Exudative pleural effusion during sunitinib treatment.

Drug-induced pleural effusion is one of the rare causes of exudative pleural effusion and a high index of suspicion is necessary to lead to early diagnosis. We hereby present the case of a young male in his late 30s, known case of metastatic gastrointestinal stromal tumour on sunitinib therapy, who presented with right-sided mild pleural effusion. Diagnostic thoracentesis showed the effusion to be a monomorphic exudate with low adenosine deaminase, which was negative for malignant cells on cytopathology. A contrast-enhanced CT chest revealed an enlarged lymph node (LN) at the 4R station, cytological analysis of which was suggestive of reactive lymphoid hyperplasia. Infective workup of the LN aspirate and bronchoalveolar lavage taken from the right middle lobe was negative. After systematically excluding the usual causes of exudative pleural effusion, sunitinib was considered to be a possible cause and was, therefore, withheld. A repeat chest X-ray after 3 weeks of stopping the drug showed resolution of the pleural effusion.

Amoxicillin Induced Fever, Rash, and Catatonia - A Case Study.

INTRODUCTION: Adverse drug reactions (ADR) are defined as any harmful or unpleasant events or injuries resulting from the use of any particular drug. Among those antibiotics that cause adverse reactions, amoxicillin is one of them. Catatonia and vasculitic rash are its rare adverse effects. CASE PRESENTATION: A 23-year-old postpartum female, with a history of taking empirical Amoxiclav (amoxicillin-clavulanic acid 625 mg) injection and oral tablets for episiotomy wound, presented with altered sensorium and fever followed by maculopapular rash. On examination, she had generalized rigidity with waxy flexibility that improved by lorazepam challenge and was diagnosed as catatonia. On evaluation, amoxicillin was found to be precipitating catatonia in this patient. CONCLUSION: Since the diagnosis of catatonia is often missed, any cases with clinical presentation of fever, rash, altered sensorium, and generalized rigidity should also be suspected for druginduced ADR and the precipitating factor should be searched for.

Comparison of Patient's Procedural Tolerance of EBUS-TBNA Performed Through Nasal Versus Oral Route: The NO-EBUS Randomized Clinical Trial.

BACKGROUND: Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) is a commonly performed procedure by the bronchoscopist for the evaluation of mediastinal lesions. However, evidence directly comparing the nasal and oral routes to guide the choice of an optimal insertion approach is scanty. METHODS: In this prospective, parallel-group, open-label randomized clinical trial, adults posted for a linear EBUS-TBNA examination under conscious sedation were randomized to undergo the procedure via the nasal or oral route. The primary objective was to assess the equivalence of subject-rated tolerance of EBUS-TBNA procedure in the 2 groups. Key secondary objectives were to assess the equivalence of subject-rated overall experience, willingness for a repeat procedure, operator-rated subject's tolerance, and operator-rated ease of performing the procedure. RESULTS: One hundred and eighty subjects were randomized in a 1:1 ratio to the nasal (n=98) or oral (n=82) group. Outcome measures were assessed by both per-protocol (PP) and intention-to-treat (ITT) analysis. Subject-rated procedural tolerance, overall satisfaction and operator's ease of performing the procedure were found to be equivalent in the 2 groups ( P <0.05 in all cases for PP and ITT analysis). The operator-rated subject's tolerance was, however, nonequivalent ( P =0.0596, 0.1286 for PP and ITT, respectively). Subject's willingness to undergo a repeat procedure was similar in both groups [90% CI of difference in proportions: (-0.023, 0.121) in PP and (-0.028, 0.115) in ITT analysis]. CONCLUSION: Nasal route for EBUS-TBNA could be considered where it is feasible and preferable for the patient as well as the operator.

Management of post-traumatic tracheal stenosis with silicone stent placement.

Benign airway stenosis often poses a therapeutic challenge and requires a multidisciplinary approach involving interventional pulmonologists and thoracic surgeons. We report the case of a man who presented with thoracic trauma following a road traffic accident. His chest X-ray showed complete collapse of the right lung, while screening flexible bronchoscopy revealed pooled secretions and asymmetric mid-to-lower tracheal stenosis. After thorough clinicoradiological evaluation and multidisciplinary discussion, we proceeded with therapeutic rigid bronchoscopy and silicone stenting of the tracheal stenotic lesion. Post-procedure, the patient improved clinically and also showed radiological improvement. Subsequently, he underwent stent removal and remains in follow-up. While surgery is a definitive modality for management of benign tracheal stenosis, most patients with advanced disease, pneumonia or with poor general condition are unfit to tolerate general anaesthesia or surgery. In such patients, minimally invasive bronchoscopic techniques that are generally safe to perform have led to substantial improvement in symptoms and long-term quality of life.

