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Pulmonary tuberculosis (TB) is the most common cause for chronic febrile respiratory illness with constitutional symptoms in India being endemic and more prevalent in the nature of disease. Acino-nodular consolidations are documented in infective, inflammatory, autoimmune, and systemic vasculitis with pulmonary involvement. Pulmonary manifestations of systemic vasculitis have very diverse involvement ranging from nodule, consolidation, and cavitation. In this case report, a 40-year male, presented with constitutional symptoms such as persistent fever, anorexia, and minimal dry cough lung parenchymal consolidations. Patients' symptoms progressed over 4 months with poor response to empirical anti-TB treatment without mycobacterial microscopic or genome documentation in sputum. Bronchoscopy workups were inconclusive and tropical screens for bacterial, fungal, TB, and malignancy were negative. Clinical-radiological worsening and acinonodular masses with cavitation guide us to work for vasculitis panel and documented proteinase 3-antineutrophil cytoplasmic antibody positive with very highly raised titers. We have started on steroids with cyclophosphamide and observed excellent clinical and radiological response in 24 weeks.

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Objective: Inhaler usage plays a key role in the treatment of chronic obstructive airway diseases. Improper usage technique is the most common but correctable aspect of the inhaler therapy, which leads to poor disease control, additional medications, morbidity, repeated exacerbations, and admissions. The usage of proper inhaler technique ensures good treatment outcome. Methods:

• This was a prospective study using a sample size of 66 adult patients of varying age group attending the Pulmonology Outpatient Department (OPD) in Sri Ramachandra Medical College and Research Institute – Porur, Chennai
• Data were collected using questionnaire
• Assessing and scoring the patient's inhaler technique on 1^st visit to pulmonology OPD followed by teaching them proper inhaler technique using simple 4-step method
• Reviewing the same patient after 1 month, assessing and scoring to grade the outcome as good (4 scores), adequate (3 scores), and inadequate (2 or less).

Results: The number of patients with inhaler technique adequacy (scores of 3 and 4) was 44% in the study's initial phase. The study participants were trained on each stage of the inhaler technique till a level of accuracy is reached and the patient is made aware about the proper technique. The participants during the review process exhibited improved levels of technique adequacy. Overall inhaler technique adequacy (score of 3 and 4) of the study participants reached 91% in the review stage (after 1 month). Part of patient care to educate the patients regarding proper inhaler technique has been found to be highly effective. Conclusion: Proper education on correct method of inhaler technique may not only improve the symptoms of the disease but also helps in dose reduction in long-term. Health professionals should encourage and instruct on correct inhalation technique and regularly re-evaluate the patient's inhalation technique during every OPD visit. Thus, proper counseling for the inhaler use in patients must be encouraged as it is closely related in quality of life of patient.

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Mediastinal tumors are commonly found in the anterior mediastinum, among which thymic tumors and lymphoma are the most common ones. Germ cell tumors constitute about 10%–15% of mediastinal tumors. Among which seminoma is an uncommon tumor. These mediastinal masses usually present with complaints of cough, chest pain, or symptoms of superior vena cava obstruction. Here, we report a case of mediastinal seminoma in a young adult presenting with complaints of syncope.

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Purpose: Infections are a serious threat in the postoperative period in cardiac surgical patients. Ventilator-associated pneumonia (VAP) is caused by multidrug-resistant organisms resulting in high mortality. Our aim is to study the prevalence of VAP, the organism associated with it and the appropriate management. Materials and Methods: Three thousand consecutive patients who underwent cardiac surgery were included and followed from admission till discharge. All baseline characteristics and intra- and postoperative details were collected. Data on microbiological sampling were noted. The duration of ventilation and time point at which samples were sent, microbiological growth, its sensitivity, and antibiotics used were analyzed. The reassessment of the need for antibiotics at the end of 48 h of sending culture and switching based on the sensitivity (antibiotic time-out) was also captured. Results: Forty-eight patients had VAP (12.78 per 1000 ventilator days); 38 patients had culture-proven growth. The most common organism in our setting was Klebsiella pneumoniae, Acinetobacter baumannii, and Pseudomonas aeruginosa. The resistance to β-lactams, cephalosporins, and carbapenems was high. Dual and triple antibiotic therapies were noted in 64% of patients. Failure to adhere to antibiotic time-out was associated with mortality in patients when it was adhered and not adhered (27% vs. 74%, respectively) (<0.015). Conclusions: The incidence of VAP in our setting is very low. However, VAP remains a serious threat and carries a high mortality. A high degree of suspicion, timely diagnosis, usage of appropriate antibiotics based on local antibiogram, and following antibiotic time-out will help to reduce the intensive care stay and mortality.

