Pulmonary Function and Diffusing Capacity of Carbon Monoxide in Hypersensitivity Pneumonitis: An Observational Study of 152 Patients.

OBJECTIVE: Hypersensitivity pneumonitis (HP) is an inflammatory and/or fibrotic lung disease. The restrictive lung function with low diffusing capacity of carbon monoxide (DLCO) is common in interstitial lung diseases (ILD). There are limited data on pulmonary function test (PFT) in HP and its role for diagnosis is questionable. We analyzed the data of 152 HP patients for type of defect, lung volume, and DLCO. MATERIAL AND METHODS: The present study is a retrospective analysis of 152 patients at one of the tertiary chest institutes in India. All diagnosed cases with at least spirometry were included. PFT findings were classified and graded as obstructive, restrictive, and mixed patterns. The correlation of PFT was calculated with disease duration and 6MWT distance. RESULTS: The majority were female [106 (70%)], with a mean age of 47.8 ± 12.3 years. Spirometry with lung volume data were available for 97% patients. PFT was abnormal in 118 (80%) cases. Among the patterns of abnormality, the most common type was restrictive (74%) followed by mixed (15%) and obstructive (11%) with the majority in the severe to very severe grade. The mean total lung capacity (TLC) and residual volume (RV) were reduced, with the grade more severe when the pattern of abnormality was restrictive while the RV/ TLC was higher suggestive of air tapping. DLCO data were available for 132 (87%) cases, with levels decreased in 67%. The severity of DLCO was highest when the pattern of abnormality was restrictive. One of the PFT parameters was abnormal in 137 (90%) cases, with isolated decreased DLCO levels seen in 16 (10%) cases. Forced vital capacity (FVC), TLC, and DLCO showed positive correlation with 6MWT distance (FVC r = .22, P = .02; TLC r = .28, P = .003; DLCO r = .30, P = .002). CONCLUSION: The PFT abnormality is seen in >80% of HP patients. All types of abnormality were seen, with the restrictive pattern being the most common. Isolated decreased DLCO levels were seen in 10% of cases. We advised to do full PFT for diagnosis and followup of HP.

Pre-conference workshop on pulmonary rehabilitation and smoking cessation - NATCON 2022.

The 77th National Conference of Tuberculosis and Chest Diseases was held on 27th February 2023. The workshop on Pulmonary rehabilitation and smoking cessation was conducted as a part of the various pre-conference workshops being conducted on the occasion. It helped the participants to know regarding the role, efficacy and benefits of pulmonary rehabilitation and smoking cessation for the management of Chronic respiratory diseases.

Uncontrolled Diabetes Mellitus Predicts Post-COVID-19 Fibrosis.

INTRODUCTION: Post-coronavirus 2019 (COVID-19) complications are now well-recognized and may involve multiple organs. Post-COVID-19 pulmonary fibrosis is one of the serious long-term consequences of COVID-19 infection, and the risk factors for its development largely remain unidentified. AIMS AND OBJECTIVES: The study aimed to evaluate the clinical and radiological profile of post COVID-19 patients with diagnosed diabetes mellitus (DM). MATERIALS AND METHODS: All the patients attending the post-COVID-19 respiratory care center over a period of 1 year who were diagnosed with cases of DM were evaluated for residual clinical symptoms and radiological changes and glycosylated hemoglobin (HbA1c) levels were measured from their blood samples. RESULTS: A total of 50 patients were enrolled in this observational cross-sectional study. Most patients were males in the age group of 45-60 years. Approximately 74% of patients had uncontrolled DM. Patients with uncontrolled DM had a higher probability of having a severe disease with an odds ratio (OR) of 7.30 (0.85, 62.42, and confidence interval (CI) 95%) and were more likely to have fibrotic abnormalities on computed tomography (CT) chest with OR of 3.38 (0.87, 16.86, and CI 95%). CONCLUSION: Uncontrolled diabetes predisposes to the development of post-COVID-19 fibrosis, so physicians should be more vigilant while managing these patients.

Initial COVID-19 Severity and Long-COVID Manifestations: An Observational Analysis.

