Role of Single Port Rigid Thoracoscopy in Undiagnosed Pleural Effusion.

BACKGROUND: In recent years, medical thoracoscopy has been well established to play an important role in undiagnosed pleural effusion; however, this procedure is underutilized due to limited availability of the instruments it requires. This study analysed the outcome of single port rigid thoracoscopy in patients with undiagnosed pleural effusions. METHODS: This study retrospectively analysed the outcomes of all patients with undiagnosed pleural effusion presenting to our centre between 2016 to 2020 who underwent single port rigid medical thoracoscopy as a diagnostic procedure. RESULTS: In total, 92 patients underwent single port rigid medical thoracoscopy. The most common presenting symptom was shortness of breath. A majority of the patients had lymphocytic exudative pleural effusion. The average biopsy sample size was 18 mm, and no major complication was reported in any of the patients. CONCLUSION: Single port rigid thoracoscopy is a safe and well-tolerated procedure that yields a biopsy of a larger size with high diagnostic yield. Moreover, the low cost of the instruments required by this procedure makes it particularly suited for use in developing countries.

Interesting case of allergic broncho pulmonary aspergillosis (ABPA) with high-attenuation mucus (HAM).

A 25-year-old man, who was taking treatment for his poorly controlled asthma, presented with symptoms of cough with expectoration, gradually progressive shortness of breath, fever on and off and diffuse wheeze for 2 years. Chest X-ray revealed hyperinflation of lung field with dense opacification at right upper lobe. High-resolution CT chest showed bilateral patchy consolidation, central bronchiectasis and high-attenuation mucus (HAM) impaction. His blood absolute eosinophil count, total serum IgE level, Aspergillus fumigatus specific IgE and IgG level were 1910, 16760 kU/L, 59.8 kU/L and 147.41 kU/L, respectively. Diagnosis of allergic broncho pulmonary aspergillosis (ABPA) was established according to International Society for Human and Animal Mycology society guidelines. He was started on systemic steroids and doing well after 6 months of follow-up. Our case illustrates HAM, which is a rare but typical radiological feature of ABPA.

Primary pleural synovial sarcoma: a rare cause of hemorrhagic pleural effusion.

Primary pleural synovial sarcoma (PPSS) is a rare malignant pleural tumor comprising < 1% of all primary lung malignancies. Primary pleural mesothelioma (PPM) has many similar features that may cause a diagnostic dilemma due to overlapping clinical and histopathological features. We present the case of a young male with recurrent hemorrhagic pleural effusion without any obvious lung mass who was diagnosed with PPSS. This rare entity must be considered with a high index of suspicion while evaluating pleural tumors.

Acute fibrinous organizing pneumonia: a rare lung pathology.

Acute fibrinous organizing pneumonia (AFOP) is a rare, non-infective lung pathology histologically characterized by patchy distribution of intra-alveolar fibrin "balls" and organizing pneumonia. It needs to be differentiated from other forms of acute pneumonia like community acquired pneumonia (CAP) because the treatment modalities are contrastingly different. Interesting case of a 45-year-old male initially suspected as a case of acute bacterial pneumonia but finally diagnosed as case of AFOP, is being reported. Initial empirical antimicrobial therapy was ineffective, and the main treatment to which the patient responded was corticosteroids.

A malignant wheeze!

Asthma is a common disorder presenting with nonspecific features, which may mimic other conditions such as tracheal tumors. Tracheal tumors are often misdiagnosed as asthma. We report a case of a 38-year female who was being worked up for persistent wheeze that was initially attributed to acute asthma, only to be later discovered as tracheal tumor. A high index of suspicion for alternative diagnoses must be kept in mind while evaluating a patient who presents with clinical features suggestive of asthma, but fails to respond to standard therapy. The present case report emphasizes the fact that not all wheezes are asthma.

Conventional TBNA experience over a 10-year period: Diagnostic yield and associated limitations in a tertiary care government set-up.

INTRODUCTION: It is challenging for pulmonologists to sample mediastinal lymph nodes or some endobronchial lesions because of safety concerns. C-TBNA (conventional transbronchial needle aspiration) is a procedure to sample such sites, but is underutilized. We present a retrospective review of patients subjected to C-TBNA through fibre-optic bronchoscopy over a 10-year period. MATERIALS AND METHODS: Year-wise statistics of C-TBNA was reviewed and results were analyzed with regard to sampling sites and type of intraluminal lesions encountered, diagnosis made and their correlation with sampling sites, sex and age. RESULTS: 160 patients underwent successful C-TBNA with 111/160 (69.4%) males and 49/160 (30.6%) females. Non-availability of in-house needles dramatically decreased the number of procedures. 17 (10.6%) patients underwent C-TBNA from intraluminal bulge, 41 (25.6%) from endobronchial growth and 102 (63.8%) from enlarged lymph nodes. Subcarinal lymph node alone was predominantly aspirated in 83/102 (81.4%) lymph node sampled patients. In 100 (62.5%) patients, diagnosis was achieved as follows: 57/100 as tumour, 30/100 as infection and 13/100 as sarcoidosis. Non-small cell lung cancer (NSCLC) and tuberculosis (TB) predominated in tumour and infection groups, respectively. Patients with intraluminal growth or bulge had higher chances of being diagnosed with tumour (p<0.001). Intraluminal bulge and growth predominated in older ages while enlarged lymph nodes predominated in the young (p=0.018). Infection was predominantly diagnosed in younger patients, sarcoidosis in the middle aged, and tumour in older patients (p<0.001). CONCLUSION: C-TBNA should be used as a diagnostic tool in developing countries like India. It can give confirmatory results in difficult cases with intraluminal growths and submucosal lesions. Cost constraints are of paramount importance, and hence continuous supply of expensive accessories should be ensured.