Predictors of Poor Outcome in Patients with COVID-19 associated Respiratory Failure: A Retrospective Observational Study.

BACKGROUND: Coronavirus disease 2019 (COVID-19) is majorly known to cause mild to moderate disease, but a small fraction of patients may develop respiratory failure due to diffuse lung injury, requiring management in the intensive care unit (ICU). This study attempts to identify factors that can predict unfavorable outcomes in moderate to severe COVID-19 patients. METHODS: Hospital records of 120 COVID-19 patients admitted to the ICU were retrospectively analyzed and data pertaining to demographic, clinical, and laboratory parameters were obtained. These data were then compared with outcome parameters like survival, duration of hospital stay, and various adverse events. RESULTS: Out of 120 patients, 70% were male, with a mean age of 54.44 years [standard deviation (SD) ± 14.24 years]. Presenting symptoms included breathlessness (100%), cough (94.17%), fever (82.5%), and sore throat (10.83%). Diabetes, hypertension, and chronic obstructive pulmonary disease (COPD) were the common comorbidities associated. Increased serum D-dimer, ferritin, interleukin-6 (IL-6) levels, and unvaccinated status were associated with higher mortality. Overall, 25.83% of patients survived, 24.41% of patients developed septic shock, and 10.6% of patients were discharged on oxygen. World Health Organization (WHO) clinical progression scale score ≥ 6 had 57 and 82% sensitivity and 83 and 77% specificity on days 7 and 14 after admission, respectively, for predicting mortality. A baseline National Early Warning Score 2 (NEWS 2) ≥ 9 had 48% sensitivity and 88% specificity for predicting mortality. CONCLUSION: Advanced age and associated comorbidities are linked to adverse outcomes in moderate to severe COVID-19. Persistently high D-dimer levels, despite standard treatment, may also contribute to increased mortality. WHO clinical progression scale and NEWS 2 have high specificity for predicting mortality.

Comparative Study Between the First and Second Wave of COVID-19 Deaths in India: A Single Center Study.

Introduction  The severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) is continuously evolving, and many mutant variants of the virus are circulating in the world. Recurrent waves of COVID-19 have caused enormous mortality all across the globe. Considering the novelty of the virus, it becomes crucial for healthcare experts and policymakers to understand the demographic and clinical attributes of inpatient deaths in the first and second waves of COVID-19. Methods This hospital record-based comparative study was conducted at a tertiary care hospital in Uttarakhand, India. The study included all COVID-19 RT PCR-positive patients admitted to the hospital during the first wave, from 1st April 2020 to 31st January 2021, and the second wave from 1st March 2021 to 30th June 2021. Comparisons were made with respect to demographic, clinical, laboratory parameters, and course of hospital stay. Results The study exhibited 11.34% more casualties in the second wave, with the number of deaths being 424 and 475 for the first and second waves, respectively. A male preponderance of mortality was evident in both waves with significant differences (p=0.004). There was no significant difference in age between the two waves (p=0.809). The significantly different comorbidities were hypertension (p=0.003) and coronary artery disease (p=0.014). The clinical manifestations demonstrating a significant difference were cough (p=0.000), sore throat (p=0.002), altered mental status (p=0.002), headache (p=0.025), loss of taste and smell (p=0.001), and tachypnea (p=0.000). The lab parameters with a significant difference across both waves were lymphopenia (p=0.000), elevated aspartate aminotransferase (p=0.004), leukocytosis (p=0.008), and thrombocytopenia (p=0.004). During the hospital course of the second wave, in terms of intensive care unit stay, the need for non-invasive ventilation and inotrope support was higher. The complications manifesting in the form of acute respiratory distress syndrome and sepsis were observed more in the second wave. A significant difference was discerned in the median duration of hospital stay in both waves (p=0.000). Conclusion Despite being of shorter duration, the second wave of COVID-19 culminated in more deaths. The study demonstrated that most of the baseline demographic and clinical characteristics attributed to mortality were more common during the second wave of COVID-19, including lab parameters, complications, and duration of hospital stays. The unpredictable nature of COVID-19 waves calls for instituting a well-planned surveillance mechanism in place to identify the surge in cases at the earliest possible time and prompt response, along with developing infrastructure and capacity to manage complications.

