Endotracheal tuberculous stenosis: Ventilation rescue and bronchography guided stenting.

We present the case of a 16-year-old female patient who presented with dyspnoea, cough and noisy breathing that progressed further in hospital with the development of stridor and severe respiratory compromise requiring mechanical ventilatory support. Investigations were consistent with a diagnosis of endotracheal tuberculosis with tracheal and bronchial stenosis. Despite adequate anti-tuberculous therapy and ventilation the patient had high airway pressures, low tidal volumes and hypercapnia, which prevented weaning from mechanical ventilation. Balloon dilatation and stenting of the 4.5cm long, 2.3mm diameter stenotic tracheal segment was performed under radiological guidance. The patient was weaned successfully from the ventilator post-procedure. This report illustrates the successful management of an uncommon presentation of a common disease with modern endoscopic therapy.

Multifocal idiopathic fibrosclerosis mimicking tuberculosis of the abdomen.

We present a 13 year old girl from Assam who had been treated as abdominal tuberculosis for 2 years due to the presence of refractory lymphocyte-predominant ascites and multiple small bowel strictures associated with significant anorexia and weight loss. On evaluation she was found to have retroperitoneal fibrosis with hydroureteronephrosis, mediastinal fibrosis and a retro-orbital pseudotumour. Based on these findings the diagnosis of Multifocal Idiopathic Fibrosclerosis (MIFS) was made. Ascites and multiple bowel strictures have been only rarely been described in association with MIFS. The other unique features in this patient were the early age of presentation, the presence of mediastinal fibrosis in association with retroperitoneal fibrosis, extensive soft tissue fibrosis of the neck, axillae and the presence of trismus. In a country like ours where Tuberculosis is commonplace, one would not think twice about treating such a case with antituberculous therapy. However, with a constellation of findings suggestive of a diffuse fibrotic process, MIFS should be an important consideration.©

Acenocoumarol and phenytoin toxicity in the presence of CYP2C9 mutation.

This case report describes a rare interaction between therapeutic doses of phenytoin and acenocoumarol resulting in both acute phenytoin toxicity and increased international normalized ratio (INR). Interactions between these drugs are due to the pharmacokinetics and the common metabolising pathway by hepatic cytochrome P450 isoenzyme-CYP2C9. Our patient was detected to be homozygous for CYP2C9*3 by PCR-RFLP analysis resulting in markedly decreased metabolism of both the drugs. Given that these two drugs are often given concomitantly in the medical out patient department, and that CYP2C9 polymorphisms are not uncommon, clinicians should be aware of this interaction and suspect this in patients with toxicity to these drugs.