Accuracy of TB-PCR using endobronchial ultrasound guided trans-bronchial needle aspiration (EBUS-TBNA) samples in mediastinal granulomatous lymphadenopathy.

INTRODUCTION: Mediastinal granulomatous lymphadenopathies, such as tuberculous lymphadenitis, sarcoidosis, are frequently encountered by respiratory physicians, and their diagnosis is based on histological and microbiological tests. Endobronchial ultrasound-guided Trans bronchial needle aspiration (EBUS-TBNA) is widely used to perform mediastinal lymph node sampling. However, very limited data is available on the yield of polymerase chain reaction for Mycobacterium tuberculosis (TB-PCR) using EBUS-TBNA samples in patients with mediastinal granulomatous lymphadenopathy. MATERIALS AND METHODS: A retrospective study using a prospectively collected database was performed from January 1, 2018 to December 31, 2018, to evaluate the efficacy of the TB-PCR test using EBUS-TBNA samples in patients with benign mediastinal lymphadenopathy which included both granulomatous lymphadenopathy and reactive lymphadenopathy. The cohort with reactive lymphadenopathy acted as the control group of the study population. The patients with mediastinal lymphadenopathy who were awaiting EBUS-TBNA either for diagnostic evaluation of primary disease or for staging of a known malignancy were included in the study. The patients were then followed up for 1 year post procedure with clinical and radiological evaluation. RESULTS: Of the 310 patients with mediastinal lymphadenopathy who underwent EBUS-TBNA, 190 cases had a benign pathology with granulomatous lymphadenopathy in 120 and reactive lymphadenopathy in 70 patients. The sensitivity, specificity, the positive predictive value and the negative predictive value of TB-PCR was at 90%, 97.14%, 98.18%, and 85% respectively. The accuracy of TB-PCR is 92.63%. CONCLUSION: TB-PCR using EBUS-TBNA samples is an effective tool for diagnosing mediastinal granulomatous lymphadenopathy. This technique can prevent further invasive interventions like mediastinoscopy in patients whose histological and microbiological tests are non-diagnostic. It should always be performed when tuberculosis is in the differential diagnosis of a patient with mediastinal lymphadenopathy.

Role of medical thoracoscopy in the diagnosis of pleural effusions.

BACKGROUND: Medical thoracoscopy (semi-rigid and rigid thoracoscopy) have revolutionized the management of undiagnosed pleural effusions. Though semi-rigid thoracoscopy has a good diagnostic yield in malignant and tubercular effusions, its role in the management of a complicated pleural effusions is debatable. Hence, rigid thoracoscopy becomes handy in these cases. The present study looked into the role of medical thoracoscopy in the diagnosis of pleural effusions in different conditions. METHODS: This study included all patients who underwent medical thoracoscopy at our center between May-2010 and March-2020. Basic demographics data, type of medical thoracoscopy used, and histopathology details were collected and analyzed. RESULTS: A total of 373 patients were subjected to medical thoracoscopy (202 semi-rigid thoracoscopy and 171 rigid thoracoscopy). Out of whom 246 (66%) were males, the mean age was 51.9 ± 13.2 years. Diagnosis was achieved in 370 patients with a yield of 99.2%. The diagnostic yield in semi-rigid thoracoscopy was 99.5% with lung malignancy being the most common diagnosis (41%; n = 81), followed by tuberculosis (31%; n = 61). The diagnostic yield in rigid thoracoscopy was 100% in our study. Along with high diagnostic yield, complete drainage and lung expansion was seen in 93.5% (160 out of 171 patients) without requiring a second procedure. CONCLUSIONS: Semi-rigid thoracoscopy and rigid thoracoscopy should complement each other in the diagnosis of pleural effusions. Rigid thoracoscopy should be considered as the procedure of choice in a complicated pleural effusion.

Evolution of semi-rigid thoracoscopy.

