Deepak Aggarwal

Acquired bronchoesophageal fistula

Bronchoesophageal fistula in an adult is rarely encountered in clinical practice. Most commonly, they have malignant origin. We report a case of bronchoesophageal fistula secondary to trauma caused by upper gastrointestinal endoscopy. The patient presented with recurrent chest infections and dysphagia since he underwent endoscopic procedure for obstructed denture. Barium swallow study revealed fistulous connection between right lower lobe bronchus and esophagus.

Pulmonary tuberculosis and mucormycosis co-infection in a diabetic patient.

Uncontrolled diabetes mellitus is associated with a variety of infections which pose management difficulties. Herein, we report a case of diabetic patient who developed combined pulmonary tuberculosis and mucormycosis. The case illustrates management of this rare co-infection which despite being potentially fatal was treated successfully.

Intra-thoracic desmoid tumor

Desmoid tumor is a rare, benign soft tissue tumor having potential for local invasion. It commonly arises in abdominal wall, presenting as a palpable mass. We describe a case of thoracic desmoid tumor in a middle aged male arising from the chest wall. Unlike the usual presentation, two separate non-palpable tumor masses protruded into left thoracic cavity mimicking lung carcinoma. The patient underwent successful complete surgical excision of the tumor. Such tumors, being rare, may pose diagnostic problems if not considered in the initial work up.

Pulmonary nocardiosis revisited: A case series

Pulmonary nocardiosis is a rising bacterial infection, with a high propensity for misdiagnosis. On account of a paucity of prospective studies, there is limited understanding on various aspects of its diagnosis and treatment. We present three patients with pulmonary nocardiosis, with emphasis on the predisposing factors, variable disease course, and treatment issues. There is a need to understand the basis of these discrepancies so as to rationalize the management of this potentially fatal infection.

CorrespondenceTreatment of extensively drug-resistant tuberculosis

1 Kenyon S, Pike K, Jones D, et al. Childhood outcomes after prescription of antibiotics to pregnant women with spontaneous preterm labour: 7-year follow-up of the ORACLE II trial. Lancet 2008; 372: 1319–27. 2 Saigal S, Rosenbaum PL, Feeny D, et al. Parental perspectives of the health status and health-related quality of life of teen-aged children who were extremely low birth weight and term controls. Pediatrics 2000; 105 (3 pt 1): 569–74. 3 Azizia M, Lloyd J, Allen M, Klein N, Peebles D. Low cord blood monocytes MHC class II expression is associated with sepsis in term and preterm neonates. Arch Dis Child Fetal Neonatal Edn 2008; 93 (suppl 1): F6–F8. 4 Lloyd J, Allen M, Azizia M, Klein N, Peebles D. Monocyte major histocompatibility complex class II expression in term and preterm labor. Obstet Gynecol 2007; 110: 1335–42. 5 Shennan A, Crawshaw S, Briley A, et al. A randomised controlled trial of metronidazole for the prevention of preterm birth in women positive for cervicovaginal fetal fi bronectin: the PREMET Study. BJOG 2006; 113: 65–74.

Serological test for tuberculosis: So near yet so far

1. Corrales-Medina VF, Musher DM. Immunomodulatory agents in the treatment of community-acquired pneumonia: a systematic review. J Infect 2011;63(3):187e99. 2. Chalmers JD, Short PM, Mandal P, Akram AR, Hill AT. Statins in community acquired pneumonia: evidence from experimental and clinical studies. Respir Med 2010;104(8):1081e91. 3. Neuhaus J, Jacobs DR Jr, Baker JV, Calmy A, Duprez D, La RA, et al. Markers of inflammation, coagulation, and renal function are elevated in adults with HIV infection. J Infect Dis 2010; 201(12):1788e95. 4. Sogaard OS, Lohse N, Gerstoft J, Kronborg G, Ostergaard L, Pedersen C, et al. Hospitalization for pneumonia among individuals with and without HIV infection, 1995e2007: a Danish population-based, nationwide cohort study. Clin Infect Dis 2008;47(10):1345e53. 5. Gordin FM, Roediger MP, Girard PM, Lundgren JD, Miro JM, Palfreeman A, et al. Pneumonia in HIV-infected persons: increased risk with cigarette smoking and treatment interruption. Am J Respir Crit Care Med 2008;178(6):630e6. 6. van Sighem A, Smit C, Gras L, Holman R, Stolte I, Prins M, et al. Monitoring report 2011. Human immunodeficiency virus (HIV) infection in the Netherlands. http://www.hiv-monitoring.nl/ nederlands/onderzoek/monitoring-reports/. 7. Moore RD, Bartlett JG, Gallant JE. Association between use of HMG CoA reductase inhibitors and mortality in HIV-infected patients. PLoS One 2011;6(7):e21843.

