Misdiagnosed case of bronchial carcinoid presenting with refractory dyspnoea and wheeze: a rare case report and review of literature.

A 59-year-old male smoker presented with persistent wheezing and occasional coughing that had been ongoing for two years and had been unsuccessfully treated with an inhalational ß2 agonist, an anticholinergic and an inhalational steroid in the last year. On clinical examination, a left-sided wheeze was detected. The initial chest X-ray was normal. A computed tomography (CT) scan of thorax demonstrated a mass lesion in the left main bronchus. On subsequent bronchoscopy, an endobronchial polypoid mass was detected in the left main bronchus, completely occluding the bronchial lumen. A biopsy taken from the mass revealed features of bronchial carcinoid. Bronchial carcinoid can present uncommonly with wheezes, resulting in misdiagnosis as bronchial asthma or chronic obstructive pulmonary disease (COPD). If an asthma or COPD patient does not respond to conventional therapy, a CT scan and subsequent bronchoscopy is warranted.

Prevalence of metabolic syndrome in chronic obstructive pulmonary disease and its correlation with severity of disease.

Introduction: The understanding of chronic obstructive pulmonary disease (COPD) has changed considerably over the past decade. The metabolic syndrome (MS) represents a cluster of risk factors that increases the risk for developing various noncommunicable diseases. In COPD, it is associated with worsening respiratory symptoms, increasing lung function impairment, pulmonary hypertension, and increasing hospitalizations. Aims: To determine the prevalence of MS in patients with COPD and correlate it with disease severity. Methodology: The present study was a cross-sectional observational study. Patients confirmed by spirometry to have COPD were included in the study. All demographic data and anthropometric, radiological, and laboratory parameters were recorded. The definition stated by modified NCEP ATP III criteria proposed by the AHA/NHLB (2005) was followed to identify patients with MS. Statistical analyses were performed using the Statistical Package for the Social Sciences (SPSS) version 20 for Windows. Results: A total of 76 patients were included in the study. MS was recorded in 42.1% of COPD cases. The average number of exacerbations and hospitalizations due to COPD in MS cases (1.38 ± 1.95 and 0.97 ± 1.51) were more than the patients without MS (1.27 ± 1.30 and 0.68 ± 0.96). The majority of patients with MS exhibited grade 3 dyspnea based on modified medical research council grading (MMRC). MS was commonest in patients with GOLD stage III disease. High serum triglyceride level was observed in an increasing trend (25%, 30%, 35.5%, and 75%) in GOLD stages I, II, III, and IV, respectively. Conclusion: Patients with MS present with more severe disease and frequent exacerbations. All COPD patients should be screened for MS at the primary level.

Treatment outcome among Post TB obstructive airways diseases and COPD: A prospective cohort study.

CONTEXT: Post Tubercular Obstructive Airways Diseases (Post-TB OAD) is a sequela of Pulmonary TB but diseases progression may not same like Chronic Obstructive Pulmonary Diseases (COPD). AIM: To compare the frequency and severity of exacerbations, change of FEV1, frequency of hospitalization and mortality among COPD and post TB OAD patients. SETTING AND DESIGN: Hospital-based prospective cohort study. METHODS AND MATERIAL: COPD cohort was diagnosed based on symptoms, history of exposure to risk factors and post bronchodilator FEV1/FVC ratio <70%. Post TB OAD cohort was diagnosed like COPD along with past history of Pulmonary TB. Both cohorts were followed up every 3-monthly intervals for up to 12 months. STATISTICAL ANALYSIS: Comparison of categorical variable was done by Chi-square test and continuous variable by unpaired t test. Longitudinal data of FEV1% were analyzed by repeated measure ANOVA test. RESULTS: Totally, 68 patients with Post TB OAD and 66 COPD patients were taken into this study. The frequency of exacerbation (3.52 ± 1.84 verses 2.70 ± 1.37), number of severe exacerbation (56 verses 24) and frequency of hospitalization (1.37 ± 0.81 verses 0.97 ± 0.94) more seen in post-TB OAD cohort in compared to COPD cohort which is statistically significant. Mortality more seen in post-TB OAD group (14 verses 6). Rate of decline FEV1 per year more seen in Post-TB OAD (0.27 ± 0.28 lit verses 0.17 ± 0.26 liter) as compared to COPD. There was overall decreasing trend of FEV1% over period of 12 month but without any difference among two cohort. CONCLUSION: There was more in frequency of exacerbations, number of severe exacerbations, frequency of hospitalization and number of mortalities among post TB OAD compared to COPD.