Pleural effusions despite being so common, there is no much literature available regarding definite diagnosis for pleural effusions. Application of Light's criteria changed the approach to pleural effusion and till date remains a very useful step in the diagnosis of pleural effusions. Pleural fluid biochemistry and adenosine deaminase (ADA) enzyme levels play a significant role in the diagnosis of tubercular effusion. Studies have shown that levels of ADA are more often higher in tubercular effusion than in any other cause for it. But ADA levels can also be elevated in other types of parapneumonic effusions (PPEs), especially complicated PPEs. Hence it is difficult to distinguish a tubercular pleural effusion (TPE) from other PPEs based on pleural fluid ADA levels alone. LDH/ADA ratio as an indicator for ruling out tuberculosis was analyzed in few studies with high sensitivity and specificity. The pleural fluid cytology has a varying sensitivity, with a maximum of only 60% and it may increase with subsequent tapping. Closed pleural biopsy using a Cope or Abrams needle has a sensitivity up to 80% in cases of tuberculous effusion and 40%-73% in cases of Malignancies. Semi-rigid thoracoscopy not only allows for visualization of the pleura but also helps in procuring the biopsies under direct visualization from the abnormal looking areas. In cases of primary pleural malignancies like mesothelioma, pleurodesis can also be done in the same setting after taking the biopsy, hence reducing the number of procedures. Limitation of the semi-rigid thoracoscopy is smaller sample size and more superficial sampling of the pleura. Cryobiopsy and Electrocautery guided pleural biopsy using the IT knife are the modifications in the semi-rigid thoracoscopy to overcome the drawback of smaller sample size. While navigation band image guided pleuroscopy helps in better visualization of the vasculature of pleura during the biopsy. Management of pleural effusions has evolved over a period of time. Starting with a single criterion based on pleural fluid proteins to semi-rigid thoracoscopy. The inexhaustible research in this field suggests the desperate need for a gold standard procedure with cost effectiveness in the management of undiagnosed pleural effusions. Semi-rigid thoracoscopy has revolutionized the management of undiagnosed pleural effusions, but it has its own limitations. Various modifications have been proposed and tried to overcome the limitations to make it a cost-effective procedure.

Role of medical thoracoscopy in the treatment of complicated parapneumonic effusions.

OBJECTIVE: The role of medical thoracoscopy in the treatment of pleural infections is increasingly being recognized. This study was done to assess the role of medical thoracoscopy in the management of carefully selected subset of patients with complicated parapneumonic effusions (PPEs). MATERIALS AND METHODS: We analyzed retrospective data of 164 thoracoscopic procedures performed at our center on patients with complicated PPE in the past 10 years. Patients were subjected to medical thoracoscopy based on ultrasonographic stratification and a computed tomography (CT) thorax. Medical thoracoscopy was performed after an intercostal block under conscious sedation with midazolam (2 mg) and fentanyl (50 mcg) and local anesthesia with lignocaine 2% (10-15 ml), through a single port 10 mm diameter thoracoscope. RESULTS: A total of 164 patients (119 males and 45 females) underwent medical thoracoscopy during the study period. The mean age was 47.4 ± 15.9 (median, 50; range, 16-86). The final diagnosis by thoracoscopy was bacterial empyema in 93 patients and tuberculosis in 71 patients. Medical thoracoscopy was successful without subsequent intervention in 160 (97.5%) patients, two patients underwent a second procedure, in the form of decortication, and two patients died due to sepsis. There were no major procedure-related complications that required intervention. CONCLUSION: Early adhesiolysis and drainage of fluid using medical thoracoscopy should be considered in patients with multiloculated complicated PPE after careful radiological (ultrasonography and CT) stratification, as a more cost-effective and safe method of management.

Multidisciplinary team obviates biopsy in most patients with diffuse parenchymal lung diseases-A retrospective study from India.

INTRODUCTION: The inflammation and fibrosis in diffuse parenchymal lung diseases (DPLDs) in varied proportions give rise to different patterns in radiology and histopathology. The radiological pattern on CT of the thorax most often allows us to make a diagnosis with varying levels of confidence, to optimize management. With a multidisciplinary team bringing the strengths of their individual domains of knowledge, clinical, radiological, histopathological, and in many cases rheumatological, the level of confidence in making this diagnosis increases, often to the stage where the diagnosis is most often right, is concordant with the diagnosis achieved at histopathology and therefore obviates the need for lung biopsy which carries its own costs and risks of complications. Our study emphasizes the role of the multidisciplinary team (MDT) in the management of DPLDs at a tertiary care referral center. MATERIALS AND METHODS: Every case of DPLD presenting to our pulmonology department was discussed in an MDT meeting before subjecting them to any diagnostic intervention or therapy. A clinico-radiological diagnosis was made according to the 2002 ATS/ERS guidelines initially. Later an official ATS/ERS/JRS/ALAT statement on idiopathic pulmonary fibrosis and a 2013 ATS/ERS consensus for the classification and diagnosis of idiopathic interstitial pneumonia was used. The concordance in our study was defined as the percentage of histopathological diagnoses that were identical to the clinico-radiological MDT diagnosis prior to the biopsy. RESULTS: A total of 434 patients with DPLDs were evaluated. The MDT suggested biopsy for only 38.7% (168/434) patients since the pattern was very clear in 266 (61.3%) cases. As not all patients consented to undergo the biopsy procedure when recommended, histopathology was obtained in 102 patients. The histological diagnosis was concordant with the initial MDT diagnosis in 80.3% (82/102) of samples. On an individual basis, connective tissue disease-interstitial lung disease and sarcoidosis showed the best concordance (87%). In idiopathic non-specific interstitial pneumonitis (NSIP) cases, the histopathological diagnosis concurred in only 53.3% (8/15), out of which 8 were NSIP, 4 were usual interstitial pneumonia, and 3 were reported as inadequate sampling on histopathology. CONCLUSION: The MDT plays a crucial role in the diagnosis of DPLDs. Not every pattern requires biopsy confirmation. However, an idiopathic non-specific interstitial pneumonitis diagnosis by the MDT should probably be better confirmed by biopsy.

