Congenital bilio-bronchial fistula in an adult: a review of literature and video demonstration of laparoscopic fistula tract excision.

This article presents a review of the literature on congenital bilio-bronchial fistula (BBF), a rare anomaly characterized by abnormal communication between the bile duct and respiratory tract. Congenital BBF often presents with bilioptysis in early neonates and infants; however, patients with no overt symptoms may occasionally present in adulthood. Our literature search in Medline from 1850 to 2023 revealed 42 reported cases of congenital BBF, primarily managed with thoracotomy and excision of the fistula tract. About one-third of these cases required multiple surgeries due to associated biliary anomalies. The review underscores the importance of diagnostic imaging, including bronchoscopy, in identifying and delineating the extent of the fistula. It also highlights the evolving surgical management, with recent cases showing the efficacy of minimally invasive approaches such as laparoscopy and thoracoscopy. In addition to the literature review, we report a young female patient with a history of recurrent respiratory infections presenting with bilioptysis and extensive left lung damage. Initial management included bronchoscopy-guided glue instillation, left thoracotomy, and pneumonectomy. Following the recurrence of symptoms, the patient was successfully treated with laparoscopic excision of the fistula tract. In recent times, minimally invasive approaches such as laparoscopy and thoracoscopy, with excision of the fistula tract are gaining popularity and have shown good results. We suggest biliary communication being the high-pressure end, tackling it transabdominal may prevent recurrent problems.

Nil Intervention is at Times the Best Intervention: Benign emptying of pneumonectomy space.

A sudden drop of air-fluid level in the pneumonectomy space in the absence of a bronchopleural fistula and pleural infection is termed benign emptying of the pneumonectomy space (BEPS). We report a 28-year-old female patient who presented to a tertiary care referral centre, in Pondicherry, India in 2020 with multiple episodes of vomiting. Subsequent to a left-sided pneumonectomy due to tuberculosis, she was diagnosed with BEPS. Generally, patients with BEPS are clinically stable, afebrile with no fluid expectoration and have a normal white blood cell count. Bronchoscopy reveals an intact bronchial stump and pleural fluid cultures are often sterile. In terms of management, close monitoring and early detection of a bronchopleural fistula are the key points. BEPS should be a differential diagnosis in case of a drop in the air-fluid level of the post-pneumonectomy space. Awareness of this entity is crucial as it helps prevent unnecessary and morbid surgical interventions.

Guidelines for endobronchial ultrasound-transbronchial needle aspiration (EBUS-TBNA): Joint Indian Chest Society (ICS)/Indian Association for Bronchology (IAB) recommendations.

Over the past decade, endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) has become an indispensable tool in the diagnostic armamentarium of the pulmonologist. As the expertise with EBUS-TBNA has evolved and several innovations have occurred, the indications for its use have expanded. However, several aspects of EBUS-TBNA are still not standardized. Hence, evidence-based guidelines are needed to optimize the diagnostic yield and safety of EBUS-TBNA. For this purpose, a working group of experts from India was constituted. A detailed and systematic search was performed to extract relevant literature pertaining to various aspects of EBUS-TBNA. The modified GRADE system was used for evaluating the level of evidence and assigning the strength of recommendations. The final recommendations were framed with the consensus of the working group after several rounds of online discussions and a two-day in-person meeting. These guidelines provide evidence-based recommendations encompassing indications of EBUS-TBNA, pre-procedure evaluation, sedation and anesthesia, technical and procedural aspects, sample processing, EBUS-TBNA in special situations, and training for EBUS-TBNA.

Splenic Silicosis: A Rare Cause of Splenic Calcifications.

Silicosis, an occupational menace is an irreversible lung disease caused by inhalation of tiny particles of crystalline silica. It is an occupational hazard both in industrialized as well as developing nations. Thoracic involvement is commonly described following exposure to silica, but extrathoracic involvement is a rare occurrence and often an incidental finding. It can manifest as calcifications in the liver, spleen, abdominal, axillary and cervical lymph nodes in addition to intrathoracic involvement. Silicosis as a cause of splenic calcifications often gets buried under the common differentials like tuberculosis, acquired immunodeficiency syndromes, amyloidosis, and Gamna-Gandy bodies. We herein describe a case of chronic complicated silicosis with splenic calcifications which appear similar to intrathoracic calcifications.

Metastatic malignant peripheral nerve sheath tumor. A diagnostic surprise.

Malignant peripheral nerve sheath tumours (MPNSTs) are rare soft tissue tumors that arise from pre-existing plexiform neurofibromas or within a normal peripheral nerve. They are aggressive tumors with high rates of recurrence and distant metastases, the most common sites of metastasis being the lung followed by bone. A 46 year old gentleman presented with breathlessness and chest pain three years after post amputation of left thumb for an ulcerative growth. CECT thorax showed a left upper lobe mass with pleural and pericardial effusion. Within a month of presentation he worsened and succumbed to the disease. Antemortem biopsy of the left hand ulcerative growth showed features suggestive of malignant peripheral nerve sheath tumour- epithelioid variant and post mortem liver and lung biopsy showed metastasis of MPNST. The diagnosis was a malignant peripheral nerve sheath tumor with lung, liver and cardiac metastasis. This case report aims to highlight the importance of upfront aggressive multimodality local therapy for achieving local disease control in patients presenting with localised MPNST and regular follow up for early detection of relapse and metastasis.

Streptomyces pneumonia in an immunocompetent adult - a rare isolate.

Streptomyces belongs to the Actinomycetes group of bacteria which are gram-positive non acid-fast bacilli, widely recognised for their potential to produce antimicrobials active against bacterial, mycobacterial, parasitic and fungal infections. They commonly cause cutaneous infections following traumatic inoculation. Visceral infections are relatively rare and limited to immunocompro-mised hosts. We describe a case of Streptomyces pneumonia in a healthy immunocompetent female, who when investigated for voluntary kidney donation, resulted in the isolation of Streptomyces species from bronchial wash cultures. Streptomyces, a potential pathogen in immunocompetent hosts is frequently underdiagnosed. Once isolated, both physicians and microbiologists should pay attention to differentiate true infection from contamination.

Spontaneous pneumomediastinum, pneumopericardium and subcutaneous emphysema in a case of interstitial pneumonia with autoimmune features.

Spontaneous Pneumomediastinum (SPM) is a benign, self-limiting but potentially fatal condition specially in underlying pulmonary disease. Spontaneous pneumomediastinum is rarely associated with connective tissue related interstitial lung disease. We report a patient of interstitial pneumonia with autoimmune features who presented with acute onset breathlessness and was diagnosed to have spontaneous pneumomediastinum, pneumopericardium, and subcutaneous emphysema. This condition are easily diagnosed by clinical findings like Hamman's crunch and plain chest radiographs in cases with normal underlying lungs. In cases of extensive pulmonary fibrosis like Interstitial Lung Diseases both clinical findings and Plain chest radiographs can be inconclusive. CT of thorax is the gold standard diagnostic modality. Pneumopericardium rarely leads to cardiac tamponade, which requires immediate surgical intervention. We conclude that every case of acute onset breathlessness in a known case of interstitial lung disease may not necessarily be an exacerbation of the underlying lung condition. Physicians need to have a high index of suspicion while treating patients of interstitial lung disease. CT thorax is gold standard diagnostic modality especially in presence of fibrotic lung diseases.