion 23%, Empyema 18%, Hydropneumothorax 9% and Hemothorax 1%
Co-morbidity: On ATT 19%, Old Treated Case of TB 13%, Malignancy 9%, COPD 7%, Bullous lung disease 4%, Lung
abscess 1%
Final outcome: Expanded fully 60%, Expanded partially 15%, Pleural thickening 14%, Collapse lung 9% and Cortex
formation 3%.
Associated events: Readjustment 12%, Repeated flushing 4%, Surgical emphysema 4%, Pleurodesis 2%, Tissue
growth 2%.
Conclusion: ICD procedure is done almost exclusively in male patients of productive age groups with
pneumothorax, they mostly present with chest pain with SOB and is mostly associated with tuberculosis.
P209
PLEURAL FLUID BILIRUBIN- A NEW DIAGNOSTIC AID IN DIFFERENTIATION OF TRANSUDATES AND EXUDATES
ANANTHA R, KISKU KH, MADHUSMITA M
DEPARTMENT OF PULMONARY MEDICINE, PONDICHERRY INSTITUTE OF MEDICAL SCIENCES, PUDUCHERRY605014
The primary aim when investigating a pleural effusion is to establish the correct diagnosis with minimal
investigation. The conventional method for classifying the pleural fluid as trtansudates and exudates is based on
the diagnostic criteria established by Light et al. The most frequently used Light’s criteria, though still considered as
a gold standard; often misclassify a transudate as an exudate which has been proven by many studies
To evaluate the diagnostic accuracy of pleural fluid bilirubin and its ratio to serum levels in differentiating the
pleural fluid into transudates and exudates
This study was conducted on 30 patients above 18 years of age who had symptomatic pleural effusions on whom a
diagnostic thoracocentesis was performed after meeting the inclusion and exclusion criteria. The initial pleural
fluid analysis were gross appearance, biochemical parameters like LDH, protein, cholesterol, albumin, bilirubin and
their serum values. The etiology of effusions were determined and the diagnostic accuracy of the bilirubin criteria
was compared with that of light’s criteria
In our study of 30 pleural effusions there were 7 transudative and 23 exudative effusions. There were 13
tuberculous, 3 malignant and 7 parapneumonic effusions. The mean bilirubin concentration ratio in exudative
effusions was 0.6 and in transudative effusions was 0.5. We found that the pleural fluid to serum total serum
bilirubin ratio is a useful marker in differentiating transudates and exudates. The correlation of a bilirubin
concentration ratio of 0.6 or more with the presence of an exudate as determined by established criteria is highly
significant and also helps in identifying false positives with that of the light’s criteria
P210
Syringo-Pleural Shunt after fifteen years- A rare cause of Recurrent Pleural Effusion.
MANDILWAR SAURABH, PRAKASH K ASHISH, PRABHUDESAI PRALHAD, SHASHTRI B S
Lilavati hospital and research centre, Mumbai, India.
This is a case report of one of the rarest cause of recurrent pleural effusion because of syringe-pleural
shunt which after fifteen years has led to the said complication. The patient reported is case of post spinal
tuberculosis who developed syringomyelia which itself is a rare sequelae of tuberculosis, has underwent
syringopleural (SP) shunting. After fifteen years of normal working of shunt, the patient developed recurrent
pleural effusion. Thoracentesis both diagnostic and therapeutic has been done. The fluid repeatedly examined was
transudative and every effort to find out the cause was non-yielding. Computed Tomography (CT) done focusing
the shunt showed that it was in exact place. Pleural fluid was positive for Beta-2 transferrin. Video-assisted
thoracoscopic (VATS) exploration done and it was found that distal tip of shunt was adhered with the lung
parenchyma. The pleural biopsy was negative for any malignancy or tuberculosis. The effusion did not progress
further after the dislodgement of distal tip from lung parenchyma.
Key words: Syringopleural shunt; Ventriculoperitoneal shunt; Pleural effusion; Thoracentesis; VATS; Beta-2
Transferrin; Transcytosis; LDH-lactate-dehydrogenase; CSF-Cerebrospinal fluid; syrinx cavities.
P211
VATS in management of Tuberculosis Sequelae
1
1
1
2
2
3
S Khandelwal , Kamran Ali , N Agarwal , A Sharma , S Khanna , T Piplani , A Z Khan
1
1
Department of Minimally Invasive and Robotic Thoracic Surgery
2
Department of Anesthesiology
3
Department of Radiology
Medanta The Medicity, Gurgaon
Objective: To present our experience of VATS for management of Tuberculosis and its sequelae in the chest
Methods: 130 patients with suspected tuberculosis presented for surgical treatment. The diagnosis included
simple and loculated pleural effusions, early and late stage empyema with thick cortices, residual pulmonary cavity
with fungal ball, and pneumothorax with air leak.
Procedures performed were; adhesiolysis, decortication, lobectomy, resection of giant bullae, lung volume
reduction surgery, bullectomy/ pleurectomy/ pleurodesis.
Results: Pleural effusions were treated with VATS (Uniportal and three ports) drainage. Empyema with thick
cortices underwent VATS drainage followed by decortication of both visceral and parietal cortices. Two patients
with cavitatory lung lesions presented with haemoptysis underwent VATS lobectomy. Two patients presented
with pneumothorax underwent VATS bullectomy and pleurectomy.
All patients had good post operative outcomes. Microbiological culture was negative before removal of drain.
Radiological improvement with good lung expansion was seen. All patients continued antituberculous treatment.
One patient with MDR TB needed treatment for 2 years. One patient with Giant Bullous disease underwent lung
volume reduction surgery. He subsequently had prolonged air leak requiring indwelling drain.
All patients with decortication were given post-operative intrapleural antibiotic washout till drain fluid is culture
negative.
One patient who was 80 years old, presented with pneumothorax was treated with
bullectomy/pleurectomy/pleurodesis had prolonged air leak and died due to secondary sepsis. One case required
conversion to open surgery.
Conclusion: VATS does have a role in the surgical management of patients with tuberculosis. We can achieve good
surgical results with minimal morbidity and mortality.
P212
Use of Urobag in place of a conventional underwater chest drainage system in patients with air leaks after VATS
Kamran Ali, S Khandelwal, N Agarwal, A Z Khan
Department of Minimally Invasive and Robotic Thoracic Surgery
Medanta The Medicity, Gurgaon
Objective: Prolonged air leak from the parenchyma is a frequent complication of lung surgery leading to an
increased hospital stay. We wish to share our experience with the use of a Urobag with a non-return valve
connected to a chest drain, which works on the same principle as a Heimlich valve, as an alternative to underwater
chest drainage system in facilitating early discharge in patients undergoing VATS.
Methods: Between August 2013 to August 2014, 58 patients with persistent air leak after VATS done for varying
etiologies, were managed with application of a Urobag to the intercostal chest drain and discharged home early.
Results: The period of chest drainage varied from 3-11 days post operatively. There were no major complications
except for clot obstruction of valve of the Urobag in 2 patients.
Conclusion: Urobag with its inbuilt one-way valve offers many advantages over the underwater seal system. It
helps maintain a more negative intrapleural pressure and by being physiologically more effective than the
underwater drain which may occasionally increase the intrapleural pressure and diminish drainage. It is light
weight and easy to manage, thereby allowing early ambulation and discharge, apart from being cost effective and
easily available at all centres. In a country like India where cost of treatment is an issue use of urobag is a cheaper
option than urobag.
P213
A study on pleural fluid eosinophilia in patients presenting with pleural effusion in RIMS, Imphal
Dr. Moirangthem Seilaja, Prof. W. Asoka Singh
Department of Respiratory Medicine,
Regional Institute of Medical Sciences, Imphal
Objectives:
пѓ� To determine the prevalence rate,
пѓ� To determine the causes of pleural fluid eosinophilia,
пѓ� To explore its clinical importance,
пѓ� To evaluate the outcome of treatment.
Methods:
A cross sectional study of 53 patients who presented in Respiratory Department of Regional Institute of Medical
Sciences with pleural fluid eosinophilia was analysed from October 2012 to August 2014.
Results:
The prevalence rate found was 7.89. Out of 53 patients, 35 were males and 18 were females with age ranging from
16 to 86 years. The causes were paragonimiasis: 15 (28.30%); tuberculosis: 10(18.87%); carcinoma: 8(15.09);
parapneumonic effusions: 6(11.32%); pneumothorax: 5(9.43%); blood or air in the pleural cavity due to chest
injury: 4(7.55%); Meig’s Syndrome and amoebiasis: 1 each (1.89%) and others: 3(5.66%). It affected all adult age
groups. Males are more affected. It affects more people from rural areas. Forty-seven(88.68%) cases showed
exudative effusion. Absolute eosinophil count was raised in 36 patients.
Conclusions
Pleural fluid eosinophilia is mostly seen in males from rural areas affecting all age groups mainly caused by
parasitic infestation, Paragonimus westermanii. Raised absolute eosinophilic count is seen in maximum cases. The
treatable cases responded well to the treatment given specific for the disease. Eleven patients are being followed
up in OPD with improvement.
A case series of pancreatic pleural effusions.
P214
K.V.V.Vijaya kumar, K. Preethi, CH.R.N.Bhushan rao, K.Venkata Ramana
Government Hospital for Chest & Communicable diseases (GHCCD), Andhra Medical College, Visakhapatnam, AP,
India.
Introduction: Chronic pancreatic pleural effusions are uncommon and often unrecognized clinical syndrome
which results from internal pancreatic fistulas and usually presents as exudative pleural effusion of unknown
cause. The effusion frequently occurs without clinical evidence of pancreatitis but occasionally it may be associated
with pseudocyst of pancreas.
Case reports: Here, we present three cases of chronic recurrent hemorrhagic pleural effusions of pancreatic
etiology. All three cases were males among whom two were alcoholics and one was non alcoholic. Two cases
presented as bilateral pleural effusions and one case presented as left pleural effusion of exudative etiology.
Pleural and serum amylase levels were elevated in all three cases. One subject had associated erythema nodosum
and another subject had coincidental finding of horse shoe kidney. Therapeutic ERCP was done in all three cases
and there was complete resolution.
Discussion: Chronic pancreatic pleural effusion is usually recurrent and characterized by very high levels of
amylase in pleural fluid. Of several possible mechanisms involved, transdiaphragmmatic lymphatic transfer of
pancreatic enzymes, intrapleural rupture of mediastinal extension of pseudocyst and diaphragmatic perforations
are the most important. Enzyme rich effusions are more commonly left sided and often hemorrhagic and
frequently associated with pancreatic pseudocysts and if long standing may be complicated by broncho pleural
fistula.
P215
Right sided massive pleural effusion secondary to Pancreatic pseudocysts and Pancreatico pleural fistula - An
Unusual Presentation
Dr.Anusha. M, Dr.Yugandhar.K , Dr.Bhanurekha.B , Dr.V.V.S.D.S.R.Sagar
Dr.Pinnamaneni Siddhartha Institute Of Medical Sciences &Research Foundation
Background:
Pleural effusion on the right side, due to acute on chronic pancreatitis, is a rare manifestation. We are here with
reporting an unusual case of Necrotizing pancreatitis with Pseudo pancreatic cyst presenting as Right sided
massive Pleural effusion secondary to Pancreatico pleural fistula.
Case Presentation:
A 35 year old alcoholic male patient presented with grade – IV breathlessness with right sided chest pain, with a
history of non-productive cough and pain abdomen on and off for six months.
Chest x-ray PA view showed right sided massive pleural effusion, tube thoracotomy was done and 2 Lts of
exudative pleural fluid with markedly elevated amylase in pleural fluid (22450 IU/Lt) was obtained.
Ultrasound abdomen, CT Chest and Abdomen, and MRCP showed acute on chronic pancreatitis with parenchymal
fluid collections/pseudo cysts and fluid collection from tail of pancreas communicating with fluid in abdominal
lesser sac and tracking upwards medially towards midline in right sub diaphragmatic region, fluid seen in right
pleural cavity.
Therapeutic Thoracoscopy was done and the locules ruptured and fluid drained. Pseudo cysts were managed
conservatively.
Conclusion:
Massive right sided pleural effusion with high amylase levels and right sided Pancreatico pleural fistula is a very
rare condition and managed with tube thoracostomy and therapeutic thoracoscopy .
P216
TOPIC NAME: PANCREATICO PLEURA FISTULA PRESENTING AS RECURRENT PLEURAL EFFUSION.
Authours: Dr.R.Nedunchezhian, Prof.Dr.D.Ranganathan, Pror.Dr.A.Mahilmaran, Dr.V.Sundar
Institution: Institute of Thoracic Medicine, Madras Medical College, Chennai-31.
Introduction:
Pancreatic pleural effusion is due to accumulation of fluid in pleural space with high amylase content resulting
from disruption of pancreatic duct.When pancreatic duct disrupts anteriorly results ascites and disrupts
posteriorly results Pseudocyst and gives rise to retroperitoneal fistula which tracts through Esophagus or Aortic
hiatus gives rise to pleural effusion.Pleural effusion also occurs with fistula from Pseudocyst extending through
dome of diaphragm.Spontaneous resolution unlikely.Endoscopic Retrograde Cholangio Pancreatography is
essential in both diagnosis and management.Partial disruption of main pancreatic duct is treated with panreatic
stent placement.Complete disruption of Main pancreatic duct needs surgical correction
Case History: 43 yr old male,chronic alcoholic ,completed cat 1 ATT for 6month 10 yr back for sputum AFB
negative Pulmonary TB,admitted in Rajiv Gandhi Govt General Hospital Madras Medical College,as Left pleural
effusion.History of Intrcostal tube drainage of pleural effusion done two times previously in private hospital
present. On examinatin left pleural effusion was present.USG&MRI abdomen done and reported as chronic
calcific pancreatitis with pseudocyst in tail of pancreas.Plueral fluid amylase reported as 34600 somaygi
units,serum amylse reported as 3640 somaygi units.Endoscopic retrograde cholangio pancreatography
done:Fistulous communication from pseudocyst to left side dome of diaphragm confirmed and pancreatic stent
placement done.patient uneventful during the hospital
Conclusion: Pancreatico pleural fistula a rare cause of recurrent pleural effusion has good prognosis with surgical
treatement or pancreatic stent placement
Key words:pleural effusion,pancreatico pleural fisula,stent placement. presentation
P217
Comparison Of Clinical diagnosis And Light's Criteria in Distinguishing Transudative and Exudative pleural effusions
G.Ramya, V.V.Ramana Reddy, Ganeswar behra, J.V.praveen, D.S.S.sowjanya, B.K.Prithvi
Department of pulmonary medicine, Maharajah’s Institute of Medical Sciences, NTR University of health Sciences ,
Andhra Pradesh, India
OBJECTIVE: The delineation of pleural effusions as being either exudate or transudate is the initial and crucial step
in the diagnosis of pleural effusions. The aim of this study is to ascertain the role of clinical diagnosis in segregating
the exudative and transudative pleural effusions and to compare with the Light’s criteria and serum-pleural fluid
albumin gradient (SAPA).
MATERIALS AND METHODS: Forty patients with pleural effusion admitted from August 2013 to August 2014 in our
institute were studied. Clinical examination, chest x-ray, Light’s criteria and serum-pleural fluid albumin gradient
were used to distinguish transudates and exudates.Further investigations like 2D echo ,pleural fluid culture,sputum
for AFB ,thoracoscpoic and bronchoscopic biopsies were done to confirm the diagnosis.
RESULTS: A total of 40 patients having pleural effusion were divided into 2 groups. Group I Transudates (n=10,
25%), Group II Exudates(n=30, 75% ) based on SAPA, which is taken as gold standard. According to the Light’s
criteria, there were 37( 92.5%) exudates and 3(7.5%) transudates. Out of the 37 exudates, 7 exudates on diuretic
therapy were found to be transudates by clinical diagnosis and SAPA which were misdiagnosed as exudates by
Lights. With clinical diagnosis 29(72.5%) cases were classified as exudates and 11(27.5%) cases were classified as
transudates. Light’s criteria misclassified 17.5% of cases whereas Clinical diagnosis misclassified only 2.5% of cases
while differentiating transudates from exudates.
CONCLUSION: The discriminative value of clinical diagnosis appears to be superior to light’s criteria in the
diagnostic separation of transudates and exudates. In conclusion, though light’s criteria is mostly recommended,
coalesced use of clinical diagnosis improves the diagnostic confidence in distinguishing exudates and
transudates.In primary care where biochemical analysis were not available clinical diagnosis alone can be
considered for treating the patients.
P218
CLINICO MICROBIOLOGICAL PROFILE OF EMPYEMA THORACIS
DR.S.SOWMYA
KAKATIYA MEDICAL COLLEGE
OBJECTIVES-comparing the clinical & microbiological profiles of patients with tuberculous and nontuberculous
empyema.
MATERIALS AND METHODS-A prospective study of adult cases of nonsurgical thoracic empyema was performed
over a period of 18 months. A comparative analysis of clinical characteristics, treatment modalities, and outcomes
of patients with tb and nontb empyema was carried out.
RESULTS-40 cases of empyema were seen during the study period, of which 18 (,45%) were of nontb etiology while
tb constituted 22(, 55%) cases. Among the nontuberculous empyema patients, pseudomonas 6( 15%) was the
most frequent pathogen isolated. tb empyema was more frequent in younger population compared to nontb
empyema (mean age of 32.7 years vs. 46.5 years). Duration of illness and mean duration of chest tube drainage
were longer (48.7 vs. 23.2 days) in pts with tb empyema. Also the presence of parenchymal lesions and
bronchopleural fistula often requiring surgical drainage procedures was more in tb empyema pts
CONCLUSION-TB empyema remains a common cause of empyema thoracis in India. TB empyema differs from
nonTB empyema in the age profile, clinical presentation, management issues, and has a significantly poorer
outcome
P219
Role of pleural fluid adenosine deaminase in etiological diagnosis of pleural effusion
Lokeswara Reddy .A, Yugandhar .P, Satya sri .S
ASRAM Medical college, Eluru, A.P
Abstract:
Objectives: To estimate ADA levels in pleural effusions and to find out diagnostic utility of ADA in etiological
diagnosis of pleural effusion.
Methods: This prospective study has been approved by our ethical committe.The study was carried out in 75
patients in age group of 10-75years both Out and In patients in ASRAM hospital,Eluru with intial diagnosis of PLEF
during September 2013 –February 2014.After taking consent ,detailed clinical history,physical examination,routine
investigations of all patients including ADA estimation by Galanti and Giusti colorimetric method was done.
Results:Total no. of Tuberculosis patients were 55 and in all of them pleural fluid ADA was more than 40 IU(mean
66.4+29.3).In 10 cases proved to be Malignant the ADA was less than 40(mean17.3+2.64) where as patients with
Transudative effusion were 7 and their pleural fluid ADA was less than 40(mean11+3.12).The mean ADA activity in
tuberculous pleural effusion is significantly high when compared to malignant and transudate
effusions(p<0.001).Based on this data we have taken 40 IU/L as cut off point in differentiating tuberculous and
non-tuberculous effusions with a sensitivity of 98.8% ,specificity 100% and positive predictive value of 100% each
for tuberculous effusion.
Conclusion: Pleural fluid ADA is a very good parameter to differentiate tubercular from non tubercular pleural
effusion. It is a simple,low cost investigation and should be considered routinely in all cases of pleural effusion.
P220
A case of asymptomatic atraumatic rupture of spleen with pleural effusion in a diabetic patient.
A.B. SRIVASTAVA, B. WAANBAH
Department of Respiratory Medicine, RNT Medical College, Udaipur
Background: Atraumatic rupture of spleen is a condition associated with many disorders and it mainly presents
with abdominal pain in the left upper quadrant, hypovolemic shock and peritonitis. We report a case of left sided
pleural effusion due to atraumatic rupture of spleen without abdominal symptoms.
Case Report: A 68 yrs old male presented with progressive shortness of breath for 10 days. No history of trauma
or syncope or any unusual effort. He is a known case of Diabetes Mellitus on oral hypoglycaemics for the last 20
yrs. On examination the patient was afebrile and vitals were normal. Respiratory system examination showed
findings of pleural effusion on the left side. Pleural fluid was aspirated in four different sittings. It was about
2500ml in amount, hemorrhagic, exudative and showed PCV = 1.2%, ADA = 25.62U/L with cell count of 80
cells/cumm which mainly included RBC, lymphocytes and few mesothelial cells. No malignant cells were found.
CECT scan showed free fluid collection in left pleural space and multiple hypodense lesion in spleen with peripheral
enhancing low attenuation fluid density collection in subcapsular region suggestive of splenic rupture.
Discussion: Atraumatic rupture of the spleen has been described in the medical literature as a clinical oddity with
grave consequences, if unrecognised and untreated. The true incidence of this condition is difficult to state as a
Medline literature search revealed only 44 such case reports over the last 34 years. Symptoms can be subtle and
the condition may be mistaken for angina pectoris, myocardial infarction, pulmonary embolism, peptic ulceration
or pneumonia. In our case, conservative management was given, though we did not rule out the possibility of a
splenectomy during the period. Patient was discharged after 2 weeks.
P221
To study the therapeutic use of streptokinase in loculated empyema
Dr. VIKASH KUMAR, Dr. G.V.SINGH, Dr. SANTOSH KUMAR, Dr. R.K.GUPTA, Dr. SANJEEV ANAND, Dr. ANKIT
DESHWAL, Dr. BHARTESH, Dr. SANTOSH
S. N. Medical College, Agra
OBJECTIVE- to study the therapeutic effect of streptokinase in loculated empyema.
MATERIAL AND METHODS- Patients complaining of fever and dry cough, having clinical and CXR findings
suggestive of empyema will be evaluated by USG, and patients having loculated empyema will be considered for
intrapeural instillation of streptokinase. In total, 30 lac IU of streptokinase will be instilled intrapleurally via
transthoracic route in three divided doses daily (diluted in normal saline) in duration of three days. Patients will be
evaluated clinically and radiologically using CXR, before and after treatment. Pt. will be kept in follow-up, along
with drugs according to the etiology of empyema, and monthly CXRs will be done to find out any recuurent
empyema.
