Vasu Vardhan

Diagnosis of osteoarticular tuberculosis

Abstract Accurate diagnosis in osteoarticular tuberculosis poses a difficulty due to deep inaccessible lesions, paucibacillary state, and initiation of empirical ATT in most of the cases. Diagnosis of osteoarticular TB evolved from clinicoradiological to serodiagnosis to detection of DNA/RNA of MTB origin. Newer modalities which aid in early diagnosis and treatment go a long way in management of osteoarticular TB by significantly decreasing morbidity. Subjecting all cases to panel of investigations including AFB staining, AFB culture/sensitivity, PCR, and histopathology on obtaining tissue have been proved more efficacious than resorting to single test. In particular serology alone is not diagnostic. High sensitivity and specificity of PCR and histopathology are found to be most useful diagnostic modalities in studies. Thus gold standard remains to be tissue diagnosis.

Hypertension and catecholamine levels in sleep apnoea.

BACKGROUND Sleep-disordered breathing has been strongly associated with systemic hypertension. Increased sympathetic activity in sleep-disordered breathing may be responsible for this association. METHOD In this sleep clinic-based study, 82 newly diagnosed patients of sleep-disordered breathing were evaluated for hypertension, and their plasma and urinary levels of catecholamines were measured. Catecholamine levels were then compared separately with the severity of sleep apnoea and blood pressure (BP). RESULTS The prevalence of hypertension in the study population was 46.3%. The BP showed a strong and statistically significant correlation with apnoea-hypopnoea index (diastolic, r = 0.65, P < 0.001 and systolic, r = 0.60, P < 0.001) which was maintained even after the results were analysed separately for obese and non-obese subjects. Both plasma and urinary levels of catecholamines were greater in patients with severe sleep apnoea (compared to nonsevere cases) and in those with hypertension compared to normotensives. However, statistical significance was achieved only for urine catecholamines and not for plasma catechol-amines in both the cases. CONCLUSION Hypertension is highly prevalent among Indian subjects with obstructive sleep apnoea. Catecholamine levels are significantly higher in hypertensive than in normotensive apnoeics and are also directly related to the severity of obstructive sleep apnoea. Twenty-four hour urinary catecholamine levels are more valid measures of sympathetic activity than spot plasma samples.

Best Treatment Guidelines For Bronchial Asthma

Asthma is a common disease worldwide with significant ethnic and regional variations. An increasing morbidity and mortality, as well as health care burden from asthma have been recognized lately. Several evidence based guidelines have been developed with an aim to standardize and improve the quality of management. These guidelines seek to translate the advances in the understanding of pathogenesis of asthma and in the development of new agents and strategies into practical application at all levels of healthcare. These advocate an assessment of the patients to classify the severity of diseases followed by a step-wise approach to treatment. With the current management we hope to achieve minimum or nil day time and night time symptoms, prevent acute exacerbations and attain normal or near normal lung function, thus improving the overall quality of life.

Intraluminal Bronchial Carcinoid Resection by Bronchoscopy.

