Unmasking of miliary tuberculosis in COVID-19: A case report

Both coronavirus disease-19 (COVID-19) and pulmonary tuberculosis (PTB) are transmitted through the respiratory route and are related to various risk factors. The index case was a 45-year-old female who presented to a tertiary care hospital in North India with complaints of dry cough, loss of weight, and appetite for twenty days followed by fever and dyspnea for five days. RT-PCR for COVID-19 turned out positive. Chest-roentgenogram revealed bilateral homogenous micronodules. She was started on COVID-19 treatment according to the Ministry of Health and Family Welfare guidelines. She was not clinically improved so CECT-thorax was performed which revealed bilateral homogenous millet-shaped micronodular opacities. Mantoux test was twenty-five millimeters in size but sputum analysis for acid-fast bacilli was negative. The patient was started on anti-tubercular-therapy (ATT). The patient got improved clinically and is being followed. This case focuses on the need for prompt diagnosis of PTB in COVID patients for the appropriate management and early recovery.

Contralateral pneumothorax after central line placement in COVID-19 positive patients

Contralateral pneumothorax after percutaneous central venous catheter placement has not been previously reported. Three patients who required intubation and mechanical ventilation for acute respiratory failure due to COVID-19 were identified with a new pneumothorax on routine post-placement chest roentgenogram on the side opposite the catheter placement. Retrospective review of charts, radiographs, and laboratory studies. No causative relationship was identified between the percutaneous placement of the central venous catheters and the subsequent pneumothoraces identified on the contralateral side, other than the presence of active COVID-19 viral pneumonia. The timing of the contralateral pneumothoraces were coincidental the placement of the central venous catheters. We believe these pneumothoraces were a consequence of the pulmonary pathology of the COVID-19 virus.

Acute Myocardial Infarction of the Left Main Coronary Artery Presenting with Cardiogenic Shock and Pulmonary Edema during Noncardiac Surgery

Acute myocardial infarction (AMI) caused by severe stenosis of left main coronary artery (LMCA) presenting with cardiogenic shock and pulmonary edema during noncardiac surgery is uncommon, but a catastrophic event. A 77-year-old male with cholangiocarcinoma underwent hepatectomy. During the surgery, he presented with cardiogenic shock, which did not respond to infusion administration or vasopressor. A transesophageal echocardiogram revealed anterior, septal, and lateral severe hypokinesia and impaired left ventricular function. Emergent coronary angiogram showed severe stenosis of LMCA. The patient underwent primary percutaneous coronary intervention (PCI) under the support of intra-aortic balloon pump, followed by extracorporeal membrane oxygenation. The chest roentgenogram showed pulmonary edema. Two days after PCI, he successfully underwent hepatectomy and bile duct resection. Early identification of the cause of hemodynamic instability during noncardiac surgery and invasive strategy are important for minimizing the myocardial injury and improving clinical outcomes in AMI of LMCA.

Imaging Findings in a Case of Carcinoma Oesophagus Presenting with an Intra-Atrial Mass on Echocardiography

A 53-year-old male presented to our tertiary care center with complaints of palpitation and difficulty in breathing on exertion which was insidious in onset and gradually progressive. He had a history of back ache and significant weight loss. His physical examination and initial laboratory work up revealed no obvious abnormality. His initial radiological investigation involved chest roentgenogram which revealed cardiomegaly with mediastinal widening and haziness in left lower lung zone (Figure 1). His (electrocardiogram) ECG revealed normal sinus rhythm. Later, patient underwent echocardiography which revealed normal systolic flow with a mass extending up to pericardium (measuring 6.9 x 4.1 cm) in left atrium obstructing mitral flow and minimal pericardial effusion. He was sent to our department for contrast enhanced computerised tomography (CT) thorax scan to evaluate the extension of the left intra atrial mass which revealed a heterogeneously enhancing circumferential wall thickening in mid oesophagus extending from T7 - T11 for an approximate length of 8.3 cm with a single wall thickness of 2.3 cm in left lateral wall. There was also a heterogeneously enhancing lobulated soft tissue density mass with hypodense area within measuring 6.4 (CC) x 7.3 (AP) x 7.9 (TR) cm in left paraesophageal region infiltrating into adjacent pulmonary vessels and left atrium forming a large intracavitary mass with collapse of adjacent lung parenchyma and pericardial effusion with a maximum depth of 1.7 cm (Figure 2 & 3). Multiple enlarged lymph nodes were noted in paratracheal, pretracheal precranial and perivascular regions, largest measuring 1.2 cm in SAD in paratracheal regions (Figure 2B). Based on the imaging findings we made the diagnosis of malignant oesophageal growth with metastatic paraesophageal nodal mass infiltrating into adjacent pulmonary vessels and left atrium forming a large intra-cavitary mass. On following up, endoscopic workup revealed a nodular growth in oesophagus extending from 33 to 38 cms with intact overlying mucosa (Figure 4). On histopathological examination of the specimen taken from the oesophageal growth revealed to be squamous cell carcinoma infiltrating to muscle coat.

