Sandeep Sahay

Bronchial anthracofibrosis and tuberculosis presenting as a middle lobe syndrome

Bronchial anthracofibrosis, a clinical entity described less than a decade ago, is characterised by anthracotic pigmentation of the bronchial mucosa with multifocal bronchial lumen narrowing. The right middle lobe is predominantly involved and is frequently associated with tuberculosis. The condition is generally seen in non-smoking elderly ladies with a longstanding history of wood smoke exposure. A 65 year-old lady presented to us with a one-month history of dry cough. The chest radiograph revealed a middle lobe syndrome which was confirmed on computed tomography (CT) scanning. In addition, narrowing of the right middle lobe bronchus was seen. This raised the suspicion of a malignancy. Fibreoptic bronchoscopy revealed anthracotic pigmentation, and bronchial aspirate showed acid fast bacilli. Culture of the aspirate grew Mycobacterium tuberculosis. The patient responded to standard antituberculous treatment.

Partial anomalous pulmonary venous connection and pulmonary arterial hypertension

Background and objective:  Isolated partial anomalous pulmonary venous connection (PAPVC) has been implicated as a cause of pulmonary arterial hypertension (PAH); however this condition is often overlooked in the diagnostic work up of patients with PH. We studied the prevalence of PAH both in patients with isolated PAPVC or associated with other congenital heart diseases (CHD) such as atrial septal defect (ASD). We also aimed to identify factors related to the presence of PAH in these patients.

Pericardial effusion in pulmonary arterial hypertension

Pulmonary arterial hypertension (PAH) is a serious condition that can lead to right heart failure and death. Pericardial effusion in PAH is associated with significant morbidity and mortality, and its pathogenesis is complex and poorly understood. There are few data on the prevalence of pericardial effusion in PAH, and more importantly, the management of pericardial effusion is controversial. Current literature abounds with case reports, case series, and retrospective studies that have limited value for assessing this association. Hence, we summarize the available evidence on this ominous association and identify areas for future research.

Ventricular fibrillation caused by extrinsic compression of the left main coronary artery

A 43-year-old woman with a history of ventricular septal defect (VSD) closure, pulmonary hypertension and partial Eisenmengers physiology presented with in-field v-fib arrest. She was defibrillated to normal sinus rhythm. Echocardiography revealed dilated right ventricle (RV), right ventricular hypertrophy (RVH) and right ventricular systolic pressure (RVSP) of 88 mm Hg. A robust right-to-left shunt through a patent foramen ovale (PFO) was seen. A coronary CT angiogram revealed compressed left main coronary artery (LMCA) by severely dilated …

Pleural effusions in acute and chronic leukemia and myelodysplastic syndrome

Purpose of review Pulmonary manifestations have been well described in leukemia, but pleural disease is less common. This review highlights pleural effusions in acute and chronic leukemia and myelodysplastic syndrome (MDS) based on the evidence to date. Diagnostic workup and recommendations for the management of these effusions are also outlined. Recent findings Pleural effusions in patients with leukemia are most often due to infection and to a lesser extent leukemic infiltration of the pleura. The prognostic implications of these effusions are unclear, but survival is most likely determined by the underlying malignancy and its response to treatment. New therapies have changed survival in these patients, and some of these treatments, such as tyrosine kinase inhibitors, have emerged as important causes for these effusions. Pleural interventions may be accomplished with few complications. Summary Pleural effusions may occur with acute and chronic leukemia and MDS. Infection remains the most common cause. Malignant pleural effusions tend to occur in advanced disease in chronic leukemia, but they can be seen at any time with acute leukemia and MDS. With standard precautions, pleural procedures may be performed safely in this population. In cases of unclear cause, pleural and bone marrow biopsy should be considered.

