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Key Clinical Message: Despite being generally treatable and preventative, pulmonary tuberculosis (PTB) is one of the most common infectious agents that cause death. Misdiagnosis of TB frequently leads to unwarranted diagnostic procedures and postpones the start of treatment. Abstract: Pulmonary tuberculosis (PTB) can present with various unusual radiological and clinical characteristics. Misdiagnosis of TB frequently leads to unwarranted diagnostic procedures and postpones the start of treatment. Here, we describe a 50-year-old man who presented with a cancerous-type lesion on radiological findings and atypical symptoms that led to an initial diagnosis of lung cancer. However, histopathology and biopsy of the lung lesion revealed chronic granulomatous inflammation with caseous necrosis, confirming PTB as the true cause, with no further indications of malignancy.
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Nivolumab is an anti-programmed cell death protein 1 (anti-PD-1) monoclonal antibody and was the first immune checkpoint inhibitor drug approved for use in advanced non-small cell lung cancer (NSCLC). In this report, we describe a rare case of Lambert-Eaton myasthenic syndrome (LEMS), which developed as a side effect of nivolumab in a patient with metastatic lung squamous cell carcinoma. Our patient, who was previously treated with nivolumab for metastatic squamous cell carcinoma of the lung, appeared with a headache, swollen face, dysarthria, asthenia, xerostomia, and drooping eyelid. Early testing indicated no thymomas or newly developing tumors in whole-body scans, and the blood workup was normal. We came to the conclusion that nivolumab-induced LEMS was the cause of the symptoms after performing nerve conduction investigations ruling out other differentials. We believe our clinical experience of this rare and unexpected adverse event should be shared.
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BACKGROUND: Musculoskeletal injuries (MSI) have plagued endoscopists and ancillary staff for decades without any innovative and strong ergonomic guidelines. It has placed a physical and mental strain on our endoscopists and ancillary staff. We have very have limited data supporting this claim in our region and most data is supported by western literature. AIM: To document the prevalence of MSI, and awareness and practices of ergonomics by endoscopists and ancillary staff. METHODS: This is an observational cross-sectional study, conducted in Karachi, a city that boasts the maximum number of daily endoscopies in the country. An eleven-point self-administered questionnaire was distributed and used to evaluate MSI and ergonomic adjustments amongst three tertiary care setups in Karachi. An onsite survey via a 13-point checklist for endoscopy suite facilities was used to assess the ergonomically friendly conveniences at five tertiary care setups in Karachi. A total of 56 participants replied with a filled survey. RESULTS: There were 56 participants in total with 39 (69.6%) males. Pain and numbness were documented by 75% of the patients, with pain in the neck (41.1%), lower back (32.1%), shoulder (21.4%), thumb (12.5%), hand (23.2%), elbow (8.9%), and carpal tunnel syndrome (CTS) (7.1%). Of those, 33.3% attributed their symptoms to endoscopy, 14.2% said that symptoms were not caused by endoscopy, and 52.4% were not certain whether endoscopy had caused their symptoms. Twenty-one point four percent of patients had to take time off their work, while 33.9% took medications for pain. Ergonomic modifications to prevent musculoskeletal injury, including placement of endoscopic monitor at eye level and the cardiac monitor in front, stopping the procedure to move patients, sitting while performing colonoscopy, and navigating height-adjustable bed were used by 21.4%. Nine out of 13 ergonomic facilities were not present in all five tertiary care hospitals. Conveniences, such as anti-fatigue mats, height-adjustable computer stations, and time out between patients were not present. CONCLUSION: Three-fourth of our endoscopists reported MSI, of which more than half were not sure or attributed this problem to endoscopy. The prevalence of MSI warrants urgent attention.
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The coronavirus disease 2019 (COVID-19) pandemic has resulted in significant morbidity and mortality since its first case was discovered in December 2019. Since then, multiple countries have witnessed a healthcare system collapse due to the overwhelming demand for COVID-19 care. Drastic measures have been taken globally in order to curb the spread of the virus. However, those measures have led to the disruption of other aspects of healthcare, increasing the burden due to other medical conditions. We have also stepped back in achieving the ambitious goal set in place by World Health Organization to eliminate viral hepatitis as a public threat by 2030. Hepatitis B and C are chronic conditions with a significant worldwide burden, and COVID-19 has resulted in many hepatitis elimination programs slowing or stopping altogether. In this review, we elucidate the impact of the ongoing COVID-19 pandemic on the interventions targeted towards the elimination of hepatitis B virus and hepatitis C virus. Some of the salient features that we have covered in this review include hindrance to screening and diagnostic tests, neonatal vaccinations, the transmission dynamics affecting hepatitis B virus and hepatitis C virus, role of limited awareness, restrictions to treatment accessibility, and disparity in healthcare services. We have highlighted the major issues and provided recommendations in order to tackle those challenges.
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BACKGROUND: Sleep medicine is an under-recognised medical specialty in Pakistan and obstructive sleep apnoea (OSA) often goes unnoticed. Final year medical students and junior doctors are the primary medical contact to elicit patient history and physical examination. We aimed to measure the current knowledge of OSA amongst the final year medical students and junior doctors at four university teaching hospitals across three large Pakistani cities. METHODS: Cross-sectional survey of final year medical students and junior doctors rotating through medical wards of four university teaching hospitals were conducted during August-October 2019. The knowledge section of the OSA knowledge and attitude (OSAKA) questionnaire was used. Descriptive statistics were used to present the data with Chi-Square test and independent samples student t-test to compare the differences between individual items and mean scores of the participants, respectively. RESULTS: A total 282 final year medical students and 204 junior doctors completed the survey yielding a response rate of 53% for medical students and 97% for junior doctors. The knowledge of sleep apnoea was poor in both groups of participants with a mean score of 7.6 (42%) on the knowledge scale of OSAKA questionnaire. Medical students scored higher on the item related to snoring as the most prevalent symptom in OSA patients when compared to the junior doctors (χ2 = 8.92, P = 0.003). More junior doctors responded correctly about the role of uvulopalatopharyngoplasty in the management of OSA when compared to the medical students (χ2 = 5.14, P = 0.02). Differences in scores of both groups of participants on other items were small and did not reach statistical significance. CONCLUSION: Final year medical students and junior doctors from a sample of four university teaching hospitals in three large cities of Pakistan have limited knowledge about the diagnosis and management of OSA. The observed limited knowledge of OSA may contribute towards under-diagnosis of this increasingly prevalent medical condition.