Haunted cave appearance during bronchoscopy: A new sign in post-tuberculosis destroyed lung.

A middle-aged, non-smoker male presented with exertional breathlessness and occasional productive cough for last two years. He had successfully completed anti-tuberculosis treatment twice in the past for microbiologically confirmed drug-sensitive pulmonary tuberculosis (TB). Upon consultation at our centre, the patient was sputum negative and imaging was suggestive of destroyed lung on the right side. Spirometry revealed airflow obstruction, and a diagnosis of post-tuberculosis obstructive lung disease was rendered. As part of an Institutional Ethics Committee-approved post-doctoral thesis protocol, this patient underwent a bronchoscopic airway evaluation wherein an unusual bronchoscopic appearance of post-tuberculosis destroyed lung was noted. We named this as the 'haunted cave sign' and believe Pulmonologists should be familiar with this appearance and its significance to ensure correct identification, given its common occurrence in high-burden TB endemic countries.

Recurrent Hemoptysis in an Adult Patient With an Unfamiliar Cause.

Most adult patients who experience recurrent hemoptysis have respiratory or coagulopathy-related causes and cardiac aetiology in very few cases. In this rare case of 56 years aged male patient who presented to us with chronic recurrent hemoptysis, Tetralogy of Fallot (TOF) was the culprit aetiology, and he was successfully managed by minimal intervention.

Five Versus 10 Pharyngeal Sprays of 10% Lignocaine for Topical Anesthesia During Flexible Bronchoscopy: A Multicenter, Randomized Controlled Trial.

BACKGROUND: Ensuring adequate patient comfort is crucial during bronchoscopy. Although lidocaine spray is recommended for topical pharyngeal anesthesia, the optimum dose of sprays is unclear. We compared 5 versus 10 sprays of 10% lidocaine for topical anesthesia during bronchoscopy. METHODS: In this investigator-initiated, prospective, multicenter, randomized clinical trial, subjects were randomized to receive 5 (group A) or 10 sprays (group B) of 10% lidocaine. The primary objective was to compare the operator-rated overall procedure satisfaction between the groups. RESULTS: Two hundred eighty-four subjects were randomized (143 group A and 141 group B). The operator-rated overall procedure satisfaction, VAS [mean (SD)] was similar between the groups [group A, 74.1 (19.9) and group B, 74.3 (18.5), P =0.93]. The VAS scores of patient-rated cough [group A, 32.5 (22.9) and group B, 32.3 (22.2), P =0.93], and operator-rated cough [group A, 29.8 (22.3) and group B, 26.9 (21.5), P =0.26] were also similar. The time to reach vocal cords, overall procedure duration, mean doses of sedatives, the proportion of subjects willing to return for a repeat procedure (if required), and complications were not significantly different. Subjects in group A received significantly less cumulative lidocaine (mg) [group A, 293.9 (11.6) and group B, 343.5 (10.6), P <0.001]. CONCLUSION: During bronchoscopy, topical anesthesia with 5 sprays of 10% lidocaine is preferred as it is associated with a similar operator-rated overall procedure satisfaction at a lower cumulative lidocaine dose compared with 10 sprays.

Primary pulmonary undifferentiated pleomorphic sarcoma: A rare malignant lung tumor.

ABSTRACT: Undifferentiated Pleomorphic Sarcoma (UPS) is a common soft tissue sarcoma that can develop in various organs, but lung involvement is usually due to metastasis. UPS originating primarily in the lungs is called primary pulmonary undifferentiated pleomorphic Sarcoma (PPUPS) and is exceptionally rare. It is a high-grade pleomorphic neoplasm with no identifiable lines of differentiation. Thus, it is essentially a diagnosis of exclusion that requires extensive clinical, radiographic and histopathological evaluation. Herein we report the case of a 49-year-old gentleman who presented with anemia and weight loss and was found to have a large right lung mass. The lesion was diagnosed as PPUPS after detailed histopathological, immunohistochemical and molecular analysis and exclusion of a possible extrapulmonary origin.

Novel use of metallic stent to control post-debulking bleeding in a patient with central airway obstruction.

