Ajay Kumar Verma

Genital tuberculosis with variable presentation: a series of three cases.

Tuberculosis (TB) is still frequently observed in third-world countries like Africa and Asia. Here we report three cases of genital TB with variable presentation. First case was a lady of reproductive age group who presented with polymenorrhagia and postcoital bleeding with unhealthy cervix. Histopathology of cervical tissue revealed tubercular cervicitis. Second and third cases presented with different complaints like discharge per vaginum, postcoital bleeding and pain in lower abdomen with growth over the cervix. Cervical biopsy was inconclusive of TB but endometrial tissue sampling for TB PCR was positive. This shows that newer diagnostic marker test can help us to detect secondary genital TB.

Primary disseminated extrahepatic abdominal hydatid cyst: a rare disease

Hydatid disease (HD) is a parasitic disease, most frequently caused by Echinococcus granulosus or Echinococcus multilocularis and rarely by Echinococcus vogeli or Echinococcus oligarthus. Mostly, hydatid cyst is primarily in liver (75%) and lung (15%). Peritoneal HD (13%) is usually secondary. Dissemination of HD may occur following rupture of the hydatid cyst into the peritoneal cavity. Primary peritoneal hydatid cyst disease is a rare phenomenon. We present a case of primary disseminated abdominal HD presenting with the complaint of a pain in the epigastric region along with intermittent fever. Radiological evaluation and serological examination confirmed it as primary disseminated HD involving pancreas, a cyst anterior to the left lobe of the liver just below the peritoneum and the left kidney.

Weaning of mechanically ventilated chronic obstructive pulmonary disease patients by using non-invasive positive pressure ventilation: A prospective study.

Background: Chronic obstructive pulmonary disease (COPD) patients frequently pose difficulty in weaning from invasive mechanical ventilation (MV). Prolonged invasive ventilation brings along various complications. Non-invasive positive pressure ventilation (NIPPV) is proposed to be a useful weaning modality in such cases. Objective: To evaluate the usefulness of NIPPV in weaning COPD patients from invasive MV, and compare it with weaning by conventional pressure support ventilation (PSV). Materials and Methods: For this prospective randomized controlled study, we included 50 COPD patients with type II respiratory failure requiring initial invasive MV. Upon satisfying weaning criteria and failing a t-piece weaning trial, they were randomized into two groups: Group I (25 patients) weaned by NIPPV, and group II (25 patients) weaned by conventional PSV. The groups were similar in terms of disease severity, demographic, clinical and biochemical parameters. They were compared in terms of duration of MV, weaning duration, length of intensive care unit (ICU) stay, occurrence of nosocomial pneumonia and outcome. Results: Statistically significant difference was found between the two groups in terms of duration of MV, weaning duration, length of ICU stay, occurrence of nosocomial pneumonia and outcome. Conclusion: NIPPV appears to be a promising weaning modality for mechanically ventilated COPD patients and should be tried in resource-limited settings especially in developing countries.

Renal tuberculosis presenting as acute pyelonephritis – A rarity

One of the major health problems faced particularly by the developing world since ages is that of tuberculosis (TB). Genito-urinary tuberculosis (GUTB) is the second most common extrapulmonary TB, with kidney being the most frequent site of infection. Due to the diverse and atypical clinical manifestations of urinary TB, the disease is easy to misdiagnose. The diagnosis of renal TB should be suspected in a nonspecific bacterial cystitis associated with a therapeutic failure or a sterile pyuria and a past history of pulmonary TB with important radiologic findings, particularly with the help of CT scan. Here, we describe a case of renal TB where no clinical or radiological features suggestive of renal TB were present. The diagnosis was only evident after the histopathological examination of the excised kidney. This case highlights the importance of suspecting renal TB as an important cause of kidney disease, which can lead to irreversible renal function loss particularly in an endemic area, and also the diversity that this disease may acquire in its presentation leading to misdiagnosis. In such a case, particularly in a high endemic area for TB, therapeutic trial of ATT may also be considered to avoid unnecessary surgical intervention and end-stage renal disease.

