Obstructive Sleep Apnoea Syndrome and Association of AHI Scores with Sensorineural Hearing Loss: An Early Predictor.

Obstructive sleep apnoea syndrome (OSAS) is a condition that is characterised by frequent apnoea and hypopnoea attacks occurring during sleep. The blood supply to cochlea and acoustic nerves is from terminal arteries, thereby making them susceptible to hypoxia. To compare the audiological profiles in patients with OSAS according to Apnoea Hypopnoea index (AHI) score. Descriptive study was conducted in 32 patients diagnosed to have OSAS in a tertiary referral centre over two year period. The study group was divided into mild, moderate, severe OSAS based on AHI score. The hearing evaluation was done using pure tone audiogram (PTA) and distortion product otoacoustic emission test (DPOAE). Moderate and severe OSAS participants had elevated thresholds at higher frequencies in PTA (4 kHz, 8 kHz), although this was not statistically significant. We also noticed, absent DPOAE responses at higher frequencies (4 k, 6 k, 8 k), with increase in the severity of OSAS at higher frequency, which was statistically significant (p value < 0.05). This study revealed elevated hearing thresholds at higher frequencies (4 kHz, 8 kHz) in PTA and DPOEA with an increase in the severity of OSAS. All OSAS patients, especially with AHI > 30 should be regularly screened for hearing loss.

Constrictive Pericarditis-A Cloak Camouflaging Lymphoma.

Non-Hodgkin's lymphoma presenting as a primary cardiac lymphoma (PCL) is extremely unusual. Having a predilection for the right side of the heart and accounting for 1% of all cardiac tumours, the difficulty in diagnosing the lesion, owing to the location and vague presenting symptoms and signs, often leads to delayed diagnosis and poor prognosis. In our case report, a middle-aged male was diagnosed with PCL presenting as pyrexia of unknown origin with the help of F18-fluorodeoxyglucose positron emission tomography (18 FDG-PET). PET-CT is an invaluable tool in patients with pyrexia of unknown origin (PUO), especially caused by neoplasms as it helps in localizing the target lesion, aiding in selecting the appropriate intervention for rapid tissue diagnosis. This case serves to sensitize the physicians of PCL presenting with PUO and mimicking a relatively common cardiac tumour such as atrial myxoma.

Shine like gold and sparkle like glitter: Three cases of lipoid pneumonia.

Lipoid pneumonia (LP) is an unwonted, mostly asymptomatic entity which has no classical radiological appearance. It can be endogenous or exogenous depending upon the type of exposure or underlying milieu. It simulates a number of infective and malignant respiratory conditions and can go undiagnosed or delayed leading to morbidity and mortality. We put forward three cases that initially presented as classical pneumonia, but on further assessment and investigations were diagnosed to be LP. All the three cases manifested with symptoms of fever, productive cough and breathlessness. Chest Xray and CT scan were indicative of consolidation. Bronchoalveolar lavage (BAL) evinced lipid laden macrophages that stained positive with fat stains (Sudan IV and Oil Red O). Two cases were endogenous and one was exogenous type. LP, owing to its nonspecific clinical presentation and radiographic signs, needs a high index of suspicion, and a detailed clinical history for accurate diagnosis. Corroboration of lipid laden alveolar macrophages in BAL is the crux to the diagnosis. Hence, clinicians should be cognizant of this condition and rule out LP in cases of non-resolving pneumonia in an appropriate clinical context.

Comorbidities of Chronic Obstructive Pulmonary Disease and Their Affect on Hospitalization of Patients in a Tertiary Care Hospital.

Introduction: COPD is an obstructive airway disease with significant systemic comorbidities that affect hospitalization and the overall severity of the disease. The aim of the study was to assess the prevalence of comorbidities and their effect on the hospitalization of COPD patients. Methods: The study was a cross-sectional study conducted in 2013 among patients of a tertiary care hospital. The sample size was 106. Inclusion criteria were diagnosed patients of COPD according to GOLD criteria. Patients were diagnosed with COPD based on GOLD criteria guidelines and evaluated for various comorbidities based on presenting complaints. Variables collected were the number and kind of diagnosed comorbidities, the average number of hospitalizations per year. The prevalence of each comorbidity was found out and the chi-square test (p < 0.05) was used to find out the correlation between hospitalization and comorbidities. Results: Of 106 participants, 63.2% had at least 1 comorbidity. 37.73% had 2-4 comorbidities. Prevalence of diabetes mellitus was 35.8%, systemic hypertension was diagnosed in 47% of the subjects. 5.7% had left heart abnormalities, 4.7% had ischemic heart disease (IHD), and 16% had pulmonary arterial hypertension. 43.4% had gastroesophageal reflux disease and gastric ulceration, 38.6% had metabolic syndrome and 8.5% had obstructive sleep apnea, 8% had psychiatric disorders, 7.5% had osteoporosis, and 1.9% were diagnosed with lung malignancy. There was a significant association between mean hospitalizations and the presence of comorbidities (p < 0.05). Hospitalizations were majorly due to exacerbation of COPD. Conclusion: Prevalence of comorbid conditions among COPD patients are concluded to be high with an adverse effect on the average number of hospitalizations per year.

