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   Table of Contents - Current issue
Coverpage
January-June 2021
Volume 9 | Issue 1
Page Nos. 1-52

Online since Monday, February 15, 2021

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ORIGINAL ARTICLES  

Utilizing flexible bronchoscopy for the diagnosis of endobronchial tuberculosis with negative sputum acid-fast bacillus p. 1
Nai-Chien Huan, Nurul Izzati Azmin Mohd Yusof, Hema Yamini Ramarmuty, Teng Shin Khoo, Yean Chen Lai, Shan Min Lo, Kunji Kannan Sivaraman Kannan
DOI:10.4103/jacp.jacp_20_20  
Background: Endobronchial tuberculosis (EBTB) should be viewed as a distinct subset of tuberculosis due to various pitfalls: (a) often diagnosed late, (b) mimicking other conditions, for example, lung carcinoma, and (c) risks of bronchostenosis if treated late. Flexible bronchoscopy (FB) offers a reliable and safe modality to increase the diagnostic yield of EBTB when sputum acid-fast bacillus (AFB) is negative. In this study, we aim to determine the clinical presentation, bronchoscopic characteristics, and safety of FB for the diagnosis of EBTB at our centers. Methods: From September 2018 to December 2019, 25 patients with EBTB from Queen Elizabeth Hospital and Labuan Hospital, Malaysia were enrolled in this study. Histopathology and/or microbiology were diagnostic in all patients. All patients underwent FB only after sputum smears for AFB were negative. Results: The most common presenting complaint was cough (68%), followed by loss of weight (52%), loss of appetite (36%), fever (32%), hemoptysis (28%), and dyspnea (24%). Lung mass/nodule was seen on imaging in 56% of patients, followed by consolidation (36%), cavity (36%), tree-in-bud appearance (32%), and collapse (24%). The most common Chung’s classification of EBTB appearance was edematous-hyperemic (60%); other appearances in order of descending frequencies were: fibro-stenotic (24%), caseating (24%), tumorous (16%), and granular (16%). Bronchial lavage cultures and/or histopathology cultures were positive for tuberculosis in 72% of patients. No procedure-related mortality or major complications were reported. Conclusion: Even in tuberculosis endemic settings, empirical pharmacological treatment of all suspected EBTB cases will inadvertently lead to delay in attaining competing differential diagnoses in some. FB in selected patients is safe and effective as it enhances treatment confidence by providing histological and/or microbiological evidence thereby ruling out other differentials when initial sputum results were inconclusive.
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COVID-19 versus H1N1: pandemic to pandemic − a comparative analysis of clinical presentation, lab parameters, disease severity and outcome Highly accessed article p. 7
Manoj Saluja, Drishya Pillai
DOI:10.4103/jacp.jacp_46_20  
Background: Since December 2019, we have been facing the coronavirus disease 2019 (COVID-19) pandemic. January 30, 2020 marked India’s first case. A similar entity H1N1 was responsible for the last pandemic our civilization saw. Comparing the clinical and radiological characteristics, severity and prognosis of the two is the objective. Methods :Cross-sectional, observational, and comparative study of patients diagnosed with COVID-19 (April–May 2020) and H1N1 (January 2017–December 2019). Results :We observed raised male to female (M:F) ratio in both, average age higher in H1N1, moderate to severe symptoms with worse clinical status in H1N1, and COVID more often being associated with mild symptoms. Thrombocytopenia, lymphocytosis, and raised lactate dehydrogenase (LDH) were seen in both the diseases but were worse in H1N1; multiorgan involvement was seen in H1N1 (P < 0.001). COVID-19 patients who did report complications were refractory to routine critical care management. Radiographic abnormality was present in both. Poor prognosis was noted in elderly, especially those with comorbidities. This association was less evident in COVID-19. Discussion: Though Severe Acute Respiratory Syndrome- Corona Virus 2 has a milder course, sudden deterioration can be fatal. Serial monitoring of history and vitals is the key. Swine flu patients with a comparatively aggressive course need to be managed accordingly, but Sequential Organ Failure Assessment, Acute Physiology and Chronic Health Evaluation Score-II, and similar scoring can help in triage and predicting prognosis. Clinical and laboratory findings are similar − swine flu has more complications but increased risk of cardiac involvement is seen in COVID. Chest X-ray proves sufficient for imaging, reducing the requirement of computed tomography (CT) scans. Studies involving larger sample size and interventional trials are need of the hour.
