Influenza A (H1N1) infection has a propensity to infect an immunocompromised host (ICH). These patients experience more severe manifestations and related complications with increased mortality. Influenza A (H1N1) infection in ICH differs from non-ICH in terms of clinical features, range of complications, radiological features, treatment response, and outcome. Radiology may show higher number of lesions but with no or minimal corresponding clinical manifestations. Coinfection with streptococci, staphylococci, and Aspergillus further increases mortality. Antiviral resistance compounds the overall picture despite optimal regimen. Use of steroids is detrimental. Extracorporeal membrane oxygenation (ECMO) is usually avoided in ICH. However, ICH groups with influenza A (H1N1) infection complicated by acute respiratory distress syndrome who have received ECMO have recorded mortality up to 61%. Nevertheless, evidence-based recommendation on use of ECMO in ICH is lacking. Annual inactivated influenza vaccine is recommended for most ICH groups with a few exceptions and for their close contacts. Hygiene measures greatly contribute to reducing disease burden. High index of suspicion for influenza A (H1N1) infection in ICH, early antiviral therapy, and treatment of coinfection is recommended. With the threat of transmission of resistant viral strains from ICH to the community, apart from treatment, preventive measures such as vaccination and hygienic practices have a significant role. Through this review, we have attempted to identify clinical and radiological peculiarities in ICH with influenza A (H1N1) infection, treatment guidelines, and prognostic factors. Influenza A (H1N1) infection in ICH may remain clinically silent or mild.

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Background: The role of nebulized lignocaine administration for flexible bronchoscopy is unclear. Methods: In this randomized, double-blind, placebo-controlled trial, subjects undergoing diagnostic flexible bronchoscopy were randomized to receive either nebulized lignocaine (2.5 ml of 4% lignocaine) or nebulized (2.5 ml of 0.9%) saline (placebo). All received 10% lignocaine pharyngeal spray (4 sprays) and 5-ml nasal 2% lignocaine gel. 1% lignocaine solution was used for spray-as-you-go administration in all. Co-primary outcomes were Operator-rated overall procedure satisfaction and Operator-rated cough scores on Visual Analog Scale (VAS). Secondary objectives were cumulative lignocaine dose, proportion of subjects receiving >8.2-mg/kg lignocaine, and complications between the groups. Results: Two hundred and twenty subjects were randomized and 217 (109 – nebulized lignocaine and 108 – placebo) received the intervention. Baseline characteristics were comparable. Operator-rated overall procedure satisfaction scores on VAS (7.30 ± 1.54 nebulized lignocaine and 7.50 ± 1.31 placebo group,P = 0.85) and Operator-rated cough scores on VAS (3 [2–5] nebulized lignocaine and 3 [2–4] placebo group,P = 0.18) were similar. Cumulative lignocaine dose was significantly greater in nebulized lignocaine group (331.46 ± 9.41 mg vs. 232.22 ± 12.77 mg,P < 0.001), and a significantly greater number of subjects in this group received lignocaine dose >8.2 mg/kg. Minor complications occurred in 6 and 9 subjects in nebulized lignocaine and placebo groups, respectively,P = 0.41. Conclusion: Administration of nebulized lignocaine in addition to pharyngeal lignocaine spray, during no-sedation bronchoscopy, increases the cumulative lignocaine dose without improved procedural comfort. Additional nebulized lignocaine during bronchoscopy is not recommended.

