Long-standing undiagnosed foreign body aspiration with concomitant pulmonary tuberculosis in an Immunocompetent man.

Foreign body aspiration is a rare clinical finding in adults, among which very few are reported, probably due to absence of classical clinical features in adults when compared to children and due to lack of awareness. We present a 57-year-old with chronic productive cough who was diagnosed to have pulmonary tuberculosis (TB), complicated by long-standing foreign body in the tracheobronchial tree. There are many cases reported in literature where there have been misdiagnosis with respect to pulmonary TB as foreign body or foreign bodies as pulmonary TB. However, this is the first case where retained foreign body and pulmonary TB coexisted in a patient.

Tracheobronchopathia osteochondroplastica: A rare case of misdiagnosis and difficult intubation.

Tracheobronchopathia osteochondro-plastica (TPO) is a rare disorder of yet unknown etiology. The common clinical features include cough with expectoration, breathing difficulty, hemoptysis, and recurrent airway infections, which can lead to a misdiagnosis as another chronic respiratory illness in a large number of cases due to the rare nature of TPO. Here we present a 25-year-old lady who was misdiagnosed as bronchial asthma for many years, and was found to have TPO after difficulty in intubation for administering general anesthesia prior to a surgical procedure.

Case Report: Chronic Cavitatory Pulmonary Aspergillosis after COVID-19.

Chronic pulmonary aspergillosis can present in four distinct clinical syndromes, one of which is chronic cavitary pulmonary aspergillosis (CCPA). CCPA is generally associated with a mildly immunosuppressed state or, in immunocompetent patients, with structural lung damage. Severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) infection has been associated with reactivation of previous quiescent infections such as tuberculosis and invasive fungal infections, but CCPA in a patient with COVID-19 is rarely reported. Here we present the case of a 57-year-old man with CCPA associated with COVID-19 infection in whom latent aspergilloma was most likely activated after SARS-CoV-2 infection. The patient presented with severe COVID and, after initial response to treatment, started to deteriorate due to reactivation of latent aspergilloma to a more aggressive CCPA form. After confirmation of the diagnosis, the patient was initiated on treatment with voriconazole. He showed a good response to treatment with clinicoradiological response. This case also depicts one of the common causes of clinical deterioration in otherwise recovering COVID-19 patients.

The Clinical, Radiological, and Laboratory Profile of Patients With Interstitial Pneumonitis With Autoimmune Features From India: An Observational, Cross-Sectional Study.

Introduction Interstitial pneumonia with autoimmune features (IPAF) refers to interstitial lung disease (ILD) with co-existing features of other clinical, serologic, or pulmonary features that suggest the presence of an underlying systemic autoimmune condition that does not fulfill the current rheumatologic criteria for connective tissue disorder (CTD). It is a relatively newly described clinical syndrome with only a handful of reports describing it. This study aimed at studying the clinical, radiological, and laboratory profiles of IPAF patients from a tertiary care hospital in South India. Methods This was an observational cross-sectional study conducted in a tertiary care hospital in South India over a period of one year. Patients diagnosed to have IPAF as per the European Respiratory Society (ERS)/American Thoracic Society (ATS) criteria were included in the study, and their demographics, clinical features, radiological features, and laboratory markers were collected along with a descriptive analysis. Results A total of 14,433 patients were screened during the study period. Twenty-four patients were diagnosed to have IPAF during the study period with a prevalence of 0.17%. Out of these 24 patients, 11 (45.8%) patients were males. The mean (M) ± standard deviation (SD) age was 47.8±10.7 years. Twenty-one (87.5%) of the patients reported having a cough, 18 (75%) patients had breathlessness, and 10 (41.7%) patients had digital clubbing. On radiological imaging, five (20.8%) patients had features of usual interstitial pneumonia (UIP) and 14 (58.3%) had nonspecific interstitial pneumonia (NSIP). On pulmonary function testing, the M±SD forced expiratory volume in the first second (FEV1) was 56.4±13.9%. The M±SD forced vital capacity (FVC) was 44.2±24.1%. The M±SD FEV1/FVC ratio was 0.8±0.04. On performing diffusing capacity of the lungs for carbon monoxide (DLCO), the M±SD was 34.2±21.9%. Of the patients, 95.8% had a positive antinuclear antibody (ANA) while 25% of patients had a positive anti-AMA-M2. Conclusions The prevalence of IPAF in the studied population was very low. IPAF had nonspecific clinical features, pulmonary function tests, and radiological findings. Further large-scale studies are required from different parts of the world in order to understand the epidemiology of IPAF. Research is also required into developing effective management options for IPAF.