Pulmonary carcinoid tumour is an uncommon malignant neoplasm derived from the surface or glandular epithelium of the conducting or transitional airways. It is a neuroendocrine neoplasm that arises from the enterochromaffin cells of the amine precursor uptake and decarboxylation system of bronchial mucosa. They represent 1-2 % of all pulmonary neoplasms [1, 2, 3, 4]. The carcinoid tumours can be divided into two clinicopathological types, typical and atypical. They behave like low grade malignant tumours and have a high rate of resectability and better prognosis [5]. The prognosis depends on size of tumour, histological type, nodal involvement and the presence of metastasis. Majority of carcinoids are located centrally within the trachea and mainstem bronchi and are reachable with flexible bronchoscope [3, 4, 5]. Curative surgical resection with focus on lung sparing or bronchoplastic surgery is the treatment of choice [1, 2, 5]. Endobronchial laser resection via rigid or flexible bronchoscope can photocoagulate and vaporize lesions. The potassium titanyl phosphate (KTP), argon dye, yttrium aluminium pevroskite (YAP), neodymium-yttrium aluminium garnet (Nd:YAG) and diode lasers are suitable for use in fibreoptic bronchoscopes. The Nd:YAG laser is currently preferred for airway resection because of its predictable effect on living tissue (photocoagulation or vaporization), depending on the amount of energy applied [6,7]. At 980 nm diode laser shows a smaller optical penetration depth than the Nd:YAG laser at 1064 nm. Thus with identical application parameters, higher temperatures are produced with the diode in most tissues at superficial and interstitial applications. Most experts use flexible bronchoscope for laser photoresection [6]. We report a case of bronchial carcinoid in the left main bronchus causing collapse of left lung. The endobronchial resection via diode laser resulted in complete removal of obstruction with an excellent result.

Ellis-van Creveld syndrome presenting in the second decade

A 19-year-old woman born to non-consanguineous parents presented with primary amenorrhoea. Examination revealed a 1.3 m tall patient with disproportionate dwarfism (arm-span/height—ratio: 0.78); she was polydactyl with hypoplastic/dystrophic nails (figure 1). She had partial anodontia, and abnormally shaded and mal-occluded teeth (figure 2). The rest of the systemic examination was unremarkable. Radiography of the hands revealed fusion of the carpal bones (figure 3). Echocardiography revealed patent foramen ovale with no flow. No haematological/biochemical abnormalities were detected. The patients history …

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.

Clivus and Dural Involvement in a Case of Multiple Myeloma: A Rare Complication of Multiple Myeloma.

Multiple myeloma (MM) represents a malignant proliferation of plasma cells derived from a single clone. The tumor, its products, and the host response to it result in a number of organ dysfunctions and symptoms, including bone pain or fracture, renal failure, susceptibility to infection, anemia, hypercalcemia, and occasionally clotting abnormalities, neurologic symptoms, and manifestations of hyperviscosity. Intracranial lesions of MM commonly involve the cranial vault, the skull base and the orbit [1]. The clivus and petrous regions are far less commonly affected [2]. We report an unusual presentation of multiple myeloma with neurological involvement in the form of clivus mass causing progressive external ophthalmoplegia which was treated with whole brain radiotherapy (WBRT).

Allergic bronchopulmonary candidiasis

Allergic Bronchopulmonary Aspergillosis (ABPA) is an allergic disorder caused by fungi of Aspergillus species in patients of bronchial asthma. Over the years other fungal species have also been implicated in causing the disease. Hence the term ABPA has been replaced by the term Allergic Bronchopulmonary Mycosis (ABPM), although Aspergillus continues to be the commonest. Candida albicans rarely causes ABPM and a few case reports suggest dual aetiology (Aspergillus and Candida albicans). We report one such case of ABPM.

Spontaneous Pneumomediastinum in a Case of Mixed Connective Tissue Disorder

Spontaneous pneumomediastinum refers to dissection of free air from the airways or lung parenchyma into the mediastinal structures without any antecedent thoracic trauma or surgical intervention. It is a rare condition associated with several pulmonary disorders such as bronchial asthma and emphysema and it can also occur in apparently healthy individuals [1]. Very rarely intestinal lung disorders may be associated with a spontaneous pneumomediastinum [2]. We describe a patient with mixed connective tissue disorder (MCTD) who developed pneumomediastinum during treatment.

Case ReportMercury Toxicity - A Case Report

Throughout the centuries, there have been several incidents of mercury toxicity. As early as 1500 B.C we know that the Egyptians used mercury, as it was found in their tombs [1]. Men may encounter mercury in an inorganic (elemental or mercuric salt) or an organic form. All three are toxic. Elemental mercury is used in Dental amalgams, thermometers and sphygmomanometers [2]. We report one such case in a dental hygienist.