Swimming-induced pulmonary edema with review of literature.

Swimming-induced pulmonary edema (SIPE) is a rare form of non-cardiogenic pulmonary edema occurring in swimmers. It is important to consider the diagnosis of SIPE and differentiate it from aspiration pneumonitis in patients presenting with respiratory distress after swimming. We report a case of military recruit who developed SIPE. This is the first reported case of SIPE from India. Owing to the paucity of reported cases, the treatment of this entity in the literature is anecdotal, and we present successful management of SIPE with non-invasive ventilation and diuretics. A review of literature is made to understand the diagnosis, pathophysiology, and management of SIPE.

Post-nephrectomy pulmonary thromboembolism.

The association of pulmonary thromboembolism with nephrectomy is well documented in malignant conditions. However, the data for incidence of pulmonary thromboembolism following nephrectomy in nonmalignant conditions remains scarce. We report the first case of an incidence of pulmonary thromboembolism following nephrectomy in a patient with a nonfunctional kidney due to multiple renal calculi.

Bilateral congenital pulmonary airway malformation presenting in adulthood with a review of the literature.

We report a rare case of congenital pulmonary airway malformation (CPAM) in a middle-aged female patient with bilateral involvement. In view of its presentation in adulthood, it presents a rare picture of a disease often diagnosed in early childhood. Until now, 65 cases of this disease have been reported in adults, including 3 cases with bilateral involvement. A classical radiological picture of CPAM can often be confused with bronchiectasis or pulmonary sequestration. A definite treatment with surgical resection poses a challenge in bilateral involvement. We highlight a rare case with its challenges in diagnosis and management. A review of literature of cases of CPAM with bilateral involvement is conducted in an effort to better understand this entity in adulthood.

Diagnostic value of bronchoprovocation challenge with adenosine monophosphate versus exercise testing in early diagnosis of asthma.

BACKGROUND: Airway hyperresponsiveness (AHR) is a characteristic feature of bronchial asthma and is diagnosed using direct and indirect bronchoprovocation tests. The diagnosis of AHR is a challenge in symptomatic patients with a normal baseline prebronchodilator spirometry and postbronchodilator spirometry. Exercise-induced asthma or exercise-induced bronchoconstriction (EIB) is a distinct form of AHR. There is no single test that is sufficient to exclude AHR in symptomatic military personnel with normal spirometry. This study was conducted to compare the diagnostic value of indirect bronchoprovocation test using inhaled adenosine monophosphate (AMP) and exercise challenge test (ECT) in the diagnosis of EIB. METHODS: A crossover study was conducted with consecutive sampling of patients presenting with symptoms suggestive of asthma and with normal spirometry results who were subjected to both ECT and bronchoprovocation test using inhaled AMP on separate days. RESULTS: Forty participants were recruited (the mean age: 25 yrs, 100% male). The commonest presentation was breathlessness on exercise (55%). With exercise alone, 40% tested positive for AHR, while with AMP alone, the positivity increased to 53%, and the difference was statistically significant (p= 0.03). Exercise alone failed to detect 8 cases that tested positive for AHR by inhaled AMP challenge. CONCLUSION: Indirect bronchoprovocation test using inhaled AMP may be used to diagnose AHR in conditions in which exercise challenge testing is not available or the patient is unable to complete ECT.

Shock due to amlodipine overdose.

Amlodipine is a commonly prescribed calcium channel blocker. Its toxicity is the leading cause of drug overdose seen in the practice of cardiovascular medicine. It can lead to profound hypotension and shock. Management involves early and aggressive supportive measures and calcium infusion in large doses to overcome competitive blockade. We report one such case that presented with amlodipine overdose and was successfully managed.

A multicenter survey study of antifibrotic use for symptomatic patients with post-COVID-19 interstitial lung abnormalities.

Background: Little data exist on antifibrotic drugs for treating symptomatic patients with persistent interstitial lung abnormalities in the postacute phase of coronavirus disease 2019 (COVID-19). Herein, we describe the physician practices of prescribing pirfenidone and nintedanib for these patients and the physician-assessed response. Materials and Methods: This was a multicenter, retrospective survey study of subjects administered pirfenidone or nintedanib for post-COVID-19 interstitial lung abnormalities. Data on the demographic details, comorbidities, abnormalities on the computed tomography (CT) of the chest, treatment, antifibrotic drug use, and physician-assessed response were collected on a standard case record pro forma. We explored physician practices of prescribing antifibrotics (primary objective) and the physician-assessed response (secondary objective). Results: We included 142 subjects (mean age, 55.9 years; 16.2% women) at eight centers. The most common abnormalities on CT chest included ground glass opacities (75.7%), consolidation (49.5%), reticulation (43.9%), and parenchymal bands (16.8%). Of the 5701 patients discharged after hospitalization at six centers, 115 (2.0%) received antifibrotics. The drugs were prescribed an average of 26 days after symptom onset. One hundred and sixteen subjects were administered pirfenidone; 11 (9.5%) received the full dose (2400 mg/day). Thirty subjects were prescribed nintedanib; 23 (76.7%) received the full dose (300 mg/day). Of 76 subjects with available information, 27 (35.6%) and 26 (34.2%) had significant or partial radiologic improvement, respectively, according to the physician's assessment. Conclusions: Antifibrotic agents were administered to a minority of patients discharged after recovery from acute COVID-19 pneumonia. Larger, randomized studies on the efficacy and safety of these agents are required.

