Acute invasive pulmonary aspergillosis, shortly after occupational exposure to polluted muddy water, in a previously healthy subject / Aspergilose pulmonar invasiva aguda, logo após exposição ocupacional a água poluída barrenta, em indivíduo previamente saudável

Invasive pulmonary aspergillosis (IPA) predominantly occurs in severely neutropenic immunocompromised subjects. The occurrence of acute IPA after brief but massive exposure to Aspergillus conidia in previously healthy subjects has been documented, although only six such cases have been reported. The diagnosis was delayed in all six of the affected patients, five of whom died. We report the case of a 50-year-old HIV-negative male, a water pipeline maintenance worker, who presented with acute-onset dyspnea and fever one day after working for 2 h in a deep pit containing polluted, muddy water. Over a one-month period, his general condition deteriorated markedly, despite antibiotic therapy. Imaging showed bilateral diffuse nodules with cavitation, some of which were surrounded by ground-glass opacity suggestive of a halo sign (a hallmark of IPA). Cultures (of sputum/bronchial aspirate samples) and serology were positive for Aspergillus fumigatus. After being started on itraconazole, the patient improved. We conclude that massive exposure to Aspergillus conidia can lead to acute IPA in immunocompetent subjects.

A aspergilose pulmonar invasiva (API) ocorre predominantemente em indivíduos imunocomprometidos com neutropenia grave. A ocorrência de API aguda após exposição breve, mas maciça, a conídios de Aspergillus sp. em indivíduos previamente saudáveis já foi documentada, embora apenas seis casos tenham sido relatados. O diagnóstico foi tardio em todos os seis pacientes afetados, dos quais cinco foram a óbito. Relatamos o caso de um homem de 50 anos de idade, HIV negativo, trabalhador de manutenção de tubulação de água, que apresentou dispneia e febre de início agudo um dia após trabalhar 2 h em uma vala funda contendo água poluída e barrenta. Num período de um mês, seu estado geral se deteriorou acentuadamente, apesar da antibioticoterapia. Exames de imagem mostraram nódulos bilaterais difusos com cavitação, alguns dos quais circundados por opacidade em vidro fosco sugestiva de sinal do halo (uma característica da API). As culturas (de amostras de escarro/aspirado brônquico) e a sorologia foram positivas para Aspergillus fumigatus. Após iniciado o tratamento com itraconazol, o paciente melhorou. Concluímos que a exposição maciça a conídios de Aspergillus pode levar a API em indivíduos imunocompetentes.

Aspergilloma formation in cavitary sarcoidosis / Formação de uma aspergilloma em sarcoidose com cavitação

Pulmonary cavitation is rather uncommon in patients with sarcoidosis, and aspergilloma is even more uncommon in such cases. Here, we present the case of a 63-year-old female patient with cavitary lung disease who had been under treatment for TB for 9 months. A diagnosis of pulmonary sarcoidosis was established based on the fiberoptic bronchoscopy finding of noncaseating granuloma. Treatment with corticosteroids led to a dramatic improvement in symptoms. While under treatment for sarcoidosis, the patient developed an aspergilloma. She presented immediate skin test reactivity to Aspergillus fumigatus, as well as positivity for A. fumigatus serum precipitins. This is the first reported case of aspergilloma formation in a patient with cavitary sarcoidosis in India.

A cavitação pulmonar é rara em pacientes com sarcoidose, e o aspergiloma é ainda mais raro nestes casos. Apresentamos o caso de uma paciente de 63 anos com doença pulmonar cavitária em tratamento para a TB por 9 meses. Estabeleceu-se o diagnóstico de sarcoidose pulmonar com base nos achados de granuloma não-caseoso na fibrobroncoscopia. Houve grande melhora dos sintomas com o tratamento com corticosteroides. A paciente desenvolveu um aspergiloma durante o tratamento para a sarcoidose. Houve reação imediata ao teste cutâneo para Aspergillus fumigatus, assim como resultado positivo para precipitinas de A. fumigatus no soro. Este é o primeiro caso relatado de formação de aspergiloma em um paciente com sarcoidose com cavitação na Índia.

Allergic rhinitis and co-morbid asthma: Perspective from India- ARIA Asia-Pacific Workshop Report.

