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   Table of Contents - Current issue
May-August 2023
Volume 6 | Issue 2
Page Nos. 37-89

Online since Thursday, July 13, 2023

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Advancing precision and patient care: The rise of robotic thoracic surgery p. 37
Ajay Narasimhan
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Comparison of various clinical scoring systems in assessing the probability of pulmonary thromboembolism in adults in a Tertiary Care Hospital in South India p. 39
Ramalingam Gogulakrishnan, Gayathri Anur Ramakrishnan
Aim: The aim of the study was to compare various clinical scoring systems used in detecting pulmonary embolism (PE) in adults in Tertiary Care Hospital in South India. Materials and Methods: Prospective study was done in Apollo Hospital, Greams Road, Chennai, from January 2016 to December 2017. Sixty-five patients with suspected PE were included in the study. Details such as age, sex, pulse rate, and blood pressure were collected. Probability of PE was calculated with all four clinical scoring systems (Wells score, simplified Wells score, revised Geneva score, and simplified revised Geneva score) and compared with computed tomography–pulmonary angiography which was considered the gold standard. Results: This study included 65 patients with suspected PE. Among 65 patients, 39 (60%) were male and 26 (40%) were female. PE was present in 23 (35.4%) patients, of which 14 (60.9%) were male and 9 (39.1%) were female, but the difference was not statistically significant (P = 0.916). Wells score had a sensitivity of 87%, specificity of 67%, positive predictive value (PPV) of 59%, and negative predictive value of 90%. Simplified Wells score had a sensitivity of 91%, specificity of 50%, PPV of 50%, and negative predictive value of 91%. The revised Geneva score had a sensitivity of 70%, specificity of 52%, PPV of 44%, and negative predictive value of 76%. Simplified revised Geneva score had a sensitivity of 65%, specificity of 57%, PPV of 45%, and negative predictive value of 75%. Conclusion: From this study, we were able to infer that the simplified Wells score had high sensitivity and Wells score had high specificity in the diagnosis of PE. Simplified revised Geneva score had the least negative predictive value. It is very important to have a high index of suspicion for the diagnosis of PE and the clinical predictability scores are valuable tools in this regard.
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Dengue-COVID-19 overlap: A single-center prospective observational study in a tertiary care setting in India p. 45
Shital Patil, Sham Toshniwal, Uttareshvar Dhumal, Ganesh Narwade
Background: Dengue-COVID-19 overlap is a mixture of both diseases sharing few similarities in pulmonary and extrapulmonary involvement. Although dengue fever is more commonly reported in tropical settings, very little literature is available regarding dengue-COVID-19 overlap in Indian context. Due to high prevalence of both diseases later being pandemic disease, and overlapping laboratory and clinical parameters, we have conducted a study to observe dengue-COVID-19 overlap in Indian settings in tertiary care hospitals. Methods: This prospective, observational study included 600 COVID-19 cases with dengue nonstructural protein 1 or dengue immunoglobulin (Ig) M positive, with lung involvement documented and categorized on high-resolution computerized tomography (CT) thorax at entry point. All cases were subjected to dengue IgG antibody titers and dengue IgM/IgG antibody titer analysis after 12 weeks of discharge from the hospital. Results: Dengue-COVID-19 overlap was documented in 16.33% (98/600) of cases. CT severity has documented a significant correlation with dengue-COVID-19 overlap cases (P < 0.00001). Hematological evaluation, white blood cell count, and platelet count were having a significant association with dengue-COVID-19 overlap (P < 0.0076 and P < 0.00001, respectively). Clinical parameters as hypoxia have a significant association with dengue-COVID-19 overlap (P < 0.00001). Inflammatory markers such as interleukin-6, C-reactive protein, and lactate dehydrogenase have a significant association in dengue-COVID-19 overlap (P < 0.00001), respectively. In study of 600 cases of “dengue COVID 19 overlap”, post COVID lung fibrosis was documented in 92/600 cases. Serological assessment between dengue IgM/IgG antibody and COVID antibody titers has a significant association with post covid lung fibrosis (P < 0.00001). Conclusions: Dengue-COVID-19 overlap is clinical syndrome with overlapping clinical and laboratory workup of both the illnesses. High index of suspicion is must in all COVID cases in tropical settings where dengue is endemic, and all cases with leucopenia and thrombocytopenia with fever should be screened for dengue serology. False-positive dengue serology or dengue antigen cross-reactivity is known to occur in underlying COVID-19 illness, and have impact on clinical outcome as it will result in delay in COVID appropriate treatment initiation and many cases require intensive care unit treatment due to progressed COVID pneumonia.
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Artificial intelligence in respiratory medicine: The journey so far – A review Highly accessed article p. 53
K Kalaiyarasan, R Sridhar
The integration of artificial intelligence (AI) and the medical field has opened a wide range of possibilities. Currently, the role of AI in the medical field is limited to image analysis (radiological and histopathology images), identifying and alerting about specific health conditions, and supporting clinical decisions. The future of lung cancer screening, diagnosis, and management is expected to undergo significant transformation with the use of radiomics, radiogenomics, and virtual biopsy. AI can also help physicians diagnose and treat a variety of respiratory illnesses, including interstitial lung diseases, asthma, chronic obstructive pulmonary disease, and pleural diseases such as effusion and pneumothorax, pneumonia, pulmonary artery hypertension, and tuberculosis. AI can also help in the automated analysis and reporting of lung function tests, polysomnography, and recorded breath sounds. Through robotic technology, AI is set to create new milestones in the realm of interventional pulmonology. A well-trained AI may also offer new insights into the genetic and molecular mechanisms of the pathogenesis of various respiratory diseases and may also assist in outlining the best course of action with the horizontal integration of patients' digital health records, digital radiographic images, digital pathology images, and biochemical lab reports. As with any technology, doctors and researchers should be aware of the advantages and limitations of AI, and they should use it responsibly to advance knowledge and provide better care to patients.
