Adenocarcinoma of the Lung Masquerading As Invasive Pulmonary Aspergillosis in an Elderly Lady: A Diagnostic Challenge.

A 59-year-old hypertensive woman presented with a year-long history of cough, expectoration, and progressive breathlessness, recently complicated by hemoptysis and significant weight loss. Initial investigations, including a chest x-ray and contrast-enhanced computed tomography (CECT) of the thorax, suggested an infective pathology. Despite negative bacterial, fungal, and tuberculosis cultures, elevated bronchoalveolar lavage (BAL) galactomannan and serum Aspergillus-specific IgG levels led to a diagnosis of invasive pulmonary aspergillosis (IPA), and antifungal treatment commenced. The patient's initial response was positive; however, symptoms recurred three months later. Further investigations revealed adenocarcinoma, confirmed by cytology from a thoracentesis. The patient, a non-smoker, began targeted therapy with tyrosine kinase inhibitors but declined further diagnostic evaluation. Despite the poor prognosis and palliative care options, the patient opted for discharge to home care. This case underscores the complexity of diagnosing lung pathologies and the importance of considering alternative diagnoses in persistent respiratory symptoms.

Hamman's syndrome - with audio file recording Hamman's sign.

A boy in his late adolescence, with no history of airway disease or medication use, presented with acute history of non-exertional chest pain increased on coughing and deep inspiration accompanied by dysphonia and odynophagia in the last 1 day. He had a notable history of viral fever with non-productive cough 2 weeks prior, which resolved spontaneously. Examination revealed stable haemodynamic parameters. Palpable non-tender crepitus was felt in left anterior chest wall, axilla and both sides of the neck. Auscultation revealed Hamman's sign. ECG showed high voltage complexes and 2-dimensional echocardiogram (2D ECHO) showed normal biventricular function. CXR was evident of subcutaneous emphysema, pneumopericardium and Naclerio's sign clinching the diagnosis of pneumomediastinum. CT findings were consistent with a diagnosis of Hamman's syndrome. Patient was admitted for observation and treated with high-flow oxygen. He improved symptomatically and was discharged on the fourth day of admission.

Assessment of left ventricular function in subjects with chronic obstructive pulmonary disease.

Chronic obstructive pulmonary disease (COPD) is the world's third leading cause of death, posing a significant public health challenge. Heart failure is an important milestone in the natural history of this disease's ever-decreasing course. Cor pulmonale alone is sometimes insufficient to explain the scenario, as many heart failures are refractory even after standard treatment. A possible explanation is involvement of the left ventricle (LV). However, there is currently no consensus on a therapeutic approach to LV dysfunction in COPD. Some previous studies were conducted on COPD patients regardless of the presence or absence of other factors influencing LV function. This study attempted to rule out all known confounding factors/co-morbidities that influence LV function. We discovered that LV diastolic dysfunction was common in subjects at all stages of COPD. We believe that all COPD patients, regardless of stage, should have screening echocardiography.

Hidden Behind a Veil: A Rare Case of Pulmonary Nocardiosis.

A 48-year-old male, a known case of seizure disorder, presented with complaints of cough for four months, which increased for two weeks, fever for two weeks and weight loss. Computed tomography (CT) scan of the thorax showed multiple heterogeneously enhancing lesions of bilateral lung fields predominantly in peribronchovascular distribution with enlarged, necrosed and conglomerated lymph nodes suggestive of infective etiology. On routine blood investigations, he was found to be reactive for the human immunodeficiency virus. He underwent bronchoscopy and bronchoalveolar lavage culture grew Nocardia. He was prescribed antibiotics based on susceptibility reports and the patient became symptomatically better after one month and was discharged.

Coccidioidomycosis where you least expect it.

An elderly man without history of travel presented with complaints of intermittent fever for 2 months, cough with scanty expectoration for 15 days and history of weight loss of 5 kg in 1 year. The chest X-ray and CT scan of the thorax showed dispersed centrilobular nodules and patchy subpleural consolidation in both lungs with mediastinal lymphadenopathy. He underwent bronchoscopy and bronchoalveolar lavage culture grew Pseudomonas aeruginosa He was prescribed antibiotics based on culture sensitivity; however, patient continued to have symptoms. All relevant blood investigations were within normal limits. He underwent CT-guided biopsy of the right lung lesion during which clearing of the radio-opacities present in the initial CT scan and appearance of fresh lesions in different locations were observed. Migratory shadows were suspected. Fine-needle aspiration cytology showed features suggestive of coccidioidomycosis for which antifungals were started. After 1 month, he improved symptomatically and chest X-ray showed clearance of shadows.

Pitfalls of AHI system of severity grading in obstructive sleep apnoea.

