Ashwini Kumar Mishra

A prospective study of ocular toxicity in patients receiving ethambutol as a part of directly observed treatment strategy therapy.

Background and Objectives: India is among the largest countries to implement the revised National Tuberculosis Control Program (RNTCP). This program provides intermittent regimens to the patients, where the doses of isoniazid and ethambutol are more as compared to the daily regimen, which is a cause of concern, particularly with regard to the ocular toxicity of ethambutol. The present study was undertaken to explore the ocular toxicity in the patients registered under the program. Materials and Methods: This was a prospective single center cohort study of 64 patients of categories I and II, coming to the RNTCP-Directly Observed Treatment Strategy (DOTS) center at a tertiary care referral hospital. The detailed history, best corrected visual acuity, fundus examination, and color vision test were carried out in all patients at the start of treatment and then at the first and second month of treatment. Results: Loss in visual acuity from the baseline was noted at the second month follow up in 12 (9.4%) eyes (P = 0.001), visual field defects were seen in eight (6.3%) eyes (P = 0.0412), and optic disc abnormalities were observed in six (4.7%) (P = 0.013) eyes. Color vision abnormalities were noted in 16 (12.6%) eyes (P = 0.003), four eyes showed impairment in red-green color perception, and the others showed impairment in blue-yellow color perception as well. Patients with ocular symptoms were advised to stop ethambutol and they showed improvement in visual acuity after follow up of one to two months. The overall outcome of treatment was not affected by discontinuation of ethambutol in these patients. Conclusion: Ethambutol when taken according to program could cause ocular toxicity. The early recognition of ocular symptoms is important to prevent unnecessary delay in diagnosis and probable irreversible visual loss.

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 study to compare the diagnostic efficacy of closed pleural biopsy with that of the thoracoscopic guided pleural biopsy in patients of pleural effusion.

Background: The diagnostic approach to exudative pleural effusion remains an underappreciated aspect of modern thoracic medicine. 15-20% of the pleural effusions remain undiagnosed. The most efficient approach to pleural exudates remains uncertain and controversial particularly if acquisition of pleural tissue is required. The clinician needs to consider various factors when confronted with the choice between closed pleural biopsy (CPB) and thoracoscopy. Hence this study was planned to compare the diagnostic efficacy of CPB and Thoracoscopic pleural biopsy (TPB). Materials and Methods: This was a prospective interventional study in patients of exudative pleural effusion. CPB was performed by Cope′s biopsy needle. Then inspection of the pleural cavity was performed by single port rigid thoracoscope (KARL, STORZ TELECAM DX II 20 2330 20) with viewing angle of zero (0) degrees and biopsy taken from the diseased or unhealthy parietal pleura. Accordingly we compared the results of CPB and TPB. Results: 46 Patients underwent this study. In all 46 patients both CPB and TPB were performed.TPB was diagnostic in 36 cases (78.2%) while CPB was diagnostic only in 10 cases i.e. 21.7%. 10 (21,7%) cases remained undiagnosed. On thoracoscopic examination 30 patients were having nodularity, 25 (54.3%) were having adhesions and 20 (43.5%) were having hyperemia. 79.3% of the patients with nodularity turned out to be malignant and 71.4% of patients with adhesions and hyperemia tubercular. Conclusions: TPB has much greater diagnostic efficacy than CPB.

A rare entity of tubercular mastitis with chest wall extension in a male

Tuberculosis (TB) is a chronic granulomatous inflammation involving usually the lung parenchyma and hilar lymph nodes. Extrapulmonary involvement is seen in about 15-20% of all cases of TB (EPTB). But breast TB is rare form of EPTB. We present a case of an immunocompetent male presenting with tubercular mastitis associated with chest wall extension. The rarity of this case lies in the site of involvement (chest wall), the way of presentation, and because of the immunocompetent status of the patient.

Tuberculosis of gallbladder neck: a cause of cholecystitis with cholelithiasis

Tuberculosis of gallbladder neck is not a very common problem reported in the literature. Here, we report a case of gallbladder neck tuberculosis complicated with chronic cholecystitis with cholelithiasis in a 55-year-old woman. Diagnosis was made postoperatively on surgical biopsy.