Bronchoscopy-related bleeding is often encountered and is usually self-limiting or controllable by conservative measures. However, major bleeds can be life threatening for the patient as well as challenging for the physician to manage. There are several methods to achieve adequate haemostasis should a significant airway bleed occur. In this context, we describe a patient who had a post-bronchoscopic debulking bleed which persisted despite use of all available measures, and we deployed a self-expanding metallic stent in an attempt to control it. To the best of our knowledge, this is the first instance of a metallic airway stent being used to control bronchoscopy associated bleeding, though reports of its usage in management of intractable haemoptysis exist in the literature.

Clinical Profile, Risk Factors, and Therapeutic Outcome of Cavitating Fungal Pneumonia Coinfection in COVID-19 Patients: A Retrospective Analysis.

BACKGROUND: An end to the novel coronavirus disease 2019 (COVID-19) pandemic appears to be a distant dream. To make matters worse, there has been an alarming upsurge in the incidence of cavitating invasive fungal pneumonia associated with COVID-19, reported from various parts of the world including India. Therefore, it remains important to identify the clinical profile, risk factors, and outcome of this group of patients. METHODS: Out of 50 moderate to severe COVID-19 inpatients with thoracic computed tomographic (CT) evidence of lung cavitation, we retrospectively collected demographic and clinical data of those diagnosed with fungal pneumonia for further investigation. We determined the association between risk factors related to 30-day and 60-day mortality. RESULTS: Of the 50 COVID-19 patients with cavitating lung lesions, 22 (44 %) were identified to have fungal pneumonia. Most of these patients (n = 16, 72.7 %) were male, with a median (range) age of 56 (38-64) years. On chest CT imaging, the most frequent findings were multiple cavities (n = 13, 59.1 %) and consolidation (n = 14, 63.6 %). Mucormycosis (n = 10, 45.5 %) followed by Aspergillus fumigatus (n = 9, 40.9 %) were the common fungi identified. 30-day and 60-day mortalities were seen in 12 (54.5 %) and 16 (72.7 %) patients, respectively. On subgroup analysis, high cumulative prednisolone dose was an independent risk factor associated with 30-day mortality (p = 0.024). CONCLUSION: High cumulative prednisolone dose, baseline neutropenia, hypoalbuminemia, multiple cavities on CT chest, leukopenia, lymphopenia and raised inflammatory markers were associated with poor prognosis in severe COVID-19 patients with cavitating fungal pneumonia.

Demonstration of Entanglement-Enhanced Covert Sensing.

The laws of quantum physics endow superior performance and security for information processing: quantum sensing harnesses nonclassical resources to enable measurement precision unmatched by classical sensing, whereas quantum cryptography aims to unconditionally protect the secrecy of the processed information. Here, we present the theory and experiment for entanglement-enhanced covert sensing, a paradigm that simultaneously offers high measurement precision and data integrity by concealing the probe signal in an ambient noise background so that the execution of the protocol is undetectable with a high probability. We show that entanglement offers a performance boost in estimating the imparted phase by a probed object, as compared to a classical protocol at the same covertness level. The implemented entanglement-enhanced covert sensing protocol operates close to the fundamental quantum limit by virtue of its near-optimum entanglement source and quantum receiver. Our work is expected to create ample opportunities for quantum information processing at unprecedented security and performance levels.

Tracheal bronchus: a rare cause of recurrent pneumonia in adults.

Tracheal bronchus, also known as bronchus suis, is a rare congenital anomaly of the airway where an accessory bronchus originates directly from the trachea. With an estimated incidence of 0.001%-2.0%, this condition is rarely reported in literature. It is usually discovered as an incidental finding in an otherwise asymptomatic individual. However, it can act as a focus of recurrent infection or present as persistent radiographic infiltrates. Multidetector CT imaging and bronchoscopy play a crucial role in the identification of this entity. We hereby report the case of a middle-aged man who presented with recurrent right upper lobe pneumonia, which was found to be due to an underlying tracheal bronchus.

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.

Vaccination-associated immune thrombocytopenia possibly due to ChAdOx1 nCoV-19 (Covishield) coronavirus vaccine.

