Clinico-Radiologic and Spirometric Profile of an Indian Population with Post-Tuberculous Obstructive Airway Disease.

INTRODUCTION: Tuberculosis is a public health problem in developing countries and in spite of receiving adequate anti-tuberculous therapy, patients often continues to have several post-tuberculous sequelae, especially airflow limitation. AIM: To evaluate pulmonary function by spirometry among post-tuberculosis cases with airway obstruction and their relationship with smoking. MATERIALS AND METHODS: All patients who presented to the pulmonary medicine Outpatient Department (OPD) with symptoms of obstructive airway disease and had completed adequate anti-tuberculous therapy for pulmonary tuberculosis were taken up for study. They were initially evaluated with sputum smear for Acid Fast Bacilli (AFB) and chest X-ray. Patients without evidence of active tuberculosis underwent spirometry and those having post-bronchodilator Forced Expiratory Volume in first second (FEV1)/ Forced Vital Capacity (FVC) FEV1/FVC<0.7 were taken up for final analysis. Spirometric parameters were compared between smokers and non-smokers. RESULTS: Out of 138 finally selected cases, 84.06% were male and 71.01% were within age range of 40-69 years. Significant positive association was found between extent of radiologic lesion and severity of airflow obstruction. Purely obstructive pattern was found in 27.54% cases and 72.46% showed mixed pattern. Patients with mixed ventilatory abnormality had worse pulmonary function and poorer bronchodilator reversibility than patients with pure obstruction. Comparison of post-bronchodilator FEV1, FVC, Peak Expiratory Flow (PEF) and Forced Expiratory Flow (FEF) 25-75 between smokers and non-smokers did not show statistically significant difference. CONCLUSION: Majority of patients with post-tuberculous obstructive airway disease have associated restrictive component. But smoking did not cause significant alteration in pulmonary function among such patients.

Calvarial Tuberculosis in a Preschool-Aged Child: An uncommon entity.

Calvarial tuberculosis is a rare manifestation of tuberculosis, especially in children under five years of age. We report a two-and-a-half-year-old male child who presented to the Nilratan Sircar Medical College, Kolkata, India, in 2015 with frontoparietal fluctuant swelling of three months' duration. He had also had chronic sinus discharge from the left lower eyelid over the previous six months. Computed tomography of the head revealed a frontal swelling along with erosion of both the outer and inner plates of the left frontal bone. Fine needle aspiration of the pus indicated the presence of acid-fast bacilli. Unfortunately, no primary focus of tuberculosis could be established. The patient improved after one year of antitubercular therapy without requiring any surgical intervention and with no sign of subsequent disease recurrence.

Superior Vena Cava Syndrome due to Thrombosis: A Rare Paraneoplastic Presentation of Bronchogenic Carcinoma.

Superior vena cava (SVC) syndrome is not an uncommon occurrence in patients with malignancy and it is often described as a medical emergency. In majority of the cases, SVC syndrome occurs due to mechanical obstruction of the SVC by extraluminal compression with primary intrathoracic malignancies. However, intraluminal obstruction due to thrombosis can also produce symptoms and signs of SVC syndrome. Clot-related SVC obstruction is mostly associated with indwelling central venous catheter and pacemaker leads, although such thrombosis can occur spontaneously in a background of a hypercoagulable state, e.g., malignancy. Here, an unusual case of sudden onset SVC syndrome has been reported, which on initial radiologic evaluation was found to have a lung nodule without any significant mediastinal mass or adenopathy compressing SVC. Subsequent investigation with Doppler ultrasonography of the neck showed thrombosis in the right internal jugular, right subclavian and right brachiocephalic vein, which was responsible for SVC syndrome. Histopathological evaluation of lung nodule confirmed presence of an adenocarcinoma. Therefore, venous thromboembolism as a paraneoplastic syndrome should be kept in mind while evaluating a case of SVC obstruction in a cancer patient. Management of the underlying disease is of prime importance in such cases and anticoagulation is the mainstay of therapy. Ability to identify paraneoplastic syndrome may have a significant effect on clinical outcome, ranging from early diagnosis to improved quality of life of the patient.

Renal Tuberculosis Presenting as a Mass Lesion in a Two-year-old Girl: Report of a rare case.

Genitourinary tuberculosis usually occurs in young adults and the middle-aged and is very uncommon in the paediatric population. It generally presents with haematuria, pyuria, irritative voiding symptoms and flank pain; presentation as a renal mass is highly unusual. We report a two-year-old girl who was referred to the Nil Ratan Sircar Medical College, Kolkata, India, in June 2014 with abdominal pain. Subsequent radiological investigations revealed a left renal hypoechoic mass lesion. A left nephroureterectomy was performed on suspicion of a Wilms' tumour. Histopathology indicated an epithelioid granuloma with lymphocytic infiltration, suggestive of a tubercular aetiology. A Mantoux tuberculin skin test was positive; however, there was no evidence of tuberculosis detected elsewhere in the body and the source of the infection could not be identified. A diagnosis of renal tuberculosis was made and the child was treated with antitubercular drugs. The patient was asymptomatic at a six-month follow-up.

Interstitial Lung Disease in Systemic Scleroderma, Complicated with Bilateral Pulmonary Aspergilloma: An Unusual Association.

Aspergilloma or mycetoma is a saprophytic fungal infection that colonizes pre-existing excavated lung lesion. However, its association with systemic sclerosis related interstitial lung disease is unusual and scarcely found in literature. We report a middle aged female with long standing systemic sclerosis, who was on immunosuppressive therapy for many years, presented with repeated haemoptysis. Although provisionally pulmonary tuberculosis was suspected, imaging investigations showed presence of bilateral masses inside bullous air spaces along with air-crescent sign suggestive of fungal ball. Subsequent Computed tomography guided needle aspiration from lung mass confirmed Aspergillus fumigatus as aetiologic agent on fungal culture. Patient was treated conservatively for haemoptysis and with oral antifungal drug as surgical removal of fungal ball was not an option due to poor pulmonary reserve. Although she had been treated with itraconazole for more than three years, she had recurrent haemoptysis during this period without any significant regression of size of the aspergilloma. Management of aspergilloma in a background of extensive interstitial lung disease remains poorly defined and complicated. Thereby, overall prognosis is unfavourable and depends on evolution of both underlying scleroderma as well as aspergilloma.

Misdiagnosed case of bronchial carcinoid presenting with refractory dyspnoea and wheeze: a rare case report and review of literature.

A 59-year-old male smoker presented with persistent wheezing and occasional coughing that had been ongoing for two years and had been unsuccessfully treated with an inhalational ß2 agonist, an anticholinergic and an inhalational steroid in the last year. On clinical examination, a left-sided wheeze was detected. The initial chest X-ray was normal. A computed tomography (CT) scan of thorax demonstrated a mass lesion in the left main bronchus. On subsequent bronchoscopy, an endobronchial polypoid mass was detected in the left main bronchus, completely occluding the bronchial lumen. A biopsy taken from the mass revealed features of bronchial carcinoid. Bronchial carcinoid can present uncommonly with wheezes, resulting in misdiagnosis as bronchial asthma or chronic obstructive pulmonary disease (COPD). If an asthma or COPD patient does not respond to conventional therapy, a CT scan and subsequent bronchoscopy is warranted.