Giant mediastinal haemangiopericytoma: an uncommon case.

Haemangiopericytoma is a rare soft tissue tumour characterised by tightly packed tumour cells situated around thin walled endothelial lined vascular channels, ranging from capillary sized vessels to large gaping sinusoidal spaces. The tumour cells are surrounded by reticulin and are negative for muscle, nerve and epithelial markers. The diagnosis of extra-pulmonary intra-thoracic, extra-pleural mediastinal mass is difficult. It constitutes only 6% of all primary tumours and cysts of the mediastinum. We report the rare occurrence of primary intra-thoracic, extra-pulmonary mediastinal haemangiopericytoma of mesenchymal origin with perivascular localisation. The patient underwent right postero-lateral thoracotomy and post-operatively received chemotherapy with adriamycin (60 mg/m2) on day 1 and ifosfamide (1.5 g/m2) on day 1 to 3. Thirty-seven months after the operation, the patient has been well with evidence of a single recurrence in the left lower lobe.

Pulmonary blastoma in a young adult.

Pulmonary blastoma is a rare but aggressive malignancy of the lung comprising epithelial and mesenchymal elements that resemble fetal lung tissue. This report described a case of an 18-year-old male who presented with cough and weight loss for a month. Computed tomography (CT) of the thorax revealed a large mass with mixed solid and cystic lesions on the right side of chest along with pleural effusion and mediastinal lymphadenopathy. Massive debulking was performed followed by chemotherapy. A biphasic pulmonary blastoma was diagnosed on histopathology.

Hematological, immunological, and cardiovascular changes in individuals residing in a polluted city of India: a study in Delhi.

Exposure to poor air quality is associated with a multitude of hematological and immunological alterations. Cardio vascular diseases, rather than respiratory ailments, are the most important cause of death from air pollution exposure. Thus, hematological, immunological and cardiovascular alterations in healthy individuals exposed to vehicular pollution (one of the leading source of air pollution in growing metropolitan cities) are investigated in this study. A total number of 2218 (21-65 years old) adults residing in Delhi participated in this study. As control, 642 age and sex matched healthy subjects from the rural areas of Uttaranchal were enrolled. Arterial blood pressure (BP) was measured by a sphygmomanometer. Blood samples were collected and routine hematology was done. Lymphocyte subset analysis and platelet P-selectin expression was measured by flow cytometry. Air quality data was collected from Central and State Pollution Control Boards and was also measured onsite by portable, battery-operated laser photometer. The prevalence of hypertension was nearly 4-times higher in Delhi when compared to the control. Platelet P-selectin was remarkably upregulated in residents of Delhi. They had depleted number of CD4+ T-helper cells and CD19+ B cells but elevated level of CD56+ natural killer cells. Altered lymphocyte subtypes and increased number of P-selectin-positive platelets suggest altered immunity (that may compromise body's defense against infections) and hypercoagulable state, a risk factor for cardiovascular diseases. The current study has identified poor air quality of Delhi as a key contributor to several adverse health conditions experienced by the general population of the city, which not only makes the quality of life compromised but also put them at a greater risk of developing cardiovascular ailments later in life.

Role of magill forcep in retrieval of foreign body coin.

Children swallow coins more than any other object. Many methods for removal of impacted coins at the upper end of the oesophagus are enumerated in literature, each having it's own merits and demerits. This retrospective study in 100 consecutive paediatric patients presents a magill forcep technique for removal of coins under inhalational anaesthesia using Mc-Intosch laryngoscope. Intubation and rigid endoscopy both were avoided, thereby minimizing hospital stay and cost of treatment. This also decreases the chances of complications. Moreover the technique was found to be at par with rigid endoscopy in term of efficacy and safety. However interestingly statistical analyses of the data by 'Chi SquareTest' (ξ(2)) revealed the technique to be more applicable in younger age group i.e. 0-6 years.

Pulmonary nocardiosis presenting as fungal ball--a rare entity.

