Palliative Care in Drug Resistance Tuberculosis: An Overlooked Component in Management.

Palliative care should be an important component in the management of drug resistant tuberculosis (DRTB); however, it is not given much importance. Even in the current scenario, many patients and their caregivers consider multidrug-resistant and extensively drug-resistant tuberculosis (TB) as a terminal illness and considering it almost as a death sentence, this group of patients also require palliative care. There is a misconception about considering palliative care as a treatment component in the terminal stage of an illness where curative treatment has no role in improving the survival of the patient. However, the real meaning of palliative care is to relieve suffering in all stages of the disease and is not limited to end-of-life care only. Palliative care in DRTB aims to improve the quality of life, intractable symptoms and physical, psychosocial and spiritual suffering of patients as well as their caregivers. There is an imminent need to train all TB healthcare workers regarding basic palliative care and integrate palliative care into the TB healthcare system.

Paradoxical reaction in peripheral lymph node tuberculosis: a review for its prevalence, clinical characteristics, and possible treatment.

The paradoxical reaction (PR) is a transient worsening following tuberculosis treatment and it is not uncommon in lymph node tuberculosis (LNTB). PR in LNTB maybe  wrongly considered as treatment failure or relapse. This review was undertaken to address various aspects of PR associated with lymph node tuberculosis prevalence, underlying mechanism, clinical pattern, predictors, and possible treatment in an immunocompetent individual. A literature review was performed using various databases (PubMed, Scopus, Science Direct, and Google Scholar) to identify relevant articles for review. The prevalence of paradoxical reactions associated with LNTB varies from as low as 13.3% to as high as 35.3%  PR may occur during antitubercular treatment or be reported even after completion of treatment called post-therapy PR. An onset of PR may occur within a month of therapy to even 12 months from the initiation of an anti-tubercular drug. Delayed hypersensitivity reaction and reduction in immune suppression is believed to be possible mechanism leading to a paradoxical reaction. PR in LNTB is characterized by either progression of pre-existing nodal enlargement or formation of abscess, sinus formation, or appearance of new nodal enlargement or rarely extra-nodal involvement. PR is a diagnosis of exclusion and may show granuloma, positive AFB smear, or positive GeneXpert but AFB culture is always negative. Younger age, lymph node size of equal to or more than 3 cm, female gender, unilateral lymphadenopathy, and those with positive AFB on initial examination are predictors for PR in peripheral LNTB. The majority of PR in LNTB have a mild course and are generally self-limited.

Sarcoidosis present as endobronchial lung mass: A rare case report with review of literature.

Sarcoidosis is a multisystem granulomatous disorder of unknown etiology, primarily affecting the intrathoracic lymph node and the lung. The endobronchial involvement in sarcoidosis is not uncommon and may appear as nodules, cobblestoning, erythema, or plaque, but presentation as an endobronchial mass has been rarely described. We report here a 50-year-old gentleman who presented with nonproductive cough and dyspnea on exertion. Video bronchoscopy revealed a polypoid mass in the right lower lobe bronchus occluding the posterior basal segment, and bronchial biopsy revealed noncaseating granulomatous inflammation. Bronchoalveolar lavage (BAL) fluid was negative for tuberculosis, fungal infection, and malignancy. Mantoux test was negative, and serum angiotensin-converting enzyme was elevated. The diagnosis of sarcoidosis was made, and the patient was started on an oral corticosteroid. After treatment, the patient showed significant improvement in symptoms. This case report highlights a rare presentation of sarcoidosis as an endobronchial mass lesion. It is important to take a biopsy to differentiate from other common causes of endobronchial mass, such as malignancy and, rarely, tuberculosis. Sarcoidosis should be considered in a differential of the endobronchial mass lesion.

Clinical characteristics, treatment outcomes and factors associated with severe illness in 813 COVID-19 patients admitted in a tertiary care hospital of eastern India.

