Endobronchial growth: Tumor or tuberculosis.

Endobronchial tuberculosis (EBTB) is characterized by tuberculosis infection of the tracheobronchial tree. It has variable presentation but tumorous growth-like presentation in bronchus is very rare. The clinical and radiological features are non-specific, which creates a diagnostic dilemma. Bronchoscopy and biopsy of the lesion are mandatory to confirm the diagnosis. In this case series, we are presenting three unique cases of endobronchial growth diagnosed as EBTB after biopsy and evaluation of bronchoalveolar lavage (BAL) with cartridge-based nucleic acid amplification test (CBNAAT) and other ancillary investigations for tuberculosis. Four patients presented to the outpatient department with non-specific symptoms of fever, cough, hoarseness of voice, and hemoptysis. They were evaluated with chest radiograph (CXR), contrast-enhanced computed tomography (CECT) thorax, and bronchoscopy. Bronchoscopy revealed growth in the bronchus in all three cases. A biopsy was taken and BAL was performed. All cases turned out to be EBTB in histopathological examination and BAL CBNAAT. They were treated with anti-tubercular drugs and all responded well to treatment. Endobronchial tuberculosis presenting as tumorous growth in the tracheobronchial tree is rare. There should be a high index of suspicion while dealing with patients with non-specific clinical and radiological features of tuberculosis. EBTB can be misdiagnosed as malignancy in most cases. Therefore, it should be kept as a differential diagnosis while encountering a mass lesion in the trachea or bronchus during bronchoscopy.

Correlation of exhaled carbon monoxide level with disease severity in chronic obstruction pulmonary disease.

INTRODUCTION: Amplification of airway inflammation and its destruction due to oxidative stress is a major step in the pathogenesis of chronic obstruction pulmonary disease (COPD). Exhaled carbon monoxide (eCO) may be quantified to evaluate the airway inflammation and oxidative stress in such patients. OBJECTIVES: To assess the disease severity of COPD and treatment response by measuring eCO as a biomarker. MATERIALS AND METHODS: COPD patients diagnosed according to the global initiative for chronic obstructive lung disease guidelines and healthy individuals as controls were selected. One hundred and fifty patients with COPD and 125 controls were included in the study. Participants were further subdivided on the basis of their smoking habits. Clinical examinations and spirometry were done to diagnose COPD by following the standard protocol. eCO was measured using a piCO + Smokerlyzer (Breath CO Monitor, Bedfont Scientific Ltd., Kent, UK). It was a single-center cross-sectional study. RESULTS: Mean (± standard error of mean) CO levels in ex-smokers with COPD were higher (5.21 ± 1.546 ppm; P < 0.05) than in nonsmoking controls (1.52 ± 0.571 ppm) but were lower than in current smokers with COPD (12.55 ± 4.514 ppm; P < 0.05). eCO levels were higher in current smokers with COPD (12.55 ± 4.514 ppm; P < 0.05) compared to healthy smokers (9.71 ± 5.649). There was a negative correlation between eCO and forced expiratory volume in 1 s (FEV1) in COPD (r = -0.28; P < 0.05). The mean eCO level was decreased (6.291-4.332; P < 0.001) with improvement in lung function (FEV1 38.75%-50.65%: P < 0.05) after treatment with inhaled steroid. CONCLUSION: Our study concludes that quantification of eCO level in COPD varies with different grades of airway obstruction and to measure the treatment response. Measuring the level of eCO can be used to assess the indirect assessment of airway inflammation, oxidative stress, and severity of airway obstruction in COPD patients.

The role of laboratory investigations in evaluating abdominal tuberculosis.

