A study of subcutaneous emphysema, factors contributing to its development, resolution and management with different modalities.

Subcutaneous emphysema is defined as an escape of air in subcutaneous tissue. It is one of the most common complications after inter-costal chest tube drainage. Subcutaneous emphysema is usually benign requiring no specific treatment, but extensive subcutaneous emphysema can be uncomfortable and alarming for the patient. It can rarely lead to airway compromise, respiratory failure and death. Factors leading to its development, following chest tube insertion and methods of management, have not been extensively studied and published. This was an analytical study done over a period of two years, on indoor patients who developed subcutaneous emphysema. These cases were managed using four different modalities and were analyzed for various factors contributing to the development, severity, and resolution of subcutaneous emphysema. Results of this study highlight that the cases of hydropneumothorax and secondary pneumothorax were significantly more predisposed to the development of severe subcutaneous emphysema (following intercostal chest tube insertion) and large air leak as compared to others. Larger air leak develops higher grades of subcutaneous emphysema. The average time for resolution of subcutaneous emphysema was similar among the different modalities of management compared in the study.

Asymptomatic Renal Function Abnormalities in Patients having Silicosis.

BACKGROUND: A number of occupational exposures are associated with various types of renal dysfunction. Several studies for many years have drawn attention to renal dysfunction and nephrotoxicity among workers exposed to silica. This study was conducted to evaluate renal dysfunction, if any, among Indian patients having silicosis and its correlation with the duration of exposure to silica dust. MATERIALS AND METHODS: This study includes 52 eligible patients with a history of silica dust exposure and silicosis confirm on radiological examination by the pneumoconiosis board. Investigations like serum creatinine, urinary albumin creatinine ratio, etc. were done. The "modification of diet in renal disease" (MDRD) formula was used to calculate the glomerular filtration rate (GFR). RESULTS: This study showed 53.84% of patients (n = 28) having albuminuria and a mean "urinary albumin to creatinine ratio" (UACR) of 101.88 ± 128.99 mg/gm. Isolated macroalbuminuria was detected in 11.5% of patients (n = 6) while 42.3% of patients (n = 22) presented with microalbuminuria. The mean GFR was 81.94 ± 22.09 mL/min/1.73 m2 among study patients of which four (7.7%) patients had GFR value <60 mL/min/1.73 m2 . We could also identify a significant association between the duration of exposure to silica dust and UACR and GFR (p < 0.01). CONCLUSION: Albuminuria and reduced estimated GFR in patients with silica dust exposure is not uncommon and reflect early underlying renal dysfunctions. Our study suggests a simple and cost-effective screening strategy for early detection of renal dysfunction among silicosis patients that may be considered as a tool to prevent further renal damage in such patients.

Adenocarcinoma lung presenting with meningeal carcinomatosis.

Meningeal infiltration by malignant metastasis process without brain parenchymal involvement is very unusual event in patients with bronchogenic carcinoma. This manuscript describes a case of adenocarcinoma right lung in a 48-year old male having persistent headache. The cerebrospinal fluid cytology revealed the presence of metastatic deposits of adenocarcinoma lung that confirmed the diagnosis of meningeal carcinomatosis.

Occult carcinoma penis presenting as malignant pleural effusion.

A case of left sided malignant pleural effusion is described in a 41-year-old male, his initial workup for primary site of malignancy was unknown but later found to have hidden squamous cell carcinoma of penis which is one of the rarest site of malignancy that metastasise to pleura. Penile carcinoma manifesting with pleural metastasis and pleural effusion as initial presentation has not been reported previously.

Obstructive Sleep Apnea in Bronchial Asthma Patients: Assessment of Prevalence and Risk Factors.

