Visual Diagnosis of Pleural Tuberculosis and its Association with Tissue Biopsy, Culture and Xpert Assay.

INTRODUCTION: The diagnosis of pleural tuberculosis remains a clinical challenge due to the paucibacillary nature of disease. Medical thoracoscopy remains the gold standard in diagnosing tuberculous pleuritis. OBJECTIVE: To establish the diagnostic yield of sago-seed thoracoscopic appearance of pleura in tuberculosis and its correlation with histopathology, tissue AFB culture and tissue Xpert MTB/Rif assay. METHODS: All consecutive patients with lymphocytic exudative pleural effusion, who fulfilled inclusion criteria of the study underwent medical thoracoscopy under local anesthesia and pleural tissue was sent for histopathology, AFB culture and Xpert MTB/Rif assay. Chronic granulomatous inflammation on histopathology and response to anti-tuberculous treatment was taken as reference standard for diagnosis of tuberculous pleurisy. RESULTS: A total of 249 patients were included in the study, out of which 168 had effusion secondary to tuberculosis. Sago-like nodules visualized on thoracoscopy had a sensitivity of 58.9 %, specificity of 92.6 % and diagnostic accuracy of 69.88 % for pleural tuberculosis. There is a strong association between the presence of sago-like nodules and detection of mycobacterium tuberculosis on Xpert MTB/Rif assay and AFB culture of pleura (p-value 0.007). CONCLUSION: Sago seed nodules on pleura have a high positive predictive value for tuberculous pleurisy. In high endemic countries patients with this finding on thoracoscopy can be commenced on anti-tuberculous treatment before histopathology or culture results are available.

Comparison of DECAF (dysponea, eosinopenia, consolidation, acidaemia, and atrial fibrillation) and APACHE II (acute physiology and chronic health evaluation ii) scoring system to predict mortality among patients with acute exacerbation of chronic obstructive pulmonary disease.

OBJECTIVES: To compare the diagnostic accuracy of two systems in predicting mortality among patients with acute exacerbation of chronic obstructive pulmonary disease. METHODS: The cross-sectional study was conducted from November 2017 to June 2018 in the Department of Chest Medicine, Jinnah Postgraduate Medical Centre, Karachi, and comprised patients with acute exacerbation of chronic obstructive pulmonary disease. Dyspnoea-eosinopenia-consolidation-acidaemia-atrial fibrillation system was compared with acute physiology and chronic health evaluation II scoring system after mortality scores were calculated for each patient. Data was analysed using SPSS 21. RESULTS: Of the 210 patients, 147(70%) were males and 63(30%) were females. Overall, 59(28.1%) patients died during hospital stay. The mean dyspnoea-eosinopenia-consolidation-acidaemia-atrial fibrillation score was 2.31±0.93 while the mean acute physiology and chronic health evaluation II score was 15.8±7.2. A decision threshold of dyspnoea-eosinopenia-consolidation-acidaemia-atrial fibrillation score >2 had a sensitivity of 84.6% and specificity of 82.3% while acute physiology and chronic health evaluation II score had sensitivity of 53.9% and specificity of 76.5%. CONCLUSIONS: Both scoring systems were found to be good predictors of mortality, but dyspnoea-eosinopenia-consolidationacidaemia-atrial fibrillation score was a simpler and effective clinical tool.

Use of Medical Thoracoscopy for Retrieval of Broken Intrapleural Catheter.

Small-bore pleural catheters are used to drain simple effusions effectively. They are less invasive and more comfortable than tube thoracostomy. As with any other intervention, these small catheters have their associated complications. Herein, we report a case of a young woman who was diagnosed with tuberculous pleural effusion. Easydrain pleural catheter was inserted to drain the effusion; it broke in situ because of improper insertion and was later removed using medical thoracoscopy. We emphasize on the need for proper training for doctors and staff regarding these procedures to avoid undue complications. We have also highlighted the importance of medical thoracoscopy in the removal of retained intrapleural foreign bodies.

Diagnostic implications of bronchial lavage in patients with pleural tuberculosis.

