Sourin Bhuniya

Role of therapeutic thoracentesis in tuberculous pleural effusion

CONTEXT: Prevalence of tuberculous pleural effusion is very high in the Asian subcontinent but very few studies have come up from this part of the world about the course of recovery of pulmonary functions after institution of anti-tubercular therapy (ATT) and thoracentesis. AIMS: To study initial lung function impairment, changes over time after institution of ATT and thoracentesis and residual abnormalities left at the end of six months of treatment. SETTINGS AND DESIGN: Randomized open level interventional study over two years in 52 patients at a tertiary level teaching hospital. METHODS: The study population was divided into two equal groups, A (therapeutic thoracentesis) and B (diagnostic thoracentesis). Spirometry, chest radiograph and ultrasonography of thorax were done initially and at each follow-up visit up to six months. Statistical analysis was done (P value < 0.05 considered significant). RESULTS: Both groups were comparable initially. After six months none in group A and five patients in group B had minimal pleural effusion. During follow up, mean percentage predicted of FEV1 and FVC increased more in A than in B and the differences were statistically significant (P < 0.05). Pleural thickening, initially absent in both groups, was found to be more in B as compared to A at subsequent follow-up visits and this was statistically significant (P < 0.05). CONCLUSIONS: Thoracentesis should be considered in addition to anti-TB treatment, especially in large effusions, in order to relieve dyspnea, avoid possibility of residual pleural thickening and risk of developing restrictive functional impairment.

Extensively drug-resistant tuberculosis in South Africa

This letter comments on Keertan Dheda and colleagues report of extremely poor treatment outcomes for patients with extensively drug-resistant (XDR) tuberculosis in South Africa. It states that an important strategy to prevent XDR tuberculosis is to ensure adequate treatment for multidrug-resistant (MDR) tuberculosis.

Five-years experiences of the Revised National Tuberculosis Control Programme in northern part of Kolkata, India.

Background: The Revised National Tuberculosis Control programme (RNTCP), India. Aim: To assess the impact of the expansion of the RNTCP in the case detection and treatment outcome. Materials and Methods: Reports of patients with tuberculosis (TB) diagnosed and treated under RNTCP from 2001 to 2005 under Bagbazar TB unit (TU), Kolkata, reviewed retrospectively. Results: Of 2814 cases registered between 2001 and 2005, 1268 were new smear-positive pulmonary TB (PTB), 308 were new smear-negative PTB and 536 were new extrapulmonary TB (EPTB). During that period, the new smear-positive case detection rate increased from 41 to 61 per lakh population, the annual total case detection rate increased from 87 to 142 per lakh and the treatment success rate reduced from 90% to 76%. The default and failure rates increased from 7% to 10% and from 3% to 10%, respectively. Conclusion: A steady increase was observed in the annual total case detection rate and annual new smear-positive case detection rate from 2001 to 2005, but the 3-month conversion rate and cure rate of new smear-positive patients were progressively decreased. Default rate and treatment failure rate of new smear-positive patients were also increased. So it needs extra attention and evaluation of this disappointing treatment outcome.

A rare mediastinal tumour in a young male mimicking massive pleural effusion

A 30-year-old male, carpenter by profession, presented with a history of dry cough and progressive shortness of breath for two months along with right-sided chest pain for one and a half months. The clinico-radiological picture was suggestive of right-sided massive pleural effusion. Computed tomography (CT) scan of the thorax showed a huge mediastinal mass occupying the entire right hemithorax with very small amount of pleural effusion. CT-guided fine needle aspiration cytology and tru-cut biopsy from the mass both revealed small round-cell tumour, possibly small cell carcinoma of the lung. However, on immunohistochemistry tumour cells expressed Mic-2 and it was consistent with a diagnosis of primitive neuroectodermal tumour.

A study on non-resolving pneumonia with special reference to role of fiberoptic bronchoscopy.

