Biological therapy for severe asthma - Indian perspectives and challenges

Asthma is a complex and heterogeneous disease. Severe asthma makes up only a minority of asthma patients encountered in clinical settings but accounts for substantial healthcare utilisation in terms of manpower as well as economic allocation. The availability of monoclonal antibodies has a major impact on severe asthmatics and has provided excellent clinical results in properly selected patients. The discovery of new molecules might present uncertainties to clinicians as to the best agent to institute in an individual patient. The practice scenario in India is unique when it comes to the commercial availability of monoclonal antibodies, patient attitudes, and allocation of the healthcare budget. The present review dissects and summarises the available monoclonal antibodies for asthma treatment in India, the perspectives of Indian patients on biological therapy, and the challenges encountered by patients and physicians in this regard. We provide practical suggestions for utilising monoclonal antibodies and deciding on the optimal agent for a given patient.

Pneumothorax ex vacuo: Three cases of an uncommon entity

Pneumothorax is a frequently encountered entity in pulmonary practice and can be primary or secondary. Traumatic and iatrogenic causes also account for a minority of cases presenting to the chest physician. The most common therapeutic intervention done is a tube thoracostomy in all but the mildest of cases. Pneumothorax ex vacuo is a distinctly uncommon entity that differs considerably from the rest of the pneumothorax cases in its pathogenesis, clinical manifestations, radiological findings, and management. Pneumothorax in this entity results from the sucking in of air into the pleural space caused by an exaggerated negative intrapleural pressure, which is most frequently secondary to acute lobar collapse. Symptoms attributable to pneumothorax per se are distinctly mild and the vital aspect of treatment is to relieve the bronchial obstruction. Tube thoracostomy fails to relieve the pneumothorax in such cases and should be avoided. We share three cases of pneumothorax ex vacuo encountered in our institution and alert clinicians of the presentation, radiology, and management of this uncommon condition.

Hospitalisation Outcomes in Pneumococcal VaccinatedVersusUnvaccinated Patients with Exacerbation of COPD – Results From TheHOPE COPD Study

Background

Infectious exacerbations are crucial events that dictate the natural course of COPD patients. Pneumococcal vaccination has shown to decrease incidence of community acquired pneumonia in COPD patients. There is paucity of data on outcomes of hospitalisation in pneumococcal vaccinated COPD patients in comparison with unvaccinated subjects.

Objectives

To evaluate the difference in hospitalisation outcomes in pneumococcal vaccinatedversusunvaccinated COPD subjects hospitalized with Acute Exacerbation.

Methods

This was a prospective analytical study on 120 subjects hospitalised with acute COPD exacerbation. 60 patients with prior pneumococcal vaccination and 60 unvaccinated patients were recruited. Outcomes of hospitalisation like mortality rate, need for assisted ventilation, length of hospital stay, need for ICU care, and length of ICU stay were collected and compared between two groups with appropriate statistical tools.

Results

60% of unvaccinated patients (36/60) required assisted ventilation whereas only 43.3% of vaccinated subjects (26/60) needed assisted ventilation (p value 0.04). Most of the secondary outcomes were better in the vaccinated group. The mean length of ICU stay in the vaccinated group was 0.67 days (±1.11) compared to 1.77 (± 1.89) in the unvaccinated group. The mean length of hospital stay was 4.50 days (±1.64) and 5.47 days (±2.03) days in vaccinated and unvaccinated group respectively (p value 0.005).

Conclusions

COPD patients who have received prior pneumococcal vaccination have better outcomes when they are hospitalised for an acute exacerbation. Pneumococcal vaccination may be recommended for all patients with COPD who are at risk of hospitalisation with acute exacerbation.

Inhaled corticosteroids and risk of tuberculosis-How bad is the risk?

