Inferior vena cava thrombosis attributable to hyperhomocysteinemia: A case report from Nepal.

Inferior vena cava thrombosis (IVCT) is a rare complication of deep vein thrombosis (DVT) in the legs. The etiology of IVC thrombosis can be divided into genetic versus nongenetic (environmental/acquired) etiological factors found in Virchow's triad of stasis, endothelial injury, and hypercoagulability. Hyperhomocysteinemia is a rare risk factor for venous thromboembolism and atherosclerotic disease. Hence, very few cases have been described to date to knowledge. A case of a 78-year-old hypertensive man who presented with hyperhomocysteinemia-induced DVT of the left leg extending toward an anatomically normal IVC is discussed in the report.

Sago-like appearance of pleura in Tuberculosis.

Medical thoracoscopy is an excellent tool for evaluation of exudative pleural effusion, and sago-like appearance of parietal pleura is highly specific for tuberculosis.

Lung Cancer in a Tertiary Hospital in Nepal: Clinical-Radiological Profile and Histological Subtypes.

BACKGROUND: Lung cancer is the most common cancer worldwide and in Nepal. Non small cell carcinoma is the commoner histological type. The incidence of adenocarcinoma subtype is increasing globally. This study aims to evaluate the clinical-radiological and histological profile and the diagnostic yield of various modalities in the diagnosis of lung cancer at a tertiary hospital in Nepal. METHODS: This is a prospective cross-sectional study conducted at National Academy of Medical Sciences, Kathmandu. Patients presenting with clinical and radiological features consistent with lung cancer and undergoing tissue sampling were included. The clinical and radiological characteristics, distribution of various histological subtypes and the diagnostic yield of various modalities were evaluated. RESULTS: Of the 253 patients screened, 77 meeting the inclusion criteria were enrolled into the study. Lung cancer was diagnosed in 53 patients. Forty (75.5%) patients had non small cell carcinoma and 13 (24.5%) had small cell carcinoma. Among the non small cell variants, 20 (37.7%) had adenocarcinoma and 19 (35.9%) had squamous cell carcinoma. Hitopathological diagnosis of lung cancer was established in 39 of the 42 (92.9%) patients by bronchoscopy. Image guided biopsy and/or aspiration yielded the diagnosis in 13 (24.5%) patients. The diagnostic yields of endobronchial biopsy, needle aspiration, bronchial brush and bronchial wash cytology were 86.5%, 70%, 63% and 34.3%respectively. CONCLUSIONS: The result of this study concurs with the global trend of rising incidence of adenocarcinoma subtype. Bronchoscopy remains the most commonly used tool for diagnosis of lung cancer and combination of procedures such as biopsy, bronchial brush, needle aspiration and bronchial wash provided the highest yield in our study.

A Prospective Outcome Assessment After Bronchoscopic Interventions for Malignant Central Airway Obstruction.

BACKGROUND: A systematic assessment of comprehensive clinical outcomes after various therapeutic procedures for malignant central airway obstruction (CAO) is lacking. METHODS: Patients with symptomatic malignant CAO undergoing various therapeutic bronchoscopy procedures were assessed for symptomatic and functional improvement using the Speiser Score, spirometry, 6-minute walk distance (6MWD), and St. George Respiratory Questionnaire (SGRQ) up to 3 months after the procedures. RESULTS: A total of 83 intervention procedures were performed in 65 patients, comprising 43 (66.2%) male individuals [overall mean age, 52.4; SD, 15.4 y]. The majority of these (92.3%) was done using rigid bronchoscope under general anesthesia. Airway stenting was the most common intervention performed (56.6%), followed by mechanical debulking (26.5%), cryodebulking (6%), electrosurgical removal (4.8%), balloon dilatation (3.6%), and laser ablation (2.4%).A total of 15 complications (18.1%) were noted. Of these, 8 (53.3%) were early complications and 7 (46.7%) were late complications. Early complications included airway bleeding, hypoxia, vocal cord injury, laryngeal injury, and pneumothorax. Late complications included significant granulation tissue formation in metallic stents and lung collapse because of mucus plug.The survival rates at 4, 8, and 12 weeks were 83%, 70.7%, and 66.1%, respectively. Significant improvement was observed in dyspnea, cough, Speiser Score, 6MWD, forced expiratory volume in 1 s, forced vital capacity, and SGRQ scores at 48 hours, 4 weeks, and at 12 weeks after the procedures and no procedure-related mortality occurred. CONCLUSION: Various therapeutic bronchoscopic interventions, including combined modalities, provide rapid and sustained improvements in symptoms, respiratory status, exercise capacity, and quality of life in malignant CAO and have a good safety profile.