RESULTS- Atotal of 7 patients established to have loculated empyema were considered for intrapleural instillation
of streptokinase, and all the 7 patients were cured as evident on serial CXRs done. In follow-up, none of the cases
was found to have recurrence of loculated empyema.
CLINICAL IMPLICATION- Patients having loculated empyema are difficult to treat, as there are loculations in pleural
cavity along with pus. Once intercostal drain is placed, it takes months to extubate such patients because of
loculations. In such patients, instead of putting ICD, intrapleural instillation of streptokinase via transthoracic route
by injection can prove to be a better treatment option as it will lead to early cure and lesser duration of hospital
admission.
P222
A rare case of left lower lobe pulmonary sequestration presenting as empyema
DR. CHETAN RAO.VADDEPALLY , Prof. Pradyut Waghray, Dr.A.N.V.Koteshwara rao, Dr. Venkateswara reddy.T,
Dr.Rama Krishna reddy.G*,Dr. Veena , Dr. Harish, Dr. sowmya, Dr. Rikin, Dr. Aditya, Dr. Krishna Chaitanya.
Dept. of Pulmonary Medicine, S.V.S medical college, mahboobnagar, Telangana.
*Dept. of Radiology
Introduction : with an overall incidence of 0.15 to 6.4% of all congenital pulmonary malformations, pulmonary
sequestration forms a rare disorder. The condition is characterized by aberrant formation of segmental lung tissue
that has no connection with the bronchial tree. It preferentially affects the lower lobes, predominantly the left
lower lobe. We hereby present a case of the rarer variety presenting as empyema.
The case report: A 35 yr old male was admitted with complaints of high grade , intermittent fever with chills and
cough with expectoration and haemoptysis since the last 10 days. The patient gave history of recurrent episodes of
fever and cough since childhood.
Physical examination revealed a healthy appearing, well nourished man. On auscultation, there were decreased
breath sounds on the left lower zones.
Total leucocyte count was raised and all other routine investigations were within normal limits. Chest X-ray
showed an ill-defined, homogenous opacity, occupying the left lower zone with obliteration of the CP angle.
Ultrasound of the thorax revealed moderate pleural effusion. Diagnostic tap showed frank pus which was drained
with ICD. After removal of ICD patient had an episode of massive haemoptysis. Subsequent contrast enhanced CT
showed heterogenous enhancing cystic mass lesion in the left lower lobe. A small arterial branch from the
abdominal aorta supplying the mass lesion was visualized. Given the history and imaging features characteristic of
intra lobar sequestration, the patient was reffered to thoracic surgeon.
Conclusion : The diagnosis of sequestration can be easily missed in adults as many of the symptoms overlap with
other pulmonary processes. The constellation of recurrent pneumonia and cystic lower lobe mass fed by an
anamalous systemic arterial vessel are hallmarks of an intralobar bronchopulmonary sequestration.
A rare case of Thoracic Empyema – Double Trouble
P223
Authors – Avik GHOSHAL, Koushik MUTHU RAJA.M, B.RAJAGOPALAN
Institution - Sri Ramachandra Medical College and Research Institute
Introduction: - Pleural space is always a riddle.Tuberculous empyema is rare compared to tuberculous pleural
effusion and the pleural fluid is smear positive for acid – fast bacilli(AFB) unlike that in pleural effusion. Presence of
other systemic disease makes the etiological diagnosis more challenging. Here we present a case of empyema, AFB
positivity and suspected Adult Onset Still’s disease (AOSD) – all together.
Case Report:A 21 years female presented with complaints of breathlessness, chest pain and high grade fever. On detailed
history patient revealed fever for 20 days-initially low grade intermittent, later high grade continuous. She had
pain with tenderness left lower chest, was febrile, toxic and breathless-MMRC grade III . She also gave history of
intermittent polyarthralgia and pink coloured rash over extremities, predominantly lower limbs, for nearly a year.
Clinical examination revealed Right cervical lymphadenopathy. Chest X-ray revealed bilateral pleural effusion left
more than right. Nearly 170ml of pus was aspirated from left pleural cavity. Pleural fluid analysis revealed Sugar-2,
Protein-6, LDH-6066, ADA-221, with smear positive for AFB. Patient was started on Anti-tubercular therapy (ATT).
Fever was not subsiding. Laboratory investigations revealed TLC-10200, S.Bilirubin-4.13(Direct-3.65), SGOT-1567,
SGPT-942. Based on history of polyarthralgia and skin rash for a year and raised S.Ferritin concentration of 2047.7
mcg/L (normal range 30 – 300mcg/L), patient was diagnosed with Adult Onset Still’s Disease. Patient was put on
oral Steroids, Hydroxychloroquine and Hepatic safe ATT regimen. Her fever subsided and liver function normalised.
Conclusion:Adult Onset Still’s Disease is uncommon (incidence < 1/1,00,000 ) and characterised by polyarthritis, rash, fever
and leucocytosis. The diagnosis is primarily a diagnosis of exclusion suggested by coexistent elevated level of
Ferritin. Pleural effusion and even pleuro-pericardial effusion are less recognised components of AOSD. We
present this case as it may be a combination of tuberculosis with AOSD.
P224
Spectrum of sleep disturbances in patients undergoing haemodialysis
KRISHNOJI RAO S, KRISHNASWAMY U, CHENNABASAPPA GK, MANTHA SP, ANEJA A
Departments of Respiratory Medicine and Nephrology
MS Ramaiah Medical College, Bangalore, Karnataka, India
Objectives: To study the spectrum of sleep disturbances in patients with End Stage Renal Disease (ESRD)
undergoing haemodialysis.
Method: This cross-sectional study was conducted on 121 ESRD patients undergoing haemodialysis in M.S.
Ramaiah Hospitals. After obtaining informed consent, patients were screened using a clinical proforma, Epworth
Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI).
Results: Out of 121 patients with ESRD included in the study, there were 34 (28.1%) females and 87 (71.9%) males,
with age ranging from 20-81 years. Ninety seven (80.2%) patients were undergoing dialysis for more than 6
months while 24 (19.8%) patients were undergoing dialysis for less than 6 months.
Ninety three (76.8%) patients reported sleep disturbances. These included excessive daytime sleepiness in
32(34.4%), insomnia in 35(37.6%), restless legs in 17(18.3%) and various combinations of the above in 9(9.7%)
patients. Among patients with excessive sleepiness, symptoms suggestive of obstructive sleep apnea (snoring,
witnessed apneas) were reported in 10 (31.2%) patients.
However, when the ESS and PSQI were administered, it was found that ESS was >10 in 61(50.4%) patients
qualifying them as excessively sleepy and PSQI score was >5 in 111(91.7%) which was indicative of poor quality
sleep.
Conclusion: This study shows that there is a high frequency of self-reported sleep disturbances among patients
undergoing hemodialysis, and the frequency further increases if validated questionnaires are administered. Thus,
there is a need to routinely screen these patients for sleep disturbances and perform polysomnography to
diagnose wherever indicated.
P225
Sleep quality in patients with Hypercapnic Chronic Obstructive Pulmonary Disease by Polysomnography
K.Rajarajan, S.P.VengadaKrishnaraj, G.AllwynVijay, R.Sridhar, O.R.Krishnarajasekhar, C.Chandrasekar
StanleyMedicalCollege, Chennai
Background:
COPD is fast emerging as global health problem and is the fourth leading cause of death among developed
countries. There are few studies on COPD establishing differences between functional parameters of the disease
and sleep variables.
Objective:
To describe the sleep pattern in COPD patients with Chronic Hypercapnic Respiratory Failure and to describe the
influence of hypercapnia on the quality of sleep .
Methods:
Patients enrolled in the COPD registry at Government Hospital Of Thoracic Medicine, Tambaram , with severe
stable COPD evidenced by FEV1< 40% by spirometry are included, Arterial Blood Gas analysis is done. Those with
Chronic Hypercapnic Respiratory Failure (Group A) are included in the study. Patients with similar degree of
obstruction without Respiratory Failure are used as comparision group (Group B). Overnight Polysomnography was
performed in those patients and Pittsburg sleep quality index scoring is done. Data is analysed by standard
statistical methods.
P226
BILATERAL TUBERCULOSIS OF AREOLA & NIPPLE–A RARE CASE
1) Dr Srikanth Ravoori, 2) Dr V.A.N.Raju, 3) Dr P.Subbarao
Department of Pulmonary Medicine, Konaseema Institute of Medical Sciences & Research Foundation, NH-214,
Amalapuram, E.G. Dist, Andhra Pradesh-533201.
BACKGROUND: Though TB is common in India, Tuberculosis of Breast is an uncommon finding or may be
overlooked and treated commonly as Pyogenic Abscess. This is a case of TB of areola and nipple.
CASE REPORT:
A 25 yr unmarried woman presented with pain, fever, and discharge from nipples for last 7 yrs. There was no
history of pulmonary tuberculosis, but her brother was treated adequately for sputum positive pulmonary
tuberculosis 5 years back. Sputum AFB of the patient was negative but mantoux with 36mm induration with a BCG
scar was noted. On physical examination, there were multiple healed scars present on both the breasts around the
retracted nipples. Grayish white thick, cheesy discharge was expressed from both the nipples and examined for
AFB by ZN staining which was found to be POSITIVE. Chest x-ray was normal. Patient is kept under DOTS and
responding well to treatment.
DISCUSSION: In India the incidence of TB breast has been reported to be 0.63%to 4.5%. Bilateral breast
tuberculosis is rare, TB of areola and nipple being rarest. Bilateral involvement holds for only 3% of patients with
breast tuberculosis. In most of cases histology contributes to diagnosis by identifying a granulomatous lesion with
typical caseous necrosis. The Gold standard for diagnosis of TB is Zeil Neelsen staining/culture, which is positive in
our case. The differential diagnosis to be considered is carcinoma, although other diseases of the breast such as
fatty necrosis, plasma cell mastitis, periareolar abscess, actinomycosis & blastomycosis should also be considered.
P227
Pulmonary Mucormycosis Masquerading As Endobronchial Growth with Non Resolving Pneumonia
1) Dr Srikanth Ravoori , 2) Dr Mootha Vamsi Krishna
Department of Pulmonary Medicine, Konaseema Institute of Medical Sciences & Research Foundation,
NH-214, Amalapuram, E.G. Dist, Andhra Pradesh-533201
BACKGROUND: Non resolving pneumonia has a wide range of etiology which needs extensive investigations
including bronchoscopy, radiological and microbiological tests. We present an unusual case of Non resolving
pneumonia
CASE SUMMARY: Patient is a 40 year old diabetic male, presented to us with complaints of chronic cough and fever
of 4 weeks duration. He was evaluated elsewhere with chest X rays, CT SCAN which showed left lower lobe
consolidation. Sputum was sent for bacterial culture. He received antibiotics for K.pneumonia infection as per
sensitivity pattern. Despite 2 weeks injectable antibiotics he had persistant symptoms. Repeated sputum
examination for AFB was negative. Repeat CT scan showed persistent consolidation. At this juncture patient was
referred to us. He was subjected to BRONCHOSCOPY. It revealed an endobronchial growth in left lower lobe main
bronchus, causing partial obstruction of lumen. Endobronchial biopsy has shown features of INVASIVE
MUCORMYCOSIS. He received liposomal Amphotericin B 100 mg/day for 10 days with which clinical improvement
was noted and was followed by Posaconazole syrup. Patient had complete clinical, radiological improvement and
confirmed by resolution of endobronchial growth and normalization of airways. Posaconzole was continued till
complete radiological resolution.
CONCLUSION: We report a case of pulmonary mucormycosis presenting as endobronchial growth. We successfully
treated the patient with liposomal Amphotericin B and Posaconazole, avoiding surgery.
CLINICAL IMPLICATION: Diabetic patients with uncontrolled blood sugars presenting with non resolving pneumonia
should be investigated for fungal etiologies
TITLE: Endobronchial tuberculosis: case report.
P228
AUTHORS: Dr.Bharat Bhushan, Dr.Ramesh Chander, Dr. N.C.Kajal, Dr. Rosy Aggarwal, Dr. Sandeep Gupta, Dr.
Satish Duggal.
Department of Chest and TB, Government Medical College, Amritsar (Punjab), India
ABSTRACT
BACKGROUND : Tuberculosis remains major threat to mankind worldwide with India accounting for one-fifth of
global incidence.
Endobronchial tuberculosis is disease of tracheobronchial tree with microbial and
histopathological evidence. It remains difficult to be diagnosed because of nonspecific clinical presentations with
normal chest skiagram and absence of acid fast bacilli in direct sputum smear oftenly. Accordingly patient remains
undiagnosed and source of infection to the family and community. Procedural investigations like fiberoptic
bronchoscopy are sometimes of great help in patients with strong suspicion of disease in country like India with
high disease incidence.
Case Report : A 27yr married female presented with three months complaint of having fever, dry cough , right side
chest pain along with hemoptysis of fifteen days duration. There was no history of ATT previously. GPE and Chest
examination were normal. Hb7 g/dl, TLC7800, DLC N60,L40, ESR110mm, HIV non-reactive, Mantoux negative, CXR
showed no abnormality. Direct sputum smear microscopy was negative for AFB. FOB showed inflammation,
hyperemia and ulceration with caseous material on bronchial mucosa of intermediate bronchus and adjoining
lower lobe bronchus on right side. Brush-smear, broncho-alveolar lavage and post bronchoscopic sputum
specimen were taken. BAL centrifuge revealed AFB on direct smear. Cytology revealed lymphocytic
predominance. Post-bronchoscopic sputum and brush-smear were negative for AFB. Accordingly diagnosis of EBTB
was established. The patient was put on anti-tubercular chemotherapy (DOTS) along with oral prednisolone (1
mg/kg). The patient improved markedly and the prednisolone dose being tapered during follow up.
Conclusion : EBTB is less frequently diagnosed because of non-specific clinical presentations, misleading normal
radiological findings and low incidence of AFB positivity in routine sputum-smear. A high index of suspicion is
required for its diagnosis, especially in high endemic regions like Indian subcontinent. Added procedural
investigations including FOB will help for early diagnostic yield.
Key words: Atelectasis, Endobronchial, cancer, complication, pneumonia, tuberculosis
P229
ALTERNARIA ALTERNATA PNEUMONIA
A RARE CASE REPORT
Dr. V.Mounika, Prof. Dr.P.Subbarao, Dr.H.V.Prasad
Konaseema Institute of Medical Sciences & Research Foundation
Amalapuram, Eastgodavari, Andhrapradesh
BACKGROUND CASEREPORT
Alternaria alternata is a rare fungal organism, that usually Seen on dead and dying plant parts , house dust.
CASE REPORT
In this case report a 50 year-old female with a 10 year history of asthma and 4 year history of diabetes mellitus,
presented with two months duration of right chest pain, cough with purulent sputum and streaky haemoptysis.
Chest x-ray and CT chest showed non homogenous opacity in right mid zone.
Ultrasound guided Fine needle aspiration of right lung lesion revelead pus.The cytology of pus showed branched
septate hyphae, and few hyphae are brown in colour and culture on sabouraud's dextrose agar showed colonies of
Alternaria alternata. The patient was treated with Amphotericin B and fluconazole. Patient was discharged after
resolution of symptoms.
DISCUSSION
ALTERNARIA fungus is a large universally occurring genus. Several form-species are found as saprophytes on dead
and dying plant parts. Commonly found in house dust, carpets, textiles, and on horizontal surfaces in building
interiors and is one of the main fungal causes of allergy. Outdoors, it may be isolated from samples of soil, seeds
and plants, and is frequently reported in air. Conidia of this fungus are easily carried by the wind. The large spore
size suggests that the spores from this fungus will deposit in the nose, mouth and upper respiratory tract causing
nasal septum infections. It has also been associated with hypersensitivity pneumonitis
It is a common cause of extrinsic asthma includes, Baker’s asthma and Farmer’s lung . Acute symptoms include
edema and bronchospasms; chronic cases may develop pulmonary emphysema. Other diseases caused by
Alternaria include mycotic keratitis, skin infections, and osteomyelitis
P230
P231
Validity of empiric anti-tubercular treatment in suspected extra-pulmonary TB patients in tertiary health careRetrospective study
Dr. Avinash Chauhan(Presenting Author), Prof. Dr. Meena Hingorani, Prof. Dr. Tushar Sahasrabudhe
Department of Pulmonary Medicine
Padmashree Dr. D. Y.
Patil Medical College Hospital and Research Centre, Pimpri, Pune, Maharashtra, India.
OBJECTIVES:
To study the validity of empiric anti-tubercular treatment in suspected extra-pulmonary TB patients
METHOD:
A retrospective case series study was conducted at Dr D.Y Patil medical college, Pune, Maharasthra. All cases
diagnosed and treated as EPTB from September 2013 to February 2014 were included. Data was retrieved from
the RNTCP register. Details of clinical, laboratory and radiological records of the patients were retrived from
respective departments. Extra-pulmonary TB was defined as patients with TB of any organ other than the lungs
according to WHO definition such as gastrointestinal (G.I), musculoskeletal and genitourinary systems.
Lymphadenopathy and pleural effusion were excluded as their diagnosis is based on histopathological and ADA
findings respectively. All cases were registered on DOTS-CAT-1 and followed up after 3 months to evaluate the
response to therapy.
RESULTS:
Out of the 36 patients treated for EPTB, 19 patients were males and 17 were females and mean age was 30 yrs
(range 15-40). Most of the patients were unskilled workers and farmers. 60% patients were alcoholics. G.I and
musculoskeletal(joints) were the most common sites involved (80.5%).Common complaints were abdominal pain
and fever when G.I system was involved, and joint pain in case of musculoskeletal system. Among G.I patients,
63.8% (12 patients out of 19) symptoms resolved at the end of 3 months and 36.2% (7 patients out of 19) patients
there was no change in symptoms- 3 defaulted within 2 months due to no improvement in symptoms and 4 are
continuing treatment inspite of no change in symptoms . Among musculoskeletal, 60%(6 patients out of 10)
symptoms resolved and 40%(4 patients out of 10) patients there was no change in symptoms-2 defaulted within 2
months due to no change in symptoms and 2 are continuing inspite of no change in symptoms. No additional
treatment was taken either as alternative therapy or treatment for co-morbidity by the patients during 3 months
period.
CONCLUSION:
Our study shows that suspected extra-pulmonary patients must be investigated thoroughly for tuberculosis and all
other differential diagnosis must be excluded before starting anti-tubercular treatment.
P232
TITLE: Diagnostic value of PCR in sputum of patients with pulmonary tuberculosis
AUTHORS: SS GUPTA, A MEHROTRA, R SHARMA
Department of Pulmonary Medicine, Era’s Lucknow Medical College & Hospital, Lucknow, India
OBJECTIVES: To find out diagnostic utility of PCR in sputum of patients with pulmonary tuberculosis, to determine
sensitivity and specificity of PCR in diagnosis of pulmonary tuberculosis, and to compare the results of PCR with
sputum smear reports of Mycobacterium tuberculosis (MTB) by Ziehl-Neelsen (ZN) staining.
METHODS: The study group consisted of 65 out-patients with strong suspicion of active pulmonary tuberculosis on
basis of clinico-radiological evidence. 40 out-patients having non-tubercular respiratory disease during the same
period formed the control group. Sputum of all the patients was subjected to smear microscopy by ZN staining and
PCR for MTB in MJ mini thermal cycler (BIO RAD UK) using IS6110 (123bp) primer for amplification. All patients
were subsequently followed clinico-radiologically.
RESULTS: Of the 65 cases, 40 were smear positive and 25 were smear negative for MTB. All smear positive cases
were PCR positive. Out of 25 smear negative cases, 14 were PCR positive. All 40 controls were PCR negative. All 54
PCR positive cases responded to anti-tuberculosis therapy. The sensitivity and specificity of smear microscopy was
found to be 61.5% and 100%, while that of PCR was found to be 83% and 100% respectively.
CONCLUSION: This study suggests that detection of MTB by a PCR based test could lead to rapid detection, early
treatment, application of isolation procedures and also, investigation of contacts.
P233
Deep Vein Thrombosis in a patient with Pulmonary Tuberculosis - A Case Report
KB GUPTA, VIPUL KUMAR, MOHIT AGGARWAL
Pt B.D. Sharma Post Graduate Institute of Medical Sciences
INTRODUCTION: Deep vein thrombosis (DVT) is clinically observed and can be confirmed with laboratory methods
in 3-4% of patients with pulmonary tuberculosis (PTB). But the real incidence may be closer to 10%, because most
of the patients are thought to be clinically inapparent. The lack of awareness regarding the association is possibly
responsible for the condition not being recognized and hence screening and treatment strategies have not been
standardized.
CASE RECORD: A 25 year old male TB patient was admitted with painful swelling of left lower limb for last 5 days.
On examination the leg was tender &signs of DVT were present. Color Doppler Ultrasonography of left limb
showed echogenic thrombus in lumen of left external iliac, common femoral, superficial femoral, popliteal,
posterior tibial and anterior tibial veins. CT Angiogram chest showed no evidence of pulmonary embolism. Patient
was treated with subcutaneous low molecular weight heparin with an overlap of warfarin for 10 days. Repeat
Color Doppler ultrasonography done after 2 weeks of treatment of antithrombotics showed resolution of
thrombus.
