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Infections continue to play a significant role in the overall global mortality and disability more so in Intensive Care Units (ICUs) and plague developing countries more intensively. The ICUs are often called “the hubs” of infections owing to highly vulnerable patients’ profile. The most important nosocomial infections in the ICU are catheter-related bloodstream infections, ventilator-associated pneumonia, and catheter-associated urinary tract infections. The epidemiology of ICU infections in India is different from its Western counterparts in terms of prevalence and nature of microorganisms causing it. While Gram-positive infections are more prevalent in Western ICUs, Indian ICUs are commonly afflicted with Gram-negative bugs showing a high degree of antimicrobial resistance with blurring of traditional boundaries of early drug sensitive and later drug resistance infections. Increasing number of multidrug resistance organism infections in ICUs is a big public health threat and challenge both from the perspective of prevention and treatment. Therefore, blindly following the Western guidelines may not provide the optimum results in India. The need of the hour is to develop and implement an antimicrobial stewardship program based on the local epidemiological data and international guidelines to optimize the antimicrobial use among the hospitalized patients and improve their outcomes.

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Tuberculoma of the brain is an important clinical entity. The main challenge in the management of brain tuberculoma is its diagnosis. Appearance in computed tomography (CT) scan of brain is common and consists of solitary or multiple ring-enhancing lesions with moderate perilesional edema, but these are not specific for tuberculoma as neurocysticercosis (NCC), coccidiomycosis, toxoplasmosis, metastasis and few other diseases may also have similar appearance on CT scan brain. Cerebrospinal fluid examination is often normal and biopsy and tissue culture from the lesion though the diagnosis of choice is technically too demanding and not feasible in most of the times. All these put the clinicians in a great dilemma as regard to a confidant diagnosis of tuberculoma of the brain. With advancement of imaging techniques, magnetic resonance imaging (MRI) of brain with magnetic resonance spectroscopy (MRS) has shown a great hope in this context as MRS shows a specific lipid peak in cases of tuberculoma which is not seen in any other differential diagnoses of tuberculoma. This review article is written to have an overview regarding the current diagnostic approach for brain tuberculoma with special emphasis on the role of MRS. Extensive literature review of the articles published in English was conducted using Google search, Google Scholar, PubMed and Medline using the keywords such as ring-enhancing lesions, etiology, tuberculoma, NCC, CT scan brain, MRI, MRS, images.

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Background: As infected children represent a large proportion of the pool from which tuberculosis (TB) cases will arise and its associated risk factors that influence TB infection are basic cause for burden of TB. Aim: This study was to determine the prevalence of latent TB and associated risk factors in children less than 5 year of age in Karachi, Pakistan. Setting and Design: Cross-sectional study and it was conducted in tertiary care hospital in Karachi. Materials and Methods: In this study, children who were living in contact with individuals who had proven smear-positive pulmonary TB cases were investigated. A tuberculin skin test (TST) was performed on each child. TST sizes ≥5 and 10 mm, respectively, were considered positive. Statistical Analysis: A random effects logistic regression model, which takes into account the clustering of contacts within households, was used to assess the relationship between the tuberculin response of the contact and risk factors. Results are reported as unadjusted and adjusted odds ratios and their 95% confidence intervals. The likelihood ratio test was used to assess the overall significance of risk factors, tests for trend, and tests for interaction. Results: The distribution of TST responses followed a bimodal pattern, with 135 (35%) children presenting a palpable induration. The risk of positive TST response in the child increased with the geographic proximity of the child to the individual with TB within the household and with the degree of activities shared with the individual with TB. Nutritional status and presence of a bacille Calmette-Guérin (BCG) scar were not independent risk factors for TST positivity in this population. On multivariate analysis, the effect of geographic proximity to the individual with TB, household size, and duration of cough in the index case persisted for TST responses ≥5 mm. Conclusions: Positive TST in a child reflects most probably TB infection rather than previous BCG vaccination. Contact tracing can play a major role in the control of TB in Pakistan.

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Hilum is a tricky part in chest X-ray (CXR) for understanding. Anatomically, pulmonary arteries and veins, major bronchi, and lymph nodes with pulmonary arteries contributed most of the radiographic density of the hila with superior pulmonary veins making a smaller contribution. Though both hila should be indistinguishable in size and density, we do not get equal hila in majority of CXRs. Rotational malpositioning must be kept in mind, while interpreting CXRs of unequal hilum. For interpreting hilum, we should search for four factors shape, radiopacity, proportionate size, absolute size, hilar angle, contour of pulmonary artery. There are numerous causes of hilar enlargement. It is the clinical presentation which will help in tapering the differential diagnosis. Asymmetric hilum is a challenging subject for pulmonologists. Interpretation of unequal hilum depends on findings of detail history, meticulous clinical examination, and appropriate investigation.