In pursuit of the primary.

Extraovarian primary peritoneal carcinoma (EOPPC) is a rare tumour of the peritoneum that shares many features with serous ovarian carcinoma because of a common embryological origin. We report a case of EOPPC presenting with a malignant pleural effusion. https://bit.ly/3GMuKgL.

Massive hemoptysis: A rare case with uncommon presentation and rapid response - A case report.

We report an unusual case of massive haemoptysis in young patient with mass lesion in left upper lobe. Bronchoscopic biopsy, percutaneous CT guided biopsy & serum marker confirmed the lesion to be granulomatous with polyangiitis (GPA). Rarity of the case was endoluminal bronchial lesion in GPA and radiographic presentation of mass lesion on the Computed Tomography. Also this case highlights that massive haemoptysis can be a sole and initial manifestation of GPA. Prompt diagnosis & pulse therapy led to dramatic symptomatic, clinical & radiological improvement, emphasizing the fact that GPA can present as acute emergency and rapid diagnosis with early treatment initiation with pulse steroid therapy & rituximab can be life saving measure.

Image-guided Fine Needle Aspiration Cytology of Intrathoracic Lesions.

BACKGROUND: Percutaneous, image-guided transthoracic fine needle aspiration cytology (TTFNAC) is a rapid, yet accurate, and well-established diagnostic method used in the cytological evaluation of intrathoracic lesions. The study was done to determine the utility of image-guided TTFNAC in diagnosis of intrathoracic lesions. SUBJECTS AND METHODS: A retrospective analysis of all cases who underwent image-guided TTFNAC of a suspected intrathoracic lesion, in a tertiary care hospital was done over a period of 3 years. RESULTS: During the study period, 124 cases of image-guided FNAC of intrathoracic lesions were obtained. The mean age at presentation was 60.5 years with M:F: 3.6:1. Neoplastic lesions (71.5%) outnumbered the nonneoplastic lesions (28.5%). The most common tumor was adenocarcinoma (25%) followed by squamous cell carcinoma (SCC, 11%), and small cell carcinoma (5%). There was one case each of anaplastic carcinoma, plasmacytoma, bronchoalveolar carcinoma, and non-Hodgkin lymphoma (NHL). Most of the lesions were found on the right side and upper lobe. Among the mediastinal lesions, we found two cases of thymoma and one case each of NHL)/primitive neuroectodermal tumor (PNET), NHL, and small cell carcinoma metastasis to lymph node followed by ten cases of inflammatory lesions and seven cases of tuberculosis (TB). CONCLUSION: Image-guided TTFNAC of intrathoracic lesions is a safe method when done by well-trained medical personnel with lesser rate of complications. An early accurate diagnosis of malignancy can be made based on the cytological features; however, further subtyping of the malignancy may sometimes be difficult due to overlapping cytological features. TTFNAC can be a diagnostic tool for identifying nonneoplastic lesion such as TB. Hence, image-guided FNAC aids in early diagnosis and management of patients with intrathoracic lesions.

Cryptogenic Organizing Pneumonia with Sarcoidosis Overlap: An Atypical Case Study.

