Pulmonary & Respiratory Medicine

There are few reported cases in the literature of metastasis to the appendix. A 44-year-old patient presented with abdominal pain and changes in the bowel pattern. Thoracic and abdominal computed tomography scans evidenced pulmonary and liver nodules. The pulmonary nodule was biopsied and the hematoxylin-and-eosin (HE) stained slides showed an adenocarcinoma. The immunohistochemistry profile demonstrated positivity for CK7 and TTF-1. The patient underwent an appendectomy. HE stained slides also demonstrated adenocarcinoma infiltrating the entire appendix wall along with the epithelial surface with immunohistochemistry study of the appendix neoplasm showing exactly the same results as seen in the first panel.

A 40 year old female, non-smoker with a past medical history of urticaria and allergic rhinitis presented with hoarseness of voice of 3 months duration without any accompanying symptoms or limitation of daily activities. Direct laryngoscopy identified palsy of the left vocal cord. The magnetic resonance imaging of the chest indicated abnormal signal intensity in the left vocal cord. The thoracic computed tomography revealed only an enlargement of the pulmonary artery, while transthoracic echocardiography estimated systolic pulmonary artery pressure of 75 mmHg. Pulmonary function tests were compatible with pulmonary vascular disease and cardiopulmonary exercise test showed exercise limitation of cardiocirculatory origin (maximum O2 consumption 60% of pred.). Catheterization of the right heart showed precapillary pulmonary hypertension (mean pulmonary artery pressure 40 mmHg) with a positive response to vasoreactivity test. A diagnosis of idiopathic pulmonary arterial hypertension (IPAH) was made, with hoarseness of voice as the only manifestation of the disease. The hoarseness of voice is believed to be the result of the compression of the left recurrent laryngeal nerve between aorta and the dilated pulmonary artery. This is an unusual case of cardiovocal syndrome (or Ortner’s syndrome) in a patient with IPH who had no perception of dyspnea or limitation of daily activities.

Objective: To assess efficacy and safety of inert cellulose powder (ICP) in the treatment of mild seasonal allergic rhinitis (SAR). Methods: An observational, non-randomized, open study including 74 examinees suffering from mild SAR was conducted. The study subjects were divided in two groups, Group 1 (G1) and Group 2 (G2). The study subjects from G1 were treated 10 days with oral cetirizine and ICP, while the study subjects from G2 were treated 10 days only with oral cetirizine. The treatment outcomes were evaluated after five and 10 days by self-assessment of the symptoms on a five-point scale. Results: In both groups improvement of the symptoms five and 10 days after the treatment was registered. There was significantly higher prevalence of the G1 study subjects in the point 4 (“major relief, casual sneezing”) five days after beginning of the treatment (43.2% vs. 18.9%; P<0.05), as well as in the point 5 (“complete relief, without symptoms”) at the end of the treatment (56.7% vs. 27.0%; P<0.05). A low frequency of adverse effects was registered among examinees of both groups. Conclusion: The results obtained indicated high efficacy and safety of ICP in the treatment of mild SAR.

Background and Aims: To assess the clinical and socio-demographic characteristics of tuberculosis patients in a tertiary care medical college hospital of Bangladesh.
Methods: An observational study was conducted over a period of one year from September 2015 to August 2016 in the Outpatient Department of Jahurul Islam Medical College Hospital and Department of Pathology, Jahurul Islam Medical College, Kishoregonj, The inclusion criteria of the study were pulmonary and extra pulmonary tuberculosis cases receiving antitubercular drugs therapy. Primary data from each patient was included in tuberculosis patient profile form such as age, gender, educational level, annual income in taka, occupational status and selected social habits like smoking, alcohol.
Results: Out of 112 patients studied, 50 (44.6%) were male and 62 (55.4%) were female. The majority of patients 69 (61.7%) were in the age group of 15-34 years. Annual family income of 78 (69.6%) patients ranged between 36,000- 1,50,000 taka. In total 112 patients 43 (38.4%) were illiterate and 36 patients (32.2%) were unemployed. 50% of the patients were smoker. The most common sites involved in extrapulmonary tuberculosis were the lymph nodes (38.2%) followed by the pleura (36.4%). The most common symptoms observed in pulmonary tuberculosis patients were cough with expectoration (96.5%) followed by weight loss (80.7%), fever (73.7%) and loss of appetite (54.4%).
Conclusion: Prevalence of infection was noticed between PTB and EPTB with age and it was more common in younger age. However, based on our results TB control programme might usefully target young middle age populations for early diagnosis of TB to decrease TB morbidity and mortality.

