Disseminated Salmonella Infection Coexisting with Thymoma.

A 21-year-old boy presented with high grade fever, diffuse chest pain and exertional breathlessness of one month duration. Radiologically he had a large lobulated anterior mediastinal mass with necrotic thick enhancing septaes. Histopathology of the mass was suggestive of thymoma and culture from the necrotic aspirate yielded Salmonella typhi. The same pathogen was isolated in subsequent blood and sputum cultures. This current report describes the rare association of salmonella infection with thymoma.

Evaluation of the diagnostic yield and safety of closed pleural biopsy in the diagnosis of Pleural Effusion.

Aim: To assess the diagnostic yield and safety of closed pleural biopsy in patients with pleural effusion. Methods: In all, 48 consecutive cases of pleural effusion were evaluated with complete pleural fluid biochemical and microbiological analysis, cytology, routine bacterial and mycobacterial cultures. In all these 48 cases of pleural effusion closed pleural biopsy was done with tru-cut biopsy needle and biopsy samples were sent for histopathology and mycobacterial culture. Results: Out of 48 cases, main causes of pleural effusion were Tuberculosis in 21(43.8%) cases, Malignancy in 14(29.2%) cases, paramalignant effusion in six (12.5%) cases, Empyema in three (6.3%) cases, transudative effusion in three (6.3%) cases and parapneumonic effusion in one (1.9%) case. Diagnostic yield of closed pleural biopsy was 62.2% in cases of all exudative pleural effusion, 76.2% in cases of tubercular pleural effusion and 85.7% in cases of malignant pleural effusion. There was no incidence of post pleural biopsy pneumothorax or hemothorax, underlining the safety of pleural biopsy procedure. Conclusion: Closed pleural biopsy provides the highest diagnostic yield in cases of pleural tuberculosis and malignancy, the two most important causes of exudative pleural effusion. In view of low cost, easy availability and very low complication rates, it is a very important diagnostic tool in the hands of a trained pulmonary physician in India.

Idiopathic pulmonary fibrosis.

Idiopathic pulmonary fibrosis (IPF) is being more frequently diagnosed in India, due to its increased awareness, better availability of computed tomography (CT) and fiberoptic bronchoscopy. IPF has the histological appearance of usual interstitial pneumonia (UIP) on surgical lung biopsy. Recent research has given a new insight into the etiology of the disease. Clinical criteria have been specified for presumptive diagnosis of IPF and distinguishing IPF from other conditions. The conventional therapy has been steroids and immunosuppressive agents. But only a minority of patients respond to such a therapy. Immunomodulators (interferon Y1b), antioxidants (Acetyl cysteine) and antifibrotic agents (like pirfenidone) are being studied as novel therapies in this, otherwise, fatal condition. Lung transplantation is the only hope for those patients who show progressive deterioration on medical treatment. Living-donor lobar lung transplantation has been developed as a procedure for patients considered too ill to await cadaveric lung transplantation.

Strongyloidosis hyperinfection in a neutropenic host diagnosed by bronchoalveolar lavage.

Opportunistic disseminated strongyloidosis is an important cause of morbidity and mortality in immunocompromised patients. In addition to a high index of clinical suspicion, alerting the microbiologist will help in diagnosing this condition early and institute therapy. We report a 51-year-old male who developed pulmonary infiltrates during the period of chemotherapy-induced neutropenia. Strongyloidosis larvae were found on bronchoalveolar lavage fluid and stool specimens. The patient responded to treatment with albendazole.

Circulating D-dimers as a marker of disease activity in pulmonary sarcoidosis.