Calcineurin-inhibitor induced pain syndrome in a lung transplant patient

Dear Sirs, The increasing number of transplant patients has changed the spectrum of the diseases encountered by the physicians. Calcineurin inhibitors (CIs) such as cyclosporine and tacrolimus, play a central role in the success of a transplanted organ. However, these agents are highly toxic and are associated with a variety of adverse effects including musculoskeletal pain syndrome [1–3]. CIs have recently been implicated as the causative agents for the posttransplant pain syndrome [4,5]. In 2001, Gortz et al. [5] coined the term Calcineurin-inhibitor pain syndrome (CIPS) for this pain syndrome. It is important to recognize this entity early, as in some patients it leads to significant morbidity in the affected patient [6]. We describe here, the first case of CIPS occurring in a post lung transplant patient. A 34-year-old Caucasian male, after 8 years of bilateral lung transplantation for cystic fibrosis, presented with intractable joint pain of 3 months duration. Pain was severe in intensity and was present in bilateral ankles, knees, elbows, and the right shoulder. It was symmetrical, sharp, stinging, and intermittent that got worse when standing or walking, making ambulation difficult. Patient did not report any associated tingling, numbness, fever, joint edema, stiffness or rash. Examination revealed moderate distress because of pain, marked tenderness in any active or passive joint movement in ankles, knee, and hip joints. Examination of the joints had to be aborted as patient refused to cooperate because of the pain. Neurological examination revealed no obvious sensory or motor deficits. Patient was currently taking tacrolimus (3 mg in morning and 2.5 mg in evening) along with prednisone 5 mg daily as immunosuppressive therapy. In addition to cystic fibrosis, he also had pancreatic insufficiency, diabetes mellitus, renal insufficiency, gastroparesis, hypertension, depression, and sinusitis. The laboratory data revealed a normal tacrolimus trough level of 10.4 ng/ml (5-20 ng/ ml). A comprehensive work to evaluate joint pain for rheumatologic diseases, porphyria, and neuropathy was inconclusive. Radiographs of the involved joints were normal. The bone scintigraphy scan showed increased tracer uptake bilaterally in the ankle, knee (along with tibial shaft), hip joints, and shoulder (Fig. 1a). The magnetic resonance imaging (MRI) of the bilateral hips and ankles revealed marrow edema that was extending into the shaft of the femora (Fig. 1b and c). A triad of unremarkable radiographs, increased uptake on bone scintigraphy, and bone marrow edema on MRI supported the diagnosis of CIPS. Along with the supportive care, pain control, the dose of the tacrolimus was reduced to the half of his current dose and amlodipine 5 mg was also started. This led to the rapid improvement in his symptoms. His repeat tacrolimus level was 7.8 ng/ml after stopping tacrolimus. Within 3 months, he was able to ambulate without any pain or residual disability. In summary, CIPS is a rare entity occurring in 1% of solid organ transplant patients [5]. Lucas et al. [4] described a musculoskeletal pain syndrome for the first time after the initiation of calcineurin inhibitor therapy that disappeared after the discontinuation of cyclosporine in renal transplant patients. This pain syndrome remained uncharacterized until Grotz et al. [5] highlighted the three typical radiological signs: (i) normal initial radiograph, (ii) increased tracer uptake on the bone scintigraphy, and (iii) bone marrow edema on MRI leading to conceptualization of CIPS. All three of these findings were observed in the patient described here. Pain in CIPS is usually symmetrical with no skin changes, episodic, and self-limiting. CIPS is reversible and is associated with CIs. Our patient developed avascular necrosis of his bilateral hip joints secondary to the prolonged corticosteroid therapy; however, at the same time he had symptoms affecting other joints along with radiological findings to support the diagnosis of CIPS. The onset of CIPS is variable. It has been d as early as 3 days following the intravenous infusion of cyclosporine [7] and as late as 8 years, as seen in our patient. Similarly, association with the trough levels of the CIs is variable too. There are reports, which showed its association with elevated trough levels of the CIs [5,8–10]; nevertheless, there is an accumulating evidence to suggest an association with the normal therapeutic levels [11,12]. A proposed hypothesis of the pathogenesis of CIPS is shown in the Fig. 1d [5,13,14]. To date, there is no specific therapy for

Management of combined pre- and post-capillary pulmonary hypertension in advanced heart failure with reduced ejection fraction

Management of pulmonary hypertension (PH) has remained an unmet need in advanced left heart failure with reduced ejection fraction. In fact, patients are frequently denied heart transplant due to untreated pulmonary hypertension. The availability of mechanically circulatory devices and PH therapies has provided a ray of hope. PH specific therapies are currently not FDA approved for patients with left heart failure with reduced ejection fraction. However, clinicians have used these medications in anecdotal manner. With this review, we want to highlight the expanding use of PH specific therapy and mechanical circulatory devices in the management of PH in the setting of advanced heart failure with reduced ejection fraction.

DIURNAL VARIATION IN HAND HYGIENE COMPLIANCE IN A TERTIARY LEVEL MULTIDISCIPLINARY INTENSIVE CARE UNIT

Background: Hand hygiene compliance among health care providers is considered to be the single most effective factor to reduce hospital acquired infections. Despite continuous education and awareness, compliance with hand hygiene guidelines has remained low, particularly during evening shifts. Objective: Our objective was to determine the compliance with hand hygiene guidelines among doctors, nurses, and paramedical staff during day and night duties in a multidisciplinary intensive care unit (ICU). Methods: We used a prospective, observational, 6-month study conducted in a 34-bed ICU within a tertiary care teaching hospital. All doctors, nurses, and paramedical staff in the ICU were included. An investigator, placed within the ICU setting, observed the hand hygiene practices during day and night. Day and night shift change times were 08:00 and 20:00 hours, respectively. Results: Of the 5639 opportunities for hand hygiene, 3383 (59.9%) were properly performed. Overall rates of compliance were 66.1% for doctors, 60.7% for nurses, and 38.6% for paramedical staff. Hand hygiene compliance dropped during the night for doctors (81% vs 46%, respectively, P , .001), for nurses (64% vs 55%, respectively, P 5 .02), and for paramedical staff (44% vs 31%, respectively, P 5 .01). Characterization of noncompliance is as follows: ‘‘No handwashing after procedure’’ in 41%,‘‘improper duration of handwashing’’ in 32%, and ‘‘no handwashing done at all’’ in 27% of the events.‘‘No handwashing done at all’’ occurred in 55% of the time at night with doctors having the highest rate of noncompliance, making 163 (34%) contacts without handwashing. Conclusion: Whereas compliance with hand hygiene guidelines was lower at night compared with day, irrespective of discipline in all 3 groups of health care providers, both periods of compliance would benefit from additional training focusing on the importance of hand hygiene around the clock.