DISCUSSION : The thrombogenic potential of TB is not well known but can have serious consequences. Activation
of endothelial cells occurs in response to numerous physiological stimuli and results in the expression of
endothelial proteins that change the normally non-thrombogenic internal surface of the vessel into a
thrombogenic surface with subsequent development of local thrombosis. Priming of vascular endothelium occurs
as a result of interaction between mycobacterial products and the host monocyte–macrophage system. It is also
postulated that these changes result in hypercoagulable state predisposing to DVT. Prognosis of the DVT in PTB
was found to be good if ATT and LMWH were started simultaneously and earlier. We emphasize on early detection
of deep vein thrombosis, early start of prophylactic low molecular weight heparin in severe pulmonary
tuberculosis
A RARE CASE OF PAROTID TUBERCULOSIS
P234
P Dani, P Dutta, R Manjhi, S Pothal
Department of Pulmonary Medicine,V S S Medical College ,Burla ,Odisha, India
Background:- parotid tuberculosis is a rare form of extrapulmonary tuberculosis which usually presents as a
unilateral parotid swelling or abscess. Only about 100 cases of parotid tuberculosis have been reported is the
literature. .
Case report:- The present case reports a 33yrs old male patient presented with swelling of left parotid area of 2 yrs
duration which gradually is increasing in size. On excamination swelling was firm in consistency non tender with ill
defined borders, which was not fixed to masseter or any underlying structure. Skin over the swelling was normal.
Facial nerve was intact.Chest X-ray and other routine blood investigations were normal.USG guided FNAC and
biopsy of the swelling were suggestive of tubercular sialoadenitis. Z-N stain for AFB was negative. Patient improved
with a course of ATT.
Conclusion:- In a case of parotid swelling the possibility of tuberculosis should be kept in mind even though it is
rare. The early diagnosis and suspicion is required to avert the need for surgery which may be a hazardous
procedure in a medically treatable condition.
P235
Calcified subcutaneous cysticercosis in a treated pulmonary TB patient--a case report
Saravanan.M, Ramanujam.P., Chitrakumar.A., Gangadharan.V
Govt.Kilpauk Medical College/ GTHTM, Chennai, Tamil Nadu, India
Introduction: WHO designated cysticercosis as one of the 17 "neglected tropical diseases" worldwide. Encystment
of larval form of tapeworm in various tissues of body is called cysticercosis.Eventhough CNS is the most commonly
involved organ, subcutaneous cysticercosis is also reported in literatures.
Objectives: To highlight that calcified subcutaneous cysticercosis has to be considered in differential diagnosis of
calcified lesions in chest xray
Case report: 70yrs non-diabetic male,agriculturist,pork eater,presented with complaints of cough and
expectoration for 2-3 weeks.10 yrs back,he was treated for pulmonary TB.On examination,there were multiple
subcutaneous small,multiple swellings all over the body.chest xray showed typical millet seed calcifications in soft
tissue areas and lung zones.xrays of abdomen and both lower limbs showed similar calcified lesions in soft tissue
areas.Excision biopsy of subcutaneous swelling revealed fibrocollagenous wall with foci of calcification.no
cysticercosis demonstratable in specimen.sputum for AFB was negative.respiratory symptoms improved with
antibiotics.
Discussion : Subcutaneous cysticercosis is a less common presentation of tapeworm infestation. Man is the
definitive host. Pigs are the intermediate host.Humans get the infection when they ingest undercooked infected
pork meat which is harbouring the cysticerci. Biopsy and HPE demonstrating the cysticerci is the definitive
diagnostic method. In FNAC, the presence of eosinophils, neutrophils, palisading histiocytes, giant cells in a typical
granular dirty background should alert the cytopathologist of a parasitic infection . When characteristic
morphology is absent in histopathology specimen, mitochondrial DNA diagnosis is a powerful tool for a definitive
diagnosis of cysticercosis. .Asymptomatic calcified subcutaneous cysticercosis can be left alone without treatment
P236
Association between DVT and pulmonary TB-- a case series report
Saravanan.M, Ramesh.P.M, Chitrakumar.A, Gangadharan.V
Govt. Kilpauk Medical College /GTHTM, Chennai, Tamil Nadu, India
Introduction: India accounts for 1/3rd of global burden of Tuberculosis. Pulmonary TB is a risk factor for DVT.
Thromboembolic complications associated with pulmonary TB had been reported in literatures with incidence
varying between 1.5 to 3.4%.
Objective: To analyze the epidemiological factors associated with DVT in pulmonary TB patients.
Methods: We did a case series study of 4 cases of smear positive pulmonary TB patients who developed DVT while
on treatment for pulmonary TB. All 4 cases reported to our hospital within a period of 2 months. All cases were
subjected to routine blood investigations, sputum for AFB, x-ray chest
Results: All the 4 patients were male smokers. Age of the patients ranged from 35 -- 53 yrs. Sputum positivity
grading was 2+ in 3 patients and 1+ in one patient. All the 4 patients had bilateral extensive lesions in chest x-ray.
All the patients developed DVT within 4 weeks of diagnosing PTB. All were poorly nourished with low BMI. Venous
Doppler USG confirmed the diagnosis of DVT in all 4 cases. All were treated with ATT, heparin and oral warfarin. All
4 patients responded well to the treatment and no one developed pulmonary embolism in our study
Discussion: Pulmonary TB infection causes elaboration of IL-1,6 and TNF-О± and release of pro-inflammatory
cytokines resulting in a hypercoagulable state. Further rifampicin used in the ATT regimen alters the coagulant and
anticoagulant protein balance resulting in hypercoagulable state. In our study, in all 4 cases, smoking, extensive
lung disease leading to release of pro-inflammatory cytokines and patient’s poor nutritional and bed-ridden
status contributed to the development of DVT..
Conclusion: In all severely ill pulmonary TB patients,we should be aware of development of DVT and early
screening for DVT and encouraging early ambulation in such patients will prevent life threatening pulmonary
embolism.
P237
A case of paradoxical TB IRIS in NON-HIV TB cervical adenitis patient on ATT--a case report
Saravanan.M, Karthikeyan J.J., Chitrakumar. A. , Gangadharan .V
Govt. Kilpauk Medical College/GTHTM, Chennai, Tamil Nadu, India
Introduction: Paradoxical TB IRIS is an immunological reaction seen in HIV patients on ART while on treatment for
tuberculosis, seen within 2 months of initiating ATT. It is characterized by enlargement of existing lymph nodes,
appearance of new nodes, tuberculoma in brain, new lesions in lung and serositis. It poses a challenge to clinician
because it is difficult to distinguish between paradoxical reaction and treatment failure or drug resistance. We
report a case of paradoxical TB IRIS in non-HIV female patient with TB cervical adenitis
Case report: A 33yrs female, non-HIV, non-diabetic, who presented with left cervical lymphadenopathy was
diagnosed as TB cervical adenitis based on symptoms, mantoux positivity and excision biopsy. After 3-4 weeks of
starting ATT, patient developed fever, chest pain,myopathy,arthritis and enlargement of existing node with
abscess formation. CT chest revealed mediastinal adenopathy, pleuro-pericardial effusion and parenchymal
involvement and presternal abscess collection. Aspirate from abscess was sent for AFB culture. Sputum for AFB
was negative. LFT was normal. Meanwhile, patient was continued ATT and treated with NSAID and steroid as
clinical features were suggestive of IRIS. Fever subsided. Pleuro-pericardial effusion resolved. AFB culture report
came as negative for Mycobacterium tuberculosis. Patient improved clinically and ATT was continued whereas
steroid was stopped after gradually tapering the dose. Patient completed full course of ATT with resolution of
nodes.
Discussion: Paradoxical reaction during ATT treatment must be considered after careful exclusion of medication
non-adherence, development of resistance and other similar conditions. The addition of short course of steroid
may be necessary to control severe form of reaction with or without drainage or surgical excision of lymph node to
avoid fistula. .
P238
Awareness of Tuberculosis among patients attending RNTCP at Siddhartha Medical College, Vijayawada
S.N. Mani devi. K , N.Gopichand , D.Sudeena
Department of Pulmonology , Siddhartha Medical College , Vijayawada , A.P.
Introduction:
Tuberculosis is one of India's major public health problems. According to WHO estimates, India has the world's
largest tuberculosis epidemic. Public awareness about its causative organism, modes of spread, diagnosis,
treatment, and prevention plays an important role in TB control. The present study was carried out to assess
awareness of Tuberculosis among patients attending tertiary care hospital(Siddhartha Medical College)
Methodology:
A cross sectional observational study was conducted among 100 patients taking treatment at Siddhartha Medical
College, Vijayawada using a preformed questionnaire. The questionnaire contains socio-demographic variables
such as age, sex, religion, literacy status, and knowledge about symptoms, mode of transmission, aetiology,
Investigations, prevention and treatment of tuberculosis
Results:
Out of these 100 Patients 97% were aware that Tuberculosis is an infectious disease. Regarding symptoms only
69% identified cough more than 2 weeks as an important warning sign for Tuberculosis. Regarding investigations
only 69% were aware that sputum test was done for diagnosis of Tuberculosis. Only 60% knew DOTS as treatment
for Tuberculosis. Only 56% were aware that Tuberculosis is most common in HIV individuals.
Conclusion:
The current study revealed that although awareness regarding certain basic aspect of tuberculosis was adequate;
however there is a great need to improve awareness about the symptoms and treatment of tuberculosis.
P239
Prevalence of extra pulmonary multi drug resistant tuberculosis among retreatment tuberculosis patient admitted
in tertiary care hospital by using gene x pert assay
Dr. K. Maheswaran, S. P. Vengada krishnaraj, G. Allwyn vijay, J. Arivozhi, R. Sridhar, O.R Krishnarajasekhar, C.
Chandrasekar
Institution.stanley.medical.college.chennai
Background:
In 2012, out of the estimated global annual incidence of 8.6 Million TB cases, 2.3 million occurred in India, of which
15% falls under extra pulmonary tuberculosis. India accounts for one fourth of global burden of tuberculosis.
Because of human immunodeficiency virus infection incidence of extra pulmonary tuberculosis is raising,
occupying 50% of tuberculosis in retro viral positive patients. Multi drug resistance among retreatment case is 1217%; primary drug resistant is 2-3%. The X pert MTB/Rif test is a cartridge-based fully automated NAAT (nucleic
acid amplification test) for TB case detection and rifampicin resistance testing, suitable for use in disease-endemic
countries. It provides results from unprocessed sputum samples in less than 2 hours, with minimal hands-on
technical time. This Study where done to identify Multi Drug Resistance tuberculosis among extra pulmonary
tuberculosis patient admitted in our hospital (Government Hospital of Thoracic Medicine tambaram), as similar
previous data unavailable in Tamil Nadu.
Study place: Government Hospital of Thoracic Medicine, Tambaram, Tamil Nadu.
Study period: Between March 2014 to August 2014.
Study design: prospective study
Methods and material:
Patient with extra pulmonary tuberculosis came for retreatments were chosen for my study to analyze drug
resistance among them. Samples from extra pulmonary sites like lymph node, pleural fluid and abscesses were
send for gene x pert analysis in IRL Chennai
Results:
71 extra pulmonary tuberculosis specimen were subjected to gene x pert of which 10 where retroviral positive,
among which pleural effusion occupies 43.6 %, lymph node tuberculosis 52.1 %, abscess 4.6%. Multi drug resistant
was diagnosed in 7 patients (9.8%), MTB detected in 50.7%, MTB not detected in 33.8%, 3 of the 71 samples (4.2%)
was repeated because of indeterminate report. sensitivity of gene x pert in diagnosing MTB complex from various
specimen includes 64.8% for lymph node aspiration, for pleural fluid it is 32.2% and for abscess is 50%.
Conclusion:
1.
Compare to conventional culture methods for diagnosis of extra pulmonary MDR TB used previously;
gene x pert method is quicker hence we are able to diagnose extra pulmonary MDR TB more easily
accounting for its higher incidence in recent years in our institute.
TB presenting as right paratracheal mass.
P240
Dr. Praveen.R, Dr. Yuvarajan.S, Dr. Kavitha devi. M
Sri Manakula Vinayagar Medical College and Hospital,Puducherry, India
Introduction:
Mediastinal tuberculous lymphadenitis is a rare disease in adults. Dysphagia as a presenting symptom is even
rarer. Dysphagia due to mechanical obstruction is usually related to malignant disease.
Case report:
Our case is a 56 year old lady who came with complaints of difficulty in swallowing for 2 months, cough with
scanty mucoid sputum and loss of appetite for six months. Patient was initially evaluated at an outside hospital
with chest x-ray, upper gastrointestinal scopy( Impression – mild oesophagitis) and treated with antacids. As the
patient did not have symptomatic improvement, came to our hospital, was evaluated with Chest x-ray which
showed well defined homogenous opacity in right paratracheal region. Bronchoscopy was done and trans tracheal
needle aspiration was taken which was suggestive of granulomatous lesion. C.T Thorax (plain and contrast ) was
done which showed conglomerated mediastinal lymph nodes present. C.T guided needle aspiration of nodes done
which was suggestive of non caseating granulomatous lesion. With a working diagnosis of sarcodosis / TB
lymphadenitis, Mantoux was done, showed 15mm induration. Patient was started on Anti-tuberculous treatment
CAT -1, improved symptomatically. Follow up chest x rays were taken which showed regression in size of the
homogenous opacity and complete resolution of it after six months of Anti-tuberculous treatment.
P241
EVALUATION OF MYCOBACTERICIDAL ACTIVITY OF SUPEROXIDIZED WATER ON CLINICAL ISOLATES OF
MYCOBACTERIUM
Dr Ritu Aggarwal, Dr Uma Chaudhary, Dr Vipul Kumar, Dr K B Gupta, Dr Nidhi Goel
Pt BD Sharma Post Graduate Institute of Medical Sciences, Rohtak (Haryana) INDIA
Objectives- In 2012, 8.6 million people fell ill with TB and 1.3 million died from TB. The main cause for concern is
the spread of MDR TB strains and HIV-TB co infection. Resistance to medication does not mean that at the same
time there is also a resistance to disinfectants. Careful disinfection in the everyday clinical environment is of great
importance today and is a particularly effective measure for the prevention and breaking down of infection chains.
In this context the methods of asepsis and active chemical antisepsis are currently becoming increasingly
important in terms of the prevention of transmission of infection. So, this study was conducted to investigate the
activity of superoxidized water on mycobacteria.
Methods- For clinical isolates of Mycobacteria and Mycobacterium tuberculosis H37Rv (NCTC 7416) were included
in the study. Suspension of the five mycobacterial strains was prepared in distilled water in six sets for each strain.
Three set of tubes were used as test and were treated with SOW for a period of 05, 10 and 15 minutes. Remaining
three acted as control and was treated with D.W.
Results- Colony counts of all strains were reduced to zero within five minutes of treatment with SOW. Control
tubes for all the organisms showed growth. Superoxidized water gave >5 log 10 reduction of Mycobacterium spp
with five minutes of exposure in the absence of organic load.
Conclusion- Our study shows, significant reduction in mycobacterial load i.e >5 log 10 in the absence of organic load
within 05 minutes of exposure with SOW. Such high level of disinfection has also been demonstrated by other
authors. So, SOW can be a good alternative high level disinfectant for various health care purposes.
P242
Comparative study of clinical and radiological features of pulmonary tuberculosis patients with or without diabetes
mellitus
AUTHORS: J SIRCAR, SS GUPTA, AS SINHA, A VERMA
Department of Pulmonary Medicine, Era’s Lucknow Medical College & Hospital, Lucknow, India
OBJECTIVES: To compare the clinical and radiological similarities/dissimilarities between diabetic and non-diabetic
pulmonary tuberculosis patients.
METHODS: The study group consisted of 65 new patients of pulmonary tuberculosis who were sputum smear for
acid-fast bacilli (AFB) positive and were either known cases of diabetes mellitus (DM) or were recently diagnosed
as having DM. The control group consisted of 65 new pulmonary tuberculosis patients who were sputum smear for
AFB positive and did not have diabetes.
RESULTS: Of the 65 patients in the study group, 40 (61.5%) were newly diagnosed cases of DM and 25 (38.5%)
were old known cases of DM. Of these 25 patients, the duration of diabetes was ≤5 years in 5 (20%) and ≥5 years
in 20 (80%) cases. 2 (8%) of these 25 patients were on insulin therapy, 21 (84%) were on oral hypoglycemic
therapy, while 2 (8%) were not taking any treatment for DM. Fifty-two (80%) out of the 65 diabetic patients were
males. Grade and duration of fever, and lower zone lung involvement was significantly higher in diabetic patients.
Incidence of cough and cavitary lesions was significantly higher in non-diabetic patients.
CONCLUSION: Male sex, old age and lower zone lung involvement are strong predictors of DM among pulmonary
tuberculosis patients. As a significant number of patients were diagnosed to have DM on screening, routine
screening for DM should be made essential for pulmonary tuberculosis patients to help improve the treatment
outcome and to prevent the emergence of multi-drug resistant tuberculosis.
P243
ABPA - A MASQUERADER OF PULMONARY TUBERCULOSIS
DR.VARIKUTI SUBBARAO, DR.A.SATHYAPRASAD, DR.Ganesh Mohapatra, Dr Vijay, Dr Nalini, Dr Prashanthy
MAMATA MEDICAL COLLEGE & HOSPITAL, KHAMMAM
Background: Allergic Bronchopulmonary aspergillosis is an idiopathic inflammatory lung disease characterized by
allergic inflammatory response to the colonization of aspergillus. High degree of suspicion is required in order to
make its diagnosis since the presenting complaints are often non specific and overlap with other clinical situations
like pneumonias, bronchiectasis, pulmonary tuberculosis.The delay in diagnosis of ABPA often leads to significant
morbidity. The wide spectrum of this disease can be severe requiring lung transplantation. However, if diagnosed
early, it can be treated effectively to reduce future remission and progressive lung damage. We report one such
case, who was treated with anti tuberculous drugs without any significant improvement.
Case Report: A 35 years old female with clinical history suggestive of bronchial asthma since childhood, presented
to us with unremitting symptoms of breathlessness, cough, expectoration, wheeze, fever, chest pain since 2 years.
She was being treated outside with ATT, based on chest radiograph finding inspite of her sputum and bronchial
washings were being negative for AFB. Upon further evaluation she was found to have elevated total serum IgE
levels, immediate skin hypersensitivity reaction was positive to aspergillus fumigatus antigen, with elevated
peripheral eosinophil count. All these findings, in addition to central bronchiectasis as seen on HRCT Thorax were
fulfilling the Greenburger and Patterson criteria for the diagnosis of ABPA. She was treated with oral steroids,
antifungal agents and followed upto 6 months with good clinical and radiological improvement.
Conclusion : Suspicion for ABPA should be maintained while managing any patient with bronchial asthma with any
severity or any level of control and should not be misdiagnosed and wrongly treated for other pulmonary diseases.
Here this case was diagnosed as per Greenberger and Patterson criteria.
P244
Pulmonary tuberculosis presenting as organizing pneumonia-a case report
Karthiga.G, Chellaraja.C, Chitrakumar A, Gangadharan .V,
Govt. Kilpauk Medical College/GTHTM, Chennai, Tamil Nadu, India
Case Report: 18 years old unmarried female, housemaid by occupation presented with severe hypoxia (SpO2-82%)
even with high flow oxygen, high grade fever with chills, dry cough and dyspnea at rest for 10 days duration. There
was no past h/o tuberculosis /ATT intake. Clinically patient was febrile (102 F), dyspnoeic, tachypnoeic and
tachycardia. Auscultation of chest revealed bilateral crepitation. Investigations done-Sputum AFB, widal, ANA, RA,
HIV, blood urine C/S were negative; CRP positive; ESR 25/50mm. Chest X ray showed bilateral peripheral air space
opacities. CT chest revealed extensive lobar consolidation with GGO pattern predominantly involving lower lobe.
Patient was treated with supportive care, antibiotics and steroids. After stabilizing patient general condition, FOB
and DLCO were done. BAL revealed mixed cellularity with increased lymphocytes. Microbiological tests showed
positive for AFB and negative for fungal and NT culture. PFT showed severe restriction with reduced DLCO. Patient
was started on ATT category I with continuous O2 flow for 2 weeks. Hypoxia improved after 2-3 weeks of O2
therapy. After 6 weeks of hospitalization with tapering steroids, patient improved clinically with minimal
radiological improvement and discharged with an advice to continue ATT.
Discussion: Organising pneumonia is a type of pneumonia in which usual process of resolution has failed and
organization of inflammatory exudates occur in alveoli by fibrous tissue. Etiology of organizing pneumonia includes
bacterial, viral, parasitic infections, connective tissue disorders, drugs, ionizing radiation and toxic fumes. It affects
people of ages 40-60 years. It has no sex predilection. Patients usually present with flu like symptoms which
include dry cough, dyspnea, fever, weight loss and fatigue. Pathophysiology-delay in clearance of fibrinous
exudates and granulation tissue which leads to intra alveolar accumulation of fibromyxoid connective tissue
leading to organising pneumonia. Our case presented like organizing pneumonia due to tuberculosis, a very rare
presentation.
P245
Case of Non-Tuberculosis infection mimicking Aspergiloma.
Dr. Abhinandan B. Mutha, Co-author- Dr. B. K. Mutha, Dr. S. Dugad, Dr. G. Kulkarni.
Case history- 50 years old female, came with C/O cough with expectoration, low grade fever & breathlessness on
exertion since 6 months. Also C/O loss of weight and appetite.
Past history of Pulmonary Koch’s 25 years back, for which treatment was taken of which details were not available.
No H/O DM, HTN, B.A.
No significant family and personal history.
O/E – patient was averagely built and nourished, vitally stable, no e/o pallor, cyanosis, clubbing, lymphadenopathy,
oedema.
On Respiratory system examination- trachea central, B/L chest movements equal, B/L BS present, crepitations
present in left infrascapular area.
CVS, CNS, PA – WNL.
CxR & HRCT Thorax – bilateral fibrocavitatory lesions with aspergiloma in left lower lobe.
Bronchoscopy done and BAL taken which was sent for AFB, Fungal & Pyogenic culture.
BAL AFB culture- Mycobacterium other than tuberculosis grown, which on identification revealed Mycobacterium
Abscessus, which was sensitive to trimethoprim sulfamethoxazole, moxifloxacin, amikacin, clarithromycin,
linezolid.