Therapeutic bronchoscopic interventions for nonmalignant central airway obstruction provide rapid and sustained improvement in symptoms and functional status.

BACKGROUND: Central airway obstruction (CAO) is a potentially lethal condition that requires urgent endobronchial intervention and may occur due to several nonmalignant causes. The effect of these interventions on clinically relevant outcomes such as symptomatic and functional status over a period of time is, however, sparsely studied. MATERIALS AND METHODS: Consecutive patients with CAO due to nonmalignant causes and undergoing various therapeutic bronchoscopy procedures were evaluated. Symptoms were assessed using the Visual Analog Scale (VAS) and Speiser score, and functional status was assessed using the 6-min walk test, spirometry, and St. George Respiratory Questionnaire (SGRQ) score at baseline and after 48 h, 4 weeks, and 12 weeks postprocedure. RESULTS: Over 2 years, 31 patients with CAO due to nonmalignant etiology underwent 41 therapeutic bronchoscopic procedures. Majority of procedures (96.8%) were done using the rigid bronchoscope under general anesthesia. Postintubation tracheal stenosis was the most common indication (32.2%). The various procedures included, controlled radial expansion balloon dilatation of the stenotic airway (53.6%), deployment of silicone stents (19.5%), and mechanical debulking of airway tumors (16.1%). Significant improvement occurred in dyspnea and cough scores and in the Speiser score from baseline to 48 h postprocedure, and further improved at 4 weeks and 12 weeks. Similarly, the 6 min walk distance, forced expiratory volume in 1 s, and SGRQ scores progressively improved from baseline to 12 weeks. Complications occurred in 26.8% of total procedures, with no procedure-related mortality. CONCLUSION: Therapeutic bronchoscopy interventions provide rapid and sustained benefits in symptoms and functional status of participants with CAO of nonmalignant etiology, with an acceptable safety profile.

Compromised longevity due to Mycobacterium abscessus pulmonary disease in lungs scarred by tuberculosis.

Structural lung diseases or scarring related to prior infections such as tuberculosis (TB) are risk factors for the development of invasive nontuberculous mycobacterial (NTM) pulmonary infections, such as Mycobacterium abscessus . M. abscessus is intrinsically resistant to many antibiotics and in vitro susceptibility correlates poorly with clinical response, especially in pulmonary disease. Treatment is often difficult due to the lack of effective antibiotic regimens. We present a case of a 56-year-old male previously treated for TB, with presumed exacerbation, who was diagnosed after much delay with pulmonary M. abscessus disease and subsequently failed initial treatment with an empirical antibiotic regimen. When placed on a synergistic combination regimen that included amikacin, linezolid, clarithromycin, ethambutol and faropenem, the patient showed a favourable response and was culture-negative for over 12 months when the treatment was stopped as per American Thoracic Society (ATS) recommendations. Unfortunately, he developed recurrent symptoms and died 9 months after stopping treatment, following an acute exacerbation of fever and respiratory failure.

Guidelines for diagnostic flexible bronchoscopy in adults: Joint Indian Chest Society/National College of chest physicians (I)/Indian association for bronchology recommendations.

Flexible bronchoscopy (FB) is commonly performed by respiratory physicians for diagnostic as well as therapeutic purposes. However, bronchoscopy practices vary widely across India and worldwide. The three major respiratory organizations of the country supported a national-level expert group that formulated a comprehensive guideline document for FB based on a detailed appraisal of available evidence. These guidelines are an attempt to provide the bronchoscopist with the most scientifically sound as well as practical approach of bronchoscopy. It involved framing appropriate questions, review and critical appraisal of the relevant literature and reaching a recommendation by the expert groups. The guidelines cover major areas in basic bronchoscopy including (but not limited to), indications for procedure, patient preparation, various sampling procedures, bronchoscopy in the ICU setting, equipment care, and training issues. The target audience is respiratory physicians working in India and well as other parts of the world. It is hoped that this document would serve as a complete reference guide for all pulmonary physicians performing or desiring to learn the technique of flexible bronchoscopy.

Endobronchial Ultrasound Guided Transbronchial Needle Aspiration.