OBJECTIVE: New-onset or persistent symptoms beyond after 4 weeks from COVID-19 are termed "long-COVID." Whether the initial severity of COVID-19 has a bearing on the clinicoradiological manifestations of long COVID is an area of interest. MATERIAL AND METHODS: We did an observational analysis of the long-COVID patients after categorizing them based on their course of COVID-19 illness into mild, moderate, and severe groups. The clinical and radiological profile was compared across these groups. RESULTS: Out of 150 long-COVID patients recruited in the study, about 79% (118), 14% (22), and 7% (10) had a history of mild, moderate, and severe COVID-19, respectively. Fatigue (P = .001), breathlessness (P = .001), tachycardia (P = .002), tachypnea (P < .001), raised blood pressure (P < .001), crepitations (P = .04), hypoxia at rest (P < .001), significant desaturation in 6-minute walk test (P = .27), type 1 respiratory failure (P = .001), and type 2 respiratory failure (P = .001) were found to be significantly higher in the long-COVID patients with a history of severe COVID-19. These patients also had the highest prevalence of abnormal chest X-ray (60%) and honeycombing in computed tomography scan thorax (25%, P = .027). CONCLUSION: The course of long COVID bears a relationship with initial COVID-19 severity. Patients with severe COVID-19 are prone to develop more serious long-COVID manifestations.

Role of sleep questionnaires in predicting obstructive sleep apnea amongst interstitial lung diseases patients.

Introduction: The co-existence of obstructive sleep apnea (OSA) and interstitial lung diseases (ILD) results in significant morbidity and mortality. So screening for OSA is important for its early diagnosis among ILD patients. The commonly used questionnaires for screening of OSA are Epworth sleep score (ESS) and STOP-BANG. However, the validity of these questionnaires among ILD patients is not well studied. The aim of this study was to assess the utility of these sleep questionnaires in detection of OSA among ILD patients. Methods: It was a prospective observational study of one year in a tertiary chest centre in India. We enrolled 41 stable cases of ILD who were subjected to self-reported questionnaires (ESS, STOP-BANG, and Berlin questionnaire). The diagnosis of OSA was done by Level 1 polysomnography. The correlation analysis was done between the sleep questionnaires and AHI. The sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) were calculated for all the questionnaires. The cutoff values of STOPBANG and ESS questionnaire were calculated from the ROC analyses. P value of <0.05 was considered to be significant. Results: OSA was diagnosed in 32 (78%) patients with mean AHI of 21.8 ± 17.6.The mean age was 54.8 ± 8.9 years with majority being female (78%) and mean body mass index (BMI) was 29.7 ± 6.4 kg/m2. The mean ESS and STOPBANG score were 9.2 ± 5.4 and 4.3 ± 1.8, respectively, and 41% patients showed high risk for OSA with Berlin questionnaire. The sensitivity for detection of OSA was highest (96.1%) with ESS and lowest with Berlin questionnaire (40.6%). The receiver operating characteristics (ROC) area under curve for ESS was 0.929 with optimum cutoff point of 4, sensitivity of 96.9%, and specificity of 55.6%, while ROC area under curve for STOPBANG was 0.918 with optimum cutoff point of 3, sensitivity of 81.2% and specificity of 88.9%.The combination of two questionnaires showed sensitivity of >90%. The sensitivity also increased with the increasing severity of OSA. AHI showed positive correlation with ESS (r = 0.618, P < 0.001) and STOPBANG (r = 0.770, P < 0.001). Conclusion: The ESS and STOPBANG showed high sensitivity with positive correlation for prediction of OSA in ILD patients. These questionnaires can be used to prioritize the patients for polysomnography (PSG) among ILD patients with suspicion of OSA.

Primary pulmonary lymphoepithelial-like carcinoma : A rare childhood malignancy.

Lymphoepithelial-like carcinoma (LELC) usually presents as a head and neck tumor with a close resemblance to nasopharyngeal carcinoma. We present an extremely rare case of Primary Pulmonary lymphoepithelioma in a 14-year-old female patient. The patient presented with a right-sided lung mass, which on biopsy revealed to be a lymphoepithelioma. There was no evidence of any mass elsewhere in the body, including the nasopharynx, as evidenced by PET CT. The IHC was positive for both cytokeratin and lymphoid cell markers. Hence, we conclude that lymphoepitheliomas can present as a primary lung mass in a young nonsmoking female, of which only two case reports are available from the Indian subcontinent till date.