Pulmonary intracavitary infection caused by Nocardia is an opportunistic infection and is believed to be a rare entity. We describe a case report of a patient with culture positive Nocardia asteroides who presented with complaints of cough and expectoration with episodes of haemoptysis and dyspnoea. The diagnosis of nocardiosis was made by microscopic examination of the surgically resected portion of the lung and confirmed on culture.

Pulmonary fungal ball in non-immunocompromised patient: a case report.

Fungal ball caused by Aspergillus species is an opportunistic infection. We describe a case report of a patient with culture positive Aspergillus fumigatus who presented with complaints of cough and expectoration with recurrent episodes of haemoptysis. Tuberculosis is the commonest cause of haemoptysis in India. However fungal ball is also one of the leading cause of haemoptysis. Hence laboratory evaluation of haemoptysis should not only include work up for tuberculosis but sample should also be submitted for mycological evaluation.

Occupational benzene exposure from vehicular sources in India and its effect on hematology, lymphocyte subsets and platelet P-selectin expression.

Benzene exposure from vehicular sources and its health impact are relatively unexplored in India. We have investigated in this study hematology and lymphocyte subsets of 25 petrol pump attendants, 25 automobile service station workers and 35 controls matched for age, sex and socioeconomic conditions. The participants were non-smoking males of Kolkata (former Calcutta) in eastern India. Compared with controls, the workers had 3.8- times more trans,trans-muconic acid in urine, suggesting higher level of benzene exposure. The exposed subjects had decreased erythrocyte, hemoglobin, lymphocyte and platelet levels, but increased neutrophil, band cells, RBC aniso-poikilocytosis and target cells. In addition, CD4+, CD8+ and CD19+ cells were decreased by 37, 20 and 47% respectively, but CD 16+ 56+ NK cells were increased by 20%. P-selectin expression on platelet surface of the workers was significantly elevated (P < 0.05), indicating upregulation of platelet activity. In summary, the study revealed high level of benzene exposure from vehicular sources in India, and the exposed subjects had hematological and immunological alterations.

Uncommon parathyroid mediastinal cyst compressing the trachea.

Mediastinal parathyroid cyst is a rare cause of space occupying lesion in the mediastinum. No specific symptomatology may be attributed to the non-functioning parathyroid cyst. The diagnosis is rarely made before exploration. The cysts are thin walled, smooth, of varying sizes and contained clear, opalescent or haemorrhagic fluid. Histopathological examination reveals clusters of parathyroid cells dispersed in the wall of the cyst. Surgical removal is the treatment of choice and can be performed with minimal morbidity.

Platelet activation, upregulation of CD11b/ CD18 expression on leukocytes and increase in circulating leukocyte-platelet aggregates in Indian women chronically exposed to biomass smoke.

The majority of households in rural India still rely on unprocessed solid biomass for domestic energy. The aim of this study was to investigate whether chronic exposure to biomass smoke causes activation of leukocytes and the formation of leukocyte-platelet aggregates. We conducted flow cytometric analysis of beta2 Mac-1 integrin (CD11b/CD18) expression on polymorphonuclear leukocytes (PMN) and monocytes, and P-selectin (CD62P) expression on the platelets of 165 women from eastern India, who cook solely with wood, dung and agricultural wastes, and 155 age- and socio-economic condition-matched control subjects, who used relatively cleaner fuel, liquefied petroleum gas (LPG). Leukocyte-platelet aggregates were defined as CD11b-positive PMN and monocytes co-expressing platelet-specific markers CD41 or CD62P. A significant increase in leukocyte-platelet aggregates was found in women who used biomass as cooking fuel. In addition, they showed increased surface expression of CD11b/CD18 in circulating PMN and monocytes and CD62P expression on platelets. The mean fluorescence intensity (MFI) of CD11b on the surface of circulating monocytes and PMN of biomass users increased by 50 and 68%, respectively. Similarly, a 62 and 48% increase in MFI was observed in CD18 expression on the surface of these cells in biomass users. The results show that chronic biomass smoke exposure activates circulating platelets, PMN and monocytes, and increases the number of leukocyte-platelet aggregates, which are considered a risk factor for thrombosis.