Review of advances in diagnosis and treatment of pulmonary tuberculosis.

There has been a substantial leap in our understanding and the management of tuberculosis over the past couple of decades. New diagnostic tests, regimens and drugs have emerged. With a background of milestones in the management of tuberculosis, we review the advances made in the diagnosis and treatment of pulmonary tuberculosis. Since India accounts for 27% of word's burden of tuberculosis, the changes in RNTCP have been highlighted.

Chemotherapy-Associated Pulmonary Toxicity-Case Series from a Single Center.

Background Pulmonary toxicity due to chemotherapeutic agents can occur with many established and new drugs. Strong clinical suspicion is important as the clinical presentation is usually with nonspecific symptoms like cough, dyspnea, fever, and pulmonary infiltrates. Timely discontinuation of the offending agent alone can improve the condition. Methods A prospective observational study on patients receiving chemotherapy at an 800-bedded tertiary care hospital was performed from 2014 to 2016. Consecutive patients on chemotherapy, presenting with nonresolving respiratory symptoms were evaluated with contrast-enhanced computerized tomography of chest, diffusion lung capacity for carbon monoxide (DLCO), fiberoptic bronchoscopy with lavage, and biopsy, after excluding all causes for pulmonary infections. Descriptive data has been depicted. Results A total of 18 patients were evaluated for persistent symptoms of dry cough, dyspnea, and fever among 624 who received chemotherapy during the study period. Ground-glass opacities on high-resolution CT was the most common imaging finding, others being patchy subpleural consolidation and pleural effusion. Lymphocyte-predominant bronchoalveolar lavage was detected in nine. Eight of the 15 patients who underwent DLCO, had abnormal results. Seven had significant histopathological findings on bronchoscopic lung biopsy, which revealed organizing pneumonia as the most common pattern. Paclitaxel, fluorouracil, gemcitabine, and tyrosine kinase inhibitors were the common culprit drugs. Discontinuation alone of the culprit drug was effective in 15 and 3 needed oral corticosteroids for relief of symptoms. None of the patients died due to the toxicity. Conclusion An incidence of 2.8% for chemotherapy-induced lung injury was seen in our observational study of 3 years, with parenchymal, interstitial, and pleural involvement due to various chemotherapeutic agents. Oral steroids maybe required in a subset of patients not responding to discontinuation of the culprit agent.

Eosinophilic Pleural Effusion in a Young Woman With Pleural Nodularity and Lytic Skeletal Lesions.

CASE PRESENTATION: A 21-year-old woman, a housewife with no known comorbidities, presented to the outpatient department with complaints of dry cough, left-sided pleuritic chest pain, modified Medical Research Council grade II breathlessness and backache. She had started developing these symptoms 1 month earlier. There was no history of fever, hemoptysis, or significant weight loss. She had no features suggestive of connective tissue disorder. There was no history of recurrent respiratory infections in the past. She was married for 1 year and had no children. Her sleep, bowel, and bladder habits were normal. No significant family history or medication history was noted.

Correlation between transbronchial lung biopsy and lung cytology.

Respiratory diseases are an important cause of morbidity and mortality worldwide. Although conventional histopathology is the gold standard for their diagnosis, cytology is a useful adjunctive diagnostic test. In the present study we evaluated the efficacy of cytology in providing a rapid diagnosis. We included lesions which were both visible and not visible on bronchoscopy. We evaluated the role of bronchoalveolar lavage (BAL), brush cytology and imprint smears both separately and in combination, and compared them with the histopathological findings of transbronchial lung biopsy (TBLB). Among 100 cases the highest concordance was seen between imprint cytology (77.78%) and biopsy for malignancy, followed by bronchoalveolar lavage (40.91%) and brush cytology (40.00%). The concordance and level of agreement between cytology and biopsy was very poor in general for non-neoplastic lesions. However, it increased when BAL and imprint smears (42.50%) were performed together, compared to other combinations. We recommend a combination of cytological techniques in suspected cases of malignancy, as more useful than a single test, and to include imprint smears in all cases. However, biopsy remains the gold standard for diagnosis in non-neoplastic lung disease.

