An Unusual Cause of a Pulmonary Mass: Actinomycosis.

We present the case of a 62-year-old male with chronic obstructive pulmonary disease and poorly controlled diabetes mellitus who presented with haemoptysis. A radiograph of the chest showed a right lower parahilar opacity which on the contrast enhanced computed tomography was seen to be an irregular, spiculated mass localised to the middle lobe. Considering malignancy as the most probable diagnosis, a bronchoscopic endobronchial biopsy was performed which surprisingly established pulmonary actinomycosis as the diagnosis. The patient was successfully managed with amoxicillin and clavulanic acid and glycaemic control.

Clinical presentation of patients with seasonal influenza and pandemic influenza A (H1N1-2009) requiring hospitalisation.

Background. A sudden increase in the number of novel influenza A virus (pH1N1-2009) infection prompted us to compare the clinical presentation and outcomes of patients infected with pH1N1-2009 and seasonal influenza A virus during the postpandemic phase. Methods. During the period August 13 to September 27, 2010, case records of 106 patients with severe influenza like illness (ILI) and respiratory complications who underwent diagnostic testing by real-time polymerase chain reaction (RT-PCR) for confirmation of pH1N1-2009 were retrospectively studied. Results. Nineteen (17.9%) patients were tested positive for pH1N1-2009 and 78 (73.6%) were tested positive for seasonal influenza A virus. The mean age of patients infected with pH1N1-2009 was 45.2±15.3 years (range of 22 to 80 years). Common presenting symptoms included fever in 17 (89.4%), cough in 16 (84.2%), myalgia in 15 (78.9%) and breathlessness in 10 (52.6%) patients. The most common comorbidities included bronchial asthma/bronchitis/chronic obstructive pulmonary disease (COPD) in 4 (21%); followed by hypertension in 3 (15.8%) and diabetes in 3 (15.8%) patients. Overall, of the 97 influenza infected patients, 9 (9.3%) needed hospitalisation to the intensive care unit (ICU); one patient with COPD died due to multi-organ failure. Conclusions. Both the pandemic and seasonal strains were found to be co-circulating in the community. Patients with severe hypoxia, hypertension, acute respiratory distress syndrome and shock required ICU care.

Sarcoidosis in north indian population: A retrospective study.

Background. Sarcoidosis is a systemic granulomatous disease of unknown origin most commonly involving the lungs. Sarcoidosis is frequently misdiagnosed due to its clinico-radiological resemblance to tuberculosis (TB). Hence, the present study was undertaken with the aim of studying the clinico-radiological profile of sarcoidosis in the Indian context. Methods. We retrospectively studied 146 patients diagnosed to have sarcoidosis during the period 2001-2010 at one of the respiratory units at Vallabhbhai Patel Chest Institute. Results. Majority of them (70%) were more than 40 years of age; females comprised 58.2% of the patients. Before coming to our clinic, 30% patients had been misdiagnosed to have TB. Cough (89.7%) was the most common presenting symptom; joint symptoms (28.8%) and end inspiratory crepitations at lung bases (49.3%) were other salient manifestations. Cutaneous involvement and digital clubbing were rarely seen. Pulmonary function testing showed restriction with impaired diffusion in 72.7% patients. The most common radiological feature was bilaterally symmetrical hilar lymphadenopathy. Transbronchial lung biopsy (TBLB) had a very high diagnostic yield (90.8%). Conclusions. Sarcoidosis is often misdiagnosed as TB in India. Transbronchial lung biopsy has high diagnostic yield in sarcoidosis.

Identification of IgE-mediated food allergy and allergens in older children and adults with asthma and allergic rhinitis.

