key: cord-0078211-4fr17ojn
authors: nan
title: Miscellaneous
date: 2022-03-03
journal: Lung India
DOI: 10.4103/0970-2113.341097
sha: dc9a5feb2fe82cf2695660e79c3a6441a44d486b
doc_id: 78211
cord_uid: 4fr17ojn

nan

pull of mediastinum. Required urgent bronchoscopy to remove endobronchial mucus plug. Conclusion: Prognosis and outcome have improved as a result of early diagnosis, newer antifungals agents & surgical debridement. Antifungal treatment, surgical interventions & high risk of post surgical complications in an immunocompromised elderly host is grave challenge. But our case had a positive clinical outcome.

Bharat Gopal E-mail: nationalchestcentre@gmail.com India has one of the highest number of smokers in the world. As per the 2017 Global Adult Tobacco Survey (GATS), 99.5 million adults smoke tobacco in India. Of those, 38.5 % reportedly attempted to quit smoking, yet only a small fraction of them succeeded. Smoking and exposure to secondhand smoke kill about 1.2 million Indians each year. Currently the smokers have a choice of either to quit or use nicotine replacement therapies as a smoking cessation tool. Although several nicotine replacement therapies (nicotine chewing gums, patches etc.) are approved, more than 80% of smokers who use them for smoking cessation do not succeed. Hence there is a strong unmet need for smokers who are unable to quit to have better alternative nicotine products. In this regard we did an online survey amongst the 1000 members of medical fraternity to evaluate the current cigarette usage patterns, intention to quit, how many adopt NRTs and how many succeed and do the physicians genuinely feel the need for relatively safer and better nicotine products. The results will be presented in the forum.

Burdwan Medical College and Hospital, Burdwan, West Bengal, India. E-mail: baruihrishi05@gmail.com Background: Lemierre's syndrome is a condition identified by septic thrombophlebitis of internal jugular vein following an oropharyngeal infection along with septic embolization to other organs mainly lungs. Case Study: A 14-year-old female presented with complaint of high-grade fever, progressive shortness of breath, painful swelling of throat for past 7 days. On chest x-ray, there was left sided whole lung consolidation with ipsilateral pleural effusion. Empirical treatment was started with intravenous piperacillin-tazobactam and levofloxacin. Complete hemogram and blood biochemistry showed neutrophilic leukocytosis only. Gram stain and aerobic culture of sputum, pleural fluid and blood were inconclusive. As there was no remission of symptoms, Contrast Enhanced Computed Tomography (CECT) scan was done and it showed bilateral moderate pleural effusion and filling defect of bilateral internal jugular veins. Ultrasonography of neck confirmed the presence of thrombus in internal jugular vein of both sides. Patient was initiated on intravenous clindamycin and subcutaneous anticoagulants. Gradually the symptoms of the patient resolved. Discussion: Lemierre's disease is caused by Fusobacterium necrophorum, an obligate anaerobic gram-negative rod, which is usually considered as a commensal of respiratory tract and typically affects young adults. Pulmonary involvement is common due to hematogenous spread of the bacteria. Most of the times, early initiation of appropriate antibiotics is essential for treatment. Conclusion: Despite being called the "forgotten disease", Lemierre's syndrome requires strong clinical judgement and prompt management to prevent mortality.

Abhishek Dey, Kohena Roy, Jaydip Deb E-mail: abhishekdey867@gmail.com Introduction: Pulmonary hypertension is one of the differentials of progressive worsening shortness of breath. It requires a thorough diagnostic evaluation by an experienced specialist and then categorization as per the latest ERS guideline, which, is further essential in mapping out a management strategy. Pulmonary hypertension in the younger population is an unusual presentation in the field of adult respiratory medicine. This is the case of a young adult who was referred to our centre for further management of severe pulmonary hypertension. He was found to have a congenital cardiovascular defect which was in fact a part of a larger syndrome. Case: This is the case of a 28-year-old gentleman, a mason by profession from West Bengal, who complained of worsening exertional breathlessness for the last 3 months. He was apparently well till 3 months back when he started to have dyspnoea on exertion. It was insidious in onset, slowly progressed over time from MMRC 1 to MMRC grade 3. He further gave a significant past history of intermittent cyanosis of lips, hands, and feet, which was not related to climate change. He recollected having cyanotic spells even in the past described as sudden fainting episodes or giddiness which would relieve on squatting. He was seen at a local centre for his syncopal episodes, where they labelled him to have a heart problem which was not evaluated in detail. However, due to financial constraints, he never sought help until he experienced shortness of breath. He was re-evaluated recently at a local hospital and was diagnosed to have severe pulmonary hypertension and was referred to Christian Medical College Vellore for further management of the same. He did not have orthopnoea or paroxysmal nocturnal dyspnoea. There was no cough / chest pain or fever. There is no history of acute coronary syndrome or cerebrovascular accident in the past. His parents were non-consanguineous and there was no family history of heart or other defects. As per recall he had speech delay but walked on time. Presently still has unclear/ nasal speech. At presentation, he was in respiratory failure with a room air saturation of 79% which increased to a maximum of 88% with supplemental oxygen. He was admitted for the same. On detailed examination it was found the he was of short stature (height -54cm, parents and sister were taller than him) with a BMI of 18.98kg/m2, and he was noted to have an unclear/ nasal speech. Vitals were stable and all peripheral pulses were palpable. He had central cyanosis and pan digital grade 4 clubbing. His right hand was significantly smaller than the left with a hypoplastic thumb. The spine appeared grossly normal, and he had Pectus excavatum. Examination of the cardiovascular system revealed a loud P2, split s2 and an early systolic murmur. Basic blood investigations showed an arterial PaO2 of 49 mmH2O and a PCV of 6%. His Chest x-ray showed an enlarged right ventricle with a Cardio thoracic ratio of 55.59%. A 2D Echocardiogram also showed features of pulmonary hypertension causing a dilated right ventricle and right atrium with a mild tricuspid regurgitation. However, the interatrial septum was intact with no evidence for an atrial septal defect. Left ventricle showed D shaped appearance. We proceeded with a CT pulmonary angiogram which showed a communication seen at the junction of upper most portion of the ascending aorta and main pulmonary artery -features suggestive of an aorto pulmonary septal defect (APSD) which was a type ii defect. Features of shunting from pulmonary artery to the aortasuggestive of Eisenmenger's syndrome were evident. It also confirmed the dilated RA and RV findings in keeping with the echocardiogram and an additional finding of segmental vertebral fusion anomaly at the cervico-thoracic junction. Creatinine was elevated (1.5mg%) which worsened after contrast injection, also uric acid was 12.8g% which was significantly elevated. An ultrasound of the abdomen showed bilaterally contracted kidneys with the right and left kidneys measuring 6.4 cm and 7.4 cm, respectively. After a thorough literature search, his case was fitting in a VACTERL ASSOCIATION with the following findings which could be a part of the syndrome.

-Segmental vertebral fusion anomaly -Cardiac-Aortopulmonary window -Limb defects-right radial hypoplasia/thumb hypoplasia -Bilateral contracted kidneys. As the patient was not affordable for genome sequencing, he was given symptomatic management. A surgical correction of the defect was also not an option due to Eisenmengerization. He was initiated on medical management of the acute on chronic renal disease, was given diuretics and a combination of endothelin receptor antagonist and phosphodiesterase inhibitor (Tab. Ambrisentan-Tadalfil (5+20mg) half tablet once daily. He was also advised phlebotomy in case the PC was above 70% or he had hyperviscocity symptoms. Discussion: Mal septation of the aortopulmonary trunk during embryogenesis results in aortopulmonary septal defect. [1] This is identified as a window which can classified into types. The Richardson classification system for aortopulmonary septal defect (APSD) includes simple defects between the ascending aorta and pulmonary trunk (type I), defects extending distally to include the origin of the right main pulmonary artery (type II), and anomalous origin of the right main pulmonary artery from the ascending aorta with no other aortopulmonary communication (type III). [2] Most defects are recognized at birth and must be corrected as soon as possible. Surgical correction procedures include autologous pericardial patch by the transaortic approach which was found to be the best, [1] ligation, direct suture, or in the patient with type III APSD, aortopulmonary septation through a trans window approach. [3] Though most cases present within the first few months of life due to symptoms of a cyanotic heart disease, some cases such as our patient may live with it without hampering of normal activities of daily living till the Eisenmengerization causes a severe pulmonary hypertension. When surgically corrected, the pulmonary hypertension is reversed and the patient needs a normal life, thus significantly decreasing mortality. In this patient, sadly due to inefficiency of the medical facility available, as it was not a straight forward atrial septal defect, his cyanotic spells were not further investigated. The identification of an APSD further distal to the origin of the great vessels becomes difficult and needs expertise for correct identification. If missed, the patient will be considered to have primary pulmonary hypertension which is not fully correctable as opposed to a cardiovascular defect which is surgically correctable. This case also sheds light on the variety of presentations of a VACTERL association. VACTERL association is the presence of a minimum of 3 of 7 congenital abnormalities including vertebral, anal, cardiac, tracheoesophageal, renal, and limb abnormalities. [4] It affects 1 in 10,000 to 40,000 new-borns, most being sporadic, and the exact aetiology being unknown. It thus remains as a diagnosis of exclusion. Due to its multiorgan involvement, VACTERL association is described as a developmental field defect, since malformations during blastogenesis usually result in congenital defects affecting many organ systems. The management of patients with VACTERL association involves long-term care, including surgical corrections of the defects and physical therapy. In this case our patient fulfilled the criteria as he had a cardiac anomaly, limb, and renal abnormality as well. He however presented atypically with pulmonary hypertension as opposed to otherwise typical presentations of VACTERL association in the younger age group. Conclusion: Since APSD is not a common finding as opposed to an ASD, it may be easily missed on Echocardiogram and a CT which will lead to misdiagnosis. Medical facilities and personnel with expertise including radiologists, cardiologists and pulmonologists in our country still need to reach the nooks and corners so that congenital heart defects are surgically corrected before the onset of Eisenmengerization and before severe Pulmonary hypertension develops. Once this takes place, only symptomatic medical management is the only available option as of today. Consent: An informed consent was taken from the patient for purpose of this clinical case write up.

to the lungs. Symptom relief is observed only when the appropriate technique is followed. Objective: To assess technique and to provide education on proper use of inhaler in patients with obstructive airway diseases and to obtain data on benefits of proper inhaler technique. Background: Poland syndrome is a rare congenital condition characterized by absence of unilateral chest wall muscles and sometimes ipsilateral syndactyly or brachydactyly. The condition typically presents with unilateral absence of sternal portion of pectoralis major muscle which may or may not be associated with the absence of nearby musculoskeletal structures. Case Study: An 18-year old male presented with complaint of asymmetry of chest. On examination, flattening was noticed in left infraclavicular and mammary area. There was also ipsilateral brachydactyly. Ipsilateral drooping of eyelid was reported to be present since birth by parents. Chest radiograph showed translucency over left side with normal bronchovascular markings. MRI chest showed deficient sternal head of left pectoralis muscle. Ophthalmological and Neurological examination were found to be normal. Discussion: The pathological mechanism is considered to be a result of interruption of the early embryonic blood supply to the subclavian artery. The absence of sternal portion of pectoralis major muscle in the patient did not result in loss of strength or malfunction. Patient and his family members were counseled about the condition and no surgical treatment was considered. There was also associated ipsilateral congenital ptosis which has never been documented before as a part of syndrome.