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Background: As to the profile of adverse drug reactions (ADRs) due to directly observed treatment, short course (DOTS), there is no report available in patients receiving antituberculosis (anti-TB) chemotherapy in Manipur, India. One of the main reasons for non-adherence to anti-TB therapy (ATT) is ADRs, even under DOTS. Aims: This study aimed to determine the incidence of ADRs due to DOTS therapy with a TB population of Manipur, India. Setting and Design: A prospective institution-based cohort study, and performed during July 2009-December 2010. Materials and Methods: The study included 102 diagnosed TB patients on anti-TB treatment under DOTS. Every patient was followed-up for the duration he/she received the treatment. Statistical Analysis: Frequency of different ADRs was assessed and p value was determined. Results: Incidence of TB was more among males than female (76.47% against 23.53%). Seventy-one patients (69.01%) showed one or more ADR. Incidence of ADRs based on affected organ was: Gastrointestinal (GI) disorders in 38 patients (53.52%), generalized weakness in 12 patients (16.9%), liver dysfunction in 11 patients (15.49%), allergic skin reactions in six patients (8.45%), neurological system disorders in two patients (2.82%), and fever in two patients (2.82%). However, 30.99% did not experience any ADRs. Conclusion: Incidence of ADRs due to DOTS therapy was 69.01%. Majority of cases suffered from GI symptoms. This highlighted the importance of developing strategies to ameliorate ADRs both to improve the quality of patient care and to control TB safely.

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Background: The association between low body mass index (BMI) and poor prognosis of patients with chronic obstructive pulmonary disease (COPD) is a common clinical observation and it varies with different stages of COPD. Aims: To find out any correlation between BMI and severity of obstruction (Global Initiative for Chronic Obstructive Lung Disease (GOLD) staging) of COPD patients. Settings and Design: We conducted a cross-sectional, observational study among 101 male patients of COPD, attending the chest medicine department in our medical college during the period from March 2011 to February 2012. Materials and Methods: We classify the severity of obstruction in COPD patients according to GOLD staging through spirometry. BMI of all the patients was measured. Correlation between BMI and severity of obstruction (post bronchodilator forced expiratory volume in 1 ^st second (FEV ₁ ) % predicted) in COPD patients was determined. Statistical Analysis: Analysis was carried out using Statistical Package for Social Sciences (SPSS) 20.0 software for windows. Pearson correlation, one way analysis of variance (ANOVA) analysis and post hoc Turkey test were used to determine the relationship between BMI and post bronchodilator FEV ₁ %predicted. Results: Mean age of the study subject was 58.18 ± 9.29 years. Commonest age group was 50-59 years (40%). Mean BMI of stage 1 COPD subjects was 26.21, stage 2 was 22.91, stage 3 was 20.78, and stage 4 was 15.71. One-way ANOVA showed that BMI of the patients were decreasing with increasing severity of the disease (GOLD) and it was statistically significant (P < 0.05). The post hoc Turkey test also indicated that there were significant differences present in different GOLD stages of COPD in respect to BMI. Conclusion: There was positive correlation between severity of airway obstruction and BMI in COPD patients.

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Bronchial carcinoids comprise of <3% of lung tumours. Though typical carcinoids are usually benign, they may, uncommonly, metastasise to regional lymph nodes as well as to distant sites, and a few cases have been associated with active tuberculosis. We report an unusual case of a typical bronchial carcinoid with regional metastasis and tuberculosis. The metastatic deposits were present in small lymph nodes, emphasizing the need for careful sampling, while grossing. In addition, coexisting tuberculosis in the same lung of the patient make the case an extremely rare one.