Background and objective. Prevalence of immunoglobulin (Ig) E-mediated food allergy is primarily reported for certain pediatric populations and adults. The present study was aimed to investigate the relative prevalence of food allergy and allergens in older children and adults with asthma and allergic rhinitis. Methods. Patients (12-62 years) were screened using standard questionnaire and skin prick-test (SPT) with common foods and aeroallergens. Specific IgE level was determined by enzyme linked immunosorbent assay (ELISA) and allergy was established by blinded food challenges. Results. Of 1860 patients screened, 1097 (58.9%) gave history of food allergy. Of the history positive patients skin tested (n=470), 138 (29.3%) showed a marked positive reaction to food extracts. Rice elicited positive SPT reaction in maximum number of cases 29 (6.2%) followed by blackgram 28 (5.9%), lentil 26 (5.5%), citrus fruits 25 (5.3%), pea 18 (3.8%), maize 18 (3.8%) and banana 17 (3.6%). The SPT positive patients showed elevated specific IgE levels (range: 0.8-79 IU/mL) against respective food allergens than normal controls (0.73 IU/mL, mean±2SD). Food allergy was confirmed in 21/45 (46.6%) of the patients by blinded controlled food challenges. The prevalence of food allergy was estimated to be 4.5% (2.6%-6.34%) at 95% confidence interval (95% CI) in test population (n=470). Sensitisation to food was significantly associated with asthma (p=0.0065) while aeroallergens were strongly related to rhinitis (p<0.01). Conclusions. Food allergy is estimated to be 4.5% in adolescents and adults with asthma, rhinitis or both. Rice, citrus fruits, blackgram and banana are identified as major allergens for inducing allergic symptoms.

Impact of domestic air pollution from cooking fuel on respiratory allergies in children in India.

This study undertaken in India was aimed at identifying the effects of the indoor air pollutants SO2, NO2 and total suspended particulate mater (SPM) generated from fuel used for cooking on respiratory allergy in children in Delhi. A total of 3,456 children were examined (59.2% male and 40.8% female). Among these, 31.2% of the children's families were using biomass fuels for cooking and 68.8% were using liquefied petroleum gas. Levels of indoor SO2, NO2 and SPM, measured using a Handy Air Sampler (Low Volume Sampler), were 4.60 +/- 5.66 microg/m3, 30.70 +/- 23.95 microg/m3 and 705 +/- 441.6 microg/m3, respectively. The mean level of indoor SO2 was significantly higher (p = 0.016) for families using biomass fuels (coal, wood, cow dung cakes and kerosene) for cooking as compared to families using LP gas. The mean level of indoor NO2 for families using biomass fuels for cooking was significantly higher in I.T.O. (p = 0.003) and Janakpuri (p = 0.007), while indoor SPM was significantly higher in Ashok Vihar (p = 0.039) and I.T.O. (p = 0.001), when compared to families using LP gas. Diagnoses of asthma, rhinitis and upper respiratory tract infection (URTI) were made in 7.7%, 26.1% and 22.1% of children, respectively. Respiratory allergies in children, which included asthma, rhinitis and URTI, could be associated with both types of fuels (liquefied petroleum gas [LPG] and biomass) used for cooking in the different study areas. This study suggests that biomass fuels increased the concentrations of indoor air pollutants that cause asthma, rhinitis and URTI in children. LP gas smoke was also associated with respiratory allergy.

Gastroesophageal reflux disease in bronchial asthma and the response to omeprazole.

The objective of this study was to determine the incidence of gastroesophageal reflux disease (GERD) in bronchial asthma and the role of omeprazole for asthmatics with symptoms of GERD. Seventy asthmatics were screened for GERD by questionnaire. Patients with a history suggestive of GERD were confirmed by Bernstein test and further investigated for airway responsiveness to instillation of HCl in the esophagus. Symptom score, drug score and spirometric values were recorded initially and after four weeks of treatment with omeprazole. It was found that 74.28% of asthmatics had a history of GERD. Forty patients tested positive by Bernstein test and also showed airway responsiveness to instillation of HCl in the esophagus. There was a significant improvement in symptom scores (p < 0.001), drug scores (p < 0.001) and spirometric values (p < 0.001) after adding omeprazole to their treatment regimen. It was concluded that bronchial asthma and GERD are associated in the majority of patients (57.14%) and such patients are likely to improve with omeprazole.

Sarcoidosis presenting as acute bilateral parotid swelling.

