Predictors of Poor Outcome in Patients with COVID-19 associated Respiratory Failure: A Retrospective Observational Study

Background: Coronavirus disease 2019 (COVID-19) is majorly known to cause mild to moderate disease, but a small fraction of patients may develop respiratory failure due to diffuse lung injury, requiring management in the intensive care unit (ICU). This study attempts to identify factors that can predict unfavorable outcomes in moderate to severe COVID-19 patients. Methods: Hospital records of 120 COVID-19 patients admitted to the ICU were retrospectively analyzed and data pertaining to demographic, clinical, and laboratory parameters were obtained. These data were then compared with outcome parameters like survival, duration of hospital stay, and various adverse events. Results: Out of 120 patients, 70% were male, with a mean age of 54.44 years [standard deviation (SD) ± 14.24 years]. Presenting symptoms included breathlessness (100%), cough (94.17%), fever (82.5%), and sore throat (10.83%). Diabetes, hypertension, and chronic obstructive pulmonary disease (COPD) were the common comorbidities associated. Increased serum D-dimer, ferritin, interleukin-6 (IL-6) levels, and unvaccinated status were associated with higher mortality. Overall, 25.83% of patients survived, 24.41% of patients developed septic shock, and 10.6% of patients were discharged on oxygen. World Health Organization (WHO) clinical progression scale score ? 6 had 57 and 82% sensitivity and 83 and 77% specificity on days 7 and 14 after admission, respectively, for predicting mortality. A baseline National Early Warning Score 2 (NEWS 2) ? 9 had 48% sensitivity and 88% specificity for predicting mortality. Conclusion: Advanced age and associated comorbidities are linked to adverse outcomes in moderate to severe COVID-19. Persistently high D-dimer levels, despite standard treatment, may also contribute to increased mortality. WHO clinical progression scale and NEWS 2 have high specificity for predicting mortality.

Idiopathic central sleep apnoea an Indian case with polysomnographic findings.

Patients with idiopathic central sleep apnoea (ICSA) usually complain of poor quality sleep; yet many of them do not receive appropriate treatment because of poor recognition of ICSA by health professionals. We report the case of a patient with ICSA who was misdiagnosed and received treatment for seizures, depression or anxiety for a number of years and discuss the differential diagnosis and treatment options for ICSA.

Transbronchial needle aspiration with rapid on-site evaluation: A prospective study on efficacy, feasibility and cost effectiveness.

Background. Transbronchial needle aspiration (TBNA) has an established role in diagnosis of hilar and mediastinal lesions. Rapid on-site evaluation (ROSE) of TBNA smears can determine the adequacy of TBNA smears that can obviate the need for repeat procedures, thus avoiding added cost. There is paucity of data from India showing efficacy and cost-effectiveness of ROSE. Hence, this study was carried out to assess the efficacy, feasibility and cost implications of ROSE assisted TBNA. Methods. Forty consecutive patients undergoing TBNA were enrolled and ROSE was performed on TBNA smears. The results were analysed using a comparative study design. Results. It was found that 45% of patients would have required a repeat bronchoscopy due to inadequacy of material, if ROSE was not used. Inadequate smears were more common in benign aetiologies than malignant ones. TBNA of mass lesions and lesions with endoluminal bulge give better results than TBNA of lymph nodes and without endoluminal bulge. Conclusions. ROSE was found to increase the yield of TBNA and help to prevent repeat procedures. It proved to be simple, cost-effective and feasible in Indian settings.

Diagnostic role of MGIT culture of BAL samples in sputum smearnegative pulmonary tuberculosis.

Background: In view of the diagnostic difficulties associated with sputum- negative pulmonary TB (PTB), we aimed at exploring if bronchoalveolar lavage (BAL) samples can be subjected to smear- microscopy and rapid mycobacterial culture (by Mycobacterial Growth Indicator Tube (MGIT) method) to achieve improved diagnosis of this condition. Methods: Patients presenting with clinico-radiological features suggestive of pulmonary tuberculosis and whose sputum smears were negative for acid- fast bacilli (AFB) or who could not expectorate sputum were prospectively enrolled in this study. BAL samples collected from them were subjected to smear- microscopy for AFB and micro-MGIT culture. BAL samples were also inoculated on Lowenstein- Jensen (LJ) slants. Results: A total of 105 patients (74 males) were recruited in the study, with a mean (±SD) age of 51 (± 15) years. The diagnosis of PTB was made in 52 patients on the basis of clinico- radiological presentation, with or without microbiological confirmation. Thirty- four patients (65.4 %) had microbiologically confirmed PTB. Of them, AFB were detected in 12 BAL samples, while culture- positivity was noted in 24 and 27 patients by the LJ and MGIT methods respectively. Intertest agreement between the LJ and MGIT methods was found to be significant (ê= 0.655; p= <0.001). However, the mean time to positivity was significantly lower for the MGIT method than for the LJ method (p= <0.001). Conclusion: Examination of BAL samples by smear- microscopy and micro-MGIT culture can, therefore, provide a rapid and definitive diagnosis of PTB in sputum- negative patients.

