Imaging Approach to Pulmonary Infections in the Immunocompromised Patient.

Pulmonary infections are the major cause of morbidity and mortality in immunocompromised patients and almost one-third of intensive care unit patients with pulmonary infections belong to the immunocompromised category. Multiple organisms may simultaneously infect an immunocompromised patient and the overwhelming burden of mixed infections further predisposes critically ill patients to acute hypoxemic respiratory failure. Notwithstanding that lung ultrasound is coming into vogue, the primary imaging investigation is a chest radiograph, followed by thoracic CT scan. This review based on our experience at tertiary care teaching hospitals provides insights into the spectrum of imaging features of various pulmonary infections occurring in immunocompromised patients. This review is unique as, firstly, the imaging spectrum described by us is categorized on basis of the etiological infective agent, comprehensively and emphatically correlated with the clinical setting of the patient. Secondly, a characteristic imaging pattern is emphasized in the clinical setting-imaging-pattern conglomerate, to highlight the most likely diagnosis possible in such a combination. Thirdly, the simulating conditions for a relevant differential diagnosis are discussed in each section. Fourthly, not only are the specific diagnostic and tissue sampling techniques for confirmation of the suspected etiological agent described, but the recommended pharmaco-therapeutic agents are also enumerated, so as to provide a more robust insight to the radiologist. Last but not the least, we summarize and conclude with a diagnostic algorithm, derived by us from the characteristic illustrative cases. The proposed algorithm, illustrated as a flowchart, emphasizes a diagnostic imaging approach comprising: correlation of the imaging pattern with clinical setting and with associated abnormalities in the thorax and in other organs/systems, which is comprehensively analyzed in arriving at the most likely diagnosis. Since a rapid evaluation and emergent management of such patients is of pressing concern not only to the radiologist, but also for the general physicians, pulmonologists, critical care specialists, oncologists and transplant surgery teams, we believe our review is very informative to a wide spectrum reader audience.

Diagnostic accuracy and feasibility of portable sleep monitoring in patients with obstructive sleep apnea: Re-exploring the utility in the current COVID-19 pandemic.

Portable sleep monitoring (PSM) is a promising alternative diagnostic tool for Obstructive Sleep Apnea (OSA) especially in high burden resource limited settings. We aimed to determine the diagnostic accuracy and feasibility of PSM device-based studies in patients presenting for evaluation of OSA at a tertiary care hospital in North-India. PSM studies (using a Type-III PSM device) were compared for technical reliability and diagnostic accuracy with the standard laboratory-based Type-I polysomnography (PSG). Patients were also interviewed about their experience on undergoing an unsupervised PSM studies. Fifty patients (68% males) were enrolled in the study, of which only 30% patients expressed their concerns about undergoing unsupervised PSM studies which included safety issues, ease of use, diagnostic accuracy, etc. Technical acceptability criteria were easily met by the PSM studies with signal loss in 12% studies (complete data loss and inaccessible data in 6% studies), warranting repetition sleep studies in four patients. The overall sensitivity of PSM device (AHI ≥5) was 93.5% (area under curve; AUC: 0.87). The diagnostic accuracy was 68.5%, 80%, and 91.4% for mild, moderate, and severe cases of OSA, respectively. An overall strong correlation was observed between PSM-AHI (apnoea-hypopnoea index) and PSG (r>0.85, p≤0.001), especially in severe OSA. The observed sensitivity was >90% for AHI>20 (clinically significant OSA), with high specificity of 91% for severe OSA (AUC: 0.94, 0.97 for AHI>20, AHI>30 respectively). The overall Bland-Altman concordance analysis also demonstrated only a small dispersion for PSM studies with a Cronbach's coefficient of 0.95. Therefore, there is good diagnostic accuracy as well as feasibility of home-based portable sleep studies in Indian patients. It can be promoted for widespread use in high burden countries like India for diagnosing and managing appropriately selected stable patients with high clinical probability of OSA, especially during the ongoing crises of COVID-19 pandemic.

Awake proning in Covid-19 pneumonia.

Not available.

Clinical and epidemiologic profile of the initial COVID-19 patients at a tertiary care centre in India.

