Pulmonary Hydatid : Diagnosis and Response to Hypertonic Saline Irrigation and Albendazole.

BACKGROUND: Pulmonary hydatid is caused by larval stage of parasite Echinococcus granulosus. Although surgery still remains the definitive therapy, various workers have tried albendazole and sterilization of cysts with varying result. METHODS: 32 patients(21 males, 11 females) of pulmonary hydatid disease with average age 32.5 years(21-51 years) treated by us between Jan 97 to Apr 2001 were analysed. Diagnosis was established clinically, radiologically and by serological testing. 16 patients who had simple cyst were treated with 20 ml percutaneous hypertonic(20%) saline irrigation of the cyst along with albendazole (400 mg twice a day, 6 cycles of 4 weeks with 2 weeks drug free period between the cycles). 13 patients of complicated cysts were treated with 6 cycles of albendazole. All cases were followed up for one year. 16 patients including three fresh cases were subjected to surgical resection. RESULTS: Pleural involvement was noted in 10 patients. On chest radiography 19 patients had homogenous oval or circular cysts, 6 patients had crescent sign and 10 had water lily sign. After percutaneous hypertonic saline irrigation all patients showed initial regression in size and developed complicated cysts with water lily sign but subsequently there was no regression. Of 13 patients treated with albendazole, 3 patients showed complete resolution and 2 patients showed regression of cyst. All these 5 patients had shown regression during first cycle of albendazole. 16 patients were subjected to surgery (6 after saline irrigation, 7 after albendazole course and 3 fresh cases). No difference was noted in these groups on histopathological examination. CONCLUSION: From this study it was evident that those patients who demonstrate regression in size during first cycle of albendazole are likely to benefit and improve with further cycles of it. Those who do not respond should be subjected to surgery. Result of percutaneous hypertonicsaline irrigation as scolicidal was not encouraging.

Outbreak of Pneumococcal Pneumonia among Military Recruits.

BACKGROUND: Between 04 Mar 2002 to 21 Mar 2002, 31 cases of pneumonia were admitted at a military hospital in South India. Most of these cases were young recruits. The out break was investigated to ascertain the cause and suggest preventive measures. METHODS: Detailed epidemiological history was taken from all 31 cases and 100 controls. Case sheets, laboratory reports and chest radiographs were studied. Laboratory investigations included sputum examination by Gram stain and blood cultures on brain heart infusion broth. Cultures grown on liquid media were subcultured on solid media. The regimental centre was visited to note the living and environmental conditions. RESULTS: Epidemiological investigations revealed overcrowding in the regimental centre. The space per recruit was below recommended standards. 51.6% of recruits who contacted pneumonia were sleeping on double deckers as compared to 21% of healthy controls. Blood culture was positive for Streptococcus pneumoniae in 25.8% of the cases. Chest radiograph showed consolidation typical of lobar pneumonia in 67% of the cases. CONCLUSION: The outbreak of pneumococcal pneumonia occurred due to overcrowding. Chilly weather conditions and stress were contributing factors.

Solitary tracheal plasmacytoma.

Primary tracheal tumours are rare and trachea is an exceedingly rare site of extramedullary plasmacytoma. We report a case of extramedullary plasmacytoma involving trachea and causing symptoms of airway obstruction in a 44-year-old man. Chest radiograph was normal. Flow-volume loop showed characteristic pattern localizing the lesion at thoracic inlet. Computerised tomography and bronchoscopy demonstrated a broad based pedunculated intratracheal mass obstructing 85% of the lumen. Tracheal tumour was excised via low tracheostomy. Histopathology of resected mass revealed extramedullary plasmacytoma. Relevant investigations excluded multiple myeloma. He was managed with radiotherapy with good response and there has been no recurrence after one-year follow-up.

Mediastinal cavernous haemangioma.

A 44-year-old man presented with palpable right supraclavicular swelling having no symptoms pertaining to respiratory tract. A routine chest radiograph showed an anterior mediastinal mass. Computerised tomographic scan (CT-scan) of chest showed an enhancing and homogeneous mass in anterior mediastinal space with few tiny calcific specks within the mass. Biopsy of cervical swelling showed cavernous haemangioma with chronic non-specific lymphadenitis. A sternotomy was undertaken and an encapsulated 9x7.5x5 cm, dark purplish mass was seen in anteior mediastinum adherent to pericardium and right pleura. The cut-surface was elastic and soft. Histology confirmed cavernous haemangioma. Post-operative course was uneventful. Mediastinal cavernous haemangioma is extremely rare and surgical excision is the treatment of choice.