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Feasibility of testing bronchodilator responsiveness with glycopyrronium in obstructive airway diseases: the initial appraisal of the pilot experience p. 16
Parthasarathi Bhattacharyya, Dipanjan Saha, Sayoni Sengupta, Debkanya De
DOI:10.4103/jacp.jacp_34_20  
Background: The short onset of action of glycopyrronium bromide, makes it a suitable antimuscarinic agent to test bronchodilator-responsiveness in airway diseases. The objective of the study was to explore the feasibility of the testing so. Methods: Subjects with features of airflow obstruction (FEV1/FVC < 0.07) were given to inhale a 50-μg single dose of dry powder of glycopyrronium bromide immediately following standard salbutamol-induced bronchodilator reversibility. A repeat spirometry was done after 30 minutes and the changes noted. The impact of both the drugs on spirometric variables suggesting airflow obstruction (FEV1. FEV1/FVC, and FEF25-75) were assessed statistically. A salbutamol-reversibility of ≥12% and >200ml was noted to differentiate asthmatics from chronic obstructive pulmonary disease (COPD) patients. Result: In a total of 35 subjects (asthma-10, COPD-25) with moderate baseline airflow obstruction [FEV1/FVC: 0.57 ± 0.12 and FEV1 (%predicted) as 46.17 ± 15.21], there was global improvement across the spirometric variables to serial inhalation of salbutamol and glycopyrronium. The post salbutamol changes in FEV1 (absolute value) were significant (P = 0.0001) overall and also for both asthma and COPD. Following inhalation of glycopyrronium, the changes were again significant for overall (P = 0.0001), asthma (P = 0.0065), and COPD (P = 0.0001). The parallel change in FEF25-75 was, however, showing better reversibility in asthma (P = 0.0008) with salbutamol compared to COPD (P = 0.1846) and the reverse to glycopyrronium inhalation that results in better reversibility in COPD (P = 0.0085) compared to asthma (P = 0.0949). Conclusion: Testing the reversibility with glycopyrronium appears feasible and safe in obstructive airway disease. It induced add-on reversibility once used after standard salbutamol reversibility. The observation demands further evaluations.
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Correlation of six minute walk test and incremental shuttle walk test with severity of airflow obstruction in patients with chronic obstructive pulmonary disease p. 22
Pavirala Sai Tej, Saka Vinod Kumar, G. Vishnukanth
DOI:10.4103/jacp.jacp_13_20  
Context: The field walking tests like 6MWT and ISWT are commonly used indicators of functional capacity in patients with cardiopulmonary diseases. This study was designed to assess the correlation of six minute walk distance (6MWD) and incremental shuttle walk distance (ISWD) with the severity of airflow obstruction (FEV1%) in patients with chronic obstructive pulmonary disease. Aims: Comparison of correlation of six minute walk test and Incremental shuttle walk test with the severity of airflow obstruction in COPD patients.Settings and Design: Hospital-based prospective cross-sectional study in a tertiary care centre. Methods and Material: One hundred and twelve (112) spirometrically confirmed COPD patients underwent 6MWT and ISWT. The diagnosis of COPD and its severity was assessed by the GOLD criteria. 6MWT and ISWT were done on the same patient with a gap of 5–6 hours and the distance walked (6MWD and ISWD) was correlated with the severity of COPD (FEV1). Statistical Analysis Used: One way ANOVA to compare mean distance walked in 6MWT and ISWT with different grades of COPD. Pearson Correlation was done to correlate packyears of smoking and age with 6MWD and ISWD. Results: The mean distance walked in the 6MWT and ISWT was estimated and compared across the four categories of GOLD grading. There was no statistically significant difference between the study subjects of corresponding GOLD grades based on the distance walked in 6MWT and in ISWT. However, a linear correlation was depicted between ISWD and post-bronchodilator FEV1. A model of linear regression showed that ISWD was an independent contributor to post-bronchodilator FEV1 in our study. Conclusions: Incremental shuttle walk test, an externally paced near to standard test with its incremental nature, can be used as an appropriate surrogate for FEV1 in determining the severity of airflow obstruction in COPD patients.
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CASE REPORTS Top

