Sibes Kumar Das

Cerebral tuberculoma as a manifestation of paradoxical reaction in patients with pulmonary and extrapulmonary tuberculosis

Expansion of cerebral tuberculomas or their new appearance as a manifestation of paradoxical reaction in patients under antituberculous chemotherapy is well documented. Distinguishing paradoxical reaction from disease progression or treatment failure is an important issue in tuberculosis management. Five cases of cerebral tuberculomas are reported here as manifestations of paradoxical reaction in patients with pulmonary and extrapulmonary tuberculosis on antituberculous treatment. Case 1 and 2 had tuberculous meningitis, Case 3 had miliary tuberculosis, Case 4 had miliary tuberculosis and destructive vertebral lesions, and Case 5 had pulmonary tuberculosis. Continuation of antituberculous drugs and addition of steroids led to full recovery of all patients.

Isoniazid-induced flu-like syndrome: A rare side effect

Drug-induced flu-like syndrome is very rare. It is mainly produced by rifampicin. We report a case of pulmonary tuberculosis (PTB) that developed isoniazid-induced flu-like syndrome, but could be cured with a modified regimen replacing isoniazid with levofloxacin. A 10-year-old girl with PTB was treated with isoniazid (H), rifampicin (R), ethambutol (E), and pyrazinamide (Z). She developed features of flu from the sixth day. Symptoms recurred everyday within 1 h of drug ingestion and subsided automatically by next 12 h. After admission, HREZ were continued. She developed symptoms of flu after 1 h of drug ingestion. Antitubercular therapy (ATT) was stopped and symptoms subsided automatically. Individual drug was started one by one after three days. Severe symptoms of flu developed after taking isoniazid, while other drugs were tolerated well. Levofloxacin was used as an alternative to isoniazid. She was cured after 6 months of chemotherapy. Isoniazid can possibly cause flu-like syndrome and the treating physician should be aware of this possible side effect when using ATT.

The role of induced sputum in the diagnosis of pulmonary tuberculosis

Background: Microbiological confirmation of pulmonary tuberculosis (TB) is of paramount importance in the era of immunocompromised host and emergence of multi-drug resistance. Objectives: To assess the value of sputum induction (SI) with hypertonic saline nebulization as a diagnostic tool in patients with suspected pulmonary TB who have no/inadequate sputum or have a sputum smear negative for acid fast bacillus (AFB). Materials and Methods: One hundred patients with clinical and radiological evidence of pulmonary TB with no/inadequate sputum or smear negative with spontaneous sputum were studied. Sputum was induced with 20 mL of 3% hypertonic saline solution delivered through ultrasonic nebulizer. The specimens were subjected to Ziehl Neelsen staining and were examined under oil immersion lens for the presence of AFB. The specimens were also subjected to mycobacterial culture in BACTEC 460 TB system. Results: Ninety five patients could produce adequate sputum after SI. Sputum from thirty two patients were found to be positive both in smear and culture while sputum from another three patients were smear negative, but culture positive. Conclusion: SI is a safe, cheap and non-invasive procedure and provides significant yield in the diagnosis of pulmonary TB; thus, increasing the case detection rate of smear positive pulmonary TB.

Closed pleural biopsy is still useful in the evaluation of malignant pleural effusion

Background: Pleural fluid cytology for malignant cells is the easiest way to diagnose malignant pleural effusion with good sensitivity and specificity. With the introduction of medical thoracoscopy, the use of closed pleural biopsy for the diagnosis of cytology negative malignant pleural effusion is gradually decreasing. However use of thoracoscopy is limited due to its high cost and procedure related complications. Aims: The aim was to assess the usefulness of closed pleural biopsy in the diagnosis of malignant pleural effusion. Materials and Methods: Sixty-six patients of pleural effusion associated with malignancy were selected from the patients admitted in the chest ward of a tertiary care hospital over a period of 1 year. Pleural fluid aspiration for cytology and closed pleural biopsy were done in all the patients. Results: Out of 66 patients, 46 (69%) patients showed malignant cells in pleural fluid cytology examination. Cytology was positive in 35 (52%), 10 (15%), and 1 (1.5%) patients in the first, second, and third samples respectively. Closed pleural biopsy was positive in 32 (48%) patients. Among them, 22 also had positive cytology. Additional 10 cytology negative patients were diagnosed by pleural biopsy. Cytology–histology concordance was seen in 12 patients. Definite histological diagnosis could be achieved in five patients with indeterminate cytology. Pleural biopsy was not associated with any major postoperative complication. Conclusion: Closed pleural biopsy can improve the diagnostic ability in cytology negative malignant pleural effusion. Closed pleural biopsy has still a place in evaluation of malignant pleural effusion especially in a resource-limited country like India.

A rare case of Kikuchi-Fujimoto disease

Kikuchi-Fujimoto disease, characterized by histiocytic necrotizing lymphadenitis, closely mimics tuberculosis, and lymphoma are two most common etiologies of cervical lymphadenitis. It is a rare, benign, and self-limited disease. Viral infections or autoimmunity are hypothesized as its etiology, but no causal relationship is definitely established till date. No specific treatment is available, only supportive treatment is given. Here, we represent a rare case of Kikuchis disease in a 29-year-old male patient who presented to us with right-sided posterior cervical lymphadenopathy with low-grade fever for three months.