Leflunomide-induced chronic cough in a rheumatoid arthritis patient with pulmonary tuberculosis

A 40-year-old lady presented with clinicoradiological features suggestive of pulmonary tuberculosis, which was confirmed on sputum smear examination, and was started on four-drug antitubercular treatment. On subsequent visits, she complained of persistent cough, despite improvement in other symptoms. A careful anamnesis revealed that the patient had been taking leflunomide for rheumatoid arthritis for the last 10 years, and this was suspected to be the cause of the cough. The patient became asymptomatic upon stopping the drug, thereby confirming the hypothesis.

Coexistence of hard palate carcinoma with tuberculosis: A rarity

Coexistence of tuberculosis (TB) and palatal malignancy is a rare phenomenon and it has never been reported. Here, we present a case of hard palate carcinoma with TB in a 60-year-old male patient who was successfully managed by three pronged approaches by combining antitubercular therapy with chemotherapy and radiotherapy.

Linezolid induced pancytopenia in a patient of extensively drug-resistant pulmonary tuberculosis: An unusual outcome

Linezolid (Lnz) is the first oxazolidinones to be developed and introduced in clinical use. Its use is growing by day and day in the treatment of resistant pulmonary tuberculosis (TB). Lnz has been associated with adverse hematological effects, primarily thrombocytopenia. But pancytopenia is a very rare complication. Myelosuppression is a rare and a serious side effect of Lnz. Here, we present a case of extensively drug-resistant pulmonary TB, which was started on Lnz. Patient returned 1-month back with clinical presentation suggestive of pancytopenia which was confirmed on bone marrow aspiration and was attributed to the use of Lnz. Patient improved on stopping the Lnz and adding steroid for a short course. This case report emphasizes the importance of both the use of Lnz for well-defined indications and appropriate hematological monitoring during the course of treatment.

Correlation between clinical characteristics, spirometric indices and high resolution computed tomography findings in patients of chronic obstructive pulmonary disease

Introduction: Chronic obstructive pulmonary disease (COPD) is a chronic inflammatory disease affecting the airways, leading to significant morbidity and mortality throughout the world. There is a need to have a holistic evaluation of COPD patients, other than just measuring the level of obstruction as performed by spirometry. High resolution computed tomography (HRCT) scan of thorax partly fulfills this requirement. Materials and Methods: Fifty patients of COPD (confirmed on spirometry as per the GOLD guidelines 2014 guidelines) were enrolled, out of which 35 patients got a HRCT done. Complete clinical evaluation was done. The Philips computer program for lung densitometry was used with these limits (−800/−1, 024 Hounsfield unit [HU]) to calculate densities, after validating densitometry values with phantoms. We established the area with a free hand drawing of the region of interest, then we established limits (in HUs) and the computer program calculated the attenuation as mean lung density (MLD) of the lower and upper lobes. Results: There was a significant correlation between smoking index and anteroposterior tracheal diameter (P = 0.036). Tracheal index was found to be decreasing with increasing disease severity which was statistically significant (P = 0.037). Mean upper lobe MLD was −839.27 HU, mean lower lobe MLD was −834.91 HU and the mean MLD was −837.08 HU. The lower lobes MLD were found to be decreasing with increasing disease severity. A mild linear correlation of pre forced expiratory volume in the first second (FEV1) was observed with lower lobe and total average MLD while a mild linear correlation of Post-FEV1 was observed with both coronal (P = 0.042) and sagittal (P = 0.001) lower lobes MLD. In addition, there was a linear correlation between both pre (P = 0.050) and post (P = 0.024) FEV1/forced vital capacity with sagittal lower lobe MLD. A predictive model can be derived to quantify obstruction severity (FEV1). Conclusion: HRCT may be an important additional tool in the holistic evaluation of COPD. HRCT can well be correlated with the spirometric and clinical features and the level of obstruction can be indirectly derived from it by measuring the MLD.

Massive pleural effusion and associated pulmonary embolism in a case of Gefitinib responsive lung cancer

Pulmonary embolism (PE) and venous thrombosis is a common complication in lung cancer patients with a high misdiagnosis rate and high mortality. However, when an undiagnosed lung cancer patient presents as PE, cancer as a cause may not always be explored. We present a case of a young male patient presenting with venous thromboembolism causing massive pleural effusion, leading to the diagnosis of epidermal growth factor receptor mutation positive adenocarcinoma, showing good response to gefitinib therapy.