Non-resolving pneumonia: A rare presentation of progressive disseminated histoplasmosis

Histoplasmosis, a fungal disease caused by Histoplasma capsulatum, is endemic in North and South America. Except few scattered cases, the disease is considered to be a non-entity in India. Furthermore, disseminated histoplasmosis is rare in the immunocompetent individuals. We report an adolescent boy presenting as middle lobe consolidation which did not respond to antibiotics. His condition deteriorated with the development of mediastinal lymphadenopathy, pleural effusion and hepatosplenomegaly. A diagnosis of progressive disseminated histoplasmosis was established by his clinical findings as well as bronchoscopic biopsy, transbronchial needle aspiration cytology and bronchoalveolar lavage culture demonstrating Histoplasma capsulatum. The case represents a unique example of progressive disseminated histoplasmosis in an immunocompetent individual in India.

Role of DR-70 immunoassay in suspected malignant pleural effusion

Context:

A good proportion of patients with undiagnosed pleural effusion (PE) turn into malignancy over a period of time. Identification of positive biomarker may help in selecting the individuals who require close follow-up.

Aims:

The aims of this study were to evaluate the role of DR-70 immunoassay in suspected malignant PE.

Settings and Design:

We conducted a cross-sectional study among 89 patients of suspected malignant PE and 50 normal subjects (NS) were taken as control.

Materials and Methods:

Patients with exudative PE; who had pleural fluid lymphocyte count greater than 50% and adenosine deaminase less than 30 U/L were taken as cases. We had selected NSs among relatives of patients having normal blood chemistry and radiological investigations. Sensitivity and specificity of the test to differentiate malignant and non-malignant PE and also to identify PE with underlying malignancy was analyzed.

Results:

Mean value of DR-70 in NS was found to be 0.83 ± 0.273 mg/L without any significant difference between males (0.82 mg/L) and females (0.85 mg/L). Mean value of DR-70 in PE with underlying cancer was 5.03 ± 3.79 mg/L. Sensitivity (80%) and specificity (77.78%) of the test was maximum in PE with underlying cancer using cut-off value of 2 mg/L. Mean value DR-70 in malignant PE was 5.18 ± 3.75 mg/L and in non-malignant PE was 3.73 ± 3.74 mg/L without any statistically significant difference (P = 0.08).

Conclusions:

DR-70 assay has high sensitivity in detecting underlying lung cancer, but has no role in differentiating malignant PE from non-malignant PE.

Recovery of fluconazole sensitive Candida ciferrii in a diabetic chronic obstructive pulmonary disease patient presenting with pneumonia

Chronic obstructive pulmonary disease (COPD) exacerbations admitted in intensive care units (ICUs) occur rarely due to fungal respiratory tract infections, but may occur when associated co-morbidities like diabetes mellitus coexist. Candida ciferrii is a new agent, recently was isolated from lung infections but usually resistant to fluconazole. Here, we report a rare case of pneumonia due to fluconazole sensitive Candida ciferrii in a COPD patient with known diabetes, admitted in our ICU.

Role of common investigations in aetiological evaluation of exudative pleural effusions

BACKGROUND

Pleural effusion is a common problem encountered in daily practice. To Establish aetiology of exudative effusions is a diagnostic challenge to general practitioners and even to pulmonologists especially in resource poor government hospitals with lack of investigations like thoracoscopy. Some recent studies had shown that around 2% of patients remained undiagnosed even after these investigations.

AIMS AND OBJECTIVE

To evaluate the role of the commonly available investigations such as pleural fluid study, blind pleural biopsy, sputum examination, CT scan thorax, bronchoscopy in the aetiological evaluation of exudative effusions and to ascertain the proportion of cases which remain undiagnosed after all the above investigations.

MATERIAL AND METHODS

This was a prospective single-centred cross-sectional study carried out at the NRS Medical College, Kolkata, India from February 2008 to February 2013 which included 568 patients of exudative pleural effusions. We performed commonly available procedures like pleural fluid study, blind pleural biopsy, sputum examination, CT scan thorax, bronchoscopic procedures to the diagnosis.