Conclusion: This case report adds to the knowledge of health professionals about this rare syndrome and its atypical presentations. Background: Paraquat is a bipyridilium compound which when ingested accidentally or with suicidal tendency has a corrosive action locally and causes free radical injury to multiple organs. Cause of respiratory distress after paraquat poisoning includes development of pneumothorax and pneumomediastinum. Pneumomediastium as a complication has 100% mortality. Case Report: A young male, farmer with alleged history of consumption of paraquat presented to EMD after gastric lavage with vomiting and having elevated RFT and LFT followed by which dialysis was planned and methylprednisolone, NAC, vitamin C administered, over 48 hours patient developed respiratory distress and subcutaneous emphysema all over the body, with CT chest revealing bilateral pneumothoraces with pneumomediastinum. ICD placement was done. Though patient was treated aggressively, deterioration ensued over a period of time leading to his death. Discussion: The mechanism of action of paraquat is by producing reactive oxygen species and hydroxyl radicals which leads to destruction of cell membranes causing impaired gas exchange and loss of surfactant which cause increase in surface tension within alveolar cells ultimately causing rupture of cells causing pneumothorax and pneumomediastium. In our case the initial imaging was normal, but after a period of 48 hours patient developed sudden respiratory distress after development of pneumothorax on both sides and with extensive pneumomediastinum. Conclusion: Development of pneumomediastinum in a case of paraquat poisoning has high mortality even after early diagnosis and aggressive management. In our case mortality could not be prevented because of presence of pneumomediastinum.

Anterior mediastinal mass: A rare case of mature teratoma with active pulmonary tuberculosis Sruthi Vijayan, N. T. Awad, Pranavi Kishore Amin, Yash Kedia E-mail: sruthi.vijayan11@gmail.com

The differential diagnosis of anterior mediastinal mass is lymphadenopathy(common tuberculosis) and teratoma. Mediastinal germ cell tumors are rare. Teratomas are defined by the presence of tissue from more than one of the three primitive germ cell layers. Mature(benign) teratomas are composed of well differentiated elements such as fat, muscle and cartilage(mesoderm), and intestinal tissue(endoderm), hair skin and teeth(ectoderm). It can be usually symptomatic or asymptomatic. Occasionally they erode into the airway and patient may cough up hair(trichoptysis) or oily sebum that is pathognomonic of benign mature mediastinal teratoma. Diagnostic procedure of choice is CECT chest. The case is of a 22 year old male who presented with complaints of left sided dull aching chest pain since 1year and fever on and off, loss of appetite, loss of weight (10 kg), cough with minimum mucoid expectoration and 2 episodes of trichoptysis since 3 months. On further investigations with CECT, a well encapsulated lobulated heterogenous mixed density mass lesion was seen in anterior mediastinum suggestive of mature teratoma. Along with it, a thin walled cavity with multiple tiny centrilobular nodules suggestive of Tuberculosis was also seen. Patient was subjected to bronchoscopy which revealed the presence of hair, calcific materials and sebum in the airways. Patient was stared on Anti-TB drugs and posted for surgical excision of the teratoma after the intensive phase of the ATT. In the general community, this disease affects roughly 1% of the population. Lung involvement in RA has a substantial impact on prognosis and is linked to greater morbidity and mortality. The aim of this study is to describe the pulmonary manifestations in Rheumatoid arthritis patients and to correlate the clinic spirometry profile and radiological findings. Methods: It's a cross-sectional study with sample size of 50 patients. After obtained consent from the patients, basic information of the patient were noted and evaluated clinically. After thorough clinical examination , patient were subjected to Pulmonary function test (Spirometry and 6Minute walk test). The spirometric test was repeated for three times and the best of the three readings were taken. Among the various parameters , the following were analysed.

[FVC, FEV1, and FEV1 /FVC ratio]. All the patients were subjected to chest XRAY and HRCT/CT Chest after getting consent. Echo done in selected cases to exclude cardiac cause. Results: ILD was the most common pulmonary manifestation in the form of Usual Interstitial Pneumonia. Among the investigations, HRCT Chest was the most sensitive method in identifying the pulmonary involvement in Rheumatoid arthritis. Conclusion: Respiratory symptoms and PFT abnormalities can be considered as the predictors of lung involvement in RA patients. So all the patients of Rheumatoid arthritis should be screened with HRCT chest and PFT for earlier identification of pulmonary involvement.

Background: Pulmonary hypoplasia is a rare congenital anomaly which is characterized by underdevelopment of alveolar tissue resulting in a small, fibrotic and nonfunctioning lung. It is often accompanied by other congenital anomalies. It is very rare in right lung as compared to left. We present a rare case of right sided pulmonary hypoplasia presenting in adulthood with bicuspid aortic valve. Case Study: A 21 year old female student was admitted to the hospital due to breathlessness with recurrent respiratory tract infections since childhood. Clinical examination revealed smaller right hemithorax compared to left. Chest X-ray showed right sided non-homogenous opacity with ipsilateral mediastinal shift. Contrast CT scan and CT pulmonary angiography showed rudimentary right upper and middle lobe and normal right lower lobe parenchymal tissue with normal right pulmonary artery. Bronchoscopy showed rudimentary right upper and middle lobe openings with patent right lower lobe opening. Echocardiography revealed bicuspid aortic valve. She was managed conservatively and is doing well on regular follow up. Discussion: According to Boyden there are three degrees of mal-development of lung: agenesis, aplasia, and hypoplasia. Hypoplasia of the lung may be primary (idiopathic) or secondary (when it occurs in association with environmental factors). Treatment consists of control of recurrent infections, bronchodilators and management of other complications. Conclusion: Pulmonary hypoplasia is a rare but important cause of recurrent childhood respiratory infections and must be diagnosed early with detection of other congenital anomalies. Study on the role of 6-minute walk test in the evaluation of patients with chronic respiratory diseases at a rural tertiary care centre of northern India

Background: Six-minute walk test (6 MWT) evaluates the integrated responses of respiratory system, cardiovascular system, blood and neuromusculoskeletal system and is a quick and inexpensive measure of physical function and an important component of quality of life since it reflects the capacity to undertake day to day activities. This study was planned to asses role of 6 Minute Walk Test in the evaluation of patients with chronic respiratory disease, at a tertiary care centre of northern India Methods: This was a Hospital based cross sectional study done between January 2020 to June 2021, Pulmonary function tests and 6-minute walk test were conducted as per ATS/ERS recommendation using Spiropalm 6MWT. Results: This study reveals that patients with COPD having 6-minute walk distance (6MWD), 73.9 ± 9.2 %, asthma had 73.6 ± 8.2, bronchiectasis had 72.3 ± 3.2, post TB sequelae had 66.0 ± 5.8, interstitial lung disease had 56.1 ± 5.0 % of the predicted distance, (P<0.001). There was significant positive correlation of 6MWD and % predicted 6MWD with spirometric parameters, forced expiratory volume during first second (FEV1), % predicted FEV1, forced expiratory capacity (FVC), % predicted FVC (except % pred. FEV1 and % pred. 6MWD). 6MWD and FEV1/FVC does not have significant correlation. % predicted 6MWD had significant negative corelation with FEV1/FVC. Conclusion: The six-minute walk distance travelled by study participants was significantly lower than predicted 6-minute walk distance and corelated with spirometric variables. Impact of addition of aerobika oscillating positive expiratory pressure device to standard of care in patients with chronic obstructive pulmonary disease exacerbations: A real-world evidence study To determine the quality of life using CAT (The COPD Assessment Test) score in patients with COPD exacerbations after 6-week use of Aerobika post discharge in an observational study. Methods: Patients with COPD exacerbations prescribed Aerobika were evaluated using a proforma wherein, they rated their symptoms using the CAT score at day 0 and post six weeks of Aerobika use. The patients, as well as physicians, provided their response regarding its ease of use and benefits experienced during the study Results: Among the 40 patients (72.5% males), in 77.5% the CAT score improved at the end of six weeks compared to baseline. Overall, the mean CAT score decreased (20 to 12) with an average change of 40%. When we considered only the patients who noted an improvement, there was a >53% decrease in the CAT scores. Most patients reported that Aerobika was convenient to use [(ease of use (>72%), easy to clean and maintain (~83%) and easy to carry (>86%)]. Around 94% of patients stated that they would continue its use. The pulmonologists found considerable improvement in ease of expelling mucus rated as 'excellent' to 'very good' Physician reported that dyspnea reduced by 50% and exacerbations by 75%. Conclusion: The use of Aerobika OPEP device as an add-on, drug-free therapy with routine care provided symptomatic relief and demonstrated improved quality of life in COPD patients experiencing mucus hypersecretion. Background: Tracheal bronchus is a rare congenital anomaly of the airway where accessory bronchus originates directly from the trachea. This condition is rarely reported in literature due to sparsely reported cases in the literature with estimated incidence of 0.1-2%. It is usually incidental findings in asymptomatic patients. However, it can be present with recurrent respiratory infection or with coexisting pulmonary complications. MDCT imaging and bronchoscopy plays a crucial role in identification of tracheal bronchus. Case: Here we present the case of 54-year-old male with 80 pack years of smoking history presented to the outpatient department with complaints of increased difficulty in breathing and cough with expectations for 7 months and on and off fever for 1 month. Patient with recurrent right upper lobe pneumonia who was discovered to have tracheal bronchus on fibreoptic bronchoscopy (FOB) findings showed a round opening measuring 1x1 cm approximately 2 cm proximal to main carina at the lateral wall of trachea. Discussion: Tracheal bronchus is described in literature as mostly incidental finding in the chest CT scans or found during fibreoptic bronchoscopy and it has been more frequently found in children with recurrent respiratory infections or part of congenital abnormalities. Multiple detector CT (MDCT) scan of the chest with the addition of 3D reconstruction is the non-invasive gold standard investigation in diagnosing tracheal bronchus. Treatment of TB depends on the underlying coexistence condition and the severity of the associated symptoms. Surgical resection of anomalous lobe is treatment of choice.