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Although genito-urinary tuberculosis is common, reports of isolated ovarian tubercular abscess are rare. Ovarian tubercular abscess may mimics that of an ovarian tumor, leading to diagnostic difficulties. We reported a case report of 35 years woman presented with chronic pain abdomen, weight loss, low-grade fever and a right ovarian mass on ultrasound, with a significantly elevated CA-125 level. On clinical and radiological evidence, diagnosis of ovarian carcinoma was made, and laparotomy was performed with resection of the ovary. Postoperative specimen sent for histological examination that revealed classic epithelioid granuloma and acid-fast bacilli were present in Ziehl-Neelsen stain. Patient was put on antitubercular regimen from our Dots center. She is improving clinical after taking antitubercular drug and is on regular follow up at our chest outpatient department. Ovarian tubercular abscess is common in young women living in endemic zones, but case report of isolated tubercular abscess is rarely reported. CA-125 can be raised in both ovarian tubercular abscess and ovarian carcinoma, and only imaging is not always conclusive. Laparotomy followed by tissue diagnosis can be helpful in this situation. As the prognosis and treatment outcome of ovarian tubercular abscess and ovarian carcinoma is different, proper diagnosis by laparotomy should be done. Early diagnosis of ovarian tubercular abscess is vital as untreated disease can lead to infertility.

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Background: The tuberculosis (TB) literature is written almost entirely from a biomedical perspective, while recent studies show that it is imperative to understand lay perception to determine why people seek treatment and may stop taking treatment. Aims: To investigate knowledge about TB, perceptions of (access to) TB treatment, and adherence to treatment among a Pakistani population. Setting and Design: Descriptive cross-sectional study. Materials and Methods: A total of 175 participants were selected nonrandomly, 100 were TB patient and 75 were non-TB patient in proportion to the total number of participants in each ward of hospital. Statistical Analysis: Analysis of attitudes and perceptions toward TB, adherence to TB treatment, health seeking behavior, and TB treatment types done by frequency counts and percentages. Regression analysis and logistic regression analysis were performed to test whether differences in age, gender, and education level led to different knowledge scores and different attitudes and preferences toward TB, adherence to TB treatment, health seeking behavior, and TB treatment types. All statistical analyses were performed using Statistical Package for Social Sciences (SPSS) 16.0. Result: TB knowledge can be considered fairly well among this community. Respondents' perceptions suggest that stigma may influence TB patients' decision in health seeking behavior and adherence to TB treatment. A full 95% of those interviewed believe people with TB tend to hide their TB status out of fear of what others may say. Conclusion: Most of the subjects were unaware of TB that seems to be due to their illiteracy and those who knew had got the knowledge from media, but the majority of the patients who were on directly observed treatment, short-course (DOTS) were found to be satisfied.

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Background: Six-minute walk test (6MWT) is a simple, objective, reproducible test which correlated well with different spirometric indices, and thus able to predict severity of chronic obstructive pulmonary disease (COPD) and can replace spirometry in resource poor set-up. Aims and Objectives: To find out correlation between spirometric indices (forced expiratory volume in 1 s (FEV ₁ ), forced vital capacity (FVC), and peak expiratory flow rate (PEFR)) and 6-minute walk distance (6MWD) in COPD patients, and thus to assess whether 6MWT can replace spirometry. Settings and Design: Institution based cross-sectional observational study. Materials and Methods: Eighty patients of COPD (diagnosis confirmed by Global Initiative for Chronic Obstructive Lung Disease (GOLD) 2010 criteria) were enrolled for the study after applying exclusion criteria. All patients underwent spirometric measurement of FEV ₁ , FVC, PEFR, and ratio of FEV ₁ and FVC and test repeated after bronchodilation by 200-400 μg of salbutamol. 6MWT was performed following American Thoracic Society (ATS) protocol of 6MWT and distance was measured in meters. Results: We found significant linear correlation of 6MWT with post-FEV ₁ (r = 0.478, P < 0.001), post-FVC (r = 0.454, P < 0.001), and post-PEFR (r = 0.408, P < 0.001), but no correlation with FEV ₁ /FVC (r = 0.250, P = 0.025). We also found significant correlation of 6MWT with BODE (body mass index (BMI), airway obstruction, dyspnea, and exercise capacity) index (r = −0.419, P < 0.001). Conclusions: 6MWT can be a useful replacement of spirometry in assessment of severity of COPD.

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Fungal pneumonia is classically found in neutropenic patients. There is increase in concern about this entity in nonneutropenic critically ill patients. Aspergillus is the main offending organism. Although Candida is frequently found in respiratory sample in intensive care unit (ICU) it is always colonization rather than pneumonia. Other than neutropenia, chronic obstructive pulmonary disease and long-term steroid use are the main risk factors for invasive pulmonary aspergillosis in an ICU setting. Treatment in a nonneutropenic patient is only considered if the culture of Aspergillus comes positive in respiratory sample in the background of risk factors.