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A case of isolated pulmonary Mycobacterium avium complex infection in an immunocompetent host p. 69
Sivanthi Sapna Rajendran, Gayathri Anur Ramakrishnan
A 48-year-old male presented with complaints of occasional dry cough and sneezing for the past 4 months and high-resolution computed tomography chest done showed tree in bud and patchy nodular opacities in the right upper lobe and right middle lobe. He underwent bronchoscopy and bronchoalveolar lavage Gene X-pert Mycobacterium Tuberculosis (MTB) was not detected, but cytology showed granulomas and hence he was started on empirical antituberculous therapy (Isoniazid, Rifampicin, Pyrazinamide and Ethambutol (HRZE) regimen). His acid-fast bacilli C/S reports during follow-up showed growth of Mycobacterium Avium complex (MAC). Drug sensitivity testing was done and then he was started on oral rifampicin, ethambutol, and azithromycin and this regimen was continued for the next 6 months.
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A rare case of lymphangitis carcinomatosis presenting as diffuse parenchymal lung disease p. 72
P Maheswari, K Krishnamoorthy, T Joseph Pratheeban, E Mathan, O M. Rahman Shahul Hameed
Lymphangitis carcinomatosis (LC) is the infiltration and inflammation of lymphatic vessel secondary to the spread of malignancy from a primary site. Most cases result from dissemination of adenocarcinomas. Its presentation may be unilateral or bilateral, it is asymmetrical and is limited to one lobe of the lung especially lower lobes, focal unilateral presentation is observed in 50% of patients, while only 6%–8% of lung metastases present as diffusely infiltrating pattern. In this case report, we present a case of adenocarcinoma with LC presenting as diffuse parenchymal lung disease which is a rare presentation. A 45-year-old female matchbox industry worker by occupation with no comorbid illness presented with 8-month history of cough with scanty mucoid expectoration and Grade II dyspnea according to the modified Medical Research Council along with history of loss of appetite and weight. CT chest shows parenchymal nodule with spiculated margin in the anterior segment of the upper lobe, nodular thickening of the Broncho vascular interstitium and pleura, diffuse interstitial septal thickening and randomly distributed nodules in all lobes. PET scan showed low grade metabolically active nodule in the anterior segment of the left upper lobe, metabolically active mediastinal, supraclavicular and retrocrural lymph nodes, mild pleural effusion and Low-grade diffuse metabolism was noted in the uterine endometrium. Low-grade diffuse metabolism was noted in the uterine endometrium. Abdominal ultrasound revealed an endometrial thickness of 8 mm. Visual inspection with acetic acid (VIA), visual inspection with lugol's iodine (VILI) and Papanicolaou smear was done which was suggestive of inflammatory smear, and Papanicolaou smear was done and was suggestive of inflammatory smear. Fiber-optic bronchoscopy was done, it was normal, and transbronchial lung biopsy revealed adenocarcinoma lung. The patient was referred to medical oncology, and the first cycle of chemotherapy was started with cisplatin and pemetrexed. Physicians should be aware of pulmonary lymphangitic carcinomatosis from lung adenocarcinoma and consider it in patients with pulmonary symptoms who are unresponsive to antibiotics. Despite establishment of diagnosis with cellular etiology even primary source, the condition is fatal. This rare condition needs to be considered in appropriate clinical settings.
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Isolated pulmonary mucormycosis in diabetic patients p. 76
Vyshnavi Rajeev, Ajay Narasimhan, Jebin Roger, R Narasimhan
Mucormycosis refers to the infection caused by a growing number of members of the Mucorales. Mucormycosis has emerged as an important opportunistic infection in severely immunocompromised patients with hematological malignancies and recipients of stem cell or organ transplantation and in poorly controlled diabetics. The diagnosis of mucormycosis relies upon histopathology and culture. Blood tests are of limited diagnostic value. Here, we present two cases of mucormycosis in diabetic patients diagnosed with tissue biopsy.
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Melioidosis: Spectrum of presentation p. 81
H Ria Lawrence, Gayathri Anur Ramakrishnan
Melioidosis is caused by Burkholderia pseudomallei, which is normally present in soil, endemic in the tropical and subtropical regions. It has a varied clinical presentation from presenting with acute symptoms and sepsis and rarely presenting as subacute to chronic disease. In this article, we have discussed the spectrum of presentation of melioidosis such as mediastinal lymphadenopathy, cavitating pneumonia, and pleural effusion.
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Pulmonary cavities following blunt chest injury p. 84
K Kalaiyarasan, A Sharmila Begam
Road traffic accidents (RTAs) are the most common cause of chest injuries. In this case report, a 17-year-old male presented with left-sided chest pain and hemoptysis after an RTA. Radiological investigations showed a left-sided pneumothorax with multiple cavities in the left lower lobe of the lung and surrounding ground glass opacities, which was suggestive of pulmonary lacerations. We managed the patient conservatively and followed up after 1 month. The computed tomography thorax showed near-complete radiological resolution after 1 month. In all patients with injuries to the chest, we have to suspect pulmonary lacerations, which can present with cavities in the lung parenchyma, and manage them accordingly. As demonstrated in this case, a pulmonary laceration following a RTA can present with pulmonary cavities. Hence, this should be kept in mind during the management of the patient with a chest wall injury.
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Radiology quiz p. 87
Aarthi Narasimhan, Vyshnavi Rajeev, Riha Mehrin
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