clinical account of ICU cases with severe H1N1 [2009 pandemic influenza A] infection

To determine clinical characteristics in adults with confirmed severe 2009 pandemic influenza A [H1N1] infection. A descriptive case series. The study was carried out at the department of Pulmonology and Critical Care, Military Hospital Rawalpindi, from 1st December 2009 to 30th May 2010. Fifteen in-hospital adults with severe H1N1 infection confirmed by reverse transciptase polymerase chain reaction [RT-PCR] were studied. A pre-designed patient data collection form was used to record clinical features, laboratory and radiological investigations and management data. Mean age for severe H1N1 cases was 41.56 +/- 15.08 years and about 75% cases were from 20-40 yrs age group. Seventy five percent of our cases had at least one risk factor for complications with 2009 H1N1 infection; namely obesity - 33.3%, smokers - 26.7%, pregnancy, COAD and diabetes mellitus - 20% each. Fever [100%], cough [100%], and shortness of breath [93.3%] were the commonest symptoms. Radiographic abnormalities were bilateral patchy consolidations [60%], interstitial/ reticular infiltrates [20%], and reticular shadows with areas of consolidation [20%]. PaO[2]/ FiO[2] ratio was less than 200 in 60% cases on presentation. 73.3% cases had 1000-2000 [U/L] lactate dehydrogenase [LDH] levels while creatinine kinase [CK] levels were 400-1000 [U/L] in 66.7% cases. Six [40%] ICU cases with severe H1N1 infection died during hospital stay. Severe H1N1 virus infection cases most commonly presented with fever, cough and shortness of breath. The severe H1N1 cases presenting with abnormal chest radiograph and hypoxemia require ICR care with high mortality

clinical account of hospitalized 2009 pandemic influenza A [H1N1] cases

To determine the clinical characteristics in adults with confirmed pandemic influenza A [H1N1] infection 2009. A case series. The study was carried out at the Department of Pulmonology and Critical Care, Military Hospital, Rawalpindi, from 1st December 2009 to 30th May 2010. Thirty six adults with confirmed 2009 pandemic H1N1 infection by reverse transcriptase polymerase chain reaction [RT-PCR] were included in the study. All patients were followed in-hospital and clinical features, laboratory and radiological investigations and management data was collected on a pre-designed patient data collection form. Mean age was 34.24 +/- 13.92 years with 61.1% females. Seventeen [47.2%] had at least one risk factor for complications with 2009 H1N1 infection; namely obesity in 19.4%, pregnancy in 8.3%, COPD in 5.6%, cardiac failure in 5.6%, chronic liver disease in 5.6%, Diabetes mellitus in 5.6%, immunosuppression in 2.3%, smoking in 25%. Fever [97.2%], cough [97.2%], rhinnorhea [80.6%], and shortness of breath [58.3%] were the commonest symptoms. Radiographic abnormalities were interstial/reticular infiltrates [30.6%], patchy consolidations [11.1%] and reticular shadows with areas of consolidation [25%]. PaO2/FiO2 ratio was less than 200 in 27.8% cases. Thirty six percent cases had creatinine kinase [CK] levels greater than 400 U/L and lactate dehydrogenase [LDH] levels higher than 1000 U/L. Twenty seven percent cases were managed in ICU and 16.7% cases died during hospital stay. The 2009 pandemic H1N1 virus infection had a wide clinical spectrum with a potential to cause high morbidity and mortality. Early empirical antiviral therapy for hospitalized suspected influenza A [H1N1] is vital to prevent the rapid disease progression

Diffuse consolidation form of bronchoalveolar carcinoma

This case report describes a patient with diffuse consolidation form of bronchoalveolar carcinoma [BAC] which is a rare type of adenocarcinoma of lung. He was diagnosed on the basis of findings on X-ray and high resolution CT [HRCT] chest later confirmed by open lung biopsy and immuno-histochemical staining. Only supportive treatment could be provided and the patient expired during the subsequent month of follow-up. Traditionally, diffuse consolidation is the radiological presentation in only 20% of patients with bronchoalveolar carcinoma