Inhaled corticosteroids (ICS) have a central role in the management of obstructive airway diseases. Use of ICS in asthma and chronic obstructive pulmonary disease (COPD) is associated with a small but clear increase in incidence of pneumonia and tuberculosis. Since ICS use in obstructive airway diseases has beneficial effects with regard to symptoms, lung function, quality of life and exacerbations, denying the benefit of ICS solely based on this small elevated risk of pneumonias and tuberculosis is not justified. The present article attempts to elucidate mechanisms contributing to the increased risk, assesses the magnitude and risk factors of tuberculosis in patients using ICS and provides practical suggestions for practising clinicians.

Disseminated tuberculosis associated with autoimmune haemolytic anaemia and adrenal deficiency: a rare association

Tuberculosis (TB) is one of the greatest masqueraders in medical practice and can have manifestations involving any organ or organ systems of the body. The presentation of disseminated TB can range from typical features like fever, weight loss and fatigue to protean manifestations. We share the case of an elderly man who presented to us with weight loss, anaemia, weakness and lymphadenopathy involving thoracic and intraabdominal locations. Work up of anaemia revealed features of Coombs-positive autoimmune haemolytic anaemia (AIHA) and evaluation of weakness showed laboratory results consistent with adrenal insufficiency. Biopsy of the abdominal lymphnode yielded caseating granulomas with CB-NAAT positivity for Mycobacterium tuberculosis Anti-TB chemotherapy with short-term replacement dose of systemic steroids corrected the haemolysis, anaemia and addisonian crisis. The case alerts clinicians regarding the uncommon association of TB with Coombs positive AIHA and adds one more aetiology to the pathogenesis of anaemia in TB. Furthermore, the occurrence of AIHA and hypoadrenalism in the same patient with TB is exceedingly rare and has not been reported.

Delayed lung function testing after COVID-19 to detect persistent lung function abnormalities – The DELTA – COVID-19 lung function study

Background

Coronavirus disease 2019 (COVID-19) has made its presence felt as the worst pandemic witnessed till date in the 21^st century. The mortality and morbidity associated with COVID-19 does not end with the acute pneumonia and respiratory failure and consequences extend well into the subsequent weeks to months in a minority. After recovery from severe disease, symptoms, lung function abnormalities and radiological changes are known to persist for varying length of time in a small proportion of patients. Various studies report different incidences of lung function abnormalities post-COVID-19. The present study describes the occurrence, severity, pattern and risk factors for persistent lung function abnormalities post-COVID-19 patients.

Aim

The present study was aimed to find out the occurrence of persistent lung function abnormalities in patients hospitalised with COVID-19 at three months of discharge who had normal previous lung function prior to COVID-19. In those with persisting abnormal lung function, the severity, pattern and risk factors for persistent lung function abnormalities were also studied.

Methods

The present study was a retrospective study in patients hospitalised with COVID-19 who had radiological evidence of pneumonia at admission. Patients with prior abnormal lung function were excluded from the study. Lung function was analysed with spirometry, 6-min walk test and diffusion capacity between day 85 and 95 of hospital discharge and the occurrence, severity and pattern of impairment was described. Lung function impairment was correlated with baseline characteristics and univariate regression analysis was done to identify risk factors for persisting functional impairment.

Results

39 patients were included in the study. Spirometry at follow up showed a restrictive ventilatory defect in 26 out of 39 patients (64%) and a normal study was noted in 12 patients. One patient had an obstructive ventilatory defect. Diffusion impairment was present in 27 patients and normal transfer factor was seen in 12 patients. The degree of diffusion impairment was mild in 16 patients and moderate in 11 patients. Univariate regression analysis revealed that age, history of systemic hypertension, severe hypoxia at presentation, and extent of lung involvement by CT chest were associated with lung function impairment.

Conclusion

Almost two-thirds of patients hospitalised with COVID-19 pneumonia have persistent lung function abnormalities at three months post-discharge. Advanced age, severe disease and medical comorbidities increase the risk of persistent functional abnormalities.