Subtyping of advanced lung cancer based on PD-L1 expression, tumor histopathology and mutation burden (EGFR and KRAS): a study from North India.

Immune checkpoint inhibitor (PD-L1) therapy of advanced non-small-cell lung cancer (NSCLC) has variable outcomes. Tumor subtypes based on PD-L1 expression, histopathology, mutation burden is required for patient stratification and formulation of treatment guidelines. Lung cancers (n=57) diagnosed at Pathology department, VPCI (2018-2021) were retrospectively analyzed. PD-L1(SP263) expressed by tumor cells [low (<1%), medium (1-49%), high (≥50%)] was correlated with histopathology, microenvironment, EGFR, KRAS expression. Patients were categorized into high and low risk based on their: i) gender: males (n=47, 30-89 years), females (n=10, 45-80 years); ii) smoking history: males 26/47 (45.61%), females 1/10 (10%); iii) tumor subtyping: squamous cell carcinoma 15/57 (26.32%), adenocarcinoma 6/57 (17.54%), NSCLC-undifferentiated 24/57 (42.10%), adenosquamous carcinoma 5/57 (8.77 %), carcinosarcoma 4/57 (7.02%), small cell carcinoma 1/57 (1.75%); iv) inflammatory tumor microenvironment/TILs 44/57 (77.1%); iv) PD-L1 positivity-31/57 (54.3%); v) concomitant EGFR/KRAS positivity. PD-L1positive cases showed squamous/undifferentiated histopathology, concomitant EGFR+ (9/20, 45%) and KRAS+ (8/15, 53.3%), smoking+ (21/31,67.74%).PD-L1 negative cases (26/57, 45.6%), were EGFR+ (2/14, 14.28%) and KRAS+ (6/19, 31.5%). The high-risk lung cancer subtypes show squamous/undifferentiated histopathology, inflammatory microenvironment, male preponderance, smoking history, higher concomitant PD-L1, KRAS and EGFR positivity. Lung cancer subtyping can predict clinical response/resistance of patients prior to initiation of PD-L1 inhibitor therapies and can be used to guide therapy.

Quantification of Indoor Respirable Suspended Particulate Matters (RSPM) and Asthma in Rural Children of Delhi-NCR.

OBJECTIVES: To assess the exposure of indoor respirable suspended particulate matters (PM10, PM2.5, and PM1) and their association with asthma in children in a rural area of Delhi-NCR. METHODS: It was a cross-sectional study. Fifty children with asthma from both biomass fuel users in group A and liquefied petroleum gas (LPG) fuel users in group B households were enrolled along with 50 healthy control subjects. The diagnosis of asthma was done as per the Global Initiative for Asthma (GINA), 2014. The 24-h levels of PM from all three groups of households were measured and compared. The level of PM with confounding factors like smoking and room occupancy was also compared between the groups. RESULTS: The 24-h concentrations of PM10, PM2.5, and PM1 were found significantly higher in the households of group A and group B as opposed to group C (p < 0.001). The number of smokers with a mean pack year and a lack of an exhaust fan was highest in group A and lowest in group C, while diesel and kerosene machines were highest in group B. The PMs were highest in group A even with different confounding factor (p < 0.001). The level of all PM was higher in group B than in group C, despite the presence of both types of fuel in group C households. The level of all PM was highest during the cooking hour. CONCLUSION: The level of 24-h PM was highest in group-A households. However, the level of PM was higher in group-B households than group C despite the presence of biomass fuel users in group C. This may be due to the higher number of smokers, poor room-occupancy and lack of exhaust fans.

Spectrum of pulmonary aspergillus diseases in post TB lung diseases.