Pulmonary embolism in soldiers serving at high altitude

To determine the frequency of different risk factors for pulmonary embolism with particular reference to high altitude as one of the factors. Cross sectional, analytical study. Department of Pulmonology, Military Hospital Rawalpindi, from December 2006 to December 2007. A total of 50 serving soldiers suspected of pulmonary embolism were enrolled. A detailed history and physical examination was carried out to ascertain the risk factors of the disease. Screening profile was performed for connective tissue and infectious diseases, thrombophilic disorders and plasma homocystein levels. If soldiers were evacuated from high altitude, their approximate height from sea level was noted. Pulmonary embolism was confirmed on spiral CT scan of chest and/or ventilation-perfusion lung scan. Results were analyzed by SPSS version 11. About 86% of patients were between 20-40 years of age. Dyspnea was the commonest symptom [40%] while tachypnea was the commonest clinical finding in these soldiers. D-dimer value was<250 in only 10% of patients. Pleural effusion was the commonest radiological abnormality[40%] while non-specific T-wave inversions were noted as the most frequent ECG change[44%]. Ventilation-perfusion [V/Q] scan was confirmatory in 80% of patients and spiral CT chest in 56%. When the frequency of risk factors of pulmonary embolism were analyzed, 50% of patients had high altitude as the only risk factor. Hereditary thrombophilic disorder was found in 14%, connective tissue disorder/infections in 20% and miscellaneous others in 16%. Pulmonary embolism occurs at an increased frequency in soldiers working at high altitude, without any other co-existent risk factor

Post-tuberculous chronic obstructive pulmonary disease

To determine the frequency of chronic obstructive pulmonary disease [COPD] as a sequel of treated pulmonary tuberculosis. A case series. Department of Pulmonology, Military Hospital, Rawalpindi, from April to November 2007. Forty seven adults, previously treated for pulmonary tuberculosis and presenting subsequently with chronic exertional dyspnoea for which no other alternate cause was found were included. Those having a probability of re-activated TB, having history of current or previous smoking or occupational exposure, asthmatics and cases of interstitial lung disease and ischemic heart disease were excluded. Pre- and post-dilator FVC, FEV1 and FEV1/FVC were recorded in each case through simple spirometry on Spirolab-II - MIR S/N 507213. Stage and pattern of COPD was recorded. There were 76.5% [n=36] males. Mean age was 56.4 and 44.2 years in males and females respectively. Twenty six [55.3%] were found to have an obstructive ventilatory defect of different degrees: severe/stage III in 69.2% [n=18], moderate/stage II in 23.0% [n=6] and mild/stage I in 5.9% [n=2]. Fourteen [29.7%] were found to have a restrictive pattern and 7 [14.8%] revealed a mixed obstructive and restrictive pattern. Chronic obstructive pulmonary disease can occur as one of the chronic complications of pulmonary tuberculosis and the obstructive ventilatory defect appears more common among various pulmonary function derangements

Swyer-james-macleod syndrome

This case report describes a patient with Swyer-James-MacLeod Syndrome [SJMS] in an adult male diagnosed on the basis of findings on X-ray chest, high resolution CT [HRCT] of chest and radionuclide perfusion lung scan. This rare syndrome is considered to be an acquired disease due to repeated pneumonias in early childhood

Diagnostic yield of transbronchial needle aspiration analysis of 30 cases

In our clinical set up transbonchial needle aspiration of lymph node and parenchymal lesions is an underutilized technique. This study was done to highlight the usefulness of this technique in the pulmonologists armamentarium. Thirty procedures were performed on patients with intrathoracic lymphadenopathy or parenchymal lung lesions in this study from October, 2006 to April, 2007. Patients with an easily accessible peripheral lymph node, bleeding diathesis and an already confirmed diagnosis were excluded from the study as were patients with a well visualized biopsiable endobronchial lesion. Nineteen patients [63.3%] on whom transbonchial needle aspirations were performed had intrathoracic lymphadenopathy while 11 [36.6%] had parenchymal lesions without endobronchial lesions which could be biopsied. Adequate samples were obtained in 23 patients [76.6%] chronic granulomatous inflammations which was diagnosed as tuberculosis in corroboration with other clinical and laboratory evidence was seen in 3 cases [10%]. Carcinoma was diagnosed in 6 cases [20%]. Thirteen cases [43%] were reported as normal and inadequate samples were obtained in 7 cases [23%]. Transbronchial Needle Aspiration [TBNA] is an effective method of obtaining cytological material from intrathoracic lymph nodes and parenchymal lesions and can provide a safe alternative to invasive mediastinotomy/mediastinoscopy and open lung biopsya

High resolution computed tomographic patterns in adults with pulmonary tuberculosis