Yield of pleural biopsy in different types of tubercular effusions.

INTRODUCTION: The yield of mycobacteria is shown to be very low in pleural effusions as it is a pauci-bacillary disease. The present study looked at the yield of mycobacterium tuberculosis (MTB) in terms of GeneXpert for acid fast bacilli (AFB) and culture using a medical thoracoscopy guided biopsy and analysed whether the yield increases in more complicated effusions. MATERIALS AND METHODS: This is a retrospective analysis of patients who underwent medical thoracoscopy for tubercular pleural effusions at our institute over the last 5-years. Patients who had no or minimal thin septations were considered as simple effusions and were subjected to semi-rigid thoracoscopy (n = 61). While patients who had multiple loculations and thick septations were considered as complicated effusions and were subjected to rigid thoracoscopy (n = 64). We considered granuloma on a biopsy as the standard for diagnosis of Tuberculosis (TB). Xpert MTB/RIF and The BACTEC MGIT was used for culture. RESULTS: Out 125 patients with granulomatous inflammation on biopsy, 56 (44.8%) were positive for either GeneXpert or culture for MTB. Only GeneXpert was positive in 43 and only culture was positive in 13. Amongst 61 patients with simple effusion, 14 had either GeneXpert for AFB or AFB culture being positive and 9 out of these patients had GeneXpert for MTB detected on biopsy sample. Only culture was positive in 5 patients. In complicated pleural effusion group either GeneXpert or culture for mycobacterium was positive in 42 (65.6%) out of 64 patients. Only GeneXpert was positive in 34 and culture alone was positive in 8 patients. CONCLUSION: The yield of MTB increases as the pleural effusion becomes more complicated. GeneXpert in a biopsy sample is a useful marker for MTB yield especially in a complicated effusion.

Pulmonary Alveolar Proteinosis Related to Chronic Cotton Dust Exposure and Hepatitis-C Infection.

A case of pulmonary alveolar proteinosis developing in a patient with chronic dust exposure and hepatitis-C infection is reported. He was managed with modified bronchoalveolar lavage and granulocyte-monophase-colony stimulating factor.

Community acquired pneumonia and cardiac diseases: a fatal association.

BACKGROUND: Community acquired pneumonia (CAP) remains a common disease condition attributing to a significant mortality and morbidity worldwide. Acute cardiac events (ACEs) are one of the most life-threatening complications in patients with severe pneumonia. METHODS: Retrospective study of burden of ACE in 105 patients admitted with CAP. RESULTS: Twenty-five patients with (CURB-65) score ranging between 0 - 2 did not require intensive care unit (ICU) admission and were admitted in the ward and high dependency unit. Of these, 12 developed ACE and 4 required to be shifted to the ICU for further management. Eighty patients with a CURB-65 score of greater than 3 were admitted to the ICU. Of the patients admitted to the ICU, 10 with ACE died; 2 patients without ACE also died. CONCLUSIONS: Our observations suggest that ACE constitute an important cause of morbidity and mortality in patients with CAP requiring hospitalisition.

Incidence of chronic thrombo-embolic pulmonary hypertension following acute pulmonary thrombo-embolism: an Indian perspective.

Chronic thrombo-embolic pulmonary hypertension (CTEPH) remains a severe disabling disease causing a significant amount of mortality and morbidity worldwide. The incidence and severity of this condition is quite obscure. The initial inciting event, the reason of progression, the natural history of the disease and the predictors of adverse outcomes are not yet adequately clarified. From the Indian subcontinent, data regarding this disease is limited. But with the advent of the multi-detector computed tomography, the understanding of this disease is gradually improving. As most of the available data suggests, acute pulmonary embolism (PE) as the main initial trigger leading to CTEPH, we prospectively analysed all patients being admitted in our hospital with acute PE and followed them over a period of one-and-a-half years to determine the incidence of CTEPH in this group. This is just an attempt to increase the awareness about the disease pattern and determine the rate of progression, risk factors of poor outcome, so that early detection and prompt treatment can benefit the patient care.