Background: Pleural effusions in respiratory intensive care unit (RICU) are associated with diseases of varied etiologies and often carry a grave prognosis. This prospective study was conducted to establish an etiologic diagnosis in a series of such patients before starting treatment. Materials and Methods: Fifty consecutive patients, diagnosed with pleural effusion on admission or during their stay in RICU, were further investigated by a two-step approach. (1) Etiologic diagnosis was established by sequential clinical history and findings on physical examination, laboratory tests, chest radiograph, CECT/HRCT/PET-CT and pleural fluid analysis. (2) Patients who remained undiagnosed were subjected to fiber-optic bronchoscopy, video-assisted thoracoscopic pleural biopsy, and histopathology. Results: Etiologic diagnosis of pleural effusion was established in 44 (88%) Metastases (24%); para-pneumonia (22%); congestive cardiac failure (18%); tuberculosis (14%); hemothorax (4%); trapped lung, renal failure, and liver cirrhosis (2% each). Six patients (12%) remained undiagnosed, as the final diagnostic thoracoscopic biopsy could not be performed in five and tissue histopathology findings were inconclusive in one. Out of the 50 patients, 10 died in the hospital; 2 left against medical advice; and 2 were referred to oncology center for further treatment. The remaining 36 patients were clinically stabilized and discharged. During a 3-month follow-up, eight of them were re-hospitalized, of which four died. Conclusions: Pleural effusion in RICU carries a high risk of mortality. Etiologic diagnosis can be established in most cases.

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Chronic obstructive pulmonary disease (COPD) is a common preventable and treatable lifestyle-related disease with high global prevalence. COPD is associated with significant morbidity and mortality worldwide. Comorbidities are important events in the natural history of the disease and have a negative effect on the morbidity and mortality of COPD patients. Cardiac diseases, lung cancer, osteoporosis, and depression are common comorbidities reported for COPD. Recently, anemia has been recognized as a frequent comorbidity in COPD patients. The prevalence of anemia in patients with COPD varies from 7.5% to 33%. Anemia of chronic disease (ACD) is probably the most common type of anemia associated with COPD. ACD is driven by COPD-mediated systemic inflammation. Anemia in COPD is associated with greater healthcare resource utilization, impaired quality of life, decreased survival, and a greater likelihood of hospitalization. We need large prospective studies to discern the association between anemia and COPD.

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Context: Pneumothorax continues to be a major cause of morbidity and mortality among respiratory patients, but there is a paucity of data regarding etiology, clinical profile, management, and outcome of spontaneous pneumothorax (SP), from this part of the world. Aims: To assess the patients of spontaneous pneumothorax in adults with special reference to the etiology, clinical presentation, management, and outcome of SP. Settings and Design: Prospective, observational study conducted in a tertiary care institution over a period of one year. Materials and Methods: All adult patients of SP attending the department of pulmonary medicine in a tertiary hospital were studied and detailed clinical, radiological, and management data were recorded and analyzed. Results: Sixty consecutive patients, who satisfied the inclusion criteria were included in the study. Among them 10 had primary spontaneous pneumothorax (PSP) and 50 had secondary spontaneous pneumothorax (SSP). The overall male to female ratio was 4:1. The mean age of the PSP patients was 26.3 ± 2.19 years, whereas, that of the SSP patients was 53.42 ± 2.07 years (P < 0.0001). Seventy percent of the patients were smokers. The most common clinical manifestation of PSP was chest pain (80%) in contrast to dyspnea in SSP (96%). The most common cause of SSP (42%) was found to be chronic obstructive pulmonary disease (COPD) followed by pulmonary tuberculosis (30%). The cases were managed with intercostal tube drainage (85%), simple aspiration (8.33%), and observation (6.67%). Full expansion of the lung was noted in 91.67% of the cases. Conclusion: Spontaneous pneumothorax was more common in men. SSP was far more common in this study, and the predominant underlying cause of SSP was COPD, which surpassed tuberculosis as the leading cause of SSP. This is in contrast to the results from previous studies done in our country. Intercostal tube drainage was the mainstay of treatment and the response was good.