A case of bilateral parotid swelling of short duration, which turned out to be sarcoidosis confirmed by fine needle aspiration cytology, is presented here. The patient also had asymptomatic bilateral hilar lymphadenopathy and dryness of the eyes suggesting sarcoid involvement of the lungs and lacrimal glands. Sarcoidosis of the parotids, although rare, should be considered in the differential diagnosis of acute bilateral parotid swelling. Clinico-radiological findings of multi-organ involvement suggest the diagnosis in such cases.

Tuberculosis in the elderly and their treatment outcome under DOTS.

Summary: A retrospective study of the profile and treatment outcome in the elderly TB patients taking DOTS was carried out in an urban TB clinic of Delhi. Out of 2118 tuberculosis patients treated between 1999-2001, a total of 238 (11.4%) patients were over 50 years of age and of these 45(2.2%) were over 65 years of age. A total of 78.6% of the 283 TB patients of all the categories included in the study had a successful outcome (cure/ completion). The overall case fatality, default and failure rates among the TB patients over 50 years were found to be 7.1%, 8.8% and 4.6%, respectively, despite directly observed treatment being given under RNTCP. The case fatality rate was significantly higher (15.6%) in the age group >65 years as compared to patients between 50-65 years (5.2%). The failure rate was significantly higher (13.3%) in the age group >65 years than among patients in the 50-65 years age-group (2.6%). This emphasizes the need for intensive motivation and stringent monitoring among tuberculosis patients over 65 years of age.

Comparative evaluation of market spacer and home made spacer in the management of bronchial asthma.

INTRODUCTION: A study was conducted to compare the efficacy of market available spacer (with valve) and home made spacer (without valve)--Bislery bottle. MATERIAL AND METHODS: Fifteen patients of bronchial asthma were included in the study. With the use of both devices there was significant bronchodilator effect. The reversibility using Bislery bottle was same as with spacer (market available) while comparing the FVC, FEV1, FEV1/FVC %, FEF 25-75 and PEFR value. RESULT: The difference in percent change in reversibility values by both the devices was not statistically significant (p < 0.05). CONCLUSION: We concluded that the Bislery bottle (without valve) is very cheap compared to market-available spacer and is equally effective which, therefore, can be substituted in bronchial asthma patients, who are unable to afford the cost of market available spacers.

Prevalence of allergic bronchopulmonary aspergillosis in patients with bronchial asthma.

Two Hundred patients with bronchial asthma were studied to identify the prevalence of allergic bronchopulmonary aspergillosis (ABPA). The patients selected required intermittent short courses of steroids and their mean duration of illness was 12 years. Absolute eosinophil count was > 500/mm3 in 53% of the cases. Chest X-rays showed small homogenous shadows with patchy infiltrations in 25% and fluctuating pneumonic shadows in 14% of the cases. Raised specific IgG and positive serum precipitin against Aspergillus fumigatus (AF) were present in 24% and 13%, respectively. Cases with radiological and immunological suspicion were further investigated for ABPA. Skin tests for Type-I and Type-III reactivity were positive with AF extract in 87% (n = 47) and 36% (n = 47) of the cases. A thorax CT of 31 patients showed central bronchiectasis in 24 cases, labeling these patients as ABPA-CB (ABPA with central bronchiectasis) and an other 7 as ABPA-S (serological positive). CT was not done in one case who, because of other positive findings, was also labeled as ABPA-S. Thus, these 32 asthmatics were found to have ABPA. Among them, there was raised specific IgG (100%) and raised specifc IgE against AF (100%), positive skin test for Type-I and Type-III reactivity (100% and 53%) against AF. There was elevated total IgE (100%, n = 29), a positive family history of asthma (63%), peripheral eosinophilia (100%) and a history of passage of brownish plugs (31%). Radiological findings suggested soft shadow with infiltration in 31% and fluctuating pneumonic shadows in 69% of cases. CT Thorax (n = 31) showed central bronchiectasis in 78% of theses patients. Based on the present data, the prevalence of ABPA in bronchial asthma patients is 16% (12% with central bronchiectasis and 4% only serologically positive). Therefore, patients should be investigated and diagnosed in an early phase of ABPA (ABPA-S) and should be treated to prevent permanent lung damage.