INTRODUCTION: This retrospective observational study has been designed to identify clinical characteristics, treatment outcomes and factors associated with severe illness in 813 COVID-19 patients hospitalised in an Indian tertiary care hospital. MATERIAL AND METHODS: This was a retrospective analysis of patient admitted between 1st July to 15th Aug 2020 with COVID-19 infections. Logistic regression was performed to explore the association of clinical characteristics and laboratory parameters with the risk of severe disease and mortality. The statistical significance level was set at 0.05 (two-tailed). RESULTS: Out of 813 study patients, 630 (77.50%) patients were categorised with mild to moderate while 183 (22.50%) patients as severe Covid infection. Mortality was significantly higher in severe Covid patients as compared to mild moderate cases (66.21% vs. 10.31%. p<0.0001. Patients with severe infection were significantly more likely to have diabetes hypertension, chronic kidney disease (CKD) and had significantly higher Neutrophil count, serum creatinine, C-reactive protein (CRP), ferritin, D-Dimer and decreased haemoglobin, lymphocyte and serum calcium than patients with mild-moderate infection. In Multivariate analy-sis, age more than 60 years [AOR: 2.114, 95% CI (1.05-4.254), 0.036], NLR more than 3.3 [AOR: 1.082, 95% CI (1.030-1.137), 0.002] and D-Dimer >1 µg/mL [AOR: 2.999 (1.464- 6.146),0.003] were found significantly associated with severe disease (p < 0.05). Factors associated with mortality were age more than 60 years, presence of breathlessness, severe disease or presence of chronic kidney disease. CONCLUSIONS: Factors like elderly age (age > 60 years), elevated NRL, CRP, D-Dimer and serum ferritin were associated with sig-nificantly higher risk to develop severe COVID-19 infections. Elderly, and patients with CKD were associated with worse outcome.

Study to assess aetiology, clinical and imaging characteristics of post Covid-19 pulmonary cavitation.

Objective: The aim of this study is to determine the aetiology and characteristics of pulmonary cavities that developed in patients recovering from COVID-19 infection. Materials and Methods: Between 1st May 2021 and 30st June 2021, we found 9 post COVID-19 patients who developed lung cavities on chest radiograph or CT during the follow-up period. These patients underwent routine blood examination, sputum examination and bronchoscopy to identify the aetiologies for the lung cavities. Results: The duration from the onset of COVID-19 symptoms to the detection of lung cavities ranged from 18 to 82 days. Out of 7 patients, 4 had recovered from severe COVID-19 disease, 2 from moderate and 1 from mild disease. After the diagnostic workup, 5 patients were found to have COVID-19 associated pulmonary aspergillosis (CAPA), 1 patient with mucormycosis and 1 patient with mycobacterium infection. Two patients with CAPA also had bacterial infection; sputum culture from both these patients grew Klebsiella pneumonia. Conclusion: Lung cavities can develop in patients recovering from COVID-19 pneumonia and fungal infection is the most common cause for such cavities.

Interim Analysis of Impact of Adding Low Dose Pulmonary Radiotherapy to Moderate COVID-19 Pneumonia Patients: IMpaCt-RT Study.