Context: Non-resolving pneumonia is often an area of concern for pulmonologists. Fiber optic bronchoscopy (FOB) may have a special role in etiologic evaluation of non-resolving pneumonias. There is paucity of recent studies in this field. Aims: This study aimed to assess the patients of non-resolving or slowly resolving pneumonia with special emphasis on efficacy of FOB and computed tomography (CT)-guided fine needle aspiration cytology (FNAC) in diagnosis. Settings and Design: Prospective, observational study conducted in a tertiary care institute over a period of one year. Materials and Methods: After fulfilling the definition of non-resolving pneumonia by clinical and radiological parameters, patients were evaluated by FOB with relevant microbiological, cytological, histopathological investigations and CT scan of thorax. CT-guided FNAC was done in selected cases where FOB was inconclusive. Results: Sixty patients were enrolled in the study. Mean age was 51.33 ± 1.71 years with male to female ratio 2:1. Right lung was more commonly involved (65%), and right upper lobe was the commonest site (25%). Pyogenic infection was the commonest etiology (53.3%), bronchogenic carcinoma and tuberculosis accounted for 26.7% and 16.7% cases, respectively. Both, FOB (85.7%) and CT-guided FNAC (91.67%) were very useful for etiological diagnosis of non-resolving pneumonia. Both the procedures were safe, and no major complication was observed. Conclusions: Because of the high yield of FOB, it is very useful and safe diagnostic tool for evaluation of non-resolving pneumonia. CT-guided FNAC also gives good yield when cases are properly selected.

A case of squamous cell carcinoma of lung presenting with paraneoplastic type of acanthosis nigricans.

A 70-years-old male presented with blackening of both hands and face for last six months which was progressive and attended dermatology outpatients department. Dermatologist opined the skin lesions as acanthosis nigricans. He was referred to our department to evaluate for any underlying internal malignancy as he was a smoker. His chest X-ray revealed right sided hilar prominence with a mid zone cavity with fluid level. Fibreoptic bronchoscopy was done, there was one ulcerative growth in right middle lobe bronchus. Biopsy from the ulcer revealed probable squamous cell carcinoma. CT scan of thorax was also done and CT guided FNAC of Rt lung lesion yielded non small cell carcinoma. His skin lesions were also biopsied and diagnosis of acanthosis nigricans was confirmed. Here we report a case of acanthosis nigricans associated with non-small cell cancer of lung.

Role of sputum examination for acid fast bacilli in tuberculous pleural effusion

Background: Sputum for acid fast bacilli (AFB) is seldom looked for in the etiological diagnosis of tuberculous pleural effusion usually due to the absence of any parenchymal lesion radiologically, but presence of tubercle bacilli in sputum may have important epidemiological and therapeutic implication. Aims: This study aims to evaluate the role of sputum examination for AFB in the patients of tuberculous pleural effusion with no apparent lung parenchymal lesion radiologically. Settings and Design: Forty-five consecutive indoor patients of suspected tuberculous pleural effusion having no apparent lung parenchymal lesion on chest radiography were selected for our study. It was a prospective and observational study conducted over a period of 1 year. Materials and Methods: After confirming the etiology of pleural effusion as tuberculous by biochemical, cytological, histopahtological, and microbiological tests, emphasis was given on sputum examination for AFB by smear examination and culture for Mycobacterium tuberculosis. Results: Sputum was bacteriologically (smear and /or culture) positive for tuberculosis in 10 out of 30 cases (33.33%) in which tuberculous etiology was confirmed by histology and /or bacteriology (definite tuberculosis). No sputum AFB (smear and culture) was found in 15 cases of probable tuberculosis where tuberculous etiology was established by indirect methods like Adenosine de aminase level more than 40 unit/l and other relevant investigations. Over all, sputum was bacteriologically smear and/or culture positive in 10 out of 45 cases (22.22%). Conclusion: Careful and thorough sputum examination in cases of tuberculous pleural effusion may help as a diagnostic tool and it has therapeutic and epidemiological implications.

Was it really hepatic hydrothorax

1300 www.thelancet.com Vol 376 October 16, 2010 Authors’ reply Although we noticed loculations on CT scan, the fl uid was transudative in origin. In a study by Chung and colleagues, 30 of 120 patients with loculations on ultra sonography turned out to have a transudate eff usion. The mechanism behind the loculation in a transudative eff usion is unclear and could possibly be a result of any previous pulmonary process. Even though fl uid was a transudate on Light’s criteria, which are very specifi c for diagnosis of transudative effusions, we did an extensive work-up to rule out all possible causes of pleural eff usion including those causing exudative eff usions as mentioned by Sourin Bhuniya. Once all causes were ruled out, hepatic hydrothorax was considered a possibility. After establishing the defi nitive presence of portal hypertension by hepatic vein catheterisation, transjugular intrahepatic portosystemic shunt (TIPS) was done. The success of TIPS in preventing reaccumulation of pleural eff usion in itself supports our diagnosis Although talc pleurodesis was done in Gulati and colleagues’ patient, the safety of talc pleurodesis has been questioned over and again, especially in North America where lung injury after thoracoscopic talc insuffl ation is reported even today.