A successful salvage story: Uveitis with nontuberculous mycobacterial infection in a patient on secukinumab

The reported occurrence of ocular infections with nontuberculous mycobacterial (NTM) infections has been increasing in the past few decades. NTM are known to cause intraocular infections as well as infections of the ocular appendages and are often recalcitrant to medical therapy. Uveal involvement due to NTM is rare and most reported cases have predisposing factors such as cataract surgery or immunocompromised states. Diagnosis and treatment pose challenge due to difficulty in procuring sufficient clinical material to obtain microbial diagnosis and inadequate response to medical therapy. The clinical challenge is further heightened in the presence of an underlying rheumatologic disease that is known to cause uveitis. We share the case of a young gentleman with ankylosing spondylitis who was being treated with secukinumab with good response to joint symptoms. He developed sudden onset uveitis which was diagnosed to be due to NTM infection based on aqueous humor polymerase chain reaction studies. He had a good clinical response to an empirical anti-mycobacterial regime with the restoration of vision. This report narrates the first case of NTM uveitis secondary to secukinumab therapy.

Acceptance and Results of Therapy with Omalizumab in Real world Kerala setting - Reports from the ARTWORK study, Kerala, South India

BACKGROUND

Despite the availability of effective medications, only a minority of asthma patients achieve guideline defined asthma control. Treatment success depends on patient concurrence to the prescribed drug and adherence to treatment. It is therefore crucial to identify the patient preferences as well as attitudes towards asthma medications. Omalizumab is recommended as a preferred option in step five of asthma therapy. There have been few studies to address patient perspectives on omalizumab therapy in India.

METHODS

This was a retrospective study. Patients with inadequate asthma control were considered for the study. Systematic evaluation was done to identify and correct modifiable factors that can worsen asthma control. Patients with persisting poor asthma control who were deemed suitable to receive this agent were evaluated with their attitudes towards acceptance or refusal and the reasons for opting out were noted. The patients who received omalizumab were followed up to determine the results of treatment and duration of adherence to therapy.

RESULTS

35 patients out of 51 patients chose to avoid this drug. The reasons for opting out included erroneous perception of optimal asthma control, cost of therapy, and concern about adverse effects. Patients took omalizumab for a median duration of 6 months. Improved asthma control and decreased frequency of exacerbation was noted in all patients which persisted during the six month follow up.

CONCLUSIONS

Majority of patients needing step five therapy opt out of omalizumab. Cost of drug, duration of therapy and erroneous perception of good asthma control account for refusing treatment. Omalizumab affords excellent clinical benefits to patients who receive it, and the benefits extend beyond the duration of therapy.

Fluticasone/formoterol compared with other ICS/LABAs in asthma: a systematic review

OBJECTIVES

An inhaled corticosteroid (ICS)-long-acting beta-2 agonist (LABA) combination has become the standard of care in asthma. Various ICS-LABAs are commercially available providing the clinician with many choices. A thorough understanding of the clinical efficacy and safety of various formulations will immensely benefit the prescribing doctor to decide the choice of agent. The present systematic review was undertaken to compare the clinical efficacy and safety of formoterol fluticasone (FF) to other ICS/LABA combinations in asthmatics.

METHODS

The review adhered to the general principles mentioned in the CRD guidance and the PRISMA statement. We searched Medline, Embase, and Cochrane Controlled Trials Register databases on the efficacy of FF in treating asthma compared with other ICS-LABAs. A total of 138 trials identified initially. Only trials comparing the efficacy and safety of FF in comparision with Salmeterol/fluticasone (SF) or Budesonide/Formoterol (BF) were selected. The outcomes compared were onset of bronchodilator action, improvement in lung function, asthma control, asthma-related quality of life and risk of pneumonia.

RESULTS

Sixteen studies were included in the final analysis. FF therapy provided faster onset of bronchodilatation than SF. A better improvement in lung function was seen with FF inhaler use as compared with comparators in two studies. Patients using the FF inhaler had a non-inferior asthma control and asthma-related quality of life. Pneumonia risk was least with FF usage.

CONCLUSION

FF provides faster onset of action, numerically superior improvement in lung function and comparable asthma control than other ICS-LABA formulations. FF has better safety evidenced by lower occurrence of pneumonia.