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Aims and Objectives: The study aims to compare the changes in the diaphragm in chronic obstructive pulmonary disease (COPD) patients in Indian population with the help of ultrasound-guided examination. (1) Changes in thickness of the diaphragm during respiration( to rule out diaphragm muscle atrophy). (2) The movement of the diaphragm(correlates with strength and endurance of diaphragm fibres) . (3) Zone of apposition(gives mechanical advantage to diaphragm). (4) Correlation with COPD severity by global initiative for chronic obstructive lung disease (GOLD) staging. Subjects and Methods: Forty-eight COPD patients attending OPD of DY Patil Hospital were recruited in the study and twenty age-matched controls were taken. Detailed history, pulmonary function test examination, and diaphragm study under ultrasonography was done. Results: The movement of diaphragm was reduced in mild to moderate COPD (A and B) but increased in COPD with Grade C. Movement of diaphragm was significantly more in cases with COPD Grade B (2.329 cm) and C (2.269 cm) as compared to controls (1.891 cm). Mean diaphragmatic thickness during inspiration and expiration, change in thickness, and zone of apposition were significantly higher in patients with COPD score Grade C as compared to Grade A or B. Zone of apposition was significantly decreased in Grade A (3.257 cm) and B (3.429 cm) compared to control (4.268 cm), while it was significantly increased in cases with Grade C (5.138 cm). Conclusion: The diaphragm is the main muscle of respiration, and study of diaphragm is very important in COPD. The diaphragm thickness, movement, and zone of apposition were significantly reduced in mild to moderate COPD but increased in severe COPD. This cannot be explained by physiotherapy or collagen accumulation. Hence, diaphragm muscle biopsy and electromyogram study in COPD patients will be required to get a better understanding of this muscle in COPD.

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Introduction: Diwali or the festival of lights is the most popular festival celebrated in India when firecrackers are burnt by almost every household for 3 days. Levels of ambient air pollution are reported to be very high during the Diwali festival in India. In this study, we aimed to measure and compare the personal exposure levels to particulate matter <2.5 μm in mass median aerodynamic diameter (PM_2.5) during burning of six of the most commonly used firecracker types in India. Methods: Sparklers, ground spinners, flower pots, pulpuls, a garland of 1000 sounding crackers, and snake tablets were burnt outdoors in an open area during the late evening hours. Minute by minute PM_2.5levels were measured at a distance and height from where they are normally burnt using Thermo pDR 1200, USA, and a set of five such experiments were conducted to examine the variability between the firecrackers. Results: When measured at a distance and height from where they are normally burnt, the burning of snake tablets produced the highest peak level of PM_2.5 (64,500 mcg/m³), followed by a garland of 1000 sounding crackers (38,540 mcg/m³), pulpuls (28,950 mcg/m³), sparklers (10,390 mcg/m³), ground spinners (9490 mcg/m³) and flower pots (4860 mcg/m³). Conclusion: Burning of firecrackers produce extremely high levels of personal exposure to PM_2.5 levels that are likely to have significant short-term and long-term adverse health effects. The initiative taken by the Supreme Court of India in 2017 to ban the sale of firecrackers seems to be a step in the right direction to reduce the adverse health impacts in the community.

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Osimertinib (AZD9291), a third-generation epidermal growth factor receptor (EGFR)-tyrosine-kinase inhibitor (TKI), is useful in the treatment of non-small cell lung cancer who show resistance to first-generation EGFR-TKIs and harbor T790M mutation. Acquisition of resistance to osimertinib due to several mechanisms has been reported. We report the first case of an Indian patient with osimertinib resistance, due to C797S mutation. A 52-year-old nonsmoker man was detected to have metastatic lung adenocarcinoma (Stage IV) with EGFR exon 19 deletion and treated with erlotinib. After 12 months of response with erlotinib, he developed resistance because of the development of T790M mutation. He was started on osimertinib, with which he responded for 20 months. A follow-up positron emission tomography scan showed progressive disease. Subsequent liquid biopsy did not detect any mutation. However, rebiopsy of the lung lesion showed additional C797S mutation (in cis association with T790M). Hence, the patient was diagnosed to have “triple whammy,” i.e., triple mutation of exon 19 deletion, T790M, and C797S mutations.