Pulmonary cryptococcosis presenting as miliary tuberculosis in an immunocompetent patient p. 29
Sharad Joshi, Nitesh Tayal, Rajesh Gupta, Ankit Bhatia, Neha Kapoor
DOI:10.4103/jacp.jacp_5_20  
Pulmonary Cryptococcosis is a rare and difficult to diagnose entity. It has been found to be associated with immunocompromised patients. Pulmonary Cryptococcosis in an immunocompetent patient is extremely rare condition. A high degree of suspicion is required to diagnose the condition. We hereby present a case of pulmonary cryptococcosis in an immunocompetent young male which is a rare clinical entity.
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Double hit: Synchronous gastrointestinal stromal tumour (GIST) & lung neuroendocrine tumour − a rare case of multiple primary malignancies p. 32
Kadli Shirish Kumar, Deepak Prajapat, Arjun Prakash, Charul Dabral, Deepak Talwar
DOI:10.4103/jacp.jacp_16_20  
Gastrointestinal Stromal Tumours (GISTs) are rare but remain the most common mesenchymal tumour of the Gastrointestinal tract (GIT). The asynchronous occurrence of other malignancies in patients with GIST during the clinical course is relatively common. However, the synchronous coexistence of GIST and lung cancer has only rarely been reported. We report the case of a 65-year-old male, a former smoker, who was diagnosed with synchronous occurrence of mesenteric GIST and Primary Large Cell Neuroendocrine Cancer (LCNEC) of the lung. There are few case reports on synchronous occurrence of GIST with primary lung cancer but till date no case report exists on GIST with primary LCNEC of lung.
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Unusual presentation of adenocarcinoma of lung with metastasis in a young female p. 37
Harshil V Pandya, Hiren P Pandya
DOI:10.4103/jacp.jacp_33_20  
Adenocarcinoma of lung remains the commonest subtype of lung cancer. Despite of recent advances, the presentation of carcinoma of lung is delayed many of the times until later stages. Here is a case of a young pregnant female with adenocarcinoma of lung with brain metastasis with unusual presentation.
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Swyer-James-Macleod Syndrome: A Rare Finding in a Case of Haemoptysis p. 41
Neeraj Sharma, Preeti Gupta, Aseem Yadav
DOI:10.4103/jacp.jacp_18_20  
Swyer-James-MacLeod Syndrome (SJMS) is a rare cause of a hyperlucent unilateral hemithorax. It is usually found in childhood and is a long-term sequalae of postinfectious bronchiolitis obliterans. It can be an incidental finding in adults. Most patients are asymptomatic. However, some patients can present with recurrent pulmonary infections, haemoptysis or dyspnoea. The diagnosis of SJMS is made radiographically by chest x-ray and CT scan. Majority of symptomatic patients will require conservative management. It is also important to rule out other diseases which have similar radiological picture as inaccurate diagnoses can lead to inappropriate therapy. Here we report a case of 63-year-old woman who presented with haemoptysis and progressive dyspnoea and was subsequently diagnosed as a case of SJMS.
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Organizing pneumonia as preliminary presentation of rheumatoid arthritis: A case report and review of literature p. 45
Vikrant Ranga, Amitesh Gupta, Parul Mrigpuri, Sonam Spalgais
DOI:10.4103/jacp.jacp_35_20  
Rheumatoid arthritis (RA) is a systemic disease frequently involving the respiratory system. Organizing pneumonia (OP) is a defined pulmonary manifestation seen in patients with RA-associated interstitial lung disease. Even though OP following articular involvement is common, rarely it could be the first manifestation of RA. We herein report a case of 45-year-old female, who presented with OP as the first manifestation of RA with negative serology at presentation.
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CHEST IMAGES Top

An unusual cause of right upper zone opacity − azygous fissure p. 49
G. Vishnukanth, Adimoolam Ganga Ravindra, C. Selvaraja, V. Narenchandra
DOI:10.4103/jacp.jacp_32_20  
Azygous lobe is a normal congenital anatomic variant of the right upper lobe. The azygos lobe is not anatomically a separate lobe. Radiologically azygous lobe is noted in the apicomedial region of the right lung and is separated from the rest of upperlobe by azygous fissure. Though not a pathology, azygous lobe can be mistaken for a lung abscess or a bulla. Other complications include hemoptysis or azygous vein aneurysm.
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Pulmonary alveolar microlithiasis p. 51
Sudheer Tale, Vipul Prakash, Mihir Gangakhedkar, Mrudula Kolli, Anil Kumar Garbhapu, Girish Sindhwani
DOI:10.4103/jacp.jacp_30_20  
Pulmonary alveolar microlithiasis is a rare genetic disorder and the affected people often presented with shortness of breath on exertion and dry cough. Chest radiology shows diffuse micronodules with calcifications that are easily visible on noncontrast computed tomography scans. It is progressive disease and treatment is only supportive.
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