Sc Tewari

PREVALENCE OF DRUG RESISTANT TUBERCULOSIS IN ARMED FORCES-STUDY FROM A TERTIARY REFERRAL CHEST DISEASES HOSPITAL AT PUNE

This study was conducted to find out the prevalence and pattern of primary and acquired resistance to antimycobacterial drugs among patients of pulmonary tuberculosis, in Armed Forces. Out of 2562 clinically diagnosed patients of tuberculosis, in a span of three years, 1146 were bacteriologically positive. The study included only 1120 smear and culture positive cases, and excluded 26 cases in which no growth was obtained on culture. 192 out of 1120 cases (17.14%), showed overall resistance to one or more antituberculous drugs (ATD). Primary drug resistance (PDR) was observed in 161 (14.37%) and acquired drug resistance (ADR) in 31 isolates (2.77%). Of the resistant cases on short course chemotherapy (SCC), single drug resistance was observed in 99 (51.56%), resistance to any two drugs in 63 (32.81%), and three or more drugs in 30 (15.62%) cases. Analysis of resistance to specific drug revealed 26.56% for streptomycin (S), 15.10% for rifampicin (R), 7.29% for isoniazid (H), 2.08% for pyrazinamide (P) and 0.52% for ethambutol (E). Resistance to H and R was present in 4.16% strain and their combination with other drugs resistance was in 16.14% of the drug resistant strains, thus constituting 2.76% of the total sputum positive cases. A group of 26 cases is also discussed, where there was discrepancy in clinical status and bacteriological parameters and treatment for multi-drug resistant tuberculosis (MDR-TB) was instituted.

FORGOTTEN FOREIGN BODIES IN BRONCHIAL TREE IN ADULT (A REPORT OF TWO CASES AND REVIEW OF LITERATURE)