BACKGROUND: Sleep-related breathing disorders are group of respiratory disease among them obstructive sleep apnea (OSA) is highly prevalent and seen among those having recognized risk factors. Recent studies have shown that asthma and OSA contribute bi directional relationship where each disorder adversely influences the other one. This study was planned to assess OSA among bronchial sthma patients. METHODOLOGY: This study was conducted at Sleep lab of our department among adult patients of bronchial asthma after institutional ethical committee approval. Eligible and willing to participate patients were subjected to clinical assessment protocol that included history, clinical examination, measurement of Sleep Score, BMI, neck circumference etc followed by overnight Level 1 polysomnography. RESULTS: 50 patients with age range 30 to 68 years constituted the study population with mean age of 48.16 years. 70% patients were female with male female ratio of 1:2.3. The prevalence of OSA in asthma patients was 46%. 12% patients had mild OSA, 14% had moderate while 20% were having severe OSA. Mean BMI in our study was 27.87 Kg/m2 . OSA patients were associated with more BMI compared to patients without OSA (42% vs. 30%) (p value 0.04). Asthma patients who were smokers had more OSA symptoms compared to non-smokers (p value 0.002). Asthma patients with OSA were also associated with higher neck circumference and more snoring at night time as compared to non OSA population. Uncontrolled asthma was seen in 18 patients and 16 of them were having OSA (p=0.001). Most common co morbid illness in patients with OSA was GERD (78.26%) followed by allergic rhinitis (56%). Most of these patients (82%) were not having associated major local anatomical defect. CONCLUSION: :OSA is not uncommon in asthma patients. Careful assessment of sleep related symptoms and demographic parameters of asthma patients are essential to suspect diagnosis of OSA. Additional factors like smoking, obesity, GERD and allergic rhinitis are important contributing factor for higher risk of OSA among asthma patients. Early diagnosis of OSA in asthma patients by polysomnography may have a clinical benefit in the management of both diseases.

Sociodemographic profile, work practices, and disease awareness among stone mine workers having silicosis from Central Rajasthan.

Background and Objectives: Silicosis continues to pose an important health hazard among workers having occupational exposure to stone dust. Several studies have addressed clinical presentation, radiographic and pulmonary function abnormalities in workers with silicosis. This study was planned to analyze sociodemographic profile and awareness about several aspects of silicosis among the stone mine workers visiting our centre. Methods: A questionnaire was administered in a convenient sample of eligible subjects over six years period. The questionnaire was aimed to collect sociodemographic variables, like age, gender, educational status, residential background, smoking status etc., apart from information on work-related profile including protective measures taken. Also knowledge and attitude regarding silicosis was assessed. Silicosis awareness index was also calculated as per the response received. Results: Majority of the study subjects were male (96.6%) with rural background (98.5%). 54.1% subjects were in the age group of 30 to 50 years. 81.9% mine workers were illiterate. The common addictions observed among them included smoking (60%), tobacco chewing (34%), alcohol (20%) etc., Varying duration of work exposure was observed with more than 10 years in 63.4% and more than 20 years in 32.2% workers. The commonest work exposing them to stone dust was breaking stones by chisel and hammer (51%) followed by separation of stone slab (20%) and stone drilling (15%). 80.9% subjects were not aware of the term silicosis, more than 80% were not aware of the symptoms and causes of silicosis. Only one fifth subjects were having awareness of using protection against the disease. Overall awareness about silicosis was better among literate and youngers participants. Conclusions: Stone mining industry reflects male dominance, poor literacy, long working hours for many years, financial compulsion to start and continue the job and very poor awareness regarding the disease silicosis and importance of personal protection at workplace.

Fluoroquinolone resistance mutations among Mycobacterium tuberculosis and their interconnection with treatment outcome.

Background: Fluoroquinolone (FQ) antibiotics are among the most potent second-line antitubercular drugs these days. The aim of the study was to analyze the frequency and pattern of genetic mutation in preextensive (pre-XDR) and extensively drug-resistant Mycobacterium tuberculosis using second-line line probe assay (LPA) and to compare drug-resistant mutations with different treatment outcomes. Methods: Sputum, lymph node aspirate, and cold accesses from patients with rifampicin-resistant Tuberculosis (TB) were subjected to first-line and second-line LPA (Genotype MTBDRsl by Hain Life Science, Germany) to assess additional drug resistance to fluoroquinolones (levofloxacin and moxifloxacin). Final treatment outcomes as per the National TB Elimination Program were assessed and compared with the mutation profile. Results: One hundred and fifty subjects were observed to have mutations associated with resistance to FQs and constituted the final study population. The most frequent mutation observed among GyrA drug resistance mutation was D94G (Gyr A MUT3C, 44/150, 66%) corresponding to high-level resistance to levofloxacin and moxifloxacin. The same mutation was associated with poor treatment outcome as died or treatment failure (odds ratio 2.50, relative risk 1.67, P = 0.043). The most common hetero-resistance mutation pattern observed in GyrA gene was wild type plus Asp94Gly mutation in 24.6% of isolates. Conclusions: GyrA MUT3C hybridization corresponding to single-point mutation of aspartic acid to glycine at codon 94 constitutes the most common mutation in GyrA gene locus in M. tuberculosis with significant association with treatment outcome as died compared to those with treatment outcome as cured.

Measurement of diffusion lung capacity (DLCO) in silicosis patients: Correlation with radiographic abnormalities on high-resolution CT scan chest.

