Animesh Ray

Scrub typhus infection presenting as acute heart failure: A case report and systematic review of literature of cardiopulmonary involvement in scrub typhus infection

We describe a middle aged previoulsy healthy female patient who presented with clinical features suggestive of acute heart failure. Investigations revealed very high NT pro-BNP, right heart enlargement, bilateral pulmonary alveolar edema and bilateral pleural effusion. In view of falling platelet counts and exudative pleural effusion inflammatory/infective causes were considered. Her Weil Felix test was strongly positive and IgM for scrub typhus also returned positive. She was started on doxycycline to which there was dramatic improvement. Thus in this case scrub typhus infection presented as acute right heart failure and the cause seemed elusive at the outset.We also systematically reviewed the existing literature on cardio-pulmonary manifestations of scrub typhus infection.

Choking after blunt trauma and an interesting radiological finding

Lung India • Vol 31 • Issue 1 • Jan Mar 2014 A 19-year-old man presented to the Emergency, few hours after sustaining a blunt trauma to the chest as he fell from a height of 10 feet above ground and landed on his chest. He complained of difficulty in taking food and water and coughing on attempting to do so. The vitals of the patient were stable and there was only a small bruise over his sternum at the site of injury. There was no evidence of injury to any other vital organs or bleeding from any site. Plain radiograph was unremarkable. An urgent Computed Tomography (CT) of Thorax was done [Figures 1 and 2], which showed an interesting feature.

Evaluation of Xpert® Mycobacterium tuberculosis/rifampin in sputum-smear negative and sputum-scarce patients with pulmonary tuberculosis using bronchoalveolar lavage fluid

Context: Sputum smear-negative and sputum-scarce pulmonary tuberculosis (PTB) is a diagnostic challenge. Xpert® Mycobacterium tuberculosis/rifampin (MTB/RIF) provides a rapid diagnosis on high-quality biological specimen obtained by bronchoscopy. Aims: The aim of this study is to evaluate Xpert® MTB/RIF on bronchoalveolar lavage (BAL) fluid in sputum smear-negative and sputum-scarce PTB patients. Settings: Tertiary care hospital in India. Design: This was prospective observational study. Materials and Methods: Between January 2015 and November 2016, we prospectively recruited sputum-smear negative and sputum-scarce patients under evaluation for PTB and performed BAL. Sensitivity, specificity, positive, and negative predictive values were calculated for the diagnosis of PTB on BAL fluid for acid-fast bacilli smear and Xpert® MTB/RIF using liquid culture as the reference standard and compared to the final diagnosis based on composite reference standard. Sensitivity, specificity, and predictive values were calculated with 95% class intervals. McNemars test was used for comparison of sensitivities. Results: Of the 60 patients included, 52 (88.3%) had a final diagnosis of PTB and 16 (26.7%) were culture confirmed. Xpert® MTB/RIF had a sensitivity and specificity of 81% (54%–96%) and 73% (56%–85%) in culture confirmed cases; 46% (32%–60%) and 100% (63%–100%) for the final diagnosis; 32% (17%–51%) and 100% (54%–100%) in culture negative cases, respectively. Culture had a sensitivity of 32% (20%–47%) for the final diagnosis. Conclusions: In sputum smear-negative and sputum-scarce patients with clinico-radiological features of PTB Xpert® MTB/RIF has good sensitivity for diagnosis on BAL fluid. It is useful even when cultures are negative.

Reverse Lemierre’s syndrome: a case report

We present the case of a 60-year-old diabetic who had acute-onset shortness of breath that was preceded by bilateral thigh and hip pain. He was initially admitted for septic arthritis with community-acquired pneumonia. His respiratory complaints resolved, but he continued to have thigh pain. Ultrasound of the lower limbs showed thrombosis of the deep veins of the thigh and MRI showed a collection in the right thigh suggestive of pyomyositis with thrombosis in deep veins abutting the collection. Contrast enhanced CT (CECT) chest showed multiple peripherally located pneumatoceles and cavities in both the lungs suggestive of septic emboli. Here, we present a case of pyomyositis of thigh muscles causing Deep vein thrombosis (DVT) and septic pulmonary emboli (reverse Lemierre’s syndrome).

Diffuse pleural thickening: cases of pseudomesotheliomatous adenocarcinoma and pleural tuberculosis

Diffuse pleural thickening is a common cause of diagnostic dilemma. We report two cases of pleural thickening that presented with similar clinical and radiological picture, thus clinching a diagnosis hinged on histopathology. In the first case, the histopatholgy and immunohistochemistry was suggestive of adneocarcinoma, thus making the diagnosis of pseudomesotheliomatous adenocarcinoma. In the second case, the histopathology was suggestive of tubercular etiology, which also is a rare presentation of active pleural tuberculosis. These cases highlight the importance of histopathological examination in establishing the etiology in cases of diffuse pleural thickening.

Respiratory failure in a patient with treated thymoma: A blast from the past

Thymomas are among the most common anterior mediastinal tumors that can uncommonly present with respiratory failure. This case discusses the development of type II respiratory failure in a patient with a history of treated and cured thymoma. The problem posed and the workup leading to the diagnosis is discussed in detail. Further, the possible and reported causes of respiratory failure in such a case has also been highlighted.

Recurrent heart failure in pulmonary tuberculosis patients on antitubercular therapy: A case of protector turning predator!

Anti-tubercular drugs are associated some common and uncommon adverse effects. We report the association between cardiomyopathy and the use of anti-tubercular drugs. In the two cases described in the case report the different causes of cardiomyopathy are ruled out leading to the diagnosis of drug induced cardiomyopathy. The report also throws light on the various aspects of this association and the clinical implications.

Bronchoscopy as a salvage therapy in a mechanically ventilated status asthmaticus patient: A case report

A 23-year-old male patient presented with acute exacerbation of asthma with type 2 respiratory failure. He was mechanically ventilated and started on intensive medical therapy including nebulization with β2 agonists and antimuscarinic drugs, steroids, antibiotics and magnesium sulphate as per standard protocol. As there was no response to the above-mentioned line of treatment, other nonstandard therapies such as intramuscular adrenaline and ketamine were also tried but to no avail. After a meticulous literature search, bronchoscopy was planned to look for any alternative diagnoses as well as to perform bronchial toileting. The patient showed dramatic improvement after the procedure, was subsequently extubated and discharged in stable condition. This case essays the significant role of bronchoscopy in refractory status asthmaticus patients, discusses the pathophysiological mechanisms addressed by bronchoscopic toileting and, furthermore, reviews the contemporary literature for evidence in its favour.

Cavitating lung disease due to concomitant drug resistant tuberculosis and invasive pulmonary Aspergillosis in a post-partum patient: A case report.

Many disorders can present as cavitating lesions in the lung. In this case report, a case of mixed infection with drug resistant tuberculosis and invasive pulmonary aspergillosis in a post-partum patient has been presented.

Ptosis of the lung

83 A young male patient of 17 years presented to the Emergency after sustaining blunt trauma to the chest as result of a road traffic accident. At the Emergency he was found to have severe hypoxemia. The chest examination was suggestive of right‐sided tension pneumothorax, for which an intercostal drainage (ICD) catheter was inserted and the patient was intubated and ventilated. There were large air‐leaks noted in the ICD bag and the pneumothorax persisted even after ICD placement. A chest x‐ray (CXR) was done, which is shown in Figure 1.