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Background: Semi-rigid thoracoscopy is a safe and efficacious procedure in patients with undiagnosed pleural effusion. Literature on its utility from developing countries is limited. We herein describe our initial experience on the utility of semi-rigid thoracoscopy from a tertiary care teaching and referral center in north India. We also perform a systematic review of studies reporting the utility of semi-rigid thoracoscopy from India. Patients and Methods: The primary objective was to evaluate the diagnostic utility of semi-rigid thoracoscopy in patients with undiagnosed exudative pleural effusion. Semi-rigid thoracoscopy was performed under local anesthesia and conscious sedation in the bronchoscopy suite. Results: A total of 48 patients underwent semi-rigid thoracoscopy between August 2012 and December 2013 for undiagnosed pleural effusion. Mean age was 50.9 ± 14.1 years (range: 17-78 years). Pre-procedure clinico-radiological diagnoses were malignant pleural effusion [36 patients (75%)], tuberculosis (TB) [10 (20.83%) patients], and empyema [2 patients (4.17%)]. Patients with empyema underwent the procedure for pleural biopsy, optimal placement of intercostal tube and adhesiolysis. Thoracoscopic pleural biopsy diagnosed pleural malignancy in 30 (62.5%) patients and TB in 2 (4.17%) patients. Fourteen (29.17%) patients were diagnosed with non-specific pleuritis and normal pleura was diagnosed on a pleural biopsy in 2 (4.17%) patients. Overall, a definitive diagnosis of either pleural malignancy or TB was obtained in 32 (66.7%) patients. Combined overall sensitivity, specificity, positive predictive value and negative predictive value of thoracoscopic pleural biopsy for malignant pleural effusion were 96.77%, 100%, 100% and 66.67%, respectively. There was no procedure-related mortality. On performing a systematic review of literature, four studies on semi-rigid thoracoscopy from India were identified. Conclusion: Semi-rigid thoracoscopy is a safe and efficacious procedure in patients with undiagnosed exudative pleural effusions.

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Pulmonary nocardiosis is a rising bacterial infection, with a high propensity for misdiagnosis. On account of a paucity of prospective studies, there is limited understanding on various aspects of its diagnosis and treatment. We present three patients with pulmonary nocardiosis, with emphasis on the predisposing factors, variable disease course, and treatment issues. There is a need to understand the basis of these discrepancies so as to rationalize the management of this potentially fatal infection.

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Background: Anthracosis is the black pigmentation of the mucosal lining of the tracheo-bronchial tree. The significance of this finding is not known and often ignored. The aim of the present study is to find the association of anthracosis with demographic variables, biomass fuel and occupational exposure, respiratory diseases, radiological pattern and functional morbidity. Materials and Methods: Enrolment of the subjects for the study was done at SMS hospital, Jaipur. Patients with anthracosis evident on bronchoscopy were included as the cases. Patients without anthracosis on bronchoscopy, matched according to age, gender and smoking habits, were included in the control group. Subjects in both the arms completed a questionnaire and also underwent computed tomography (CT) of the chest and six minute walk test (6MWT). Results: Thirty cases and 53 controls were included in the study. The patients with anthracosis presented with symptoms ranging from cough (76.65%), hemoptysis (46.6%), fever (26.6%), dyspnea (90%) and malaise (73.3%). Biomass fuel exposure for the cases was 35.13 ± 55.86 hours in a year and for the controls was 28.15 ± 40.09 hours in a year (P > 0.05). Stone mining was significantly associated with anthracosis (P < 0.05). CT chest revealed fibrosis (43.3%), consolidation (33.3%), cavitation (16.6%) and mass (46.6%) in the cases. Sixty percent of cases and 15% of controls were diagnosed to have either old or active pulmonary tuberculosis (P < 0.05). Conclusions: Anthracosis is associated with pulmonary tuberculosis. Biomass exposure is not significantly associated with anthracosis. Post tubercular fibrosis is more common on CT chest of patients with anthracosis.

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The use of continuous positive airway pressures (CPAP) is considered standard treatment of moderate to severe obstructive sleep apnea (OSA). Treatment of the disease poses a great challenge not only for its diagnostic purpose but also for its treatment part. In about 29-83% of the patients, treatment is difficult because of non-compliance resulting due to high pressures, air leaks and other related issues. In such situations, alternative methods of treatment need to be looked for so as to ascertain better management. Mandibular advancement devices along with CPAP may show better treatment outcome in specific situations.

