MDR tuberculosis in elderly.

Tuberculosis is very common in young population, but it has emerged in a significant number in geriatric/elderly population (>60 Yrs. of age) as the population is ageing. Most cases of TB in the elderly are linked to the reactivation of lesions that have remained dormant. The awakening of these lesions is attributable to changes in the immune system related to senescence. Mortality rate from tuberculosis remains higher in elderly patients. Diagnosis is difficult as symptoms of active TB are nonspecific and less pronounced in the elderly. MDR TB is known to occur in poorly compliant patients (non-adherence) and this can be a major issue in elderly due to loss of independence and frailty resulting in treatment failure. Multidisciplinary management, involving geriatricians and infectious disease specialists is essential throughout care to optimize a favourable outcome in these vulnerable patients.

A Comprehensive Comparison of Clinical Presentation and Outcomes of Kidney Transplant Recipients with COVID-19 during Wave 1 versus Wave 2 at a Tertiary Care Center, India.

Data comparing the clinical spectrum of COVID-19 in kidney transplant recipients (KTRs) during the first and second waves of the pandemic in India is limited. Our single-center retrospective study compared the clinical profile, mortality, and associated risk factors in KTRs with COVID-19 during the 1st wave (1st February 2020 to 31st January 2021) and the second wave (1st March-31st August 2021). 156 KTRs with PCR confirmed SARS-CoV-2 infection treated at a tertiary care hospital in New Delhi during the 1st and the second waves were analyzed. The demographics and baseline transplant characteristics of the patients diagnosed during both waves were comparable. Patients in the second wave reported less frequent hospitalization, though the intensive care unit (ICU) and ventilator requirements were similar. Strategies to modify immunosuppressants such as discontinuation of antinucleoside drugs with or without change in calcineurin inhibitors and the use of steroids were similar during both waves. Overall patient mortality was 27.5%. The demographics and baseline characteristics of survivors and nonsurvivors were comparable. A higher percentage of nonsurvivors presented with breathing difficulty, low SpO2, and altered sensorium. Both wave risk factors for mortality included older age, severe disease, ICU/ventilator requirements, acute kidney injury (AKI) needing dialysis, Chest Computerized Tomographic (CT) scan abnormalities, and higher levels of inflammatory markers particularly D-dimer and interleukin-6 levels. Conclusions. KTRs in both COVID-19 waves had similar demographics and baseline characteristics, while fewer patients during the second wave required hospitalization. The D-dimer and IL-6 levels are directly correlated with mortality.

Mortality and Clinical Outcomes among Patients with COVID-19 and Diabetes.

Background Diabetes mellitus (DM) is a decisive risk factor for severe illness in coronavirus disease 2019 (COVID-19). India is home to a large number of people with DM, and many of them were infected with COVID-19. It is critical to understand the impact of DM on mortality and other clinical outcomes of COVID-19 infection from this region. Aims The primary objective of our study was to analyze the mortality rate in people with DM infected with COVID-19. The secondary objectives were to assess the effect of various comorbidities on mortality and study the impact of DM on other clinical outcomes. Methods This is a retrospective study of COVID-19 infected patients admitted to a tertiary care hospital in north India in the early phase of the pandemic. Results Of the 1211 cases admitted, 19 were excluded because of incomplete data, and 1192 cases were finally considered for analysis. DM constituted 26.8% of total patients. The overall mortality rate was 6.1%, and the rate was 10.7% in the presence of diabetes (p < 0.01, OR 2.55). In univariate analysis, increased age, chronic kidney disease (CKD), coronary artery disease (CAD), stroke, and cancer were associated with mortality. On multiple logistic regression, the independent predictors of mortality were CAD, CKD, and cancer. Breathlessness and low SpO2 at presentation, extensive involvement in CXR, and elevated ANC/ALC ratio were also significantly associated with mortality. Conclusions The presence of comorbidities such as DM, hypertension, CAD, CKD, and cancer strongly predict the risk of mortality in COVID-19 infection. Early triaging and aggressive therapy of patients with these comorbidities can optimize clinical outcomes.

Bronchoscopic lung cryobiopsy: An Indian association for bronchology position statement.

