A rare case of lung abscess due to esophageo-pulmonary fistula in asymptomatic carcinoma of esophagus.

Acquired esophago-respiratory fistulae are usually esophago-tracheal or esophago-bronchial. Esophago-pulmonary fistulae are rare. Most patients present with cardinal symptoms of esophageal carcinoma or esophago-pulmonary fistula leading to early diagnosis. We report a 56-year-old female with an unusual presentation. She presented with high grade fever with chills and rigor, cough with mucopurulent expectoration and shortness of breath for 15 days without dysphagia, nausea, vomiting or chest pain. Clinically and radiologically a diagnosis of lung abscess was entertained and she was treated with multiple antibiotics without any improvement. Contrast Enhanced Computed Tomography (CECT) chest revealed esophageal malignancy with esophageal-pulmonary fistula communicating with abscess cavity. Patient responded to palliation with self-expandable esophageal stent and drainage of abscess. Although rare, asymptomatic malignant esophageal disease should be considered in the differential diagnosis of lung abscess, which does not follow a usual course. Keywords: Lung abscess, Esophageal cancer, Esophageo-pulmonary fistula, Self expandable metallic stent.

Prevalence and characteristics of venous thromboembolism in severe exacerbation of chronic obstructive pulmonary disease in a tertiary care hospital in India.

Acute exacerbation of chronic obstructive pulmonary disease (AECOPD) carries a high risk of venous thromboembolism (VTE). Pulmonary embolism (PE) and AECOPD increase the mortality and morbidity risk associated with each other. Racial and ethnic differences in VTE risk have been documented in multiple studies. However, there is a dearth of reliable Indian data on the same. This study was planned to find the prevalence of VTE in the setting of severe AECOPD in a tertiary care hospital in India and to identify the clinical, laboratory and radiological characteristics of VTE in severe AECOPD. A total of 156 consecutive patients admitted with severe AECOPD and meeting the specified inclusion and exclusion criteria were recruited. Thorough workup of all patients was done including ABG, serum D dimer, ECG, compression ultrasound of lower limbs and 2-D echocardiography. Patients with high pre-test probability score, or intermediate pre-test probability score at presentation with serum D dimer above the age adjusted cut-off underwent computerised tomography pulmonary angiography (CTPA).  Results were analysed using SPSS version 23.  Sixteen (10.3%) patients had VTE, 15 (93.75%) of them being cases of isolated PE. Female gender, higher cumulative past exposure to corticosteroid, higher alveolar-arterial gradient, right ventricular dysfunction, and higher mean pulmonary artery pressure were associated with increased risk for VTE. The prevalence of VTE in AECOPD in this study among an Indian population is higher than among other Asians, but lower than among the Blacks, the Caucasians and the Middle-East ethnicities. Since a vast majority of VTE presents as PE without DVT in the setting of AECOPD, the absence of deep vein thrombosis of lower limbs does not rule PE in the setting.

Bronchoscopic Cryotherapy for Acute Hypoxemic Respiratory Failure in Three Mechanically Ventilated Patients: A Case Series.

Endobronchial blood clots or mucus plugs can present with minimal symptoms or acute airway obstruction in the intensive care unit (ICU) patients. Acute airway obstruction can lead to rapid worsening of dyspnea owing to poor oxygenation due to collapse of the lung. Prompt recognition and treatment of this condition can translate into a successful outcome by decreasing morbidity and mortality and facilitating successful weaning of these patients. When conventional methods fail to relieve the obstruction, cryoextraction a novel technique, may prove to be a useful alternative for the removal of these clots and mucus plugs. Cryoextraction is best performed with rigid bronchoscopic intubation. However, in certain conditions, it may be used with a flexible fiberoptic bronchoscope (FOB) through an endotracheal tube, especially when bedside procedure is required in ICU patients. In this series, three cases are being discussed where bedside flexible bronchoscopy-guided cryoextraction was done leading to a successful resolution of acute hypoxemic respiratory failure. How to cite this article: Tale S, Meitei SP, Prakash V, Negi A, Mishra M, Sindhwani G. Bronchoscopic Cryotherapy for Acute Hypoxemic Respiratory Failure in Three Mechanically Ventilated Patients: A Case Series. Indian J Crit Care Med 2021;25(1):94-96.