BACKGROUND AND AIMS: The search is on to find an easily measurable marker of disease activity in sarcoidosis. The present study was carried out to evaluate the utility of plasma D-dimer as a marker of disease activity in sarcoidosis. METHODS: Thirty newly diagnosed cases of sarcoidosis with clinical indications for treatment and an equal number of matched healthy controls were studied for the presence of D-dimers (DD) in the plasma before starting treatment with oral prednisolone and after clinical remission. Semi-quantitative estimations of DD were done using the latex agglutination slide test method (Commercial Kit - Diagnostica Stago, France) as per the manufacturer's recommendations. RESULTS: The mean age of cases and controls were 45.43 +/- 8.5 (range 34-60) and 46.16 +/- 8.07 (range 32-61) years, respectively. Of the 30 patients, nine (30%) were DD positive at baseline. The DD positive patients presented more often with dyspnoea, had radiological stage III (7 out of 9) disease and abnormal spirometry compared to patients with no detectable DD in their plasma. Of the 16 patients re-evaluated after clinical remission, eight (50%) were D-dimer positive. Two of the five patients initially DD positive had become negative and five additional patients who were negative at baseline had become positive. CONCLUSIONS: Plasma D-dimers, which were positive in 30% of untreated patients of sarcoidosis, indicate patients with significant pulmonary parenchymal involvement; but have no correlation with clinical disease remission.

Profile of repeat fiberoptic bronchoscopy.

BACKGROUND: Fiberoptic bronchoscopy (FOB) is invaluable in the diagnosis of a variety of pulmonary diseases, but in many instances the procedure has to be repeated because of an inconclusive initial FOB or for reassessment. METHODS: A retrospective analysis of all the fiberoptic bronchoscopic procedures done between September 2000 and February 2003 was performed and details of patients undergoing repeat FOB abstracted. RESULTS: Of the 2,270 bronchoscopies performed on 2114 patients, 132 procedures were repeated, yielding an over all frequency of repeat FOB of 6.34 percent. Bronchoscopy was done twice in 112 patients, thrice in 16 patients and four times in four patients. The commonest diagnosis in patients undergoing repeat bronchoscopy was bronchogenic carcinoma, followed by non-resolving pneumonia or presence of pulmonary infiltrates in immunocompromised host. The major indications for repeating FOB included obtaining specimens for pathological examination, pre and postoperative evaluation of airways, localization of site of bleeding in patients with hemoptysis, and placement of catheters for intraluminal brachytherapy. Of the 88 cases undergoing repeat bronchoscopy for diagnostic purposes, 41 (46.6%) yielded positive results, either in form of positive histology or localisation of source of hemoptysis. CONCLUSIONS: The frequency of repeat bronchoscopy was low. Commonest indication for a repeat procedure was to obtain repeat/additional diagnostic samples. A repeat procedure can yield positive results even when the initial FOB is nondiagnostic.

Indoor air pollution as a risk factor for lung cancer in women.

OBJECTIVES: Tobacco smoking is the most common risk factor for lung cancer. But a significant proportion of lung cancer occurs in non-smokers. Indoor pollution due to domestic fuels has been recently implicated as a causative agent in lung cancer especially in women. We conducted a case control study to find out the role of indoor air pollution due to domestic cooking fuels in Indian women. METHODS: In a case control study 67 women with proven lung cancer were recruited. Forty-six females having a non-malignant respiratory disease constituted the control group. The patients and controls were asked about the exposure in various cooking fuels using a questionnaire. RESULT: There were 50 (74.6%) non-smokers and 17 (25.4%) smokers among the female cancer cases (p = 0.016). Adenocarcinoma was the commonest histological type of malignancy (n = 26, 38.8%) in the whole group and was the predominant form in the nonsmoking females. Tobacco smoking was the most important risk factor for lung cancer with OR of 4.87 (95% CI 1.34-17.76). Among non-smokers out of all the cooking fuels the risk of development of lung cancer was highest for biomass fuel exposure with an odds ratio of 5.33 (95% CI 1.7-16.7). Use of mixed fuels was associated with a lesser risk (OR = 3.04, 95% CI 1.1-8.38). ). In multivariate logistic regression analysis biomass fuel exposure was still significant with OR of 3.59 (95% CI 1.07-11.97) even after adjusting for smoking and passive smoking. CONCLUSION: This study indicated that biomass fuel exposure is an important risk factor in the causation of lung cancer among women in addition of exposure to tobacco smoke.

Serum surfactant protein-A levels in chronic bronchitis and its relation to smoking.