Background: Hamartomas are the most common benign tumours of the lung, bronchial location of these are less common than a peripheral pulmonary location. These also known as mesenchymomas . they can be parenchymal (80%) or endobronchial (10-20%) . parenchymal lesions are usually an incidental finding and usually range in size from (1-5cms) . The endobronchial tumors usually present with new onset of respiratory symptoms , which are most commonly recurrent chest infections or hemoptysis Case Study: A Case of a 55yr old female patient known diabetic, hypertensive, old cerebrovascularattack with right hemiparesis , walks minimally with support , most of the time bedridden complaining of cough dry in nature since 3 months with CT chest soft density foreign body measuring left upper lobar bronchus approximately 4cm from bifurcation of trachea, Air trapping in left upper lobe. is rare ,but it commonly associates with Neurofibromatosis type 1 (NF1). The incidence of MPNST is 0.001% in general population and 0.16% in patients withNF1. Case Study: We report a male patient with a special condition ,whose tumors in body surfaces were benign neurofibroma and tumors in posterior mediastinum are MPNST. The CECT(contrast enhanced computed tomography) chest revealed large well defined soft tissue mass in left mid and lower portion of posterior mediastinum .The diagnosis was established by pathology and immunehistochemistry Discussion: The majority of mediastinal neurogenic tumors arise in the posterior mediastinum with only 3% found in anterior mediastinum MPNST arising at the thoracic cavity is difficult to diagnose in early stages , as the patients are usually asymptomatic .therefore , tumors of large size ,with invasion of the surrounding organs , are occasionally discovered . it has very poor prognosis complete resection is the mainstay. Conclusion: The appearance of neurofibroma should draw particular attention to the possibility of developing MPNST. More careful imaging examinations should be carried out. RAA can be associated with other congenital heart defects, chromosomal abnormalities or can present as an incidental finding Echocardiography, cardiac magnetic resonance (MR) imaging, and computed tomographic (CT) angiography are important imaging modalities used to identify and diagnose aortic arch variants. Case Report: A 46 year old male attended Surgery OPD with lower abdominal pain, both sides, since two months. During evaluation he was found to have Right aortic arch on screening CT chest. RAA with mirror imaging was confirmed by HRCT chest and reconstruction. Patient was found to have no other abnormality related to RAA. Discussion: Normal aortic arch development occurs by elongation, sprouting/splitting, and regression. Mirror imaging RAA is the most common form with congenital heart disease in 98 % of the cases. The present case has no evidence of other cardiac defects and was diagnosed incidentally. Conclusion: This is a rare presentation of mirror image Right aortic arch with no other cardiac defect. We translated and developed the Marathi version of ASTHMAXcel application. We aimed to evaluate the satisfaction of asthma subjects with use of the Marathi version of ASTHMAXcel application and change in asthma related knowledge in Pune.

The study was conducted in 50 Marathi speaking adult asthmatics visiting the outpatient department of Respiratory Medicine Department of Bharati Hospital, Pune. Questionnaire for User Interface Satisfaction (QUIS) was used to assess patients' satisfaction related to application. QUIS assessed users' interaction satisfaction of software on dimensions such as screen quality, usefulness of system provided feedback, responsiveness and usability of graphic user interface. Pre and post intervention asthma related knowledge was assessed using 16-item Asthma Knowledge Questionnaire (AKQ). Results: The Marathi version ASTHMAXcel application showed satisfactory performance [ Table 1 ]. Paired t-test showed that, there is a significant increase (p<0.0001) in average Pre (5.12± 2.7) and Post (12.4 ± 1.6) intervention AKQ Score (t=-18.699). Conclusion: The Marathi ASTHMAXcel application offers good participants' satisfaction and significantly enhances asthma related knowledge. Background: Breath-actuation type nebulizers only deliver medication during inhalation. Most nebulizers deliver aerosol continuously during inhalation and exhalation. The inspiratory/expiratory (I/E) ratio of a patient can change due to lengthening expiration in obstructive lung disease, or as a result of distractions to the patient during treatment. These changes may consequently decrease the delivery efficiency by nebulization. This laboratory study compared the delivery of salbutamol via a range of different nebulizer types. Methods: Nebulizers (n=5/group) were evaluated with 3-mL fill of 833µg/mL salbutamol solution. The nebulizer was connected to a simulator (ASL5000, IngMar Medical) mimicking adult (tidal volume=500-ml) tidal breathing, with I/E ratios of 1:1, 1:2 and 1:3. Emitted aerosol was captured by filter at 1-minute intervals until sputtering to determine total mass of drug delivered. Albuterol assay was undertaken by HPLC-UV spectrophotometry. Fine droplet mass (µg<4.7µm) was determined by laser diffractometry as the product of total mass and fine droplet fraction (%<4.7µm). Results: Average fine droplet salbutamol mass at extended I:E ratios are shown in the Figure. Conclusion: Higher, more consistent dose delivery was achieved by AEROECLIPSE* II BAN* Nebulizer across the range of I:E ratios tested compared to all other types of nebulizers. Clinicians should be aware of the opportunity to deliver effective and consistent doses more assuredly without the risk of potential under-dosing as disease progresses or if the patient pauses during treatment. Acknowledgement: Previously presented at American Thoracic Society 2021 Virtual Conference.

Background: Platypnea-orthodeoxia is a rare clinical entity characterized by dyspnoea and deoxygenation accompanying changing of position to sitting or standing from recumbent position. It's usually seen with patent foramen ovale and hepatopulmonary syndrome. Ventilation perfusion is a rare cause of the same. We report case of bilateral lower-lobe consolidation due to Pneumocystis carinii pneumonia and Cytomegalovirus due to HIV. Case Study: A 53-year-old male, reformed smoker, hypertensive, presented with history of intermittent fever since 2 to 3 moths (undocumented), cough with expectoration since 4 to 6 months and shortness of breath only on exertion since one and a half year, which progressed to rest over the past 7 days, associated with Loss of appetite, loss of weight and palpitation. Patient was intubated in view of respiratory distress and altered sensorium (no records of ABG available). CT brain was normal. HRCT showed left sided pneumothorax with bilateral basal infiltrates with emphysematous changes. Post extubation, patient continued to complain breathlessness, patient was managed with oxygen therapy via face mask, transferred to our department(respiratory) for further management. Physical Examination Findings: On presentation patient was conscious, alert, hyperpigmented scars observed over anterior chest, trunk and upper thigh which patient had for 5 months. His vitals were oxygen saturation by pulse oximetry 96% with 3 litres oxygen via nasal prongs, respiratory rate 24 breaths/min, heart rate 102 beats/min BP-136/88mmhg. Respiratory system examination revealed normal chest movements with bilateral basal crepitations.

Other system examination such as cardiovascular, per abdomen and central nervous system examination was normal. Bedside point-of-care ultrasound, revealed bilateral B-profiles in bilateral lower zones. Cardiac function was normal (ejection fraction ∼60%). An abdominal scan and DVT screening were normal. Diagnostic Studies: Accidentally we noticed that he was breathlessness more in the sitting position than the recumbent position. He maintained 96% saturation with 3L of oxygen in the recumbent position, and his saturation dropped to 88% in the sitting position, which further dropped in the standing position to 80%. He also developed tachycardia and tachypnoea in sitting position. Serial ABGs showed a 7% difference in saturation and a 19-mmHg difference in arterial oxygen tension (PaO2) in a recumbent and sitting position. Discussion: Platypnea (increased dyspnea in the erect position relieved by assuming a recumbent position) and orthodeoxia (accentuated hypoxemia in the erect position, improved by assuming a recumbent position), it is a rare clinical entity. It is first described by Burchell et al.

Quantitatively, orthodeoxia is defined as a drop in arterial oxygen saturation of 5% and P aO2 of 4 mmHg in the upright position. Most common etiological factors are intracardiac shunting, pulmonary shunting, ventilation-perfusion mismatch, and disorders such as pericarditis, emphysema, and pneumonectomy. Our patient did not have any history of COPD, cirrhosis or chronic liver disease. Air bubble contrast echo didn't not show any evidence of intracardiac or intrapulmonary shunt. USG abdomen was normal and CT pulmonary angiography showed no evidence of pulmonary artery venous malformation. None of the above investigation revealed any possible aetiology hence low/zero ventilation/perfusion (V/Q) ratio (zone 1 phenomena) was considered as a cause, because patient showed bilateral lung bases involvement. Possible explanation to this is, in normal individuals in standing position, the apical portion of the lung, termed as zone 1, remains hypo perfused during most of the cardiac cycle, except for flushes of blood during the peak ejection phase of systole. The lying position places more of the lung in zone 3 and virtually eliminates zone 1. In our patient, the basal parts of both lungs were predominantly affected by the disease, as a consequence, it is possible that when the described patient was in supine position, all the under perfused upper part of the lung (zone 1) converted in zone 3 leading to equal ventilation and perfusion, and ultimately adequate oxygenation. By contrast, whenever the patient was in the standing position, increased perfusion of the poorly ventilated diseased lower zone presumably elicited a marked ventilation/ perfusion mismatch leading to platypnea-orthodeoxia. In our patient, Pneumocystis carinii and CMV were detected in BAL specimens using reliable methods (immunostaining and PCR, respectively) in an immunosuppressed patient. Our patient had coinfection of CMV and PCP. There are suggestions that corticosteroids used in PCP patients with CMV co-infection could promote the development of CMV pneumonia. It is arguable whether CMV infection in symptomatic PCP patients should be treated. We treated patient for PCP alone. Patient improved over the time.

Conclusion: Platypnea -orthodeoxia is rare clinical entity. The most common causes are intracardiac and intrapulmonary shunt. If thorough work up do not reveal any of these aetiologies as a probable cause, V/Q mismatch should be considered as a possible aetiology. Results: The mean time for the pre-operative preparation was significantly longer in the study group (p=0.0001). The incidence of postoperative lung atelectasis (p=0.0001), time to return to work (p=0.0001) and incidence of shoulder dysfunction (p=0.004) were significantly lower in the study group. However, the incidence of postoperative pneumonia (P = 0.21) and mean hospital stay was no different between the two groups. Conclusion: Implementation of structured physiotherapy protocols helps in enhanced recovery after chest surgery. In opposition to unstructured physiotherapy care, application of standardized protocols leads to better pre-operative In Chest X ray,36 (69.23%) had Stage 0 and 9 (17.31%) had Stage 1 and correspondingly in CT Thorax,30 (57.69%) had Stage 2 followed by 18 (34.62%) had Stage 1.Mode of Diagnosis among 29 (55.77%) was by EBUS-TBNA followed by 5 (9.62%) had Skin Biopsy. Conclusion: Sarcoidosis is common among females predominantly in the middle age group.Cough is the common presenting symptom.The most common extra pulmonary manifestations was cutaneous manifestations. EBUS-TBNA and Skin Biopsy were useful diagnostic tools. The awareness of the profile of these patients will help in better diagnosis and treatment of these patients.