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Tuberculosis (TB) is a chronic granulomatous inflammation involving usually the lung parenchyma and hilar lymph nodes. Extrapulmonary involvement is seen in about 15-20% of all cases of TB (EPTB). But breast TB is rare form of EPTB. We present a case of an immunocompetent male presenting with tubercular mastitis associated with chest wall extension. The rarity of this case lies in the site of involvement (chest wall), the way of presentation, and because of the immunocompetent status of the patient.

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Wegener's granulomatosis (WG) is an uncommon autoimmune disease with multi-system involvement that manifests as vasculitis, granulomatosis, and necrosis. While its standard form involves the upper and lower respiratory tracts and kidneys, it may essentially involve any organ. We present a case in a young female patient presenting with symptoms of cough with expectoration, fever, dyspnea and chest discomfort, having cavitating lesion in right upper lobe and nodule in left upper lobe with bilateral paranasal sinus involvement on computed tomography. Allergic rhino-sinusitis with pulmonary tuberculosis was suspected, and patient was investigated further. Upon further investigation, renal involvement was detected, and serology revealed cytoplasmic antineutrophil cytoplasmic antibody. WG was suspected and was proven by histopathology of nasal tissue which revealed necrotizing granulomas.

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Pulmonary embolism (PE) and venous thrombosis is a common complication in lung cancer patients with a high misdiagnosis rate and high mortality. However, when an undiagnosed lung cancer patient presents as PE, cancer as a cause may not always be explored. We present a case of a young male patient presenting with venous thromboembolism causing massive pleural effusion, leading to the diagnosis of epidermal growth factor receptor mutation positive adenocarcinoma, showing good response to gefitinib therapy.

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Tubercular splenic abscess is an extremely rare entity among immunocompetent individuals. Here we describe two cases of tubercular splenic abscess in immunocompetent individuals, the first had to undergo emergency splenectomy for pain abdomen. The second case presented with pyrexia of unknown origin where pus aspirated from spleen stained positive for acid fast bacilli. Both had favorable response to anti-tubercular therapy. Tuberculosis although uncommon should be kept as a differential diagnosis of splenic abscess presenting with pain abdomen or pyrexia of unknown origin with multiple hypodense lesions in spleen on imaging.

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A 61-year-old male admitted in chest clinic with complaints of left-sided chest pain, sudden onset breathlessness, and cough since last 15 days. Patient was anex-smoker with no past history of tuberculosis. He was diagnosed with esophageal cancer and received radiotherapy 1 year back. On chest X-ray, left-sided hydropneumothorax was found and intercostal drainage insertion was done. A week later patient complained of extrusion of food particles into intercostal drainage bag. On evaluation, esophageopleural (EP) fistula was confirmed.

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The concomitant occurrence of the two oldest mycobacterial diseases that is tuberculosis and leprosy in a single individual is not rare but has been infrequently reported. Herein, we report a case of 34-year-old laborer who concomitantly presented with both sputum positive pulmonary tuberculosis and lepromatous leprosy. The diagnosis of the two diseases was made simultaneously, which is again infrequent in literature. The treatment of leprosy warrants screening of individual for tuberculosis because multi-drug therapy for leprosy may lead to acquired drug resistance for rifampicin, which is a mainstem of anti-tubercular therapy.

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Lobar or segmental collapse and secondary spontaneous pneumothorax are two unusual presentations of allergic bronchopulmonary aspergillosis (ABPA). First one is found in acute and exacerbation phases of ABPA due to "mucoid impaction" into damaged bronchi, and latter one is due to rupture of sub-pleural fibro-cystic spaces of pulmonary parenchyma, mainly in the fibrotic stage of ABPA. Clinical presentation of these two in the background of poorly controlled asthma in compliant individuals confuses the diagnosis, and ABPA should be searched for. Here, we report a rare case of right upper lobe collapse and right sided pneumothorax in separate occasions in an 18-year-old male, suffering from asthma with ABPA.

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The ectopic adrenocorticotropic hormone (ACTH) syndrome is an uncommon cause of hypercortisolism, which should be considered in patients with hypokalemic metabolic alkalosis and hypertension in the context of lung neoplasm. We report a 60-year-old male patient with severe hypertension, metabolic alkalosis, and hypokalemia as the initial manifestations of an ACTH-secreting small cell lung carcinoma. Ectopic Cushing's syndrome should always be ruled out in patients with severe hypertension and hypokalemia.