Pure red cell aplasia associated with thymoma.

A case of thymoma with mixed spindle and lymphocytic variety along with acquired, secondary, chronic pure red cell aplasia is an uncommon entity. The presented case is a case of anterior mediastinal tumour with marked anemia. On histopathologic and hematological examinations, it proved to be a case of thymoma along with pure red cell aplasia. High index of suspicion, bone marrow examination, radiological including CT scan examination, total thymectomy after preparation with repeated blood transfusion remains the mainstay of treatment. Prolonged corticosteroid therapy leads to remission for upto ten months after operative intervention.

Abundance of siderophages in sputum: indicator of an adverse lung reaction to air pollution.

OBJECTIVE: To investigate the lung response to traffic-related air pollution by enumerating hemosiderin-laden alveolar macrophages (AM) in sputum. STUDY DESIGN: Sputum samples were collected from 103 urban adult males from Calcutta chronically exposed to automobile exhaust. Forty-nine rural individuals served as controls. AM were identified by nonspecific esterase staining. Perl's Prussian blue technique was employed for the detection of hemosiderin-laden AM (siderophages). RESULTS: The urban group, consisting of 31 traffic officers, 25 automobile service station workers and 47 street hawkers, had seven times more AM in their sputum than did the matched controls. Besides, a remarkable rise (27-fold) in the number of siderophages in sputum was observed in urban individuals. Smoking further elevated the AM count and number of siderophages. CONCLUSION: Abundant siderophages in the urban group may indicate the toxic effect of airborne pollutants on the lung, leading to phagocytosis of destroyed cells, including erythrocytes, and accumulation of iron in AM. Enumeration of siderophages in sputum appears to be a simple, noninvasive, inexpensive cytochemical technique well suited to preliminary assessment of the adverse effects of air pollution on the lungs in large, population-based studies, especially in developing countries.

Preimmunization anti-pneumococcal antibody levels are protective in a majority of patients with cystic fibrosis.

OBJECTIVE: Although invasive pneumococcal disease is infrequent in cystic fibrosis (CF), it is recommended that all patients with CF receive pneumococcal immunization. As part of a comprehensive program to immunize our clinic population, we obtained preimmunization anti-pneumococcal antibody levels. We hypothesized that the percentage of CF patients without protective levels of anti-pneumococcal antibody levels would be high, as they are exposed to frequent antibiotic therapy that may eradicate organisms before generation of an antibody response. METHODS: An observational study of 100 patients with CF, aged 1 to 39 years, was conducted in a regional CF center. Preimmunization anti-pneumococcal antibody levels against 6 serotypes were measured by enzyme-linked immunosorbent assay. Protective antibody levels were defined as >200 ng/mL. RESULTS: A majority of CF patients-61% to 100%, depending on age and serotype-had protective levels of pneumococcal antibody. There was a significant positive correlation between antibody level and age for 5 of the 6 serotypes tested. CONCLUSIONS: In contradistinction to our hypothesis, the majority of CF patients have protective preimmunization anti-pneumococcal antibody levels. However, a significant proportion-between 17% and 39%, depending on the serotype-did not exhibit adequate levels. Therefore, we concur with current recommendations for pneumococcal immunization in CF.

Endoscopic sinus surgery in cystic fibrosis: do patients benefit from surgery?