Obstructive sleep apnoea (OSA) is the major underlying co-morbidity in many of the non-communicable diseases (NCD) due to obesity as a common risk factor. Incidence and prevalence of OSA is on the constant rise ever since this entity came to forefront three decades ago. Precise treatment of underlying OSA is extremely important in major NCDs like diabetes mellitus, hypertension, endocrine disorders and vascular diseases. OSA is subcategorized in to mild, moderate and severe based of apnoea-hypopnea index (AHI). Based on the severity grading, treatment of OSA ranges from life style modifications to oral appliances, continuous positive airway pressure (CPAP) and surgeries. AHI system of severity grading in OSA has several inherent shortcomings and using AHI system for severity grading as the holy grail is likely to be counter-productive. AHI system equates apnoea and hypopnea as equal events, whereas physiological effects vary significantly. AHI system does not account duration of apnoea or body position during apnoeic events. We discuss at length the pitfalls of AHI system of severity grading in OSA.

Repertoires of MicroRNA-30 family as gate-keepers in lung cancer.

Lung cancer is a prominent global health issue responsible for the highest fraction of cancer-related mortality. The disease burden has incited the investigation of associated molecular pathways, to explore better therapeutic possibilities. MicroRNAs are extensively studied in recent years for their pivotal role in the regulation of several tumorigenic pathways. MicroRNA-30 (miR-30) family is primarily investigated in case of non-small cell lung cancer (NSCLC) and has been found to play the role of a tumour suppressor. There are six members of miR-30 family: miR-30a, miR-30b, miR-30c-1, miR-30c-2, miR-30d and miR-30e. They regulate several imperative signalling pathways like p53, PI3K/AKT, resulting in the modulation of key carcinogenic events involving cell proliferation, apoptosis, metastasis, epithelial-mesenchymal transition, and drug resistance. Their altered levels are documented in NSCLC tissue and blood samples. They are suggested as biomarkers of disease progression and therapeutic outcomes in lung cancer. They possess immense therapeutic potential in the treatment of lung cancer and combat the emerging problem of drug resistance by modulating prime regulatory axes. However, there are many limitations in the existing studies, and additional research is required for the comprehensive understanding of pathways so that the tumour suppressive potential of miR-30 can be translated into clinical benefits. In this review, we present a deeper understanding of the regulatory role and clinical significance of miR-30 and have emphasized the emerging roles in lung cancer.

Cardiac tamponade and massive pleural effusion in a young COVID-19-positive adult.

COVID-19 has a broad spectrum of cardiac manifestations, and cardiac tamponade leading to cardiogenic shock is a rare presentation. A 30-year-old man with a history of COVID-19-positive, reverse transcription polymerase chain reaction (RT-PCR) done 1 week ago and who was home-quarantined, came to the emergency department with palpitations, breathlessness and orthopnoea. His ECG showed sinus tachycardia with low-voltage complexes, chest X-ray showed cardiomegaly and left pleural effusion and two-dimensional echocardiography showed large pericardial effusion with features suggestive of cardiac tamponade. He was taken up for emergency pericardiocentesis which showed haemorrhagic pericardial fluid. Intercostal drainage insertion was done for left-sided large pleural effusion. After ruling out all the other causes for haemorrhagic pericardial effusion, the patient was started on colchicine, steroids, ibuprofen and antibiotics to which he responded. Both pericardial and pleural effusions resolved completely on follow-up.

Recurrent pleural effusion secondary to endometriosis: a rare malady.

Thoracic endometriosis is a rare entity, wherein thoracic endometrial tissue deposition occurs. Recurrent pleural effusion is one of its manifestations. Diagnosis and treatment are often challenging, owing to the rarity of the condition and recurrences. We present an interesting case of a young woman of childbearing age who presented with recurrent haemorrhagic pleural effusion. She was referred to our centre after her initial video-assisted thoracoscopic biopsy was inconclusive. She was re-evaluated, and video-assisted thoracoscopic biopsy confirmed thoracic endometriosis. She underwent pleurodesis two times and currently on hormonal treatment, maintaining well.

Titration of Ideal Positive End-expiratory Pressure in Acute Respiratory Distress Syndrome: Comparison between Lower Inflection Point and Esophageal Pressure Method Using Volumetric Capnography.

The tenets of mechanical ventilation in acute respiratory distress syndrome (ARDS) include the utilization of low tidal volume and optimal application of positive end-expiratory pressure (PEEP). Optimal PEEP in ARDS is characterized by reduction in alveolar dead space along with improvement in the lung compliance and resultant betterment in oxygenation. There are various methods of setting PEEP in ARDS. Herein, we report a patient of ARDS, wherein we employed measurement of dead space using volumetric capnography to compare two different PEEP strategies, namely, the lower inflection point and transpulmonary pressure monitoring.