BACKGROUND AND OBJECTIVES: Tuberculosis (TB) continues to be a major health problem in developing countries like India. Abdominal TB is defined as an infection of the peritoneum, or hollow or solid abdominal organs with Mycobacterium tuberculosis (Mtb). The gastrointestinal tract is one of the most frequent sites of extrapulmonary involvement in TB. The present study was undertaken to evaluate the role of laboratory investigations in the diagnosis of abdominal TB. MATERIALS AND METHODS: The study was conducted on 300 patients admitted to various departments of our hospital from November 2005 to October 2007. Detailed histories and thorough clinical examinations together with relevant hematological, biochemical, cytological, radiological, and histopathological investigations were carried out in suspected cases of Koch's abdomen. RESULTS: Erythrocyte sedimentation rates with positive results were seen in 79.3% patients. Serological test enzyme-linked immunosorbent assay was performed on only 30 patients and was found to be positive for IgG, and IgM in 25 cases with a sensitivity of 83%. Thirteen out of 15 cases were positive for adenosine deaminase done on ascitic fluid. The results of the two patients who underwent Mtb polymerase chain reaction (PCR) were consistent with TB. Out of 21 image-guided fine-needle aspiration cytology (FNAC) cases, 10 (48%) of the positive cases showed caseating necrosis while 7 (33%) had noncaseous necrosis. Stain for acid-fast bacilli (AFB) was performed on all cases and was positive in 42 cases (38.8%). Lymph node biopsy was done in 95% of the cases. CONCLUSIONS: Serological investigations have a limited value, while PCR is a highly specific test. Since cost restricts its use, only two patients in our study could afford it. BACTEC is more sensitive and faster than culture techniques for the diagnosis of mycobacterial infections. FNAC is a reliable, cost effective alternative, and 81% diagnostic yield in the present study suggests that ultrasound guidance is a useful tool. Histopathological evaluation with positive AFB staining remains the gold standard for diagnosing abdominal TB. However, although the demonstration of AFB in aspirates and tissue sections is a definitive diagnostic method for TB, the positivity for AFB is variable.

Fibrous dysplasia of rib presenting as a cystic mass in the lung.

Fibrous dysplasia (FD) is a benign skeletal disorder that can affect one bone (monostotic form) or multiple bones (polyostotic form). It is a non-inherited bone disease, in which abnormal differentiation of osteoblasts leads to replacement of normal marrow and cancellous bone by immature bone with fibrous stroma. It is often asymptomatic and incidentally detected on radiographs. We report this rare disorder in a 22-year-old lady who presented to us with cough and breathlessness. Her chest radiograph showed a cystic mass extending into the chest wall. On computed tomography scan, mass turned out to be FD of the second rib. Histopathology of the lesion confirmed the diagnosis.

Occupational Health Hazards among Sewage Workers: Oxidative Stress and Deranged Lung Functions.

BACKGROUND: Sewage workers, because of their occupation, are exposed to different types of dusts, bio-aerosols, fumes and gases like methane, hydrogen sulfide, sulphur dioxide, etc, which contribute towards oxidative stress and detrimental effects on various body functions, especially lung functions. AIMS AND OBJECTIVES: This study was carried out on sewage workers (who had been working for more than five years). We wanted to study the role of oxidative stress in development of impaired lung functions among sewage workers. MATERIALS AND METHODS: This cross sectional study was done in a tertiary care hospital (J.N. Medical College) in Aligarh, U.P. Study was done from March 2008 to December 2009. The study group comprised of 62 sewage workers who had been working for more than five years (32 non-smokers and 30 smokers) and 60 control subjects (30 smokers and 30 non-smokers). The pulmonary functions of these workers were assessed by using a MIR (Medical International Lab) Spiro Lab II Spirometer, with subjects in sitting position. Valid written consents were obtained from all the subjects. Malondialdehyde (MDA) is produced as a result of the action of reactive oxygen species (ROS) on the lipids present in the membranes of the cells, especially, contracting muscle cells. Serum MDA levels were assessed as an indirect measure of oxidative stress in these sewage workers and they were compared with serum MDA levels of control subjects. Appropriate statistical tests were applied for analysis of the data which was generated. OBSERVATION AND RESULTS: There were statistically significant decreases in Peak Expiratory Flow Rate (PEFR), Forced Expiratory Volume in first second (FEV1) and FEV1/FVC percent ratio (<80%) and Forced Expiratory Flow at 25%-75% of volume as percentage of Vital Capacity (FEF 25%-75%). Also, we found statistically significant increased levels of serum MDA in these sewage workers as compared to those in control subjects (with a p-value of <0.05 with a confidence interval of 95%). CONCLUSION: Our study found that the occupational exposure of the sewage workers to harmful dust, fumes, gases and bio-aerosols contributed to oxidative stress among them. This oxidative stress was one of the mechanisms which led to the development of obstructive impairment of lung functions in these sewage workers.