Expecting the unexpected - Primary mediastinal large B cell lymphoma presenting as huge lung parenchymal mass

The first possibility considered in the etiology of large lung masses is neoplastic lesions. The differential diagnoses of these masses include bronchogenic carcinoma, pulmonary sarcoma, primitive neuroectodermal tumor etc. Primary or secondary pulmonary parenchymal lymphomas presenting as large mass is distinctly rare. We share the case of a young lady who presented with a large left lung mass almost entirely replacing the left lung parenchyma, with associated intrathoracic lymphadenopathy. On evaluation she was proved to have primary mediastinal large B-cell lymphoma. Treatment with an aggressive chemotherapy regimen led to complete remission of the parenchymal and nodal disease. The uncommon radiological presentation and the excellent therapeutic response despite huge tumor load merit clinical attention.

Endobronchial Hamartoma with Postobstructive Pneumonia- A Case of Successful Treatment with Endobronchial Interventions

Airway hamartomas are of mesenchymal tissue origin and have predominance of adipose tissue. Hamartoma refers to a tumour-like structure within an organ composed of an abnormal arrangement of tissue components normally found in that organ. The pulmonary parenchyma and airways are commonly described sites for this lesion, although endobronchial location is far less common than its parenchymal counterpart. When present within a major airway, the usual symptoms of an airway lesion like cough, wheezing, stridor, haemoptysis and postobstructive consolidation ensue. We describe the case of a 60-year-old gentleman who presented with cough of 9 months duration. On evaluation he was found to have an endobronchial lesion in the right main bronchus. The histopathology revealed features of endobronchial hamartoma which was then subjected to endobronchial intervention with electrocautery and cryoablation achieving complete removal and restoration of luminal patency. This case underscores the ability of endobronchial treatment modalities to successfully treat benign airway lesions like hamartoma when undertaken in experienced centres.

Acute Presentation of Amiodarone Toxicity with Pleural Involvement

Amiodarone is a frequently prescribed anti-arrhythmic drug which is used to treat ventricular and supraventricular tachyarrhythmia. Although it has excellent efficacy in controlling or preventing common arrhythmias, it is potentially associated with a variety of adverse effects, the most serious of these being pulmonary toxicity. Amiodarone-associated toxicities are usually seen in solid organs like lung, spleen and thyroid due to extension of its pharmacokinetic properties. The presentation is often subacute. Acute presentation with pleural involvement is distinctly uncommon in amiodarone toxicity and can pose diagnostic challenges. Here the case presented is of a 67 year old female with multiple co-morbidities on amiodarone therapy, who presented with massive pleural effusion and respiratory failure. Typical radiological findings along with exclusion of alternate causes with appropriate tests led to a diagnosis of amiodarone toxicity involving lung parenchyma, pleura, liver and other organs. She responded to withdrawal of drug, steroid therapy and supportive care.

A case of young woman with recurrent right pleural effusion

Endomterisois is usually found in women of child-bearing age. A case is presented of massive right-sided pleural effusion caused by endometriosis. The final diagnosis was made by thoracoscopic pleural biopsy. Physicians should be aware of this potentially treatable cause of pleural effusion having excluded other possibilities such as malignancy and tuberculosis.

Different strokes for different folks

A 42-year-old woman, presented to our emergency room with chief complaints of acute onset of dyspnea, left-sided chest pain, and respiratory distress. On arrival, she had blood pressure of 90/50 mm Hg, respiratory rate of 40/min, and oxygen saturation of 95% breathing on 10 L oxygen. She was in significant respiratory distress. On examination, she was found to have diminished breath sounds on the left side of chest. Her chest radiograph showed left massive pleural effusion causing contralateral shift of mediastinum. Diagnostic pleural aspiration was done; results were consistent with hemothorax. Her multidetector computed tomography chest showed features of left-sided hemothorax (high attenuation) along with a 2 cm-enhancing lobulated opacity in the left lingular lobe, suggestive of pulmonary arteriovenous malformation (PAVM). She was successfully treated with surgical resection of PAVM.