Department of Pulmonary Medicine, Gauhati Medical College and Hospital, Guwahati, Assam, India. E-mail: niyor411@gmail.com Background: Cavitary lung diseases are commonly encountered in clinical practice and require a careful evaluation to reach an accurate diagnosis. The objectives of our study were to evaluate the clinical, radiological and microbiological profile of cavitary lung diseases Methods: Eighty consecutive cases, 57 male and 23 female, who presented with respiratory symptoms and showed Pulmonary cavity on radiological evaluation were enrolled in the study. Their clinical presentation, radiological features and microbiological findings were assessed to reach a diagnosis. Results: Out of the eighty cases, Pulmonary Tuberculosis was diagnosed in 25 cases(31.2%), Pneumonia in 20 cases(25%), Squamous cell carcinoma lung in 11 cases(13.8%), Non Tubercular Mycobacterial infection in 6 cases(7.5%), Lung abscess in 5 cases(6.2%), Granulomatosis with polyangitis in 5 cases(6.2%), Adenocarcinoma lung in 3 cases(3.8%), Septic emboli in 3 cases(3.8%), and Pulmonary candidiasis in 2 cases(2.5%). The most common complaints were cough(95%) followed by hemoptysis(50%). All cases of primary lung carcinoma presented with single thick-walled cavities. Among Pulmonary Tuberculosis cases, most had single cavities (88%), while multiple thin walled cavitary lesions were seen in 65% cases of pneumonia, 66.6% of cases of septic emboli and in 80% cases of Granulomatosis with Polyangitis. Mycobacterium Tuberculosis(31.7%) and Klebsiella pneumonia(13%) were the most common organisms isolated among the cases. Conclusion: Proper clinical, radiological and microbiological evaluation is necessary to evaluate the etiology of cavitary lung disease.

Background: Kartagener's syndrome is a subset of primary ciliary dyskinesia, an autosomal recessive inherited disorder characterized by the clinical triad of chronic sinusitis, bronchiectasis, and situs inversus. Abnormal ciliary structure or function leading to impaired ciliary motility is the main pathology in Kartagener syndrome. Case Study: A 34year old male presented with complaints of recurrent episodes of nasal congestion and productive cough since childhood with the two episodes of blood-stained sputum 20 days back, he also had history of infertility. On chest percussion cardiac dullness noted on right precordial region, on auscultation heart sounds heard over the right side, crepitation and rhonchi heard over left inter and infra scapular region and right inter scapular region. Chest x-ray, CT chest, paranasal sinus and abdomen reveals bronchiectasis, dexto cardia, sinusitis, and situs inversus respectively. semen analysis reveals non motile sperm. he was treated with antibiotics, mucolytics, chest physiotherapy and advised for follow up. Discussion: Kartagener's syndrome is rare disorder with the prevalence of one in 30,000 live birth. Normal ciliary function is critical for respiratory tract host defense, sperm motility, and normal visceral orientation during embryogenesis. Abnormal ciliary motility leads to chronic sinopulmonary disease, infertility, and situs inversus totalis. A long-term low-dose prophylactic antibiotic required. Influenza and pneumococcal vaccine should be given. Conclusion: Correct diagnosis of this disorder in early life is important to prevent complications and improve quality of life. Failure to recognize the condition may subject the patient to unnecessary and repeated hospital admissions, investigations and inappropriate treatment.

Introduction: Dyspnea is unpleasant undue awareness of one's own breathing. Etiology of dyspnea is diverse, making diagnosis a dilemma. BLUE protocol describes lung profile for main etiologies of dyspnea with more than 90% accuracy, and also reduces radiation doses. Objectives and Methods: A prospective observational study comprising of 66 consecutive patients presenting to Emergency Department (ED) with dyspnea over a period of one year. Objective was to evaluate accuracy, sensitivity and specificity of BLUE protocol in initial diagnosis of patients with dyspnea in ED. After managing patients as per standard protocol, BLUE protocol was done as a part of primary assessment. Results of BLUE protocol were compared with final diagnosis and analyzed using SPSS software. Results: Among the study population, 63.6% were males and 36.4% were females. Mean age was 65.50 ± 9.32 and 66.95 ± 13.53 among males and females respectively. Most common lung profile was B (63.6%). Provisional diagnosis was made as pulmonary edema in 63.6%, COPD/ Asthma in 19.7%, pneumonia in 9.1%, pneumothorax in 4.5%, pulmonary embolism in 3.0%. Final diagnosis was pulmonary edema (56.1%), COPD/asthma (15.2%), pneumonia (12.1%), pulmonary embolism (4.5%), ARDS (4.5%), pneumothorax (3.0%), LRTI (3.0%) and hemothorax (1.5%). Sensitivity and specificity for acute pulmonary edema, pulmonary embolism, COPD/asthma, pneumonia, pneumothorax were 92.5 and 93.9, 88.1 and 85.3, 87.5 and 89.3, 92.5 and 90.4, 90.5 and 89.9 respectively. Conclusion: Study showed an accuracy of 96% in initial diagnosis of patients with dyspnea in ED. POCUS is cheap, radiation free and rapidly detects life threatening causes of dyspnea.

Background: Adherence to National Airborne Infection Control Guidelines by health Care professioinals is an effective way of reducing the risk of air-borne infections such as H1N1, COVID19 and TB. This study aims to assess the knowledge, attitude and implementation of national airborne infection control guidelines by resident doctors in a tertiary medical college hospital at Jabalpur. Methods: A cross-sectional study was conducted from December 2019-February 2021. Total 301 Interns, postgraduates and senior residents in surgery and medicine aligned clinical departments were included by convenient sampling method. Pre-designed questionnaire was used to assess Knowledge, Attitude and Practice on National Air-borne infection control guidelines. Data was analysis by using SPSS and presented in Percentages, Mean (Standard Deviation). Chi-Square test was used to find the association and t -test was used to find the mean difference between KAP and Resource scores. p-value of less than 0.05 was considered as statistically significant. Results: Almost 95%,77% and 74% of study participants were having adequate knowledge, attitude and practice on National Airborne Infection Control Guidelines respectively. Statistically significant association was observed between participants age, designation with their KAP score (p value<0.05). Conclusions: The overall knowledge, attitude and practice were adequate but there was significant gap persist between KAP and satisfaction on available resources. The study findings were useful for healthcare professional in designing interventions to improve the adherence towards the NAIC guidelines and also to benchmark evaluation of interventions.

Background: Wegener's granulomatosis (Granulomatosis with polyangiitis) is a rare systemic autoimmune disease of unknown etiology characterised by triad of necrotising granulomatous inflammation of upper and lower respiratory tract, glomerulonephritis, and disseminated vasculitis. Case Study: A 50 year old female presented with complaints of running nose since last 8 months. Patient also had low grade fever, generalised body pain, productive cough, shortness of breath on exertion, pedal oedema for last 2 months. She had an 2-3 episodes of blood in sputum 15 days back. On examination saddle nose found. HRCT chest shows multiple cavitating nodules with consolidation. Lab findings shows raised ESR, CRP, COVID RT PCR negative and positive C-ANCA (Anti neutrophilic cytoplasmic antibody), red blood cell casts, and albumin present in urine. Sputum for AFB negative. Patient discharged on corticosteroids and cyclophosphamide and advised for regular follow up. Discussion: Wegener's granulomatosis is an antineutrophilic cytoplasmic antibody associated small vessel vasculitis. Prevalence of this disease varies from 3/1,00,000 to 16/1,00,000. Typically this involve the lungs and kidneys. It can be of generalised severe form or localised limited form. Our patient clinical course, CT findings and his strongly positive C-ANCA were considered diagnostic of wegener's granulomatosis. Treatment include corticosteroids and immunosuppressants. Conclusion: The early diagnosis and prompt treatment of multisystem disorder is necessary to prevent complication such as diffuse alveolar haemorrhage CT is the imaging modality of choice for diagnosis, surveillance and follow up in patients with wegener's granulomatosis.

Background: ANCA associated vasculitis can involve any organ of the body but upper and lower respiratory tracts and kidneys are most commonly affected. Most patients present with nodules and alveolar opacities on radiology. We present a case of ANCA associated vasculitis presenting as lung mass with pleural effusion. Case Study: A 58 years female, never smoker, asthmatic from 30 years, presented with complaints of gradually progressive dyspnoea for one month associated with cough, fever and loss of appetite for 2 weeks. Radiology of neck, thorax and abdomen revealed malignant appearing right lower lobe mass and minimal right pleural effusion. Pleural aspiration revealed exudative lymphocytic effusion with ADA of 5.3. ANA screening and profile was negative. Bilateral bronchial tree was normal on fibreoptic bronchoscopy and BAL was negative for infective aetiology. CT guided biopsy of lung mass revealed alveolar haemorrhage and intra alveolar oedema with alveoli showing hyaline membrane formation. Interstitial stroma showed thin capillaries surrounded and infiltrated by inflammatory cells. Thoracoscopic pleural biopsy revealed inflammatory lesions with secondary vasculitis. A diagnosis of small vessel vasculitis was made. Antineutrophil cytoplasmic antibody (ANCA) titre gave a strongly positive result. Urinary microalbumin-creatinine Ratio was 436.16. Patient was diagnosed as granulomatosis with polyangitis and treated with corticosteroids and 4 cycles of weekly Rituximab therapy to which she responded. Discussion: Patients with vasculitis present with nonspecific symptoms and are treated as infections or malignancies leading to delayed diagnosis. Positive ANCA along with lung and pleural biopsy can enable early diagnosis. Conclusion: ANCA associated vasculitis can manifest as lung mass with effusion.

Background: Pulmonary arteriovenous fistulas(PAVFs) are rare vascular malformations of the lung.They occur with an incidence of 2-3 per 100,000 population.Females are more often affected than males. Case Study: Incidently, it was noted that this 43 years old women had a hypoxemia with a partial pressure of oxygen, arterial(Pao 2 ) of 40.9mmHg.She was subjected for chest radiography, having left parahilar well defined opacity.The patient's medical history included dyspnea on exertion.On physical examination there was a clubbing.The blood gas analysis yielded, along with a regular acid base status, a normal partial pressure of carbon-di-oxide, arterial(PaCo 2 ) but PaO 2 -40.9mmHg at room air.Under a fraction of inspired oxygen (FiO 2 ) of 1.0 for 15min the PaO 2 increased only to 57mmHg.Laboratory test results were normal except for an increased hemoglobin of 16.7 g/dL.CT Pulmonary Angiogram identified left sided lingular PAVF(feeding artery measuring 12mm,Venous sac measures 25mmX20mm).She underwent therapeutic embolization of PAVFs using metal coils. Discussion: PAVFs are vascular malformations that represent direct communications between the pulmonary artery and vein without an intervening capillary bed.Among reported cases 80% are congenital.There is a strong association with Rendu-Osler-Weber disease.Those lesions are thought to represent persistent primitive arteriovenous communications from pulmonary buds that fail to mature into capillary beds and thereby function as persistent right-to-left shunts. Although most patients are asymptomatic,PAVFs can cause Fatigability, exertional dyspnea,and palpitations.Therapeutic options include angiographic embolization with metal coils or balloon occlusion and surgical excision. Conclusion: Long term follow-up of treated PAVFs is mandatory to monitor the development of new lesions and recurrence of previously treated ones.

