Non-resolving pneumonia: primary pulmonary MALT lymphoma.

Mucosa-associated lymphoid tissue (MALT) lymphoma is an uncommon extranodal low-grade B-cell lymphoma. Pulmonary MALT lymphomas originate from bronchial MALT and are also referred to as bronchial-associated lymphoid tissue lymphomas. MALT lymphomas of the lung are slow-growing tumours and usually present as asymptomatic chronic alveolar opacities visible on chest radiographs or with non-specific pulmonary symptoms. Here we described a case of a male patient in his early 50s with cough and chest pain for 4 years. His CT chest scan showed consolidation in the lingula and left lower lobe. Histopathology of the specimen obtained from cryobiopsy of the lung lesion showed a dense monomorphic lymphoid infiltrate, and immunohistochemistry confirmed the diagnosis of MALT lymphoma. The prognosis of pulmonary MALT lymphomas is good with >80% 5-year survival rates. This case highlights that MALT lymphoma should be considered as a differential diagnosis while evaluating cases with non-resolving consolidation.

Iatrogenic Cushing's syndrome in a case of allergic bronchopulmonary aspergillosis treated with oral itraconazole and inhaled budesonide.

Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity reaction to Aspergillus fumigatus that occurs in patients with asthma or cystic fibrosis. Here, we report a case of a young female with bronchial asthma who presented to our hospital with worsening breathlessness on exertion. She was diagnosed to have ABPA and was initiated on oral itraconazole while continuing inhaled long acting beta-2 adrenergic agonist and medium dose inhaled corticosteroid (ICS) for her asthma. Three months after initiation of therapy, the patient had significant improvement in breathlessness. However, she had weight gain, facial puffiness, increased facial hair and development of striae on her inner thighs, calf and lower abdomen. Her serum cortisol levels were found to be suppressed and hence a diagnosis of iatrogenic Cushing's syndrome was made. Our case describes the potentially serious interaction between ICS and oral itraconazole, a treatment very commonly prescribed in patients with ABPA.

Endobronchial chondroid hamartoma of left main bronchus and its bronchoscopic management.

Most tumours of the tracheobronchial tree are malignant. Benign tumours such as hamartoma are infrequent and generally intra-parenchymal. Here we present a case of a 65-year-old male patient who presented with a purely endobronchial lobulated mass lesion in the left main bronchus. This central airway obstruction was managed by a complete endobronchial resection using an electrocautery snare and cryo-recanalisation techniques. A diagnosis of endobronchial chondroid hamartoma was made on histopathological examination. Such endobronchial lesions are rare and constitute less than 2% of all hamartomas.

Atypical mycobacterial infection masquerading as an endobronchial growth in an immunocompromised host.

Non-tuberculous mycobacteria (NTM) are ubiquitous organisms. Endobronchial growth as a presenting feature of NTM disease is uncommon. Here we present a case of a patient with retroviral disease on antiretroviral therapy, presenting with cough, wheezing and exertional dyspnoea. High-resolution CT showed a partial obstruction of the left main bronchus (LMB). Bronchoscopy showed an endobronchial growth in the distal LMB. An endobronchial biopsy showed non-necrotising granulomas; bronchial wash for acid-fast bacilli was positive and culture grew Mycobacterium avium complex. He was treated with a combination therapy of clarithromycin, rifampicin and ethambutol. Repeat bronchoscopy after 6 weeks of therapy showed complete resolution of the endobronchial growth.

Pleural Pustule-a Novel Thoracoscopic Appearance of Pleural Tuberculosis.

BACKGROUND: Thoracoscopic pleural biopsy is the gold standard for diagnosing tubercular pleural effusion (TPE). Various thoracoscopic appearances like sago grain nodules, caseous necrosis, and adhesions have been described in TPE. However, none of these have high specificity for diagnosing TPE. In this study we evaluate a novel finding on thoracoscopy, the " Pleural Pustule." METHODS: This is a retrospective analysis of patients who underwent thoracoscopy for undiagnosed pleural effusion. Visual inspection of the pleura was performed to identify abnormalities. Biopsies were obtained from those areas and sent for histopathology, acid fast bacillus (AFB) smear, culture, and Xpert MTB/Rif assay. Pleural pustule was defined as a pus filled nodule on the pleural surface. RESULTS: Of the 259 patients included, 92 were diagnosed with TPE. Pleural pustule(s) were identified in 16 patients with TPE. Presence of pleural pustule had a sensitivity, specificity, positive predictive value, and negative predictive value of 17.4%, 100%, 100% and 68.7%, respectively, for diagnosing TPE. Histopathology of pleural pustule demonstrated necrotizing granulomas in all. In patients with pleural pustule, a microbiological diagnosis of tuberculosis was achieved in 93.7% patients (AFB smear, Xpert MTB/Rif assay, and MTB culture positive in 31.3%, 93.7%, and 43.7% cases, respectively). There is a strong association between pleural pustule and positive Xpert MTB/Rif assay ( P =0.002) and microbiologic confirmation of diagnosis ( P =0.017). CONCLUSION: The presence of pleural pustule on thoracoscopy has a high positive predictive value for TPE. In tuberculosis-endemic countries, this can be considered suggestive for TPE. When identified, a biopsy from the pleural pustule should be performed as it will likely yield a positive microbiologic diagnosis.

Endobronchial ultrasound guided intracardiac needle aspiration (EBUS-ICNA).

Most cardiac tumours are secondary to metastasis from extracardiac tumours. Obtaining biopsy from intracardiac lesions, especially from the left heart, is challenging, and the conventionally used methods are invasive and involve significant risks such as arrhythmias, tamponade, valvular damage and tumour embolisation. Endobronchial ultrasound (EBUS) is a minimally invasive procedure used to biopsy lymph nodes or mass lesions adjacent to the airways. Its safety and usefulness have been well established. Use of EBUS has expanded to several novel indications over the last few years. Here we report a case of a young woman with suspected metastatic disease to the heart, in whom traditional methods of biopsy had failed to give a diagnosis. EBUS-guided transbronchial intracardiac needle aspiration was safely performed from the left atrial mass lesion to obtain tissue for histopathological diagnosis. A diagnosis of metastatic adenocarcinoma with tumour embolisation to the heart was established.