Pulmonary infarction mimicking a lung mass: a case report.

Pulmonary infarction usually appears as a wedge-shaped opacity with its base placed laterally. Rarely, pulmonary infarctions may appear as a well-defined rounded opacity mimicking lung cancer and surgical lung biopsy may often be required for definitive diagnosis. We report a patient who was admitted with submassive pulmonary embolism who had an incidental finding of a well-defined opacity in computed tomography (CT) scan. The lesion was avid on positron emission tomography (PET) scan and the patient was a smoker. So, we investigated him further with a percutaneous and later a thoracoscopic lung biopsy. Tumour-like pulmonary infarction is often a challenge for the clinicians.

Hypercalcaemia: A portent of sarcoidosis in cystic fibrosis.

The coexistence of cystic fibrosis (CF) and sarcoidosis is rare. We report a 22-year-old male cystic fibrosis patient who presented multiple times to the Sultan Qaboos University Hospital, Muscat, Oman, in 2013. He was diagnosed with non-parathyroid-related hypercalcaemia and anterior uveitis, while computed tomography revealed mediastinal and abdominal lymphadenopathy and mild hepatosplenomegaly. These findings, in addition to the presence of calciuria and a high angiotensin-converting enzyme (ACE) level, confirmed a clinical diagnosis of sarcoidosis. The patient responded well to treatment with oral prednisolone which, over the course of two years, resulted in the near-complete resolution of parenchymal nodular infiltrates, regression of hilar lymphadenopathy, resolution of hypercalcaemia and the normalisation of his ACE levels. Diagnosing pulmonary sarcoidosis in CF can be challenging as most adult patients already have extensive lung disease. Physicians should be aware that hypercalcaemia may be an early manifestation of sarcoidosis in such cases.

Clinical features of Sarcoidosis in Oman: A report from the Middle East region.

BACKGROUND: Though clinical features of sarcoidosis follow a similar pattern, some heterogeneity is seen in different ethnic and racial groups. OBJECTIVES: To describe for the first time the clinical characteristics of sarcoidosis patients in the Sultanate of Oman. METHODS: The data on all cases of sarcoidosis followed up in the two tertiary hospitals in Oman were retrieved retrospectively. RESULTS: Of the 92 patients, for representing the ethnic data only Omani patients (n=83) were included. The mean age was 52.90±12.35 years. Majority were females (72.3%, n=60). Cough (n=44, 53.0%), dyspnea (n=39, 47%), arthralgia (n=26, 31.3%) and fatigue (30.1%) were the major symptoms. Arthralgia was reported by 41.7% of the females and 4.3% of the males (p= 0.001). Uveitis was present in 16 (19.3%), erythema nodosum in 8 (9.6%) and hypercalcemia in 13 (15.7%). The radiological stage at presentation was stage 0, 18.7%; I, 28%; II, 17.3%; III, 24% and IV, 12%. Majority (61.4%) of the patients had tissue diagnosis; intra-thoracic site 70.6%. Pulmonary function showed abnormal diffusion in 75%. Sixty eight received treatment, 81.9% took prednisolone. Based on radiograph good outcome (Resolving) was noted in 20.9%, intermediate (Stable) in 73.1% and poor (Progressive) in 6%. Lung function wise, resolving, stable and progressive disease was seen in 31.4%, 40.0% and 28.6% respectively. CONCLUSION: The clinical picture of the patients with sarcoidosis from Oman was similar to that reported from the rest of the world. Region wise, our patients were older and arthralgia and hypercalcemia were more common. The management of sarcoidosis needs a more organized approach in the country with clear guidelines on monitoring and treatment.

Varicella zoster virus pneumonitis and brainstem encephalitis without skin rash in an immunocompetent adult.

Varicella zoster virus (VZV) pneumonitis and brainstem encephalitis developed in an immunocompetent adult without rash. Chest computed tomography exhibited nodularity; lung biopsy revealed multinucleated giant cells, Cowdry A inclusions, VZV antigen, and DNA. Varicella zoster virus central nervous system disease was verified by cerebrospinal fluid (CSF) anti-VZV IgG antibody with reduced serum/CSF ratios.

Severe Pulmonary Involvement in Leptospirosis: Alternate antibiotics and systemic steroids.