COVID-19 has now become a pandemic. It has spread from Wuhan, China, in December 2019 to a large number of countries within three months. The objective of this work is to report the initial experience with epidemiologic and clinical features, as well as with the management of COVID-19 patients in India. This is a descriptive case series of the first 21 COVID-19 infected patients confirmed with polymerase chain reaction (PCR) and admitted to a tertiary care centre in India from 01.02.2020 to 19.03.2020. Clinical, laboratory, and radiologic data were collected, including age, sex, nationality, travel history, symptoms, duration of stay, and comorbidities. The mean age of the population was 40.3 years with a male preponderance. Thirteen (62%) patients had recent travel history outside India in the previous 30 days, two thirds of whom had travelled to Italy. The most common symptoms were fever and cough (42.9%) followed by sore throat, headache and breathlessness. Vital and laboratory parameters were preserved in all patients and none of them required ventilatory support. Among the first 21 patients diagnosed with COVID-19 infection in India, the typical clinical presentation consisted in a mild upper respiratory tract infection predominantly affecting the young male population. One patient required supplemental oxygen. All patients recovered with no residual symptoms.   *The Safdarjung Hospital COVID 2019 working group: Nitesh Gupta, Sumita Agrawal, Pranav Ish, Suruchi Mishra, Rajni Gaind, Ganapathy Usha, Balvinder Singh, Manas Kamal Sen, Shibdas Chakrabarti (Consultant and Head, Pulmonary Medicine); NK Gupta (Professor, Pulmonary medicine); Dipak Bhattacharya (Consultant, Pulmonary medicine); Rohit Kumar (Assistant Professor, Pulmonary Medicine); Siddharth R. Yadav (Assistant Professor, Pulmonary Medicine); Rushika Saksena (Specialist, Microbiology); Rojaleen Das (Assistant Professor, Microbiology); Vikramjeet Dutta (Assistant Professor, Microbiology); Anupam Kr Anveshi (Senior Resident, Microbiology); Santvana Kohli (Assistant Professor, Anaesthesiology); Naveen KV (Assistant Professor,  Anaesthesiology); Amandeep Jaswal (Assistant Professor, Anaesthesiology).

Fatal pulmonary infection by trimethoprim-sulfamethoxazole resistant Nocardia otitidiscaviarum: report of two cases and review.

INTRODUCTION: Nocardia otitidiscaviarum is a rare cause of human infections, mostly causing cutaneous and lymphocutaneous infections of mild severity. We report two cases of fatal pulmonary infection caused by Nocardia otitidiscaviarum in elderly patients. METHODOLOGY: Case 1: A 70-year old woman presented with fever and cough with expectoration for a month. On physical examination, she had tachypnea and inspiratory crepitations in bilateral basal regions. Case 2: A 74-year old man presented with productive cough with foul smelling expectoration, fever and shortness of breath for one week. On examination, he had tachypnea, bilateral wheezing and inspiratory crepitations. In both cases, sputum was sent to microbiology laboratory. On direct microscopy Gram-positive, finely branching filaments were observed which were acid fast with 1% sulphuric acid. Chalky white opaque wrinkled colonies with musty basement type odour were seen on blood agar. Both patients were treated empirically with trimethoprim-sulfamethoxazole for Nocardia infection after notification of microscopy findings however both expired on Day 2 and Day 5 of admission, respectively. Both isolates were susceptible to amikacin, linezolid, ciprofloxacin and gentamicin. They were resistant to trimethoprim-sulfamethoxazole, ampicillin, amoxicillin-clavulanic acid, erythromycin, and imipenem. Based on biochemical identification and antimicrobial susceptibility pattern, the organism was identified as Nocardia otitidiscaviarum. The identification was confirmed using MALDI-TOF (Vitek MS, Biomerieux, France). CONCLUSION: Our report highlights the importance of early identification of Nocardia to species level to improve treatment outcomes especially in critically ill patients. Mass spectrometry can become an integral part of diagnostic algorithms for nocardiosis.

Utility of bedside lung ultrasound for assessment of lung recruitment in a case of acute respiratory distress syndrome.