Department of Respiratory Medicine, JSS Medical College, Mysore, Karnataka, India. E-mail: rekha.setty23@gmail.com Background: Wegener's Granulomatosis is a rare disorder of chronic granulomatous vasculitis involving small and medium sized vessels with circulating anti-neutrophil cytoplasmic antibodies against protienase-3 and myeloperoxidase. It involves upper and lower airway and glomerulonephritis. Pulmonary findings include waxing and waning nodules, ground glass opacities and masses. Case Study: A 37year old female, presented with complaints of dry cough since 1month. Clinical findings revealed reduced breath sounds in left infra-scapular area, dullness on percussion and increased vocal fremitus with occasional crepititions. Discussion: Investigations showed elevated WBC counts, chest x-ray showed left lower lobe consolidation. She was started on empirical antibiotics. HRCT thorax showed large consolidation in left lower lobe with central cavitation; multiple soft tissue nodules with cavitation and adjacent feeding vessel sign suggestive of septic emboli. Patient did not respond to antibiotic therapy and persisting consolidation was noted radiologically. Repeat urine analysis showed microscopic hematuria. Further investigations revealed positive C-ANCA and tissue biopsy from the consolidation showed features of granulomatosis with polyangitis suggestive of Wegener's granulomatosis. She was initiated on steroid therapy and discharged. Conclusion: Any pneumonia, non-resolving with adequate antibiotic therapy, should be evaluated for non-infectious causes, relevant timely investigations must be done, to prevent-misdiagnosis, worsening of conditions leading to life threatening complications if not initiated on treatment at the right time. This leads to longdelay in making the correct diagnosis from the first onset of the symptoms. There are many studies which have shown that the prevalence spontaneous pneumothorax ,bullous emphysema, thin-walled cysts are increased in these patients. Case report: A 39 year old male presented with complaints of mild fever for 5 days duration and shortness of breath for 1 day. Fever was continuous in nature, not associated with chillls and rigor. He denied history of diabetes mellitus, hypertension, tuberculosis , bronchial asthma .He was evaluated for covid 19. RT PCR for covid 19 came positive. HRCT chest was done. HRCT showed bilateral peripheral and peribronchovascular non lobar distribution of ground glass opacities with septal thickening in bilateral lung parenchyma. The CT severity score was 14/25. HRCT also showed multiple thin walled cyst in both lungs, largest measuring 22 X 27mm. Few subcentrimetric pre/paratracheal , prevascular and sub carinal lymph nodes was noted.His oxygen saturation was 89% on room air. He was admitted and started on oxygen inhalation via face mask and was managed medically. Relevant blood investigation and bio markers for COVID 19 were done. Reports were total count 3570, differential count N51L35M11E1.8B0.6., Hb 15.4 G/dl, platelet count of 2.14 lakhs/mm 3 , ESR 16 mm/hr, d dimer 0.77mg/l,, LDH 203 U/L, CRP 21.774mg/l, procalcitonin 0.122ng/ml. 3 days later dyspnea aggravated and he was started on non invasive ventillation ( BiPAP). His clinical condition was stable on NIV. On the fifth day of NIV, he started developing subcutaneous surgical emphysema. HRCT chest was done, showed gross left and mild right pneumothorax, moderate pneumomediastinum, multiple focal patchy and confluent ill defined areas of ground glass and reticular densities predominant in basal and peripheral distribution involving bilateral lung parenchyma, diffuse subcutaneous emphysema extending into neck spaces.CT severity had increased to 17/25. He was managed by Intercostal chest tube insertion on left 5th intercostal space in mid axillary line connected to a underwater seal. He improved clinically with subcutaneous emphysema resolving in the next 3 days. He was later discharged and his chest tube was removed on followup. We conclude that Birt-Hogg-Dubé syndrome can be a rare cause of secondary pneumothorax in a patient with multiple skin follicles and having multiple cyst in HRCT.

Background: Double-positive patients (DPP) exhibiting anti-glomerular basement membrane (GBM) and antineutrophil cytoplasmic antibodies (ANCAs) belong to an entity that is rare and hasn't been described enough. Majority of DPP exhibited pulmonary involvement, and more than half of them presented with pulmonary-renal syndrome, similar to anti-GBM vasculitis patients Case Study: 55 yr male, chronic smoker, occasional alcoholic, with no previous history of ATT intake presented with cough, dyspnea, and hemoptysis for 10 days. Hemoptysis was massive in amount, 80-100 ml/ episode with 3-4 episode/day. Routine investigations revealed anaemia and deranged renal function. CXR suggested bilateral diffuse consolidation. CECT THORAX showed cavitatory changes in bilateral lung fields with crazy pavy appearance suggestive of granulomatosis polyangitis with diffuse alveolar hemorrhage. Further investigation revealed both p-anca and Anti-GBM positive antibodies. Renal biopsy suggested focal necrotizing and crescentic glomerulonephritis. Patient was treated with antifibrinolytics, pulse dose corticosteroids, prbc was transfused and hemodialysis followed by plasmapheresis. Discussion: A double positive panca and Anti-GBM is rare presentation with low incidence, manifesting with both pulmonary and renal involvement with poor prognosis eventually succumbing to renal failure. Conclusion: Pulmonary involvement may precede renal involvement in case of rapidly progressive glomerulonephritis. DPP are associated with the characteristics of two eponymous vasculitis types, responsible for poor prognosis. Simultaneous testing of both antibodies and systematic renal biopsy should be recommended for early diagnosis and management. 

The patient who was a painter by occupation with a smoking index of 400 and no known co-morbidities presented with a history of predominant dry cough of 1 month duration and a CT report of anterior mediastinal mass. Definitive diagnosis was made by histopathological examination and immunohistochemistry of CT guided biopsy of mediastinal mass. PET CT did not reveal any other metabolically active lesions. Conclusion: Patients with mediastinal tumors may be asymptomatic (30%) at presentation which may cause delay in diagnosis. 70% of patients develop local symptoms such as dry cough and breathlessness explained by compression or invasion of mediastinal structures. Primary mediastinal adenocarcinoma is a rare malignancy that can arise from normal or ectopic tissue in the mediastinum, furthermore neuroendocrine differentiation of adenocarcinoma is rare and the evidence of such differentiation in literature is limited to genital and colorectal cancers. Thereby, this case is the first primary mediastinal tumour-Adenocarcinoma(NOS) with neuroendocrine differentiation as per our literature review.

A rare case report of hydatid cyst with hemoptysis as complication

Department of Respiratory Medicine, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India. E-mail: shravani.963@ gmail.com Introduction: Hydatid disease is a parasite infestation caused by echinococus granulosus characterised by cystic lesions in liver and other parts of body.Most patients with intact pulmonary hydatid cyst are asymptomatic and are discovered incidentally. Case Report: A 32 year old female presented to our OPD with complaints of massive hemoptysis since 2 days ,cough with expectoration and breathlessness since 15 days. Present no past history of tuberculosis .On examination showed decreased intensity of breath sounds in right lower inter scapular area and right infra scapular area. CXR showed opacity in right lower lobe.HRCT thorax showed thick walled non enhancing cavitating lesion with crenated appearance ,intralesional lamellations at right middle and lower lobes.Due to ongoing and uncontrolled hemoptysis(no bleeding disorders) surgery was planned. Right middle and lower lobectomy was done and the specimen was confirmed to be hydatid cyst. Conclusion: Massive hemoptysis is a rare but life threatening complication of pulmonary hydatid disease that needs emergency management.Along with other complications hemoptysis should also be considered.

Systemic sclerosis is a systemic autoimmune disease of unknown origin characterized by excessive deposition of collagen and other connective tissue macromolecules in skin and multiple internal organs, prominent and often severe fibroproliferative alterations in the microvasculature, and numerous humoral and cellular immunologic abnormalities. It is predominant in females with 3-6:1 female to male ratio. Limited cutaneous systemic sclerosis (CREST syndrome(calcinosis, Raynaud phenomenon, oesophageal dysmotility, sclerodactyly, and telangiectasias).Antinuclear antibodies are present in about 90%-95% of affected patients usually with a speckled or centromere pattern, nucleolar pattern is rare but more specific for systemic sclerosis. Scl-70 antibodies are present in 30% of diffuse systemic sclerosis and absent in limited. In 45-50% of limited scleroderma patients have anticentromere antibodies. Here we present 29yrs old male who was presented with chest pain and chest x-ray is suggestive of pneumothorax. Patient was also started on antitubercular treatment on the basis of CT (computed tomography) chest, history and contact of Tuberculosis. Patient also had history of skin tightening, decreased mouth opening, discoloration of skin, dysphagia, digital ulceration. CT chest is suggestive of Interstitial lung disease (ILD) with Usual Interstitial Pneumonia pattern. On further investigation Scl-70 came strongly positive with SS-A positive lead to diagnosis of systemic sclerosis. ICD(Intercostal Drainage) tube was inserted for pneumothorax and pleurodesis was done after expansion of lung. Patient had 3 episodes of pneumothorax. Pulse cyclophosphamide therapy was started. As there is no cure for scleroderma a variety of treatment can improve quality of life.