In India, allergic rhinitis (AR) is considered to be a trivial disease, despite the fact that symptoms of rhinitis were present in 75% of children and 80% of asthmatic adults. Traditionally, AR was also divided into sea-sonal or perennial, based on the time of occurrence of symptoms during the year. The ARIA workshop report pro-posed that patients be categorized as “intermittent” and “persistent” while severity was classified as “mild” and “moderate-severe”. Patients with AR, depending on their predominant symptom, can also be categorized as “sneezers-runners” and “blockers”. On sketching their clinical profile, it was observed that “blockers” had signifi-cantly higher sinusitis and had higher sensitization to fungi. Skin allergy testing in Indian adults showed that in pa-tients with AR house dust mite (Dermatophagoides farinae) was the most common allergen. Studies conducted in India have shown that AR often restricts the patient’s quality of life (QOL). It can affect the physical, psychological and social aspects of the patients’ life and can also impact their functions at work. Furthermore, AR adversely af-fects sleep related QOL. Topical corticosteroids are now considered as the cornerstone of the treatment for AR. In spite of causing a major impact on the QOL in Indian patients, AR is rarely given the importance it deserves.

Aspergillus-associated hypersensitivity respiratory disorders.

The mould Aspergillus is responsible for a gamut of respiratory diseases ranging from saprobic colonisation to rapidly invasive disseminated disease. The clinical spectrum of Aspergillus-associated hypersensitivity respiratory disorders includes Aspergillus induced asthma, allergic bronchopulmonary aspergillosis (ABPA), allergic Aspergillus sinusitis (AAS) and hypersensitivity pneumonitis. Inhalant allergens, in patients with allergic asthma, play a key role in bringing about the inflammation present in the airways, and fungi are increasingly being recognised as important inhalant allergens. Aspergillus is linked to asthma in more ways than one. In the asthmatic subjects, the fungal spores are trapped in the thick and viscid secretions that are usually present in the airways. This generally develops in atopic subjects and is sustained by continuous inhalation of Aspergillus antigens, triggering asthma that may be more severe in form. Aspergillus induced asthma is yet to receive the recognition that it deserves. Allergic bronchopulmonary aspergillosis is the best known form of allergic aspergillosis and is an emerging disease in India. An immunologically mediated lung disease, ABPA occurs predominantly in patients with asthma. A set of diagnostic criteria is required as there is no single test that establishes the diagnosis apart from demonstration of central bronchiectasis with normal tapering bronchi, a feature considered to be pathognomonic of ABPA. Radiologically, ABPA is characterised by 'transient pulmonary infiltrates' or 'fleeting shadows', often confused with pulmonary tuberculosis. A comparatively more recently recognised clinical entity, AAS is characterised by mucoid impaction in the paranasal sinuses which is akin to that in ABPA. Although it appears that the patient with ABPA provides a favourable milieu for the occurrence of AAS, it is perhaps surprising that in spite of similar histopathological features the co-existence of both these diseases has not often been reported. Aspergilloma, a fungal ball that appears in a pre-existing cavity due to saprobic colonisation of Aspergillus species, can often present with asthma. The association of ABPA and aspergilloma is also known. Although cavitation can occur in ABPA, the co-existence of ABPA with aspergilloma is rather uncommon. Aspergillomas may function as a nidus for antigenic stimulation in a genetically predisposed individual resulting in the occurrence of ABPA. Contemporaneous occurrence of ABPA, AAS and aspergilloma has also been reported. Screening all asthmatic subjects for Aspergillus sensitisation could identify those with a severe form of the disease as well as those at risk for developing ABPA. Furthermore, concomitant occurrence of ABPA and AAS is now being increasingly recognised, and AAS must be excluded in all patients with ABPA.

Nocturnal symptoms and sleep disturbances in clinically stable asthmatic children.

Presence of nocturnal symptoms is related to asthma severity. Clinically stable asthmatic children, too, report frequent nocturnal symptoms and sleep disturbances. The study determined these parameters in stable, asthmatic children, in their home environment. This case-control, questionnaire-based study in 70 school-going children comprised 40 asthmatics (Group 1) and 30, age/gender matched, healthy children (Group 2). Parents maintained peak expiratory flow (PEF) and sleep diaries for one week. Group 1 had significantly lower mean morning (250.3 vs. 289.1 I/minute) and mean evening PEF values (261.7 vs. 291.3 I/minute). Group 1 (38.95%), reported frequent nocturnal symptoms like cough (36.90%), breathlessness (32.80%), wheeze (27.68%) and chest tightness (14.35%). Sleep disturbances, significant in Group 1 (38, 95% vs. 14.35%), included daytime sleepiness (24.60%), daytime tiredness (20.50%), difficulty in maintaining sleep (15.38%), early morning awakening (14.35%), struggle against sleep during daytime (12.30%), and involuntarily falling asleep (17.43%). On a scale of 1-6, Group 1 scored significant sleep disturbances/patient (3 vs. 0.8); lethargy/tiredness in morning (2.9 vs. 2.2), poorer sleep quality (4.7 vs. 5.4), less parents' satisfaction with child's sleep (4.5 vs. 5.5) and daytime fitness (4.1 vs. 5.3). Group 1, when exposed to environmental tobacco smoke (22, 55%), reported significant nocturnal symptoms (18/22, 81%) and reduced mean morning and evening PEF values (17/22, 77%). It is concluded that clinically stable, asthmatic children reported increased nocturnal symptoms, sleep disturbances and poorer sleep quality. Lack of awareness of asthma-sleep association and its clinical implications could lead to poor asthma control and impaired daytime activity.