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Background: In a high tuberculosis (TB) burden county like India with different regional demography, knowledge about patient profile has a pivotal role in determining and identifying the factors associated with poor treatment outcomes among TB re-treatment cases. Aim: The aim was to describe the demography and clinical characteristics of TB re-treatment cases and to evaluate the factors associated with poor treatment outcomes among those patients. Settings and Design: A prospective longitudinal cohort study was carried out at chest medicine outdoor from February, 2011 to 2014 in a district medical college of West Bengal, India. Materials and Methods: Sputum smear positive re-treatment pulmonary TB patients attending our chest medicine outdoor during the 3 years study period were evaluated for demographic and clinical characteristics on the basis of previous treatment history and records at the beginning of the study. Patients were followed-up during the 8 months treatment period (Category II treatment regimen under Revised National TB Control Program). At the end of the study period, treatment outcomes were analyzed and factors associated with poor treatment outcomes were identified. Statistical Analysis: All variables were described by proportions, and differences between independent groups were compared using the Chi-square test and Fisher's exact test, as applicable. Results: Among 74 patients, re-treatment was successful in 75.7% of relapse case, 66.7% of loss to follow-up cases and 53.8% of failure cases. Re-treatment failure was higher (38.5%) in treatment failure cases compare to relapse cases (10.8%) and initial loss to follow-up cases (16.7%). Young age, male, unmarried, employed who work outside appears to be the risk factors for loss to follow-up. Low body mass index, treatment from the private sector, history of alcoholism, radiological cavitory lesion, larger duration of previous treatment, lesser gap from previous treatment has unfavorable outcome. Conclusion: Patients relapses after a single course of anti-TB treatment are likely to be cured with the Category II re-treatment regimen and failure cases have a high risk of re-treatment failure. Loss to follow-up patients should be educated, and extra care must be taken to prevent further loss to follow-up during re-treatment.

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Context: Etiology and clinical spectrum of mediastinal diseases are very wide. Clinico-radiological pattern of mediastinal diseases depends on the size, location and etiology. Hence, noninvasive approach to these cases sometimes leads to diagnostic dilemma. Aims: We performed a prospective study over a 1-year period with the objective of evaluation of diagnostic yields and risk of trans thoracic ultra sound (TTUS) and computed tomography (CT) guided fine-needle aspiration cytology (FNAC) and Tru-cut biopsy along with comparison of cost-effectiveness among mediastinal diseases where clinical and noninvasive imaging could not conclude the diagnosis. Materials and Methods: A prospective study of mediastinal diseases of the adult population without having any diagnosis admitted in a tertiary care hospital in Eastern India was performed after clearance of the ethical committee of the institute. Fifty cases of mediastinal diseases were seen during the study period. One patient sometimes had undergone more than one procedure. The choice of a procedure depended upon the location of the lesion, need of further detail and patient's financial status. During the calculation of diagnostic yield of procedure, conclusive results and concordant results to more invasive procedures were considered. Statistical Analysis Used: Statistical analysis was performed using MedCalc ^® Version 11.3.3.0 for analysis of data. Results: Among 50 patients TTUS guided FNAC were conducted in 26 (52%) occasions and CT guided FNAC were conducted in 26 (52%) occasions. TTUS guided Tru-cut biopsy were done in eight cases (16%), and CT guided Tru-cut biopsy were done in 32 cases (64%). CT guided Tru-cut biopsy had higher diagnostic yield (96.87%) than TTUS guided Tru-cut biopsy (75%). TTUS guided, and CT guided procedures had similar complication rates. Conclusion: Tru-cut biopsy if applicable is much superior to FNAC for a definite diagnosis of the mediastinal diseases. TTUS guided invasive procedures are very much cost-effective and comparable with CT guided invasive procedures in respect to risk and diagnostic yields.

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Pneumothorax occurs more frequently in people with Human immunodeficiency virus infection in comparison with the general population. In most cases it is secondary the underlying pulmonary disorder, especially pulmonary infections. Though Pneumocystis jiroveci pneumonia is most common pulmonary infection associated with pneumothorax, other infections, non-infective etiology and iatrogenic causes are also encountered. Pneumothorax in these patients are associated with persistent bronchopleural fistula, prolonged hospital stay, poor success with intercostal tube drain, frequent requirement of surgical intervention and increased mortality. Optimal therapeutic approach in these patients is still not well-defined.

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