A review of the efficacy and safety of fluticasone propionate/formoterol fixed-dose combination.

INTRODUCTION: Fluticasone propionate/formoterol fumarate (FP/FORM) is one of the newer combinations among inhaled corticosteroid (ICS) and long-acting ß2-agonist (LABA) combination formulations currently available. To evaluate the efficacy and safety of this FP/FORM combination, it is important to review all the available evidence and take a comprehensive look at the current and relevant data in the patient population suffering from asthma and chronic obstructive pulmonary disease (COPD). AREAS COVERED: In this focused review, we summarize the available literature published until January 2021 using the PubMed/Medline and Cochrane Controlled Trials Register databases on the efficacy and safety of FP/FORM with its mono-components; concurrent administration of FP+FORM; and with other ICS/LABA combinations in asthma and COPD patients. EXPERT OPINION: FP/FORM combination therapy is a strong alternative in the treatment of persistent asthma and moderate-severe COPD. Extensive study of several trials has established the superior efficacy of FP/FORM combination therapy over FP or FORM monotherapy, comparable efficacy with FP+FORM and non-inferiority to other ICS/LABA fixed-dose combinations. The safety profile of FP/FORM has also been found to be comparable with respect to its mono-components and their concurrent use, and also other ICS/LABA combinations such as formoterol/budesonide and fluticasone/salmeterol.

Challenges of diagnosing and treating non-tuberculous mycobacterial pulmonary disease [NTM-PD]: A case series.

Non-tuberculous mycobacterial pulmonary disease (NTM-PD) may simulate Pulmonary Tuberculosis (PTB) in its clinical and radiological expression posing a diagnostic dilemma and challenge to the treating physician, especially in high TB prevalent countries. Though recent emerging data indicates inter-human transmission, infection with non-tuberculous mycobacteria (NTM) is commonly acquired from the environmental sources [1]. NTM can produce disease not only in immunocompromised populations but also in healthy individuals leading to significant morbidity and mortality [2]. Unlike PTB, NTM-PD is usually difficult to confirm and speciate in resource limited clinical settings and high TB endemic countries due to non-availability, poor accessibility and affordability to a specific culture facility. Apart from diagnostic challenges, adverse drug effects with treatment leading to non-adherence are another vexing problem. We present here case descriptions of four patients of NTM-PD, confirmed by culture isolates, one was a rapid grower and the other three were slow growers. All four patients were treated with available guideline-based treatment protocols and followed up.

Tuberculous mediastinal lymphadenopathy presenting with left vocal cord palsy: A rare entity.

A 23-year-old-male student, never-smoker presented to our hospital outpatient department with complaints of loss of appetite, unintentional weight loss, fatigue and low-grade fever for two months, hoarseness of voice (HOV) for two weeks. He was evaluated for HOV with video laryngoscopy which demonstrated left vocal cord palsy. Contrast enhanced CT Chest (CECT) was performed for evaluation of mediastinal lesions which revealed multiple peripheral enhancing conglomerate mediastinal lymph nodes. EBUS-trans bronchial needle aspiration (TBNA) and endobronchial biopsy were performed and specimens sent for smear and culture for AFB, Xpert MTB/RIF assay and histopathology. Results were consistent with Mycobacterium tuberculosis (MTB) infection and culture was positive for M. tuberculosis complex. Patient had been started on anti tubercular therapy (ATT) and during his 4th month follow up he showed clinicoradiological improvement without recovery of recurrent laryngeal nerve palsy.

Role of Xpert MTB/RIF in Bronchoalveolar lavage fluid of sputum-scarce, suspected Pulmonary TB patients.

SETTING: A prospective observational study conducted in Medical college hospital, in a high-TB- prevalence region of northern Telangana, India. OBJECTIVE: To know the diagnostic role of Xpert MTB/RIF assay in bronchoalveolar lavage fluid (BALF) in sputum-scarce, suspected pulmonary tuberculosis (PTB) patients. DESIGN: Study period was between October 2014 and March 2017. Suspected pulmonary tuberculosis patients aged 15 years or more, who were sputum-scarce and conforming to the inclusion criteria were submitted to bronchoscopy. BALF thus obtained was submitted to smear for acid fast bacilli (AFB) and Xpert MTB/RIF assay as index tests along with culture for Mycobacterium tuberculosis complex (MTBC). Culture for M. tuberculosis complex was considered as gold standard for the diagnosis of PTB. The sensitivity, specificity and predictive values were calculated for smear AFB and Xpert MTB/RIF assay. RESULTS: 56 of the 81 patients were included and evaluated in the final analysis. In 10 of these 56 patients PTB was confirmed by culture positivity. The sensitivity and specificity of Xpert MTB/RIF assay was 90% (9/10,95%CI 59.6- 98.2) and 52.2% (24/46, 95%CI 38. 1-65.9) respectively and that of the smear AFB was 60% (6/10, 95%CI 31.2-83.1) and 67.4% (31/46, 95%CI 53.0-79.1). All the patients considered 'probable' PTB (pending culture results), were administered antituberculous treatment and showed complete clinicoradiological improvement on follow up. Three of the 31 Xpert MTB/RIF positive patients were detected as resistance to rifampicin (RR). CONCLUSIONS: Xpert MTB/RIF assay of BALF in the study cohort provides rapid diagnosis of Mycobacterium tuberculosis, and detection of rifampicin resistance at the very outset, aiding in selection of appropriate ATT regimen. In this context, it can be recommended as the first line investigation. Xpert MTB/RIF assay aided by HRCT Chest and suggestive clinical presentation may be helpful in early institution of ATT especially in smear negative, culture negative cases.