Background: Treatment for coronavirus disease 2019 (COVID-19) pneumonia remains largely supportive till date and multiple clinical trials took place within the short span of time to evaluate the role of investigational therapies. The anti-inflammatory effect of low dose whole lung radiation in treating pneumonia has been documented earlier. This clinical trial analyzed the effect of low dose radiation therapy (LDRT) in a moderately affected COVID-19 pneumonia patient cohort and has evaluated its effect in stopping the conversion of moderate disease into severe disease. Methods: Patients with moderate COVID-19 pneumonia as characterized by the Ministry of Health and Family Welfare (MOHFW), Government of India, were randomized (1:1) to low dose whole lung radiation versus no radiation. All treatment of patients was concurrently being given as per institutional protocol. Patients were followed up with clinical and laboratory parameters monitored on Days 1, 3, 7, and 14. Computed tomography scan (CT scan) of thorax was performed on Days 1 and 7. Patients were evaluated for conversion of moderate into severe disease as per National Early Warning Score-2 (NEWS-2 score) as the primary end point. The secondary endpoints included changes in ratio between peripheral capillary oxygen saturation and fraction of inspired oxygen (SpO2/FiO2), biochemical markers, 25-point CT severity score, and radiation induced acute pulmonary toxicities. Findings: At the interim analysis, there were seven patients in the radiation arm and six in the control. A whole lung LDRT improved the outcome of SpO2/FiO2 at Day 3; however it did not convert into a statistically significant improvement for the NEWS-2 score. The serum levels of LDH, CRP, Ferritin and D-dimer were significantly reduced on 14 days in the LDRT arm in comparison to the baseline value but were not significant between the two groups. Interpretation: LDRT seems to have the potential to prevent moderate COVID-19 pneumonia from a deteriorating to severe category. However, further randomized clinical trial with an adequate number of such patients is warranted to establish the definitive role of LDRT in the management of COVID-19 pneumonia. Funding: An intramural research project bearing code: I-27/621, was sanctioned from the All India Institute of Medical Sciences, Patna, India. Clinical Trial Registration: Clinical Trials Registry-India (CTRI/2021/06/033912, 25th May 2021) ctri.nic.in/Clinicaltrials/login.php.

Six-month Morbidity and Mortality in Patients after Recovery from COVID-19.

Background: This telephonic survey was aimed to identify the proportion of coronavirus disease-2019 (COVID-19) patients who died from any cause, within 6 months of discharge from a tertiary COVID-19 care hospital. We also analyzed whether any clinical and/or laboratory variables were associated with post-discharge mortality. Materials and methods: All adult patients (age ≥18 years) who had been discharged during the period between July 2020 and August 2020 from a tertiary COVID-19-care hospital after initial hospitalization for COVID-19 were included. A telephonic interview was conducted 6 months after discharge to assess morbidity and mortality in these patients. Results: Out of the 457 patients who responded, 79 patients (17.21%) were symptomatic, and breathlessness was found as most common symptom (6.12%). Fatigue was noted in (5.93%) of study patients, followed by cough (4.59%), sleep disturbances (4.37%), and headache (2.62%). Of the 457 patients who responded, 42 patients (9.19%) required expert medical consultation for their persistent symptoms. Thirty-six patients (7.88%) required re-hospitalization for post-COVID-19 complications within 6 months of discharge. A total of 10 patients (2.18%) succumbed within 6 months of their discharge from the hospital. 6 patients were males and 4 females. Most of these patients (7/10) succumbed in the second month after discharge. Seven patients had moderate-to-severe COVID-19 disease and most of these (7/10) had not been treated in the intensive care unit (ICU). Conclusion: Post-COVID-19 mortality figures were not very high in our survey despite the high perceived risk of thromboembolic events after recovery from COVID-19. A significant proportion of patients reported persistent post-COVID-19 symptoms. Breathing difficulty was the most common symptom noted by us, closely followed by fatigue. How to cite this article: Rai DK, Sahay N. Six-month Morbidity and Mortality in Patients after Recovery from COVID-19. Indian J Crit Care Med 2022;26(11):1179-1183.

A rare case of sclerosing hemangioma of the lung with a review of literature.

A rare case of sclerosing hemangioma (SH) of the lung is described in a 23-year-old gentleman, who presented with cough with expectoration, breathlessness, and left-sided chest pain with recurrence. We present a brief review of SH, an uncommon but histologically distinctive neoplasm of the lung. SH of the lung is generally considered to be a benign lesion, and surgical excision is curative without the need for additional treatment.

Evaluation of Ivermectin as a Potential Treatment for Mild to Moderate COVID-19: A Double-Blind Randomized Placebo Controlled Trial in Eastern India.