BACKGROUND: Surfactant protein-A (SP-A), which is an important constituent of natural surfactant, occurs physiologically in small amounts in blood. Tobacco smoke induces increased alveolo-capillary leakage of surfactant proteins into blood and its level in blood may help in the assessment of lung injury caused by smoke. Little is known on the SP-A levels in patients with chronic obstructive pulmonary disease (COPD). METHODS: Prospective analytical study of 30 patients with clinical diagnosis of chronic bronchitis, which was made on the basis of symptoms, signs and chest radiographic findings. Serum SP-A and serum cotinine levels were measured. RESULTS: Out of 30 patients, 21 were smokers and nine were non-smokers. The serum SP-A level in smokers with chronic bronchitis is significantly higher than the non-smokers. The plasma cotinine levels are also high in smokers. However, there was no correlation between the serum SP-A level and plasma cotinine level (r=0.044). Serum SP-A levels were related to age in smokers (r=0.566, p<0.01) but not in non-smokers with chronic bronchitis (r=0.017, p>0.05). CONCLUSION: The increase in SP-A level in smokers with chronic bronchitis suggests that tobacco smoking causes a chronic increase in permeability of the lung parenchyma. The SP-A, a lung-specific secretory protein, is a potential marker for non-invasive assessment of the integrity of the lung epithelium. Further studies are required to find out whether SP-A can be used as a marker for early identification of smokers who are at risk of COPD.

Lung cancer in India.

BACKGROUND: Lung cancer is one of the commonest malignant neoplasms all over the world. It accounts for more cancer deaths than any other cancer. It is increasingly being recognized in India. METHODS: We did a systematic review of the published studies on epidemiology, diagnosis and treatment of lung cancer in India. Literature from other countries was also reviewed. RESULTS: With increasing prevalence of smoking, lung cancer has reached epidemic proportions in India. It has surpassed the earlier commonest form of cancer, that of oropharynx, and now is the commonest malignancy in males in many hospitals. In addition to smoking, occupational exposure to carcinogens, indoor air pollution and dietary factors have recently been implicated in the causation of lung cancer. Squamous cell carcinoma is still the commonest histological type in India in contrast to the Western countries, although adenocarcinoma is becoming more common. Molecular genetics of lung cancer has opened up new vistas of research in carcinogenesis. Various modalities for early detection through screening are being investigated. Majority of the patients have locally advanced or disseminated disease at presentation and are not candidates for surgery. Chemotherapy applied as an adjunct with radiation improves survival and the quality of life. New anticancer drugs, which have emerged during the last decade, have shown an improved efficacy-toxicity ratio. CONCLUSIONS: In view of our large population, the burden of lung cancer will be quite enormous in India. Drastic measures aimed at discouraging people from smoking must be taken to reduce the morbidity and mortality due to lung cancer.

Surfactant protein-A levels in patients with acute respiratory distress syndrome.

BACKGROUND & OBJECTIVES: The decrease in surfactant protein-A (SP-A level) has recently been implicated in the pathophysiology of acute respiratory distress syndrome (ARDS). Mechanical ventilation is the main modality of treatment of ARDS. But information on the SP-A levels after mechanical ventilation is scanty. We therefore studied the effect of mechanical ventilation on SP-A levels in patients with ARDS. METHODS: In a prospective, observational study conducted in the Respiratory Intensive Care Unit of a tertiary care hospital in north India, 13 patients with ARDS requiring mechanical ventilation were included. SP-A levels in the bronchial aspirates were serially estimated by ELISA at the start of mechanical ventilation and after 24 and after 48 h. RESULTS: The SP-A level at the start of mechanical ventilation was 3.06 +/- 2.56 microg/ml. The levels gradually increased to 3.99 +/- 2.39 and 6.64 +/- 2.72 microg/ml, at 24 and 48 h respectively, and this increase was statistically significant (P < 0.05). Patients having an infectious etiology had lower SP-A levels compared to those with non-infections causes. Neither the initial SP-A level nor the increase in SP-A level correlated with the improvement in lung function or duration of ventilation. INTERPRETAION & CONCLUSION: The present study showed a progressive increase in the SP-A levels in patients with ARDS on mechanical ventilation. Further studies are required to confirm that the increase in SP-A levels may be one of the contributors for recovery in ARDS.