Balamugesh Thangakunam

High annual risk of tuberculosis infection among nursing students in South India: a cohort study.

Background Nurses in developing countries are frequently exposed to infectious tuberculosis (TB) patients, and have a high prevalence of TB infection. To estimate the incidence of new TB infection, we recruited a cohort of young nursing trainees at the Christian Medical College in Southern India. Annual tuberculin skin testing (TST) was conducted to assess the annual risk of TB infection (ARTI) in this cohort. Methodology/Principal Findings 436 nursing students completed baseline two-step TST testing in 2007 and 217 were TST-negative and therefore eligible for repeat testing in 2008. 181 subjects completed a detailed questionnaire on exposure to tuberculosis from workplace and social contacts. A physician verified the questionnaire and clinical log book and screened the subjects for symptoms of active TB. The majority of nursing students (96.7%) were females, almost 84% were under 22 years of age, and 80% had BCG scars. Among those students who underwent repeat testing in 2008, 14 had TST conversions using the ATS/CDC/IDSA conversion definition of 10 mm or greater increase over baseline. The ARTI was therefore estimated as 7.8% (95%CI: 4.3–12.8%). This was significantly higher than the national average ARTI of 1.5%. Sputum collection and caring for pulmonary TB patients were both high risk activities that were associated with TST conversions in this young nursing cohort. Conclusions Our study showed a high ARTI among young nursing trainees, substantially higher than that seen in the general Indian population. Indian healthcare providers and the Indian Revised National TB Control Programme will need to implement internationally recommended TB infection control interventions to protect its health care workforce.

Cerebral air embolism complicating CT-guided trans-thoracic needle biopsy of the lung.

Background and Aims:  Systemic air embolism is recognized as a rare but potentially fatal complication of trans‐thoracic needle biopsy of the lung.

Maximal Oxygen Uptake Is Lower for a Healthy Indian Population Compared to White Populations

PURPOSE: Presently used prediction equations for maximal oxygen uptake are mostly derived from studies of western populations. However, the interracial differences are quite large when prediction equations for the Western-white population are applied to Asian-Indians. The present study was aimed at the initial development of a prediction equation for the healthy sedentary Indian participants using symptom limited graded incremental exercise testing and to compare the new regression equation to other published data. METHODS: Participants were staff and caregivers of patients from different states of India. All participants completed a maximal graded exercise test on a motorized treadmill at Christian Medical College, Vellore, Tamil Nadu to determine maximal oxygen uptake (O2max). RESULTS: Predictive equations for both men and women were obtained from multiple linear regression analysis and significant correlations were found for weight and height. The correlation coefficients of the new regression equations with measured O2max of study population were R2 = .511 for men and R2 = .656 for women. These were compared with other published equations with differences ranging from 7% to 50% for men and 10% to 36% for women. CONCLUSIONS: The present study derived a prediction equation for O2max applicable to the Asian-Indian population. The predicted maximal oxygen uptake of the study population using the new equation is significantly lower than the white population. The new equation may facilitate more meaningful interpretation of the test data in this population and possibly a wider use.

Small Sample Lung Biopsy Findings in Patients With Clinicoradiologic Suspicion of Pulmonary Venoocclusive Disease-Pulmonary Capillary Hemangiomatosis.

Pulmonary venoocclusive disease (PVOD) and pulmonary capillary hemangiomatosis (PCH) form a sinister subgroup of pulmonary arterial hypertension where the predominant pathology lies in the pulmonary veins and capillaries, thus making the use of pulmonary vasodilators potentially dangerous in these patients. Radiologically, the presence of centrilobular nodules, interlobular septal thickening, and significant mediastinal adenopathy are useful in identifying this subgroup from patients with pulmonary arterial hypertension. The combination of all three has a sensitivity of 66% and a specificity of 100% in identifying this subgroup. We present a case series of 3 patients who were radiologically suspected to have PVOD or PCH and in whom pathologic corroborative evidence suggestive of PVOD and PCH was found in small sample lung biopsy specimens: transbronchial lung biopsy (2 patients) and trucut biopsy of the postmortem lung (1 patient). Histopathology, in our patients, showed pulmonary arteriole smooth muscle proliferation and narrowing, capillary proliferation, intimal fibrosis of pulmonary veins and arteries, interstitial fibrosis, interstitial foreign body type of multinucleate giant cells, and aggregates of alveolar and interstitial hemosiderophages. In conclusion, histopathology of small lung biopsy samples can provide useful corroborative pathologic evidence in patients with clinicoradiologic suspicion of PVOD-PCH.