Presenting experience of managing abdominal tuberculosis at a tertiary care hospital in India

Background: Abdominal tuberculosis remains the great mimic despite years of experience and awareness. Reliable epidemiological data on abdominal tuberculosis are lacking in India. Objectives: To define the most suggestive clinical features of abdominal tuberculosis, to evaluate the usefulness of the normally available investigations, and the response of anti-tuberculous drugs. Study Design: Retrospective study. Materials and Methods: Out of 110 patients attending our hospital between July 2000 and June 2002, with clinical suspicion of abdominal tuberculosis, 46 patients had confirmed abdominal tuberculosis. Their clinico-radiological and cyto / histopathological profiles, side effects of anti-tuberculous drugs, and the outcome of the treatment were analyzed. Results: Weight loss, abdominal pain, and bowel disturbances were the most common symptoms. Anemia and under- nutrition, abdominal tenderness, ascites, and hepato / splenomegaly were the most common findings. Chest radiography showed active or healed tuberculous focus in 16. Ultrasonography revealed abdominal lymphadenopathy, ascites, and mass lesions in 26, 12, and four patients, respectively. Barium examination showed abnormality in eight patients out of 18, among whom it was performed. An ascitic fluid study done in 12 patients showed high adenosine deaminase in all, and positive acid fast bacilli in one. Laparoscopic peritoneal biopsy was done in18 patients, and 13 showed tuberculous granuloma. Treatment success was achieved in 38 patients with anti-tuberculous drugs. Most patients tolerated the anti-tuberculous drugs well. Conclusion: With good clinical examination and appropriate investigations definitive diagnosis of abdominal tuberculosis can be reached in a significant number of patients. Strongly suggestive clinical and laboratory data are also indications for anti-tuberculous therapy in an endemic country like India. Anti-tuberculous drugs are well tolerated and highly effective.

Pancoast syndrome: A rare presentation of non‑Hodgkin's lymphoma

Pancoast syndrome is a common presentation of bronchogenic carcinoma, but other malignancies are rarely cited as its cause. Pancoast syndrome due to non-Hodgkins lymphoma is rarely described in the literature. Here, we report a case of Pancoast syndrome due to non-Hodgkins lymphoma to increase the awareness of the clinicians regarding essentiality of tissue diagnosis of Pancoast tumor before starting the treatment.

Delayed Presentation of Traumatic Diaphragmatic Rupture with Herniation of the Left Kidney and Bowel Loops

Rupture of the diaphragm mostly occurs following major trauma. We report a case of delayed presentation of traumatic diaphragmatic hernia on the left side in a 44-year-old male who presented two weeks after a minor blunt trauma. Left kidney and intestinals coils were found to herniate through the diaphragmatic tear. This case demonstrates the importance of considering the diagnosis in all cases of blunt trauma of the trunk. It also illustrates the rare possibility of herniation of kidney through the diaphragmatic tear.

A rare case of Kartagener's syndrome

A young boy presented with cough and intermittent breathlessness for 3 months. He used to suffer from frequent cough and cold since childhood. Clinical examination revealed bilateral coarse basal crepitations and rhonchi. His apex beat was on right 5th intercostal space in mid-clavicular line. Investigation revealed situs inversus, bi-lateral bronchiectasis, and chronic sinusitis. His semen analysis revealed the complete absence of sperm. The Saccharin test revealed impaired nasal ciliary movement. Considering all the finding, he was diagnosed as a case of Kartageners syndrome. We are reporting this case because of its rarity and rare presence of aspermia in Kartageners syndrome.

Bronchogenic Carcinoma with Cardiac Invasion Simulating Acute Myocardial Infarction.

Cardiac metastases in bronchogenic carcinoma may occur due to retrograde lymphatic spread or by hematogenous dissemination of tumour cells, but direct invasion of heart by adjacent malignant lung mass is very uncommon. Pericardium is frequently involved in direct cardiac invasion by adjacent lung cancer. Pericardial effusion, pericarditis, and tamponade are common and life threatening presentation in such cases. But direct invasion of myocardium and endocardium is very uncommon. Left atrial endocardium is most commonly involved in such cases due to anatomical contiguity with pulmonary hilum through pulmonary veins, and in most cases left atrial involvement is asymptomatic. But myocardial compression and invasion by adjacent lung mass may result in myocardial ischemia and may present with retrosternal, oppressive chest pain which clinically may simulate with the acute myocardial infarction (AMI). As a result, it leads to misdiagnosis and delayed diagnosis of lung cancer. Here we report a case of non-small-cell carcinoma of right lung which was presented with asymptomatic invasion in left atrium and retrosternal chest pain simulating AMI due to myocardial compression by adjacent lung mass, in a seventy-four-year-old male smoker.