Lung recruitment maneuvers are rescue measures commonly used to improve oxygenation in severely hypoxemic patients with acute respiratory distress syndrome (ARDS), who fail to improve on standard treatment. After recruitment, appropriate level of positive end-expiratory pressure (PEEP) is applied to prevent alveolar de-recruitment during expiration. Computed tomography scan of thorax and quasi-static pressure-volume curves have played a pivotal role are important in the assessment of recruitment, but they have several limitations. Lung ultrasound (LUS), which is now easily available in nearly every Intensive Care Unit, could be an attractive alternative method for assessing lung recruitment. It is noninvasive, easily repeatable and is devoid of radiation hazards. We are presenting a case of 24-year-old female patient with moderate ARDS in whom bedside LUS was successfully used into assessing lung recruitment as well as into determining the appropriate level of PEEP.

Neurocognitive and behavioral abnormalities in Indian children with sleep-disordered breathing before and after adenotonsillectomy.

OBJECTIVES: Children with untreated sleep-disordered breathing (SDB) have impaired intellectual ability and behavioral effects. Timely treatment of SDB by adenotonsillectomy (AT) may prevent this morbidity. This study was designed to assess the prevalence of neurocognitive and behavioral dysfunction in Indian children with SDB and to evaluate the impact of AT. METHODS: Children recruited underwent diagnostic polysomnography (PSG), a detailed neurocognitive and behavioral assessment using a battery of validated instruments - the Malin's Intelligence Scale (MIS) for Indian children, Modified Wisconsin's Card Sorting Test, Parent Conners' Scale, and the Childhood Behavior Checklist (6-18). These children then underwent AT and subsequent reassessment at 3 and 6 months. RESULTS: Neurocognitive impairment was common among the 33 enrolled children (mean age 9 [±2.97] years; 78.8% males). There was a significant correlation between the lowest O2saturation and the "categories completed" (r = -0.379; P = 0.029); and the lowest O2saturation and the "failure to maintain sets" (r = 0.386; P = 0.026) of the Modified Wisconsin's Card Sorting Test. Postsurgery, although apnea-hypopnea index (AHI) significantly decreased after surgery, 15 children still had SDB. Mean scores of most of the tested neurocognitive and behavioral domains showed improvement, although residual deficits were prevalent even after 6 months. Patients with a baseline AHI >5/h and those who had complete resolution of SDB (postoperative AHI <1/h) showed improvement in more subscales than patients with baseline AHI < 5/h and patients with incomplete resolution of SDB. CONCLUSION: The decreased neurocognitive performance related to SDB may be a result of hypoxemia, rather than the frequency of SDB events. Despite AT, residual disease is common and such patients may require further treatment.

A rare case of squamous cell carcinoma lung with multiple locoregional recurrences and histological transformation.

A 52-year-old female nonsmoker with localized squamous cell carcinoma (T3N1M0) of lung underwent lobectomy with adjuvant chemotherapy. Two years later, the patient had her first locoregional recurrence with adenosquamous cell carcinoma, and pneumonectomy with adjuvant chemotherapy rendered her disease free. Subsequent isolated locoregional recurrence with squamous cell carcinoma 18 months later was treated with chemoradiotherapy and had a complete response. Patient yet again had locoregional recurrence after 4 years and had progressive disease despite subsequent multiple line of treatment with platinum-based chemotherapy, stereotactic body radiation therapy, and nivolumab. This case is unique in presentation due to prolonged survival with multiple line of treatment of recurrent locoregional tumor without distant metastasis and alteration in the histology of tumor during illness.

Comparison of diagnostic yield and safety profile of radial endobronchial ultrasound-guided bronchoscopic lung biopsy with computed tomography-guided percutaneous needle biopsy in evaluation of peripheral pulmonary lesions: A randomized controlled trial.

BACKGROUND: Peripheral pulmonary lesions (PPLs) pose a diagnostic challenge, and the optimal investigation in many such cases remains unclear. Computed tomography (CT)-guided percutaneous needle biopsy (CT-PNB) has been the modality of choice for such lesions with a high diagnostic accuracy but with high rates of pneumothorax. Endobronchial ultrasound (EBUS) with a radial probe is an alternate diagnostic modality with increased diagnostic yield of bronchoscopy in the evaluation of PPL. We conducted a randomized controlled trial comparing the diagnostic accuracy and complication rates of radial EBUS with CT-guided lung biopsy for the evaluation of PPL. METHODS: Fifty patients with PPL surrounded by lung parenchyma on all sides were randomly assigned to either radial EBUS or CT-PNB group (25 each). RESULTS: Both groups had similar clinicoradiologic characteristics. The diagnostic accuracy of radial EBUS was comparable to CT-PNB with no statistically significant difference (72 vs. 84%; P = 0.306). However, the yield was significantly lower in right upper lobe lesions (20% vs. 83.3%; P = 0.03). CT-PNB group had significantly higher pneumothorax rates than radial EBUS (20% vs. 0%; P = 0.03). The lesions that were more than 2 cm, those with ultrasound feature of continuous hyperechoic margin around the lesion (P = 0.007), and the position of the ultrasound probe within the lesion (P < 0.001) were associated with a higher diagnostic yield with radial EBUS. CONCLUSION: Our findings suggest that radial EBUS is a safer investigation than CT-PNB with a comparable diagnostic accuracy for PPL not abutting the chest wall (CTRI/2017/02/007762).