Isolated left lung aplasia with bronchial asthma.

Congenital lung anomalies are categorised as pulmonary agenesis, aplasia and hypoplasia with distinct clinical implications. An 8-year-old boy was referred for an opaque left hemithorax for which he had received antituberculous therapy. A detailed evaluation including flowing contrast computed tomography of the thorax and fiberoptic bronchoscopy led to a diagnosis of left lung aplasia. He also had wheezing dyspnea, which was confirmed as bronchial asthma. Congenital lung defects with associated asthma was reported only twice till date. A high index of suspicion is required to recognise such a patient.

Hydrocarbon pneumonitis following diesel siphonage.

In our country, siphoning of diesel/petrol from fuel tanks is a common practice. We describe a 50-year-old farmer, who accidentally aspirated fuel while siphoning from his tractor. A diagnosis of diesel induced aspiration pneumonitis was confirmed by the presence of foam cells on bronchial biopsy. The patient showed gradual recovery with the symptomatic therapy. However two weeks later, he developed sudden chest pain and irregularly irregular pulse that proved fatal. Diesel aspiration leading to bilateral pneumonitis is yet to be reported in our country.

A 35-year old man with a non-resolving pleural effusion.

A thirty-five-year old male, a nonsmoker, was referred to us for evaluation of progressive pulmonary disease. His clinical course during the past 2 years was characterized by paroxysmal attacks of cough with scanty mucoid sputum. This was accompanied by intermittent fever and malaise. There was no history of wheezing, nasal symptoms or loss of weight. Eighteen months prior to referral, based on his symptomatic and roentgenologic profile, he was clinically diagnosed as a case of tuberculous mediastinal lymphadenitis. He was initiated on antituberculous therapy (ATT) comprising rifampicin 450 mg, isoniazid 300 mg, pyrazinamide 1500 mg and ethambutol 800 mg once daily. Prednisolone (10 mg thrice daily) was added after 2 months when the patient did not experience any relief. He was however irregular with the oral steroids and stopped it after 1 month. One year prior to referral, while on ATT for 6 months, he had few episodes of blood-streaked sputum, episodic exertional dyspnoea, and rightsided chest pain that increased on coughing and deep breathing. This was diagnosed as right-sided pleural effusion, and the patient was initiated on second line ATT in the form of kanamycin 1gm intramuscularly, sparfloxacin 400 mg, prothionamide 750 mg, clofazamine 200 mg, clarithromycin 500 mg, thiacetazone 150 mg and isoniazid 300 mg once daily. Kanamycin was stopped after 6 months but the other drugs were continued for a period of 1 year. In spite of regular second line ATT for 1 year, the patient remained symptomatic and as the effusion persisted, he was referred to us for evaluation. Physical examination revealed a middle-aged male in no acute distress. There was no clubbing or cyanosis. Chest examination suggested a right-sided pleural effusion. Examination of other systems, including an ophthalmologic referral, did not detect any abnormality.

Isoniazid associated, painful, bilateral gynaecomastia.

Gynaecomastia is a rarely reported adverse drug reaction due to isoniazid therapy. We describe a 25-year-old, human immunodeficiency virus (HIV)--negative man, who was started on antituberculosis treatment (ATT) with isoniazid (H), rifampicin (R), pyrazinamide (Z) and ethambutol (E) in the combination RHZE for the first two months and RH there on. After four months, while receiving RH, he developed painful bilateral gynaecomastia. ATT had to be stopped because of this adverse drug reaction. Gynaecomastia, however, persisted even after three months of cessation of therapy. A year later, the patient reported complete disappearance of pain and swelling, although right breast continued to appear larger than the left.