Lung function in mitral stenosis.

OBJECTIVES: The aim of this study was to look to for a relationship between pulmonary artery pressure (PAP), left atrial pressure (LAP), mitral valve area (MVA) and transmitral gradient (Gr) on the one hand and the spirometric data on the other, in cases of mitral stenosis. METHODS: The spirometry values measured were forced vital capacity (FVC), forced expiratory volume in one second and as percent of FVC (FEV1, FEV1/FVC%), forced expiratory flow between 25% to 75% of FVC (FEF 25-75%), at 50% of FVC (FEF 50%) 75% of FVC (FEF 75%) and peak expiratory flow rate (PEFR). The PAP, LAP, MVA and Gr were measured at echocardiography and cardiac catheterisation. RESULTS: Analysis of results was done of 60 patients in four groups divided on basis of mean PAP: Group 1 with least and group 4 with highest mean PAP. FVC values were reduced in direct proportion to PAP, LAP, MVA and Gr in three out of four groups. FEV1% as a percent of predicted value showed uniform reduction in all the groups, PEFR was moderately affected in group 1 and most severely in group 4. Values of FEV1/FVC% were within normal range in all the groups. FEF 25-75%, and FEF 50% showed serial reduction in values in keeping with the elevation of the PAP. FEF 75% was also moderately affected in group 1 and most severely in group 4. CONCLUSION: We found that a moderate restrictive defect and a small airway defect which is found in cases of mitral stenosis, directly correlates to the PAP, LAP, MVA and Gr. There was no significant involvement of the larger airways.

Treatment of Allergic Bronchopulmonary Aspergillosis with Fluconazole and Itraconazole.

Treatment of allergic bronchopulmonary aspergillosis (ABPA) has remained both problematic as well as controversial. Although the sheet anchor in treatment of ABPA still remains steroids, various workers have tried oral antifungals (fluconazole and itraconazole) with encouraging results. This study evaluates the effect of fluconazole or itraconazole in the treatment of ABPA patients and compares them with the patients who had received palliative therapy other than antifungals. Case records of 44 proven cases of ABPA treated at our referral service hospital during February 1998 to April 2001 were analyzed. In addition to oral and inhaled bronchodilators, 16 patients received fluconazole 150 mg OD and 13 patients itraconazole 200 mg OD for six months. Response to therapy was assessed clinically, radiologically and by spirometry every 3 months. Patients who did not receive antifungals had chronic course characterized by airway obstruction, recurrent pulmonary consolidation and obstructive defect on pulmonary function test (PFT). Patients treated with itraconazole had better control of asthma symptoms, less requirement of reliever inhalers, steroids and lesser exacerbations of asthma during follow-up even after stopping antifungal. Fluconazole group had better control of symptoms but improvement in other parameters was not statistically significant. From this study it was evident that itraconazole improved the symptoms of airway obstruction, pulmonary functions, pulmonary opacities and decreased exacerbations during follow up.

DRUG RESISTANT TUBERCULOSIS - THE EMERGING SCENARIO.

During the period April 1992 to September 1994 a total of 2288 patients of pulmonary tuberculosis were treated at our centre. M. tuberculosis could be isolated from the sputa of 1037 patients (45.3%). All the isolates were subjected to indirect susceptibility testing using drug incorporated Lowenstein-Jensen medium slants. A total of 142 (13.7%) patients showed drug resistance. Single drug resistance was observed in 86 (8.3%) patients whereas resistance to two or more drugs was observed in 56 (5.4%) patients. Patients showing initial drug resistance were more in number (83 cases) than those showing acquired drug resistance (59 cases). Resistance to streptomycin was commonest (8.3% of isolates) followed by isoniazid (5.7%) and rifampicin (5.0%). Multiple drug resistance was mostly acquired (71.4% of drug-resistant isolates).

THE ROLE OF RAPID SLIDE CULTURE IN THE DIAGNOSIS AND MANAGEMENT OF PULMONARY TUBERCULOSIS.

Rapid slide culture method using human blood medium was utilized for the primary culture of Mycobacterium tuberculosis and the results obtained were compared with results of smear examination of sputum specimens from fresh cases of pulmonary tuberculosis. Smear and rapid slide culture results of a total of 320 patients were analyzed. Slide culture was positive in 104 cases whereas smears were positive in 90 cases. Early culture confirmation in 7 days coupled with positivity better than smear examination, makes rapid slide culture a better method for diagnosis.