Treatment was given as per sensitivity report and patient responded well to treatment.
Fig 1 &2 are pre treatment, fig 3 is post treatment.
P246
Clinical and Bacteriological profile of Comminity Acquired Pneumonia among adult patients
Aji Mathew Joseph, R N toshniwal
Department of Pulmonary Medicine, Navodaya Medical College Hospital and Research Centre, Raichur, Karnataka,
India.
Objectives:
1. To assess the types of clinical presentation of Comminity acquired pneumonia (CAP)
2. To study the associated risk factors and their outcome on the disease.
3. To study the spectrum of organisms causing CAP
4. To study the drug sensitivity pattern of the organisms isolated.
Methods:
Etiology and clinical profile of 50 patients with CAP above 18 years were studied retrospectively from October
2012 to November 2013. Data regarding clinical features, physical examination, chest xray, sputum samples for
smear microscopy and cultures were collected in a preformed proforma and analysed.
Results:
The commonest mode of presentation was cough (96%), followed by fever (94%) and expectoration(86%).All
patients had bronchial breathing and 70% had crepitations.The commonest risk factor was copd (20%) with a
mortality of 2%.,. Streptococcus pneumonia was the commonest pathogen(38%) followed by pseudomonas
aeruginosa (18%) , staphylococcus aureus (12%), klebsiella pneumonia (8%).organisms were most sensitive to
ciprofloxacin (44%) followed by amikacin (32%), piperacillin tazobactum (28%),and amoxicillin clavulanic acid (26%)
Conclusions:
CAP was common in elderly (>50 years) .Incidence was more common in men .Commonest predisposing factor was
copd. Majority of the patients had cough with expectoration and fever followed by chest pain and dyspnea.Most
patients had leukocytosis and sputum examination showed predominance of gram positive organisms.
Streptococcus pneumonia was the commonest organism isolated which was most sensitive to fluoroquinolones
followed by aminoglycosides and broad spectrum pencillins with beta lactum inhhibitor.The mortality was high in
copd patients.
P247
Unusual presentation of tuberculosis
N.G.KUNJIR, R. NARASIMHAN
Department of Respiratory Medicine, Apollo hospital, Chennai.
Hereby we report a case of 27 year old female, who presented with persisting moderate to severe left sided chest
pain since last 3 weeks. Pain was localised to left infraaxillary and interscapular region and was not responding to
analgesics. She denied any other co-existing respiratory complaints or any constitutional symptoms. Breast
examination was normal. ECG showed sinus rhythm. Chest X ray and Plain CT scan chest revealed pleuroparenchymal nodule in the left lower lobe region. She was referred to our hospital for further evaluation. Contrast
CT chest was done which showed that nodule was localized to costal pleura and was associated with pleural
thickening. CT guided biopsy of the nodule showed perivascular round cell infiltrates. PET CT showed
hypermetabolic soft tissue mass in left chest wall and FDG avid pleural nodules in left hemithorax region, with
imaging differentials of Lymphoma or Askins tumour/PNET or Metastasis. Since suspicion of malignancy was high,
she was subjected to open pleural biopsy. Left pleural nodule biopsy showed necrotizing granulomatous
inflammation with few acid fast bacilli. We report this case to emphasis the fact that false positivity of PET CT in
high prevalent countries like India should be always kept in mind while interpreting the results.
CONCLUSION
All that glitters on PET, is not cancer.
P248
Spirometric analysis in post-tuberculois sequelae
BHATIA H, GUPTA P, MITTAL R, DASH DJ, CHHABRA SK
Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, Delhi
Background. In a substantial proportion of cases, treatment of tuberculosis does not ensure a complete
anatomical and functional recovery and the patient is left with posttubercular sequelae. These sequelae lead to
significant impairment of lung function that is responsible for significant morbidity and mortality. The present
study was carried out to explore the spectrum of spirometric abnormalities in patients presenting with Posttuberculosis sequlae.
Methods: A retrospective analysis of spirometric patterns of cases diagnosed with posttubercular sequelae over a
period of two years was carried out. Active tunerculosis was ruled out. The patients underwent spirometry for
their functional assessment.
Results: There were 37 subjects (22 male and 15 females) with mean age of 44.78 В± 12.67 years. All the studied
subjects confirmed pulmonary or pleural tuberculosis in the past with 4 (11%) patients having received treatment
twice or more frequently. Majority had completed treatment or were declared cured (33/37) while 4 had
defaulted at different stages. The main symptoms on presentation were cough with expectoration and
breathlessness on exertion. Thirteen subjects (13/37,35%) had clinical history suggestive of bronchial asthma.
Active tuberculosis was ruled out by sputum examination for acid fast bacilli by direct smear and culture.
Spirometry revealed abnormality in 27/37 (73%) subjects. It showed obstructive pattern in 7 (19%) subjects
(6male/1female) restrictive pattern 11 (30%) subjects (4male/7female) & mixed pattern 9 (24%) subjects
(7Male/2Female) while it was normal in Normal 10 (27%) subjects (4Male/6Female). Significant response to
bronchodilator was observed in 14 (38%). Eight subjects (8/37,22%) were smokers, out of whom 43% (3/7) had
mixed abnormality, 43% (3/7) had airflow limitation & 14% ( 1/7) had restrictive pattern.
Conclusions: Functional abnormalities are common in tuberculosis after completion of treatment and result in
continued morbidity. The majority of patients had restrictive pattern followed by mixed patterns of abnormalities.
P249
An Interesting Case of Tuberculosis with Intraoral Involvement
Dr Karl DM, Dr Ajit H, Dr Sivaraj AL, Dr Alamelu H, Dr Rajashekar MB, Dept of Pulmonary Medicine and Dr
Rachna K, Dept of Oral Medicine & Radiology
Vydehi Institute of Medical Sciences & Research Centre and Vydehi Institute of Dental Sciences & Research Centre
Tuberculosis is still endemic to India. Mycobacterium tuberculosis’ ability to infect any part of the human body is a
fact. Tuberculosis of oral cavity is an uncommon entity because of the bacilli’s inability to penetrate the intact
squamous epithelium.
This case report is of a 63 year old farmer, a smoker for more than 35 years. He presented with complaints for the
last 3 months, which were: pain in the left side of the mouth, which was aggravated on opening his mouth, while
talking and chewing food. Pain arose from an ulcerative lesion in the left buccal mucosa, which gradually increased
in size to involve the left angle of the mouth. For the last 1 month he also complained of progressive trismus. He
also gave history of productive cough with scanty, white, mucoid sputum, non-blood stained and intermittent, lowgrade fever. He denied losing weight and claimed to have a normal appetite.
On clinical examination, he had fever of 101oF. Local examination showed an irregularly shaped solitary ulcer,
about 2.5 cm x 3 cm, involving the left buccal mucosa, extending anteriorly to involve left commissure, left
mucocutaneous junction of lower lip and upper lip. Auscultation of his lung fields revealed bilateral scattered
crepitations.
A punch biopsy of the ulcer was reported as caseating granulomatous inflammation while Ziehl-Neelson stain
confirmed the presence of acid-fast bacilli. Incidentally, his sputum was positive for acid-fast bacilli. A diagnosis of
pulmonary tuberculosis with intraoral involvement was made. He was started on RNTCP Category 1 antitubercular
treatment.
This case illustrates an atypical presentation of tuberculosis and the diagnostic challenge clinician’s face. India
being a high burden country for TB, our clinicians must continue to remain aware of this disease and keep it as a
differential diagnosis in any atypical medical scenario.
P250
SPUTUM POSITIVE PULMONARY TUBERCULOSIS WITH HANSEN’S DISEASE(PURE NEUROTIC TYPE) - An Unusual
Presentation
Dr.Kiran, Dr.Krishnamurthy , Dr.Vijay kumar,Dr.Pramod kumar
OSMANIA MEDICAL COLLEGE ,GGCH
Background:
Pulmonary koch’s with hansen’s, is a rare manifestation. We are here with reporting an unusual case of sputum
positive pulmonary tuberculosis with pure neurotic type of leprosy
Case Presentation:
A 34 year old male patient presented with grade – I breathlessness , cough with expectoration since 2 months
and inability to use left upper limb and tingling sensation of left upper limb for one month.Chest x-ray PA view
showed left upper zone infiltrates, sputum for AFB 3+ and 1+
Skin chip for AFB taken from right ear and left hand dorsum suggestive of pure neurotic type leprosy
Patient treated with anti tubercular treatment under RNTCP DOTS cat-1 and and hansen’s treatment under NLEP
P251
Role of geneXpert in lymph node aspirates via EBUS in diagnosis of TB in evaluation of isolated mediastinal
lymphadenopathy
A.BHANOT, S.JOSHI, R.GUPTA, D.TALWAR
Pulmonary Medicine and Critical Care, Metro centre for respiratory diseases, Noida, Uttar Pradesh, India.
OBJECTIVE: To investigate the role of geneXpert in diagnosis of tubercular mediastinal lymphadenopathy from
real-time endobronchial ultrasound and transbronchial needle aspiration (EBUSTBNA) material. EBUS-TBNA of the
mediastinal and hilar lymph nodes is now becoming a standard care that is safe and has a good diagnostic yield.
GeneXpert assay has high sensitivity and specificity for identification of MTB in expectorated samples of lower
airways secretions. However, few performance data have been published to date on non-respiratory specimen in
TBNA samples from mediastinal lymphnodes where the diagnosis of tuberculosis depends upon the cytology
findings.
METHODS: We collected clinical, cytological, and microbiological data from 30 patients admitted to our centre
from January-August 2014 with mediastinal lymphadenopathy. All patients underwent EBUSTBNA.
Performance of a single Xpert-MTB assay as compared to the cytology was evaluated against microbiologically
confirmed TB lymphadenitis. “Definite-TB” was defined as positive microscopy and/or culture with consistent
clinical features.
RESULTS: A total of 30 patients with a mean age of 46.3 В± 17.3 years underwent EBUS-TBNA in whom mediastinal
TB was clinically suspected. Xpert-MTB demonstrated an overall sensitivity for stain and/or culture positive TB of
33% and specificity of 94.4%, PPV of 80% and NPV of 60%. Positive TBNA Cytology showed an overall diagnostic
sensitivity of 75% for stain and/or culture positive TB patients but with a specificity of 27.8% , PPV of 41% and NPV
of 62.5%.
CONCLUSION: Our study showed that although sensitivity of geneXpert in EBUS-TBNA material from mediastinal
lymphnodes (believed to be paucibacillary) is low but high specificity and high positive predictive values would
support the use of positive result to start empirical treatment in patients with pending microbiological data or
justify in its absence. Therefore we conclude that Xpert-MTB in EBUSTBNA aspirate provides a rapid, useful, and
accurate test to diagnose mediastinal nodal TB.
P252
A STUDY OF 70 CASES OF PULMONARY TUBERCULOSIS IN HIV INFECTED PATIENTS
DR.HEMANT NAYI, DR.PRAGNESH PATEL, DR.SAVITA JINDAL, DR.NALIN T.SHAH, DR.KUSUM V.SHAH
Department of pulmonary medicine, BJ Medical college, Ahmedabad,
INTRODUCTION:
The emergence & pandemic spread of AIDS and HIV have posed the greatest challenge to public health in modern
times. The rate of TB infection has been steadily mounting.
AIM
1.
2.
3.
To study the relation b/w HIV infection & Pulmonary TB.
To assess the clinical profile and outcome of pulmonary TB in HIV seropositive patient.
To study the presentation of pulmonary TB in relation to CD4+ T Cell lymphocyte count among HIV
seropositive case.
MATERIAL AND METHODS
A study was carried out on 70 patients, from April 2013 to April 2014 in pulmonary medicine department, BJMC,
Ahmedabad Gujarat.
RESULTS
1.
2.
3.
57 cases (82%) were males and 13 (18%) cases were females with Male : Female ratio 4:1. This suggests
that males are commonly affected in HIV with TB than females.
3
As far as pulmonary TB is concerned, 43 cases (61.43%) had CD4+ T Cell count < 200/mm and 27 cases
(38.57%) had CD4+ Cell ≥ 200.
In pulmonary TB Sputum smear for AFB was positive in 14 cases (19.99%) and Negative in 56 cases (80%)
3
10 cases (14.28%) with CD4+ T Cell count ≥ 200.mm had positive sputum smear for AFB as compared to
3
4 cases (5.71%) with CD4+ T cell count <200 /mm . Majority of these patients with positive sputum smear
3
had CD4+ T Cell count ≥ 200/mm .Detail results will be discussed in case study.
CONCLUSION:
HIV and pulmonary TB co-infection may aggravate both conditions as both are intracellular organism and TB coinfection increase replication of HIV virus.
P253
A survey of knowledge and attitude of general population about tuberculosis
Sivakumar Reddy P, Nageswari AD, Srinath D, Rajalakshmi R,Kavita Vani K
SRM Medical college and hospital, Kattankulathur
Background: Tuberculosis is a major public health problem. Tuberculosis the most common opportunistic infection
in diabetes, hiv and aids, it has gained even greater importance. RNTCP depends on the passive reporting of the
chest symptomatic patients to the health institutions. Therefore, it is important that the basic knowledge about
the disease and the availability of treatment is clear among the individuals in the community. Equally important is
to assess the practices of the people to find out unhealthy practices.
Objectives: To assess the knowledge about symptoms, mode of transmission, causation, prevention and treatment
relating to tuberculosis in a general population.
Study design: Cross-sectional.
Setting: Kanchipuram dist.
Participants: Individuals above 18 years and who are willing for answering tuberculosis questionnaire were
selected. A total of 350 patients were selected
Results: A total of 350 individuals with mean age of 43.02 years (Range: 20-70 years) were interviewed, out of
which 202(57.7%) were males and 148(43.3%) were females. One-fourth (24.6) of the individuals were illiterate.
94.6% were aware about tuberculosis disease. cough with sputum (31.5%) was common symptom associated with
tuberculosis. 27.7% of responders said TB is not contagious.51% responders thought TB is spread through
coughing. 59% responders believed TB is curable. When questioned about the social acceptance of tuberculosis,
16.3% said they will hide the disease. Only 13.9% responders had heard about TB through media. 22.5%
responders had said that TB is associated with DM followed by HIV (19.9%) and both DM & HIV (20.5%).
Conclusion: Although knowledge regarding symptoms, mode of transmission and causation was fairly good,
misconception like non contagious nature of disease still exist among the general population. despite advances in
medicine the stigma attached to tuberculosis is still prevalent.
P254
PYRAZINAMIDE INDUCED CUTANEOUS LEUKOCYTOCLASTIC VASCULITIS
SINGH A, MISHRA M, JAIN V K, SHARMA A, NAYYAR P , KUMAR A
DEPARTMENT OF RESPIRATORY MEDICINE, MAHATMA GANDHI MEDICAL COLLEGE & HOSPITAL, JAIPUR, INDIA
Cutaneous leukocytoclastic vasculitis is a small vessel Vasculitis localized to skin. There are any possible causes for
this pathological condition like infections, collagen vascular disorder, use of medications and malignancies. A 30
year old male was diagnosed as left sided tubercular pleural effusion. He was put on daily anti-tubercular therapy,
regimen comprising of isoniazid, ethambutol, rifampicin and pyrazinamide. After 1.5 months of initiation of
treatment patient presented to us with complaint of purpuric lesions that developed on bilateral lower legs. The
lesion first appeared over the both ankles and spread upwards upto the knees. Histopathically the lesion was
leukocytoclastic vasculitis. The lesions improved after the discontinuation of ATT. ATT was re-challenged one by
one over next few days. The lesions reoccurred with Pyrazinamide. Thereafter pyrazinamide was withdrawn and
remaining drugs were continued. Diagnosis of pyrazinamide induced leukocytoclastic vasculitis was made.
P255
A Rare Case of Disseminated Tuberculosis - Laryngeal Tuberculosis with Lupus Vulgaris and Pulmonary
Tuberculosis
B.SriTeja, V.V.Ramana Reddy, Ganeswar behera, J.V.Praveen, D.S.Sowjanya, G.Ramya, B.K.Prithvi,
P.V.V.Bharadwaj
Department of Pulmonary Medicine, Maharajah’s Institute of Medical Sciences, NTR University of health sciences,
India.
Laryngeal tuberculosis is a rare disease. It is almost always associated with pulmonary tuberculosis. Lupus vulgaris
is a common morphologic form of cutaneous tuberculosis, but this type of association with laryngeal and
pulmonary tuberculosis is rare.
CASE REPORT: A 46 yr old female patient presented to the department of Pulmonary Medicine with complaints of
dry cough, skin lesions over nose and lip, hoarseness of voice, dysphagia since 1year. On examination large skin
lesions with crusting over plaques were present all over the nose extending onto the upper lip and filtrum.
INVESTIGATIONS:
Chest X ray - a large nodular opacity of approximately 1x 1cm size in the left upper zone. Sputum for AFB negative. Mantoux test - 25 mm of induration at the end of 72 hrs. ESR - 45 mm. CECT chest - a well defined
nodular lesion with central calcification and air lucencies in posterior segment of left upper lobe suggestive of
pulmonary tuberculosis. Bronchoscopy showed yellow coloured crusts in the base of the both nostrils. Normal
architecture of Epiglottis, ariepiglottic folds, arytenoids, false cords and Vocal cords was lost, which were replaced
by the thick proliferative granulomatous lesion. We proceeded with biopsy from the skin and epiglottic lesions.
Histopathological examination revealed typical granulomatous tubercle with epitheloid cells, langhan’s giant cells
and a mononuclear infiltrate with minimal caseation suggestive of tuberculosis. Diagnosis of lupus vulgaris with
laryngeal and pulmonary involvement was made. The patient responded very well and the lesions in the lip, larynx
and lung regressed with ATT.
DISCUSSION: A high index of suspicion and a thorough clinical examination of the pharynx and larynx is mandatory
for not missing this diagnosis of laryngeal lupus. Therefore, efforts should be made to locate an active or inactive
lesion elsewhere in the body.
P256
MDR TB-Cold Abscess in Chest Wall—Secondary To Mediastinal And Pulmonary Tuberculosis In a HIV Patient
RAHAMAN TANZIL*, HARI PRASAD**, BHARGAV PRASAD **, VAMSI KRISHNA** SUBBA RAO***
DEPARTMENT OF PULMONARY MEDICINE, KONASEEMA INSTITUTE OF MEDICAL SCIENCES, CHAITANYA NAGAR
,AMALAPURAM,EAST GODAVARI, ANDHRA PRADESH-533201.
INTRODUCTION: Tuberculosis is a major public health problem in India. Further it’s complicated by the spread of
HIV and increased drug resistance. There are very few reports of MDR-TB at extra-pulmonary sites from India. We
report here about a rare occurrence of MDR-TB involving chest wall abscess.
CASE REPORT: A 35 year old, HIV positive male patient, initially presented with symptoms suggestive of PTB .
Sputum for AFB was positive. We started him on ATT with CAT-1. After completion of ATT there was no relief in
symptoms and developed left suprascapular lymphadenopathy, firm with matting. Chest x ray showed mediastinal
widening in addition to persistent pulmonary infiltrates. CECT chest showed multiple enlarged mediastinal
lymphnodes with peripheral rim enhancement suggestive of tuberculous lymphnodes. FNAC of cervical
lymphnodes showed granuloma due to tubercular etiology. CAT 2 ATT was started.
While patient was in 5th month of CAT II ATT, he presented with complaints of large swelling over sternum. On
examination, swelling of 8 X 8 cm in size, skin is shiny and fluctuation test was positive. Aspirated pus was sent for
ZN staining and DST. Z N staining positive 2+ for AFB. As patient had already received CAT I and was on CAT II
treatment, MDR TB was suspected. On L J medium, culture growth was seen after 3 weeks. DST done from the
growth showed Mycobacterium tuberculosis which is resistant to INH and rifampicin. MDR –TB was
confirmed&CAT IV regimen started. Patient responded very well to the treatment with complete reduction in size
of chest wall
DISCUSSION: MDR-TB is an emerging and alarming health problem. The actual treatment regimens for MDR-TB are
complex, expensive, long term, associated with high rates of side effects and poor outcome, and high morbidity
and mortality.pulmonary TB is the common mode of presentation of MDR-TB.
P257
ATYPICAL PRESENTATION OF GENITO URINARY TUBERCULOSIS
KRISHNA KARTHIK *, HARI PRASAD**, BHARGAV PRASAD **, VAMSI KRISHNA** SUBBA RAO***
DEPARTMENT OF PULMONARY MEDICINE, KONASEEMA INSTITUTE OF MEDICAL SCIENCES, CHAITANYA NAGAR
,AMALAPURAM,EAST GODAVARI, ANDHRA PRADESH-533201.
INTRODUCTION: Lymph nodes, pleura, and osteoarticular areas are common sites of extra pulmonary tubercular
nd
involvement but any organ can be involved. Genitourinary TB is the 2 most common cause of extra pulmonary TB
with kidney being the most common site.
CASE REPORT: A 26 year old married woman presented with a 6 months history of recurrent episodes of increased
frequency of micturation and dysuria. She has anorexia, weight loss, fatigue ,evening rise of temperature and
irregular periods since 1 yr.On examination chest was clear, per abdomen a suprapubic mass of 7 Г— 8cm was
found, which diminished in size on micturition.Urine AFB was negative.CT abdomen showed B/L enlarged kidneys
with hydroureteronephrosis, bladder wall thickening with patulous vesicoureteric junctions. Multiple calcifications
in peritoneal cavity, hydrosalpinx and retroperitoneal lymphadenopathy. Bladder biopsy revealed caseous necrosis
sugessestive of tuberculosis cystitis.
