Abhishek Goyal

Association of Sleep Disordered Breathing with Mono-Symptomatic Nocturnal Enuresis: A Study among School Children of Central India

Objective To study the prevalence of primary monosymptopomatic nocturnal enuresis (PMNE) in children aged 5–10 year and to find its association with sleep disordered breathing (SDB) by using a 22 item pediatric sleep related breathing disorder (SRBD) scale. Methods This was a school based cross sectional epidemiological study from July 2015 to November 2015. A questionnaire seeking information on socio-demographic variables, nocturnal enuresis (NE) frequency, school performance and a validated 22 item pediatric sleep related breathing disorder scale (SRBDs) was distributed to 1820 pupils in three primary schools. Results A total of 1528(83.95%) questionnaires were retrieved. Out of 1528 forms, 182(11.9%) forms were incomplete for requested information and hence 1346 (73.9%) questionnaires were finally analyzed. The prevalence of NE was found to be 12.7% (95% CI; 11–14.6), whereas prevalence of primary nocturnal enuresis (PMNE) was 8.2% (95% CI; 7.1–10.1). SRBD scale score >0.33 (adjusted OR: 2.87; 95%CI: 1.67–4.92), paternal history of enuresis in childhood (adjusted OR:4.96; 95% CI: 2.36–10.45), and inappropriate toilet training (adjusted OR: 1.64; 95% CI: 1.01–2.66) were independently associated with PMNE. Conclusion Sleep disordered breathing, inappropriate toilet training and a history of childhood NE in father were found to be significant risk factors for PMNE in the present study. Thus, these findings suggest that it is imperative to rule out SDB in PMNE patients as they may require different therapeutic interventions.

Pulmonary Alveolar Microlithiasis: A commonly misdiagnosed rare entity

Pulmonary alveolar microlithiasis (PAM) is an uncommon entity which can pose a diagnostic challenge. We report a 45-year-old female who was referred to the All India Institute of Medical Sciences, Bhopal, India, in 2017 with a two-year history of progressively worsening dyspnoea and dry coughing. She had been previously diagnosed with pulmonary tuberculosis elsewhere and prescribed antitubercular therapy; however, there was little improvement in her symptoms. Following referral, the patient was diagnosed with PAM based on high-resolution computed tomography findings and the abundance of lamellar microliths in a bronchoalveolar lavage sample. She was subsequently managed symptomatically and enrolled in a rehabilitation programme.

Thoracic Endometriosis Presenting with Bilateral Hydropneumothorax

A 36-year-old woman was admitted to the All India Institute of Medical Sciences, Bhopal, Madhya Pradesh, India, in 2018 with complaints of breathlessness upon exertion and a dry cough of one week’s duration. She had been previously diagnosed with recurrent right-sided hydropneumothorax and one episode of left-sided hydropneumothorax over the course of the past two years; at these times, she was treated with an intercostal drain (ICD), antibiotics and analgaesics. Serosanguinous aspiration revealed lymphocytic and exudative pleural effusion and her adenosine deaminase levels were below normal. A polymerase chain reaction-based assay for Mycobacterium tuberculosis was negative. A detailed medical history indicated a clear correlation between the patient’s symptoms and her menstrual cycle. Upon admission, a chest X-ray showed right-sided hydropneumothorax and minimal pleural effusion and an air pocket on the left side [Figure 1A]. Computed tomography of the thorax confirmed these findings [Figure 1B]. An ICD was inserted in the right lung and the patient underwent pleurocentesis to relieve the air pocket in the left lung. A pleural fluid analysis yielded similar results to those of prior investigations. An echocardiograph and ultrasonogram of the abdomen were normal and tests revealed no indication of collagen vascular disease. The patient underwent video-assisted thoracoscopic surgery in the right pleural cavity, combined with a thoracotomy on the left side due to intercostal narrowing. Marked adhesions and haemorrhagic spots were observed [Figure 2], which were successfully treated using adhesiolysis. Multiple biopsies of the pleural surface revealed the presence of endometrial gland fragments, confirming a diagnosis of thoracic endometriosis [Figure 3]. A pleurodesis procedure using povidone-iodine was performed on both sides of the lungs. The patient made an uneventful recovery and was prescribed danazol and gonadotropin-releasing hormone analogues to suppress ovulation. There was no evidence of recurrence at a six-month follow-up appointment. intErEsting mEdical imagE Sultan Qaboos University Med J, May 2018, Vol. 18, Iss. 2, pp. e245–246, Epub. 9 Sep 18 Submitted 25 Feb 18 Revision Req. 10 Apr 18; Revision Recd. 25 Apr 18 Accepted 10 May 18

Case of postural complex sleep apnea: effect of gravitational forces

We report a case of an elderly male with predominant obstructive sleep apnea and who developed or complex sleep apnea (CxSA) at the start of continuous positive airway pressure (CPAP) titration. This CxSA was more prominent in supine position, and he was not settling with either CPAP/bilevel positive airway pressure (PAP) in supine position. He finally settled with CPAP along with position therapy. This case highlights the importance of treating CxSA with basic PAP modes like CPAP along with positional therapy before switching to costlier therapies such as adaptive servo-ventilation.