Pulmonary complications in leptospirosis, though common, are often unrecognized in a non-endemic area. We report here a patient with leptospirosis and severe pulmonary involvement who was treated with meropenem (1 g every 8 hours), moxifloxacin (400 mg once daily), and high doses of corticosteroids. Systemic steroids were continued for 3 months because of persistent pulmonary lesions.

Is Clinical Judgment of Asthma Control Adequate?: A prospective survey in a tertiary hospital pulmonary clinic.

OBJECTIVES: Asthma control is often difficult to measure. The aim of this study was to compare physicians' personal clinical assessments of asthma control with the Global Initiative for Asthma (GINA) scoring. METHODS: Physicians in the adult pulmonary clinics of a tertiary hospital in Oman first documented their subjective judgment of asthma control on 157 consecutive patients. Immediately after that and in the same proforma, they selected the individual components from the GINA asthma control table as applicable to each patient. RESULTS: The same classification of asthma control was achieved by physicians' clinical judgment and GINA classification in 106 cases (67.5%). In the other 32.5% (n = 51), the degree of control by clinical judgment was one level higher than the GINA classification. The agreement was higher for the pulmonologists (72%) as compared to non-pulmonologists (47%; P = 0.009). Physicians classified 76 patients (48.4%) as well-controlled by clinical judgment compared to 48 (30.6%) using GINA criteria (P <0.001). Conversely, they classified 34 patients (21.7%) as uncontrolled as compared to 57 (36.3%) by GINA criteria (P <0.001). In the 28 patients who were clinically judged as well-controlled but, by GINA criteria, were only partially controlled, low peak expiratory flow rate (PEFR) (46.7%) and limitation of activity (21.4%) were the most frequent parameters for downgrading the level of control. CONCLUSION: Using clinical judgment, physicians overestimated the level of asthma control and underestimated the uncontrolled disease. Since management decisions are based on the perceived level of control, this could potentially lead to under-treatment and therefore sub-optimal asthma control.

Development of acute ischemic stroke in a patient with acute respiratory distress syndrome (ARDS) resulting from H1N1 pneumonia.

Pneumonia due to H1N1 infection is now very common. We report a case of ischemic stroke which arose subsequently to H1N1 influenza. The patient was a female who developed acute respiratory distress syndrome (ARDS) after H1N1 influenza, was ventilated as per standard protocol and started treatment with oseltamivir. When sedation was stopped during weaning from the ventilator, she was found to have left hemiparesis resulting from multiple infarctions in the brain. Contrary to thrombocytosis usually seen in acute influenza, the platelet counts in our patient actually dropped. We suspected that increased interleukin release or stickiness of the platelets might have caused this ischemic stroke. In the course of time, she had acceptable neurological recovery following treatment with aspirin and neuro-rehabilitation. This case report provides evidence that a rare, debilitating complication like stroke can occur in H1N1 infection. A high index of suspicion of the probability of a cerebrovascular event should be borne in mind and regular neurological assessment should be done in such cases.

Laparoscopic loop ileostomy reversal: reducing morbidity while improving functional outcomes.

INTRODUCTION: Loop ileostomy reduces the morbidity associated with pelvic sepsis. However, its reversal carries a 10% to 30% complication rate. We present our technique for laparoscopic ileostomy closure. METHODS: We conducted a retrospective chart review of subjects undergoing laparoscopic-assisted loop ileostomy closure between 2006 and 2009. Operating time, length of hospital stay, return of bowel function, and complication rates were assessed. RESULTS: There were 24 (13 males) patients. Average age was 63 with a BMI of 25.9. Eighteen (75%) had a planned loop ileostomy, and 6 (25%) were emergent. Average time to reversal was 135 days. Average length of surgery was 79 minutes (range, 48 to 186), average stay was 4 days and return to bowel function was 3.6 days. We had no wound infections. Our complication rate was 29% (n=7), and reoperation rate was 12.5% (n=3). Only 1 major complication occurred, an anastomotic dehiscence. CONCLUSION: A thorough, well-visualized lysis of adhesions and mobilization of the stoma and surrounding small bowel is the main advantage of our approach. We had no wound infections and no reoperation for bowel obstruction, which we feel is a direct advantage of our technique. Our complication rate and surgical time are comparable to those of the open technique.