Comparative study of pulmonary functions and oxidative stress in smokers and non-smokers.

Chronic Obstructive Pulmonary Disorder (COPD) is projected to rank third leading cause of deaths by 2030 as per WHO. COPD is a multi-etiological disease. The airflow dysfunction is usually progressive, associated with an abnormal inflammatory response of the lungs to noxious particles or gasses. As the lung is exposed to high levels of oxygen, it is more susceptible to oxidants mediated injury. Gender based differences are identifiable risk factors. Smoking is found to be a major risk factor in the causation of COPD resulting in oxidative stress . The aim of the present study is to evaluate the oxidant antioxidant imbalance in healthy non smoker controls and smokers with COPD. A total of 60 control (healthy non smokers) and 121 smokers having COPD were studied. The mean age is more in smoker group as compared to healthy controls, which identifies advancing age as a risk factor for COPD. The mean BMI and weight of smoker group is reduced as compared to control group. GOLD 2008 criteria was used to assess lung functions. Lung functions namely FEV1, FVC, FEV1/FVC% and FEV1% Predicted showed significant reduction in smoker group as compared to healthy non smoker controls. MDA in control and smoker group (1.09 +/- 0.09 and 1.41 +/- 0.23 nmol/ml respectively) showed significant changes (P < 0.001). Our results also demonstrate significant reduction in anti oxidant enzymes namely SOD (units/mg of serum protein), Catalase (units/mg of serum protein) and GPX (nmol of NADPH oxidized/ min/mg of serum protein) in smoker group as compared to healthy controls. On the basis of study it is concluded that smoking, gender and oxidant antioxidant imbalance are identifiable risk factors in COPD.

Doxofylline and theophylline: a comparative clinical study.

OBJECTIVES: COPD is one of the major public health problems worldwide. Theophylline has been used in the treatment of COPD for decades. Doxofylline a new theophylline congener has been claimed to have better safety profile. The study was undertaken to compare theophylline and doxophylline at doses recommended and commonly used in clinical practice. METHODS: The study was conducted in patients of COPD in TB chest department of a medical college hospital. It was randomized, prospective and open label. A total of 154 patients were divided in two group .Group I was administered 400 mg theophylline SR once daily and group II was administered doxofylline 400 mg twice a day orally. Spirometric variables symptom score, and adverse effects were recorded on day 0, 7 and 21 of therapy. Data were compared and analysed using SPSS version 16. RESULTS: Results of the study showed that there was no statistically significant difference with respect to spirometric variables and symptom score in the two groups and there was no significant difference in two groups with respect to side effects (p>0.05). CONCLUSIONS: It is concluded that doxophylline has no advantage over theophylline in terms of either efficacy or safety on the doses commonly used in current clinical practice.

Association between serum C- reactive protein levels and other important predictive markers of outcome in COPD.

C-reactive protein (CRP) is an acute-phase protein synthesized predominantly by the hepatocytes in response to tissue damage or inflammation. Levels of acute-phase proteins rise rapidly, during infection and after injury. We take up the study to correlate serum CRP levels with other important predictive markers of outcome in COPD. Patient with stable COPD (no exacerbation in the last two months) were taken up for the study. Parameters taken to correlate were age, grade of dyspnea, FEV1. It was found the CRP is negatively correlated with FEV1 and grade of dyspnea but not correlated with age.

Relative and additional bronchodilator response of salbutamol and ipratropium in smoker and nonsmoker asthmatics.