CASE SUMMARY: We present a case of a young female with subacute symptoms of cough and progressive dyspnoea. On evaluation, the patient was diagnosed as cryptogenic organizing pneumonia based on her histopathological reports. However, her significant elevation of serum angiotensin-converting enzyme (SACE) levels which drop after treatment with oral steroids, relapse, and clinical presentation pointed towards sarcoidosis as clinical diagnosis. DISCUSSION: Here, in this patient, transbronchial biopsy was suggestive of cryptogenic organizing pneumonia along with chest X-ray, and the HRCT finding was also favouring the same. But in this case, we have also seen elevated levels of serum ACE which dropped significantly to the normal level along with a complete clearance of lesions with systemic steroids, and this favours sarcoidosis. Also, the recurrence was in different areas of the lung, and lesions once again responded both clinically and radiologically to steroids with a consistent drop in serum angiotensin-converting enzyme (SACE) levels, which again is a feature common in sarcoidosis. In COP, often complete clearance of the lesions is seldom seen, even though they do respond to steroids but not as dramatically as in our case. Also, recurrence of the lesion with BOOP at different sites is uncommon as it generally progresses in the same site. CONCLUSION: This case report suggests that sarcoidosis as a possible cause of cryptogenic organizing pneumonia is worth considering with the mixed spectrum of presentation as in our case. And to our knowledge, this type of presentation of cryptogenic organizing pneumonia with sarcoidosis as an overlap disease is very rare, and this possibility needs to be explored by more series of such cases.

Cardiorespiratory Responses to Glittre ADL Test in Bronchiectasis: A Cross-Sectional Study.

Background: Bronchiectasis is a chronic respiratory condition characterised by chronic sputum production, fatigue, and dyspnoea. These symptoms will lead to reduced exercise capacity and a reduced ability to carry out activities of daily living. Glittre ADL test is a valid and reliable test which evaluates the activities of daily living. Aim: To investigate whether the Glittre ADL test can differentiate the functional capacity and cardiorespiratory responses of patients with bronchiectasis from those healthy individuals using the six-minute test as a functional performance standard. Methods: This study included 30 subjects: 15 bronchiectasis and 15 age- and gender-matched healthy subjects. The patients and healthy subjects were made to perform the Glittre ADL and six-minute test on two consecutive days. Parameters such as time taken, distance walked, HR, RR, SpO2, and dyspnoea were recorded before and after the tests. Results: The performance of bronchiectasis was worse than the healthy group on the Glittre ADL test (4.78 ± 1.33 min, 3.94 ± 0.82 min, p=0.04). Distance walked in the six-minute walk test by the bronchiectasis was 42 meters lesser than the healthy (400.33 ± 77.99, 442 ± 89.21, p=0.18). The Glittre ADL test was correlated with 6MWT when the total sample was analysed (r=-0.41, p=0.05). There was moderate positive correlation between heart rate variation, dyspnoea, respiratory rate, and peripheral saturation (SpO2) between the tests (Glittre heart rate versus six-minute walk test heart rate (r=0.55, p=0.001); Glittre (Borg) versus six-minute walk test (Borg) (r=0.72, p=0.00); Glittre respiratory rate versus six-minute walk test RR (r=0.62, p=0.00); Glittre SpO2 versus six-minute walk test SpO2 (r=0.40, p=0.02)). The bronchiectasis group had a statistically significant higher (p=0.08, p=0.46) increase in dyspnoea and RR than the controls in both the Glittre ADL test and six-minute walk test (p=0.009, p=0.03), with the similar HR variation in both the groups (p > 0.05). There was statistical difference in peripheral oxygen saturation in bronchiectasis in the six-minute walk test (p=0.03). Conclusion: The Glittre ADL test induced similar cardiorespiratory responses when compared to the six-minute walk test. So, the Glittre ADL test can be used as an assessment tool besides the six-minute walk test for the more complete evaluation of functional capacity and activities of daily living.

A Fortuitous Turn of Evidence in an Elderly Female - A Case of Pulmonary Fusariosis.

Pulmonary mycosis is seen infrequently in our country. It is more common in the immunocompromised. The infections caused by less known species like Fusarium have been found to be increasing in incidence in other parts of the world. We hereby report its occurrence in a 79-year-old, non-immunocompromised female who presented with pyrexia of unknown origin. Her Alanine Phosphatase (ALP) and Lactate Dehydrogenase (LHD) levels were raised. CT scan showed interstitial thickening in subpleural aspect of lungs and multiple enlarged lymph nodes in mediastinum. Liver showed multiple hypodense lesions. Metastasis was suspected for which Fine Needle Aspiration Cytology (FNAC) of liver was done which showed foci of regenerative hepatocytes with desmoplastic stromal tissue fragments and negative for tumour. Her Alpha Fetoprotein (AFP) was normal. The bronchial tree cytology showed endobronchial cells, dust-laden macrophages and chronic inflammatory cells along with fungi on Pap smear studies. This was confirmed by culture that grew Fusarium species. after one week of incubation. The acutely branching septate hyphae of Fusarium species are identical to those of Aspergillus species. In a patient who has a disseminated infection with a septate fungus, growth in culture is important to identify the specific organism and subsequently treatment with appropriate antifungals. In cases like ours, where the infection simulates malignancy, it is even more important to make the correct diagnosis to give the appropriate treatment.