Radiation Pneumonitis After Conventional Radiotherapy For Breast Cancer: A Prospective Study

BACKGROUND Loco-regional radiotherapy is an important treatment modality in breast cancer and radiation pneumonitis (RP) is one of the early toxicities. AIM To study the occurrence, correlation of RP with patient and radiotherapy related factors and the effects on pulmonary function following conventional radiotherapy in breast cancer. SETTINGS AND DESIGN Prospective study, from a tertiary hospital in a developing country. MATERIALS AND METHODS Prospective analysis of clinical symptoms, pulmonary function and radiologic changes was done prior to and 12 weeks after adjuvant radiotherapy (n=46). Statistical analysis was done using SPSS version 10 software. RESULTS Radiological and clinical RP was seen in 45.65% (n=21) and 19.56% (n=9) respectively. RP was significantly higher with age >50 years (OR 4.4), chest wall irradiation with electrons, (electrons 83.3% vs cobalt60 32.4%, p=0.02) and supraclavicular field treatment with 6 MV photons (p= 0.011). There was significant relationship between Inferior Lung Distance (ILD) and RP (p=0.013). The fall in Total Lung Capacity (TLC) was significantly more in those with RP (p=0.02). CONCLUSION Clinical RP occurs in almost one-fifth of breast cancer patients treated with conventional radiotherapy. Chest wall irradiation with electrons, supraclavicular field irradiation with 6 MV photons, higher ILD and age >50 years was associated with increased RP. The pulmonary function parameter most affected was TLC. The factors associated with increased RP should be considered when adjuvant radiotherapy is planned to minimize its likelihood and intervene appropriately.

Disseminated solitary fibrous tumour of the lung and pleura

Solitary fibrous tumours (SFTs) are a heterogeneous group of rare spindle-cell tumours. Classically they presented as a solitary pleural-based mass. Pulmonary parenchymal SFT is rare and multiple bilateral lesions are extremely rare. We present the clinical, imaging and histological features of SFT which are presented as multiple nodular lesions of the lung and pleura with probable distant metastasis.

Thoracoscopic pleural biopsy improves yield of Xpert MTB/RIF for diagnosis of pleural tuberculosis: Xpert in thoracoscopic pleural biopsy

Extrapulmonary tuberculosis (EPTB) accounts for ~15% of all TB patients, and TB pleural effusion is the second most common site of EPTB. The diagnosis of pleural TB is challenging due to the pauci‐bacillary nature of the disease. Histopathology of thoracoscopically obtained pleural biopsy provides the highest diagnostic yield. The Xpert MTB/RIF assay (Xpert) is a PCR test that can identify both Mycobacterium tuberculosis (MTB) and rifampicin resistance. Currently, there is a lack of clarity regarding the value of Xpert on pleural tissue. We report our experience of using Xpert on thoracoscopic pleural biopsy samples.

Endobronchial ultrasound experience in a high tuberculosis prevalence setting

BACKGROUND Most of the published endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) data are from the western countries, establishing the role of EBUS-TBNA in the diagnosis and staging of lung cancer. The etiology of mediastinal lymphadenopathy may be different in an ethnic group with a high prevalence of tuberculosis (TB). OBJECTIVE To assess the etiology of mediastinal adenopathy in a high TB prevalence setting and to determine the performance of various tests in the diagnosis of tuberculous mediastinal lymphadenitis. METHODS Retrospective analysis of bronchoscopic data of patients who underwent endobronchial ultrasound (EBUS) in a tertiary care center in India. RESULTS Out of 138 patients who underwent EBUS, 63 (46%) had granulomatous disease. Of the 35 patients with a diagnosis of TB, in 10 (29%), microbiology of EBUS specimens was diagnostic and in 3 (9%), this was the sole diagnostic feature. In 5 (14%) mycobacterial cultures were positive, in 6 (17%) GeneXpert for Mycobacterium tuberculosis/rifampicin resistance (Xpert MTB/RIF) was positive, and in 3 (9%) acid fast smears were positive. CONCLUSION In high TB prevalence countries, EBUS diagnoses a higher number of granulomatous than malignant diseases. EBUS specimen should, therefore, be subjected also to mycobacterial smear, culture, and Xpert MTB/RIF for optimal results.

Idiopathic pleuroparenchymal fibroelastosis – A rare idiopathic interstitial pneumonia

Idiopathic pleuroparenchymal fibroelastosis is a rare idiopathic interstitial pneumonia. It was first described in 2004 and subsequently included in the ATS/ERS classification of idiopathic interstitial pneumonia in 2013. There have been few cases reported so far. The diagnostic criteria is still emerging and its etiology is being questioned. We report a case of pleuroparenchymal fibroelastosis probably idiopathic, the first of its kind to be reported from India, and a brief review of the literature.

Mesenchymal stromal stem cell therapy in advanced interstitial lung disease - Anaphylaxis and short-term follow-up.

There are limited treatment options for advanced interstitial lung disease (ILD). We describe a patient of ILD treated with mesenchymal stromal stem cell infusion. The index patient had end-stage ILD due to a combination of insults including treatment with radiotherapy and a tyrosine kinase inhibitor Erlotinib. He was oxygen-dependent and this was hampering his quality of life. He tolerated the first infusion stem cells without any problem. During the second infusion he developed anaphylactic shock, which was appropriately managed. At 6-months follow-up he had no improvement in oxygenation, pulmonary function or CT scan parameters. In view of anaphylaxis, further infusions of MSC were withheld. A longer follow-up may reveal long-term benefits or side effects, if any. However the occurrence of anaphylaxis is of concern suggesting that further trials should be conducted with intensive monitoring.