HIV IN TUBERCULOSIS.

This study was undertaken to evaluate clinical and laboratory parameters of 29 HIV-infected male patients with tuberculosis. Out of the 243 human immune deficiency virus (HIV) seropositive patients, 15 (6.2%) were diagnosed to be suffering from tuberculosis whereas out of 3502 cases of tuberculosis random HIV surveillance in 350 cases showed HIV infection in 14 (4%). Mantoux positivity at the time of diagnosis of tuberculosis was noted in 16 (55.1%) patients, and out of them 17.1% showed tuberculin conversion within 2 years of detection of HIV infection. Diagnosis of tuberculosis was based on demonstration of acid fast bacilli in sputum of 8 (27.6%), and in lymphnode aspirate in 4 (13.8%). Tubercular granuloma was demonstrated in 3 more patients, 2 in lymphnodes and one in liver parenchyma. In another 14 cases, there was classical clinical presentation and chest radiogram findings with excellent therapeutic response. Chest radiograms showed pulmonary infiltrate in 20, pleural effusion in 5, pleural thickening in 2, and intrathoracic adenopathy in 6 patients. Exclusive extrapulmonary tuberculosis was present in 4 patients.

Noninvasive Positive Pressure Ventilation in Patients with Acute Respiratory Failure.

Noninvasive positive pressure ventilation (NIPPV) delivered by nasal route or facemask is increasingly being used in the management of patients with acute respiratory failure. 45 patients (29 males,16 females) with a mean age of 68.32 years (range 29 to 82 years) having acute onset hypoxemic and/or hypercapnic respiratory failure who were managed with NIPPV in a tertiary care centre of Armed Forces were analyzed retrospectively. Patients with hemodynamic instability, coma and uncooperative patients were excluded from study. Etiology of acute respiratory failure was acute exacerbation of chronic obstructive pulmonary disease (COPD) in 29 patients, adult respiratory distress syndrome (ARDS) in 4 patients, severe kyphoscoliosis in 2 patients, interstitial lung disease (ILD) in 4 patients, lung contusion with pneumonia in 1 patient, thoracoplasty in 1 patient and difficult weaning in 4 patients. Initial resting arterial blood gases showed mean arterial oxygen tension (PaO2) 61 mmHg (range 45 to 78 mmHg), mean arterial carbon dioxide tension (PaCO2) 75.2 mmHg (range 32 to 127 mmHg) and mean arterial pH-7.26 (range 7.03 to 7.45). Mean inspiratory positive airway pressure (IPAP) was 14 cm H2O (range 10 to 20 cm H2O). Mean expiratory positive airway pressure (EPAP) was 5.8 cm H2O (range 4 to 8 cm H2O). On an average, NIPPV was required for 5.4 days (range 2 to 15 days) prior to discharge. 11 patients required long term intermittent NIPPV along with domiciliary oxygen therapy. 9 patients died out of which 4 patients had advanced interstitial lung disease. NIPPV has been found useful in acute respiratory failure due to acute exacerbations of COPD, thoracic wall abnormalities and ARDS. It has not been found useful in hypoxemic respiratory failure due to interstitial lung disease and diffuse interstitial pneumonia.

ALVEOLAR PROTEINOSIS (A Case Report).

A case of pulmonary alveolar proteinosis diagnosed by open lung biopsy is being reported and relevant literature is discussed.

A COMPARATIVE STUDY OF CHEST RADIOGRAPHIC FEATURES BETWEEN HIV SEROPOSITIVE AND HIV SERONEGATIVE PATIENTS OF PULMONARY TUBERCULOSIS.

Chest radiographic appearance of pulmonary tuberculosis (TB) in Human Immunodeficiency Virus (HIV) positive patients was reviewed. A study group of 50 HIV +ve cases and a control group of 100 HIV -ve cases were analysed. The chest radiographs of HIV seropositive group showed significantly higher incidence of thoracic lymphadenopathy (36% vs 8%, P<.001), pleural effusion (28% vs 10%, P<.01) and miliary pattern (12% vs 2%, P<.05) as compared to the seronegative group. Cavitation was less common in the seropositive group (8% vs 35%, P<.001) than the seronegative group. Upper zone involvement was significantly less common in the study group (38% vs 77%, P<.001) as compared to the control group.