Aspiration of foreign bodies into bronchial tree is rare in adults compared to children [1]. In adults foreign body aspiration is usually immediately identified as the episode occurs [2]. However, off and on reports appear in literature when even large foreign bodies have been aspirated by fully conscious adults without remembrance of the episode [3, 4]. Subsequent sequelae like recurrent infections, lobar collapse or bronchiectasis may bring to light the presence of foreign bodies [5]. We present two such cases treated at our centre. Case Report-1 A 29 year old male soldier from Nepal presented in June 98 to a peripheral hospital with complaints of right-sided pleuritic chest pain, cough with mucoid expectoration and moderate fever with chills for 3 days. He gave history of pneumonia on right side in April 97. He was febrile. There was clinical and radiological evidence of pneumonia of right lower lobe with a small pleural effusion. Investigations showed a leucocytosis of 10,600/cmm with 78% polymorphs. Pleural aspirate was exudate with predominant cells being polymorphs. Culture of aspirate was sterile. He was treated with parenteral antibiotic combinations. He became asymptomatic after 3 weeks but there was residual pleural thickening on chest X-ray. He again became symptomatic after two months with recurrence of pneumonia at the same site (Fig-1). He was treated with a course of antibiotic with which there was partial resolution and he was transferred to a referral chest disease centre. A fibreoptic bronchoscopy done there, showed evidence of extensive granulation tissue in right main bronchus and a “feel” of a foreign body beyond that area but the same could not be confirmed. Fig. 1 Right lower lobe pneumonic consolidation At this centre also even on persistent questioning he denied any history of foreign body aspiration, drunken spell, epilepsy or general anaesthesia. A CT scan chest (Fig-2) showed bronchial wall thickening and partial obstruction of lumen of right main bronchus with high attenuating lesion. There was air trapping in right lower lobe. On fibreoptic bronchoscopy, it was confirmed that there was a foreign body impacted in the right main bronchus but only its tip was visible and it was well surrounded by granulation tissue. Finally, using a rigid bronchoscope under general anaesthesia a partial base of denture, 4.5 cms in length was removed (Fig-3). On persistent probing, the patient recalled that he had been given a partial denture in October 1995 after he had lost his lower incisor teeth following an accident. A few months later, he lost that denture during a train journey. He was then given another denture, which he was still using. Following foreign body removal, he recovered completely. Fig. 2 CT scan thorax : thickened wall and granulation tissue right bronchus (foreign body non radio-opaque) Fig. 3 4.5 cm long base of denture removed from right bronchus Case Report-2 A 32 year old soldier was investigated for extensive right lower lobe bronchiectasis. Fever with foul expectoration had been recurring for 6 months despite treatment with antibiotics etc. at various hospitals. Clinical and radiological examination confirmed extensive right lower lobe bronchiectasis (Fig-4). The patient denied any history suggestive of a foreign body aspiration. He also had no predisposing factor for the same. He was referred for surgical excision. Fibreoptic bronchoscopy was done, which revealed a hard concretion blocking the bronchus intermedius. This hard object was caught with a grasping forceps and removal was attempted. There was bleeding, oozing of pus and fibreoptic bronchoscopy vision was poor when the foreign body was pulled out; it was stuck in the nasopharynx. The patient was asked to cough as the forceps grip was loosened. It was a surprise to see that the foreign body was a large part of a bone (goat vertebra) (Fig-5). On subsequent questioning the patient admitted to have had a prolonged episode of coughing nine months ago when he had a mutton biryani meal along with alcohol. Fig. 4 Right lower lobe bronchiectasis and pneumonia (foreign body not well visualised) Fig. 5 Large piece of bone removed from right bronchus Discussion Tracheobronchial foreign body may be defined as any solid object aspirated below the level of vocal cords [2]. Foreign body aspiration is frequently suspected in children with acute or recurrent pulmonary symptoms. However, it is rarely considered in adults with subacute or chronic respiratory symptoms, unless the patient gives a clear history of an aspiration event. The most important factor in detection of a tracheobronchial foreign body is a high index of suspicion [2]. Forgotten episode of a foreign body aspiration in adults may remain undetected for years. These cases are usually diagnosed as chronic pneumonia [6], bronchiectasis [1] and lung abscess or rarely as malignancy. The longest bronchial foreign body retention in an adult recorded in medical literature is 40 years [2]. Radiolucent foreign bodies may be missed on routine chest X-ray [7]. This happened in both our cases. In the second patient perihiliar structures in chest X-ray masked the foreign body. Commonly aspirated tracheobronchial foreign body are bone fragments including fish bones [4], organic matter like peanuts, corn and beans [8] as well as straight and safety pins [2]. There are also reports of aspiration of cobblers shoe nail [6], teeth [9], stones, coins and buttons [2]. Lodgment of a foreign body is more common in the right side due to anatomic structuring especially in the intermedius and basal bronchi [2]. Precipitating factors include altered consciousness, fits, dental procedures, facial trauma and intubation [2]. Many patients do not have any precipitating factors. In our first case, no precipitating factor was obvious while second case had alcohol intake prior to a non-vegetarian meal. Recurrent infection caused by the impacted foreign body is usually localised to a lobe as was seen in both our cases. Pieces of denture are not infrequently aspirated by adults, but the long term unsuspected presence in an airway is uncommon. In such cases, a history of seizures or alcohol consumption is usually present [10]. It is important to remember that chronic unexplained respiratory symptoms with lobar consolidation, collapse or bronchiectasis appearing in an otherwise healthy adult should alert the clinician for investigations to exclude a retained foreign body in tracheobronchial tree. Finding of granulation tissue on bronchoscopy is also an important clue to the presence of foreign body as occurred in our first case. Definitive treatment of tracheobronchial foreign body aspiration is removal as soon as possible [2]. Chronic sequelae like bronchiectasis may persist and need further management. Granulation tissue may cause difficulty in diagnostic recognition of foreign body and interfere with removal as occurred in our cases. It is stressed that foreign body removal is safer and preferred with rigid bronchoscopes in most situations.

A PERSISTENT TRANSPLEURAL FISTULOUS COMMUNICATION BETWEEN LUNG AND CHEST WALL

Lung abscess is a suppurative necrotizing collection occurring within the lung parenchyma. Symptoms of lung abscess include productive cough, fever, weight loss, putrid sputum and leukocytosis. Most lung abscesses are caused by mixed bacterial flora. Anaerobes are causative organism in 90% of lung abscesses, whereas aerobes often coexist in upto 50% of patients. Typically chest radiograph reveals a solitary cavitary lesion measuring around 4.0 em in diameter with an air fluid level. Among the complications are progression to a chronic stage, empyema, hemoptysis, metastatic abscesses and bronchopleural fistula (BPF). Treatment of lung abscess is primarily medical consisting of an appropriate antibiotic regimen and chest physiotherapy. Surgery is reserved for unresponsive patients or those with complications. We report a case of lung abscess that ruptured into chest wall through a transpleural fistulous communication. This is a very rare event, which was diagnosed by imaging modalities and successfully treated by antibiotics. Interestingly this fistulous communication persisted even six months after treatment.