Needlescopic cholecystectomy.

Minimally invasive techniques have revolutionized the art of surgical practice. The laparoscopic approach to cholecystectomy has become the gold standard and is the most common laparoscopic general surgery procedure worldwide. In an effort to further enhance the advantages of laparoscopic surgery even less-invasive methods have been attempted, including smaller and fewer incisions. The objective of this study was to describe our results with over 15 years of needlescopic cholecystectomies. At the Texas Endosurgery Institute, 434 operations were done by a single surgeon from 1995 to 2010. Eighty-six percent of subjects were female, and the average age of all subjects was 41.9 years (range 14-82). The average operating time was 59.3 minutes (range 30-200). The 200-minute operation required laparoscopic CBD exploration, accounting for the extended time. Average estimated intraoperative blood loss (EBL) was <15 cc (range 0-50 cc). Two percent of cases required conversion to standard 5-mm cholecystectomy and were completed without incident. All patients are followed up at two weeks and then at six months. Since 1995, only one patient presented with a hernia at the umbilical site. Otherwise, no wound, bile duct, bile leak, bleeding, or thermal injury complications have been identified.

Management and control of asthma in patients attending a specialist centre in oman.

OBJECTIVES: The management of asthma by specialists is likely to become more evidence-based. This study analysed the characteristics of patients reporting to a specialist clinic including demographics, dispensed medications and the level of asthma control. METHODS: All consecutive stable asthmatics seen in the adult pulmonary clinics of Sultan Qaboos University Hospital, Oman, between December 2005 and November 2006 were prospectively evaluated using a structured assessment protocol. RESULTS: Of the 207 patients, (mean age 40.64 ±14.8), 72% were females. The majority, 83.1%, had moderate persistent asthma. A positive history of allergic rhinitis, eczema and a family history of asthma were obtained in 58.0%, 11.1%, and 50.7% of patients respectively. Total serum immunoglobulin E (IgE) was elevated in 66.7%. Skin testing was positive for more than 2 antigens in 52.3%, with the house dust antigen being reactive in 49%. Inhaled steroids, long-acting beta agonists (LABA), antihistamines and leukotriene receptor antagonists were prescribed in 94.2%, 85%, 54.5% and 11.6% of cases respectively. The majority (40.1%) was receiving medium dose inhaled steroids. Although asthma was controlled in 162 (78.3%), during the previous month 66 (31.9%) patients had visited the emergency department and 31 (15.0%) patients were hospitalised at least once during the previous year. Only 63 (30.4%) patients were using their inhalers correctly. Good compliance with inhaled steroids was observed in only 53 (25.6%) patients. CONCLUSION: Allergic comorbidities and a strong family history of asthma were common. Although the level of asthma control in the previous month was high, it was much lower in the long term. The concepts of short term, long term and total control of asthma need to be explored.

Absence of Left Pulmonary Artery: Case report.

Agenesis and hypoplasia of left-sided pulmonary artery anomalies have been infrequently reported. The majority of cases are diagnosed in childhood, but occasionally some asymptomatic cases are first recognised in adulthood when detected by an abnormal chest radiograph. We report a twenty-one year old female patient with left pulmonary artery agenesis who was asymptomatic till adulthood, but presented with mild respiratory symptoms and an abnormal chest X-ray. A contrast enhanced computerised tomography (CECT) scan helped to establish the diagnosis. Early diagnosis of this condition is essential to avert potentially lethal complications.

CT bronchoscopy in the diagnosis of Williams-Campbell syndrome.

Williams-Campbell syndrome, a rare disorder, is characterized by a congenital deficiency of cartilage, typically involving the fourth to the sixth order bronchi, and resulting in expiratory airway collapse and bronchiectasis. The authors report a patient with Williams-Campbell syndrome with type II respiratory failure due to extensive cystic bronchiectasis and secondary emphysema. CT of the thorax showed the affected bronchi had characteristic ballooning on inspiration and collapse on expiration. Three-dimensional images of the tracheobronchial tree were constructed from a volume of data acquired by thin-slice CT scanning. Apart from confirming expiratory collapse of the affected bronchi, these images revealed an absence of the cartilage ring impressions in the bronchial wall, extending bilaterally from the mainstem down to subsegmental bronchi, suggesting cartilage deficiency.