Objective: This study was conducted to evaluate diffusion capacity of lung for carbon monoxide (DLCO) in patients with simple and complicated silicosis and to correlate abnormal findings detected, if any, with the computed tomography abnormalities in these patients. Methods: This study included 56 patients with simple and complicated silicosis and without tuberculosis, in whom we performed DLCO as per standard technique. Various computed tomography findings, that is, presence, size and distribution of nodules associated with relative parenchymal and vascular markings, were recorded in the study subjects and classified into standard grading to be finally compared with DLCO. Visual grading score system was used to describe the extent of emphysematous changes based on the area of abnormally low attenuation, vascular disruption, bullae and so on and data were recorded. Results: Results showed that 85.7% patients had small opacities of varying grades and 28.5% showed large opacities, with 16% of them having type 'C' large opacities. The mean DLCO (% predicted) of patients with category '0' high-resolution computed tomography (HRCT) abnormality was 92.3 ± 6.8 (within normal limits), and this gradually decreased with increasing HRCT category to 44.2 ± 11.2 in grade '4' of progressive massive fibrosis (PMF) patients in this study (P < 0.01). This reflects a significant inverse correlation between visual HRCT category and the DLCO % predicted (r > -0.89, P < 0.001). The mean DLCO (% predicted) was 51 ± 12.6 in patients with grade '1' emphysema in HRCT, 53 ± 13.5 in grade '2', 43 ± 6.4 in grade '3' and 37.7 ± 6.3 in grade '4'; however, there was no correlation between emphysema grading and pulmonary functional index (r = -0.33, P = 0.15). Conclusion: This study observed significant abnormality in DLCO among silicosis patients and its strong correlation with the extent of radiological abnormality. HRCT finding of large opacities could be an important indicator of the severity of silicosis, as reflected by significantly reduced DLCO in such patients.

Middle Lobe Syndrome in Silicosis.

A case of silicosis presenting as middle lobe syndrome is described in a middle-aged female. The diagnosis was confirmed by both bronchoscopy and demonstration of right middle lobe lumen narrowing and compression by calcified hilar lymph nodes on computerized tomographic scan. Simultaneous occurrence of endobronchial silicosis and bronchial stenosis by enlarged calcified peribronchial lymph nodes causing middle lobe syndrome has not been described previously as reported in this case.

Spontaneous expectoration of tumor tissue in primary adenocarcinoma lung.

Spontaneous expectoration of the tissue fragments in primary lung carcinoma is an extremely unusual event. Expectoration of tumor fragments is a significant event that should not be ignored as it serves itself as a noninvasive tool to diagnose underlying malignancy if such samples are immediately preserved and subjected to histopathological examination. More so, expectoration of a large-sized fragment may provide substantial relief from the breathlessness. Reported here is the case of a middle-aged male patient with adenocarcinoma in the right lung, and mass extended up to trachea, who spontaneously coughed out pieces of tumor tissue.

Giant primary pulmonary fibrosarcoma.

A rare case of primary fibrosarcoma in a 48-year-old male is described who presented with a huge pulmonary mass on the left side. The diagnosis was established on fine needle aspiration cytology (FNAC) and percutaneous transthoracic lung biopsy, supported by immuno-histochemistry.

Pattern of InhA and KatG mutations in isoniazid monoresistant Mycobacterium tuberculosis isolates.

AIMS AND OBJECTIVES: The aim of the study is to detect the pattern of genetic mutation, i.e., Inh A or Kat G or both (Inh A and kat G) in isoniazid (INH) monoresistant mycobacteria and to correlate with the pattern in multidrug-resistant (MDR) isolates. MATERIALS AND METHODS: In this study, a quantitative research approach was used. The research design was descriptive observational study. The study was conducted at the Department of Respiratory Medicine, JLN Medical College, Ajmer, Rajasthan, and Intermediate Referral Laboratory, State TB Demonstration Centre, Ajmer. A total of 298 samples found to have resistant strains of Mycobacterium tuberculosis were enrolled with purposive sampling. RESULTS: The mean age of patients was 40.27 ± 13.82 years. There were 250 (83.9%) males, while 48 (16.1%) were females. One hundred ninety-two (64.4%) were resistant for INH only, while the rest were resistant to both INH as well as rifampicin (MDR-tuberculosis). The most common mutation in INH monoresistance was kat G (125; 65.1%) as compared to inh A (54; 28.1%) and both inh A and kat G (13; 6.7%). Among kat G mutations, the most common gene pattern was the absence of WT (S315T) and the presence of MUT1 (S315T1). CONCLUSION: Knowledge about mutation patterns of different INH resistant strains is important in the present era where there is a provision of separate regimens for INH monoresistant TB. Since these mutations are very closely related to high- or low-degree resistance to INH, the therapeutic regimens cannot be generalized.