Silent Brain Tuberculomas with Acute Miliary Tuberculosis in 13-Year Old Girl - Case Report

We describe iron deficiency and silent intracranial tuberculomas with pulmonary miliary tuberculosis in 13-year old girl which can be rare seen, particularly in immunocompetent children. She presented as respiratory infection with lack of menstrual bleeding. She didn’t receive BCG vaccination. Chest roentgenogram showed miliary pattern while MRI of brain revealed parenchymal tuberculomas. Empirical 4 antitubercular drug treatments were initiated. Control showed a decrease in size and number of brain tuberculomas. Silent brain tuberculomas with miliary tuberculosis could be rare seen, particularly in immunocompetent children. It remains an open question whether the irregular menstrual bleeding and iron deficiency was associated with the drop of her immunity and increased risk for military tuberculosis. Key words: BCG vaccination, irregular menstrual bleeding, MRI of endocranium.

Comparing a new device to measure lung volumes with three traditional methods in individuals with different lung conditions

BackgroundLung volumes can be measured by body plethysmography (BP), by inert gas dilution during a single-breath or multiple breaths and by radiographic methods based on chest roentgenogram or CT scanning. Our objective was to analyze the concordance between several methods including a new instrument in a variety of pulmonary conditions.MethodsWe recruited four groups of adult volunteers at the COPD and Tobacco Clinic of a respiratory referral hospital: patients with lung bullae, with obstructive lung diseases, with restrictive lung diseases and healthy controls; all subjects underwent lung volume measurements according to ATS/ERS standards in random order with each method and then CT scanning. Differences among groups were estimated by Kruskal-Wallis tests. Concordance correlation coefficients (CCC) and Bland-Altman plots were performed.ResultsSixty-two patients were studied including 15 with lung bullae, 14 with obstructive lung diseases, 12 with restrictive lung disease and 21 healthy subjects. Highest concordance was obtained between BP and CT scanning (CCC 0.95, mean difference −0.35 L) and the lowest, with TLC-DLCOsb (CCC 0.65, difference - 1.05 L). TLC measured by BP had a moderate concordance with Minibox (CCC=0.91, mean difference −0.19 L). Minibox, on the other hand had the lowest intratest repeatibility (2.7%) of all tested methods.ConclusionsLung volumes measured by BP and CT had a substantial concordance in the scenario of varied pulmonary conditions including lung bullae, restrictive and obstructive diseases. The new minibox device, had low intratest variability, and was easy to perform, with a reasonable concordance with BP.