Malignant pleural mesothelioma without asbestos exposure.

A 45-year-old male, non smoker and lecturer by profession was diagnosed as an advanced case of bilateral mesothelioma involving lung and pleura. He was never exposed to asbestos, which makes it a rare case.

A placebo controlled trial of two dosages of LPC antagonist--choline in the management of bronchial asthma.

The present study was conducted to compare choline with a placebo for its dose-effect relationship in management of bronchial asthma. Three groups: Group A: taking placebo (sorbitol), Group B: low dose choline (500 mg TDS), and Group C: high dose choline (1000 mg TDS) were assessed after a trial of four months. A decrease in symptoms score and increase in percent asymptomatic days was observed in all the three groups but was statistically significant only in the groups taking choline (Group B and C). Further, it was more significant in the group taking higher dose of choline (Group C). Average drug-requirement decreased in all the three groups but was significant only in the high dose choline group (Group C) Specific airway conductance (SGaw) at FRC and RV improved significantly only in group taking higher dose of choline (Group C), while no significant change in percent fall in SGaw at RV was observed in any group. It is, thus, concluded that choline is a useful prophylactic drug in the management of bronchial asthma. The improvement was more significant at a higher dose. Further studies are required to establish optimal dose of choline in the management of bronchial asthma.

Use of LPC antagonist, choline, in the management of bronchial asthma.

The present study was conducted to compare the effects of disodium cromoglycate (DSCG) and choline, a lipotropic factor, in management of bronchial asthma. Two groups taking DSCG and choline were compared between themselves and with a control group (on bronchodilators only) in a three month trial. A significant improvement in average symptoms scores was observed in all groups but was clinically significant only in the groups taking choline. Percent asymptomatic days increased in all the groups, but was not significant. The additional drug requirement decreased significantly only in the group taking choline. All groups showed an improvement in SGaw at FRC and percent fall in specific airways conductance (SGaw) at RV, but non-significant. A significant fall in bronchial hyperreactivity (BHR) was observed in the group taking choline, which was not consistent, whereas a marginal increase in BHR in the control and DSCG groups was observed. It is concluded that choline, an anti-inflammatory agent which acts by lowering lipophosphatidyl choline (LPC), plays an active role in subjective as well as functional improvement in bronchial asthma. However, a dose related response is yet to be established.

Farmer's lung disease in north-western India--a preliminary report.

A study of farmer's lung (FL) disease was carried out in 197 subjects engaged in farming and having respiratory complaints of varying duration. It revealed that 13.2% of the subjects had precipitating antibodies against thermophilic actinomycetes, with Faenia rectivirgula (Micropolyspora faeni) alone accounting for 85% of the positive reactions. Precipitating antibodies against Thermoactinomyces vulgaris and T. thalpophilus were observed only in 1.5% and 0.5% of the subjects, respectively. Two subjects concomitantly demonstrated F. rectivirgula and T. vulgaris-specific serum precipitins. Sixty (30%) of the subjects related their respiratory symptoms to exposure to wheat straw/thresher's dust or other vegetable substrata in the working environment. Based upon a suggestive clinical history, roentgenography, pulmonary function studies and demonstration of serum precipitins against F. rectivirgula, FL was diagnosed in 4 subjects whose salient features are presented and discussed. To the best of our knowledge, this is the first authentic report on FL from India. A comprehensive epidemiological survey is indicated to determine the prevalence of FL in different geo-climatic regions of the country.

Reproducibility of histamine inhalation bronchial challenge test.

Broncho-provocation tests with inhaled histamine were performed in 61 asthmatics twice at a gap of 4 weeks. Ten of them also underwent a third test after 16 weeks. More than 80% of the patients had a reproducibility of response within 1 to 2-fold concentration difference. It is concluded that under carefully controlled conditions broncho-provocation tests with histamine are reproducible.