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Background: Alterations in body composition are common in cancer and may affect outcomes differentially based on geographical and ethnic factors. However, data in lung cancer are sparse and conflicting. Methods: We compared the body composition of Indian lung cancer patients with healthy subjects using a retrospective review of all newly diagnosed patients with nonsmall cell lung cancer. Age- and sex-matched healthy controls were recruited prospectively. Basal metabolic rate (BMR), total body water (TBW), fat mass, and fat-free mass (FFM) were calculated by bioelectric impedance method. Results: A total of 256 patients (83.6% males) and 210 controls (81.4% males) were studied. The mean (standard deviation) age of patients was 54.5 (9.0) years, median smoking index was 598.2 (range, 0–2500), and median Karnofsky performance scale (KPS) was 80 (range, 40–100). Majority (54.7%) had Stage IV disease. All components of body composition, i.e., BMR, TBW, fat mass, and FFM, were significantly lower (P < 0.01) in patients as compared to controls. Body mass index, fat mass, FFM, and TBW were lower in older subjects with poorer KPS. The presence of metastasis or symptom duration did not affect body composition. Conclusion: These results indicate that Indian patients with lung cancer have altered body composition which declines with increasing age and worsening performance status.

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Hermansky-Pudlak syndrome (HPS) is an extremely subtile autosomal recessive disorder characterized by tyrosinase-positive oculocutaneous albinism (Ty-pos OCA), bleeding tendencies, and systemic complications associated to lysosomal dysfunction. The most grave complication of disease is interstitial lung disease (ILD) leading to irrevocable pulmonary fibrosis. Patients with HPS-1, HPS-2, and HPS-4 variants have a penchant to develop pulmonary fibrosis. The pulmonary involvement is characterised by progressive dyspnea hypoxemia respiratory failure and corpulmonale. The disease has an unfortunate prognosis with a high mortality rate and a poor quality of life. The options currently available in the therapeutic armamentarium are dismal with a dire need for opportune research. We hereby narrate an intriguing case scenario of a pair of siblings affected with this rare disorder with its associated ILD.

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Background: Obliterative bronchiolitis (OB) forms a major proportion of chronic airway diseases (CADs). OB is often misdiagnosed and included under the umbrella term 'chronic obstructive pulmonary disease'. We set out to identify the proportion of OB cases among the CADs and study the clinical profile of OB. Materials and Methods: This prospective, observational study noted all patients with Chronic airway obstruction (CAO), of which patients with OB were included and the clinical profile was studied. Data were subjected to statistical analysis. Results: Five hundred patients with CAO were noted in the study period, of which 115 patients were found to be OB amounting to a prevalence of 23%. The mean age of presentation was 51.8 years (standard deviation 12.1) with a male–female ratio of 1:1. The most common etiology for OB was as sequelae to past treated pulmonary tuberculosis (PTB) seen in 82 patients (71%) of cases. Dyspnea in 114 patients (99%) and productive cough in 110 patients (95%) were the predominant symptoms. Postexercise desaturation was seen in all 115 patients (100%). Forty-six patients (43%) presented with either Type 1 or Type 2 respiratory failure. Spirometry showed obstructive pattern in 68 patients (59%) with forced expiratory volume in 1 s/forced vital capacity (FEV1/FVC) ratio of <70% and FEV1 <70% postbronchodilator and mixed pattern in 47 patients (41%) with a reduction in both FEV1 and FVC and normal FEV1/FVC ratio. There was the presence of mosaic attenuation on high-resolution computerized tomography (HRCT) of the chest with expiratory scans in all 115 patients (100%). Pulmonary hypertension was documented in 109 patients (95%). Conclusion: OB is one of the major causes of CAO. HRCT of the chest with expiratory scans plays a important role in the diagnosis. Early diagnosis can prevent irrevocable complications.

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Although being the second most common cause of disabling daytime sleepiness in the world, narcolepsy in India is seldom diagnosed. So far, only two cases had been reported. This is the case of narcolepsy in a 15-year-old female student struggling in her scholastic pursuit because of the disease.