Metabolic changes in normal- and underweight children with obstructive sleep-disordered breathing.

OBJECTIVE: This study evaluates the metabolic profile of normal- and underweight children with sleep-disordered breathing (SDB) due to adenotonsillar hypertrophy. METHODS: A total of 39 children aged 3-15 years with SDB and 28 age- and gender-matched controls were included in the study. Body mass index z score, blood pressure, and fasting serum levels of triglycerides (TGs), high-density lipoprotein (HDL), low-density lipoprotein (LDL), total cholesterol, very-low-density lipoprotein (VLDL), blood glucose, plasma insulin, and homeostatic model assessment (HOMA) were determined in both case patients and controls. RESULTS: We observed significantly lower levels of fasting blood glucose (p = 0.015) and higher levels of HDL (p = 0.002), LDL (p = 0.002), and cholesterol (p = 0.001) in case patients than in controls. The mean values of fasting insulin and HOMA were higher in case patients (6.42 ± 6.47 and 1.40 ± 1.48) than in controls (5.31 ± 3.40 and 1.20 ± 0.84) respectively. No direct correlation between indices of severity of SDB and various metabolic and blood pressure parameters was found. When the effect of body weight was studied by subgrouping case patients according to normal weight and underweight, significant increases in the levels of fasting insulin (p = 0.039), HOMA (p = 0.017), and fasting blood glucose (p = 0.021) were observed. Also, a significant correlation was observed between the duration of illness and fasting insulin (p = 0.023), HOMA (p = 0.020), fasting glucose (p = 0.004), and diastolic blood pressure (p = 0.030). CONCLUSION: This study shows an independent effect of body weight and duration of illness on various metabolic and blood pressure parameters in normal- and underweight children with SDB.

Diagnosis of extrapulmonary tuberculosis by smear, culture, and PCR using universal sample processing technology.

Definitive and rapid diagnosis of extrapulmonary tuberculosis is challenging since conventional techniques have limitations. We have developed a universal sample processing (USP) technology for detecting mycobacteria in clinical specimens. In this study, this technology was evaluated blindly on 99 extrapulmonary specimens collected from 87 patients. USP-processed specimens were submitted to smear microscopy for detection of acid-fast bacilli (AFB), culture, and two PCR tests targeting devR (Rv3133c) and IS6110 gene sequences. On the basis of clinical characteristics, histology and cytology, conventional microbiology results, and response to antitubercular therapy, 68 patients were diagnosed with tuberculosis. Although USP smear and culture were significantly superior to conventional microbiology, which was not optimized (P < 0.0001), these approaches fell short of PCR tests (P < 0.0001). The low yields by smear and culture are attributed to the paucibacillary load in the specimens. The highest sensitivity in PCR was achieved when devR and IS6110 test results were combined; the sensitivity and specificity values were 83 and 93.8%, 87.5 and 100%, and 66.7 and 75%, respectively, in pleural fluid, needle-biopsied pleural tissue, and lymph node specimens. In conclusion, the application of USP technology, together with clinicopathological characteristics, promises to improve the accuracy and confidence of extrapulmonary tuberculosis diagnosis.

Polymerase chain reaction to identify mycobacterium tuberculosis in patients with tuberculous lymphadenopathy.

Tuberculous lymphadenopathy is often diagnosed and treated on clinical and cytopathological grounds as Mycobacterium tuberculosis remains undetected in tissue specimens from such patients. At times, lymph nodes are known to respond sluggishly to and reappear during antitubercular therapy. We report a polymerase chain reaction-based approach to confirm the presence of M. tuberculosis in 4 such patients.