RESULTS

Total number of patients studied were 568. Tuberculosis was the most common cause (54.57%) followed by malignancy (28.17%), empyema (10.56%), parapneumonic effusion (5.28%) and others. Carcinoma of the lung was the commonest cause of malignant effusions and bronchoscopic biopsy was given the highest yield of histological diagnosis (84.6%) followed by CT guided FNAC (77.6%) and pleural fluid cytology (55%). Highest yield to diagnose tubercular effusion was found in lymph node FNAC (81.5%) followed by pleural biopsy (62%). Sputum smear for AFB was positive in only 27.4% cases. Bleeding followed by pneumothorax were the most common complications. Complications are very less (1.3% and 0.9% respectively). 2 patients (0.34%) remained undiagnosed even after these all above said investigations.

CONCLUSION

Above mentioned commonly available investigations can ascertain diagnosis in most of the cases in the aetiological evaluation of exudative effusions and they are relatively safe procedures.

A rare case of ethambutol induced pulmonary eosinophilia

Antitubercular drug (ATD) induced eosinophilic lung disease is a rare phenomenon. It usually occurs due to isoniazid and para amino salicylic acid. A 34-year-male of sputum positive pulmonary tuberculosis, on antitubercular drugs (rifampicin, isoniazid, ethambutol, and pyrazinamide) for last 3 weeks, presented with generalized arthralgia and maculopapular rash for last 2 weeks and shortness of breath for last 1 week. Chest X-ray and High resolution computerized tomographic scan thorax showed bilateral peripheral airspace opacification. Bronchoalveolar lavage revealed 51% eosinophils of total cellularity (1200/cmm) confirming the diagnosis of pulmonary eosinophilia. ATD was stopped for 2 weeks and then reintroduced one by one. Patient again developed similar kind of symptoms with reintroduction of ethambutol. According to criteria for drug induced pulmonary eosinophilia, he was diagnosed as a case of ethambutol induced pulmonary eosinophilia.

Squamous cell lung cancer producing bilateral air bronchograms on CT scan thorax

A young lady presented with cough for three months and dyspnoea for one month along with clinical signs of bilateral consolidation of lung. On CT scan thorax there were bilateral air bronchograms with alveolar filling opacities predominantly in lower lobes. After bronchoscopy when there was presence of suspicious malignant cells on bronchoalveolar lavage fluid, transbronchial lung biopsy diagnosed the case as squamous cell lung cancer. Radiological presentation of squamous cell lung cancer as air bronchogram is not a very common phenomenon and can present a diagnostic challenge to the clinician.

Three body dissociation of CS2(2+) subsequent to various S(2p) Auger transitions

Fragmentation kinematics of CS2 following various S(2p) Auger transitions is studied. Employing a combination of electron energy analysis and recoil ion momentum spectroscopy, changes in the dissociation channel yields, as well as the differences in the kinematical parameters for various bands of Auger hole states are presented. The fragmentation mechanism for dissociative channels leading to complete atomization of CS2(2+) molecular ion is studied in detail. We find that CS2(2+) does not retain linear geometry and is bent before undergoing concerted break-up. It is also observed that different geometric configurations of the CS2(2+) precursor result in different kinetic energy release values.

Aspergillus endocarditis presenting as acute right lower limb pain

Corrigendum: On 31/10/2013 the name of the author K. Shah was corrected to read K. Saha.Aspergillus endocarditis is an 2nd most common cause of endocarditis having poor prognosis. We report a rare case of fungal endocarditis following cardiac valve replacement presenting as acute pain in the right lower limb. Embolism and endocarditis were primarily detected by CT angiography and echocardiography respectively. Diagnosis was established by histopathology and culture of the emboli and was confirmed later by isolation of the Aspergillus species from the resected valve tissue. DOI: http://dx.doi.org/10.3126/jpn.v3i6.9002   Journal of Pathology of Nepal (2013) Vol. 3, 502-504

Camp based awareness and screening programme of cervical cancer in rural area of Bangladesh