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Objectives: Children with untreated sleep-disordered breathing (SDB) have impaired intellectual ability and behavioral effects. Timely treatment of SDB by adenotonsillectomy (AT) may prevent this morbidity. This study was designed to assess the prevalence of neurocognitive and behavioral dysfunction in Indian children with SDB and to evaluate the impact of AT. Methods: Children recruited underwent diagnostic polysomnography (PSG), a detailed neurocognitive and behavioral assessment using a battery of validated instruments – the Malin's Intelligence Scale (MIS) for Indian children, Modified Wisconsin's Card Sorting Test, Parent Conners' Scale, and the Childhood Behavior Checklist (6–18). These children then underwent AT and subsequent reassessment at 3 and 6 months. Results: Neurocognitive impairment was common among the 33 enrolled children (mean age 9 [±2.97] years; 78.8% males). There was a significant correlation between the lowest O₂saturation and the “categories completed” (r = -0.379; P = 0.029); and the lowest O₂saturation and the “failure to maintain sets” (r = 0.386; P = 0.026) of the Modified Wisconsin's Card Sorting Test. Postsurgery, although apnea–hypopnea index (AHI) significantly decreased after surgery, 15 children still had SDB. Mean scores of most of the tested neurocognitive and behavioral domains showed improvement, although residual deficits were prevalent even after 6 months. Patients with a baseline AHI >5/h and those who had complete resolution of SDB (postoperative AHI <1/h) showed improvement in more subscales than patients with baseline AHI < 5/h and patients with incomplete resolution of SDB. Conclusion: The decreased neurocognitive performance related to SDB may be a result of hypoxemia, rather than the frequency of SDB events. Despite AT, residual disease is common and such patients may require further treatment.

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Lymphangioleiomyomatosis (LAM) is a rare disease associated with cystic lung destruction and abdominal tumors, including lymphangioleiomyomas, which frequently occur in the retroperitoneal region. Sirolimus therapy is currently recommended for LAM patients with abnormal or declining lung function with an adjusted dose to maintain a serum trough level of 5–15 ng/mL. We describe a significant reduction of retroperitoneal lymphangioleiomyomas after treatment with low-dose sirolimus therapy (serum trough level <5 ng/mL) in a patient with sporadic LAM.

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Hemothorax is an important complication of blunt trauma chest. The presentation may be delayed, especially in elderly patients with multiple rib fractures. Delayed presentation can be associated with retained hemothorax where a simple chest drain is often insufficient to evacuate the pleural cavity. Video-assisted thoracoscopy surgery is often used to manage such patients in a minimally invasive manner. Here, we demonstrate a novel application of flexi-rigid thoracoscopy with CryoProbe^® for evacuation of retained hemothorax in an elderly woman through a subcentimeter incision.

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Objectives: The aim of this study was to determine the predictive role of TLR4 polymorphism in CAP course among young cytomegalovirus-positive patients. Subjects and Methods: One hundred and five patients with pneumonia (age range: 18–44 years) and 61 healthy respondents were observed clinically and specifically (by cytomegalovirus markers and TLR4 + 3725 G/C polymorphism). Results: Among CAP patients, there were 51 male (48.6%) and 54 female (51.4%), with average age 34.1 ± 0.8 years, and there were 19 (18.1%) patients with Pneumonia Patient Outcomes Research Team (PORT) I, 46 (43.8%) patients with PORT II, 31 (29.5%) patients with PORT III, and 9 (8.6%) patients with PORT IV. Cytomegalovirus persistence was detected in 80 (48.2%) patients and 34 (20.5%) healthy respondents (P = 0.003). G/G genotype of TLR4 signaling was found in 78 (74%) patients with pneumonia, G/C in 24 (23%) patients, and C/C in 3 (3%) patients. Among G/C patients, there were 16.2% cytomegalovirus-positive patients versus 6.7% negative patients (P < 0.05), as well as among G/G patients, and there were 59% versus 15,2%, accordingly (P < 0.01). The patients of the main group with G/G genotype were characterized by mostly mild (PORT I – 15 [14.3%]) and moderate pneumonia severity (PORT II – 32 [30.5%] and PORT III – 26 [24.8%] patients). The patients with G/C genotype were characterized by mostly PORT II (11 [10.5%] patients). All C/C genotype patients have PORT II (P < 0.05). Conclusions: Cytomegalovirus persistence worsens the pneumonia course. G/G and G/C TLR4 genotypes are associated with mild pneumonia severity.

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