INTRODUCTION: The presence of Mycobacterium tuberculosis in a respiratory specimen is diagnostic in patients with pleural effusion. It is difficult to obtain sputum even after induction in these patients. An alternative method of acquiring respiratory specimens is via bronchial lavage. This study was undertaken to evaluate the diagnostic yield of acid-fast bacilli (AFB) smear, AFB culture, and Xpert assay of bronchial lavage fluid in the workup of pleural tuberculosis patients. MATERIAL AND METHODS: All patients who met the inclusion criteria of the study underwent thoracentesis, pleural biopsy, and bronchial lavage. Specimens of pleural fluid, pleural biopsy, and bronchial lavage fluid were sent for acid fast bacilli smear, culture, and Xpert assay. RESULT: Bronchial lavage AFB smear, culture, and Xpert assay was positive in 9.5%, 17.9%, and 26.2% of patients, respectively. It gave an immediate diagnosis in 22 (26.2%) patients. CONCLUSION: Bronchial lavage, though not a surrogate to pleural biopsy, offers an additional approach to the early diagnosis of pleural tuberculosis in patients not producing sputum. Besides being diagnostic, this method also has epidemiologic significance in containing the tuberculosis epidemic because detecting Mycobacterium in bronchial lavage confirms that the patient is infectious.

Factors affecting spirometry reference range in growing children.

OBJECTIVES: To find out the association of weight, height and age with spirometry variables and to generate a regression equation by taking weight as an independent variable beside age and height among children and adolescents of Karachi. METHODS: A modified form of ISSAC questionnaire was used. The spirometry variables recorded were Forced vital capacity (FVC), Forced expiratory volume in 1 second (FEV1), FEV1/FVC, Peak expiratory flow rate (PEF), Forced expiratory flow between 25% and 75% expired volume (FEF25-75). A person's correlation coefficient among boys and girls were calculated for all spirometry variable considering age, height and weight as independent variables. The linear regression models were calculated. RESULTS: The results reported a linear correlation of lung function variables with all three independent variables (i.e. p-value = 0.000), in which age and height manifested a strong positive correlation while weight reported a moderately significant correlation. All spirometry variables such as FVC, FEV1, PEF and FEF25-75 reported a significant coefficient of dependency and coefficient of correlation individually with age, height and weight. CONCLUSION: It is concluded that beside age, height and weight both also have significant correlation with lung volumes so these should be taken into account when using spirometry as a diagnostic test.

Black pleural effusion: an unusual presentation of metastatic melanoma diagnosed by medical thoracoscopy.

Melanoma presenting with black pleural effusion is rare, with only five cases reported till date. In distinction to others, this is the only case where patient did not have a prior diagnosis of melanoma and was diagnosed by thoracoscopy. Reported is the case of a 49-year-old male who presented with dyspnoea and weight loss. Patient had a large left-sided pleural effusion. Ultrasound showed thickened irregular pleura and multiloculated pleural effusion. Diagnostic pleural aspiration was performed, and fluid was black in colour and was exudative lymphocytic. Atypical cells were noted on pleural fluid cytology. Medical thoracoscopy was carried out and histopathology suggested metastatic melanoma. Patient had multiple nevi all over the body, but clinically none was indicative of melanoma. He refused skin biopsy. The case was referred to medical oncology where palliative management was planned. Patient died within two weeks of diagnosis.

Establishing age specific spirometry reference ranges for children/adolescents of Karachi, Pakistan: Randomized trials.

OBJECTIVE: To establish age-specific normative spirometry reference range along with regression equation for children and adolescents. METHODS: The cross-sectional study was conducted from April to October 2017, and comprised children and adolescents aged 7-18 years at 8 educational institutions representing various socio-economic strata of Karachi. A modified version of the International Study of Asthma and Allergies in Childhood Questionnaire was used. Spirometry variables including forced vital capacity, forced expiratory volume in 1 second, ratio between the two, peak expiratory flow rate, forced expiratory flow between 25% and 75% expired volume were recorded and interpreted. By normal distribution curve the reference values were established, and mean}2 standard deviation values were taken as significant. Pearson's correlation coefficient and linear regression models were calculated for all pulmonary variables with age. RESULTS: Of the 751 subjects, 484(64.4%) were boys and 267(35.5%) were girls. The overall mean age was 12.96}2.8 years. The mean lung volume for forced vital capacity was 2.21}0.75, forced expiratory volume in 1 second 2.08}0.73, ratio between the two 92.9}4.7, peak expiratory flow 231.3 } 70.5 and forced expiratory flow between 25% and 75% expired volume was , , , 2.68}1.2. These lung volumes directly increased with age from children to adolescents (p<0.05). All variables showed a significant difference between boys and girls (p<0.05). CONCLUSIONS: There was a linear positive correlation of age with lung function variables, while the boys presented higher values than the girls.