INTRODUCTION: Post-Pulmonary TB structural lung disease with cavitation and bronchiectasis favours the growth of Aspergillus. It leads to progressive lung destruction and the persistence of symptoms after successful ATT and can mimic smear-negative PTB. There is lack of prevalence study of this disease from India. Antifungal therapy is very beneficial, as it reduces both morbidity and mortality. The present study is being undertaken to study the occurrence of spectrum of PA in PTBLD. METHODS: This is a prospective observational study, conducted at one of the tertiary chest institute of India over a period of one year, after approval from institutional human ethics committee. A total of 60 patients with history of treatment for PTB were recruited. Active PTB were excluded. Diagnosis of PA in were established on the basis of clinical, radiological, microbiological and serological parameters. Based on this, the spectrum of PA viz. CPA, ABPA and IPA were established. RESULTS: The mean age was 47.88 ± 12.89 years with males being 60%. Mean duration of illness was 6.57 ± 5.11 years with mean asymptomatic period of 4.97 ± 7.41 year. Cough and breathlessness (100%) being the most common symptom followed by wheezing (58%). PA was diagnosed in 48% of cases out of which 43% cases were of CPA. The most common subtype of CPA was simple aspergilloma 14 (54%) followed by CCPA 10 (38%), 2CFPA (8%). ABPA was diagnosed in two cases of PA and one case of aspergillus sensitization. None of the case diagnosed as IPA. CONCLUSION: We found high prevalence of PA among PTBLD, especially CPA. Early recognition and treatment with antifungal has the potential to reduce the morbidity and mortality. There is a need of prospective community-based larger multicentric studies to precisely define the prevalence of these disorders.

Prevalence and Profile of Obstructive Sleep Apnea in Patients with Interstitial Lung Diseases of North India.

BACKGROUND: The OSA is commonly found in ILD with overall incidence varying from 17 to 88 %. The morbidity and mortality of OSA are high when it occurs with chronic respiratory diseases like ILD. There is lack of data on sleep breathing disorder in ILD patients from India. The present study aims is to assess the occurrence of OSA in ILD patients and its correlation with other parameters. METHOD: Prospective observational study of 41 ILD patients of one year duration. All patients underwent detailed clinical examination, radiological, laboratory investigations and Type 1 diagnostic polysomnography according to AASM guideline. The severity of OSA was defined as per AHI and the correlation of OSA with other parameters were assessed.& & Result: The mean age was 55.5±10years with 73% female. The mean BMI of 28.8±6.5 kg/m2 with dyspnea and cough were the common symptoms. The most common type of ILD was HP (46.3%). The common HRCT findings were GGO (82.9%), and fibrosis (65.9%). The OSA was seen in 32(78%) patients with 24 females. The AHI showed significant positive correlation with BMI (p=0.000, r= 0.535) and ODI (p=0.000, r=0.725), while negative correlation with FEV1 /FVC% (p=0.007, r= -0.417). CONCLUSION: The prevalence of OSA is common in north Indian ILD patients. Polysomnography should be done in all the patients with ILD whenever feasible for early diagnosis and treatment of OSA, as the coexisting of both will further decrease quality of life and increase morbidity in this chronic progressive lung disease.

Asthma phenotype: Clinical, physiological, and biochemical profiles of North Indian patients.

Background and Objectives: Asthma is a common, chronic and heterogeneous disease with various phenotypes. The clinical phenotypes has aided in revealing the genetic heterogeneity, provide education, life style advice and novel biological treatments. The few common factors associated with phenotypes are smoking, rhinitis and obesity. The present study was thus planned to analyse and correlate the clinical, physiological, biochemical and serological parameters of asthma and to study the phenotypic characteristics in different asthmatic. Methods: This was a prospective observational study of 120 patients with 30 each in BA-rhinitis, BA, BA-obesity and BA smoker phenotypes. All the enrolled patients were assessed by SGRQ, Mini-AQLQ, GINA with ACE, chest X ray, Spirometry, SPT against common aero-allergens, FENO, hsCRP, vitamin-D, IgE, and Interleukins (IL) including IL-5, IL-6, IL-8, IL-13, IL-17 and IL-33. The mentioned profiles of each phenotype correlated and characterized among different phenotypes. Results: The majority of patients 78(65%) were female with mean BMI of 24.07±4.73kg/m2. Majority of the patient in BA and BA-rhinitis phenotype are in mild severity and young compared to majority in BA-obesity and BA-smoker are moderate to severe severity with older. (p<0.001) The SPT and FENO level were highest among BA-rhinitis phenotype with significant difference among phenotypes. (p<0.001) Similarly the most of inflammatory markers were significantly different in various phenotypes. The FEV1 showed correlation with most of parameters with statistically significant correlation with IL-5, IL-8 and FENO. Conclusion: The majority of parameters were significantly different among various phenotypes. We advise to phenotypic classification of asthma whenever possible for better management and quality of life.