A STUDY ON ETIOLOGY AND DIAGNOSTIC MODALITIES OF CASES WITH SOLITARY PULMONARY OPACITY IN CHEST ROENTGENOGRAM

INTRODUCTION: In various mass screening programmes, 0.09-2% of chest radiographs have revealed solitary pulmonary nodules. This continues to pose a diagnostic challenge and therefore the signicance of its proper evaluation to differentiate between benign and malignant causes. The study was carrie MATERIALS AND METHODS: d out in the Department of Respiratory Medicine of IPGMER, Kolkata for a period of one & half year (November 16 to May 2018). Help was also sought from various departments of IPGMER, specially the Departments of Pathology, Microbiology, Cardiothoracic surgery and Radiotherapy. Fine needle aspiration cytology of lung opacity under guidance of computerized tomography was performed in Radiology Section of the Bangur Institute of Neurology, Calcutta, Department of Radiotherapy, IPGMER and The CT-Scan Centre of Medical College, Kolkata. A total of 73 cases showing solitary pulmonary opacity and obeying the selected criteria were selected for the study of which 56 cases are being evaluated in this study as 17 cases were either lost to follow-up or data was incomplete and hence were excluded. The study showed RESULT AND ANALYSIS: bronchogenic carcinoma as by far the most common cause of solitary pulmonary opacity occurring in 45% of the total cases. Majority of the cases of bronchogenic carcinoma were of squamous cell variety (48%) followed by adenocarcinoma (36%). Small cell carcinoma (4%) and anaplastic carcinoma (12%) were less common. Among the benign causes, tuberculoma was the commonest cause seen in 21.4% cases followed by metastasis from other sites (9%). Solitary pulmonary opacity due to bronchogenic carcinoma was seen more in elderly subjects (Mean age of the subjects with bronchogenic carcinoma was 58.9 years while for tuberculoma & hydatid cyst cases the mean ages were 43.3 years and 41 years respectively). The present study showed that meticulous clinical evaluation, careful study of c CONCLUSION: hest roentgenogram coupled with judicious use of investigations like ber optic bronchoscope andCT guided aspiration cytology make it possible to diagnose the etiology of solitary pulmonary opacitieswithoutresortingtomajorsurgicalprocedures.Althoughthis doesnotunderestimatethe needforthoracotomy whichisthenalanswertotheproblemofundiagnosedsolitarypulmonary opacity, The present study can be regarded as yet another illustration of the current trend of evaluation of pulmonary opacities by increasing use of non-invasive investigation procedures bases on recent technologicaladvances.

Impossible Airway: A Case Report

Background: Wheezing is a common presentation of asthma and chronic obstructive pulmonary disease (COPD). However, other rare etiologies such as endotracheal tumor should be kept in mind. Case presentation: We report a case of mucoepidermoid carcinoma of carina in which the patient initially presented with wheezing mimicking COPD. Chest roentgenogram showed a soft-tissue density in the tracheal air column. Surgical resection of the tumor was technically hindered by difficulty in airway establishment during anesthesia. Extracorporeal membrane oxygenation (ECMO) was employed to secure adequate blood-gas exchange during operation, after which the tumor was resected smoothly and the patient discharged uneventfully.Conclusions: Endotracheal tumor should be kept in mind when facing a patient presenting with wheezing. Careful auscultation and interpretation of the chest roentgenogram are two important keys for differentiating such lesions from asthma or COPD. If further intervention was hindered by difficulty in airway establishment, ECMO proves effective and safe to “bypass” such an impossible airway and secure the procedures.

Lung Pseudomesothelioma in Patient with Asbestos Exposure: A Case Report

Background: Pseudomesotheliomatous carcinoma is a rare case of lung cancer with marked pleural extension resembling malignant pleural mesothelioma on diagnostic imaging. One of tool to diagnose lung pseudomesothelioma is by performing thorocoscopy pleural biopsy. Diagnostic thoracoscopy also has a higher sensitivity than pleural fluid cytology and needle biopsy.Case: We report a rare case of pseudomesotheliomatous carcinoma of the lung in a 50-year-old man with asbestos exposure. The patient had complained of dyspnea and chest roentgenogram showed left pleural effusion. Computed tomography (CT) of the chest revealed diffuse irregular left pleural thickening and without a clear initial primary lesion found in both of lung parenchyma, which mimicked pleural mesothelioma. Pleural tissue sampling was performed to obtain definitive diagnosis by video-assisted thoracoscopic surgery. At the operation, the tumor was found to have spread along the pleural surface and primary lesion was not detected in the right lung parenchyma. Immunohistochemically, the tumor was positive for Thyroid Transcription Factor- 1 (TTF-1), but negative for calretinin, P63, and Neuron Specific Enolase (NSE). Final diagnosis was adenocarcinoma of the lung and patient had good clinical response to Gefitinib.Conclusion: Based on the results of clinical studies (images and clinical observations), although pseudomesotheliomatous in patient with asbestos exposure is difficult to distinguish from pleural mesothelioma, we have a case of pseudomesotheliomatous lung diagnosed by a thoracoscopic pleura biopsy. For such cases, thoracoscopic pleural biopsy should be performed at an early stage.