Management of primary pulmonary alveolar proteinosis: A multicentric experience.

BACKGROUND: Pulmonary alveolar proteinosis (PAP) is a rare disease characterized by alveolar accumulation of surfactant material with reduced lung function and resulting hypoxemia. It is characterized by a variable clinical course, and whole lung lavage (WLL) is the standard treatment. Herein, we report our multicentric experience of management of primary PAP. MATERIALS AND METHODS: This retrospective study included patients with PAP managed at various armed forces respiratory centers from 2009 to 2019. The diagnosis of primary PAP was based on histopathologic confirmation on transbronchial lung biopsy or open lung biopsy and absence of causes of secondary PAP. We analyzed the response to WLL in these patients as well as the safety of the procedure. RESULTS: During the above-specified period, ten patients with a diagnosis of PAP were admitted to various armed forces respiratory centers. The median age of the patients was 34.5 years (range 23-59); there were nine males (90%). The mean duration (± standard deviation) of symptoms was 10.8 (±2.70) months. For management, WLL was done for eight patients with a median volume of 23.5 L (range 18-45) per patient. All the patients showed significant symptomatic response as well as improvement in physiological parameters with no major complications. The median follow-up of all patients was 18 (range 5-44) months. CONCLUSIONS: WLL is a safe, effective therapy in an experienced setting in patients with PAP and provides long-lasting benefits.

Outcomes of noninvasive ventilation in acute hypoxemic respiratory failure in a respiratory intensive care unit in north India.

OBJECTIVES: To determine the outcomes of noninvasive ventilation (NIV) and the factors associated with NIV failure in patients with acute hypoxemic respiratory failure (AHRF). METHODS: This was a prospective observational study and all patients with AHRF requiring NIV over a one-and-a-half-year period were enrolled in the study. We recorded the etiology of AHRF and prospectively collected the data for heart rate, respiratory rate, arterial blood gases (pH, P(aO2), P(aCO2)) at baseline, 1 hour, and 4 hours. The patients were further classified into 2 groups, based on the etiology of AHRF: either acute lung injury/acute respiratory distress syndrome [ALI/ARDS], or AHRF due to other causes. The primary outcome was the need for endotracheal intubation during the ICU stay. RESULTS: During the study period, 287 patients were admitted in the ICU, and of these 40 (13.9%) (21 ALI/ARDS, 19 AHRF due to other causes; 16 male, 24 female patients; mean +/- SD age 43.2 +/- 20.6 years) patients with AHRF were initiated on NIV. The baseline characteristics were similar in the 2 groups. After 1 hour there was a significant decrease in respiratory rate and heart rate, with increase in pH and P(aO2); however, there was no difference in improvement of clinical and blood-gas parameters between the 2 groups. The NIV failures, the mean ICU and hospital stay, and the hospital mortality were similar in the 2 groups. In the univariate logistic regression model the only factor associated with NIV failure was the baseline ratio of P(aO2) to fraction of inspired oxygen (P(aO2)/F(IO2)) (odds ratio 0.97, 95% confidence interval 0.95-0.99). CONCLUSIONS: NIV should be judiciously used in patients with AHRF. A low baseline P(aO2)/F(IO2) ratio was associated with NIV failure.

Electrical injury: an unusual cause of pneumothorax and a review of literature.

Electrical injuries are a common occurrence and can be minor or even fatal depending on the voltage to which an individual has been exposed to. Electrical current causes tissue damage by producing heat due to local tissue resistance. Serious electrocution may manifest with cutaneous burns, visceral injuries, organ perforation, and cardiac and respiratory effects. Pneumothorax as a complication of electrical injury is a very rare entity. We report one such case of electrical burn injury with right-sided pneumothorax as an immediate complication.

Joint Indian Chest Society-National College of Chest Physicians (India) guidelines for spirometry.

Although a simple and useful pulmonary function test, spirometry remains underutilized in India. The Indian Chest Society and National College of Chest Physicians (India) jointly supported an expert group to provide recommendations for spirometry in India. Based on a scientific grading of available published evidence, as well as other international recommendations, we propose a consensus statement for planning, performing and interpreting spirometry in a systematic manner across all levels of healthcare in India. We stress the use of standard equipment, and the need for quality control, to optimize testing. Important technical requirements for patient selection, and proper conduct of the vital capacity maneuver, are outlined. A brief algorithm to interpret and report spirometric data using minimal and most important variables is presented. The use of statistically valid lower limits of normality during interpretation is emphasized, and a listing of Indian reference equations is provided for this purpose. Other important issues such as peak expiratory flow, bronchodilator reversibility testing, and technician training are also discussed. We hope that this document will improve use of spirometry in a standardized fashion across diverse settings in India.

A comparative study of the health record cards in primary schools of Delhi.

