Frequency of thrombocytopenia in severe COVID-19 pneumonia and its effects on clinical outcomes.

To aim of the study was to determine the frequency of thrombocytopenia and its effect on clinical outcomes in South Asian patients admitted with severe COVID-19. It was a cross-sectional study conducted at the COVID intensive care unit of tertiary care government hospital of Karachi, Pakistan. 190 patients admitted in five months from 1/2/2021 till 30/6/2021 were included in the study. Platelet counts were recorded at presentation and all patients were also followed to observe if they develop thrombocytopenia during the course of hospital stay. The patient outcome and need for mechanical ventilation was assessed 28 days after admission and compared with the frequency of thrombocytopenia. Thrombocytopenia was seen in 26.8% (n=51) admitted patients. Among these, 68.6% patients had thrombocytopenia at presentation and 31.4% patients developed thrombocytopenia during the course of hospital stay. The range of platelet count in thrombocytopenic patients was 11x109 - 150x109. Mean platelets count in thrombocytopenic patients was 110x109 (SD 33). Mortality in patients who developed thrombocytopenia was 73.6% and 56.9.2% in patients without thrombocytopenia (p 0.034). Patients with thrombocytopenia were more likely to require mechanical ventilation (p 0.024). Thrombocytopenia is frequently observed in patients with severe COVID-19 and can be used as a tool for risk stratification.

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.

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.

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.

Comparison between the diagnostic accuracy of Xpert MTB/Rif assay and culture for pleural tuberculosis using tissue biopsy.

BACKGROUND: Early diagnosis of pleural tuberculosis is difficult as it is a paucibacillary disease and a combination of tests is required to diagnose it, which have varied diagnostic accuracy and increase the cost. The aim of this study was to evaluate the diagnostic performance of the Xpert MTB/Rif assay on thoracoscopic pleural biopsy specimens. METHODS: A total of 201 patients with exudative pleural effusion and normal lung parenchyma were included in the study. All patients underwent thoracoscopic pleural biopsy under local anaesthesia. Biopsy samples were sent for Xpert MTB/Rif assay and culture, along with histopathology. Chronic granulomatous inflammation on histopathology and response to antituberculous treatment was taken as the reference standard for diagnosis of tuberculous pleurisy. RESULTS: Of the 198 patients included in the final analysis, 134 had pleural tuberculosis. The sensitivity of the Xpert assay was 52.2% and specificity was 100%, and that of pleural biopsy cultures were 41% and 100% respectively. CONCLUSION: The sensitivity and specificity of Xpert MTB/Rif assay scores were high, hence escalating the speed of diagnosis and imparting marked impact on patient outcomes. The Xpert MTB/Rif assay is a potential game changer in diagnosing pleural tuberculosis.

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.