OBJECTIVE: To examine the effects of endoscopic sinus surgery on the pulmonary status of cystic fibrosis (CF) patients through the objective parameters of steroid use, pulmonary function tests (PFTs), and inpatient hospital days (IHDs). METHODS: Retrospective chart review of all patients with CF who underwent endoscopic sinus surgery from 1993 to 1999 at a tertiary care children's hospital. Preoperative pulmonary function, inhaler and steroid use, and IHDs were compared to postoperative parameters within a 1-year period. RESULTS: Sixty-six patients, including eight lung transplant patients, underwent a total of 112 endoscopic sinus surgery procedures; 25 patients underwent more than one procedure. Patients were taking oral steroids preoperatively in 28% of procedures and inhaled steroids in 40%. Postoperatively, there was no statistically significant change in oral or inhaled steroid use, or in postoperative pulmonary function. If the index hospitalization, which was often for reasons not related to sinus disease, was considered part of the preoperative time period, endoscopic sinus surgery (ESS) was noted to result in a marked reduction (9.5 days (adjusted), P=0.001) in hospital days during the subsequent 6 months. If the date of the procedure alone was used to define pre- and postoperative time periods, the reduction in postoperative days was more modest and not statistically significant (3.5 days (adjusted), P=0.21). CONCLUSIONS: Although we found no statistically significant difference in PFTs, or steroid requirements following ESS, ESS may have resulted in a reduced need for hospitalization in the 6 months following the procedure. Future prospective studies in a larger number of patients and using more detailed outcome measures are needed to better evaluate the effects of endoscopic sinus surgery in pediatric patients with CF.

Pulmonary mucoraceous fungal ball.

A case of opportunistic pulmonary infection in the form of fungal ball produced by the family of mucoraceae in the class of phycomycetes having nonseptate hyphae (cellophane tubules) with haphazard branching in a post-tubercular immunocompetent patient is described. Clinical course was chronic with right upper lobe cavity invaded by fungi of mucor species, pathology was granuloma with blood vessel thrombosis, and a fungus ball. The host had no associated predisposing diseases. Segmental resectional surgery of the right upper lobe along with removal of fungus ball under the coverage of modified dose of amphotericin B was performed. Literature scanning revealed rarity of mucormycosis in immunocompetent host.

Selected contribution: synergism between TNF-alpha and IL-1 beta in airway smooth muscle cells: implications for beta-adrenergic responsiveness.

In human cultured airway smooth muscle cells, interleukin (IL)-1 beta increases cyclooxygenase (COX)-2 expression and PGE(2) release, ultimately resulting in decreased beta-adrenergic responsiveness. In this study, we aimed to determine whether tumor necrosis factor-alpha (TNF-alpha) synergizes with IL-1 beta in the induction of these events. TNF-alpha alone, at concentrations up to 10 ng/ml, had no effect on COX-2 protein expression; at concentrations as low as 0.1 ng/ml, it significantly enhanced the ability of IL-1 beta (0.2 ng/ml) to induce COX-2 and to increase PGE(2) release. IL-1 beta and TNF-alpha in combination also significantly enhanced COX-2 promoter activity, indicating that synergism between the cytokines is mediated at the level of gene transcription. Although IL-1 beta and TNF-alpha each increased nuclear factor-kappa B activation and induced extracellular regulated kinase and p38 phosphorylation, combined administration of the cytokines did not enhance either nuclear factor-kappa B or mitogen-activated protein kinase activation. Combined administration of IL-1 beta (0.2 ng/ml) and TNF-alpha (0.1 or 1.0 ng/ml) reduced the ability of isoproterenol to decrease human airway smooth muscle cell stiffness, as measured by magnetic twisting cytometry, even though individually these cytokines, at these concentrations, had no effect on isoproterenol responses. Treatment with the selective COX-2 inhibitor NS-398 abolished the synergistic effects of TNF-alpha and IL-1 beta on beta-adrenergic responsiveness. Our results indicate that low concentrations of IL-1 beta and TNF-alpha synergize to promote beta-adrenergic hyporesponsiveness and that effects on COX-2 expression and PGE(2) are responsible for these events. The data suggest that the simultaneous release in the airway, of even very small amounts of cytokines, can have important functional consequences.

Interleukin-6 family cytokines: signaling and effects in human airway smooth muscle cells.

