Tapan Das Bairagya

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.

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.

Immune thrombocytopenic purpura associated with pulmonary tuberculosis

Thrombocytopenic purpura as a manifestation of pulmonary tuberculosis is very rare. We report a case of 25-year-old female who presented with thrombocytopenia-induced purpuric spots and an abnormal chest X-ray. There was no hepatosplenomegaly while the bone marrow examination revealed normal maturation of myeloid and erythroid series with increased megakaryocytes. Acid fast bacilli were seen in the sputum microscopy. A diagnosis of sputum smear positive pulmonary tuberculosis along with immune thrombocytopenia was made. High dose intravenous immunoglobulin therapy along with antituberculous drugs corrected the thrombocytopenia and also cured pulmonary tuberculosis. This case report illustrates the causal association between immune thrombocytopenia and tuberculosis.

Tuberculosis verrucosa cutis: A case report from a rural medical college of India

We report a case of tuberculosis verrucosa cutis (TBVC) on the foot that had been present for more than 6 years in a 42-year-old man. He had a positive Mantoux test and a normal chest radiograph. This case demonstrates the indolent nature of the disease. The diagnosis of TBVC should be based on history and evolution of the disease, cardinal morphological features and histopathological characteristics. Adequate therapeutic response may also helpful.

Silicosis presenting with simultaneous bilateral spontaneous pneumothorax

Secondary unilateral spontaneous pneumothorax can occur in a silicosis patient. We are reporting a case of bilateral simultaneous pneumothorax in a silicosis patient.

Staphylococcal tricuspid valve endocarditis in a non-addicted patient with structurally normal heart

Tricuspid valve endocarditis in non-addicted patients without underlying cardiac disease is extremely rare. Therefore, its diagnosis often presents a clinical challenge. We report a case of a 24-year-old female who presented with bilateral lower lobe cavitary pneumonia. She remained febrile in spite of 5 days of intravenous antibiotic therapy. On subsequent investigations, she was found to have isolated tricuspid valve endocarditis caused by Staphylococcus aereus . She was not an intravenous drug abuser and there was no underlying cardiac disease. She responded well to medical therapy. We report this case because of rarity of tricuspid valve endocarditis is a non-addicted person with structurally normal heart and its atypical presentation with paucity of cardiac symptoms at initial stage.

A comparative study of efficacy and safety of arformoterol and salbutamol nebulization as rescue therapy in acute non-severe asthma

Arformoterol, a long-acting beta-2 agonist, has a rapid onset and long duration of action. Its role as rescue medication in acute asthma attack is undetermined. To compare the efficacy and tolerability of arformoterol with salbutamol nebulization, a study was conducted among 50 patients with acute non-severe asthma. Patients were randomly assigned to group 1 (n = 25) and group 2 (n = 25) who received three doses of salbutamol and arformoterol nebulization, respectively, at 20-min intervals. The peak expiratory flow rate (PEFR) was measured at the baseline and 5 min after each dose. The demographics and baseline characteristics were comparable between the two groups. The mean PEFR significantly increased in both these groups when compared with the baseline. The increases in the PEFR in two groups were similar after the third dose. The adverse effects in both these groups were minor. Arformoterol was as effective and safe as salbutamol in acute non-severe asthma.