Association Between Non-Cystic Fibrosis Bronchiectasis and Quality of Life: A Single-Center Cross-Sectional Study.

Introduction Bronchiectasis is a chronic respiratory disease that can affect patients of all ages and significantly impact the quality of life (QOL) in patients who suffer from it. In spite of its widespread prevalence, and the significant impact on QOL, data on the quantitative impact of bronchiectasis on QOL is lacking. The Quality of Life-Bronchiectasis (QOL-B) is a self-administered patient-reported outcome measure, that was recently developed as a response to the emergent need for such measurement tools to study the impact of bronchiectasis on QOL. Methods We conducted a single-center cross-sectional study to study the correlation between QOL and various other outcome parameters such as exercise capacity, lung functions, co-morbidities, inflammatory markers, and body mass index (BMI). The secondary outcome was to find out various determinants of quality of life in non-cystic fibrosis bronchiectasis (NCFB). Results Forty-four patients who determined the pre-determined criteria for NCFB were enrolled in this study. This study demonstrated a significant impact on the QOL of NCFB patients based on the QOL-B scoring system. Almost all domains of QOL-B were found to be adversely impacted as measured by one or more of the outcome parameters but the FEV1, age, colonization, extension, dyspnea (FACED) score, bronchiectasis severity index (BSI) score, six-minute walk test (6MWD), and FEV1 showed associations across most scales while the other outcome parameters showed varying associations. Conclusions The QOL is significantly reduced in NCFB and it may be quantified using the QOL-B questionnaire. The impact on QOL in NCFB may be assessed using validated tools such as the FACED and BSI scoring systems, as well as other well-established outcome parameters like 6MWD and FEV1 predicted.

A Unique Case of Arterial Thrombosis and Recurrent CVA in ICU: Unfathomable Presentation of an Occult Malignancy.

INTRODUCTION: Critically ill patients may present with prothrombotic manifestations. Carcinoma cervix with prothrombotic manifestations are not common. Arterial thrombosis in such cases is very rare. We present a case of carcinoma cervix which posed a diagnostic dilemma and difficulty in localizing primary. This patient also had recurrent strokes and cardiac metastasis with metastatic arterial thrombosis. CASE DESCRIPTION: A 34-year-old lady presented with a history of acute lower limb ischemia and recurrent strokes. Transthoracic echocardiography showed valvular vegetations. Prothrombotic and infective endocarditis workup were negative. Histopathological examination (HPE) of clot showed metastatic squamous cells. Contrast CT of chest and abdomen only showed mediastinal lymphadenopathy. Endobronchial ultrasound (EBUS) with mediastinal lymph node biopsy showed metastatic squamous cells. As the patient gave a history of hysterectomy, Pap smear from the vault was sent, which was suggestive of high grade squamous intraepithelial neoplasia. Palliative chemotherapy was started. The patient made a good recovery and was discharged home in a stable condition. CONCLUSION: Arterial thrombosis is an uncommon manifestation of occult malignancy. Carcinoma cervix usually does not metastasize to heart, brain, and arteries, which was the case in our patient. A high index of suspicion and systematic evaluation can clinch the diagnosis even when rare complications of malignancy are presented by critically ill patients. CLINICAL SIGNIFICANCE: Any unprovoked thrombotic episodes should be extensively worked up for occult malignancies. We present a case demonstrating challenges faced by critical care physicians and benefits of methodical evaluation when confronted with unusual presentation of a malignancy. HOW TO CITE THIS ARTICLE: Rangappa R, Shetty RM, Denzil M, Haranahalli PE, Susmita S, Chaurasia S. A Unique Case of Arterial Thrombosis and Recurrent CVA in ICU: Unfathomable Presentation of an Occult Malignancy. Indian J Crit Care Med 2020;24(7):585-588.