DISCUSSION: Genitourinary TB complicates 3-4% of pulmonary TB cases & constitutes 30 % of extra pulmonary
disease. Involvement of the bladder is usually secondary to renal infection and is found in nearly one-third of the
patients Chronic inflammation causes reduced compliance and capacity manifesting as frequency of micturition
.The common presentation is irritative voiding symptoms, renal mass, hematuria,sterile pyuria,etc. In our case the
women had a suprapubic swelling which is a rare presentation of genitourinary tuberculosis.
P258
P259
Initial sputum smear grading as a factor to predict treatment outcome in new sputum smear positive pulmonary
tuberculosis
Don Gregory MASCARENHAS, Vishal CHOPRA, Prabhleen KAUR, AP KANSAL
Department of Chest & TB, GMC, Patiala, Punjab
Introduction: Sputum positivity is used as a basis for initiating antitubercular treatment(ATT) under RNTCP. Though
sputum smear grading is done, its not used to modify ATT regimen
Objective: To assess the association between the initial sputum smear grading and treatment outcomes in new
sputum smear positive pulmonary tuberculosis patients.
Method & Materials : 500 patients who were started on RNTCP Category 1 ATT on sputum positive basis in our
department were analysed for sputum conversion and cure in relation to their initial sputum grading. In our study,
we considered scanty and 1+ as low grade sputum smear specimen and 2+ as well as 3+ as high grade sputum
smear specimen.
Observations: Majority of the patients belonged to the age group of 21-40 years. The mean age was 36.6 years,
68.6% being males and 31.4% being females. The initial sputum smear grading was scanty in 29(5.8%) cases, 1+ in
158 (31.6%) cases, 2+ in 143( 28.6%) cases and 3+ in 170(34%) cases. Sputum conversion rate at 2 months was
inversely related to initial sputum grading(p=0.0005) and age. At the end of treatment, a cure rate of 85.8% was
accomplished. cure rate was high in patients with initial low sputum grading(p=0.045),age 60 years or less
(p=0.0255) and in patients who had sputum conversion at 2 months(p<0.001). There was a high default rate in high
initial sputum grading group(7.66%) and in patients who had persistent sputum positivity at 2 months of
ATT(12.72%).Death rate was high in initial high grade group(p=0.08) and patients >60years (p=0.0004).Failure rate
was high in initial high grade group and in those with low SCR at 2 months of ATT (p=0.0004)
Conclusion: Initial sputum grading, sputum conversion rate and advancing age appear to be strong predictors of
treatment outcome in new sputum positive patients put on category 1 ATT. In patients with initial high bacterial
load(2+ and 3+), advanced age (>60 years ), a modification of current RNTCP regimen (which as of now, has a
unified chemotherapy regimen irrespective of initial bacteriological load ) and greater vigilance is called for.
P260
The Sternoclavicular Joint Involvement: A Rare Presentation Of Tuberculosis
Vishal CHOPRA, Don Gregory MASCARENHAS, Prabhleen KAUR, Parul MRIGPURI
Department of Chest & Tuberculosis(TB), Govt Medical College, Patiala , Punjab
Introduction: The involvement of the sternoclavicular joint in TB is rare and have been reported in 1-2% of all cases
of peripheral TB.
Case report: A 43 year-old woman presented with the left sternoclavicular joint swelling which was gradually
increasing in size since 4 months. The swelling was associated with pain that radiated to the left side of neck and
aggravated with bending and turning. She gave a history of low grade fever especially in the evening. There was no
history of cough, expectoration, weight loss or dyspnea.
Local examination of the sternoclavicular joint revealed a rounded swelling about 7cm in diameter. The overlying
skin was shiny and red. The swelling was immobile, non tender and fixed to underlying tissue. The local
temperature was normal. Patient gave past history of uveitis, since 6 years for which patient was on oral and local
steroids off and on. There was no evidence of any cervical or axillary lymphadenopathy. There was no history
suggestive of involvement of any other organ system.
The haematological investigations were within normal limits. Mantoux test was strongly positive (18*18mm). CT
scan revealed cortical erosions at medial end of left clavicle and along left lateral margin of sternum with
associated soft tissue component. FNAC of the swelling revealed a chronic granulomatous pathology and also
showed the presence of AFB which is very rare. Patient was put on antitubercular treatment and responded well.
Discussion: Extrapulmonary tuberculosis presenting with involvement of the skeletal system accounts for
approximately 1 to 4% of cases. Tuberculosis of sternoclavicular joint has been reported in 1-2% of all cases of
peripheral tuberculosis and 1- 9% of septic arthritis. Differential diagnosis for swelling at the sternoclavicular joint
can be due to sternoclavicular hyperostosis, condensing osteitis, septic arthritis, tumor, rheumatoid arthritis,
ankylosing spondylitis, osteoarthrosis or Tietze syndrome The diagnosis of tuberculosis should be considered in
every patient with involvement of sternoclavicular joint. The features of any monoarticular arthritis, cold abscess,
positive tuberculin skin test, epidemiological risk factors or chest Xray abnormalities consistent with healed or
active pulmonary tuberculosis.
Conclusion: A high index of suspicion of TB is to be maintained in swellings at unusual sites even if they lack
systemic features of tuberculosis as in this case.
P261
Non resolving pneumonia: A clinicopathologic dilemma
DR P.SHARMA, DR S. MOTIWALE
Department of Respiratory Medicine, Shri Aurobindo Institute of Medical Sciences, Indore, India.
Background: Pneumonia showing a slow resolution of radiologic infiltrates and/or clinical symptoms inspite of
giving adequate antibiotic therapy ,has been defined as non-resolving pneumonia .The term “unresolved
organizing or protracted pneumonia” was first coined by Amberson in 1943. Approximately 10% - 15% of
nosocomial pneumonias ultimately converts into non resolving or slowly resolving pneumonia and delayed
treatment may lead to rise in its mortality by 3-5%. The common causes of non-resolving pneumonia are incorrect
diagnosis, inadequate and irrational antibiotic therapy, impaired host defence, atypical organisms, resistant
pathogens, non-infectious causes, and tuberculosis and endobronchial lesions.
Case report: We report a case of 53 yr old female admitted in SAIMS with the presenting complaints of fever with
chills and rigors since four months and cough with minimal expectoration since fifteen days. She reported
shortness of breath, pain in chest and generalized bodyache since ten days. Patient was febrile( temperature was
0
102 F) with remarkable pallor. Fibreoptic bronchoscopy showed right lower lobe inflammed mucosa with retained
purulent secretions. Bronchoalveolar lavage/ culture sensitivity showed growth of Pseudomonas aeruginosa which
was sensitive to- Amikacin , Imipenem , Tobramycin and Colistin. During hospital stay course, patient was treated
initially with antibiotics like Piperacillin - Tazobactum combination along with Levofloxacin for 7 days then started
on injection Gentamicin and Imipenem for 10 days.Significant clinical improvement was noticed by 7 days and then
the patient was discharged on tablet Faropenem for 2 weeks, and on follow-up, she became alright.
Conclusions: Non-resolving pneumonia has always been referred as an area of clinical dilemma by pulmonologists.
Its early diagnosis by fibreoptic bronchoscopy and rational treatment is mandatory for its treatment.
Study of Tuberculosis with Diabetes Mellitus
P262
DR. POOJA SHARMA, DR. RAVI DOSI
Department of Pulmonary Medicine, SAIMS, Indore, India
OBJECTIVES: To analyze presentation of Pulmonary Tuberculosis with Diabetes mellitus in terms of clinical and
radiological pattern.
METHODS: The study includes 100 cases, among these, 50 are diabetic patients with sputum positive
tuberculosis and 50 are non-diabetic patients with sputum positive tuberculosis visiting SAIMS Hospital ,Indore
during the study period (July 2012 to June 2014).
RESULTS: There was male preponderance, 76% males in diabetic group and 80% in non diabetic group with
majority of the patients in the age groups more than 40 years in diabetic and less than 40 years in non-diabetic
group. Weakness and cough were predominant symptoms with 94% and 90% in diabetic group, and 70% and 90%
in non- diabetic group respectively. Mean FBS was 201.55 В± 67.34 mg/dl and mean PPBS was 268.94 В± 93.93 mg/dl.
Cavitary lesion was more common in diabetic group. There was a linear relation between the duration of diabetes
mellitus and the development of tuberculosis. Poorly controlled hyperglycemia is associated with development of
tuberculosis. Lower lung field tuberculosis was more common in diabetics.
CONCLUSIONS: All the diabetics with abnormal weight loss, unexplained cough or sudden increase of insulin
requirement should have sputum examination and chest x-ray done thus helping in early diagnosis and treatment.
P263
Comparison of rate of sputum conversion in smokers and non-smokers on DOTS Category I under RNTCP
Kandala Venu, Srikar Darisetty, Raghudeep Palla, Mateenuddin Saleem, Laxman Babu
Department of Pulmonary Medicine, Kamineni Institute of Medical Sciences, Narketpally, Telangana, India.
AIM AND OBJECTIVES:
1.
To assess and compare the rates of sputum conversion in smokers and non smokers on DOTS category I
(RNTCP) after 2 months of therapy.
MATERIALS AND METHODS:
A prospective study was conducted in our institute between the periods of August 2012 to January 2014 among
patients who were newly diagnosed as sputum smear positive for AFB using LED microscopy (Auramine staining)
after fulfilling the inclusion and exclusion criteria. A total of 100 subjects were studied. (55 smokers, 45 non
smokers). Amongst these, 5 subjects were lost to follow up, 5 subjects died during the study period. The remaining
90 subjects (48 smokers, 42 non smokers) were followed up. The data was tabulated and analyzed after 2 months
of therapy.
RESULTS:
SMOKERS (N = 48)
NON SMOKERS (N = 42)
SPUTUM SMEAR POSITIVITY
INITIATION OF THERAPY
AFTER 2 MONTHS OF THERAPY
48 (100%)
22/48 (45.8%)
42(100%)
3/42 (7.14%)
The Chi Square test was used to analyze the data. Chi square value = 8.47,
P value < 0.05
CONCLUSION:
The response of subjects to ATT was better in non smokers when compared to smokers. Hence, it is advisable for
patients with pulmonary tuberculosis to quit smoking to enhance the efficacy of therapy and hence, to control the
spread of tuberculosis in the community.
P264
Outcome of chemotherapy in lung cancer : Effect on quality of life & reasons of default among patients
AUTHOR(S) - DR TARUSHI SHARMA, DR BABAJI GHEWADE
INSTITUTION- Jawaharlal Nehru medical college, Sawangi(meghe),Maharashtra,India
ABSTRACT
OBJECTIVES-The objective is to study the outcome of chemotherapy in lung cancer patients in form of Survival &
Quality of life and investigate the factors that contribute to low rate of acceptance and adherence to
chemotherapy.
METHODS- A prospective study of lung cancer patients admitted in AVBRH,SAWANGI who had taken atleast one
cycle of chemotherapy was performed from Sept 2013 to Sept 2014. FACT-L questionnaire was used to measure
Qol(Quality of life) in patients who completed the course of chemotherapy.
RESULTS- A total of 20 patients were included in the study. The ages ranged from 20 to 70 years.Only 3(15%)
patients completed the course of chemotherapy.An increase in Qol score was seen in these patient. 17
patients(85%) dropped out of chemotherapy during the treatment. 9(53%) of these defaulted due to inadequate
funds to procure chemotherapy.5 (30%)patients switched to alternate form of medication and the rest 3
(17%)discontinued due to non tolerance of the side effects of treatment.
CONCLUSION- Lack of funds to procure chemotherapy was the major factor responsible for default among
patients. In patients completing the chemotherapy, significant improvements were seen in Qol. In past few years ,
little progress has been made in treatment of lung cancer patients in form of increased survival. As a result, the
effect of chemotherapy on Qol becomes important while discussing the benefits of treatment with patients.
P265
Disseminated tuberculosis in an immunocompetent host: A rare entity
AUTHOR(S)- DR TARUSHI SHARMA, DR BABAJI GHEWADE
INSTITUTION- Jawaharlal Nehru medical college, Sawangi(meghe),Maharashtra,India
ABSTRACT
OBJECTIVES- Disseminated tuberculosis with liver and spleen involvement in an immunocompetent host is a rare
entity today, not frequently diagnosed and reported. We report a case of 22 year old female which was diagnosed
as a case of Disseminated tuberculosis and started on antitubercular therapy & responding well.
METHODS-Patient was referred to our hospital as a suspected case of malignancy from PHI. A detailed history of
patient was taken and physical examination done. Routine blood investigations such as CBC and serum
biochemistry were ordered .Radiological investigations included chest Xray, HRCT Thorax and USG abdomen.
Sputum smear for AFB and USG guided FNAC was done along with bone marrow examination before arriving on
final diagnosis.
RESULTS-A final diagnosis of disseminated tuberculosis was made based on investigations & clinical findings. The
patient was started on category-I antitubercular drugs.Gradually patient improved symptomatically and repeat
radiograph after 1 month showed good radiological improvement.
CONCLUSION- Disseminated tuberculosis is a potentially lethal form of tuberculosis arising from hematogenous
dissemination of Mycobacterium tuberculosis bacilli. Disseminated tuberculosis is rare, particularly in
immunocompetent people. Diagnosis is often difficult due to variable clinical presentations,poorly sensitive smears
and diverse radiologic findings. Although positive chest radiographic findings or a positive tuberculin skin test may
support the diagnosis, negative results however do not exclude extrapulmonary tuberculosis. A high index of
clinical suspicion is needed and antimycobacterial therapy should be administered urgently to prevent an
otherwise fatal outcome. 1-2 % of all cases of tuberculosis in immunocompetent patients
FIGURE- On Admission, Chest X-Ray PA view showing diffuse nodular opacities of variable sizes
P266
Outcome of Cat IV ATT from DOTS-plus site: Govt Fever Hospital, Guntur, Andhra Pradesh, India.
Dr. K. Rajendra Kumar, Dr. S. Raghu, Dr. M. Venkata Rao, Dr. N. Bhaskara Rao, Dr. S. Lakshmi Kumari, Dr. CH.
Hanumantha Rao.
Dept. of Pulmonary Medicine, Guntur Medical College/Govt Fever Hospital, Guntur, Andhrapradesh, India.
Abstract:
Introduction: India is one of the high burden countries for tuberculosis as well as drug-resistant
tuberculosis. Standardized treatment regimen (STR) for management of multi-drug resistant tuberculosis (MDRTB)
has been approved by RNTCP national DOTS-plus committee. Objective: Study was done at Government fever
hospital / Guntur medical college, Guntur, to know the effectiveness, adherence and the outcome of DOTS-plus.
Methodology: A total of 106 patients who were confirmed to have MDRTB and came for pre-treatment evaluation
were enrolled in to this prospective study conducted from October 2009 to March 2012. Patients were treated
rd
with DOTS-plus and were followed up mainly on out-patient basis. Results: At the end of 3 month 61 (57.5%)
th
patients were culture converted and at the end of 6 month 68 (64%) patients were culture converted. At the end
of treatment, 57 were cured, 25 defaulted, 13 failed, 11 died. 5 failure cases were converted to extensively drug
resistant (XDR) TB during the treatment. 92 patients were complained of adverse drug reactions (ADR) and change
of medication needed in 13 (12%) patients with severe ADR. Conclusion: The treatment outcome results of
patients treated with DOTS-plus was not up to the mark. Defaulters are main obstacle to the success of DOTS-plus.
Patient as well as family counselling, close attention to the timely recognition and treatment of ADRs will improve
the adherence to the treatment and thus the cure rate.
P267
Childhood tuberculosis presenting as multiple rib osteomyelitis: A rare case report
Dr. K. Rajendra Kumar, Dr. S. Raghu, Dr. CH. Hanumantha Rao.
Although tuberculous infection of bone is fairly common i.e., 15% of all tuberculosis, tuberculous osteomyelitis of
the rib shaft is rare. Rib involvement occurs in approximately 5% of all bony tuberculosis and in 0.1% of all
tuberculosis cases. And tubercular parietal chest wall abscess is also a rare form of extrapulmonary TB. Though
bony tuberculosis is common between 2 to 10 years of age, rib involvement is common between 20 to 30 years of
age. We report a case of 3 year male child presented with chest pain, fever and posterior chest wall swellings.
Chest X ray revealed osteolytic lesions of multiple ribs and homogenous opacity in right mid and lower zones.
Computed tomographic findings suggestive of multiple rib osteomyelitis with extension into the both chest wall
and right hemithorax. FNAC of chest wall lesion suggestive of cold abscess formation. The pathogenesis,
differential diagnoses and management for rib osteomyelitis were reviewed and briefly discussed.
Key words: childhood tuberculosis, rib osteomyelitis, chest wall abscess
P269
Tuberculous Dactylitis (Spina Ventosa) In A 17 Year Old Girl - A Rare Entity
SR YADAV, M SALUJA, S TANEJA, K CHOUDHARY, K LOCHAB
Subharti Medical College, Meerut , India
Vertebral tuberculosis is the most common form of skeletal tuberculosis and it constitutes 50% of all cases of
skeletal tuberculosis. The less common sites of skeletal tuberculosis are mandible, tempromandibular joint, scull
and metacarpals and phalanges. Tuberculous infection of metacarpals, metatarsal and phalanges of hands and
feet is known as tubercular dactylitis. Tuberculosis of the short tubular bones quite uncommon after the age of 5
years.
Here we present a case of 17yrs. girl who presented with swelling of left middle finger since one month which was
tender, non-mobile with slight increase in local temperature. Patient was previously treated by private doctors and
antibiotics were given to her which gave no relief to her. Her detailed history was took which was insignificant
except of family history of extra pulmonary TB in her sister. She was admitted and entire work up was done
including general blood tests, urine, montoux test, sputum examination, USG abdomen, and X-ray of chest and left
hand.
All the test reports were with in normal limits, montoux test was strongly positive and X-ray of left hand was
suggestive of spondylarthropathy- juvenile RA. Patient RA factor was tested and was found to be negative. Patient
was subjected to FNAC from her swelling which was suggestive of tuberculosis and Z-N staining of smear revealed
acid fast bacilli (grade1+), hence a diagnosis of Tuberculous Dactylitis was made.
Patient was put on ATT according to her weight; dramatic improvement was seen as all her symptoms subsided.
Size of swelling also decreased to normalcy.
P270
Pulmonary Tuberculosis presenting as Pneumomediastinum with Subcutaneous emphysema: A Rare
Presentation
K.BHARATH , P. SWETHA, K.SAILAJA, H.NAGASREEDHAR RAO, U. KIRAN KUMAR
Department Of Pulmonary Medicine, Kurnool medical college
Back ground: Pneumomediastinum may develop due to (i) mediastinal sepsis from gas forming organism or
traumatic disruption of large gas containing organs or damage to alveoli and to bronchioles, allowing gas to leak
towards the mediastinum. Chest pain, tachypnea, cyanosis and respiratory failure are seen. Pulmonary
tuberculosis presenting as Pneumomediastinum with subcutaneous emphysema without Pneumothorax is rare.
Patient and methods: A 65 year old male patient presented with Acute onset of dyspnea with cough and swelling
of chest wall, neck and face. Patient also complained of chest pain and change in voice two days duration. History
of intermittent fever, shortness of breath, cough, Loss of weight and appetite for 2 months duration. Examination
of respiratory system reveals palpable crepitus all over the front and back of neck, chest wall and both upper limbs
upto to the tip of fingers. Emergency chest X ray showed features suggestive of air in subcutaneous planes. HRCT
revealed Fibrobronchiectactic changes in left upper lobe, pleural thickening, Pneumomediastinum and no evidence
of Pneumothorax. Sputum for AFB was positive. Patient was started on ATT and high flow Oxygen. Complete
resolution of the subcutaneous emphysema was noted at the end of one week. There was no recurrence of
pneumomediastinum thereafter.
Conclusions: It is said that in both tuberculosis and bronchiectasis, local airway obstruction with distal air trapping
can cause alveolar rupture and subsequent Pneumomediastinum. Conservative treatment is indicated in majority.
The present report describes a self limiting case of Pneumomediastinum with subcutaneous emphysema a rare
complication of pulmonary tuberculosis.
P271
ATYPICAL PRESENTATION OF DISSEMINATED TUBERCULOSIS IN AN IMMUNOCOMPETENT PATIENT
DR.PRASANTHY REDDY CH,dr.A Sathya prasad,dr.M ganesh,dr nalini G,dr vijay kumar K,dr subba rao V
Mamata medical college and general hospital
Introduction: Disseminated tuberculosis refers to involvement of 2 or more non contiguous sites. it is rare in
immunocompetent host
Case report: A 30 year old female presented to out patient department with bleeding per vagina and lower
abdominal pain since 3 months with no past history of tuberculosis. on further evaluation chest x ray pa view
showed ill defined opacities in right lower zone. Sputum for AFB was negative. Fibre optic bronchoscopy was done
and bronchial washings and brushings for AFB were positive. Dilatation and curettage was done and menstrual
blood for AFB stain was positive. Ultrasound abdomen revealed bilateral hydronephrosis. urine for AFB negative.
Patient was started on anti tubercular therapy. Patient improved symptomatically after intensive phase of therapy.
Conclusion: This is an atypical presentation of disseminated tuberculosis in an immunocompetent host where
diagnosis was achieved and confirmed
P272
Association of tuberculosis with deep venous thrombosis
DR.TARUN SHARMA, DR.K.N.MOHAN RAO
rajarajeswari medical college and hospital, bangalore, india
Introduction: Tuberculosis (TB) is one of the most devastating curable infectious diseases and persists as a major
cause of morbidity and mortality in India. India accounts for almost one-third of the global burden of TB.
Respiratory infections have been documented to increase the risk of venous thromboembolism. There is also
evidence that there is a hypercoagulability state in TB, which may be attributed to the increase in plasma
fibrinogen and factor VIII, and reactive thrombocytosis. There can also be stasis due to local compression of veins
by lymph nodes or immobility due to respiratory compromise. There is also evidence regarding endothelial
dysfunction in tuberculosis, which may be a result of bodily reactions to Koch's Bacillus, or the use of Rifampin.