Cockroach exposure and its allergy sensitization in asthma patients.

Asthma is a heterogeneous disease with distinct phenotypes. Serum tIgE, SSIgE and SPT are the methods of evaluating allergen sensitization. The present study evaluates the exposure and sensitization to cockroach (Periplaneta americana) antigens in asthma patients in a metropolitan city of India. The study enrolled 200 consecutive bronchial asthma patients, diagnosed as per GINA guidelines. As per history of exposure to cockroaches, the patients are divided in two groups as exposed and non-exposed asthmatic. All the enrolled subjects underwent SPT against common aeroallergens including cockroach, spirometry and estimation of tIgE level and SSIgE against cockroach. Out of 200 asthma patients, a total of 114 (57%) asthmatic were found SPT positive against one of the common aeroallergens, of which 68 (34%) showed SPT sensitivity against cockroach. A total of 103 (51.5%) patients were found exposed to cockroaches. In the cockroach exposed group, the mean serum tIgE was found significantly higher than the non-exposed group (569.31±224.64 vs 479.29±237 IU/ml; p=0.007). The mean SSIgE against cockroach in exposed groups was found not significant than non-expose group (4.87±11.19 vs 4.11±8.39 KUA/L; p=0.589). The mean tIgE was also not significant in atopic compared to non-atopic asthmatic (553.25±218.12 IU/ml vs 489.1±251.16 IU/ml; p=0.056). The mean SSIgE against cockroach was 5.66±10.45 KUA/L for atopic and 2.96±8.98 KUA/L for non-atopic (p=0.054). The airway obstruction was almost the same in both groups.  Asthmatic patients who were exposed to cockroach and atopic had high tIgE, SSIgE levels and SPT positivity against cockroach antigen compared to non-exposed patients.

Expression profile of MUC1 protein in Pigeon allergens positive asthmatic.

BACKGROUND: Certain urban areas could contain many pigeon's allergens, which may play an imperative role in the exacerbation of asthma in pigeon allergen sensitive asthma patients. The circulating form of MUC1 in human serum has been considered as a biomarker for some allergic diseases. The study aimed to investigate the role of MUC1 in pigeon allergens positive asthma patients. METHODS: We were enrolled 200 asthma patients including 81 males and 119 females. After positive pigeon exposure history, 108 patients underwent SPT testing against pigeon allergens (dropping and feather). A total of 17 patients, who had exposure history with SPT positive were undergone detail clinical examination. Serum MUC1expression analysis was done by western blotting method. RESULTS: Out of 200 asthmatic patients, 108 (54%) patients had a history of exposure to pigeons. Skin prick test against pigeon (feather & dropping) allergens was positive in 17 (15.7%) patients among exposure asthmatics. The mean age of the study population was 28.8 ± 10.4 years with 9 males and 8 females. Baseline airway obstruction was seen in 58.8% cases. Out of 17 pigeons expose and sensitive asthmatic the MUC1 expression was up-regulated in 15 (88.2%) and down-regulated in 2 (11.8%). The mean value MUC1 fold change of 15 patients with up-regulation was 4.63 ± 3.00 fold. CONCLUSION: MUC1 expression was up-regulated in 88.2% of patients, who were exposed and sensitive to pigeon allergen (dropping and feather). MUC1 may consider as a biomarker in pigeon sensitive asthma patients.

Pulmonary sarcoidosis presenting as hoarseness and mass lesion.

A 46-year male, ex-smoker presented with cough and hoarseness for 2-3 months. The CECT chest revealed a left upper lobe mass. BAL was negative for AFB, GeneXpert, and malignant cells. The bronchial biopsy showed granuloma with no caseation and infiltration of lymphoid cells. The ultrasound abdomen was normal. The patient was started on prednisolone 0.5 mg/kg. He improved clinic-radiologically. Ex-smoker, middle-aged man with hoarseness and mass lesion on CECT chest is highly suspicious of lung malignancy. Pulmonary sarcoidosis should be kept in the differential diagnosis of unexplained hoarseness and mass lesion as the disease has diverse presentations.