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Background: A majority of cystic lesions in the western world are detected antenatally, whereas, the diagnosis in our setup occurs once the child becomes symptomatic. Surgical management is primarily dictated by the presence of symptoms, recurrent infection, and rarely by the potential risk of malignant transformation. Materials and Methods: A retrospective analysis was carried out on all consecutive patients with cystic lung lesions managed at our center from January 2000 through June 2011 for antenatal diagnosis, presentation, diagnostic modalities, treatment, and complications. Results: Forty cystic lung lesions were identified. Only 8% were antenatally detected. Out of 40, the final diagnosis was congenital cystic adenomatoid malformation in 19, congenital lobar emphysema in 11, and bronchogenic cysts and pulmonary sequestration in five each. Of these, 20% had received a course of prior antitubercular therapy and 30% had an intercostal drain inserted prior to referral to our center. Postoperative morbidity in the form of bronchopleural fistula, pneumothorax, and non-expansion of the residual lung was noted in 10% of the patients. Conclusion: Antenatal diagnosis of these lesions is still uncommon in third world countries. Prior to referral to a pediatric surgical center a large number of patients received antitubercular drugs and an intercostal drain insertion, due to incorrect diagnosis.

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Introduction: Chronic obstructive pulmonary disease (COPD) is an important non-communicable disease worldwide with a rising global incidence. COPD is associated with multiple co-morbidities. Patients with COPD are at increased risk of atherosclerosis and other cardiovascular events. Cardiovascular diseases are an important cause of morbidity and mortality in COPD. The present case-control study was designed to assess the relationship between sub-clinical atherosclerotic vascular diseases with COPD. Methods: It was a prospective case-control blinded observational study. There were 142 COPD patients and 124 age-and sex-matched controls without COPD and cardiovascular diseases. Frequency of sub-clinical atherosclerosis was assessed by the carotid B-mode duplex ultrasonography assessment of carotid wall intima medial thickness (IMT). Plaque was defined as IMT of more than 1.2 mm. Results: Prevalence of carotid plaqing was significantly higher amongst patients of COPD (38.7%) compared to controls (13.7% , odds ratio 3.9, P < 0.0001). Multinomial logistic regression analysis revealed COPD as an independent predictor of carotid plaqing (r = 0.85, P < 0.023). Conclusion: The frequency of carotid plaqing is high in COPD patients. Carotid plaqing may be due to shared risk factors or the presence of low-grade systemic inflammation. Presence of increased CIMT and carotid plaqing in COPD patients identifies early atherosclerotic changes and future cardiovascular risk. Hence screening of CIMT should be a part of cardiovascular assessment in patients with COPD.

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Background: Programmatic management of drug-resistant TB (PMDT) under the RNTCP is being implemented in West Bengal in a phased manner since 2011. During the initial years MDR-TB cases were identified based on criteria A. This study examines the first line anti-tubercular drug resistance pattern of mycobacteria cultured from sputum samples of MDR suspects who were retreatment cases smear positive from 4 ^th month onwards. Materials and Methods: In the following retrospective record based study, data on Drug Sensitivity Testing (DST) of sputum samples of MDR suspects between September 2011 and August 2012 were collected from the IRL Kolkata and analysed. Sputum samples, collected in the districts maintaining adequate aseptic containment measures, were decontaminated and centrifuged and the sediment inoculated on LJ medium. Probable M. tuberculosis colonies were identified by typical colony characteristics and Ziehl-Neelsen (ZN) staining. Sensitivity of the four 1 ^st line drugs (Streptomycin, Isoniazid, Ethambutol and Rifampicin) was deduced by the economic variant of the proportion method. Results: Of all the 917 MDR suspects whose sputum was examined, 64 mycobacteria culture positive strains (6.98%) were mono-resistant to any of the four first line anti-tubercular drugs. Among the mono-resistant strains 43 (4.69%) were resistant to Rifampicin while 12 (1.31%) were resistant to INH. There were a total 78 (8.51%) poly drug-resistant strains. MDR-TB strains were seen in 741 (80.81%) samples. Conclusion: The magnitude of drug resistance were very high among retreatment patients that were smear positive from 4 ^th months onwards probably because of repeated courses of anti-tubercular drugs prior to drug sensitivity testing (DST). The decision of the PMDT to enlist all retreatment patients as MDR suspects at initiation will result in early identification and treatment of MDR-TB patients.

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We report the case of a 58-year-old man on chronic steroid therapy, who developed a rapidly progressive right upper lobe infiltrate/mass that extended into the right hilum. Respiratory failure necessitated endotracheal intubation. Broad spectrum antibiotics were initiated without clinical improvement and because of his immunosuppressive therapy opportunistic pathogens were considered. Endobronchial ultrasound-guided transbronchial needle aspiration (EBUS-TBNA) was performed in the Medical Intensive Care Unit (MICU) with rapid onsite evaluation. Specimens obtained from the right hilar mass revealed organisms suspicious for cryptococcal infection, subsequently confirmed via a culture. No complications occurred during the EBUS procedure despite the patient requiring vasopressor support and 100% inspired oxygen. Little data exists regarding the use of EBUS in patients admitted to the MICU with respiratory failure of unknown etiology and mediastinal/hilar lymphadenopathy. This case illustrates the potential safe use of EBUS-TBNA in patients presenting with respiratory failure, with a mediastinal or hilar mass and suspected infectious etiology.