"Bright asteroids in the polar sky"-clinic-radio-pathological correlation in an unusual case of silicotuberculosis.

We present a case of acute silicosis presenting with severe breathlessness and respiratory failure. An unusual aspect in our case was the presence of acute silicosis with respiratory failure in backdrop of long-term silica exposure. The other striking aspect in this case was the demonstration of crystalline silica particles under polarizing light in bronchial lavage fluid sample and coexistence of tuberculosis with acute silicosis.

An unusual case of refractory wheeze.

A 37-year-old man presented with a history of episodic wheeze and breathlessness of 3 years' duration refractory to treatment. Physical examination revealed diffuse expiratory polyphonic rhonchi while the remainder of the examination including the cardiac examination was reported as normal. Pulmonary function testing revealed mild obstruction with bronchodilator reversibility. The patient was discharged on a 6-month course of antitubercular treatment (ATT) as bronchial brush cytology (obtained via bronchoscopy) was positive for acid-fast bacilli. The patient presented after completing 6 months of ATT with persistent symptoms, a loud S1 and a mid-diastolic murmur at the apex. High-resolution CT of the chest showed bilateral dependent ground glass opacities. An echocardiogram revealed a left atrial myxoma, and normal RV size and pressures. The patient underwent successful surgical removal of the same, and made a complete recovery. Refractory wheeze is a very unusual presentation of a left atrial myxoma.

PUO--a rare (and forgotten) cause!

Splenic tuberculosis is an extremely rare clinical entity and a frequently forgotten cause of pyrexia of unknown origin (PUO). We present the case of a 42 year old man who presented with fever of unknown origin. Ultrasonography revealed multiple hypoechoic areas within the spleen. As the abscesses did not respond to broad spectrum antibiotics splenectomy was done. The excised organ showed multiple cysts filled with pultaceous material. Histopathological examination revealed areas of granular caseating necrosis surrounded by epitheloid cells and Langhan's type giant cells consistent with splenic tuberculosis.There was no evidence of a primary focus in the lungs or in any other organ.The presence of isolated tubercular foci in the spleen without any evidence of tuberculosis in lung or other extra-pulmonary site prompted us to report this case.

Pleural effusion: An unusual cause and association.

Filaria has a wide spectrum of presentation. We hereby present a case of Filarial pleural effusion that is a rarity in itself. Filarial lung involvement is usually in the form of tropical pulmonary eosinophilia with pulmonary infiltrates and peripheral eosinophilia, unlike our case where isolated pleural effusion of Filarial etiology was detected. Microfilaria has been isolated from Pleural fluid in very few cases, and ours was one such. Of late, there have been many incidental detections of Filarial parasites from varied anatomical sites in association with malignancy. Even in our case, we had one such unusual association.

A comparison of the Acapella and a threshold inspiratory muscle trainer for sputum clearance in bronchiectasis-A pilot study.

BACKGROUND: Inspiratory muscle training is used to specifically strengthen the respiratory muscles. Controversy exists regarding the use of inspiratory muscle training as a method of facilitating airways clearance. Acapella is already known to be effective in airway clearance. OBJECTIVE: The objective of the study was to compare the effects of the Acapella and a threshold inspiratory muscle trainer as a method of airway clearance in subjects with bronchiectasis and to determine patient preference between the two techniques. METHODS: Thirty patients (10 males, 20 females) mean age of 50.67+/-6.37 (mean+/-SD) with a history of expectoration of more than 30 ml sputum per day were recruited. The sequence of therapy was allocated by block randomization. Assessment and familiarization session was performed on day 1. Treatments employing the Acapella and inspiratory muscle trainer were done on days 2 and 3. Treatment order and allocation was determined by block randomization. Sputum volume was measured during and 2 hours after the treatment and patient treatment preference was recorded. RESULTS: A statistically significant difference was found in the sputum volume expectorated after treatment with the Acapella (7.16+/-1.12 ml) compared with the threshold inspiratory muscle trainer (6.46+/-1.08 ml). Patients preferred Acapella in terms of usefulness of clearing secretions. CONCLUSION: The present study demonstrated increased sputum clearance following the use of the Acapella when compared to the threshold inspiratory muscle trainer. In addition, the Acapella was preferred by patients who judged that it was more useful in clearing secretions.