BACKGROUND: There has been a growing interest in ivermectin ever since it was reported to have an in-vitro activity against severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). This trial was conducted to test the efficacy of ivermectin in mild and moderate coronavirus disease 19 (COVID-19). METHODS: A double blind, parallel, randomised, placebo-controlled trial conducted among adult COVID-19 patients with mild to moderate disease severity on admission in a COVID dedicated tertiary healthcare of eastern India. Enrolment was done between 1st August and 31st October 2020.  On day 1 and 2 post enrolment, patients in the intervention arm received ivermectin 12 mg while the patients in the non-interventional arm received placebo tablets. RESULTS: About one-fourth (23.6%) of the patients in the intervention arm and one-third (31.6%) in the placebo arm were tested reverse transcriptase polymerase chain reaction (RTPCR) negative for SARS-CoV-2 on 6th day. Although this difference was found to be statistically insignificant [rate ratio (RR): 0.8; 95% confidence interval (CI): 0.4-1.4; p=0.348]. All patients in the ivermectin group were successfully discharged. In comparison the same for the placebo group was observed to be 93%. This difference was found to be statistically significant (RR: 1.1; 95% CI; 1.0-1.2; p=0.045). CONCLUSIONS: Inclusion of ivermectin in treatment regimen of mild to moderate COVID-19 patients could not be said with certainty based on our study results as it had shown only marginal benefit in successful discharge from the hospital with no other observed benefits.

Post covid 19 pulmonary fibrosis. Is it real threat?

After the COVID-19 outbreak, increasing number of patients worldwide who have survived COVID-19 continue to battle the symptoms of the illness, long after they have been clinically tested negative for the disease. As we battle through this pandemic, the challenging part is to manage COVID-19 sequelae which may vary from fatigue and body aches to lung fibrosis. This review addresses underlying mechanism, risk factors, course of disease and treatment option for post covid pulmonary fibrosis. Elderly patient who require ICU care and mechanical ventilation are at the highest risk to develop lung fibrosis. Currently, no fully proven options are available for the treatment of post inflammatory COVID 19 pulmonary fibrosis.

Sarcomatoid carcinoma of the lung.

Sarcomatoid carcinoma (SC) of the lung is a rare histological subtype of nonsmall cell lung cancer and comprises a diagnostically and therapeutically challenging group of tumors. We report a patient of SC of the lung in an elderly patient who presented with a lung mass. Computed tomography-guided biopsy of the lung mass was done, which clinched the diagnosis. We present this case because of the rarity of this histological subtype and to expand understanding regarding this rare cancer.

Diagnostic yield of semi rigid thoracoscopy in unexplained exudative pleural effusion- Experience from tertiary care hospital of east India.

INTRODUCTION: In most of the pleural effusion, fluid analysis generally gives the etiological diagnosis but in almost 20% it remains unclear. This study was designed to determine the diagnostic yield of a pleural biopsy using semi rigid thoracoscope and its complication rates. MATERIALS AND METHODS: This was a retrospective observational study conducted in the Department of Pulmonary Medicine, AIIMS Patna. All the patients diagnosed as unexplained pleural effusion between Jan 2018 and December 2019 were included in the study. RESULTS: Total 76 out of 97 patients with unexplained exudative pleural effusion underwent medical thoracoscopy in the given period of 2 years. The mean age of the patients was 57.63 years. There were 46 males and 30 females. 38 patients (50%) had right-sided pleural effusion. More than half (52.6%) of study patients were on Anti-tubercular treatment in which only 11.84% had tuberculosis. In both unilateral and bilateral pleural effusion, the proportions of small, moderate, and large size of pleural effusions were 10.52, 42.10, and 47.36%, respectively. Thoracoscopy yielded a definitive diagnosis in 66 out of 76 patients (86.84%), and in 10 patients (13.15%), biopsy was inconclusive. Of 76 patients, malignancy was confirmed in 58 (76.31%), and tuberculosis in 8 (11.84%) patients CONCLUSION: This study concludes that, medical thoracoscopy with semi-rigid thoracoscope is an invaluable tool in the diagnosis of patients with unexplained exudative pleural effusion. It is a very simple and safe method with high diagnostic yield and associated with few complications. Malignancy was found to be the most common cause of unexplained exudative pleural effusion.