Improving the yield of diagnostic medical thoracoscopy for undiagnosed exudative pleural effusions using a rigid diagnostic algorithm.

Background: Establishing the etiology of exudative pleural effusions in the setting of an unrewarding pleural fluid analysis often requires biopsies from the parietal pleura. However, it may be noted that diagnosis such as pulmonary embolism and connective tissue diseases can result in an exudative pleural effusion where a pleural biopsy can yield nonspecific results. Medical thoracoscopy (MT) is a minimally invasive procedure performed under local anesthesia or moderate sedation with excellent yield and favorable safety profile. We analyzed the diagnostic yield of MT for exudative pleural effusions after employing a rigid diagnostic algorithm. The study was undertaken to ascertain the yield of MT in establishing the diagnosis in diagnosis of exudative pleural effusions, to find out the relative contribution of pleural tuberculosis (TB) as a cause of undiagnosed exudative pleural effusion, to describe the etiology of undiagnosed exudative pleural effusion in patients undergoing MT and to determine the correlation between pleural fluid adenosine deaminase (ADA) levels and TB pleuritis in patients undergoing MT. Methods: This was a retrospective study. Patients with undiagnosed exudative pleural effusion were included in the study. MT was performed with semirigid thoracoscope (Olympus LTF 160) under local anesthesia and conscious sedation. Gross appearance and ADA level of pleural fluid were noted. Pleural biopsy material was subjected to histopathology examination and culture for mycobacteria along with cartridge-based nucleic acid amplification test for TB. The yield of MT for establishing the etiology of pleural effusion and the relative contribution of tuberculous pleuritis as a cause of undiagnosed pleural effusion was ascertained. Correlation of pleural fluid ADA levels was done with a final diagnosis of TB pleuritis in patients undergoing MT. Results: Twenty-five patients with undiagnosed exudative pleural effusion underwent thoracoscopy of which 16 were male and 9 were female. MT was able to establish the diagnosis in all cases, providing a diagnostic yield of 100%. Histopathological examination of biopsy specimens yielded a diagnosis of malignant involvement of pleura in 10 patients and granulomatous pleuritis consistent with TB in 14 patients. Pleural TB contributed to 60% of undiagnosed pleural effusions in the present study. The mean ADA value among those who turned positive was 56.338 and 35.300 among those who turned negative using genexpert, which was found to be statistically significant. A value of 31 IU/L showed a sensitivity of 93.3% and specificity of 99.8% and hence can be taken as a cut off value for the diagnosis of pleural TB based on receiver-operating characteristic analysis. Conclusion: TB contributed to 60% of undiagnosed exudative pleural effusions in the present study. MT had 100% yield in the diagnosis of undiagnosed exudative effusions. Pleural fluid ADA levels may help in differentiating TB versus malignant effusion.

Per-Pass Analysis of Thrombus Composition in Patients With Acute Ischemic Stroke Undergoing Mechanical Thrombectomy.

Background and Purpose- Mechanical thrombectomy may involve multiple attempts to retrieve the occluding thrombus. This study examined the composition of thrombus fragments retrieved with each pass of a device during the thrombectomy procedure. Second, the per-pass composition was compared with procedural and clinical data including angiographic outcome and stroke etiology. Methods- Thrombi were retrieved from 60 patients with acute ischemic stroke, where thrombus fragments retrieved in each pass were segregated as individual samples and maintained throughout the histological analysis as independent samples. All samples were stained with hematoxylin and eosin and Martius Scarlet Blue. The relative composition of red blood cells, fibrin, and white blood cells in thrombus fragments from each pass was quantified. Results- Over the 60 cases, thrombus material was retrieved in 106 of 138 passes. The number of passes required to complete the cases ranged from 1 to 6 passes. The analysis of thrombus fragments retrieved in each pass provided a greater insight into the thrombectomy procedure progression than the overall thrombus composition; the red blood cell content of thrombus fragments retrieved in passes 1 and 2 was significantly higher than that retrieved in passes 3 to 6. The removal of thrombus material in a total of 1, 2, or 3 passes was associated with the highest percentage of final modified Thrombolysis in Cerebral Infarction score of 2c-3. There was no association between modified Thrombolysis in Cerebral Infarction score and per-pass thrombus composition. Conclusions- The differentiation achieved through the per-pass analysis of acute ischemic stroke thrombi provides a greater insight into the thrombectomy procedure progression than the combined per-case thrombus analysis. Insights gained may be a useful consideration in determining the treatment strategy as a case evolves and may be useful for the development of new devices to increase rates of 1-pass recanalization.

"Cryptic" mediastinal tuberculosis with myasthenia-thymoma complex.

Mediastinal tuberculosis, although common in endemic areas, is rare in association with myasthenia-thymoma complex. Immunosuppressive therapy for myasthenia with thymoma might increase the susceptibility for mediastinal tuberculosis. Previous reports suggest aggravation of myasthenic symptoms with this association. This rare combination of pathologies adds to the diagnostic dilemma of the surgeon. Further research is warranted in the management aspects of this combination as regards to the timing of radiotherapy, weaning of immunosuppression and anti-tubercular therapy after maximal thymectomy. This case report emphasises the possibility of mediastinal tuberculosis as a differential diagnosis for mediastinal lymphadenopathy in the setting of a preoperative diagnosis of invasive thymoma.

Uterine Angioleiomyoma with Atypia, Raised CA-125 Levels, and Pseudo-Meigs Syndrome: An Alarming Presentation.

Angioleiomyomas are benign mesenchymal tumours commonly occurring in the subcutis of extremities. They are typically composed of interlacing fascicles of smooth muscle cells with intersecting vascular channels. Angioleiomyomas of the uterus are rare with only very few case reports available in literature. Herein, we report a case of this rare entity in a 47-year-old woman owing to its highly unusual features of cellular atypia, raised CA-125 levels, and pseudo Meigs syndrome.

Subcutaneous human dirofilariasis.

Subcutaneous human dirofilariasis is caused by the zoonotic filariae Dirofilaria repens. The frequency of reports is increasing in literature during the last few years and is considered by some authors as an emerging zoonosis. Here we report 21 cases of subcutaneous dirofilariasis, which were encountered over a period of 8 years. None of these cases were associated with peripheral eosinophilia. Since these lesions can mimic benign and malignant tumors, it is important to consider this as a differential diagnosis of subcutaneous nodules especially in an endemic area. In this report we would like to emphasize the importance of studying multiple deeper levels in suspected cases of parasitic granuloma to demonstrate the parasite.

Hybrid maxillofacial prosthesis: a case report.

The role of a prosthodontist in the management of cleft lip & palate patients is pertinent involving restoration of mastication, facial harmony, dental harmony and phonation. This article presents the prosthodontic rehabilitation of a congenitally bilateral cleft lip and palate patient with a unique method which fulfilled the patient's needs, esthetics and psychological well being.