Haemoptysis after four years of lobectomy for aspergilloma.

We present a case of a 26-year-old male who underwent lobectomy for life-threatening haemoptysis due to aspergilloma in an old tuberculosis left upper lobe cavity who presented with recurrence of haemoptysis four years after the surgery. Fibreoptic bronchoscopy revealed Aspergillus colonisation in the ectatic residual bronchus which is an uncommon complication of lobectomy. The patient was successfully managed with antifungal agents.

Effects of ergoreflex on respiration and other efferent effects in adult male patients with chronic obstructive pulmonary disease.

In COPD, overactivation of ergoreceptors may be a link between peripheral changes, sympathetic over activation and increased hemodynamic and ventilatory responses to exercise. The current study was undertaken to test the hypothesis that, ergoreflex in COPD patients is hyperactive and contributes to breathlessness and exercise limitation. The aim of study was to (1) demonstrate its hyperactivity in COPD (2). To record other efferent effects. Twenty stable COPD male patients aged 50±2.5 years and twenty healthy male subjects aged 48±3.5 years were studied under experimental and control groups. The ergoreflex contribution to cardio respiratory parameters was assessed by post-handgrip regional circulatory occlusion method (PH-RCO) and computed as the difference in heart rate and respiratory rate response between PH-RCO and control run without PHRCO. Results were analyzed for significance between two groups by repeated measures ANOVA. COPD patients showed over activation of ergoreflex as compared to control subjects in terms of heart rate during sustained hand grip (SHG) exercise (117±1.22 versus 89±0.89) beats/min, recovery heart rate (p<0.001), and respiratory rate during SHG (24±0.54 versus 19±03.24) breaths/min and recovery respiratory rate (p<0.001). Degree of overactivation of ergoreflex was significant in COPD patients (p<0.001). In COPD, overactivity of ergoreflex is associated with abnormal cardio respiratory reflex control. COPD patients showed overactivation of sympathetic nervous system as evidenced by heart rate changes during exercise and delayed recovery.

Role of endobronchial electrocautery in management of neoplastic central airway obstruction: Initial experience with seven cases.

Background. Central airway obstruction (CAO) due to malignant and benign conditions is common. Tumour ablation by various techniques helps effective palliation of symptoms in such patients. Tumour ablation using endobronchial electrocautery (EBEC) with flexible bronchoscope (FB) is an established procedure. However, there is paucity of data from India on this topic. Methods. EBEC was performed in seven patients with CAO; six of these patients had malignant (non-small cell carcinoma) and one had benign aetiology (tracheal fibro-epithelial polyp) as the cause of CAO. Pre- and post-procedure assessment was done with the help of Speiser’s symptomatic scoring. Results. Mean age of the patients was 52.9±7.0 years; there were five males. All the patients had symptomatic relief after the procedure; in five of them the improvement in symptom scores was significant. No major complication was encountered in any patient. Conclusions. EBEC can be a safe, effective and cost-effective tool for palliation in patients with benign or malignant CAO. It is especially beneficial for centres where cost of bronchoscopic laser and cryotherapy is prohibitive.

Tracheal polyp treated with endobronchial electrocautery.

Fibroepithelial polyps of trachea are extremely rare. Here, we report a case of tracheal polyp in a 40-year-old woman that was managed successfully with endobronchial electrocautery with a review of the relevant literature.

Intrapulmonary teratoma presenting with tricoptysis: A case report and review of the literature.

Intrathoracic teratoma usually occurs in the mediastinum but rarely, these may originate from the lung. We report a case of an intrapulmonary teratoma in a 34-year-old male.

Exfoliative Dermatitis to all four first line oral antitubercular drugs.