Being able to affect all the three components of the Virchow's triad, TB could be a significant risk factor for venous
thromboembolism.
Objective: To highlight occurrence of DVT in severe pulmonary and extrapulmonary TB.
Method: We report 5 cases of pulmonary and extrapulmonary TB associated with venous thromboembolism who
presented to our department. A 45 year-old male who had DVT, a 60 year-old male that developed deep venous
thrombosis later in the course of the disease, a 20 year old male who presented with effusion and later developed
DVT and massive pulmonary embolism, a 25 year old woman with disseminated TB and DVT with pulmonary
embolism, and a 32 year old male with pulmonary TB and DVT.
Conclusion: There is a strong association between inflammation induced by TB and a hypercoagulable state.
Therefore, the occurrence of DVT or pulmonary embolic episodes should be considered in patients with TB
particularly those with poor response to treatment. The treating doctor’s awareness of this phenomenon while
treating severe forms of TB is important for early diagnosis and starting anticoagulation to prevent fatal outcomes.
P273
An Interesting Case of Tuberculosis of the Left Breast
Dr Ajit H, Dr Karl DM, Dr Sivaraj AL, Dr Alamelu H, Dr Rajashekar MB, Dept of Pulmonary Medicine and Dr
Sabaretnam M, Dept of Endocrine & Breast surgery
Vydehi institute of medical sciences and research centre Bangalore Karnataka
Tuberculous breast abscess continues to be an uncommon presentation in developing countries where
tuberculosis is an endemic disease. It still poses a clinical challenge with its presentation being similar to breast
carcinoma and pyogenic breast abscess. Its incidence in developing countries is: less than 4% of mammary
diseases.
This is a case report of a 28 year old housewife who presented to our hospital with complaints of: left breast lump
for the last 8 months that gradually progressed from 1.5 cm x 1.5 cm to 8 cm x 6 cm on presentation associated
with intermittent pain to touch and lifting heavy weights. It was not associated with menstrual cycles, which were
regular. She gave no history of respiratory symptoms, constitutional symptoms, comorbidities or past surgeries.
Her general physical and systemic examination was unremarkable. Breast examination revealed diffuse firm
swelling palpable in the upper-inner quadrant of the left breast extending into the upper part of the lower left
quadrant which was 8 cm x 6 cm, immobile and adherent to the chest wall with an area of cystic consistency.
There were no signs of breast tenderness and nipple discharge. There were no palpable axillary and supraclavicular
lymph nodes. Routine investigations and CXR-PA were unremarkable. Purulent fluid aspirated showed: occasional
acid-fast bacilli (AFB) on Zeihl-Neelson stain. Multiplex DNA TB-PCR was positive for Mycobacterium tuberculosis.
However, AFB culture report is awaited. She was started on RNCTP Category-I ATT for Tuberculous breast abscess.
P274
Quantitative assessment of MDR positives among MDR suspects during the period of six months
K.V.V. Vijaya kumar, S. Vinay kumar, G.Sambasiva rao, A.Prem kumar
Government Hospital for Chest & Communicable diseases (GHCCD), Andhra Medical College,
Visakhapatnam,AP,India.
Background: Multi Drug Resistant tuberculosis (MDR-TB) is an increasing global problem with most cases arising
from a mixture of physician error and patient noncompliance during treatment of susceptible tuberculosis. There
should be strong suspicion of drug resistance in persons with a history of prior treatment or treatment failure
cases. We have tried to ascertain the number of MDR-TB cases in MDR suspect patients
Objectives: To identify the number of MDR positives among MDR suspects who are subjected to culture and drug
susceptibility testing ( C-DST) laboratory at GHCCD, a teaching hospital of Andhra Medical College, from 3 north
Andhra Pradesh Districts(Srikakulam, Vizianagarm and Visakhapatnam)from January 2014 to June 2014 as per
PMDT suspect criteria 2012.
Methods: Two sputum samples ( early morning and spot ) are taken from the cases with the above criteria and
sent to C/DST laboratory at GHCCD , Visakhapatnam. Line probe assay (LPA) is used for the rapid DST.
Results: The results of first 3 months are as follows- Out of total 932 MDR suspects, 58 were MDR positive.
Among 932 suspects ,3 were failures(none of them were found to be MDR), 1 was a contact of MDR-TB(found to
be MDR), 396 suspects were smear positive at time of diagnosis, retreatment(40 were found to be MDR), 129
suspects were any smear positive follow up results(9 were found to be MDR), 159 suspects were smear negative at
diagnosis of retreatment case(3 were found to be MDR), 244 suspects were HIV-TB coinfected group(5 were found
to be MDR).The entire data will be projected during platform presentation.
P275
Correlation of CD4 count with respect to opportunistic infections (OIs)
K.V.V. Vijaya kumar, L.Haritha kumari, G. Sambasiva Rao, A.Prem Kumar
Government Hospital for Chest & Communicable diseases, Andhra Medical College, Visakhapatnam, AP, India.
Background: human immunodeficiency virus pandemic is among the greatest health crisis ever faced by humanity.
Morbidity and mortality in HIV disease is due to immunosuppression leading to life threatening opportunistic
infections during the natural course of the disease. The most common OI among them being the pulmonary or
extra pulmonary tuberculosis. This study was aimed to asses prevalence and CD4 correlates of OIs among adult HIV
infected patients attending Government Hospital for Chest & Communicable diseases, a teaching hospital of
Andhra medical college, Visakhapatnam.
Objective: To correlate CD4 count with respect to OIs in HIV infected patients.
Methodology: Cross sectional study was conducted on 200 adult HIV infected patients attending GHCCD, ART
centre from September 2013 to july 2014. Patients OIs status determined through clinical diagnosis, laboratory
investigations and clinical data obtained from medical records. CD4 count was assessed by using flow cytometry.
Results: Preliminary results of the study of 200 HIV infected patients included 64.5% males, 35.5% females. Out of
200 seropositives 82.5% were between 15-45 years and 17.5% were greater than 45. Tuberculosis carrying the
major burden of OIs i.e 89% of which 42.5% pulmonary tuberculosis, 44.5% extra pulmonary tuberculosis and 2%
disseminated tuberculosis. The entire study data would be projected at the time of presentation.
P276
Massive hemoptysis in a pulmonary Koch’s patient: A case report of Rasmussen’s aneurysm
AP KANSAL, Don Gregory MASCARENHAS, Kamal Deep, Prabhleen KAUR, Hardik JAIN
Dept. of Chest and TB, GMC, Patiala.
Introduction: Massive hemoptysis is a serious complication of Pulmonary Koch’s. We present a case report of a
patient of massive hemoptysis which was later proven to be a case of Rasmussen’s aneurysm.
Case report: A 52 year old male patient, manual labourer by occupation, presented to us with persistent cough
and progressive breathlessness since 7 months, fever since 1 month and massive hemoptysis since 2 days. He had
completed RNTCP Cat I anti-tubercular treatment one month ago. He was a chronic smoker and type 2 diabetes
mellitus patient on irregular treatment. On chest examination, rhonchi were present over all lung fields along with
crepitations in right infraclavicular and mammary areas. Chest X ray showed bilateral diseased lung with
heterogenous opacity in right upper zone. Hb was 9.5 gm%, TLC 10,600/mm3, platelet count 2.2 lakh/mm3, RFT,
LFT and BT/CT/PT-INR were normal.
Patient came sputum positive for AFB and LPA showed resistance to Rifampicin and Isoniazid. He was treated with
DOTS PLUS regimen and symptomatically for hemoptysis. But hemoptysis was persistent. CECT chest showed
bilateral emphysematous changes and consolidation with cavity formation in right upper lobe. Multidetector
computerised tomography angiography revealed a pseudoaneurysm in one of the segmental branches of
pulmonary artery in right upper lobe cavity, suggestive of Rasmussen’s aneurysm. Patient was referred for
embolisation.
P277
HEPATOTOXICITY AS AN ADVERSE EFFECT WITH FIRST LINE ANTI-TUBERCULAR AGENTS: A PROSPECTIVE STUDY
AP KANSAL, Shiyas MOHAMMED, Kiran N, Kamal Deep, Hardik JAIN, Komal BHATTI,
Department Of Chest & TB,GMC, Patiala , Punjab
Introduction: The incidence of Anti-tuberculosis drug induced liver injury( ATLI) during standard multi-drug TB
treatment has been reported varying from 2.0% to 28.0% according to different populations and definitions.
Material and methods: Present study was conducted on 200 patients (100 in cat I and cat II) presenting to
Department of TB and Chest Diseases and Department of biochemistry, Government Medical College, Patiala. Liver
function tests were performed before initiating the treatment and thereafter every month till the regimen
continued (6 months in Cat-I and 8 months Cat-II).
Results: In the present study, out of total 114 patients with ADRs, 33 developed raised liver enzymes (Serum
Bilirubin, SGOT, SGPT) due to ATT and it was second most common ADR after gastrointestinal side effects. It was
observed that it was found more in females (n=18) as compared to males (n=15), in patients on cat I (n=18) as
compared to patients on cat II (n=15). Most common age group affected was in range of 40-60 years. Weight band
which was affected the most was of less than 40 kg. Patients with moderately advanced lesion on CXR were most
commonly affected.
Discussion: Out of total 10 patients who required their regimen to be changed due to various adverse effects,
hepatotoxicity accounted for 5. Predicting who will be at an increased risk for ADRs to first-line TB therapy can
assist in identifying the patients who require closer monitoring to prevent potential morbidity, hospitalization and
mortality .Therefore, close monitoring of patients is crucial to ensure that the adverse effects of drugs are
recognized as soon as possible by health care personnel
P279
TUBERCULOSIS AND LEPROSY CO-INFECTION: A RARE CASE IN THE MODERN ERA.
Dr. Priti Meshram, Dr. Rohit Hegde, Dr. N N Ramraje (Professor & Head)
Department of Pulmonary Medicine. Grant Govt. Medical College & sir J J Group of Hospitals, Mumbai.
Introduction:
The concommitant occurrence of both tuberculosis and leprosy in a singal individual,the oldest reported
mycobacterial diseases, is not rare. Tuberculosis and Leprosy have been diagnosed together since antiquity.
However, since the Industrial revolution of the 16 th century, there has been a steady decline in Leprosy though
Tuberculosis has now reached epidemic proportions. The decline has been partly explained due to some studies
showing that Tuberculosis provides protective immunity against Leprosy. Hence, there is very infrequent reporting
of the occurrence of these infections together in modern medicine.
Case Report:
We report one such case a 18 yr old male diagnosed as borderline lepromatous leprosy with type 2 reaction, who
later developed pulmonary tuberculosis. The patient had received steroids for his Lepra reaction for 9 mths prior
to becoming symptomatic with respiratory complaints. On investigating, patient had bilateral infilates with Rt
sided hydropneumothroax which was respiratory complaints. On investigating, patient had bilateral infiltates with
Rt sided hydropneumothorax which was treated with Intercostal drain insertion. His sputum was also screened for
MDR TB. He was sensitive to both INH and Rifampicin. The patient was treated with both AKT and MBMDT and
steroids for his Type 2 Lepra reaction.
Conclusions:
The use of steroids in leprosy (for treating Lepra reactions and neuropathy) warrants screening of individual for
tuberculosis including Multi drug resistant TB. Multi-drug therapy for leprosy may lead to acquired drug resistance
for Rifampicin, which is mainstream of anti-tubercular therapy. Hence awareness is necessary for screening and
diagnosing tuberculosis, especially MDR TB in patients who infected Leprosy and are on steroids.
P280
Persistent upper lobe pneumonia- a case report
A YADAV, D BHATTACHARYYA, CDS KATOCH, T AJAI KUMAR, SAFIA AHMED
Dept of Respiratory Medicine, Military Hospital CTC, AFMC, Pune
Non resolving pneumonia is a challenging, interesting and intriguing puzzle for the clinician to unravel. We treated
one such unusual case in our hospital recently. The patient was a 31 year old soldier who presented with
complaints of cough with mucoid expectoration, breathlessness (mMRC grade II), intermittent fever, new onset
wheeze and 10 kg weight loss of one year duration. The complaints were associated with episodic exacerbations
on exposoure to dust and cold. He gave history of treatment for tuberculosis a year back. Examination revealed
bilateral polyphonic expiratory wheeze. At this point a differential diagnosis of collagen vascular diseases,
cryptogenic organising pneumonia, sarcoidosis, hypersensitivity pneumonitis and chronic eosinophilic pneumonia
was entertained. Investigations revealed an eosinophilia of 58% and AEC of 4,350/cumm. Chest x-ray showed
bilateral upper zone peripheral non homogenous opacities with air bronchograms. HRCT chest showed multifocal
peripheral airspace opacities in bilateral upper lobes. Pulmonary function testing revealed obstruction with
significant reversibility and mild diffusion defect. Bone marrow biopsy showed increase in eosinophilic precursors
with no atypical/blast cells. The diagnosis of chronic eosinophilic pneumonia was confirmed by fibre optic
bronchoscopy which showed 10% eosinophils in broncho alveolar lavage and eosinophilic infiltration on
transbronchial lung biopsy. The patient was managed with oral corticosteroids (tab prednisolone 1mg/kg), inhaled
corticosteroids and long acting ОІ2-agonists, which led to prompt clinical improvement and resolution of upper lobe
opacities, which is a hallmark of the disease. Considering his clinico-radiological presentation in conjunction with
histopathological examination reports, the final diagnosis of Chronic eosinophilic pneumonia with adult onset
asthma was made. At follow up after 3 months, patient was asymptomatic with normal chest x ray on a tapering
steroid regime.
P281
PREVALENCE OF CARDIAC COMORBIDITIES AND ITS RELATION TO SEVERITY STAGING OF CHRONIC OBSTRUCTIVE
PULMONARY DISEASE
Dr.VINEETH ALEXANDER, DR.R.PAJANIVEL ,DR.K.SURENDRA MENON, DR.ARUN PRASATH
DEPARTMENT OF PULMONARY MEDICINE, MAHATMA GANDHI MEDICAL COLLEGE AND RESEARCH INSTITUTE
INTRODUCTION: Complexity of COPD and mortality from the disease is increased by co morbidities and
exacerbations
OBJECTIVE: This study was conducted with aim to find the prevalence of cardiac co morbidity in COPD and its
relation to severity staging of COPD.
METHODS: The study was done in the Department of Pulmonary medicine for 1 year. The study subjects were all
the patients which were previously diagnosed and newly diagnosed of COPD. The selected patients were subjected
to Pulmonary Function Test, assessment of blood pressure, electrocardiography and echocardiography. The
statistical analysis was done to assess the cardiovascular status and its relation to severity staging of COPD.
RESULTS: On the basis of GOLD guidelines there were 5(11.4%), 13(29.5%), 16(36.4%) and 10(22.7%) mild,
moderate, severe, and very severe COPD respectively. Right axis deviation, p-pulmonale, T-wave inversions,
dominant R-wave, persistent S-wave in electrocardiography were present in 45.5%,52.6%,40.0%,33.3%,36.4% of
severe and 54.5%, 36.8%, 60.0%, 58.3%, 63.6% in very severe cases of COPD. In echocardiography, right atrium and
ventricle dilatation, left ventricular dysfunction, tricuspid regurgitation, and regional wall motion abnormalities
were present in 55.6%, 46.15%, 50.0%, 37.5% of severe and 38.9%, 53.85%, 33.3%, 62.5% of very severe cases of
COPD. All the cases of mild and moderate COPD had mild (30-50mmHg) Pulmonary artery systolic pressure (PASP).
In severe COPD, 5(19.2%), 10(76.9%) and 1(20.0%) had mild (30-50mmHg), moderate (50-70mmHg) and severe
(>70mmHg) PASP respectively. In very severe COPD, 3(11.5%), 3(23.1%) and 4 (80.0%) had mild (30-50mmHg),
moderate (50-70mmHg) and severe (>70mmHg) PASP respectively. In severe COPD 7(29.2%), 5(62.5%), 3(30.0%)
and 1(50.0%) had normal, pre hypertension, stage 1 hypertension, stage 2 hypertension respectively. In severe
COPD 3(12.5%), 6(60.0%), 1(50.0%) had normal, prehypertension, stage 2 hypertension respectively.
CONCLUSION: Prevalence of cardiac co morbidities has a linear relationship with severity of COPD with severe and
very severe COPD associated with cardiovascular diseases. Early detection of cardiac complications in COPD cases
give time for early interventions
P282
OCCURRENCE OF ATOPIC MANIFESTATIONS IN PULMONARY TUBERCULOSIS SEQUELAE
T. VIVEK
KAKATIYA-MEDICAL-COLLEGE
OBJECTIVES-Mycobacterium tuberculosis has been shown to suppress allergic airway disease driven by type 2
helper T cells in animal models.In this study we investigated development of allergic airway disease in pulmonary
tuberculosis (PTB) sequelae pts presenting with airway obstruction.
MATERIALS AND METHODS-Twenty one pts with a past history of PTB without any past history of airway disorder
presenting with SOB and/or wheeze were prospectively studied from july 2013 to july 2014.They were evaluated
by spirometry, total serum IgE levels, sputum for eosinophil count and absolute eosinophil count (AEC).Other
systemic manifestations of atopy were also taken into account.
RESULTS-Out of the 21 pts,12 pts had reversible and 9 had irreversible airway obstruction.Out of the 12 reversible
pts,10 had elevated serum IgE(mean IgE-1150.3IU/L),8 had sputum eosinophilia and 8 high AEC(mean AEC431.6).Out of the 9 irreversible pts,4 had elevated IgE(mean-450 IU/L),no pt had sputum eosinophilia and 2 had
elevated AEC(mean-314).4 pts among the reversible group presented with other systemic manifestations of allergy
like rhinitis(3) and dermatitis(1).
CONCLUSION-Our study does not support the hypothesis that PTB supresses atopy (manifestations).On the
contrary atopic manifestations occur with an increasing incidence after PTB,but larger prospective experimental
studies are needed before excluding possibility of relationship.
P283
Bronchoscopic diagnosis of Tuberculosis: A stitch in time saves nine
PASHA MD, MANTHA SP, ANEJA A, PRASHANTH D, HALAPPA S, KRISHNASWAMY U
M.S.Ramaiah Medical College, Bangalore, India
Objective:
To report a case of actively caseating type of endobronchial tuberculosis presenting as community acquired
pneumonia. (CAP)
Case report:
A 31 year old immune competent patient with no co-morbidities had presented to another hospital with history of
persistent productive cough, high grade fever, wheezing and dull left sided chest pain since one month. She had
been treated with multiple courses of broad spectrum antibiotics including cephalosporins and PiperacillinTazobactum. She was referred to us after 1 month of the above treatment in view of persistent high fever and
opacities on serial chest radiograms. On evaluation in our hospital, sputum analysis was negative for Acid Fast
Bacilli (AFB) and did not grow any organism on culture. Respiratory system examination revealed reduced breath
sounds, rhonchi and coarse crepitations all over the left hemi-thorax. A diagnosis of non-resolving pneumonia was
made and bronchoscopy was performed. It revealed tenacious cheesy material lining the entire left bronchial tree.
Endobronchial biopsy was taken and BAL fluid was sent for Gram stain, culture and AFB smear.
BAL and post-bronchoscopy sputum were positive for AFB (+++) and no other organism was grown on culture.
Endobronchial biopsy report was also consistent with tubercular pathology. Patient was started on anti-tubercular
therapy (ATT).Oral steroids were also given in view of the extensive endobronchial component to prevent
fibrostenotic sequelae. Patient came for follow up after 1 month of ATT and had improved clinically and
radiologically. It is planned to repeat the bronchoscopy after completion of intensive phase.
Conclusion:
This case highlights importance of timely performance of bronchoscopy in patients with pneumonia who have
persistent unilateral wheeze and exhibit sub-optimal response to treatment for CAP.
P284
P285
MDR-Pott’s Spine: The hidden danger
P286
DR.SAURABH SINGH, DR.MEDHA BARGAJE, DR.ANITA ANOKAR, DR.RAM DEOSKAR.
Department of Pulmonary Medicine, Bharati Vidyapeeth Deemed University Medical College and Hospital,
Pune-43, India.
Background:
Tuberculosis (TB) of the spine (Pott’s disease) is the most common and dangerous form of skeletal TB infection.
The exact incidence and prevalence of spinal tuberculosis in most parts of the world are not known.
Case report:
We report MDR Potts spine in two previously treated TB cases.
1. A 34 years man was diagnosed for lumbar spine tuberculosis based on MRI and biopsy with initial isolation of
Mycobacterium TB monoresistant to streptomycin. Despite 1 year of treatment with first line drugs, clinical and
radiological progression warranted repeat spinal abscess drainage and was found to have MDR M. tuberculosis
nd
complex. Patient is being treated with 2 line drugs and followed up.
He had sputum positive pulmonary, lymph node and shoulder joint tuberculosis 13 years back and was treated. (2
HRZE, 12HRE).
2. A 20 years woman, with lymph node TB (biopsy proven) and Potts spine (radiology based) received
(2HRZE+6HRE+9HR) was on regular treatment with symptomatic and radiological improvement in spinal TB and
lymph node regression. She showed clinical and radiological deterioration while on treatment (18 months). Hence,
tissue biopsy obtained and MDR M.tuberculosis complex was grown on culture. The patient was put on DOTS
category 4 under RNTCP.
Both the patients showed symptomatic improvement after 6 months with satisfactory radiological response of
properly supervised treatment with adverse effects prominently due to aminoglycosides. Both the patients are
following up with our department regularly.
Conclusion:
In India, with increasing incidence of MDR TB, stress should be given on obtaining tissue sample for
mycobacterial culture and sensitivity. This is important in order to diagnose MDR cases early and promptly treat
the otherwise disabling spinal tuberculosis with correct regimen.
H-Isoniazid, R-Rifampicin, Z-Pyrazinamide, E-Ethambutol, MDR- Multidrug Resistant,
RNTCP- Revised National TB Control Programme.