Tuberculosis (TB) is an infectious disease which is transmitted by air. This disease damages the lungs and other organs in the human body. It is one of the leading causes of morbidity and mortality despite the fact that it can be cured with adequate treatment. The entry of multidrug resistant tuberculosis (MDR-TB) or extensively drug resistant (XDRTB) is biggest challenges in our effort to control the disease complications. A cross-sectional study was conducted to assess TB related knowledge, its complications and control among the patients from the outpatient Pulmonology department of Owaisi Hospital and Research Center- HYD. The research shows that maximum number of patients (59%) was unsure about the severe complication of TB whereas patients did not adhere to the treatment and discontinue it half-way, this become the prime reasons for the gap between treatment and control, thereby non-adherent treatment could have severe consequences of diseases and might lead to death. Knowledge about pulmonary complication and duration of treatment has to be emphasized.

Introduction: Multi-drug-resistant tuberculosis (MDRTB) is a major public health problem due to longer duration of treatment and unfavourable outcome in comparison with sensitive TB.
Aim: Registered Drug resistant tuberculosis (DRTB) patients were prospectively followed from 2011-2015. Analysis of treatment outcomes was by done by their demographic and clinical data which were hypothesized to be outcome predictors.
Methods: Logistic regression and univariate logistic regression were used upon data of patients registered for MDRTB treatment in Trichy district Tamilnadu, India. Totally 63 MDRTB patients were treated from 2011-15. Outcomes were reported as success & failure. Success included cured and treatment completed patients and Failure included treatment failure, death, defaulted, untraceable cases. SPSS 21 was used.
Results: Out of total 63 cases, 33 cases had failed outcome and 30 cases had successful outcome. Among variables Diabetes, XDRTB suspects, drug abuse & smoking were associated with failed outcome. Sex, age, chest x-ray lesion, pre-treatment resistance profile, did not affect the outcome. By logistic regression (enter) method the odds of failed outcome were 11.737 with smoking, the odds of failed outcome was 12.43 with XDRTB suspects, and the odds of failure with diabetes was 12.61. The P-value of smoking, XDRTB suspect, diabetes obtained was 0.019, 0.049, and 0.036 respectively. Chi square test showed significant P-value for variables sex, diabetes, XDR suspects, smoking and drug abuse, but insignificant P-value for HIV, comorbid illness like renal failure. Similarly, age, chest x-ray lesion like cavitary, caseous lesion, did not affect the outcome as per logistic regression analysis.
Conclusion: Smoking, PreXDRTB, Diabetes, were factors affecting the outcome of treatment independently hence predictors of outcome in MDRTB. The emergence of preXDRTB as independent factor determining the outcome is significant emphasizing the earlier switch to XDRTB regimen.

Background: LCI has been proven an effective tool in the detection of lung disease in CF.
Objectives: a) To assess the correlation of ventilation inhomogeneity indices with structural damages of the lung, among different groups of disease severity and b) To compare the associations among MBW parameters with spirometry and CT.
Method: Forty-four children and adolescents with CF participated in the study. Spirometry and multiple breath washout tests were performed. All children had a HRCT scan. The study population was divided into two groups, according to FEV1% predicted values: Group A: ≥ 85% predicted (normal) and Group B: 40-84% predicted (mild-moderate disease).
Results: The patients’ mean age was 12.9 (5.67; 23.25) years, mean FEV1: 91.22 ± 24.22% and mean LCI: 10.72 ± 3.51. Children of Group A had significantly lower LCI, compared to Group B (p<0.001). Among the whole study group all the ventilation inhomogeneity indices were correlated with FVC%, FEV1% and FEF50% and the severity and extent of bronchiectasis, the generation of bronchial division and the presence of emphysema (p<0.05). Among patients with normal FEV1, MBW parameters showed stronger correlation with the structural changes of HRCT, while among patients with mild-moderate lung disease, they showed stronger correlation with spirometry.
Conclusion: MBW is a reliable method to assess the structural and functional lung disease in CF. However in mild disease ventilation inhomogeneity outcomes were better associated with CT changes, while in mild - moderate disease MBW outcomes were better associated with spirometry.