A Case of Life-threatening Amlodipine and Atenolol Overdose.

Treating a patient of amlodipine-atenolol poisoning is nightmare for a physician. In high dose both the drugs individually cause severe bradycardia and hypotension. In combination they cause severe cardiovascular depression. Here we report a case of 66-year-old obese, hypertensive, depressed male, who presented to emergency 9 hours after consumption of 25 tablets of amlodipine-atenolol (5 mg+50 mg). On evaluation, he had refractory bradycardia, hypotension and acute kidney injury (AKI). Eventually he developed cardiac arrest. He was revived after 5 minutes of cardio-pulmonary resuscitation (CPR). He was successfully managed with gastric lavage, fluids, inotropes, atropine, isoprenaline and subsequently with calcium gluconate infusion, high-dose insulin euglycemia therapy (HIET) and lipid emulsion therapy. Glucagon infusion was also planned but it was not available. Patient hemodynamics improved and on 8th day he got the discharge. Our case exemplifies the importance of timely and aggressive management of lethal overdose of amlodipine-atenolol poisoning. How to cite this article: Tale S, Kumar M, Ghosh S, Bhalla A. A Case of Life-threatening Amlodipine and Atenolol Overdose. Indian J Crit Care Med 2019;23(6):281-283.

Pulmonary Cryptococcosis Mimicking Lung Cancer: A Diagnostic Challenge.

Pulmonary cryptococcosis, although rare, maybe seen in both immunocompromised and immunocompetent patients. Cryptococcosis presenting as a lung mass mimicking lung cancer is very rare. Here, we report our experience with pulmonary cryptococcosis presenting as a lung mass mimicking malignancy in an immunocompetent patient. In this case, the patient presented to us with left-sided pleural effusion and lung mass on computed tomography (CT) of the chest. Bronchoscopy and endobronchial ultrasound (EBUS)-guided fine needle aspiration cytology (FNAC) was performed, which showed cryptococcal organisms. He responded well to oral anti-fungal therapy without any need for surgical interventions.

Immunoexpression of Programmed Death-1 Receptor (PD-1) and Programmed Death-Ligand 1 (PD-L1) in Non-Small-Cell Lung Carcinoma and Its Correlation With Other Clinicopathological Parameters: A Cross-Sectional Study From North India.

Aim To study the prevalence of programmed death-1 receptor (PD-1) and programmed death-ligand 1 (PD-L1) positive cases in non-small-cell lung carcinoma (NSCLC) and their association with other clinicopathological parameters in a tertiary care setting in North India. Material and methods One hundred histologically proven NSCLC cases having sufficient tumor material from July 2016 to July 2018 were examined, and the prevalence of PD-1 and PD-L1 positivity in NSCLC was studied. In addition, H&E-stained sections were reviewed, and 100 consecutive cases meeting study criteria were identified as study cases. Histopathological categorization was done using a panel of immunohistochemical markers. Statistical analysis and results The PD-1 positivity in lymphocytes was 29% (95% CI: 20.4%-38.9%). Membranous positivity for PD-L1 in tumor cells was 27% (95% CI: 18.6%-36.8%) and in tumor-infiltrating lymphocytes was 22% (95% CI: 14.3%-31.4%). There was no statistically significant association between PD-1 or PD-L1 status with age, gender, smoking, pleural effusion, clinical stage, histological type, or lymphocyte infiltration. Conclusion The moderately high prevalence may justify routine testing for PD-1 or PD-L1 in NSCLC, which should preferably be carried out in all cases rather than any selected subsets. However, there was no significant correlation between PD-1 and PD-L1 with the clinical parameters studied.

Care of tuberculosis patients in the times of COVID-19.