P287
Additional yield of cases of tuberculosis from household contact screening of newly diagnosed sputum smear
positive tuberculosis patients.
M. GUPTA, A.A. SAIBANNAVAR
RCSM Government Medical College, Kolhapur, India
Objectives: Aim of present study was to assess prevalence of tuberculosis among household contacts of newly
diagnosed sputum positive tuberculosis index cases. Secondary objective was evaluation of risk factors in
household contacts for acquiring tuberculosis disease; and also evaluation of various characteristics of index cases
which influence transmission of disease to household contacts.
Methods: 521 household contacts of 133 newly diagnosed sputum smear positive tuberculosis patients which
were registered for RNTCP at the DOTS centres of DTC, Kolhapur from July 1, 2013 to February 28, 2013 (8 months)
were included in the study. Household contacts with symptoms suggestive to TB subjected to sputum AFB
examination and X ray Chest PA view. Presence of risk factors in suspected contacts was also recorded
Results: 18 contacts out of 521 (3.45%) had symptoms suggestive of TB. Out of them 8 (44.44%) were female and
10 (55.55%) mere male. Mean age of symptomatic contacts was 43 years. In 5 contacts, sputum AFB came out
positive. In one of the contact, sputum AFB was negative, but chest X ray was suggestive of TB. This resulted in
4.51% (6 cases) secondary yield of tuberculosis cases.
Conclusions: Although additional yield (4.51%) is very modest, but the effort put in to detect these cases is very
minimal. Also, lead time is obtained in these cases by means of early diagnosis. Household contact screening for
tuberculosis cases is a very promising tool for case detection. Therefore, it can prove to be an important method to
boost case detection rate for tuberculosis.
P288
Tuberculosis of the thyroid gland. a rare case report
DR. KRISHNACHAITANYA PANYAM**,, Prof. Pradyut Waghray**, Dr.A.N.V.Koteswara rao**,Dr. Venkateswara
Reddy T**, Dr.v.veena**, Dr. Chetan**, Dr.Harish**, Dr. Sowmya**, Dr. Aditya**, Dr. Rikin**.
Prof. k.p.a.chandrashekhar #
Dr.suresh kumar reddy.g ^
п‚·
п‚·
п‚·
* DEPT OF PULMONARY MEDICINE,S.V.S.MEDICAL COLLEGE, MAHABUBNAGAR,A.P
# DEPT OF PATHOLOGY, S.V.S.MEDICAL COLLEGE, MAHABUBNAGAR,A.P
^ DEPT OF GENERAL SURGERY, S.V.S.MEDICAL COLLEGE, MAHABUBNAGAR,A.P
Abstract.
We report the case of a 54-year old female patient with tuberculosis of the thyroid gland. She presented to the
pulmonology o.p with h/o swelling at the neck region since 2months,evening rise of temp,cough with mild
sputum,loss off appetite&weight since 30 days in jan 2014.All routine investigations were unremarkable.
Sputum&BAL are negative for AFB. FNAC of thyroid-Features suggestive of nodular goiter. Specimen- caseating
granulomatous lesion. On ATT for 6 months. Doing well.
P289
SIDS WITH PULMONARY TUBERCULOSIS WITH BILATERAL PNEUMOTHORACIES
Introduction : A case of SIDS on ART and Cat-1 ATT for Pulmonary Tuberculosis presenting with Pneumothorax.
During treatment developing contraletaral Pneumothorax.
Discussion : Cases of SIDS ,quite commonly present with PCP. Quite a few of such cases develop
Pneumothorax,even biletaral ones, which have been known to enhance mortality in such cases.
A YOUNG patient with SIDS on ART , presented with features suggestive of PULMONARY TUBERCULOSIS. He was
investigated and was found to be SPUTUM POSITIVE.There were no other co-morbidities. CAT 1 was started and
the patient was discharged. Within the next 2 months the patient presented again with history of chest pain and
dyspnoea since last 5 days. Xray chest PA view suggested a Left Pneumothorax.Vitals were normal and , again , on
other comorbidities were noticed. ICD under water seal was done and the patient was continued on CAT 1 and
Sulfa-Methoxazole –Trimithoprim, Ceftriaxone and other supportive treatment. Within a span of 5 days , the
patient , developed , Pneumothorax on Right Side. ICD under water seal was done on and the medical treatment
continued as required. Patient’s respiratory parameters kept on deteriorating and he expired within 10 days
despite adequate treatment.
P290
Title: IL-1ОІ & IL-12p70 cytokine secretion in Tuberculosis patients
Author: Nazish Fatima, Mohammad Shameem, Nabeela, Haris M Khan, Asma Roohani
Institute: Department of Microbiology, Jawaharlal Nehru Medical College, A.M.U, Aligarh.
Introduction: Tuberculosis (TB) remains a significant public health problem with an estimated one-third of the
world’s population being infected. If TB control is not improved, 1 billion people will be infected by 2020. Cytokines
play a major role in protection against Mycobacterium tuberculosis infection and regulate the immune responses
at a cellular level. The discovery of biomarkers for TB treatment response is therefore important for both clinical
practice and clinical trials of new anti TB drugs.
Objectives: To determine the levels of IL-1ОІ & IL-12p70 in the serum of TB patients.
Materials and Methods: The study was conducted in the Deptt. Of Microbiology, J.N.M.C., A.M.U, Aligarh.
Cytokines levels were measured in 76 serum samples from tuberculosis patients of whom 30 were new TB cases,
24 under-treatment, 22 were MDR TB cases, 44 were pulmonary and 36 were extra-pulmonary TB cases by ELISA
kit (Diaclone France) along with 20 healthy BCG vaccinated controls. A complete clinical, radiological & treatment
data was collected.
Statistical analysis was done by using sigma plot 10.1.
Results: The serum levels of IL-1ОІ & IL-12p70 were significantly higher in new & MDR TB cases (P<0.001). During
treatment IL-1ОІ & IL-12p70 remained low or unchanged. IL-1ОІ & IL-12p70 showed no significant variations according
to the site of involvement in Pulmonary vs. Extra-pulmonary TB cases.
Conclusions: The above findings are encouraging as they support the concept of host biomarkers IL-1ОІ & IL-12p70
for the prediction of differential TB treatment responses. This concept, if validated, could lead to the development
of clinical interventions and accelerate the conduction of TB clinical trials.
P291
DIAGNOSTIC ACCURACY OF COMBINED PLEURAL FLUID ADENOSINE DEAMINASE AND LYMPHOCYTE/
NEUTROPHIL RATIO IN TUBERCULAR PLEURAL EFFUSION
Dr. ANIRUDDHA UDUPA K , Dr S Vinod Kumar, Dr Manju R and Dr. H.Nandeesha
Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
Increased pleural fluid adenosine deaminase (ADA) activity is classically associated with tuberculous pleural
effusion. However, increased activity can also occur in a number of other diseases and this may negatively affect
the diagnostic utility of ADA measurements and decrease its specificity for the diagnosis of tuberculosis (TB). The
presence of ADA in pleural fluids reflects the cellular immune response in the pleural cavity and in particularly, the
activation of T lymphocytes. Different disease entities are typically associated with the presence of particular types
of leukocytes.
OBJECTIVE: To evaluate efficacy of combined use of ADA activity and lymphocyte/neutrophil ratio for diagnosing
tuberculous pleural effusion.
METHODS: Biochemistry, cytology, and microbiology studies were performed on 164 consecutive pleural fluids.
ADA and differential cell counts were determined on all exudative effusions.
RESULTS: Pleural fluid ADA activity at a level of ≥40 U/L, the sensitivity=95.5%, specificity=93.4%, positive
prediction value=94.4%, negative prediction value=94.7% and efficacy= 94.5 %. It was statistically significant (p
value<0.001). When the additional requirement of a lymphocyte/neutrophil ratio of ≥0.75 was included, had
sensitivity=95.45, specificity=100%, positive prediction value=100%, negative prediction value=97.45 and
efficacy=97.5.
CONCLUSION: 1. ADA is a highly sensitive diagnostic marker of tubercular pleural effusion, 2. Combined pleural
fluid ADA and Lymphocyte /neutrophil ratio increases diagnostic accuracy in tubercular pleural effusion patients
compared to pleural fluid ADA alone.
P292
Role of Non invasive Ventilation in the Management of Acute Respiratory Failure
Dr. Srinivas Banoth, Dr S Vinod Kumar and Dr Manoj Kumar Panigrahi
Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India
Objective: To assess the effect of Noninvasive ventilation (NIV) and to identify the factors associated with the
outcome in NIV among patients with acute respiratory failure.
Study Design: Descriptive study
Methods: All the patients with acute respiratory failure requiring NIV were enrolled in the study. We had collected
serial clinical and arterial blood gas parameters at baseline, one hour and four hours. These parameters include
respiratory rate, heart rate, mean blood pressure, PH, PaO2, PaCO2 and PaO2/FiO2 ratio.
Results: A total of 122 patients presented with acute respiratory failure during the study period and 82 patients
fulfilled the inclusion criteria were enrolled in the study. The study included 54(65.9%) male and 28 (34.1%)
female. It showed significant decrease (p < 0.05) in respiratory rate, heart rate and PaCO2 at one and four hour
and significant increase (p < 0.05) in PH at one and four hour compared to baseline values after NIV application.
The overall NIV success and failure rates in our study were 82.92% and 17.07% respectively. NIV was most
successful in patients with COPD (92.1%) and bronchiectasis (90.9%) with failure rates of 7.89% and 9.1%
respectively. All patients of pneumonia with COPD failed the NIV trial. In our study, it was observed that the
duration of the hospital stay was significantly higher in patients with bronchiectasis with corpulmonale (9.41В±4.47
days) than COPD with corpulmonale (5.26В±2.25 days)(P <0.05).
Conclusion: Noninvasive ventilation is an effective modality in preventing endotracheal intubation in acute
(hypercapneic) respiratory failure with possible exception of pneumonia. The duration of the hospital stay was
significantly higher in patients with bronchiectasis with corpulmonale than COPD with corpulmonale.
P293
Aortic Aneurysm presenting as a Posterior Mediastinal Mass- a case report
Dr Bhumika Madhav, Dr Aparna Iyer, Dr Girija Nair, Dr Abhay Uppe, Dr Jayalakshmi T.K, Dr Lavina Mirchandani, Dr
Mugdha Bhide
Dr D.Y.Patil Hospital and Research Centre, Sector 5, Nerul, Navi Mumbai - 400706. Maharashtra India.
Background- Descending Aortic Aneurysm is one of the rare causes of Posterior Mediastinal masses.The sources of
posterior mediastinal masses are usually neurogenic tumors, cysts, malignancy, paraspinal abscess or
lymphadenopathy .Prompt recognition and earlier identification of thoracic aortic aneurysm upon routine
screening is necessary since it can be catastrophic. Descending aortic aneurysm mimicking a posterior mediastinal
mass is a rare presentation.
Case Report- A 65 yr old male was referred in view of chest xray findings patient was posted for cataract Surgery.
Patient was asymptomatic. Patient denied of any respiratory complains. He was non diabetic, non hypertensive.
Respiratory system examination was suggestive of breath sounds reduced in the infrascapular area with a few
crepts. On cardiovascular examination a mid systolic murmur was heard.
Chest X Ray showed a well defined rounded opacity seen in the Left Lower Zone with rounded regular margin not
obscuring the cardiac border or diaphragm. A rim of calcification seen in lower part of the opacity. Thoracic lesion
has its caudal end visible below the dome of diaphragm. Thoraco abdominal sign was positive. High Resolution
Computer Tomography was suggestive of fusiform thoracic descending aortic aneurysm with eccentric mural
thrombosis with impending rupture with a small abdominal aortic aneurysm with mural thrombosis within with
bilateral renal artery ostial stenosis.
Conclusion-Aortic Aneurysm can present as Posterior Mediastinal opacity or an Anterior Mediastinal Opacity
depending on the site of aneurysm- ascending or descending aorta.
P294
A CASE REPORT OF RARE PLEURAL TUMOUR MIMICKING MALIGNANT MESOTHELIOMA
M.L.VED, MAHENDRA KUMAR, MINI GARG
RNT MEDICAL COLLEGE, UDAIPUR
Background: Solitary fibrous tumour of pleura(SFTP) represent 5% of all pleural tumours.It resemble malignant
mesothelioma in clinicoradiological presentation.It is mostly benign and localised,tumour though rare but still
present in community.So need to be kept in differential diagnosis as its treatment is completely different from
malignant tumours.
Case Report:A 65 years old ,non smoker female presented with right side chest pain,cough,exertional dyspnoea
for one month.On examination,clubbing was present.Respiratory system examination reveals decreased intensity
of breath sound in right suprascapular region.Other system examination were normal.Xray showed multiple soft
shadows in right upper and mid zone.`CT reveals multiple nodular pleural masses and thickening in right upper and
mid zone with mild pleural effusion suggestive of malignant mesothelioma more likely than benign.Pleural fluid
examination and percutaneous fine needle aspiration cytology reports were inconclusive.The diagnostic dilemma
was overcome by histopathology examinationof tissue taken by video thoracoscopy and confirmed to be SFTP
from immunohistochemistry staining.
Discussion:SFTP originates from submesothelial mesenchymal layer of pleura.These are most common pleural
tumours after malignant mesothelioma.Unlike malignant mesothelioma,SFTP is not associated with tobacco smoke
or asbestos exposure.SFTP is associated with two paraneoplastic syndromes:1)Pierre Marrie Bamberger Syndrome
2)Doege Potter Syndrome.Radiolologically,diffuse pleural involvement without loss of volume is unlikely for
malignant mesothelioma and other malignant pleural effusion.The treatment of malignant pleural tumour and
benign sftp is entirely differentand it is treated by en bloc resection.Its survival is excellent(96%).One should have
high suspicion of SFTP in such presentation for early diagnosis and treatment to improve quality of life of patient.
P295
CASE OF POST HEMOPTYSIS LUNG COLLAPSE IN A PATIENT OF PULMONARY TUBERCULOSIS
A.B. SRIVASTAVA, DINESH KUMAR SHARMA, PRIYANK JAIN
RNT MEDICAL COLLEGE, UDAIPUR
Background: Endobronchial obstruction by blood clot following massive hemoptysis is an unusual cause of lung
collapse. It is seen in variety of clinical conditions but very few cases are reported in pulmonary tuberculosis
patient. We are presenting such a case of smear positive pulmonary tuberculosis female.
Case Report: A 20 yrs old female admitted with productive cough and fever for one month and one episode of
hemoptysis 2 days back. On examination the patient was anaemic and respiratory system examination revealed
coarse crepitations in left interscapular region. Chest x ray was normal and sputum examination for AFB was
positive.
During hospitalization, 2 days later patient had another episode of massive hemoptysis in night with sudden onset
of dyspnoea. By next morning dyspnoea relieved to some extent and on examination vitals were normal.
Respiratory system examination and chest x ray were suggestive of complete collapse of left lung. Routine blood
investigations were normal including BT & CT except low blood hemoglobin level. Patient was stable and SpO2 was
95%, so managed conservatively.
Subsequent chest x ray after 3 days showed partial expansion of left lung. On fiberoptic bronchoscopy there were
few patches of blood clots adherent to wall of left main bronchus and CECT Thorax showed a cavity in left upper
zone posteriorly. There was no hemoptysis thereafter and patient was referred for category I under DOTS.
Discussion: Pulmonary collapse due to an endobronchial obstruction by blood clot following hemoptysis is seen in
bronchiectasis, tuberculosis, mitral stenosis, pulmonary infraction, sarcoidosis, bronchial carcinoma and post
operative patients. Lung collapse is diagnosed by clinical examination and radiology. Blood clot is confirmed by
direct endoscopic visualisation. Stable patient are managed conservatively until clot resorbs, and in
haemodynamically unstable patients clot is removed urgently by way of lavage, suctioning, or bronchoscopy.
P296
A CASE REPORT OF DEEP VEIN THROMBOSIS IN SMEAR POSITIVE PULMONARY TUBERCULOSIS PATIENT
A.B. SRIVASTAVA, PRIYANK JAIN, DINESH KUMAR SHARMA
RNT MEDICAL COLLEGE, UDAIPUR
Background: An association between tuberculosis induced inflammation and hypercoagulable state is well known.
Venous thromboembolism (VTE) is a rare complication of extensive pulmonary and disseminated tuberculosis
which can cause a potentially life threatening event. Undiagnosed pulmonary thromboembolism may be one of
the cause of sudden unexplained death in patient of tuberculosis with clinically asymptomatic DVT. Here we report
a case of extensive pulmonary tuberculosis with DVT without any other risk factor
Case Report: A 15 years old girl with constitutional symptoms of pulmonary tuberculosis for 2 months, also having
left leg pain and edema since 12 days was admitted. Her chest x ray showed bilateral extensive pulmonary
tuberculosis and sputum examination for AFB was also positive. On routine blood investigation hemoglobin was
9.8 gm% and platelet count was 4.93 lakh/cumm, ESR was 35mm/hr. DVT was suspected on clinical grounds and
color Doppler confirmed thrombosis of left lower limb veins. Anti-tubercular therapy was started and anti
coagulation therapy and related blood investigations were planned meanwhile patient absconded.
Discussion: VTE may occur at presentation or later in the course of pulmonary tuberculosis. Elevated plasma
fibrinogen coupled with decreased Antithrombin III , reactive thrombocytosis, platelet hyperaggregation and
protein S deficiency favor the development DVT in pulmonary tuberculosis as inflammatory cytokines produced by
inflammatory cells in tuberculosis such as IL-6, TNF-О± which are responsible for reactive thrombocytosis and down
regulation of protein S. These hematological parameters worsen during the first 2 weeks of therapy in most of the
cases, but normalize after a month of anti tuberculer therapy. Association between DVT and rifampicin is also
present.
Our report emphasise the need of clinical suspicion of DVT in cases of extensive pulmonary tuberculosis.
297
THE UTILITY OF SINGLE SITE CONVENTIONAL TRANSBRONCHIAL NEEDLE ASPIRATION (C-TBNA) IN PATIENTS WITH
DIAGNOSIS OF BRONCHOGENIC CARCINOMAS AND MEDIASTINAL LYMPHADENOPATHIES WITHOUT ROSE
DR. MAHENDRA KUMAR, DR.MAHESH MAHICH ,DR.BANAME WAANBAH, DR.RAVI PANWAR
RNT MEDICAL COLLEGE, UDAIPUR
Introduction : Transbronchial needle aspiration of mediastinal structures was described by Schiepatti in 1949, but
its use with flexible bronchoscopy was described and systematized by Wang in 1978. Currently the usefulness of CTBNA lies mainly in its effectiveness as a diagnostic tool and in the mediastinal staging of bronchial carcinoma. It is
a simple technique to learn, with a short learning curve, and has proven to be cost effective, despite which it has
always been underused.
Objective : To analyze the utility of C-TBNA for diagnosis.
Patients and methods : Retrospective observational study. All the TBNA was performed in suspected cases of
bronchogenic carcinoma having mass presentation with or without mediastinal or hilar adenopathies on CT
Thorax. We did C-TBNA by single site puncture technique with a 19G needle without the facility of ROSE.
Result : We performed C-TBNA in 21 patients (19 male, 2 female). 16 cases were true TBNA, 4 were EBNA and 1
ETNA was done. The overall diagnostic yield was 90.47% in our cases. Out of that, 15 cases (71.42%) were
confirmed as malignancy, 2 cases (9.52%) were Tuberculosis, 2 were non diagnostic, 1 case (4.76%) Non Hodgkins
Lymphoma and 1 case was non specific inflammation. We did the single site puncture in these cases at 4R (13),
7(5), 10R (2), 11R (2), and 4L (1) for confirmation of diagnosis. Peri-procedural complications included 2 cases of
chest pain on puncture by needle, 1 minimal pneumothorax and 1 was needle stuck at lower end of scope.
Conclusion : C-TBNA is a clinically useful, cost effective technique with minimal complications. It could therefore
be performed on a regular basis during diagnostic bronchoscopy of such patients.
P298
Chyluria and Recurrent Chylothorax cause - Idiopathic Lymphatic dysplasia syndrome
AuthorsPRAKASH K ASHISH , MAMNOON FATIMA, PRABHUDESAI PRALHAD, SHASTRI B S.
Institute – Lilavati Hospital and Research Centre, Mumbai, India.
AbstractThis is a case report of one of the rarest cause of recurrent left sided pleural effusion which was basically recurrent
chylothorax. The patient reported is case of lymphatic duct dysplasia which has led to said problem. He also had
history of chyluria in 2005 for which he was operated. He had post operative complication of shrunken kidney.
Patient after being asymptomatic for such long period has presented to us with recurrent chylothorax. We
investigated with computed tomography, PET-CT, magnetic resonance imaging and finally with lymphoscintigraphy
and came to the conclusion that it was the lymphatic duct abnormality which has initially presented with chyluria
and after being operated for that has presented with chylothorax. We ultimately did pleurodesis and thoracic duct
ligation through VATS (videoscopic assisted thoracic surgery).
Key words: chylothorax; idiopathic lymphatic dyslpasia; Pleural effusion; Thoracentesis; positron emission
tomography-CT; computed tomography; lymphoscintigraphy; LDH-lactate-dehydrogenase; chyle. VATSvideoscopic assisted thoracic surgery
P299
No scope without bronchoscope in abnormal chest x- ray
Dr.J.SOWMYA , Prof.Pradyut waghray, Dr.A.V.N.Koteshwar Rao, Dr.Venkateswar reddy T, Dr.Veena, Dr.Harish,
Dr.Chetan, Dr.Aditya, DrKrishna Chaitanya, Dr.Rikin
Dept of Pulmonary Medicine, SVS medical college, Mahabubnagar,TS
INTRODUCTION: Flexible bronchoscopy has evolved in recent years to be the first choice of investigation in
radiologically abnormal cases for both diagnostic and therapeutic purposes.