A comparative study was undertaken to understand the various measures required to strengthen and improve the health record cards (HRC) of various schools that subsequently help in improving the medical examination of children. By using a multi stage stratified random sampling method, 24 schools from Delhi, eight each from three broad categories of (i) corporation schools, (ii) other government schools, (iii) private schools were included in the study. The study finding revealed that in most of the government schools the health record cards were properly developed and structured as per the recommendations of various committee, though they are always in short supply.

Primary cavitary sarcoidosis: A case report, systematic review, and proposal of new diagnostic criteria.

Primary cavitary sarcoidosis (PCS) is a rare form of pulmonary sarcoidosis. In this report, we present a case of a 47-year-old male patient with PCS who was initially treated as pulmonary tuberculosis. We also systematically review the literature on PCS and propose a new classification for this entity.

Effect of oral vitamin D supplementation on glycemic control in patients with type 2 diabetes mellitus with coexisting hypovitaminosis D: A parellel group placebo controlled randomized controlled pilot study.

CONTEXT: Vitamin D supplementation in type 2 diabetes mellitus patients may lead to improved glycemic control by improving insulin secretion and decreasing insulin resistance. AIMS: To investigate effect of oral vitamin D supplementation on glycemic control, in patients with type 2 diabetes mellitus and coexisting hypovitaminosis D. SETTINGS AND DESIGN: Randomized, Parallel Group, Placebo Controlled Trial carried out in a tertiary care hospital of Indian Armed Forces. METHODS AND MATERIAL: Sixty patients with coexisting type 2 diabetes mellitus and hypovitaminosis D were randomized into cases and controls and were supplemented with oral Vitamin D and microcrystalline cellulose respectively for six months. Subjects' HbA1c and vitamin D levels were monitored at the beginning and end of the study, fasting plasma glucose (FPG) & post prandial plasma glucose (PPPG) during monthly OPD visits. STATISTICAL ANALYSIS USED: Intra-group comparison was made by paired t test & unpaired t test was used for inter-group (A v/s B) comparisons. Repeated measures ANOVA was undertaken to compare values over time. RESULTS: The two groups were comparable for all parameters at baseline. Case group showed significant decrease in mean HbA1c levels (7.29% to 7.02%; P = 0.01), mean FPG levels (131.4 to 102.6 mg/dl; P = 0.04) and mean PPPG levels (196.2 to 135.0 mg/dl; P < 0.001). Incidentally, significant improvement in systolic as well as diastolic blood pressure and total cholesterol was also noted in the cases, while for LDL cholesterol improvement tended towards significance (p = 0.05). CONCLUSIONS: We found that oral vitamin D supplementation was associated with improved glycemic control and other metabolic parameters in patients with type 2 diabetes mellitus. Supplementation to achieve normal levels of vitamin D can be a promising adjuvant therapy for T2DM patients & coexisting hypovitaminosis D.

Innovative endovascular technique for treatment of rare cause of haemoptysis in young.

A 17-year-old boy reported for evaluation of two episodes of massive haemoptysis. His clinical examination was unremarkable and investigations (haemogram, coagulogram, serological tests for connective tissue disorders) were normal. A 64-slice CT angiography revealed a saccular aneurysm of 3.8×3.7×3.3 cm arising from the right lower lobe pulmonary artery which was confirmed by cardiac catheterisation. The aneurysm was successfully blocked with a 16-14 Amplatzer duct occluder. A repeat CT angiogram performed after 15 days revealed the device in situ obliterating the aneurysm. Pulmonary artery aneurysm is an extremely rare cause of massive haemoptysis and indicates imminent rupture of the aneurysm which can be rapidly fatal. This case highlights the importance of using an innovative endovascular technique for treatment of a rare cause of haemoptysis.

Pulmonary hypertension in a patient with hereditary haemorrhagic telangiectasia.

A young male patient reported for evaluation of progressive easy fatigability, accompanied by a recent history of recurrent haemoptysis. His clinical examination was unremarkable except for evidence of pulmonary arterial hypertension (PAH). Routine investigations (haemogram, coagulogram, serological tests for connective tissue disorders and a sputum Ziehl Neelsen stain for acid-fast bacilli) were normal. Two-dimensional echocardiography suggested PAH (pulmonary artery systolic pressure-67 mm Hg), whereas the 64-slice spiral CT pulmonary angiogram showed a dilated main pulmonary artery along with bilateral arteriovenous malformations. Cardiac catheterisation performed subsequently confirmed the presence of PAH. On the basis of the above findings, a diagnosis of hereditary haemorrhagic telangiectasia (HHT) complicated with PAH was made, and the patient was started on oral sildenafil therapy to which he responded well. This rare complication of HHT, which requires a high degree of suspicion for diagnosis, is discussed.