Manoj Meena

Diagnosis and management options in malignant pleural effusions

Malignant pleural effusion (MPE) denotes an advanced malignant disease process. Most of the MPE are metastatic involvement of the pleura from primary malignancy at lung, breast, and other body sites apart from lymphomas. The diagnosis of MPE has been traditionally made on cytological examination of pleural fluid and/or histological examination of pleural biopsy tissue that still remains the initial approach in these cases. There has been tremendous advancement in the diagnosis of MPE now a day with techniques i.e. characteristic Ultrasound and computed tomography features, image guided biopsies, fluorodeoxyglucose-positron emission tomography imaging, thoracoscopy with direct biopsy under vision, tumor marker studies and immunocytochemical analysis etc., that have made possible an early diagnosis of MPE. The management of MPE still remains a challenge to pulmonologist and oncologist. Despite having various modalities with better tolerance such as pleurodesis and indwelling pleural catheters etc., for long-term control, all the management approaches remain palliative to improve the quality of life and reduce symptoms. While choosing an appropriate management intervention, one should consider the clinical status of the patient, life expectancy, overall cost, availability and comparative institutional outcomes, etc.

Comparative study of clinico-bacterio-radiological profile and treatment outcome of smokers and nonsmokers suffering from pulmonary tuberculosis

Introduction: Tuberculosis (TB) is one of the leading causes of death and disease worldwide. Tobacco smoking has been linked as a risk factor for TB. This study was aimed to affirm the strength of association between smoking and pulmonary TB. Materials and Methods: Pulmonary TB patients aged between 18 and 65 years were enrolled and followed-up until treatment completion. Two consecutive sputum smears were examined from each patient for the presence of acid-fast bacilli (AFB) using Ziehl-Neelsen technique. Radiological severity of disease was assessed using guidelines of National TB Association of USA. Sputum smears for AFB were graded for positivity as per WHO Revised National TB Control Programme criteria. Response was determined in terms of sputum conversion at the end of intensive phase and final treatment outcomes. Results: Sputum smear grading of 3+ increased from 12.5% to 68.18% and 66.66% as smoking index increased from <100 to 100-299 and >300 (P < 0.05). In nonsmokers, 79.2% patients had minimal disease while only 4.2% had advanced disease as compared to smokers where 52.4% had moderate disease, 26.2% advanced disease, and 21.4% minimal disease (P < 0.01). Smokers had significantly lower treatment success rate (69%) as against nonsmokers and former smokers (93.8% and 90.9%, respectively, P = 0.001) owing to a higher default rate among smokers (28.5%) than nonsmokers (6.3%) and former smokers (9.1%). Conclusion: Smokers during initial presentation, as well as at end of the treatment demonstrate more radiological findings, cavitary disease, and worse sputum AFB smear grading. Smokers also have a poorer treatment success rate largely due to high percentage of default rate thus suggesting noncompliance as a main confounder to treatment success. Focus needs to be made to reduce defaulters which are more common among smokers.

Primary/local hepatic tuberculosis without dissemination

We present a rare case of primary hepatic tuberculosis in a 50-year-old man who presented with pain at the right hypochondrium. The diagnosis was established by fine-needle aspiration cytology (FNAC) of the primary hepatic lesions in both lobes of the liver, which was further supported by histopathological examination and tissue PCR for Mycobacterium tuberculosis in the FNAC specimens.

Absent Unilateral Pulmonary Artery: A Report of Two Cases

Unilateral absent pulmonary artery is an uncommon condition and may be associated with other congenital cardiac defect. Patients without associated cardiac abnormality usually present in adulthood with symptoms of dyspnea, hemoptysis, etc. We encountered two adults with absent right pulmonary artery who presented with hemoptysis and on investigations found to have absent right pulmonary artery. Considering the rarity of this entity, we found it worthy of reporting.

An unusual chest wall swelling mimicking tumorous growth

Chest wall swelling with underlying lung involvement is a rare phenomenon and it poses certain diagnostic challenges as well. It has to be differentiated from other swellings with different underlying etiology. We present a case where a 60-year-old man presented with a progressive chest wall swelling over right sterno-clavicular joint abutting the manubrium sterni. The origin of the swelling resulted from a leak of air from a tense tubercular cavity in the lung parenchyma that was diagnosed with the help of a contrast-enhanced computerized tomography thorax. The case was managed conservatively with antitubercular therapy and evacuation of air from the chest wall swelling by a nasogastric tube.