Background: Chlorine is highly used chemical in industry and society. Human exposures to toxic levels of chlorine are accidental data regarding these exposures is often not available. Case Report: 22 year old male, no prior comorbidities presented to hospital with acute onset dry cough and mMRC grade 3 breathlessness following exposure to fumes of sodium hypochlorite and hydrochloric acid while working in factory. On arrival he was tachypneic and hypoxic. Initial investigations reported leukocytosis. Chest skiagram showed mild patchy haziness in bilateral lung fields. HRCT Chest showed ground glass opacities with interlobular septal thickening in both upper, right middle lobe and lower lobes. Multiple nodular opacities and consolidation in both upper and lower lobes posteriorlysuggesting acute lung injury. He was treated with injectable steroids, antibiotics,nebulization and supportive treatment. Initially admitted in intensive care unit, requiring oxygen support which was tapered off. Patient condition improved he was shifted to ward. PFT reported mild restriction with no reversibility. DLCO showed mildly reduced DLCO.6 MWT no significant desaturation. Patient discharged in a hemodynamically stable condition. Discussion: Sodium Hypochlorite used as general disinfectant and bleaching agent. Industrial bleaches may contain up to 50%.Accidental inhalation of gases formed by mixing of sodium hypochlorite with acidic or alkaline solution is most frequent route of exposure producing chlorine gas which can cause burning of throat, affecting mucous membrane of eyes, pharynx and respiratory tract. Conclusion: Unusual case of acute chlorine gas exposure with subsequent reactive reactive airway dysfunction syndrome treated with injectable steroids and inhaled bronchodilators. Background: Pulmonary rehabilitation (PR) is an effective non-pharmacological management strategy for chronic respiratory diseases (CRDs). Considering India's huge burden of ~100 million cases of CRDs, there is a necessity for robust PR services. However, the needs remain unmet due to lack of knowledge among stakeholders and unavailability of need-based PR programs. Objectives, Methods: To explore the willingness and general interest in interventions for relieving symptoms and preferred mode of PR delivery, we conducted a crosssectional survey among 345 CRD patients (59% male; mean (SD) age 56±16 years). Results: Participants with Asthma (n=175;50%), Chronic Obstructive Pulmonary Disease (COPD) (n=154;45%) and others (n=16;5%) in the out-patients respiratory medicine departments in Pune, India were included. 72%(n=248) participants reported inability to be as active as they would like. Where most patients (n=297; 87%) were keen on participating in a treatment indicative of PR that can help them relieve breathlessness and be more active; of which, 175 were willing to spend around 30-60 minutes/day for the referred treatment. They preferred remotely delivered modes of this treatment which included exercising at home with minimal monitoring from healthcare providers (n=218) as well as attending a web based PR programme (n=249). Conclusion: Majority of the patients are willing to participate in PR, on being aware of a treatment that would help them relieve their sufferings. Patients likely to engage in the PR sessions that are remotely delivered and can be conducted in a home setting. More qualitative inputs from patients will be needed to help develop a contextualized PR.

Department of Respiratory Medicine, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India. E-mail: 127renu@gmail. com Background: Schwannomaare benign tumors arising from Schwann cells of nerve root sheaths. Schwannomasare mostly solid / heterogeneous solid tumours, rarely cystic. Presentation of cystic schwannomainthorax is extremely rare. Case Study: A 62-year-old female came to our hospital withthe complaint of right sided chest pain for 2 months, which is dull, non-radiating. She had history of fever 4 months back, diagnosed to have covid and took treatment at home. Chest x-ray showed a homogenous opacity in the right upper lobe extending up to 1 st intercostal space. Ct reported well-defined thick-walled cyst, hypodensewith central low attenuation, forming acute angles with lung parenchyma in apical segments of right upper lobe towards mediastinum. Mild perilesional atelectasis is seen.On contrast, cyst is non enhancing. Patient is evaluated for the possibilities of Foregut duplication cyst, Hydatidcyst, Neoplasm. Endoscopic ultrasonography revealed a 5cms×5cms cyst, which is not communicating, infiltrating to esophagus. Patient was referred to ctvswhere excision of cyst is done by right thoracotomy .A 6cms×6cms×2cms unilocularcyst with wall thickness ranging from 0.1-0.4cms. Its outer surface is congested, inner surface showed dark-brown hemorrhagic contents. Histopathological examination revealed cystic schwannoma. Discussion: Schwannomasare mostly benign in nature .Treatment includes excision of Bronchogenic cyst, Brachial cyst, neurogenic tumours, apical lung tumour, hydatid cyst, foregut duplication cyst are to be considered as differential diagnosis. It is important to consider cystic schwannomasin the differential diagnosis of thoracic cystsince the best surgical outcome is strongly related to earlier diagnosis and total resection of the lesion.

Department of Pulmonary medicine, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India. E-mail: lavanyag0023@ gmail.com Background: Pulmonary alveolar proteinosis ( PAP ) is a rare, diffuse interstitial lung disease characterized by alveolar obstruction due to accumulation of PAS positive lipoproteinaceous material in the alveoli due to defective clearance of surfactant by alveolar macrophages. The resultant disturbance leads to clinical manifestations ranging from asymptomatic disease to life threatening respiratory failure. Case Study: A 48 year old male with progressively worsening dyspnoea and non productive cough for 8 months. He was an auto driver and painter and had prior recurrent respiratory infections. Physical examination revealed clubbing and bilateral fine basal crackles. Chest computed tomography showed diffuse crazy paving pattern. Bronchoscopy with bronchoalveolar lavage yielded a foamy whitish material. Cytology revealed alveolar macrophages with PAS positive acellular proteinaceous eosinophilic material. Transbronchial biopsy confirmed the diagnosis of PAP. Patient does not meet the criteria for whole lung lavage, so treated conservatively. He is symptomatically better and is on regular follow up. Discussion: Patients with minimal symptoms are managed conservatively, where as patients with hypoxemia require a more aggressive approach. Whole lung lavage is the most widely accepted therapy for symptomatic pulmonary alveolar proteinosis. Conclusion: Generally Pulmonary alveolar proteinosis present with progressive exertional dyspnea of insidious onset but rarely it can present like ARDS and respiratory failure. It is a rare lung disease and important to consider due to the diagnostic and therapeutic challenge it represents and should be considered as a rare differential while managing the patient with ARDS.

What are the influencing factors for referral of patients to pulmonary rehabilitation services according to the medical staff?

perceptions of the MS regarding the PR referral process and criteria. Results: The mean (SD) work experience of the MS was 11±9 years.Most participants (81%) believed that PR is an effective strategy in management of CRDs.On a 0(Not at all)-10(completely) Likert scale, only 19% of MS believed that they understood the referral criteria completely.They reported factors like increasing shortness of breath (n=95, 65%)as strong influencers for them to refer patients. However, only 28% (n=41) perceived patient anxiety as an important factor for referral to PR. 38% participants and 68% participants respectively reported some influence and strong influence of patient refusal on their willingness to refer them to PR; attributable to lack of transportation and PR services nearby. The majority of participants (85%) felt the need for training of their MS in referring to PR. Conclusion: According to the MS, very few were completely aware of the referral criteria for PR. Patientcentric factors and their potential refusal is perceived as important barriers for referral to PR that must be addressed before routine PR services can be established.

Background: Erdheim-Chester disease (ECD) is an uncommon aggressive, multisystem form of non-Langerhans' cell histocytosis rarely involving the lung. The disease pathological features encompass an aberrant multiplication, overproduction and accumulation of histiocytes within multiple tissues and organs. Herein, we present a case of ECD presenting as pulmonary mass lesion. Case Study: Our case was encountered in a 28 year old male who was suffering from cough for 1.5 years along with chest pain, shortness of breath and fever. CECT thorax showed large lobulated heterogeneously enhancing soft tissue mass in the left upper lobe with invasion of anterolateral chest wall and destruction of 2 nd and 3 rd ribs. CT guided tru-cut biopsy showed fragments of tumour which were predominantly spindle shaped and arranged in sheets. IHC showed lesional cells positive for CD68 while CK, CD30, CD1a, S100 and Fascin were negative which was suggestive ECD. Discussion: ECD was originally described in 1930. Foamy histiocytes and mononuclear cells infiltrate affected tissues. The histiocytes may stain for S100 but not for CD1a. Pulmonary ECD typically presents with dyspnoea and sometimes a dry cough. In our case, a 28 year old male presented with left lung mass which was diagnosed as ECD and was started on cyclophosphamide pulse therapy along with oral prednisolone. Conclusion: ECD presenting as a lung mass lesion is very rare. Clinical examination, radiological investigations followed by lung biopsy and immunohistochemistry examination are essential for the diagnosis. The burden of chronic respiratory diseases (CRDs) in India is underlined as the country notes the largest number of deaths due to CRDs in the world. Globally, with appropriate pharmacotherapy, disease management for CRDs includes Pulmonary Rehabilitation (PR), a non-pharmacological strategy that reduces suffering and improve patients' quality of life. The objective of this study was to explore the experiences and perceptions of people living with CRDs about their disease and management strategies, including PR. In-depth qualitative semi-structured interviews were conducted with fourteen people living with CRDs. Data were analysed using thematic analysis. The data were arranged in two broad themes: 1. Patients' sufferings and perceptions about the disease and 2. Patients' perceptions and experiences about self-management strategies. Theme 1: All study participants equated the disease with 'breathlessness'. They shared helplessness due to the inability to do routine activities because of breathlessness and lack of physical strength. They had views about the tentative causation of their CRD-heredity, lifestyle choices and physical and mental stress. Theme 2: The participants availed multiple management strategies like Yoga (including the breathing exercises), routine walks and home remedies, in addition to Allopathy and Ayurveda treatment for immediate symptom relief. The primary source of knowledge about Yoga was the television and YouTube. Alteration in food habits to include non-fried, non-spicy homemade food was described as a strategy. This research highlights that patients with CRD are managing their disease with 'non-guided' strategies, are eager to improve and would benefit from a 'guided' programme to 'feel better'.

Background: Sarcoidosis is a multisystem granulomatous disease that can affect any organ in the body, but commonly the lung. At times, the presentation could be atypical. Atypical presentations may result in a delay in diagnosis,unnecessary investigations and treatment. Case Study: A 57 year old male patient presented with fever, cough and chest pain. Computed tomography showed lung consolidation and mediastinal lymphadenopathy. Lung biopsy (TBLB) was suggestive of granulomatous inflammation with negative acid fast bacilli (AFB), CBNAAT and Mantoux test but raised serum angiotensin converting enzyme(ACE) levels. The patient subsequently also developed macular discoloration of skin followed by necrotic skin lesion in the chest. Skin biopsy was suggestive of panniculitis, eventually a diagnosis of systemic sarcoidosis was made involving the lung, lymph node and skin. Patient was treated with systemic steroid and hydroxychloroquine(HCQ) and showed response. Discussion: More than 90% of patients with sarcoidosis have pulmonary involvement. Commonly involved extrapulmonary organs include the skin(30%), eyes(25%), lymph nodes, liver, and spleen (20%). Cutaneous involvement varies from erythema nodosum, plaques, nodules and papules to Lupus pernio. Conclusion: Uncommonly Sarcoidosis can have nonpulmonary initial presentation, thus a high index of suspicion should be kept for sarcoidosis as a differential diagnosis in such patients.