Recurrent haemoptysis following sildenafil administration.

Sildenafil is widely used in the treatment of male erectile disorder and is generally well-tolerated. Its adverse effects are reported to be mild and include flushing, headache, dyspepsia and visual disturbances. We document a case of recurrent haemoptysis observed soon after self administration of sildenafil in a 38-year-old male with no other causative factors. The episodes of haemoptysis stopped following stoppage of sildenafil.

A study on procedural delay in diagnosis and start of treatment in drug resistant tuberculosis under RNTCP.

BACKGROUND: Multi-drug-resistant TB (MDR-TB) has become a significant public health problem and an obstacle to effective TB control. Rapid diagnostic tests for anti tubercular drugs sensitivity have significantly reduced total time in initiation of treatment. Still there is a significant gap between MDR diagnosis and start of category IV treatment. Delay in establishing the diagnosis may cause disease progression, transmission, lost to follow up and death. This study was planned to assess the actual delay from day one of sputum examination to the day of initiation of category IV in operational settings. METHODOLOGY: MDR-TB suspected patients attending the Respiratory medicine department, JLNMC, Ajmer from June-15 to July-16 were followed from sputum examination to sample deposition for drug sensitivity testing (LPA/CBNAAT) to MDR detection to category IV initiation, for assessment of procedural delay at various steps. RESULTS: LPA group (371 patients): Sputum smear to LPA deposition mean duration was 8.02 days, LPA deposition to LPA result upload mean duration was 3.78 days, LPA deposition to patients received LPA reports mean duration was 21.73 days and reports received to PMDT site admission (if drug resistant) mean duration was 3.61 days. Total time duration in category IV initiation was 32.63 days. CBNAAT group (50 patients): Sputum smear to CBNAAT deposition mean duration was 6.70 days, CBNAAT deposition to CBNAAT result upload mean duration was 1.13 days, CBNAAT deposition to patients received CBNAAT reports mean duration was 6.53 days and reports received to PMDT site admission (if R-resistant) mean duration was 3.8 days. Total time duration in category IV initiation was 12.4 days. CONCLUSION: Major delay seen on part of receiving sensitivity reports indicates the need to stress upon field staff motivation, appropriate training, sensitisation and expert counselling.

A study on pattern of resistance to second line anti tubercular drugs among multi drug resistant tuberculosis patients.

AIMS AND OBJECTIVES: To determine the prevalence and pattern of resistance to second line drugs among multi drug resistant (MDR) tuberculosis patients being treated on category IV regimen. METHODOLOGY: This study was conducted at Department of Respiratory Medicine, J.L.N. Medical College, Ajmer in collaboration with IRL, STDC, Ajmer. Second line anti tubercular drug sensitivity for 398 multi drug resistant tuberculosis patients (between June-2015 and June-2016) was done to find out prevalence and pattern of resistance to second line drugs. Second line drug sensitivity was performed at accredited laboratory, Microbiology department, S.M.S. Medical College, Jaipur. RESULTS: Among these 398 patients, 136 (34.17%) were resistant to fluoroquinolones (Ofloxacin) (Pre XDR); 18 (4.52%) were resistant to one of the aminoglycosides (Inj. Kanamycin, Capreomycin, Amikacin) (Pre XDR); while 22 (5.53%) patients were resistant to fluoroquinolones as well as aminoglycosides (XDR). 148 (37.18%) patients were found sensitive to both the drugs. Samples of 41 (10.3%) patients were contaminated and no growth was seen in 33 (8.29%) patients. CONCLUSION: Nearly half of the multi drug resistant (MDR) tuberculosis patients (44.22%) being treated on category IV regimen also have resistance to either fluoroquinolones or aminoglycosides or both i.e. Pre XDR or XDR. This may result in poor outcome of category IV regimen under RNTCP. There is a strong need for provision of culture sensitivity for all first line drugs and at least two second line drugs viz. Fluoroquinolones and aminoglycosides for all the patients registered as smear positive under RNTCP. There is also a need for development of rapid culture technique for sensitivity to second line drugs.

pulmonary tuberculosis: A neglected risk factor for deep venous thrombosis.

A case of deep venous thrombosis (DVT) of the lower limb in the absence of known common risk factors and its link with underlying pulmonary tuberculosis is described in a young female patient. Possible underlying mechanisms and awareness regarding tuberculosis as a risk factor for DVT is also emphasized.