Asmita Mehta

Clinical Profile of Patients Admitted with Swine-Origin Influenza A (H1N1) Virus Infection: An Experience from A Tertiary Care Hospital.

BACKGROUND Pandemic influenza A (H1N1) 2009 has posed a serious public health challenge world-wide. H1N1 critical illness mostly affects young patients and is often fatal. OBJECTIVE Primary objective was to study clinical profile of the patients admitted with confirmed H1N1 swine flu infection. Secondary objective was to observe the risk factors associated with complications like need of mechanical ventilation and or death among H1N1 infected patients. MATERIAL AND METHODS A prospective observational study was conducted in a tertiary care teaching hospital from June 2009, to December, 2011. H1N1 infection was confirmed by reverse transcriptase PCR. Statistical analysis was done by SPSS, version 11. Binary logistic regression was used to find out independent risk factors for morbidity. RESULTS Total 495 patients were tested for H1N1 infection. Among them, 115 (23%) were positive and 88(76%) required admission. Median age of cohort was 29 years and 87% of the patients were below 54 years of age. Most common presenting symptoms were fever (98%), followed by cough (86%) and sore throat (54%). Out of 88 patients, 14 (16%) required mechanical ventilation and 6(6.8%) died. Lymphopaenia (Lymphocytes <10%) and presence of patchy infiltrates on chest X-ray (CXR) the time of presentation were independent risk factors associated with need of mechanical ventilation or death in H1N1 infected patients by multivariate analysis. CONCLUSION Present study showed that H1N1 swine flu mainly affected people who were < 54 years of age. Majority of patients improved with antiviral treatment. Lymphopaenia and CXR which showed bilateral pneumonia at time of presentation were found to be independent risk factors associated with requirement of mechanical ventilation and/or death in H1N1 infection. Pregnant females with flu constituted 33% of total mortality. High priority should be given to such patients. Further community based studies are required to analyze the actual impact of H1N1 infection in the community.

The role of Gefitinib in patients with non-small-cell lung cancer in India

Background: Gefitinib, an epidermal growth factor receptor-tyrosine kinase inhibitor, represents a new treatment option for patients with advanced non-small-cell lung cancer (NSCLC). We analyzed the data of patients who received Gefitinib for NSCLC in a tertiary care center in South India. Materials and Methods: Sixty-three patients with advanced NSCLC who had received Gefitinib either after failure of conventional chemotherapy or were previously not treated as they were unfit or unwilling for conventional treatment were included in the analysis. Results: The median follow-up for the cohort was 311 days (range 11-1544 days). Median time to progression was 161 (range 9-883) days. Complete and partial remission was seen in 1 (2%) and 6 (9%) patients, respectively, with overall response rate of 11%. Twenty-four (38%) patients had stable disease. Gefitinib was well tolerated with no significant side effects. Conclusion: Gefitinib shows anti-tumor activity in pretreated or previously untreated patients with advanced NSCLC. It has a favorable toxicity profile and is well tolerated. Gefitinib should be considered as a viable therapy in patients with NSCLC.

Predictors of mortality of severe sepsis among adult patients in the medical Intensive Care Unit

Background: Sepsis is an important cause of mortality in the Intensive Care Units (ICUs) worldwide. Information regarding early predictive factors for mortality and morbidity is limited. Aims and Objectives: The primary objective of the study was to estimate the mortality of severe sepsis among adult patients admitted into the medical ICU. The secondary objective was to identify the predictors associated with mortality. Materials and Methods: Adult patients admitted with severe sepsis in the medical ICU were studied. The primary outcome was the mortality among the study population. Baseline demographic, clinical, and laboratory data were recorded upon inclusion into the study. Risk factors associated with mortality were studied by univariate analysis. The variables having statistical significance were further included in multivariate analysis to identify the independent predictors of mortality. Results: Out of eighty patients, 54 (67.5%) died. Univariate analysis showed that age >60 years, tachycardia, hypotension, elevated C-reactive protein (CRP) and lactate, thrombocytopenia, need of mechanical ventilation, and high Acute Physiology and Chronic Health Evaluation (APACHE) II and Sequential Organ Failure Assessment scores were variables associated with high mortality. The independent predictors of mortality identified by multivariate regression analysis were platelet count below 1 lakhs, serum levels of CRP >100, APACHE II score >25 on the day of admission to the ICU with severe sepsis, and the need for invasive mechanical ventilation. Conclusions: Low platelet count, elevated serum levels of CRP, APACHE score >25, and the need for invasive mechanical ventilation were found to be independent predictors of mortality of severe sepsis among adult patients with severe sepsis in the medical ICU.

