Psychological profile of multi drug resistance TB patients: A qualitative study from a Tertiary care Centre of Kolkata.

INTRODUCTION: There has been a new challenge to the already existing threat of tuberculosis (TB) and that is drug resistance TB (DR-TB). The causal relationships between mental disorders and TB are complicated and relatively unexplored. For this reason a qualitative study was done on DR-TB patients attending R G Kar Medical College. MATERIALS AND METHODS: The study population consisted of the patients who are registered for the DR-TB regimen are followed up four times with General Health Questionnaire (GHQ). Those scoring poorly were sent for expert evaluation by psychologist, who counselled them, and followed them up after in-depth interviews. These records of in-depth interview were analysed as qualitative research inputs. RESULTS: In our study out of 165 patients, (4.8%) needed interventions. The domains emerging from the study are worried about future and as well as family, disbelief about the diagnosis, embarrassment regarding the diagnosis, fear of death, blaming fate for the disease, stigma, suicidal ideation. CONCLUSION: This study finds out the important domains of psychogical problems among the patients and also advocates a psychologist to remain at DR-TB centres.

Occurrence of Anxiety and Depression among Stable COPD Patients and its Impact on Functional Capability.

INTRODUCTION: Anxiety and depression are important but often under-diagnosed co-morbid conditions in patients with Chronic Obstructive Pulmonary Disease (COPD) which may affect the functional capacity of the patients. AIM: To find out the proportion of depression and anxiety among stable COPD patients using a validated questionnaire suitable for use in clinic and the factors affecting their reduced functional capability as assessed by six-minute walk test. MATERIALS AND METHODS: This was a descriptive cross-sectional study. Seventy five patients diagnosed with stable COPD in outpatient Department of Pulmonary Medicine in a tertiary care hospital, satisfying all inclusion criteria, were included in the study. They were examined clinically, categorized as per Global Initiative for Chronic Obstructive Lung Disease (GOLD) severity assessment guideline and interviewed by designated interviewer using validated questionnaire for depression (Hamilton depression rating scale, HAM-D) and anxiety (State Trait Anxiety Inventory, STAI). The functional exercise capacity of the patient was assessed by six-minute walk test. Statistical analysis was performed using Minitab software (version16.1). RESULTS: Among 75 stable COPD patients (68 male, 7 female), majority (32 out of 75) had both depression and anxiety, while only anxiety or depression was present in 9 each. The patients with depression had no significant difference in six-minute walk distance, change in heart rate and respiratory rate (p = 0.4186, 0.219 and 0.41 respectively) as compared to those without depression, but were found to be more dyspnoeic at the end of the test (p= 0.003). There was also no significant difference in walk distance in patients with high STAI score as compared to those with low STAI score (p= 0.276). CONCLUSION: Both anxiety and depression were present in majority of the stable COPD patients. The presence of these co-morbid conditions had no significant effect on the functional status of the patients in the form of reduced six-minute walk distance, though they were more symptomatic than those without these co-morbidities.

Effect of Sequential Intravenous Pulse Cyclophosphamide-Azathioprine in Systemic Sclerosis-Interstitial Lung Disease: An Open-Label Study.

BACKGROUND: Systemic sclerosis (SSc) is a rare connective tissue disorder of unknown aetiology. Pulmonary involvement contributes substantially to its morbidity and mortality. Treatment of pulmonary disease due to SSc remains unsatisfactory. We examined the effect of sequential six-month intravenous pulse therapy with cyclophosphamide (CYC) followed by azathioprine and low-dose corticosteroids on SSc associated interstitial lung disease (SSc-ILD). METHODS: In a single-centre, prospective, observational, open-labelled study; nine patients (eight females, one male) with SSc-ILD were treated with intravenous pulse CYC (600mg/m(2) body surface area) at monthly interval for six cycles with oral prednisolone 10mg daily. Subsequently, azathioprine (2-3mg/Kg) was administered while continuing with the same dose of prednisolone. Primary end-points were forced vital capacity (FVC) and high resolution computed tomography (HRCT) scan of thorax score. Secondary end-points were quality of life measured by health assessment questionnaire-disability index (HAQ-DI) and six-minute walk distance (6WMD) test. RESULTS: After one year of observation, the FVC showed significant improvement (p=0.003). The 6WMD also improved significantly (p=0.0028). However, change in HRCT scan scoring and HAQ-DI score was not significant. CONCLUSIONS: Intravenous, pulse CYC followed by azathioprine along with low-dose corticosteroids produces significant improvement in FVC and 6WMD at 12-month follow-up without significant change in radiological manifestations and health status.

Common Presentation with Uncommon Diagnosis: Multifocal Epithelioid Hemangioendothelioma.

A young female patient presenting with recurrent hemoptysis, neck swelling, and mediastinal mass mimicking lymphadenopathy was admitted to the Institute of Post Graduate Medical Education and Research and SSKM hospital, Kolkata, India. Clinical features, radiological studies, fibre optic bronchoscopy, and fine needle aspiration cytology from the neck swelling created a diagnostic dilemma until surgical resection and immunohistochemistry reports confirmed the diagnosis of multifocal epithelioid hemangioendothelioma, a rare vascular tumor with intermediate malignancy potential. Because it is a slow-progressing disease and due to the non-availability of standard chemotherapy, the patient, and her legal guardian, opted for palliative care only. She was asymptomatic for four years but again presented with hemoptysis, reappearance of the neck swelling on the same side, and a mediastinal mass compressing the superior vena cava and right pulmonary artery. This report describes the diagnostic problems and therapeutic challenges in the management of this rare tumor over a four-year follow-up period. The clinical course emphasizes the highly unpredictable nature of this tumor.