This population based cross sectional study was carried out in Muktagacha Upazilla Health Complex, Mymensingh, Bangladesh during the period of 26th to 28th June, 2012. The objective was to create awareness, to find out the precancerous lesion of cervix and to evaluate the effectiveness of this approach for prevention of cervical carcinoma. Women who were married and between 30-60 years and also women of below 30 years (who were married below the age of 18) were included in this study. All pregnant women were excluded from this study. After counseling, pelvic examination and VIA (visual inspection of cervix with application of 5% acetic acid) test was done. If the squamo-columner junction of cervix turned to white then it was called VIA positive (+ve) cases. Then they were referred to colposcopy clinic of Mymensingh Medical College with a red card for evaluation and management. During the 3 days campaign, 395 cases were examined. Among them, majority (49%) of the women were below the age of 30. It was observed that still 48.2% were married below the age of 18 and 31% had first pregnancy at an age or below 18 years. But number of grand multiparity is lowering now a days. Only 25% had para ≥4. Others have para 1-3. During pelvic examination, the common cervico-uterine pathologies like chronic cervicities (16.5%), cervical erosion (14.4%), uterine prolapse (2.3%), cervical polyp (1%), myomatous polyp (0.3%) and advanced cervical carcinoma (0.5%) were also diagnosed clinically. Among the participants, 11.9% was detected as VIA+ve cases. A significant association of VIA+ve cases with low socio-economic conditions, hindu religion, early age at marriage and high parity were observed in this study (p<0.05). The findings of this study highlight the utility and need of camp based cervical cancer screening service at regular interval in the community.

Small cell lung carcinoma associated with progressive systemic sclerosis

The association between progressive systemic sclerosis (PSS) and malignancy is uncommon. The possibility of development of small cell carcinoma lung (SCLC), among all the reported lung malignancies in PSS patients is lowest. A fifty-five year old non-smoker female diagnosed as PSS for 1 year presented to our outpatient department with dry cough for 2 months, shortness of breath for the last 1 month and progressive facial and right upper limb oedema for the last 15 days. Chest X-ray showed homogenous opacity in the right upper and mid zones of lung and the obliteration of both costophrenic angles. High resolution computed tomography (CT) of the thorax revealed a right upper lobe lung mass with bilateral minimal pleural effusion and the presence of bilateral reticular opacities, with basal predominance, associated with septal thickening, suggestive of interstitial lung disease of non-specific interstitial pneumonia pattern. CT guided fine needle aspiration cytology (FNAC) from the right upper lobe mass was suggestive of small cell carcinoma. Patient was improved after 6 cycles of chemotherapy with carboplatin and etoposide.

Squamous cell carcinoma in exstrophy of the bladder

Exstrophy of the bladder is a rare congenital anomaly with an incidence of about 1 per 50,000 newborns. The malignant potential of the exstrophied bladder mucosa is well known; 95% are adenocarcinomas, and 3% to 5% are squamous cell carcinomas. Most of the malignant tumors (60%) associated with an exstrophy of the bladder occur during the fourth and fifth decades of life. Of the remaining, about 20% each occur after 60 years and before 40 years. Here we present a case in which squamous cell carcinoma developed in an unrepaired exstrophy of the bladder. We present the management of the case and a brief review of the literature.

The Incidence of Hyponatraemia and Its Effect on the ECOG Performance Status among Lung Cancer Patients

CONTEXT

Hyponatraemia is one of the common electrolytic disorders which are associated with lung cancer. Hyponatraemia may influence the ECOG performance status at presentation. Also, to the best of our knowledge, we found only limited Indian studies where the ECOG score was correlated with the serum sodium status in lung cancer patients on presentation.

AIM

To assess the incidence of hyponatraemia among the patients of carcinoma of the lung before putting them into the specific treatment category for cancer and to check the effects on their ECOG performance status.

SETTINGS AND DESIGN

A cross-sectional, observational study was conducted on 116 consecutive patients of lung cancer during the period from November 2011 to October 2012.

MATERIAL AND METHODS

The patients with a histologically proven diagnosis of lung cancer were grouped initially according to their ECOG performance statuses. The serum sodium value of each patient was measured and the hyponatraemic patients were given treatment according to the protocol. The correlation of the ECOG performance status with the serum sodium of the lung cancer patients was measured. To check for any laboratory error in serum sodium, we selected (n = 58) age, sex and socioeconomic matched control patients.

RESULTS

At presentation 44.8% of the lung cancer patients showed hyponatraemia [52/116]. The ECOG score was significantly poor in the advanced clinical stages (ECOG ≤2 Vs ECOG ≥ 3 in NSCLC cases, χ(2) =11.25, P=.0008). The ECOG performance status score at admission showed a negative correlation with the serum sodium status which was measured on admission among all the patients (Pearson correlation coefficient = - 0.186). The clinical stage of the lung cancer also showed a positive correlation with the ECOG score at admission in our study (Pearson correlation coefficient = 0.295).