Risk factors for mortality in Acinetobacter calcoaceticus-baumannii bacteraemia

Article history: Objective: To determine the risk factors associated with mortality in Acinetobacter calcoaceticus- baumannii (Acb) complex blood stream infection. Methods: This was an observational study conducted in tertiary care hospital of South India. All patients with blood culture positive for Acb complex from January 2008 to December 2009 were included and a standardized abstraction form was used to abstract data. P value was calculated by Chi square test. Univariate analysis was done by using 2x2 tables and the variables with P value of <0.1 were further subjected to multivariate analysis. Multivariate analysis was done by logistic regression method. Results: After excluding the polymicrobial infections and duplicate isolates from the same patients, 81 cases were included in our study. Out of 81 patients, 20 (24.6%) patients had positive isolate from body secretion other than blood for Acb complex, majority were hospitalized in intensive care unit (74%), had indwelling vascular catheters (68%) and were mechanically ventilated (61%). Multi drug resistant phenotypes were seen in 56 (69.1%) isolates and among them 13 (16%) were resistant to carbapenems. Univariate analysis showed renal disease, diabetes mellitus, use of mechanical ventilation and absence of appropriate antibiotic therapy, leucopenia, thrombocytopenia and raised prothrombin time were related to increased mortality in Acb complex bacteraemia. However, in multivariate analysis independent risk factors for mortality in Acb complex bacteraemia were platelets of less than 1.5 lacks and inappropriate empirical antibiotics. Conclusions: Thrombocytopenia and absence of appropriate antibiotics were risk factors associated with mortality in Acb bacteraemia. Patients with blood culture showing Acb complex bacteraemia with above findings should be attended with aggressive management. Clinician of hospitals with high incidence of Acb complex bacteraemia, should predict the chances of such infection even prior to blood culture reports are available, and should initiate appropriate antibiotics according to their institution antibiogram.

Multiple myeloma presenting as eosinophilic pleural effusion

An elderly man, with no comorbidity, presented with rapidly accumulating left pleural effusion. He also had generalized adenopathy. Pleural fluid cytology showed exudative pleural effusion with eosinophilia. Supraclavicular lymph node biopsy was reported as amyloid. On further investigation he was found to have kappa‐light chain multiple myeloma. The final diagnosis was eosinophilic pleural effusion in a patient with multiple myeloma.

A case of young woman with recurrent right pleural effusion

Endomterisois is usually found in women of child-bearing age. A case is presented of massive right-sided pleural effusion caused by endometriosis. The final diagnosis was made by thoracoscopic pleural biopsy. Physicians should be aware of this potentially treatable cause of pleural effusion having excluded other possibilities such as malignancy and tuberculosis.

Diagnostic utility of adenosine deaminase in exudative pleural effusions

Objective: To determine the diagnostic utility of adenosine deaminase (ADA) in exudative pleural effusions of different etiologies. Setting and Design: It was an observational study conducted at a tertiary care teaching institute. Materials and Methods: Of a total of 171 pleural fluid samples, 122 were found to be exudates and were included in the study. Pleural fluid ADA was done for all included patients. Pleural fluid ADA ≥40 U/l was taken as diagnostic cut off for TB effusion. Statistical Analysis: Sensitivity, specificity positive and negative predictive value of pleural fluid ADA for diagnosing TB was calculated by using clinical calculator – 1, Richard Lowry 2001-2013. Results: There were 171 patients with pleural effusion, out of which 122 (71.8%) were found to be exudative and were studied further. There were 49 (40.1%), 36 (29.5%) and 33 (27%) cases of TB, malignancy and para pneumonic effusion respectively, whereas 4 (3.3%) cases remained undiagnosed. Median ADA values for TB, malignancy and para pneumonic effusion were 55.8 U/l (range 9.7-756 U/l), 18 U/l (6.5-81 U/l) and 25 U/l (3.4-172 U/l) respectively. Pleural fluid ADA >40U/l yielded 85.7% sensitivity, 80.8% specificity, 75% positive predictive value and 89.5% negative predictive value. Conclusion: Pleural fluid ADA remains useful in diagnosing tuberculosis pleural effusion. The median ADA for TB effusion in present cohort was 51.8 IU/ml. Pleural fluid ADA of 40 U/L yielded 89.5% negative predictive value and 75% positive predictive value. Pleural fluid ADA is cost effective and good screening test for diagnosis of TB.

A young woman with recurrent lower respiratory tract infection.

Tracheobronchomegaly is a rare congenital abnormality with marked widening of the trachea and major bronchi, in most cases associated with chronic recurrent respiratory tract infection. We present this rare syndrome in a young woman who presented with recurrent respiratory tract infection. She was found to have tracheobronchomegaly on flexible bronchoscopy, which was confirmed with high-resolution computed tomography findings.

Different strokes for different folks

A 42-year-old woman, presented to our emergency room with chief complaints of acute onset of dyspnea, left-sided chest pain, and respiratory distress. On arrival, she had blood pressure of 90/50 mm Hg, respiratory rate of 40/min, and oxygen saturation of 95% breathing on 10 L oxygen. She was in significant respiratory distress. On examination, she was found to have diminished breath sounds on the left side of chest. Her chest radiograph showed left massive pleural effusion causing contralateral shift of mediastinum. Diagnostic pleural aspiration was done; results were consistent with hemothorax. Her multidetector computed tomography chest showed features of left-sided hemothorax (high attenuation) along with a 2 cm-enhancing lobulated opacity in the left lingular lobe, suggestive of pulmonary arteriovenous malformation (PAVM). She was successfully treated with surgical resection of PAVM.

Right hilar mass with hemoptysis: An unusual presentation of uncommon disorder

Common differential diagnosis of lung and hilar opacity includes infectious pathology or a mitotic lesion. Behcets disease (BD) is a rarely diagnosed disease in Indian subcontinent. BD is a multisystem inflammatory disorder that presents with recurrent orogenital ulceration, uveitis, and erythema nodosum. We present here the case of a patient who presented with recurrent hemoptysis with radiological picture of hilar mass, during the evaluation of which the diagnosis of BD was established.