Interleukin (IL)-1beta induces cyclooxygenase (COX)-2 expression and prostanoid formation in cultured human airway smooth muscle (HASM) cells. In other cell types, IL-6 family cytokines induce COX-2 or augment IL-1beta-induced COX-2 expression. The purpose of this study was to determine whether IL-6 family cytokines were involved in COX-2 expression in HASM cells. RT-PCR was used to demonstrate that the necessary receptor components for IL-6-type cytokine binding are expressed in HASM cells. IL-6 and oncostatin M (OSM) each caused a dose-dependent phosphorylation of signal transducer and activator of transcription-3, whereas IL-11 did not. IL-6, IL-11, and OSM alone had no effect on COX-2 expression. However, OSM caused dose-dependent augmentation of COX-2 expression and prostaglandin (PG) E(2) release induced by IL-1beta. In contrast, IL-6 and IL-11 did not alter IL-1beta-induced COX-2 expression. IL-6 did increase IL-1beta-induced PGE(2) formation in unstimulated cells but not in cells stimulated with arachidonic acid (AA; 10(-5) M), suggesting that IL-6 effects were mediated at the level of AA release. Our results indicate that IL-6 and OSM are capable of inducing signaling in HASM cells. In addition, OSM and IL-1beta synergistically cause COX-2 expression and PGE(2) release.

p38 MAP kinase regulates IL-1 beta responses in cultured airway smooth muscle cells.

We have previously reported that interleukin (IL)-1 beta causes beta-adrenergic hyporesponsiveness in cultured human airway smooth muscle (HASM) cells by increasing cyclooxygenase (COX)-2 expression. The purpose of this study was to determine whether p38 mitogen-activated protein (MAP) kinase is involved in these events. IL-1 beta (2 ng/ml for 15 min) increased p38 phosphorylation fourfold. The p38 inhibitor SB-203580 (3 microM) decreased IL-1 beta-induced COX-2 by 70 +/- 7% (P < 0.01). SB-203580 had no effect on PGE(2) release in control cells but caused a significant (70-80%) reduction in PGE(2) release in IL-1 beta-treated cells. IL-1 beta increased the binding of nuclear proteins to the oligonucleotides encoding the consensus sequences for activator protein (AP)-1 and nuclear factor (NF)-kappa B, but SB-203580 did not affect this binding, suggesting that the mechanism of action of p38 was not through AP-1 or NF-kappa B activation. The NF-kappa B inhibitor MG-132 did not alter IL-1 beta-induced COX-2 expression, indicating that NF-kappa B activation is not required for IL-1 beta-induced COX-2 expression in HASM cells. IL-1 beta attenuated isoproterenol-induced decreases in HASM stiffness as measured by magnetic twisting cytometry, and SB-203580 abolished this effect. These results are consistent with the hypothesis that p38 is involved in the signal transduction pathway through which IL-1 beta induces COX-2 expression, PGE(2) release, and beta-adrenergic hyporesponsiveness.

Air pollution in Calcutta elicits adverse pulmonary reaction in children.

BACKGROUND & OBJECTIVE: Pulmonary responses of children chronically exposed to ambient air pollution in Calcutta have been investigated. METHODS: A total number of 153 children from Calcutta and 116 from rural West Bengal in the age group of 6-17 yr were included in this study. Respiratory symptom complex, sputum cytology and micronucleus (MN) count of buccal epithelial cells were evaluated. Blood smears were examined for WBC differential count and RBC morphology. RESULTS: Marked rise in respiratory symptoms (43% in urban vs 14% in rural) and sputum alveolar macrophage (AM) number was observed in urban children compared to their rural counterparts (14.2 +/- 1.4 AM/hpf vs 6.7 +/- 1.4 AM/hpf, mean +/- SE, P < 0.001). The urban group also demonstrated increased numbers of neutrophils, eosinophils and iron-laden AM in their sputum. Besides, buccal epithelial cells of urban children exhibited higher MN frequency than their rural counterparts (0.22 vs 0.17%, P < 0.05). While sputum neutrophilia and eosinophilia suggest inflammatory and allergic lung reactions, elevated MN count is indicative of greater genotoxic effect on the exposed tissues of urban children. Hypochromic red cells in peripheral blood smear was a common finding in both urban and rural groups, but eosinophils and monocytes were present in elevated frequencies in the rural children. INTERPRETATION & CONCLUSION: The study demonstrated that children inhaling grossly polluted air of Calcutta suffer from adverse lung reactions and genetic abnormality in the exposed tissues.