To determine the High Resolution Computed Tomographic [HRCT] patterns in adults with Acid Fast Bacillus [AFB] positive new cases of Pulmonary Tuberculosis [PTB]. The study was carried out at the Department of Pulmonology and Department of Radiology, Military Hospital, Rawalpindi, from June 2006 to August 2007. Fifty adults with AFB positive new pulmonary tuberculosis were included in the study, while PTB cases in the retreatment category, Multi Drug Resistant [MDR] tuberculosis, PTB with Chronic Obstructive Airways Disease [COPD], pneumoconiosis, Diffuse Parenchymal Lung Diseases [DPLDs] etc. were excluded. All cases underwent HRCT chest with 2 mm collimations at 10 mm intervals. Relevant data was collected on a pre-designed patient proforma. The mean age was 40.18 +/- 14.55 years with 88% males; 46% and 30% samples were sputum and endobronchial washings smear positive for AFB respectively, while the rest were culture positive. HRCT findings included centrilobular nodules in 92% cases, lobular consolidation in 84%, cavitation in 76%, 'tree-in-bud' appearance in 68%, lymphadenopathy in 8% and miliary nodules in 4% cases. HRCT patterns included centrilobular nodules and lobular consolidation in 80% cases, while centrilobular nodules with cavitation and centrilobular nodules with 'tree-in-bud' appearance were noted in 72% and 68% patients respectively. Thirty two [64%] cases had centrilobular nodules, cavitation and lobular consolidations and about half cases had centrilobular nodules, 'tree-in-bud' appearance and lobular consolidation. Centrilobular nodules and lobular consolidations [80%], centrilobular nodules with cavitation [72%] and centrilobular nodules with 'tree-in-bud' appearance [68%] were the most common HRCT patterns in adults newly diagnosed with pulmonary tuberculosis

Correlation of eosinophil cationic protein with severity of asthma

Activated eosinophils play an important role in the pathogenesis of bronchial asthma. Upon activation eosinophils release their granular proteins. Eosinophil Cationic Protein [ECP] is a highly basic protein of ribonuclease-A family that is released from matrix of eosinophil granules. In the recent past a number of studies have shown increased levels of ECP in serum and induced sputum of asthmatics. We carried out this study to find out correlation of serum ECP with severity of asthma. This study was carried out on 44 asthmatics and 44 matched controls at Department of Physiology, Army Medical College, Rawalpindi from June 2002 to December 2003. Lung function tests were done using spirometer [Vitalograph-Compact] and severity of asthma was graded into four classes, mild intermittent, mild persistent, moderate persistent and severe persistent. Serum was used to assess ECP by ELISA. Statistical correlation between ECP and severity of asthma as well as lung function tests was calculated. The asthmatics as compared with the controls had significantly more serum ECP. Serum ECP increased significantly with increase in severity of asthma [from mild intermittent to severe persistent]. Serum ECP was negatively correlated with FEV1 and FEV1/FVC[r=-.823 and r=-.772, p<.001 respectively]. There was a significant positive correlation between serum ECP and severity of asthma [r=0.947 p<0.001] Conclusions: We conclude from this study that serum ECP can be used as a useful laboratory investigation for severity of asthma

Small cell lung cancer chemotheryapy: a nine year experience of, London lung cancer group protocol

Lung cancer is the leading cause of cancer related deaths. Small cell lung cancer is found in 20-25% cases. Chemotherapy is cornerstone of treatment. With appropriate therapy majority of patients with small cell lung cancer can expect to achieve remission and a significant prolongation of life. Our objective was to evaluate the 'London Lung Cancer Group Protocol' for chemotherapy of Small Cell Lung Carcinoma being followed in our unit. This hospital based prospective study was carried out in Pulmonology Department of Military hospital, Rawalpindi between May 1989 to May 1998. In total 484 cases of bronchogenic carcinoma were diagnosed. Sixty eight had small cell cancer while 416 had non small cell lung cancer. 39 patients who fulfilled the inclusion criteria were subjected to thorough clinical examination and detailed investigations to ascertain the stage of the disease. The patients were then divided into groups according to the staging. Fifteen patients [38.4%] with limited disease were in Group I, while 24 patients [61.5%] with extensive stage disease and good prognosis were in Group II. Most patients [43.5%] were between age 51-60 years, [38.4%] 61-65 years of age, [12.8%] were 41-50 years and only 5.1% patients were between 31-48 years. Commonest presenting symptom [92.3%] was cough, while 58.9% had hemoptysis, 48.7% severe dyspnoea, 20.5% superior venacaval obstruction and 38.4% chest pain. The most common side effect of chemotherapy was alopecia [61.5%] followed by GI symptoms other than vomiting [30.7%]. One patient had cardiac decompensation and two had myelosupression. In total 30 cases [76.9%] completed chemotherapy. Treatment was abandoned in five cases [12.8%] due to various reasons while 4 were lost to follow up. Out of the 30 patients who completed chemotherapy 60% were complete responders while 40% were partial responders. Symptoms regressed considerably after treatment. Median survival was fifteen months in group I and nine months in group II. We concluded that 'London Lung Cancer Group Protocol being followed at our unit had good response rate, was safe and cost effective and had minimal side effects