MULTIDRUG RESISTANT TUBERCULOSIS – BIOMECHANISM, EPIDEMIOLOGY AND MANAGEMENT STRATEGIES

Muitidrug resistant tuberculosis has shown an alarming increase and this assumes added importance in view of the increasing number of HIV infected patients. This article reviews the biomechanism of resistance and discusses the present stategies that are available and recommended to tackle the rising incidence of tuberculosis due to resistant mycobacteria.

A COMPARATIVE STUDY OF CHEST RADIOGRAPHIC FEATURES BETWEEN HIV SEROPOSITIVE AND HIV SERONEGATIVE PATIENTS OF PULMONARY TUBERCULOSIS

Chest radiographic appearance of pulmonary tuberculosis (TB) in Human Immunodeficiency Virus (HIV) positive patients was reviewed. A study group of 50 HIV +ve cases and a control group of 100 HIV -ve cases were analysed. The chest radiographs of HIV seropositive group showed significantly higher incidence of thoracic lymphadenopathy (36% vs 8%, P<.001), pleural effusion (28% vs 10%, P<.01) and miliary pattern (12% vs 2%, P<.05) as compared to the seronegative group. Cavitation was less common in the seropositive group (8% vs 35%, P<.001) than the seronegative group. Upper zone involvement was significantly less common in the study group (38% vs 77%, P<.001) as compared to the control group.

SCLEROSING HAEMANGIOMA OF LUNG PRESENTING AS SPONTANEOUS HAEMOTHORAX

Sclerosing haemangioma was first described by Leibow and Hubbell [I] in 1956. This is a rare differential diagnosis of pulmonary nodule, which is much commoner in young females. Initially it was thought to be of endothelial origin but some recent electron microscopic studies have demonstrated surfactant apoprotein, their origin being suspected from type II pneumocytes. We present here a young lady of 37 years who presented with sudden spontaneous haemothorax and left lower lobe atelectasis due to nodular mass in perihilar area in lower lobe with absorption atelectasis. Diagnosis was made by histopathological studies after removal of the mass on surgery. We have not come across any case report of this lesion presenting as sudden massive spontaneous haemothorax and major lobar atelectasis.

MALAKOPLAKIA OF LUNG IN AN IMMUNOCOMPROMISED PATIENT

Malakoplakia of the lung is rare and till 1999 only 14 cases had been described in medical literature, in AIDS patients. It is an unusual inflammatory process of unknown cause which is characterised by yellow brown plaques composed primarily of macrophages with large PAS positive intracytoplasmic inclusions and concentrically laminated calcific spherules known as Michaelis Gutmann bodies [4]. It clinically simulates malignancy in a variety of organs and most commonly it affects the lower urinary tract [5]. We describe here a case of pulmonary malakoplakia in an immunocompromised host.

AN EPIDEMIC OF PLEURISY AMONGST MILITARY RECRUITS

An epidemic amongst recruits who presented with acute viral exudative pleural effusion with lymphocytic pleocytosis is analysed. Histologic and bacteriologic proof of tuberculosis was lacking in majority. Most of them recovered without pleural thickening. Overcrowding, inadequate clothing protection, stress and strain of vigorous recruit training could be important precipitating factors. None reported with parenchymal tuberculosis in two year follow up.

MANAGEMENT OF LUNG ABSCESS WITH PERCUTANEOUS CATHETER DRAINAGE

Percutaneous catheter drainage was used to treat 12 among 34 cases of lung abscesses, who were refractory to medical therapy, severely ill and high risk cases for surgery. A complete clinical and radiological recovery was achieved in all the cases who underwent catheter drainage, thereby obviating the need for surgery. None of the cases had catheter or procedures related complications. From this study it is inferred that percutaneous transthoracic catheter drainage is a safe and an effective modality of therapy for patients with lung abscess in whom medical therapy has failed and those who are unsuitable for surgery.

Review ArticleMULTIDRUG RESISTANT TUBERCULOSIS – BIOMECHANISM, EPIDEMIOLOGY AND MANAGEMENT STRATEGIES

Muitidrug resistant tuberculosis has shown an alarming increase and this assumes added importance in view of the increasing number of HIV infected patients. This article reviews the biomechanism of resistance and discusses the present stategies that are available and recommended to tackle the rising incidence of tuberculosis due to resistant mycobacteria.