Osmania Medical College, Hyderabad, Telangana, India. E-mail: b.g.vasanth35@gmail.com Introduction: Infection caused by a facultative intracellular Gram-negative bacterium, Burkholderia pseudomallei. It has recently gained importance as an emerging pathogen in India. . Cases have been reported from Southeast Asia mainly Thailand, Malaysia, Vietnam, etc. In India, few cases have been reported mainly from the southern part of the country. It presents as a febrile illness with protean manifestations ranging from chronic localized infections to acute fulminant septicemia with dissemination to multiple organs. Case Presentation: 30 yr old male car driver came with c/o high grade fever , cough with expectorationand SOB for 45 days treated antibiotics for 20 days with no symptomatic and radiological improvement.elevated wbc with neutrohilia xray-bilateral ML&LL necrtoizing pneumonia with negative gram stain and AFB. Bronchoscopy findings was full of pus in bronchus ,sent for analysis . culture sensitivity report came positive for B.pseudomallei sensitive for cotrimoxazole and ceftazidime. Discussion: Since the clinical presentation of melioidosis is not distinctive, and may range from acute septicaemia to a chronic suppurative disease, a high index of clinical suspicion is required. In our patient, suspicion of melioidosis was aroused due to the clinical presentation of a non-resolving pneumonia . Definitive diagnosis of melioidosis is made, by isolation of the causative bacterium, B. pseudomallei, in culture from bronchial washings. Management of melioidosis consists of 2 phases. The intensive phase and the eradication phase. These are aimed at the importance of rapidly treating the septicemia, the need of eradication of the persistent disease and the prevention of recurrent infections or relapses. The intensive phase consists of minimum 10-14 days of IV antibiotics: IV ceftazidime or IV carbapenem (meropenem/ imipenem). Eradication phase should be followed by 3-6 months of oral co-trimoxazole alone or in combination with oral doxycycline/ oral amoxiciliin clavulanic acid. Conclusion: as melioidosis is not endemic in india the data about this infection unnoticed and diagnosistic options for this infection is very limited . so in all non resolving necrotizing pneumonia melioidosis etiololgy should also be considered.

A rare case of posterior mediastinal mass -leiomyosarcoma 

Background: Hydatid disease is caused by ingesting embryonated eggs of cystode tapeworm of the genus Echinococcus. Infection with Echinococcus leads to development of hydatid cyst in various organ, but most common site is liver followed by lung. Here we present a 35-year old female belong to rural area was found to have disseminated hydatid cyst of lung and liver. Case Study: A 35-year old housemaker was admitted to our hospital with symptoms of cough and expectoration since 7 month, hemoptysis, breathlessness, right side chest and abdomen pain since 6 month, fever since 3 month. On examination of chest, 2 visible soft fluctuant cystic swelling present over 9 th and 10 th intercostal space in posterior axillary line of right side of chest. Chest X-ray revealed multiple rounded opacities in both lung field with some air fluid level. Computed tomography of thorax showed multiple cystic lesion in both lung field and liver with air-fluid level in few cyst. Cystic fluid aspirated revealed scolex of Echinococcous granulosis. The patient was started on albendazole. Due to disseminated disease, surgery was not performed, and patient continued on medical therapy. Discussion: Hydatid disease particularly endemic in cattle/sheep-raising rural area. Individual may remain asymptomatic for long time. Various radiological features of pulmonary and hepatic cyst are present. Conclusion: From this case we can conclude that Hydatid disease is uncommon and disseminated Hydatid disease is rare. Also herniation of cyst to external surface is also rare. Treatment with albendazole with surgery if possible is best management for it.

A rare case report of unilateral usual interstitial pneumonia in a patient with pulmonary artery agenesis

Department of Pulmonology, Yashoda Hospitals, Secunderabad, Telangana, India. E-mail: yasasvini.ganjam@gmail.com Background: Unilateral pulmonary artery agenesis is a rare congenital anomaly due to malformation of the sixth aortic arch during embryogenesis. The diagnosis is usually set at adolescence, however it can remain asymptomatic and late diagnosis is possible. We herein report a unique case of asymmetrical interstitial lung disease (ILD) with a UIP pattern suggesting that agenesis of pulmonary artery may be related to the development of UIP in the affected lung. Case Study: A 79 year-old male patient never smoker presented with history of recurrent respiratory tract infections since childhood. He underwent a pre-employment check up at the age of 25 where his abnormal chest radiograph wasn't evaluated further but diagnosed & treated as kochs..Patient had recurrent exacerbations of respiratory symptoms for which he received multiple courses of antibiotics and steroids.Sputum analysis was inconclusive and two consecutive sputum samples were negative for AFB. Patient was referred to our centre for further management where CT chest showed unilateral ILD with UIP pattern & agenesis of right pulmonary artery. Discussion: We encountered a case of asymmetrical ILD with UIP pattern that remained almost completely asymmetrical over an extended period of time. Asymmetrical IPF may be favoured by several underlying conditions, with decreased pulmonary artery perfusion and development of systemic vessel collateralization being potentially responsible in the above case. Conclusion: In conclusion, present case and previous literature postulate that low pulmonary artery perfusion capacity and systemic-pulmonary anastomoses can cause UIP changes. E-mail: gokulpalanisamy04@gmail.com Background: Bronchogenic cyst are rare congenital malformation arising from the abnormal budding of ventral diverticulum of foregut or tracheobronchial tree between 26 th and 40th day of gestation. Bronchogenic cyst are the most common primary cyst of the mediastinum and are usually unilocular. It is often an incidental finding on chest x-ray and require no treatment. Case Study: A 19year old male presented with the complaints of cough and chest pain for the last 1 month, dyspnea for the last 20 days. He had the past history of hemoptysis 2-3 episodes 5-6 month back. No history of smoking and alcohol. Sputum for AFB negative. Chest x ray suggestive of homogenous opacity, Ultrasound shows a cystic lesion of approximate size 80*81*79mm (270cc) is seen in right upper lung field, CT chest shows round mass with uniform attenuation. PFT restrictive pattern. Patient referred to thoracic surgery. Advised for follow up. Discussion: Bronchogenic cyst is a rare cystic lesion with a prevalence of 1 per 42,000. Most of the cyst arise from mediastinum while 15% occurs within lung parenchyma. They are lined by respiratory epithelium The etiology of our patient was found to be congenital. Diagnosis is primarily radiological with CT and MRI. Surgery is the treatment of choice in symptomatic patient. Postoperative complications include recurrence, infection. During follow up patient had improvement in symptoms. Conclusion: Patient with large symptomatic bronchogenic cyst will be evaluated for surgery. Cyst must be resected because their content may get infected.

Background: There is rising burden of respiratory diseases in India as highlighted by GBD data. There is paucity of real-time IPD data across respiratory services in India. The present study was conducted as an extension of Indian Chest Society -Seasonal Waves Of Respiratory Disorders (SWORD) survey to know the effect of transition of four seasons on proportionate admissions with major respiratory diseases. Methods: The SWORD study methodology was followed. In this multicenter project members of ICS and NCCP were invited to conduct study at their centres. After ethical clearance, data of all patients admitted during 24 hours were recorded on predesigned IPD proforma of SWORD study. Demographic data, major ICD 10 based respiratory diagnoses and risk factors were part of the proforma. Results: A total of 2650 patients from 238 sites across India were included for analysis. The mean age was 53.9±17.6 with highest 1058(39.9%) in 40-60 yr group. The male:female ratio was 1.9:1. Most of them 1278(48.2) were admitted for the first time and 1588(60.5%) had duration of disease < 1 year. Flu and pneumococcal vaccination coverage was merely 5.1%. Smoking 600(22.6%), biomass fuel exposure 777(29.3%) and pets at home 458(17.3%) were main exposures. COPD, asthma, pneumonia, tuberculosis and pleural effusion were major diagnoses. At sites(57) participating in all phases respiratory disease burden was maximum in post-rainy season 386(28.1%) and minimum in summer transition 327(23.8%) with a p-value of 0.02. Conclusions: OADs and tuberculosis surpass other diagnoses with a significant effect of seasonal transitions on the proportionate admission. was carried out in the Department of Pulmonary Medicine, SRN Hospital, MLN Medical College, Prayagraj (Allahabad) Aug 2020 to July 2021 and were classified into Diabetic and Non-Diabetic and markers of coagulation dysfunction were studied. Results: There was a significant difference between the 2 groups in terms of PT (Sec) (W = 8275.000, p = <0.001), aPTT (Sec) (W = 7092.500, p = <0.001), INR (W = 8316.500, p = <0.001), D-Dimer (µg/mL) (W = 8523.000, p = <0.001) with the median PT (Sec), aPTT (Sec), INR and D-Dimer (µg/mL) being highest in the Diabetics group. Conclusion: These results show that the hypercoagulability markers significantly increased in diabetic group of Post-COVID-19 patients when compared to their non-diabetic counterparts. It is known that during cytokine storm, as a result of plasmin activation, the significant rise in D-dimer level indicates hypercoagulability. The significant rise in D-dimer indicate diabetic Post-COVID-19 patients are more susceptible to hypercoagulable state leading to more chances of intravascular coagulation. Since the association of diabetes and hyperglycemia with disease progression has been linked to increased inflammation, hypercoagulability and lung dysfunction in Post-COVID-19 patients. Determining HbA1c level after hospital admission is thus helpful assessing inflammation, hypercoagulability, and prognosis of patients. Our data support the notion that diabetes should be considered as a risk factor for a rapid progression and bad prognosis of Post COVID-19. More intensive attention should be paid to patients with diabetes, in case of rapid deterioration. However, little is known about the mechanism concerning the increase in the levels of coagulation dysfunction markers and HbA1c level in case of post COVID-19 patients and more further studies are also required. Introduction: Microalbuminuria in COPD is related to generalize endothelial dysfunction as well as systemic inflammation, considered as vital marker of early cardiovascular involvement. Therefore, it is an indirect manifestation of both renal perfusion and permeability, as well as endothelial dysfunction of lungs, it may show a significant association with the cardiac comorbidity among COPD patients. Aims and Objectives: To study the frequency of occurrence of microalbuminuria in COPD patients. To Assess any correlation between microalbuminuria, disease severity and exacerbations.Comparison of levels in between COPD patients with and without any cardiac involvement. Materials and Methods: Prospective observational study. 110 COPD patients were included. Severity was assessed with the help of spirometry, mMRC dyspnoea grade, CAT score and GOLD staging. Two dimensional echocardiography was performed and assessed for microalbuminuria. Results: Microalbuminuria was present in 80.91% of patients. It was significantly associated with number of exacerbations of COPD (P=0.0003), however, no association was with mMRC grading (p>.05), CAT score (>0.05), and GOLD staging(>0.05). COPD patients with cardiovascular involvement had significantly higher proportion of patients with microalbuminuria as compared to COPD patients without cardiovascular involvement (88.57% vs. 67.50%)(p value<.05). Conclusion: Assessment of microalbuminuria is, simple, less costly, and non-invasive; therefore, it can be used on a routine basis in COPD cases, particularly in patients who are more symptomatic and are at an increased risk of cardiovascular morbidity and mortality.