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In the COVID-19 pandemic era, an increasing number of cases of mucormycosis have been associated with COVID-19. Mucormycosis is an invasive fungal infection in the background of immunosuppression state. COVID-19 and its treatment cause immunosuppression in patients. Mucormycosis commonly causes necrosis in the nose, paranasal sinuses, and facial bones and may also spread into the brain and lungs. A 58-year-old male, who was a known case of diabetes mellitus, was admitted with COVID-19 reverse transcription–polymerase chain reaction positive and B/L GGO with 50% lung involvement in computed tomography (CT) chest, treated as per protocol, and discharged. After 2 weeks of discharge patient presented with hemoptysis, cough with expectoration and breathlessness. Patient was admitted and stabilized. CT chest taken showed right (Rt) upper lobe and lower lobe mucormycosis and left (Lt) upper lobe and lower lobe aspergilloma. Fiberoptic bronchoscopy was done and bronchial wash taken then sent for fungal KOH and culture.fungal culture report showed mixed fungal infection like mucormycosis and aspergilloma. Patient treated with tablet posaconazole and other supportive measures and discharged. Patient asked to review every month. Followup CT chest taken at 1 month and end of 5 months. CT chest revealed partial resolution of Rt upper and lower lobe mucormycosis and persistence of Lt upper and lower lobe aspergilloma lesions. The patient persistently had hemoptysis and hence was referred to cardiothoracic surgery for surgical management of aspergilloma. COVID-19 and treatment of COVID-19 cause underlying immunosuppression that leads to fungal infections such as mucormycosis and aspergilloma. Early identification and treatment of fungal infection reduce morbidity and mortality.

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Introduction: Robust data of C-reactive protein (CRP) are available in bacterial infection, and it can be utilized in this coronavirus disease 2019 (COVID-19) pneumonia pandemic for initial assessment and planning of treatment in indoor setting in association with high-resolution computed tomography (HRCT) severity. Methods: A prospective, observational, 12-week follow-up study included 2000 COVID-19 cases confirmed with reverse transcription–polymerase chain reaction (RT-PCR). All cases were assessed with lung involvement documented and categorized on HRCT thorax, oxygen saturation, CRP at entry point, and follow-up. Protocolised recordings of age, gender, comorbidity, and bilevel-positive airway pressure (BIPAP)/non-invasive ventilation (NIV) use were done. Final radiological outcome as with or without lung fibrosis as per follow-up computed tomography in accordance to entry point severity were analysed. Clinical and final outcomes were recorded as per requirement of interventions in indoor units. Statistical analysis was done by Chi-square test. Results: HRCT severity score at entry point has a significant correlation with CRP titer (P < 0.00001). CRP titer has a significant association with duration of illness (P < 0.00001). Comorbidities have a significant association with CRP titer (P < 0.00001). CRP titer has a significant association with oxygen saturation (P < 0.00001). BIPAP/NIV requirement during hospitalization has a significant association with CRP titer (P < 0.00001). Timing of BIPAP/NIV requirement has a significant association with CRP titer (P < 0.00001). Follow-up CRP titer during hospitalization as compared to entry point (initial) normal and abnormal CRP has a significant association in post-COVID lung fibrosis (P < 0.00001). Conclusions: CRP has documented a very crucial role in COVID-19 pneumonia in predicting severity of illness at entry point and progression of illness during course of hospitalization. Role of CRP as “a jack of all trades is a master of none” in COVID-19 pneumonia is a real misnomer due to its major impact on guiding step-up and step-down interventions in critical care units. CRP is considered a 'game changer' inflammatory molecule during the entire course of COVID-19 assessment. Role of CRP as an inflammatory marker “oftentimes better than a master of one” in comparison to other available markers interleukin-6, ferritin, and lactate dehydrogenase due to easy availability and cost-effectiveness.

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Cardiovascular involvement in tuberculosis is not uncommon. Cardiac dysfunction is a clinical presentation due to direct or indirect affection due to tuberculosis. Cardiac dysfunction is possible without structural cardiac disease. In this case report, a 32-year-old male presented with constitutional symptoms for 6 months with acute deterioration with tachycardia and tachypnea with hypoxia 2 weeks before hospitalization. Radiological investigations documented conglomerated miliary tuberculosis and confirmed by sputum smear microscopy and Gene Xpert MTB/Rif. Cardiac investigations revealed sinus tachycardia in electrocardiogram, raised cardiac enzymes in laboratory evaluation, and “global left ventricular hypokinesia” with reduced ejection fraction in echocardiography. We have started Anti-tuberculosis treatment as per National guidelines for 6 months with steroids backup for four weeks. We have documented cardiac function improvement in one month post treatment, bacteriological cure after 2 months of ATT and near complete radiological resolution after 6 months. We recommend cardiac workup in all pulmonary tuberculosis cases with disproportionate tachycardia and tachypnea with or without hypoxia.

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