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Pulmonary alveolar proteinosis (PAP) is a rare disease, characterized by alveolar accumulation of surfactant composed of proteins and lipids due to defective surfactant clearance by alveolar macrophages. Mainstay of treatment is whole lung lavage, which requires general anesthesia. Herein, we report a case of primary PAP, successfully treated with serial bronchoscopic lung lavages under local anesthesia.

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Tuberculosis (TB) is a major public health issue in India. Although dual infection with tuberculosis and bacteria/fungi has been reported in immunocompromised patients, their co-occurrence in individuals with preserved immunity may complicate the clinical presentation, leading to inadequate treatment and unsatisfactory outcomes. In patients with pulmonary tuberculosis, the occurrence of tubercular lesions in atypical locations may further confound the clinical picture if only one of the pathogens is isolated, initially leading to a suboptimal therapeutic response. A strong index of suspicion and additional diagnostic testing may be required for diagnosis and treatment of the second infection. We report three unusual cases of concurrent tubercular and bacterial infection, of which two are pulmonary and one is extrapulmonary.

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A 50-year-old male patient, a known case of chronic obstructive pulmonary disease (COPD), presented with the features of bronchopleural fistula (BPF) on the right side for 1 month. The patient was a chronic smoker and did not give any history suggestive of pulmonary Koch's. The patient had sudden-onset breathlessness and chest pain 1 month before, which was diagnosed to be due to spontaneous pneumothorax. An intercostal drain was inserted but even after 1 month of all conservative measures, the lung remained collapsed and there was large air leak in the intercostal drain. Computed tomogram (CT) of the chest revealed collapsed and entrapped lung with surgical emphysema of the subcutaneous tissues due to rupture of the emphysematous bulla on the right side along with the presence of emphysematous bullae on the left upper lobe also. Surgical intervention in the form of decortication of entrapped lung and repair of the BPF with intercostal muscle flap was performed. The patient recovered well and was discharged after 10 days.

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Valproic acid (VPA) is one of the most frequently used antiepileptic drugs for the treatment of focal and generalized epilepsies, absence seizures, and Lennox-Gastaut syndrome (LGS). VPA has been demonstrated to have a negative effect on both the intrinsic and extrinsic coagulation systems and controversy exists about the clinical relevance of such hematological abnormalities. We describe a case of reversible lung hemorrage due to VPA. In English-language literature only two other similar cases (one of which fatal) have been described so far.

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Uterine sarcomas are rare and represent approximately 3.2% of all invasive uterine cancers. The annual incidence rate is less than two per 100,000 women. The median age at which uterine sarcoma diagnosed is 56 years. The most common histologic pattern is leiomyosarcoma (LMS) which originates from the myometrium or myometrial vessels. Uterine LMSs are aggressive tumors with high rates of recurrence. The most common mode of spread is hematogenous, with lymphatic spread being rare. Recurrences of up to 70% are reported in stage I and II disease with the site of recurrence being distal, most commonly the lungs or the upper abdomen. But the intra bronchial spread is extremely rare. Here we are reporting a case of uterine LMS with endobronchial metastasis causing whole lung collapse.

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Chronic arsenic exposure causes cutaneous effects like hyperkeratosis, peripheral vascular disease, hypertension, ischemic heart disease, non-cirrhotic portal hypertension, hepatomegaly, peripheral neuropathy, respiratory involvement, bad obstetrical outcome, hematological disturbances, and diabetes mellitus. Here we present a case of a 24-year-old lady, with chronic exposure to arsenic, presenting to us with progressive dyspnea. We found pulmonary arterial hypertension (PAH) as a cause of her dyspnea. PAH can occur in arsenicosis, secondary to arsenic-induced chronic obstructive pulmonary disease (COPD), lung fibrosis, and portal hypertension, which we excluded by appropriate investigations in our case. We also excluded a familial or heritable form of PAH. Thus, with the exclusion of all these secondary causes of PAH, as well as a hereditary cause, we came to a conclusion that this PAH might be due to chronic arsenic exposure. To the best of our knowledge, no case of PAH in chronic arsenicosis has been reported to date.

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