AIM: To evaluate the yield of fibreoptic bronchoscopy in our institute over a period of 18 months.
TYPE OF STUDY: Observational study
MATERIALS AND METHODS:
The study was conducted in 200 patients with abnormal chest x rays in whom it was indicated and were subjected
to bronchoscopy. All the findings and complications were noted , materials taken were sent for pathological and
microbiological examination.
RESULTS AND DISCUSSIONS:
Out of 200 patients 130 patients were males with in the range of 14-75 yrs. Following findings were observed.
Plenty of thick secretions in 85 pts(42.5%), Extraluminal compression in 15 pts(7.5%), Intraluminal growth in 3
pts(1.5%), Anatomical variations in 4 pts(2%) Post intubatioin tracheal stenosis in 1 pt(0.5%), Visible fungal ball in
3 pts(1.5%) , Blood clot in1 pt(0.5%), Endobronchial TB in 2pts(1%), Nodules in the airways in 4(2%), Paralysis of
vocal cords in 3pts(1.5%), Air leak in 2 pts(1%), Icd in the bronchus visible through bronchoscope in 1 pt(0.5%),
Fibrotic changes in airway walls in 9pts(4.5%), Black coloured patches in 6 pts(3%), Foreignbodies in 14 pts(7.5%),
Active bleeding in 10 pts(5%), Inconclusive in 30 pts (15%).
CONCLUSION: Disease was found in 89.1% cases in bronchoscopy .Thus flexible bronchoscopy should be the
investigation of choice in abnormal chest x rays
P300
PULMONARY MUCORMYCOSIS MASQUERADING AS ENDOBRONCHIAL GROWTH WITH NON RESOLVING
PNEUMONIA
MOUNIKA.V*, VAMSIKRISHNA.M* , J ** , DR.P.SUBBARAO *** .
DEPARTMENT OF PULMONARY MEDICINE, KONASEEMA INSTITUTE OF MEDICAL SCIENCES
NH-214, CHAITANYA HEALTH CITY, AMALAPURAM, ANDHRA PRADESH-533201
BACKGROUND: Non resolving pneumonia has a wide range of etiology which needs extensive investigations
including bronchoscopy, radiological and microbiological tests. We present an unusual case of Non resolving
pneumonia
CASE REPORT: Patient is a 40 year old diabetic male, presented to us with complaints of chronic cough and fever
of 4 weeks duration. He was evaluated elsewhere with chest X rays, CT SCAN which showed left lower lobe
consolidation. Sputum was sent for bacterial culture. He received antibiotics for K.pneumonia infection as per
sensitivity pattern. Despite 2 weeks injectable antibiotics he had persistent symptoms. Repeated sputum
examination for AFB was negative. Repeat CT scan showed persistent consolidation. At this juncture patient was
referred to us. He was subjected to BRONCHOSCOPY. It revealed an endobronchial growth in left lower lobe main
bronchus, causing partial obstruction of lumen. Endobronchial biopsy has shown features of INVASIVE
MUCORMYCOSIS. He received liposomal amphotericin B 100 mg/day for 10 days with which clinical improvement
was noted and was followed by posaconazole syrup. Patient had complete clinical, radiological improvement and
confirmed by resolution of endobronchial growth and normalization of airways. Posaconzole was continued till
complete radiological resolution
CONCLUSION: we report a case of pulmonary mucormycosis presenting as endobronchial growth. We successfully
treated the patient with liposomal amphotericin B and posaconazole, avoiding surgery.
CLINICAL IMPLICATION: Diabetic patients with uncontrolled blood sugars presenting with non resolving
pneumonia should be investigated for fungal etiologies
P301
A COMPARITIVE STUDY OF SPIROMETRIC PATTERNS IN OBESE AND NON-OBESE ASTHMATICS
Dr.VARGHESE LOUIS, DR.K.SURENDRA MENON, DR.R.PAJANIVEL
DEPARTMENT OF PULMONARY MEDICINE, MAHATMA GANDHI MEDICAL COLLEGE AND RESEARCH INSTITUTE
BACKGROUND: The incidence of obesity and asthma has increased by 75% in recent decades and this has led
clinicians to investigate potential links between the two medical conditions. There is an increased annual risk of
asthma if associated with antecedent obesity.
OBJECTIVES: The aim of this study was to estimate pulmonary function parameters in obese and non-obese
asthmatics, and to observe the relation between obesity and spirometric patterns in asthma.
METHODS: The study was carried out in the Out-Patient Department of Pulmonary Medicine in our institute. The
participants (n=90) included all patients above sixteen years of age of both sexes with signs and symptoms of
Asthma,. BMI was measured in all subjects using height/weight2 and waist circumference measured in
centimetres. Spirometric parameters studied were FEV1 and FVC and derived parameters based on pulmonary
function tests, before and after bronchodilator therapy. Data was then analysed using statistical tests.
RESULTS: Of the total 90 patients studied, 77 (85.5%) had post-bronchodilator therapy reversibility of obstructive
pattern on spirometry. Of these 27(37.1%), were classified as obese based on BMI measurements (p=0.05), and
32(42.6%) were classified as obese based on waist circumference (p=0.018). These values were statistically
significant. These patients were also found to have a restrictive pattern on spirometry assessment, as shown by a
FVC less than 80% recording (p=0.05).
CONCLUSION: Based on the present descriptive study, the following factors were determined: There is a significant
correlation between asthma and obesity. Waist Circumference helped us identify more Obese asthmatics than
Body Mass Index. Obese Asthmatics had a more Restrictive pattern on spirometry compared to Non- Obese
Asthmatics.
P302
Aortic Aneurysm presenting as a Posterior Mediastinal Mass- a case report
Author(s)–Dr Bhumika Madhav, Dr Aparna Iyer, Dr Girija Nair, Dr Abhay Uppe, Dr Jayalakshmi T.K, Dr Lavina
Mirchandani, Dr Mugdha Bhide
Institution-Dr D.Y.Patil Hospital and Research Centre, Sector 5 , Nerul, Navi Mumbai - 400706. Maharashtra India.
Address- 43/1, RCF Row Houses. Sector-6, Vashi, Navimumbai, Maharashtra 400703
BackgroundDescending Aortic Aneurysm is one of the rare causes of Posterior Mediastinal masses.The sources of posterior
mediastinal masses are usually neurogenic tumors, cysts, malignancy, paraspinal abscess or lymphadenopathy
.Prompt recognition and earlier identification of thoracic aortic aneurysm upon routine screening is necessary
since it can be catastrophic. Descending aortic aneurysm mimicking a posterior mediastinal mass is a rare
presentation.
Case ReportA 65 yr old male was referred in view of chest xray findings patient was posted for cataract Surgery. Patient was
asymptomatic. Patient denied of any respiratory complains. He was non diabetic, non hypertensive. Respiratory
system examination was suggestive of breath sounds reduced in the infrascapular area with a few crepts. On
cardiovascular examination a mid systolic murmur was heard.
Chest X Ray showed a well defined rounded opacity seen in the Left Lower Zone with rounded regular margin not
obscuring the cardiac border or diaphragm. A rim of calcification seen in lower part of the opacity. Thoracic lesion
has its caudal end visible below the dome of diaphragm. Thoraco abdominal sign was positive. High Resolution
Computer Tomography was suggestive of Fusiform thoracic descending aortic aneurysm with eccentric mural
thrombosis with impending rupture with a small abdominal aortic aneurysm with mural thrombosis within with
bilateral renal artery ostial stenosis.
ConclusionAortic Aneurysm can present as Posterior Mediastinal opacity or an Anterior Mediastinal Opacity depending on the
site of aneurysm- ascending or descending aorta.
P303
Diagnostic yield of various techniques 0f Fibreoptic video bronchoscopy in diagnosing lung cancer
Dr.VEENA REDDY VANKAYALA, Prof.Pradyuth Waghray, Dr.A.N.V.Koteswara Rao ,Dr. Venkateswara Reddy
Tummuru , Dr. Chetan, Dr.Sowmya, Dr. Harish, Dr.Aditya, DR. Rikin, DR. K.C , Dr.Ramakrishna reddy*
Dept. of Pulmonary Medicine, S.V.S. Medical college, Mahabubnagar, Telangana.
*Dept of Radiology
Introduction: Lung cancer is today the most common amongst the malignancies in the world. Several studies have
demonstrated that early detection, localisation, and aggressive treatment of lung cancer results in five year
survival rate of 70 to 80%.
objective: Study to know the value of various diagnostic methods like bronchial brushings , bronchial wash,
TBNA(transbronchial needle aspiration) , bronchial biopsy , TBLB(transbronchial lung biopsy) under fluoroscopic
guidance.
Type of study: observational study conducted in Pulmonary Medicine department at SVS Medical College ,
Mahabubnagar during a period of 2 years.
Method: patients in whom lung cancer was suspected , bronchoscopy was done and the yeild of different
diagnostic techniques was observed.
Observation: out of total 100 patients , 70 patients had central lesions and 30 patients had peripheral lesions. for
patients with central lesions bronchial brushings in 54 patients (77.14%) ,bronchial wash in 46 patients (65.71)
,bronchial biopsy in 62 patients (88.57 % ) , TBNA done in 32 patients 25 patients (78.12%) gave diagnosis.
In 30 patients who had peripheral lesions bronchial brushings in 12 patients ( 40%) , bronchial wash in 16 patients
(53.3%), TBLB under fluoroscopic guidance in 21 patients( 70%) could give diagnosis.
CONCLUSION: Our study suggests that, in investigating suspected cases of lung malignancy we should adopt all
diagnostic techniques of biopsy, brushing, and washing ,TBNA to increase the yield of diagnosis. Cytological
procedures of washing and brushing yield acceptable optimum results in case of peripheral lesions but fluoroscopy
guided biopsy is best.
P304
Primary pulmonary Lympho Epithelioma like Carcinoma;
Rare case Report in South India.
Abstract:
Primary pulmonary lymphoepithelioma-like carcinoma (LELC) is a rare tumor, with more favorable prognosis
compared with other type of non small cell lung cancer. This tumour is a variant of large cell carcinoma
characterised by abundant invasion of lymphocytes. Here in we describe an interesting case of primary pulmonary
LELC in 26 year old male, smoker confirmed post operatively.
305
Serum concentration of IFN-Оі in patients with new, Under-treatment & MDR tuberculosis cases
Nazish Fatima*, M Shameem**, Nabeela*, Haris M Khan*, Afreen Hashmi
Department of Microbiology, Jawaharlal Nehru Medical College, A.M.U, Aligarh
Introduction: - Mycobacterium tuberculosis (Mtb) infects approximately one third of world population. Many
cytokines are produced during tuberculosis (TB) with predominance of Th1 cytokines during the early stage and
Th2 cytokines in the later stages of the infection. INF-Оі play a key role in control of Mtb infection is produced by
both CD4+ and CD8+ T cells, as well as by NK cell.
Objectives: To evaluate the levels of IFN-Оі, in the serum of New, Under-treatment (UT) & Multi-drug resistant
(MDR) TB patients.
Materials and Methods: The study was conducted at Department Of Microbiology, J.N.M.C, A.M.U, Aligarh.76
patients of TB cases were enrolled in this study of whom 30 were new TB cases, 24 under-treatment, 22 were
MDR TB cases, 44 were pulmonary and 36 were extra-pulmonary TB cases by ELISA kit (Diaclone France) along with
20 healthy BCG vaccinated controls. A complete clinical, radiological & treatment data was collected. Statistical
analysis was done by using sigma plot 10.1.
Results: The levels of INF-Оі were significantly increased in new and MDR TB cases compared to healthy and
untreated cases (P<0.001). There were no significant variations in their level according to the site of infection
(Pulmonary vs. extra-pulmonary).
Conclusions:- Measuring the serum levels of several cytokines may be useful for evaluating the activity of TB
disease and monitoring the clinical effects of ATT. INF-Оі can serve as a potential biomarkers of anti-tuberculosis
treatment response. The discovery of biomarkers for TB treatment response is therefore important for both
clinical practice and clinical trials of new anti TB drugs.
306
Comparative study of Indacaterol and Tiotropium in patients of COPD
Dr. Mohammad Sajid alam, Dr. Jameel Ahmad, Prof. Anil Kumar, Dr. Mohammad Shameem
*
: Department of Pharmacology and Department of Tuberculosis & Respiratory diseases, J.N.M.C. & Hospital,
A.M.U
Objective: Comparative study of safety and efficacy of Indacaterol and Tiotropium in patients of moderate &
severe grade of COPD.
Method: This is a randomized, prospective, open labelled and parallel group study. Eligible patients were enrolled
and randomized according to the table generated by random allocation software into two groups (20 patients in
each group).
Group I patients received Indacaterol in the dose of 150Ојg once daily and Group II patients received Tiotropium
18Ојg once daily for 10 weeks. The patients were evaluated by measuring FEV1 at zero, two weeks, four weeks, six
weeks, eight weeks and ten weeks.
Results: The gradual improvement is observed in both the groups. There is more improvement in Indacaterol as
compared to Tiotropium. Although the difference was not statistically significant.
P307
Association of body mass index with severity of obstructive sleep apnea
Nitin Goel, Mandeep Singh, Vikas Dogra, Kuldeep Patial, Raj Kumar, Rajendra Prasad
Sleep Disorder Centre, Vallabhbhai Patel Chest Institute
University of Delhi, Delhi- 110007, India
Background: Obesity has reached epidemic proportions in India in the present century, with National Family
Health Survey 2007, showing 12% males and 16% females to be obese.Obesity is one of the most powerful
reversible risk factor for obstructive sleep apnea (OSA). The present study was planned to assess the association
between body mass index in adults on the severity of obstructive sleep apnea.
Materials and Methods: The present study is a retrospective analysis of the sleep studies done in Vallabhbhhai
Patel Chest Institute over a period of one year from 1 January to 31 December 2012. The patients were divided into
2
2
2 groups based on their body mass index (BMI) into non-obese (18.50 - 24.99 kg/m ) and obese (> 25kg/m ). The
patients from these groups were then assessed for apnea hypopnea index (AHI).
Results: There were 81 subjects who underwent sleep study in 2012 comprising of 52 males and 29 females with
the mean age of 52.62 В± 10.03 years. Most of the subjects belonged to obese group (n = 75) whereas non-obese
group comprised of only 6 subjects. 66.67% subjects in non-obese group and 78.66% subjects in obese group had
severe obstructive sleep apnea (AHI ≥ 30/ hour). The difference in occurrence of severe OSA in non-obese versus
obese subjects was not statistically significant (p>0.05).
Conclusions: OSA has high occurrence in obese individuals and severity of OSA may not be related to obesity
alone.
Table 1: Apnea hypopnea index in different groups of body mass index
Body mass
index
2
(kg/m )
Number of
Patients
<25
≥ 25
6
75
Percent of cases having AHI ≥ 30
Apnea hypopnea index
<5
1
0
≥5- <15
0
9
≥ 15- <30
1
7
≥ 30
4
59
66.67%
78.66%
P308
Bronchial anthracosis and anthracofibrosis
RAJ KUMAR, MOHAMMED NOUFAL POONGADAN, MANDEEP SINGH, NITIN GOEL, NITESH GUPTA, SAURAB,
RAJENDRA PRASAD
National Centre for Respiratory Allergy, Asthma and Immunology
Vallabhbhai Patel Chest Institute, Delhi-110009, India
Objective: Anthracosis is a term used to describe a condition in which there is deposition of black pigments on the
bronchial mucosa. On the other hand, bronchial anthracofibrosis (BAF) has been used to describe bronchial
stenosis associated with anthracosis without a relevant history of pneumoconiosis or smoking. The present study
was planned to assess the clinico-radiological, bronchoscopic and pathological features of anthracosis with or
without BAF
Method: The present study is a retrospective review of bronchoscopic cases of anthracosis diagnosed in a unit of
Vallabhbhai Patel Chest Institute from Jan-August 2014. The clinical presentation, radiological features,
bronchoscopic findings and histopathogical specimens of patients having anthracosis were analysed.
Results: There were a total of nine patients who were diagnosed to have anthracosis, out of which two had
associated BAF during the study period. All the subjects were female with an average age of 59.4 years (age range:
38-70 years). Past history of tuberculosis was present in 2 cases. The most common clinical symptoms in patients
with anthracosis were cough in 9 (100%), breathlessness in 8 (88.9%) cases. All the subjects had history of biomass
fuel exposure. Computed tomography chest showed consolidation, nodules, bronchiectasis. Evidence of bronchial
stenosis or obstruction was seen in 2 cases. Bronchoscopy revealed black bronchial deposits in all cases, with 2 out
of them showing bronchial stenosis. Histo-pathological evaluation showed chronic inflammation of the bronchial
mucosa, submucosal anthracotic pigment deposition in all and fibrosis in 2 cases.
Conclusions: The diagnosis of anthracosis and BAF is based mainly on bronchoscopic evaluation. It may be
associated with biomass fuel exposure or tuberculosis.
P309
Effect of household air pollution from biomass combustion on respiratory related illness in rural area of NCRDelhi
Raj Kumar, Mandeep Singh, Kamal Singh, Mohammed Noufal Poongadan, Nitin Goel, Nitesh Gupta, Saurab, Uday
Kumar Mehto, Anil Mavi, Deepak Kumar, Rajendra Prasad
National Centre of Respiratory Allergy, Asthma and Immunology (NCRAAI), Vallabhbhai Patel Chest Institute, Delhi
University, Delhi-110007
Introduction: Indoor air pollution is the third leading cause of disease burden in South East Asia as per Global
burden of disease study 2010. Indoor air pollution as assessed by particulate matters (PM10, PM2.5, and PM1) and
volatile organic compounds (VOCs) includes combustion of solid fuels and tobacco smoking. The present study was
thus planned to assess the effect of indoor air pollution on the health of adults.
Methodology: The present study is a cross sectional study to assess the difference in household air quality in
houses having adults (>18 years age) with or without asthma in a rural area (Village Khanpurjupti, Loni, Ghaziabad)
of Delhi NCR region. 83 households (Group-A: controls) were selected in which none of the adult had any
respiratory symptoms (breathlessness, cough and/or sputum) while the other 83 households (Group-B: cases) had
at least one adult with one of the above respiratory symptoms. A standard questionnaire was filled and levels of
various indoor air pollutants were measured using standard instruments.
Result: Out of total 430 adults, 94 (21.86%) adults in Group-B had respiratory illness related symptoms. The PM
and VOCs levels of homes of Group-B, were higher than homes of Group-A. Average 24 hours and 6 hours PM2.5
levels were significant high in homes of Group-B compared with homes of Group-A. 6-hours PM10 mean level of
homes of group-B were also significantly high than Group-A. PM1 and VOC levels were also higher in Group B as
compared to Group A but could not reach stastically significant value.
Conclusion: Indoor air pollution from smoking, chemicals and biomass fuel combustion results in increased levels
of particulate matters and volatile organic compounds in indoor air, which may be responsible for increased level
of respiratory illness in adults.
P310
Effect of household air pollution from biomass combustion on respiratory related illness in women
Raj Kumar, Mandeep Singh, Kamal Singh, Mohammed Noufal Poongadan, Nitin Goel, Nitesh Gupta, Saurab, Uday
Kumar Mehto, Anil Mavi, Deepak Kumar, Rajendra Prasad
National Centre for Respiratory Allergy, Asthma and Immunology
Vallabhbhai Patel Chest Institute, Delhi-09
Background: Indoor air pollution is third leading cause of disease burden in South East Asia as per Global burden of
disease study 2010 published in lancet. The most significant sources of indoor air pollution in developing countries
are combustion of solid fuels, including biomass or coal and active and passive smoking. Females are much more
susceptible to household air pollutants as they spend most of their time indoors. The present study was planned to
assess the correlation between respiratory symptoms in women and levels of indoor air pollution as assessed by
particulate matter 2.5 (PM 2.5) and volatile organic compounds (VOCs).
Methods: The present study is a cross sectional study of adult women from 77 households in a rural setting
(Village Khanpurjupti, Loni, Ghaziabad) of Delhi NCR region. A questionnaire based assessment for respiratory
illness related symptoms (cough, sputum, breathlessness) was done in women of these houses. In these houses
assessment of PM 2.5 and VOCs levels were done by standard instruments.
Results: A total of 190 adult women from 77 households were included in the study. A total of 56 women from 44
households had history of respiratory illness related symptoms. The PM 2.5 and VOC levels were measured from
all 77 households. The average PM 2.5 concentration was found to be significantly higher in houses with
respiratory illness as compared to controls (10.13mg/m3 versus 4.36mg/m3). The average level of VOCs was also
higher in these households as compared to controls but could not reach statically significant value.
Conclusion: Household air pollution from biomass fuel use and smoking resulted in increased levels of PM2.5 and
VOCs in household air, which may be responsible for increased level of respiratory illness in women.
P311
A 54 year old man presented with dry cough, breathlessness on exertion, itching all over the body and heaviness in
the chest from last 2-3 months. He noticed progressive bulging of his anterior chest wall also. On examination his
anterior chest wall was bulged, anterio-posterior diameter was 90 cm and transverse diameter was 75 cm. There
were multiple enlarged lymph nodes in both the axillas. His X-ray chest PA view showed mediastinal widening and
left lateral view showed mediastinal mass extending into anterior chest wall. CT scan showed a large homogenous
minimally enhancing soft tissue density mass lesion diffusely involving anterior and middle mediastinum extending
from thoracic inlet superiorly, up to the level of diaphragm inferiorly, anteriorly causing destruction of upper part
of sternum with infiltration into overlying pectoralis muscles, subcutaneous tissue and skin. CT abdomen showed
multiple hypodense lesions in spleen. Biopsy of chest wall lesion and axillary lymph node showed features
suggestive of lymphoma. He was diagnosed as having stage 4 Hodgikns lymphoma and was treated with combined
chemotherapy and radiotherapy. Size of the tumour reduced and patient discharged in satisfactory condition with
advice of regular follow up. We report this case because of its unusual presentation.

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