Immune thrombocytopenia (ITP) is an acquired haemorrhagic diathesis of immune-mediated destruction, impaired production or increased splenic sequestration of platelets. It can be idiopathic (primary) or secondary (infections, medications, HIV infection, malignancies, connective tissue diseases or rarely secondary to vaccination). ITP postvaccination is termed vaccine-associated ITP (VITP) and is known to be caused by vaccines against various infectious agents such as measles-mumps-rubella, Haemophilus influenzae, pneumococcus, hepatitis B virus and human papilloma virus. Cases of VITP post SARS-CoV-2 vaccination have also been reported in the literature. Various hypotheses on the occurrence of the same are theorised, but no single theory has been proven to cause VITP conclusively. Management includes routine treatment of ITP with use of agents such as steroids, intravenous immunoglobulins, or on rare occasions a thrombopoietic agent or vinca alkaloids. We present a case of VITP possibly due to ChAdOx1 nCoV-19 (Covishield) vaccination in a middle-aged woman who responded to steroid therapy.

Primary pleural liposarcoma: a rare differential for an opaque hemithorax.

Primary pleural liposarcoma (PPL) is a rare primary malignant pleural tumour originating from primitive mesenchymal tissue. We report the case of a 25-year-old man with a 6-week history of shortness of breath, cough, chest pain and hoarseness of voice. Chest X-ray showed a left opacified hemithorax, and thoracic CT scan revealed a large, heterogeneous, hypodense mass in the left hemithorax. The patient was taken up for ultrasound-guided core biopsy of the mass lesion, and histopathological examination revealed the diagnosis as a pleomorphic variant of PPL. We highlight the importance of considering PPL as a differential diagnosis in cases of large hemithoracic masses.

Management of chronic respiratory diseases during viral pandemics: A concise review of guidance and recommendations.

Coronavirus disease 2019 (COVID-19), caused by the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2), is an acute respiratory disease that can lead to respiratory failure and death. Although anticipated that patients with chronic respiratory diseases would be at increased risk of SARS-CoV-2 infection and more severe presentations of COVID-19, it is striking that these diseases appear to be underrepresented in the comorbidities reported for patients with COVID-19. The first wave of COVID-19 has taught us important lessons concerning the enormous burden on the hospitals, shortage of beds, cross infections and transmissions, which we coped together. However, with the subsequent waves of COVID-19 or any other viral pandemic, to ensure that patients with respiratory illnesses receive adequate management for their diseases while minimizing their hospital visits for their own safety. Hence, we prepared an evidence-based summary to manage outpatients and inpatients suspected or diagnosed with COPD, asthma and ILD based on the experience of the first wave of COVID-19 and recommendations by expert societies and organizations.

Molecular characterization of lung carcinomas: A study on diagnostic, predictive, and prognostic markers using immunohistochemical analysis at a Tertiary Care Center in Uttarakhand, India.

INTRODUCTION: Focused studies in different geographic regions would delineate the underlying biological differences and molecular alterations in non-small cell lung cancer (NSCLC) worldwide. Previous studies in literature have documented limited characterization by studying a minimal number of biological markers. This study was done to evaluate expression of multiple immunomarkers including diagnostic, prognostic, and predictive markers in NSCLC for its characterization. MATERIALS AND METHODS: This was an observational study conducted on 60 consecutive cases of NSCLC. Immunomarkers comprising of p63, p40, TTF-1, napsin A, B-Raf, c-Met, phospho-AKT (P-AKT), PTEN, anaplastic lymphoma kinase (ALK), epidermal growth factor receptor (EGFR) and K-Ras, synaptophysin, chromogranin and pan-cytokeratin were evaluated on paraffin-embedded tissue sections of NSCLC. RESULTS: Age of patients with NSCLC in our study ranged from 35 to 90 years, and 93.3% of them were chronic smokers. 93.3% of cases presented in late stages (Stages III and IV) and 78% of cases were squamous cell carcinoma (SCC). EGFR positivity was noted in 83.3% of cases. ALK was positive in one case while C-Met and PTEN immunopositivity was noted in only two cases. Ten cases showed positivity for K-Ras and 90% of these were SCC. Ten cases were positive for B-Raf and 80% of these were SCC. 30% of cases showed immunopositivity for P-AKT. None of the molecular markers was found to have statistically significant correlation with clinicopathological parameters. CONCLUSION: SCC is the predominant histological subtype of NSCLC in the region of Uttarakhand, India, with a high proportion of cases harboring EGFR mutation. Variable expression of K-Ras, P-AKT, ALK 1, and PTEN in NSCLC signifies that molecular profile of every case is individualistic and independent. We attribute this to ethnicity, influence of implicated substance or metabolite in tobacco, and variable mutations incurred in tumor cells over a period of time.