Objective: Trimethoprim-Sulfamethoxazole (TMP-SMX) is a relatively commonly prescribed antibiotic. One of the rare but dramatic reactions to TMP-SMX is severe systemic reaction which can mimic sepsis or septic shock and this can be a diagnostic challenge especially in critical care setting. The objective is to raise information about this side effect. Study Selection: The case series includes two patients’ reports. The first patient was 85 year old woman who received TMP-SMX before dental extraction and presented with rash and fever. She met SIRS criteria with leukocytosis, bandemia, lactic acidosis and acute kidney injury. All the infectious work remained negative. She improved with supportive care. She received TMP-SMX again after a few weeks and again presented with similar clinical course. Again the infectious work up remained negative and she improved with supportive care. It was thought that TMP-SMX contributed to this. The second patient was 85 year old man who took TMP-SMX for right leg cellulitis and presented with systemic inflammatory response resembling septic shock. All the infectious work up remained negative. The patient recovered completely with supportive care. TMP-SMX was thought to be responsible for the side effect. Conclusion: TMP-SMX induced systemic reaction resembling anaphylaxis or sepsis is rare. Symptoms are very similar to classic sepsis and septic shock including fever, chills, leukocytosis and hemodynamic instability. This has been described mostly in HIV patients but this may happen in non-HIV patients as well.

A 19-year-old male presented with upper abdominal pain, shortness of breath and loss of consciousness. X-rays revealed a tension hemothorax and a chest tube was inserted evacuating 2500 ml of blood. Bleeding in the tube ceased after the initial evacuation and the patient was monitored closely and could be discharged in good health on the second day after admission. We hypothesize, that the tension hemothorax was preceded by a spontaneous pneumothorax, which caused a tear in scar tissue following the Nuss procedure five months previously.

Background: The purpose of this systematic review was to compare the diagnostic accuracy of axial thoracic CT, other imaging techniques and image reconstruction algorithms with the endoscopic findings of Fiberopptic Bronchoscopy (FOB), in patients with newly detected endobronchial lesions.

Methods: A systematic review of the literature for retrospective and prospective studies was performed. Articles considered included patients with endobronchial stenosis that were subjected to axial Computed Tomography of the chest with or without an image reconstruction technique, and Fiberoptic Bronchoscopy.

Results: 10 studies (6 prospective/4 retrospective) that were published in PubMed or CancerLit met the inclusion criteria. A total number of 633 patients were involved in the studies and an additional number of 53 patients were included as controls. All the patients were subjected to Fiberoptic Bronchoscopy (FOB) and imaging of the chest. The meta-analysis showed a high sensitivity for most imaging techniques, comparable with this of Fiberoptic Bronchoscopy, but with a significant Negative Predictive Value.

Conclusion: Even though the imaging techniques are a useful, fast and safe modality for the detection of endobronchial lesions, the high negative predictive value raises a concern on their sufficiency for the exclusion of lung cancer on high risk patients.

Objective: Reexpansion pulmonary edema (RPE) is a severe disorder, and its pathophysiology is not well understood. One proposed mechanism for RPE is that chemical substances such as cytokines increase alveolar permeability. Another possible mechanism is that alveolar distention during reexpansion causes physical damage. To test the hypothesis that sudden alveolar distention damages alveolar cellular structure and identify the underlying cause of RPE, we developed and evaluated the morphological characteristics of a rat RPE model.

Methods: Lung from a rat model of RPE was observed by using live imaging from intravital fluorescence microscopy with fluorescein isothiocyanate labelled albumin as tracer, light microscopy, and electron microscopy (with and without horseradish peroxidase [HRP] as tracer).

Results: Intravital fluorescence microscopy and light microscopy showed that RPE developed almost immediately after lung reexpansion and that blood flow in pulmonary capillaries slowed substantially. In some capillaries, however, blood flow had stopped entirely; in others, anterograde and retrograde flow alternated. Electron microscopy revealed pores in type I pneumocytes and overt fissures in alveolar walls. Electron microscopic observation with HRP revealed that HRP moved from capillaries to the inner surfaces of alveolar epithelia in reexpanded lungs. In addition, diaminobenzidine reaction products from the HRP enzyme reaction were visible in areas with pores.

Conclusions: RPE occurred almost immediately after lung reexpansion. Pores developed in type I pneumocytes in alveolar epithelium. These pores, together with overt fissures in alveolar walls, allowed leakage of plasma components into alveoli. These findings appear to be important features of RPE development.