Globally during this time of Covid-19 pandemic health care services are overhelmed and it has negative impact on other diseases like Tuberculosis (TB). High TB burden countries like India despite being faced by several other problems in present times, is continuously trying to provide uninterrupted services to TB patients through the national programs. In this general perspective we have shared our opinion on problems faced by TB patients in the times of covid-19.

Interesting case of allergic broncho pulmonary aspergillosis (ABPA) with high-attenuation mucus (HAM).

A 25-year-old man, who was taking treatment for his poorly controlled asthma, presented with symptoms of cough with expectoration, gradually progressive shortness of breath, fever on and off and diffuse wheeze for 2 years. Chest X-ray revealed hyperinflation of lung field with dense opacification at right upper lobe. High-resolution CT chest showed bilateral patchy consolidation, central bronchiectasis and high-attenuation mucus (HAM) impaction. His blood absolute eosinophil count, total serum IgE level, Aspergillus fumigatus specific IgE and IgG level were 1910, 16760 kU/L, 59.8 kU/L and 147.41 kU/L, respectively. Diagnosis of allergic broncho pulmonary aspergillosis (ABPA) was established according to International Society for Human and Animal Mycology society guidelines. He was started on systemic steroids and doing well after 6 months of follow-up. Our case illustrates HAM, which is a rare but typical radiological feature of ABPA.

Rare case of red tears: ocular vicarious menstruation.

Bloody tears or haemolacria is a rare clinical entity. It is caused by various ocular and systemic conditions. Haemolacria due to vicarious menstruation is even rarer. In this article, we presented a case of cyclical episodes of bloody tears coinciding with menstrual cycle in a 25-year-old married female patient. Extensive physical, ophthalmological and radiological evaluation failed to reveal other potential causes of her complaint. A diagnosis of ocular vicarious menstruation was made and she was treated with oral contraceptive pills. No such episode recurred during 3 months follow-up period.

Cerebral salt-wasting syndrome in a patient with status epilepticus: a rare association.

Hyponatraemia is one of the most common and serious electrolyte abnormalities in patients with neurological diseases. Assessing the intravascular fluid status, urine sodium, urine and serum osmolality helps to narrow down the differential diagnosis. Differentiation between cerebral salt-wasting syndrome (CSWS), diabetes insipidus and syndrome of inappropriate antidiuretic hormone (SIADH) secretion is absolutely necessary for correct management of hyponatraemia in this group of patients. In this case report, we have presented a 46-year-old gentleman who was admitted to intensive care unit (ICU) with status epilepticus and developed hyponatraemia during course of his ICU stay, diagnosed as CSWS and managed with normal saline and fludrocortisone. His serum sodium gradually improved, consciousness was regained and later shifted to general ward on antiepileptic treatment.

Sleepwalking and prolonged partial sleep paralysis in a case of obstructive sleep apnea.

Observation of episodes of sleepwalking and prolonged partial sleep paralysis in the same patient is a rare condition. We present a case of 42 years gentleman who presented with recurrent episodes of sleepwalking and prolonged incomplete sleep paralysis. He was on tablet divalproate 1000mg/day and tablet olanzapine 5mg/day in view of a psychotic episode that occurred 4 years ago. Polysomnography suggested presence of moderate obstructive sleep apnea (OSA) with intrusion of alpha waves in sleep. Considering only one psychotic episode with no other risk factors, these medications were gradually tapered and discontinued. Symptoms improved after tablet clonazepam 0.5mg at bedtime even while he was not compliant to continuous positive airway pressure (CPAP).

Cardiogenic shock with first-degree heart block in a patient with glyphosate-surfactant poisoning.

Glyphosate is a commonly used non-selective herbicide in agriculture and aquafarms. Gastrointestinal, respiratory and cardiovascular symptoms are predominant manifestations of glyphosate poisoning. Cardiac dysfunction should be kept as a possibility in patients presenting with shock, and the treatment is mainly supportive. We present such a case.