Significance of sputum purulence to guide antibiotic therapy in exacerbations of COPD

To the Editor: We read with interest the study by Soler et al. 1 evaluating role of sputum purulence as a guide for antibiotic use in hospitalised patients with exacerbations of chronic obstructive pulmonary disease (COPD). Besides bacteria, viruses and air pollution can also lead to exacerbations of COPD. These episodes are characterised by recruitment of leukocytes …

Performance of an interferon-gamma release assay to diagnose latent tuberculosis infection during pregnancy.

To the Editor: Fisher et al1 have nicely evaluated interferon (IFN)-gamma release assays in the diagnosis of latent tuberculosis during pregnancy. In view of the lack of a gold standard test, the efficacy of IFN-gamma release assays may be established by their ability to estimate the risk of active tuberculosis. Hence, it would be useful if authors could provide follow-up data of infected patients who developed active disease. Retrospective evaluation of IFN-gamma levels in such patients may provide a basis for incorporating them in guidelines for tuberculosis management during pregnancy. Further, a prior tuberculin skin test may alter subsequent IFN-gamma levels2 by boosting the anamnestic immune responses measured by IFNgamma release assays.3 Hence, it may lead to decreased specificity of IFNgamma release assays. Because sequence and timing of both investigations were not discussed in the study, it might have affected the results. Additionally, pregnancy is associated with a decrease in the number and activity of T-lymphocytes along with a reduction in adaptive immunity,4 which also may affect the sensitivity of IFN-gamma release assays. In view of confounding factors, it is important that, pending future studies, IFN-gamma release assays in pregnancy be interpreted cautiously in a comprehensive manner.

Closed needle pleural biopsy: A victim of western advancement?

1. Hira HS, Ranjan R. Role of percutaneous closed needle pleural biopsy among patients of undiagnosed exudative pleural effusion. Lung India 2011;28:101.2. Accreditation Council for Graduate Medical Education. Internal medicine program requirements. Available from: http://www.acgme.org/acWebsite/downloads/RRC_progReq/149pr707_ims.pdf. [Last accessed on 2011 May 13].3. Baumann MH. Closed needle biopsy of the pleura is a valuable diagnostic procedure: Pro closed needle biopsy. J Bronchology Interv Pulmonol 1998;5:327.

Role of serum adenosine deaminase in pulmonary tuberculosis

BACKGROUND Definitive laboratory diagnosis and confirmation of tuberculosis remains a major challenge because of lack of specificity and sensitivity of diagnostic methods especially in sputum smear negative tuberculosis. Many studies have proved the role of ADA in diagnosis of tuberculosis in effusion fluids and a decrease in ADA activity after treatment. This study was aimed to investigate the role of serum ADA level as an early diagnostic and prognostic marker for pulmonary tuberculosis (PTB). MATERIAL AND METHODS This was a cohort study done on patients visiting the OPD Clinics of the department of Pulmonary Medicine at GMCH, Chandigarh. 50 sputum positive and 50 sputum negative tuberculosis patients and 100 controls were recruited. Serum ADA levels were measured at the start of treatment and again after two months of treatment. Its correlation with severity of disease was seen. RESULTS Mean serum ADA (IU/L) was found to be 35.293±30.941 in PTB patients and 11.819±8.023 in control groups and the difference was found to be highly significant (P<0.00). Mean ADA was 31.107±29.32 in sputum positive patients, 39.478±32.22 in sputum negative and 11.819±8.0235 in control groups. No statistically significant difference was observed amongst sputum positive and sputum negative patients. The levels decreased significantly after intensive phase of treatment. At the cut off values of 14.6IU/L, serum ADA had 78% sensitivity and 76% specificity (AUC=0.801, P value<0.00) to differentiate between PTB from healthy controls. CONCLUSION Serum ADA levels may be used as a biomarker for diagnosis of PTB and to evaluate the response to treatment at follow up.