PURPOSE: This study was conducted in the Department of Tuberculosis and Respiratory Diseases, J. N. Medical College, Aligarh, India, from January 2006 to December 2007. The fact that smoker asthmatics can behave like chronic obstructive pulmonary disease (COPD) patients encourages the researcher to therapeutically exploit the important cholinergic influence in these patients. To clarify the clinical importance of the issue, the present nonblind and nonrandomized study was aimed at relative bronchodilator response to adrenergic and cholinergic agents. METHODS: Ninety-six patients of asthma, 48 nonsmokers and 48 smokers, were given sequential doses of inhaled salbutamol and after achieving maximum bronchodilation, ipratropium was administered to observe the additional bronchodilation. On the next day, the sequence of drugs was reversed. Ipratropium was given first and after achieving maximal response, salbutamol was given. RESULTS: On giving salbutamol first, maximal improvement in forced expiratory volume in one second (FEV(1)) was 67.04% +/- 12.98% in nonsmokers and 60.64% +/- 13.6% in smokers. The additional improvement with ipratropium was 9.22% +/- 2.08% in smokers and was significantly higher (p <.001) than in nonsmokers (0.13% +/- 2.14%). When ipratropium was given first, maximum improvement in FEV(1) was 41.95% +/- 4.57% in smokers, which was significantly higher (p <.001) than in nonsmokers (20.06% +/- 7.06%). The additional improvement with salbutamol was 23.16% +/- 5.07% and 19.09% +/- 4.9%, respectively, in nonsmokers and smokers. CONCLUSIONS: With the above results, the authors concluded that in smoker asthmatics, cholinergic tone was more prominent and there was down-regulation of adrenergic receptors, as both drugs caused significant additional dilatation. So in smoker asthmatics, addition of a cholinergic agent will result in better control of asthma. In nonsmoker asthmatics, addition of cholinergic agent is of little or no value.

Frontal bone tuberculosis presenting with blindness in a 14-year-old girl: a case report.

INTRODUCTION: The occurrence of tuberculosis in the flat bones of the skull is very rare. Only eight cases of tuberculosis of the frontal bone have been reported in the literature. CASE PRESENTATION: A 14-year-old girl of Asian ethnicity presented with gradual loss of vision. A computed tomography scan of her head showed a diffuse, homogeneously ill-defined hyperdense lesion of size 2.9 x 5.3 cm (anteroposterior x thickness) involving the right orbit. Biopsy of the lesion confirmed the presence of epithelioid cells and Langerhans giant cells with caseous material. After surgical debridement with antitubercular treatment, the patient had an uneventful recovery. CONCLUSION: Although rare, tuberculosis can affect the flat bones of the skull. Tuberculosis of the frontal bone can be included in the differential diagnosis of blindness.

Traumatic pulmonary pseudocyst: a case report.

Traumatic pulmonary pseudocyst is a rare clinical event that may occur following chest trauma. This complication usually occurs as a result of blunt trauma and rarely, due to a penetrating injury. We report an unusual case of a 10-year-old boy who developed a left-sided pneumothorax along with a traumatic pulmonary pseudocyst when he was hit by a cricket ball while playing.

Unusual presentation of tuberculosis.

Mediastinal mass is not an unusual entity. It occurs mostly due to lymphoma, thymoma, germ cell tumours, granulomatous diseases, and so on. Tuberculosis is an uncommon cause of mediastinal mass. It is rarely suspected when it is presented in such an unusual way. We report here a case of a 35-year-old male who presented with mediastinal mass, which was later confirmed as a case of tuberculosis on histopathological examination. He was successfully treated with anti-tubercular drugs.

Role of fine-needle aspiration cytology in evaluating mediastinal masses.

BACKGROUND: Fine-needle aspiration cytology is an important and useful investigation and is considered next to imaging in the diagnosis of mediastinal lesions. We carried out this study in the Department of TB and respiratory diseases JNMC Aligarh from March 2000 to March 2002 with the following aims. OBJECTIVES: To make etiological diagnosis of mediastinal lesions, determine the pathological type of the tumor in cases of malignancy and evaluate the role of fine-needle aspiration cytology in staging of bronchogenic carcinoma. MATERIALS AND METHODS: A total of 56 patients were included in this study who had mediastinal mass with or without lung lesions on chest X-ray or computed tomography scan. Of these patients, 36 had mediastinal mass only and 20 had mediastinal mass with parenchymal lesion. RESULTS: In the present study, of 56 patients, 36 had mediastinal masses and 20 had pulmonary mass. CONCLUSION: Percutaneous fine-needle aspiration is an easy and reliable method for reaching a quick tissue diagnosis in pulmonary and mediastinal masses.

Trauma: an unusual aetiology of pulmonary pseudocyst.

Traumatic pulmonary pseudocyst due to blunt chest trauma is rare. It is a clinical entity that manifests itself with minor clinical and major radiological signs. We report a case of a 16-year-old girl, who during an attack by a violent cow sustained a chest impact that resulted in a traumatic pulmonary pseudocyst, confirmed with a computed tomographic (CT) scan of the chest. The patient recovered with conservative management.