Role of medical Thoracoscopy in the Management of Multiloculated Empyema.

BACKGROUND: The treatment of early pleural empyema depends on the treatment of ongoing infection by antimicrobial therapy along with thoracocentesis. In complicated empyema this treatment does not work and lung will not expand until removal of adhesions. The objective of the current study is to analyze the experience of management of multiloculated, exudative and fibrinopurulent empyema through rigid medical thoracoscopy under local anaesthesia and to explore new ways to manage the entity. METHODS: This is a descriptive case series in which 160 patients were recruited through non-probability convenient sampling, from department of pulmonology, Jinnah postgraduate medical centre, Karachi, from September 2014 to August 2016. All patients underwent medical thoracoscopy under local anesthesia. Written Informed consent was taken from the study participants. Ethical approval was obtained from Ethical Review Committee of the hospital. Patients age > 70 years, those with multiple organ failure and bleeding disorders were excluded. RESULTS: Out of 160 patients, 108 (67.50%) were male and 52 (32.5%) were female with mean age 25.37 years (range 16 to 70 years). Out of total, 102 (63.7%) had tuberculous empyema, while pleural biopsy of 58 (36.3%) patients was suggestive of non-tuberculous empyema. Final evolution through chest x-ray revealed complete resolution in 92 (57.5%), partial resolution in 58 (36.25%) patients. 9 (5.6%) developed persistent air leak while 1 (0.6%) patient expired due to urosepsis. CONCLUSION: Medical Thoracoscopy under local anesthesia is a safe, efficient and cost effective intervention for management of complicated empyema, particularly in resource constraint settings.

Interstitial Lung Diseases Misdiagnosed as Tuberculosis.

OBJECTIVE: To determine the frequency of misdiagnosis of tuberculosis in interstitial lung disease cases. METHODS: This is a prospective study including patients registered in the interstitial lung disease clinic, Jinnah Postgraduate Medical Center, Karachi, during May-June 2017. Diagnosis of tuberculosis was only confirmed if there was any bacteriological evidence of tuberculosis at the time of diagnosis or if there was improvement in symptoms after treatment in patients diagnosed as having tuberculosis on clinical grounds. RESULTS: Seventy-three patients were included in the study, out of which 53 (72.60%) were females and 20 (27.39%) were males. Tuberculosis was treated before presentation in 28 (38.35%) of interstitial lung disease patients. Except for two silicosis patients who had smear positive tuberculosis, rest of the patients were misdiagnosed as having tuberculosis. CONCLUSION: Interstitial lung diseases are the disorders that are frequently unrecognized and misdiagnosed. More commonly the confusion is with tuberculosis. Thorough knowledge about interstitial lung diseases should be provided to the primary care physicians, especially in countries with high tuberculosis burden, so that to limit maltreatment with anti-tuberculous drugs when they are not needed and early referral to interstitial lung disease clinic.

Application of BiPAP through Endotracheal Tube in Comatose Patients with COPD Exacerbation.

OBJECTIVE: To evaluate the effectiveness and safety of using BiPAP through endotracheal tube in comatose Chronic Obstructive Pulmonary Disease (COPD) patients with hypercapnic respiratory failure. METHODS: This is a prospective study done at Department of Chest Medicine, Jinnah Postgraduate Medical Centre, Karachi, during March to June 2017. It included all comatose COPD patients with hypercapnic respiratory failure who had a poor functional status prior to the illness and who did not meet the criteria to be kept on mechanical ventilator. Patients with apnea and other causes of coma were excluded. These patients were applied BiPAP through endotracheal tube and its response on blood gases and neurological status was evaluated. RESULTS: The success rate of BiPAP through endotracheal tube was 70.5% (31/44). Improvement in Glasgow Coma Scale (GCS) score (p<0.01), pH (p<0.01), and PaCO2 (<0.01) was observed among the responders following two hours and 24 hours of therapy. No significant difference was found in response with regards to gender, smoking status, prior use of noninvasive ventilation or duration of disease. No complications were observed during the therapy. CONCLUSION: In resource poor settings, the use of BiPAP through endotracheal tube can be an effective and safe intervention for comatose COPD patients with hypercapnic respiratory failure.