Uncontrolled diabetes mellitus: A risk factor for post COVID fibrosis.

Dear Editor, The Corona virus disease (COVID-19) caused by severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) emerged in the Wuhan province of china in December 2019. COVID-19 spread to the world in a short time and was declared as public health emergency of international concern by World Health Organization...

Isolated Pulmonary Cysticercosis Presenting as Mass Lesion.

We report a case of pulmonary cysticercosis manifesting as a mass lesion. Cysticercosis confined to lungs is a rare manifestation of human cysticercosis. The disease mainly affects the central nervous system, skeletal muscles, and eyes. Pulmonary involvement is rare and usually presents as bilateral pulmonary nodules. The diagnosis was made based on positive enzyme-linked immunosorbent assay (ELISA) for anticysticercal antibodies, and the patient was started on antiparasitic therapy along with steroids. Symptomatic and radiological improvement was seen. There is no previous case report of isolated pulmonary cysticercosis presenting as mass lesion.

Characteristics of COVID-19 at a non-COVID tertiary pulmonary care centre in Delhi, India.

The pandemic of COVID-19 has emerged as a serious health crisis globally and India too has been extensively affected with 604,641 active cases reported, till date. The present study focuses on the demographic, clinical and laboratory profile of such patients from a tertiary level non-COVID respiratory care hospital. This is a retrospective observational study. Seventy-seven sick patients fulfilling COVID suspect criteria were admitted to the isolation area. Their RT-PCR test was done from the designated laboratory and 35 of them  were confirmed to be COVID-19 patients. The detailed demographic, clinical and laboratory profile of these COVID-19 patients was studied. The mean age was 46±17 years with male predominance (57%). Majority  of the cases (83%) were symptomatic. The most common symptom was cough (66%) followed by breathlessness and fever. Nineteen (54.3%) patients had one or the other co-morbidity and 16 (45.7%) had chronic lung diseases as one of the comorbidities. Nearly half of the patients (51%) required supplementary oxygen on presentation. Two patients were put on invasive mechanical ventilation while 4 patients required non-invasive ventilation before being shifted to the COVID hospital. Hence, it can be concluded that COVID-19 in patients of chronic respiratory diseases  manifests with higher prevalence of symptoms and also higher severity of disease. Further, the  symptomatology of COVID-19 closely mimics the acute exacerbation of chronic lung diseases, so cautious screening and testing should be done, especially at the pulmonary department.

Hypersensitivity pneumonitis: clinical, radiological and pathological profile of 103 patients from North India.

Hypersensitivity pneumonitis (HP) is an interstitial lung disease, commonly occurring due to exposure to various inciting agent related to occupation. Few studies have shown that it can also occur without any occupation exposure. In this study we are presenting clinical, radiological and bronchoscopic finding of 103 HP patients. We retrospective analysis of 5½ years HP patient's data from a chest institute of India. The diagnosis of HP was considered with following criteria: i) known exposure to an inciting antigen; ii) presence of respiratory symptoms; iii) radiologic evidence of diffuse lung disease; iv) no other identifiable cause; v) lung biopsy specimen that demonstrated features of HP; and vi) bronchoalveolar lavage lymphocytosis (≥30%). The mean ±SD age was 47±12.8 years; 67% were female. The common symptoms were cough (97%) and dyspnea (91%). History of exposure to inciting agent was present in 61% with pigeon exposure being the most common (56%). Majority of patients (86%) were having chronic symptoms for >6 months. On 6MWT oxygen desaturation >4% was seen in 57% patients. Centrilobular nodules (61%) and ground glass opacity (47.5%) were common finding on HRCT chest. Bronchoalveolar lavage (BAL) lymphocytosis >30% was present in 48.5% and histopathological diagnosis HP on transbronchial lung biopsy (TBLB) and/or endobronchial lung biopsy (EBLB) was in 50% patients. HP is exposure related environmental disease, as it can occur without any occupational history. Bronchoscopy with BAL and lung biopsy should do in all suspected cases to confirm diagnosis in our country as it is less invasive, day care procedure with less complication.