Exfoliative dermatitis to all four first line drugs singly or rarely in combination has been reported. Here we report a rare case of pulmonary tuberculosis with exfoliative dermatitis to all four oral first line antitubercular drugs. (Rifampicin, Isoniazid, Ethambutol, Pyrazinamide). To the best of our knowledge, this is the first such case.

Perianal tuberculous ulcer in an immuno-competent patient.

Perianal tuberculosis, without the presence of any previous or active pulmonary infection, is extremely rare. A wide range of differential diagnosis for perianal ulcers might be one reason for a possible delay in establishing this diagnosis.

Primary multi-drug resistant tubercular lymphadenitis in an HIV infected patient.

Cervical lymphadenitis is a common extra-pulmonary manifestation of tuberculosis in HIV patient; nevertheless, it seems that the primary Multi Drug Resistant (MDR) involving extra-pulmonary site is uncommon. We report a case of tubercular lymphadenitis by multi-drug resistant strain of Mycobacterium tuberculosis in an HIV seropositive male, which has not been reported so far in literature.

Clinico-radiological profile of new smear positive pulmonary tuberculosis cases among young adult and elderly people in a tertiary care hospital at Deheradun (Uttarakhand).

SETTING: Patients of pulmonary tuberculosis (TB) attending the out and in patient department of pulmonary medicine, Himalayan Institute of Medical Sciences (HIMS), a post graduate institute and a large tertiary care center in Dehradun. OBJECTIVE: To compare the clinico-radiological pattern of pulmonary tuberculosis in the young adult (18-59 years) and elderly (> or = 60 years) patients. DESIGN: Prospective observational study of pulmonary and associated extra pulmonary tuberculosis cases, diagnosed between October 2005 to September 2006 in pulmonary medicine department of HIMS. RESULT: Mean age of young adult and elderly patients was 35.71 +/- 5.7 years and 68.57 +/- 3.03 years respectively. Elderly patients had a higher number of co-morbidities like diabetes mellitus, hypertension, and malignancy. Tuberculin positivity was less among elderly patients (36.0%) as compared to young adults (65.9%). Hemoptysis (29.5% vs. 6%), fever (95.4% vs. 76%) and night sweats (54.5% vs. 18.0%) were significantly higher in the young adult patients than the elderly. As for roentgenographic abnormalities, a higher involvement of lower zone (24.0% vs. 7.9%) and far advanced lesions (32.0% vs. 14.7%) were seen in the elderly patients as compared to young adults. The elderly showed a higher frequency of TB related mortality (8% vs. 1.1%) and associated extra pulmonary involvement (40% vs. 7%). CONCLUSION: Young adults are more likely to have hemoptysis, night sweats and positive PPD response while lower lung field involvement is more common in elderly.

Unusual occurrence of allergic bronchopulmonary aspergillosis in a family.

Allergic bronchopulmonary aspergillosis is now a well known entity in asthmatic patients. Despite the familial occurrence of bronchial asthma, the familiar occurrence of allergic bronchopulmonary aspergillosis is a rarity. Here 2 cases of allergic bronchopulmonary aspergillosis in a family (brother and sister), treated with prednisolone with complete remission are reported. The clinicans should have a high index of suspicion to investigate all the members of a patient with allergic bronchopulmonary aspergillosis, who are having history of asthma or rhinitis.

HIV Sero-pervalence and Tuberculosis in Uttaranchal.

Setting: Patients of tuberculosis attending the out patient department of Himalayan Institute of Medical Sciences (HIMS), a post graduate institute and a large tertiary care centre in Dehradun. Objective: To study the trend of HIV seropositivity in patients of tuberculosis along with demographic profile, clinical features and associated complications, in patients of HIV-TB co-morbidity. Design: HIV seropositivity was assessed among all tuberculosis patients (pulmonary &extra-pulmonary), diagnosed between January 1999 and August 2005 attending the out patient department of HIMS. Result: HIV seropositivity in tuberculosis patients rose from 1.19% in 1999 to 4.19% in 2005. Out of total 42 HIV seropositive patients, 71.42% were males, 88.09% were married, and 69.04% belonged to rural population. Most common route of HIV transmission was heterosexual (66.67%) followed by blood transfusion (16.67%). 64.28% of the patients had pulmonary tuberculosis and 35.71% had extra-pulmonary tuberculosis. Sputum was positive for Acid Fast Bacilli in 40.74%. Fever was the most common (83.33%) symptom and oral candidiasis (40%) was the most commonly associated complication.