CONCLUSION

Hyponatraemia is not an uncommon condition and it should be suspected and screened in each patient, as it may influence the ECOG performance status score, which serves as an important factor in the prognosis of lung cancer.

Comparative evaluation of six cytological grading systems in breast carcinoma

Background:

Cytological grading is a useful tool for selection of therapy and prognosis in breast carcinoma. Despite having many cytological grading systems, there is still no agreement among pathologists to accept one of them as a gold standard.

Aim:

This study was undertaken to evaluate six such three-tier cytological grading systems to determine which system corresponds best to histological grading done by Nottingham modification of Scarff Bloom Richardson (SBR)'s method.

Materials and Methods:

In a double-blind study, preoperative cytological grades obtained by six systems on fine-needle aspiration cytology (FNAC) smears were compared by testing concordance, association and correlation with histological grade derived postoperatively by the SBR's method in 57 patients of breast carcinoma. Bivariate correlation studies and multiple linear regressions were done to assess the significance of the different cytological parameters to predict final cytological grades.

Results:

Robinson's system demonstrated the best correlation (ρ = 0.799; P = 0.000 and τ = 0.765; P = 0.000), maximum percent agreement (77.19%) and a substantial kappa value of agreement (κ = 0.62) with the SBR's grading system. All the six cytological grading systems correlated with histological grading strongly and positively. In multiple regression analysis, all of the cytological parameters of Robinson's system except cell size and nucleoli had significance in predicting the final cytological grade.

Conclusions:

Robinson's grading system is simple, more objective and reproducible, and demonstrated the best concordance with histological grading. So, Robinson's system should be used routinely for breast carcinoma aspirates.

A combined electron-ion spectrometer for studying complete kinematics of molecular dissociation upon shell selective ionization

A combined electron-ion spectrometer has been built to study dissociation kinematics of molecular ions upon various electronic decay processes ensuing from ionization of neutral molecules. The apparatus can be used with various ionization agents. Ion time-of-flight (ToF) spectra arising from various electronic decay processes are acquired by triggering the ToF measurement in coincidence with energy analyzed electrons. The design and the performance of the spectrometer in a photoionization experiment is presented in detail. Electron spectra and ion time of flight spectra resulting from valence and 2p1∕2 ionization of Argon and those from valence ionization of CO are presented to demonstrate the capability of the instrument. The fragment ion spectra show remarkable differences (both kinematic and cross sectional) dependent on the energy of the ejected electron, corresponding to various electron loss and decay mechanisms in dissociative photoionization of molecules.

Usefulness of induced sputum eosinophil count to assess severity and treatment outcome in asthma patients

Context:

Currently treatment decisions in asthma are governed by clinical assessment and spirometry. Sputum eosinophil, being a marker of airway inflammation, can serve as a tool for assessing severity and response to treatment in asthma patients.

Aims:

To establish correlation between change in sputum eosinophil count and forced expiratory volume in one second (FEV₁)% predicted value of asthma patients in response to treatment. In this study, we also predicted prognosis and treatment outcome of asthma patients from baseline sputum eosinophil count.

Settings and Design:

A longitudinal study was conducted to determine the treatment outcome among newly diagnosed asthma patients who were classified into A (n = 80) and B (n = 80) groups on the basis of initial sputum eosinophil count (A ≥ 3% and B < 3%).

Materials and Methods:

After starting treatment according to Global Initiative for Asthma Guideline, both A and B groups were evaluated every 15 days interval for the 1^st month and monthly thereafter for a total duration of 12 months. In each follow-up visit detailed history, induced sputum eosinophil count and spirometry were done to evaluate severity and treatment outcome.

Results:

FEV₁% predicted of group A asthma patients gradually increased and sputum eosinophil count gradually decreased on treatment. Longer time was required to achieve satisfactory improvement (FEV₁% predicted) in asthma patients with sputum eosinophil count ≥3%. There was statistically significant negative correlation between FEV₁% predicted and sputum eosinophil count (%) in of group A patients in each follow-up visit, with most significant negative correlation found in 8^th visit (r = −0.9237 and P = < 0.001). Change in mean FEV₁% (predicted) from baseline showed strong positive correlation (r = 0.976) with change in reduction of mean sputum eosinophil count at each follow-up visits in group A patients.

Conclusions:

Sputum eosinophil count, being an excellent biomarker of airway inflammation, can serve as a useful marker to assess disease severity, treatment outcome, and prognosis in asthma patients.