A search for covert precipitating clinical parameters in frequent exacerbators of chronic obstructive pulmonary disease

Introduction: Acute exacerbations are a significant source of morbidity and mortality associated with chronic obstructive pulmonary disease (COPD). Some patients suffer an inordinate number of exacerbations while others remain relatively protected. The aim of this study was to evaluate the potentially modifiable precipitating parameters of frequent severe exacerbations requiring hospital admission in COPD. Materials and Methods: Consecutive patients admitted with acute exacerbation of COPD for a period of one year in a tertiary care hospital were evaluated prospectively. Data regarding the number of exacerbations in the previous year, current comorbidities, medications, and clinical and functional status of COPD patients were evaluated. Results: We included 98 COPD patients (81.63% men) admitted consecutively with exacerbations in our department. The mean number of severe exacerbations was (2.42 per patient/per year), and 65% of the patients had frequent severe exacerbations. Multivariate analysis indicated that serum uric acid, serum total IgE, depression and anxiety, gastroesophageal reflux disease symptoms, air pollution, poor adherence to inhaled therapy, and irregular outpatient followup visits were independent predictors of frequent severe exacerbations. Conclusion: COPD patients with frequent exacerbations should be carefully assessed for modifiable confounding risk factors regardless of poor lung function to decrease exacerbation frequency and related poor prognosis. Raised serum total IgE levels may point towards atopy as an additional comorbidity in COPD while uric acid can have a clinically useful role in risk stratification in a primary care setting.

Noninvasive mechanical ventilation: An 18-month experience of two tertiary care hospitals in north India

Background: Noninvasive mechanical ventilation (NIMV) is the delivery of positive pressure ventilation through an interface to upper airways without using the invasive airway. Use of NIMV is becoming common with the increasing recognition of its benefits. Objectives: This study was done to evaluate the feasibility and outcome of NIMV in tertiary care centres. Materials and Methods: An observational, retrospective study conducted over a period of 18 months in two tertiary level hospitals of north India on 184 consecutive patients who were treated by NIMV, regardless of the indication. NIMV was given in accordance with the arterial blood gas (ABG) parameters defining respiratory failure (Type 1/Type 2). Results: The most common indication of NIMV in our hospitals was acute exacerbation of chronic obstructive pulmonary disease (AE-COPD 80.43%), and 90.54% AE-COPD patients were improved by NIMV. Application of NIMV resulted in significant improvement of pH and blood gases in COPD patients, while non-COPD patients showed significant improvement in partial pressure of oxygen (PaO2) alone. The mean duration of NIMV was 8.35 ± 5.98 days, and patients of interstitial lung disease (ILD) were on NIMV for the maximum duration (17 ± 8.48 days). None of the patients of acute respiratory distress syndrome were cured by NIMV; 13.04% patients on NIMV required intubation and mechanical ventilation. Conclusion: This study demonstrates and encourages the use of NIMV as the first-line ventilatory treatment in AE-COPD patients with respiratory failure. It also supports NIMV usage in other causes of respiratory failure as a promising step toward prevention of mechanical ventilation.

A study to know the knowledge, attitude, and practices of patients of bronchial asthma