A rare pleural effusion in a young male.

A 28-year-old male presented with fever with right-sided chest pain for 2 weeks. Clinicoradiological picture was suggestive of right-sided pleural effusion. He had history of polytrauma following a road traffic accident and had to undergo emergency laparotomy a month ago. Microscopic and culture examination of the pleural fluid showed neutrophilia, high bilirubin content and presence of gram-negative bacilli. Ultrasound of the abdomen showed the presence of biloma in the liver and right subdiaphragmatic space with fistulous communication into the right thoracic cavity. The patient was managed successfully with complete recovery.

Granulomatosis with polyangitis with mononeuritis multiplex-immunosuppressives playing a double-edged sword.

A 52-year-old female was diagnosed with rheumatoid arthritis and was on methotrexate and prednisolone. She developed fever, cough, hemoptysis, and cavitary lesion on chest skiagram. She was put on antitubercular therapy without any improvement, meanwhile she developed painful right foot drop. Clinicoradiology and C-ANCA study confirmed the diagnosis of granulomatosis with polyangitis (GPA). She was started on cyclophosphamide, corticosteroid, and co-trimoxazole. While her treatment was being continued she showed significant improvement of pulmonary manifestations. About 1 year later, there was reappearance of fever, cough, and radiological opacity with oropharyngeal candidiasis. She became very ill with disseminated intravascular coagulation (DIC)-like features. Immunological markers were negative but bronchoalveolar lavage fluid study showed growth of Aspergillus spp. The patient was promptly put on intravenous voriconazole but unfortunately she succumbed to her illness.

Ancient schwannoma of vagus nerve mimicking hamartoma.

Schwannomas arising from vagus nerve sheath are rare mediastinal neurogenic tumours. Schwannomas usually arise from left hemithorax. Unlike a hamartoma, radiologically, calcification is rarely seen in schwannomas. We present the rare case of an ancient schwannoma arising from vagus nerve sheath from the right hemithorax presenting with gross calcification.

Habitual physical activity score as a predictor of the 6-min walk test distance in healthy adults.

BACKGROUND: The 6-min walk test (6MWT) is a simple, inexpensive test of functional exercise capacity. The 6MWT distance (6MWD) in healthy adults varies geographically, emphasizing the need for population-specific reference equations. The purpose of the present study was to investigate the influences of the habitual physical activity (HPA) score and other anthropometric and demographic parameters on the variability of the 6MWD among healthy adults and to propose a reference equation. METHODS: This was a prospective, cross-sectional, observational study. The 6MWT was conducted in a 30-m hospital corridor on 201 healthy volunteers, 125 men and 76 women, aged 20-60 years. The HPA in the previous 6 months was assessed using Baecke's questionnaire. Univariate analysis followed by multiple regression analysis was performed to analyze the significance levels of different probable predictors. RESULTS: The 6MWD was significantly greater in more active than in less active subjects (663.8±55.4m vs. 599.9±67.8m, p<0.001). The regression analysis showed that the subject's age in years (p=0.017), gender (p=0.006), height in cm (p=0.004), weight in kg (p<0.001), total activity score (TS) (p<0.001), and absolute difference in heart rate before and after exercise (p<0.001) could explain 48.9% of the variability in the 6MWD in healthy adults. CONCLUSIONS: The HPA score is probably the most appropriate variable to include in the reference equation predicting the 6MWD in healthy adults from the Indian subcontinent.

Pulmonary arteriovenous malformation: An uncommon disease with common presentation.

A 45-year-old male presented with massive hemoptysis, clubbing in all limbs, disproportionate hypoxia and persistent ill-defined shadow in left lower zone in chest radiograph since his childhood. The patient received empirical anti-tuberculosis treatment and the chest X-ray finding was misinterpreted as tuberculoma. Subsequently, CT pulmonary angiography proved it to be a case of a simple type solitary pulmonary arteriovenous malformation with a saccular aneurysm in left lower lobe.

It's easy to miss complicated hydatid cyst of lung.

A 60-year-old female presented with pneumonitis of right lower zone. CT scan revealed mass like lesion with multiple air pockets. FNAC and ultrasound confirmed the diagnosis as isolated active pulmonary hydatid cyst, which is not common finding in adult population.

Aspergillus hypersensitivity and allergic bronchopulmonary aspergillosis among asthma patients in eastern India.

To find out the clinicoradiomycopathological profile of allergic bronchopulmonary Aspergillosis (ABPA) and incidences of aspergillus hypersensitivity (AH) among asthma patients, 215 consecutive extrinsic asthma patients were screened with aspergillus intradermal test and those found positive for AH were investigated further for ABPA. Out of 215 asthma patients (124 males and 91 females), 54 were hypersensitive to AH and 15 of them fulfilled criteria for ABPA. On repeated culture of sputum and/or broncho-alveolar lavage fluid, A flavuswas the most common isolate (40%), followed by A fumigatus (26.67%). No species was isolated in 4 cases (26.6%). AH/ABPA is not very uncommon in this part of the country. Diseases similar to ABPA caused by other fungus might be diagnosed if allergen tests for other fungal antigens are made widely available. A strong clinical suspicion and proper laboratory backup is essential for diagnosing ABPA and related diseases.