Abhishek Mishra Department Methods: In this single centre post-COVID observatory study, 100 patients were included and divided to mild, moderate and severe/critical groups. Their clinical sign and symptoms and blood biochemical markers were analyzed. Results: Our findings suggested that post-COVID patients had varying degree of breathlessness requiring specific oxygen therapy. Other clinical features include marked muscle weakness, lethargy, sleeplessness and forgetfulness. Majority of them had uncontrolled diabetes and hypertension in terms of co-morbidities. In blood biochemical characteristics we observed that majority of patients had raised levels of D-Dimer, S.ferritin, S.LDH, S.procalcitonin, ESR and CRP. Maximum of them had raised PT-INR, TLC, SGOT, SGPT, RBS, urea and creatinine level. Some of them also had electrolytes disturbances in terms of deranged sodium and potassium levels. Conclusion: POST-COVID patients had different clinical and blood biochemical characteristics which indicates multiple organ dysfunction. Severe patient's group had age > 50 years, co-morbidities in terms of uncontrolled diabetes and hypertension, markedly increased D-Dimer, S.LDH, S.ferritin, ESR, CRP, PT-INR levels and deranged liver and kidney function of varying degrees. These blood biochemical indicators could reflect the severity of disease to a certain extent and should be considered in clinical management of the disease. Some of the parameters like D-Dimer, S.LDH, S.Procalcitonin, lymphopenia may also be a prognostic indicator. Sarcoidosis is an idiopathic, noncaseating granulomatous disorder with wide systemic involvement. Lungs, eyes, and skin are the organs most commonly affected. Bone involvement, which is very rare, was reported as present in 3 to 13% of affected cases. Here we present a case of young female with ribs, vertebrae and pulmonary involvement, lesion mimicking as metastasis or tuberculosis thus emphasizing the importance of differential diagnosis. Pulmonary involvement (80-90%) is commonly seen with osseous sarcoidosis as was present in our case. Confirmation of the diagnosis is always made by the histopathological examination which shows granuloma in the medullary cavity and destruction in the surrounding bone tissue. Non necrotizing histiocytic granulomas are characteristic for diagnosis. The early and definitive diagnosis is important for adequate treatment of this disease.

Kakatiya Medical College, Warangal, Telangana, India. E-mail: mandasrujana@gmail.com Introduction: Pleural effusion as a cause of ascending urological infection is rare. Mechanism is unclear.we report a case of pleural effusion with previous perinephric abscess with confirmed diaghrammatic defect and retroperitoneal extension.

A 70 year old male presented to the department with history of left side chest pain,fever,SOB on exertion since 1month.History of loss of appetite and loss of weight present.Recently diagnosed with dilated cardiomyopathy and DM.known case of chronic pyelonephritis. Physical Examination: Entire left hemithorax there were dullnote on percussion.on auscultation there were decreased breath sound and decreased vocal resonance on left hemithorax. Investigations and Diagnosis: Chest X-ray demonstrated a homogenous opacity in the left hemithorax. ICD was done ,pus was drained. Analysis of pleural effusin showed exudative pattern,pus for CBNAAT MTB detected from both pleural effusion and perinephric abscess. CECT abdomen revealed retroperitoneal extension with diaghrammatic defect with perinephric abscess.previous US abdomen scan 6 months back showed perinephric abscess with out effusion. Management: Patient was adviced ATT and referred to higher centre.

The result of this case study showed that in patients presenting with massive pleural effusion , with history of perinehric abscess,TB may be one of cause .we should rule out diaghrammatic defect.

Introduction: COPD is common,preventable and treatable disease that is characterized by persistent respiratory symptoms and airflow limitation that is due to airflow limitation that is due to airway and/or alveolar abnormalities usually caused by significant exposure to noxious particles or gases. The original Body mass index, airflow Obstruction, Dyspnea, Exercise capacity (BODE index) are simple multidimensional grading system which is superior to lung function alone for prediction of mortality and hospitalization rates among COPD patients. The present study has been undertaken to determine the factors other than the lung function which affect the outcome in COPD patients.

1 To compare BODE index in predicting severity of chronic obstructive pulmonary disease.

Aortopulmonary septal defect: Hemodynamics, angiography, and operation

Early and late results after repair of aortopulmonary septal defect and associated anomalies in infants <6 months of age

Aortopulmonary septal defects. A review of the literature and report of ten cases

VACTERL association

Introduction: Mucormycosis is an emerging angioinvasive infection caused by the ubiquitous filamentous fungi of the mucorales order of the class of zygomycetes. It has emerged as one of the most common invasive mycosis in patient with hematological and allogeneic stem cell transplantation. It also remains threat in diabetic and also recently in post covid patients. Case Report: A 62 year old male farmer patient came with complaints of cough with expectoration, fever, moderate hemoptysis and headache. Patient is having uncontrolled diabetes mellitus. All routine blood investigations and coagulation profile was normal. CECT Thorax suggestive of ring like opacities with areas of ground glass opacities surrounded by ring of consolidation suggestive of fungal pneumonia. Simultaneously patient is having severe throbbing headache. So MRI brain with orbit and paranasal sinus done, which suggestive of ethamoidal sinusitis ,osteomyelitis of clivus. Hence IV antifungal amphotericin b started as immediate measure in a view of disseminated fungal infection with strict glycemic control. Sputum smear, microscopy, bacterial culture, gene xpert are negative. Lung biopsy done which suggestive of branching ribbon like hyphae. Hence patient posted for right upper lobectomy. Patient discharged on Tab. Posaconazole. Patient came follow up after 3 months , symptomatically improved and radiological resolution of lesions of chest xray. Conclusion: Mucormycosis is a life threatening infection, and usually the diagnosis late because of nonspecific clinical ,radiological features and need biopsy for confirmation of the organism. The cornerstone for the management and increase the survival rate remain on rapid diagnosis ,treatment of the underlying predisposing condition and urgent surgical debridement.

Department of Respiratory Mdicine, SRMS IMS, Bareilly, Uttar Pradesh, India. E-mail: yasmoon.siddiqui@gmail.com Background: Cough is the most common symptom for which patients seek medical attention. Estimates of the prevalence of cough vary, but as much as 12% of the general population report chronic coughing, defined as a cough lasting for more than 8 weeks. Growing Evidence suggest that the common medical conditions associated with chronic cough are cough variant asthma (CVA), upper airway cough syndrome (UACS), non asthmatic eosinophilic bronchitis (NAEB) and gastroesophageal reflux cough (GERC). 

Atul Kumar Singh index than primary lung function test alone. Methods: A total of 120 patients were enrolled into the study. Of these, 90 patients with symptoms suggestive of COPD were selected as cases and 30 patients were selected as controls. For each enrolled subject, detailed history of smoking, personal and family medical histories were obtained. The lung function parameters were assessed by spirometry and they were categorised into mild, moderate and severe COPD cases. All of them underwent detailed clinical examination, electrocardiography, echocardiography and routine investigations with specialreference to Hb%, Albumin and C reactive protein levels. These parameterswere later compared between the different groups.

The result and conclusion of the study will be presented at the conference.

Introduction: Pneumothorax is an abnormal accumulation of air between the visceral and parietal pleura with underlying lung collapse.Spontanous Pneumothorax is a type of pneumothorax that occurs spontaneously in the absence of iatrogenic or traumatic factors .spontaneous pneumothorax can be either primary spontaneous pneumothorax or secondary spontaneous pneumothorax. Case: 80 year old male patient chronic smoker came with complaints of breathlessness on exertion and worsened since 1 day,cough since 1 week ,chest pain since 1 day .no previous history of pulmonary tuberculosis. On Exmaination: PR-116/min ,sp02-20%,in RA,BP-60/40mmHg ,RR-56 cycles/min , trachea central ,bilateral hyper resonant note on percussion over all the areas of lung fields ,bilateral decreased breath sounds. Chest x ray shows bilateral massive pneumothorax. Management: Patient was managed with supplemental high flow oxygen and placement of ICD bilaterally .patient improved symptomatically .blood pressure and oxygen saturation improved within 5 hours. REPEAT CHEST XRAY -after 24 hrs showed bilateral expansion of lungs .pleurodesis was done bilaterally using povidone iodine .ICD was removed and patient was discharged. Discussion: Although in clinical practice spontaneous pneumothorax is a frequently encountered disease .It is rarely reported in the literature .PSP occurs due to rupture of subpleural emphysematous blebs located in the apex of lungs .frequently seen in tall and thin individuals between the age group of 10 -29 .it has been reported that primary spontaneous pneumothorax is seen more frequently in smokers 12% than in non smokers 0.9%.The incidence of PSP is 7.4 /100000 in men and 1.2/100000in women .secondary spontaneous pneumothorax cause there is actually an underlying lung disease .most SRSP causes are seen as result of underlying pulmonary disease such as COPD ,bronchial asthma ,ILD ,Connective tissue disorders ,malignant neoplasms ,parenchymal TB ,Pneumocystitis carinii, pneumonia .SBSP is commonly seen in elderly .the incidence of SBSP is 6.3/100000 in men and 2/100000 in women .SBSP is rare condition and forms only 1.3% of all spontaneous pneumothorax cases .patients with secondary pneumothorax presents with severe respiratory distress and diminished pulmonary reserve .The risk of recurrence for SBSP is 40 -80% hence higher risk of mortality upto 36% in SSP . Conclusion: Spontaneous bilateral secondary pneumothorax is a rare clinical entitiy because SBSP and its recurrence is life threatening an appropriate treatment approach should be applied to prevent recurrence .

Introduction: Hypoxia is a very common symptom during this COVID-19 pandemic. Detailed history, clinical examination and relevant investigations are important in distinguishing rare causes from commonest. Case Report: 52-year-old lady presented to emergency room with sudden onset breathlessness. She was recently diagnosed with Idiopathic Thrombocytopenic Purpura (ITP). She was found to be hypoxic with a room air saturation of 82% in pulse oximeter. She was started on high flow oxygen. But her saturation didn't improve. Chest X-ray showed normal lung fields and bedside echocardiography revealed normal cardiac status. Point of care blood gas analysis (ABG) revealed a normal partial pressure of oxygen (Pao2-100). The discrepancy between oxygen saturation recorded in pulse oximetry and PaO2 in blood gas analysis tempted us to relook the ABG. It was found that the methaemoglobin level in ABG was 10.7%. When we analysed her drug history, we found that there was dapsone intake for the treatment of ITP which strongly supported us to reach the diagnosis of methemoglobinemia. She was then treated with intravenous methylene blue in the emergency room. She responded well and her repeated ABG revealed normalized level of methaemoglobin. Her hypoxia also resolved. Dapsone was later removed from her regular medications. Conclusion: Methemoglobinemia is an extremely rare cause for hypoxia. Though rare its potentially life threatening if not identified on time. Refractory hypoxia with a discrepancy in spo2 and PaO2 should raise the suspicion of methemoglobinemia. IV methylene blue is the recommended treatment for methemoglobinemia.