BACKGROUND: Bronchoscopic lung cryobiopsy (BLC) is a novel technique for obtaining lung tissue for the diagnosis of diffuse parenchymal lung diseases. The procedure is performed using several different variations of technique, resulting in an inconsistent diagnostic yield and a variable risk of complications. There is an unmet need for standardization of the technical aspects of BLC. METHODOLOGY: This is a position statement framed by a group comprising experts from the fields of pulmonary medicine, thoracic surgery, pathology, and radiology under the aegis of the Indian Association for Bronchology. Sixteen questions on various technical aspects of BLC were framed. A literature search was conducted using PubMed and EMBASE databases. The expert group discussed the available evidence relevant to each question through e-mail and a face-to-face meeting, and arrived at a consensus. RESULTS: The experts agreed that patients should be carefully selected for BLC after weighing the risks and benefits of the procedure. Where appropriate, consideration should be given to perform alternate procedures such as conventional transbronchial biopsy or subject the patient directly to a surgical lung biopsy. The procedure is best performed after placement of an artificial airway under sedation/general anesthesia. Fluoroscopic guidance and occlusion balloon should be utilized for positioning the cryoprobe to reduce the risk of pneumothorax and bleeding, respectively. At least four tissue specimens (with at least two of adequate size, i.e., ≥5 mm) should be obtained during the procedure from different lobes or different segments of a lobe. The histopathological findings of BLC should be interpreted by an experienced pulmonary pathologist. The final diagnosis should be made after a multidisciplinary discussion. Finally, there is a need for structured training for performing BLC. CONCLUSION: This position statement is an attempt to provide practical recommendations for the performance of BLC in DPLDs.

Endotracheobronchial lymphoma: Two unusual case reports and review of article.

The tracheobronchial origin of non-Hodgkin's lymphoma (NHL) is a very rare presentation, and there are only a few case reports of primary tracheal or endobronchial NHL. We have two cases of primary tracheobronchial NHL; one case was incidentally diagnosed as anaplastic large cell lymphoma of endobronchial origin when a comprehensive workup and surgery were carried out for an endobronchial aspergilloma which was actually sitting on top of lymphoma. The second patient was a case of myelodysplastic syndrome who presented with acute respiratory distress; on thorough workup, he was found to have endotracheal B-cell lymphoma. Both cases were responding well with standard chemotherapy. The mortality in these kinds of patients is due to disease progression or airway compromise and treatment complications.

A case of pulmonary alveolar proteinosis treated with whole lung lavage.

Pulmonary alveolar proteinosis represents a rare syndrome characterized by the accumulation of proteinaceous phospholipid-laden material in the alveoli. This leads to impaired gas exchange and arterial hypoxemia of varying degrees. The diagnosis is confirmed by lung biopsy. Sequential whole-lung lavage (WLL) first described in 1963 is the standard of care. We report a case of a male diagnosed of having pulmonary alveolar proteinosis (PAP) on transbroncial lung biopsy (TBLB). He was treated with sequential WLL (Left followed by right, Left being more involved on chest X-ray) followed by recombinant GM-CSF, with good result.

Comparison of non-invasive diagnostic tests to multi-detector CT pulmonary angiography for the diagnosis of pulmonary embolism.

CONTEXT: Acute pulmonary embolism (PE) remains a diagnostic and therapeutic challenge to physicians. There are various non-invasive diagnostic modalities been suggested to diagnose pulmonary embolism. AIM: We tried to find the performance of various non-invasive investigations in comparison to multi-detector Computerized Tomography (MDCT pulmonary angiography for the diagnosis of PE). SETTINGS AND DESIGN: A prospective cohort study was conducted in 80 hospitalized medical patients. MATERIALS AND METHODS: There were 80 patients with Wells score > 2 who were included. The demographic data, non-invasive investigations, and MDCT pulmonary angiography were conducted in these patients. The sensitivity (SEN), specificity (SPE), positive predictive value (PPV), and negative predictive value (NPV) were calculated for each test. RESULTS: Out of 80 patients, 77.5% patients were with Wells score 3-6 and 22.5% patients were with Wells score more than 6. The test with highest sensitivity was d-dimer (SEN - 90%, P = 0.091) followed by PAH on TTE (SEN - 83%, PPV - 86%, P = 0.006). The most specific test was ECG showing S1Q3T3 (SPE - 100%, P = 0.421), followed by Wells score > 6 (SPE - 91%, P = 0.211). There was no test with sensitivity and specificity more than 90% CONCLUSION: In all patients with intermediate to high-risk probability MDCT pulmonary angiography is the most accurate test to diagnose PE and should be performed at the earliest. The combination of 2-dimensional ECHO and d-dimer can be used in patients with a high clinical suspicion of PE on pre-test probability where MDCT pulmonary angiography is not possible.