Introduction: Asthma being a chronic inflammatory disease needs treatment for prolonged duration. To increase treatment compliance, each patient should know the course of disease, its precipitating factors, and management protocol. Despite the magnitude of the asthma, very little is known about its public perception. Aim: This study was done to know the knowledge, attitude, and practices of patients of bronchial asthma. Materials and Methods: In this prospective study, subjects were asthmatic patients attending the department of pulmonary medicine, KGMU Lucknow, India. A questionnaire including general understanding of asthma, its triggers and management was given to each patient and results were recorded. Results: A total of 140 patients with confirmed diagnosis of asthma were included in this study. On an average, each patient had already visited 3.2 doctors prior to coming to us. Out of 140 patients, 64% patients were ignorant regarding disease etiology, 47.1% patients thought that their disease is fatal, 30% patients were reluctant to accept the diagnosis of asthma. Regarding precipitating factors, 25.71% patients could not relate to any cause with their disease exacerbation. A total of 62.14% patients used alternative system of medicine too in the hope of getting rid of their disease. Oral medications were preferred by 62.1% patients, while 73.6% were using inhalers and out of them 71.8% were using inhalers incorrectly. Conclusion: Patient education program should augment awareness; eliminate social stigma, and misconcepts in the community regarding asthma. Knowledge about the prevailing perception in community would be the first step in achieving this.

Impact of psychiatric profile and personality trait on directly observed tuberculosis treatment outcome

Background: Psychiatric morbidity in tuberculosis (TB) patients is well-known and its impact on treatment compliance needs to be evaluated. Objectives: To study psychiatric profile, personality trait of TB patients registered on directly observed treatment-short course (DOTS) and to evaluate their impact on treatment completion and default. Materials and Methods: Psychiatric morbidity and personality traits were assessed by Cornell Medical Index and 16PF personality questionnaire, respectively. Patients with psychiatric comorbidity were randomized into two groups. Group A: DOTS with psychiatric intervention and Group B: DOTS alone. They were followed-up till treatment completion. Results: Out of 214 patients registered, 176 (82.2%) had psychiatric comorbidity. 150 (85.2%) had anxiety neurosis, and 26 (14.8%) had depression. On personality assessment, 54.1% were neurotic, 26% introverts, 15.8% extroverts, and 4.1% had other traits. Forty-one (23.3%) patients defaulted. Default rate was low (13.6 vs 33%, P = 0.002) and patient retrieval was good (67 vs 24%, P = 0.01) in group A. Patients with neurotic trait defaulted more ( P = 0.006). On multivariate analysis, smoking (odds ratio (OR) = 3.76, 95% confidence interval (CI): 1.7-8.28); alcoholism (OR = 15.4, CI: 6.67-35.72); and neurotic personality (OR = 3.54, CI: 1.61-7.79) were strongly associated with default whereas age, sex, social class, literacy, and psychiatric morbidity type were not. Conclusion: Pretreatment psychological assessment and intervention reduces default rate.

Rifampicin-induced thrombocytopenia.

In the treatment of tuberculosis there are special therapeutic problems related to adverse effects of drugs, compliance to treatment, and microbial resistance. Thrombocytopenia is an uncommon but potentially fatal adverse effect of certain anti-tubercular drugs when the incriminating drug is taken by a susceptible individual. We report a case of rifampicin-induced thrombocytopenia, which although rare, needs attention.

Identifying the levels of pro-fibrotic cytokines in pulmonary tuberculosis

259 The investigators have reported no significant difference in terms of gender of the patients suffering from PTB with minimal lesions and extensive lesions. Furthermore, results of sputum smear examination were mostly negative in both groups of minimal and extensive lesions of PTB. The average of ESR was 39.22 mm/h in individuals with a minimal lesion and 69.19 mm/h in individuals with an extensive lesion of PTB; however, normal ESR was found in one patient with a minimal lesion and one patient with an extensive lesion of PTB. The authors have stated that the plasma levels of TNF-α, IGF-1, and TGF-β1 in TB groups were higher to the healthy controls, although not significant. TNF-α level is nonsignificantly higher in the minimal lesion of TB group than extensive lesion group. IGF-1 is increased as well as TGF-β1 is decreased significantly in minimal lesion TB group in comparison with their extensive lesion TB group. There are some limitations of the study: due to its smaller sample size, results could not be generalized in a population and there is no information about patients whether they have been previously treated for PTB or not, before enrolling in the study.