Abdominal tuberculosis: experience with RNTCP category III antitubercular therapy -

Background: Abdominal tuberculosis as such has been put in seriously ill category III regimen because the therapy of abdominal tuberculosis throws up many challenges, especially those presenting with immune compromised and malnourished state. To accommodate all the accompanying challenges, it is prudent to keep the regimen flexible. Objective: To study the 30- and 60-day efficacy of daily versus alternate-day self-administered therapy of abdominal tuberculosis in young adults with ileocecal tuberculosis (IC) and mesenteric tubercular lymphadenitis (ML). Materials and Methods: This study was conducted for a duration of 2 years, starting June 2013, in an outpatient setting of a tertiary referral center in north India. Patients identified during a study of causes of functional abdominal pain syndrome (FAPS) or “only pain” presentation in gastroenterology (GI) outpatient and diagnosed as IC or ML on the basis of contrast-enhanced computerized tomography (CECT) and/or colonoscopy with ileoscopy were given daily (weight based) versus alternate-day revised national tuberculosis control program (RNTCP) category III regimen therapy in a nonrandom manner. Result: Twelve patients of abdominal tuberculosis were identified: eight cases had IC with varying degrees of gastrointestinal disturbances whereas four had ML with no other organic disease explaining the symptoms. Groups prescribed daily versus alternate-day therapy did not differ significantly because of the presentation as FAPS in young adults. All patients received clinically significant improvement with antitubercular therapy. Four patients prescribed RNTCP category III regimen showed excellent clinical relief. Dyspepsia occurred significantly more with alternate-day therapy. Conclusion: Self-administered DOTS alternate-day therapy according to RNTCP category III regimen is equally efficacious to daily-weight-based regimen in young adults with abdominal tuberculosis.

A study to compare prognostic utility of procalcitonin with existing biomarkers (CRP and TLC) and clinical risk scores (PSI and CURB 65) in community acquired pneumonia

Background: Community-acquired pneumonia (CAP) is a leading cause of morbidity and mortality. Biomarkers are increasingly being used to distinguish bacterial pneumonia from other causes, to help reduce the duration of antibiotic therapy, and to assess the prognosis of CAP and thereby aiming to complement Pneumonia Severity Index (PSI) and other scores. Aims & Objective: To compare prognostic utility of procalcitonin (PCT) with existing biomarkers [C-reactive protein (CRP) and total leukocyte count (TLC)] and clinical risk scores (PSI and CURB-65). Materials and Methods: Fifty patients diagnosed with CAP were included in this study. Baseline serum PCT was measured, which was then stratified according to four predetermined tiers (tier I:

A rare case of pulmonary cysticercosis manifesting as lung cavity with pleural effusion.

Isolated pulmonary cysticercosis is extremely rare manifestation of a rather common disease which is distributed worldwide. Most common sites which provide perfect nourishment for the growth of cysticercosis are muscle and brain followed by eye. Pulmonary involvement in cysticercosis is very rare and if at all present, then ill-defined nodular shadows distributed throughout the lung is the usual radiological presentation. No case of cysticercosis presenting as lung cavity with pleural effusion has been reported so far in literature. We came across a rarest presentation of cysticercosis as cavity in the lung with effusion. After nullifying all the differential diagnosis of cavitary lung lesions, a diagnosis of pulmonary cysticercosis was made by histopathological examination of the lung cavity aspirate and enzyme linked immunosorbent assay (ELISA) for cysticercosis. Case was successfully treated with albendazole (15mg/kg) with steroid cover.

Pneumomediastinum, bilateral pneumothorax and subcutaneous emphysema complicating acute silicosis.

A case of acute silicosis complicating as spontaneous pneumomediastinum, bilateral pneumothorax and subcutaneous emphysema is described in a 35-year-old male engaged in stone crusher unit. Diagnosis was established on clinical and radiological assessment and supported by occupational history of the patient. This case is unique one as all these 3 complications at the same time are very uncommon in acute silicosis.

Tuberculosis of the triceps muscle

A tubercular swelling of the triceps muscle in a 25-year-old immunocompetent man is described in this report. He presented with hard, fixed swelling at the lower end of the triceps muscle. Confirmatory diagnosis was established by fine-needle aspiration cytology (FNAC) of the swelling with subsequent PCR for Mycobacterium tuberculosis of the FNAC specimen. The patient was completely cured with antitubercular therapy.