Focal organizing pneumonia simulating lung malignancy: treated with prednisolone.

Focal cryptogenic organizing pneumonia (FOP) is a localized form of cryptogenic organizing pneumonia (COP). It is an uncommon clinicopathological entity associated with non-specific symptoms and radiographic findings simulating lung malignancy. Incidence of idiopathic FOP is not known and only reported as case series. Its treatment usually involved surgical resection. Here, we report a case of a 62-year-old female presenting with a history of dyspnoea, persistent paroxysms of dry cough, and low-grade fever of three weeks duration with a solitary consolidation on imaging. Computed tomography-guided biopsy showed an organizing pneumonia pattern. A therapeutic trial with prednisolone resulted in resolution without the need for surgical resection, without recurrence after follow-up for 12 months.

Active pulmonary tuberculosis presenting with acute respiratory failure.

Four patients with active pulmonary tuberculosis (PTB) presenting with respiratory failure are reported here. Bronchogenic PTB, simulating an acute febrile illness or diffuse interstitial lung disease with short duration of symptoms, as a cause of acute respiratory failure is less recognized. If diagnosed and treated early, it has good prognosis. Three of the four patients presented here had an acute presentation with fever, dyspnoea, and hypoxemia with diffuse infiltrative lesions on radiography, and the other younger patient presented predominantly with lobar consolidation. These patients presenting with respiratory failure required intensive care management, and a diagnosis was made with bronchoalveolar lavage fluid and transbronchial lung biopsy. All four patients promptly received antitubercular therapy, showed clinicoradiological improvement, and were stable at 1 year follow up.

Massive hemoptysis from Rasmussen's aneurysm in active pulmonary tuberculosis; A case report of successful treatment with bronchial artery embolization.

Rasmussen's aneurysm, a very rare complication of active pulmonary tuberculosis (TB), is a pulmonary artery aneurysm adjacent to or within a tuberculous cavity. It may lead to rupture and life threatening massive hemoptysis, an uncommon but challenging medico-surgical emergency. This complication warrants attention in view of the resurgence of tuberculosis and increasing occurrence of multi-drug resistant TB, especially in resource-poor, high-TB burden countries like India. We present a case of an elderly man who presented to the emergency room with low-grade fever, cough and hemoptysis. Thoracic Multidetector row Computed Tomographic Angiography (MDCTA) showed left upper lobe consolidation with thick walled cavitary lesions and aneurysm along the apical segmental branch of left upper lobar pulmonary artery. Hemoptysis was successfully controlled with systemic artery embolization using polyvinyl alcohol (PVA) particles. He was treated with antitubercular chemotherapy and was followed for more than a year without further recurrence of hemoptysis.

Nasal application of petrolatum ointment - A silent cause of exogenous lipoid pneumonia: Successfully treated with prednisolone.

We report a case of exogenous lipoid pneumonia from chronic, extranasal use of petrolatum ointment (Vicks VapoRub in this case) for nasal decongestion in a young woman, presenting with cough, dyspnea and fever. Exogenous Lipoid pneumonia is a rare condition, underdiagnosed and is more prevalent in adults. Usually asymptomatic and diagnosed while evaluating predisposed patients who become clinically unstable or an abnormal lung shadow or during evaluation of rhinobronchial allergy. It is rarely reported from chronic use of petrolatum ointment extranasally and was diagnosed by transbronchial biopsy in the present case. She was found, retrospectively, to have been using petrolatum ointment, as an extranasal application since more than a year at bedtime. She didn't give history of using any other oil-based nasal topical vasoconstrictor preparations for sinusitis. Our patient was managed with discontinuation of further use of the petrolatum ointment and treatment with prednisolone apart from her regular treatment for chronic rhinobronchial allergy. Patient is stable without any further radiological deterioration during follow-up of one year.