Evaluation of mediastinal lymphadenopathy is often challenging. Endobronchial Ultrasound (EBUS) is a novel technique which provides real time sonographic guidance during Transbronchial Needle Aspiration (TBNA) from mediastinal and hilar lesions. A 60-year-old smoker presented with two months history of cough and chest pain on the right side. CT thorax revealed a right upper lobe spiculated mass with paratracheal (Station 4R) and subcarinal (Station 7) lymph nodes. Bronchoscopy did not reveal any endobronchial mass. Since EBUS-TBNA is superior to conventional TBNA for malignant mediastinal node, an EBUS- TBNA was performed from both lymph node stations. . Cytopathology and histopathology revealed non-small cell lung cancer. We hereby report the first use of EBUS-TBNA in Nepal, in a patient with lung cancer and mediastinal lymphadenopathy. Keywords: Endobronchial ultrasound; lung cancer; mediastinal lymph node; transbronchial needle aspiration.

Diffuse Alveolar Haemorrhage as Initial Presentation of Systemic Lupus Erythematosus: A Case Report.

Diffuse alveolar hemorrhage results from accumulation of red blood cells in the alveolar space originating from alveolar capillaries. Alveolar hemorrhage in Systemic Lupus Erythematosus is rare but catastrophic and can rapidly progress to respiratory failure. We report a 22-year old lady who presented with dyspnoea on exertion, hemoptysis, bilateral leg swelling and oliguria. Diffuse alveolar hemorrhage was confirmed by bronchoalveolar lavage fluid analysis. Serologic tests and renal biopsy confirmed lupus nephritis. She was treated with systemic immunosuppressive therapy and plasma exchange, to which she had a favourable response. Lupus presenting as alveolar hemorrhage is rare which warrants prompt diagnosis and treatment to prevent complications. Keywords: Bronchoalveolar lavage; Case report; Diffuse alveolar hemorrhage; Systemic lupus erythematosus.

Bronchoscopic management of critical central airway obstruction by thyroid cancer: Combination airway stenting using tracheal and inverted-Y carinal self-expanding metallic stents.

Central airway obstruction (CAO) can result from various benign and malignant etiologies. Anaplastic thyroid cancer (ATC) is the most aggressive form of thyroid cancer. Rapid airway compromise is the main cause of death in ATC. We report a patient with ATC who presented with a large neck mass leading to CAO with long segment tracheal and right main bronchial compression and respiratory failure. Urgent Rigid Bronchoscopy was performed for airway stabilization and patient was managed with a combination airway stenting approach. A combination of self expanding, metallic, covered inverted Y and straight tracheal stents was used to stabilize the near complete airway structure. We herein highlight the role of therapeutic rigid bronchoscopy with airway stenting as an efficacious treatment modality for management of malignant CAO.

Development of a mortality prediction formula due to sepsis/severe sepsis in a medical intensive care unit.

BACKGROUND: Although sepsis is one of the leading causes of mortality in hospitalized patients, information regarding early predictive factors for mortality and morbidity is limited. MATERIALS AND METHODS: Patients fulfilling the Infectious Disease Society of America criteria of sepsis within the medical intensive care unit (ICU) were included over two years. Apart from baseline hematological, biochemical, and metabolic parameters, Acute Physiology and Chronic Health Evaluation II (APACHE II), Simplified Acute Physiology Score II and III (SAPS II and SAPS III), and Sequential Organ Function Assessment (SOFA) scores were calculated on day 1 of admission. Patients were followed till death or discharge from the ICU. RESULTS: One hundred patients were enrolled over two years (54% males). The overall mortality was 53%, (69.5% in females, 38.8% in males (P < 0.01). Mortality was 65.7%, 55.7%, and 33.3% in patients with septic shock, severe sepsis, and sepsis, respectively. Patients who died were significantly older than the survivors (mean age, 57.37 ± 20.42 years and 44.29 ± 15.53 years respectively, P < 0.01). Nonsurvivors were significantly more anemic and had higher APACHE II, SAPS II, SAPS III, and SOFA scores. The presence of acute respiratory distress syndrome and renal dysfunction were associated with higher mortality (75% and 70.2%, respectively). There was no significant difference in the duration of mechanical ventilation or ICU stay between survivors and nonsurvivors. On multivariate analysis, significant predictors of mortality with odds ratio greater than 2 included the presence of anemia, SAPS II score greater than 35, SAPS III score greater than 47, and SOFA score greater than 6 at day 1 of admission. CONCLUSION: Several demographic and laboratory parameters as well as composite critical illness scoring systems are reliable early predictors of mortality in sepsis. A sepsis mortality prediction formula (AIIMS Sepsis Score) based on SAPS II, SAPS III, and SOFA scores and hemoglobin has greater predictive power than these scoring methods individually. Routine use of critical illness scoring systems and a composite mortality prediction formula may provide useful early prognostic information in sepsis/severe sepsis.