Diagnostic efficacy of broncho-alveolar lavage carcino-embronic antigen in carcinoma of lung.

CONTEXT: Biomarkers can be used for screening lung cancer and the clinician can decide for further invasive workup for diagnosis. AIMS: To know the diagnostic sensitivity and specificity of Carcinoembryonic antigen (CEA) in Broncho Alveolar Lavage Fluid (BALF) and serum of bronchogenic carcinoma. SETTINGS AND DESIGN: Case-Control study was conducted in the Medical College Hospital during a period of 2 years. METHODS AND MATERIAL: We randomly selected 50 cases and 50 controls subjects. Cases were the patients with proven malignancy by biopsy or cytology, and controls were other non-malignant pulmonary diseases. All patients' CEA of Broncho Alveolar Lavage Fluid and serum was done. STATISTICAL ANALYSIS: The mean and receiver operating curve were done for CEA of serum and BAL fluid, and based on the cut-off values, sensitivity and specificity were calculated. RESULTS: Mean value of CEA in both BALF and serum in non-smoker patients of the malignant lesion was significantly higher than the non-malignant lesion. Mean value of CEA in both BALF and serum in smoker patients of the malignant lesion was higher than the benign lesion, but statistically not significant. The cut-off value for Serum CEA is 1µg/l, whereas for BALF CEA is 2µg/l. Sensitivity, specificity of CEA of Serum and BALF combined were 92% and 62% respectively. CONCLUSIONS: Determination of CEA in the BALF and serum may be helpful as a screening tool for further workup for malignancy.

Esophago-pleural fistula with pulmonary tuberculosis.

A patient with clinical diagnosis of pulmonary tuberculosis and right sided hydropneumothorax found to have fistulous connection of pleura with oesophagus as evidenced by upper GI endoscopy and intrapleural instillation of radio-opaque dye. He was managed with intercostal chest tube drainage, antibiotics, antitubercular regimen and nasogastric tube feeding, resulting in eventless recovery subsequently.

Clinico-Radiologic and Spirometric Profile of an Indian Population with Post-Tuberculous Obstructive Airway Disease.

INTRODUCTION: Tuberculosis is a public health problem in developing countries and in spite of receiving adequate anti-tuberculous therapy, patients often continues to have several post-tuberculous sequelae, especially airflow limitation. AIM: To evaluate pulmonary function by spirometry among post-tuberculosis cases with airway obstruction and their relationship with smoking. MATERIALS AND METHODS: All patients who presented to the pulmonary medicine Outpatient Department (OPD) with symptoms of obstructive airway disease and had completed adequate anti-tuberculous therapy for pulmonary tuberculosis were taken up for study. They were initially evaluated with sputum smear for Acid Fast Bacilli (AFB) and chest X-ray. Patients without evidence of active tuberculosis underwent spirometry and those having post-bronchodilator Forced Expiratory Volume in first second (FEV1)/ Forced Vital Capacity (FVC) FEV1/FVC<0.7 were taken up for final analysis. Spirometric parameters were compared between smokers and non-smokers. RESULTS: Out of 138 finally selected cases, 84.06% were male and 71.01% were within age range of 40-69 years. Significant positive association was found between extent of radiologic lesion and severity of airflow obstruction. Purely obstructive pattern was found in 27.54% cases and 72.46% showed mixed pattern. Patients with mixed ventilatory abnormality had worse pulmonary function and poorer bronchodilator reversibility than patients with pure obstruction. Comparison of post-bronchodilator FEV1, FVC, Peak Expiratory Flow (PEF) and Forced Expiratory Flow (FEF) 25-75 between smokers and non-smokers did not show statistically significant difference. CONCLUSION: Majority of patients with post-tuberculous obstructive airway disease have associated restrictive component. But smoking did not cause significant alteration in pulmonary function among such patients.