Chylothorax in a case of non-Hodgkin's lymphoma

A case of asymptomatic 60 years old male diagnosed as Non-Hodgkin's lymphoma [angioimmunoblastic T-cell type] invading thoracic duct leading to chylothorax is presented. Generally, patients with this moderately aggressive lymphoma are adults who exhibit generalized lymphadenopathy, B-symptoms, polyclonal hypergammaglobulinemia, skin rash and various autoimmune phenomena. Case Reports: A 60 years old male from Lahore, who had Spigelian hernia and ascites, referred from surgical OPD, was admitted in medical ward for evaluation of pleural effusion and ascites. He was essentially asymptomatic, other than moderate swelling of abdomen and sometimes feeling dragging sensation at epigastric lump on prolonged walking. On clinical examination, he was cachexic male with generalized discrete lymphadenopathy [size 1 '2 cm], right-sided moderate pleural effusion, well healed cicatrix of right inguinal region surgery, spigelian hernia and massive ascites. Chest x-ray showed right-sided pleural effusion. Ultrasound abdomen showed diffuse coarse hepatic echo-texture, chronic left-sided pyelonephritis, lymphadenopathy, gross ascites and moderate right-sided pleural effusion. Diagnostic thoracentesis and paracentesis revealed chylothorax and chylous ascites confirmed on bio chemical analysis with triglyceride of 7.3 and 10.3 mmol/L respectively. Contrast enhanced CT scan of chest and abdomen discovered bilateral pleural effusion [massive on right side] with partial collapse of right lung, massive ascites and massive abdominal lymphadenopathy invading both kidneys and psoas major muscle. Lymph node biopsy [deep cervical region] showed angioimmunoblastic lymphoma. Serum protein electrophoresis and plasma immunoglobulin levels were normal. Complete blood count showed mild anemia with normal differential count. Liver and renal function tests, sputum for AFB, Mantoux test and other baseline investigations were normal. Serum for ANF and RA-factor was negative. Endobronchial biopsy suggested histopathology consistent with acute on chronic inflammation from lower lobe of right lung. He was treated symptomatically during admission, remaining ambulant and afebrile. Subsequently he was referred for Oncologist's opinion

Eosinophils and eosinophil products in asthma

Eosinophils are known to be an indirect marker of airway inflammation in asthma. It is known since long that the total eosinophil count reflects asthmatic activity and is useful for regulating steroid dosage and for early detection of exacerbations. Eosinophils are currently regarded as the effector cells responsible for much of the pathology of asthma. Eosinophil-mediated damage to the respiratory epithelium is a major pathogenetic mechanism in asthma. This article is a review of the latest works about the relationship of eosinophil and eosinophil products with asthma. This is a review article

Endobronchial tuberculosis: clinical and diagnostic aspects

This study was conducted at the Department of Pulmonology, Military Hospital Rawalpindi from Jan 1990 to Dec 2000 to determine common clinical features and diagnostic aspects especially bronchoscopic characteristics of endobronchial tuberculosis. A total of 180 consecutive cases of Endobronchial Tuberculosis of all ages and both sexes were included. The mean age was 29.82 ['4.32] years. Male to Female ratio was 2.4:1. Cough was the most common symptom [90.59%] with expectoration in 50.55% patients. Fever and hemoptysis were noted in 83 and 67 cases respectively. History of weight loss was present in 20.55% patients while chest pain and exertional dyspnea were noted in 17.77% and 13.33% cases respectively. Chest X-rays were normal in 77.77% cases. Endobronchial lesions on bronchoscopy were noted in upper lobes in 59.74% cases while lower lobe lesions were seen in 40 [25.97%] cases and 22 [14.28%] patients had involvement of right middle lobe or major bronchi. Endobronchial secretions yield for AFB positivity was cent% and commonest histopathological feature was non caseating granuloma. Endobronchial tuberculosis is not an uncommon entity but due to non specific symptomatology and normal chest X-ray, a high index of clinical suspicion is required for timely diagnosis and appropriate management. Fiberoptic bronchoscopy with biopsy and bronchial washings is the investigation of choice