Recurrent tuberculosis due to subtherapeutic levels of antitubercular treatment

Most patients with tuberculosis respond well to treatment. Even in patients with good compliance to DOTS and sensitive to first-line drugs, treatment failure or relapse still occurs, the phenomenon of cryptic adherence needs careful evaluation. We present a case of frequent recurrence due to possible subtherapeutic levels of isoniazid (INH) and rifampicin. A 32-year-old male with no other comorbidities came with complaints of cough with expectoration with constitutional symptoms. He was treated for the primary complex at the age of 12 years and declared as cured. In 2006, he was diagnosed as right axillary TB lymphadenitis which was confirmed by histopathological examination and treated with Anti tubercular treatment (ATT) for 9 months. After 2 years (2008), he had developed left axillary lymphadenitis for which he was treated again with Anti tubercular treatment empirically. In 2016, he was diagnosed as smear-negative pulmonary tuberculosis (PTB) whose chest X-ray suggestive of PTB. Hence, he was treated with Anti tubercular treatment for 6 months, declared as cured. Now (2018), he was diagnosed as sputum-positive PTB with INH and rifampicin sensitive. Hence, we did a pharmacokinetics study, which revealed subtherapeutic levels of rifampicin and isoniazid. The patient responded well after increasing the dosage of drugs. Slow responders and patients with complications warrant the need of therapeutic drug monitoring (TDM). Drug concentrations which may be help resolve the problem of slow response to Anti Tuberculosis Therapy. TDM however is not routinely indicated in each case

The role of computed tomography chest in correlating with the severity and outcome of COVID-19 patients admitted in a tertiary care hospital in South India

Aim: To assess the role of computed tomography (CT) chest in correlating with the severity and outcome of COVID-19 Patients. Background and Materials and Methods: A prospective study was done on 160 hospitalized patients who were COVID-19 positive by reverse transcription-polymerase chain reaction in Apollo Hospital, Greams Road, Chennai, India. We collected epidemiological data, comorbidities, clinical manifestations, oxygen requirement, and CT chest details of all patients. All images were reviewed by a single consultant radiologist and CT chest severity scoring was done as per the guidelines published in the American Journal of Radiology. CT chest severity score (CTSS) was then compared with clinical severity and various parameters. Results: This study included 160 hospitalized COVID-19 patients with a mean age of 61 ± 13.97 years. Male (74.4%) patients were more when compared to female patients (25.6%). Majority of the patients were belong to mild category (44.38%), followed by severe (28.7%) and moderate (26.8%) categories. Fever (73.8%) was the most common symptom. Diabetes mellitus (57.5%) was the most common comorbidity of COVID-19 patients in our study, followed by hypertension (55%). The average CTSS of mild category was 7.4 ± 4.7; for moderate category, the mean CTSS was 14.6 ± 5.78; and for severe category, it was 18.3 ± 5.28. There was increasing trend of severity score, as clinical severity increases which was statistically significant (P = 0.0001). The mean CTSS of patients who required no oxygen, low flow oxygen, high flow oxygen, noninvasive ventilation, and intubated patients was 8.3 ± 5.71, 14.84 ± 5.39, 18.17 ± 5.7, 18.17 ± 6.04, and 22.18 ± 4.07, respectively, which was statistically significant (P = 0.0001). The mean CTSS of patients discharged without oxygen requirement was 11.09 ± 6.48 and patients discharged with oxygen requirement was 18.09 ± 6.12 (P = 0.001). The mean CTSS of patients who died was 20.27 ± 4.62. Conclusion: There was a significant correlation between CT chest severity score and clinical severity and oxygen requirement. CT chest is one of the best screening tools for rapid identification as well as to predict the clinical severity; thereby, it helps the clinician in managing the COVID-19 patients at crucial points during the progression of disease

A rare case of anti-jo1 syndrome presenting as a interstitial lung disease

Antisynthetase syndrome is a rare entity and can be missed if not specifically looked in patients whose initial presentation is with Interstitial Lung Disease. Prognosis is altered when patients presenting with Interstitial Lung Disease. A 45 years old lady with no known comorbidities came with complaints of fever, breathlessness and cough for 4 months. She also had history of muscle weakness. She was treated as COVID pneumonia with oral steroids as her CT chest showed bilateral GGO's. When she came to our hospital she was afebrile, hemodynamically stable, SPo2-88% on room air. She was negative for COVID and COVID antibodies were also negative. On Investigations her CPK, Aldolase, CKMB were elevated. Her ENA profile showed positive anti-Jo1 and anti Ro 52 antibodies. Electromyography and Muscle biopsy suggestive of Inflammatory Myopathy. PFT showed restrictive pattern with reduced Diffusing Capacity of Lung for Carbon Monoxide(DLCO). She was treated with high dose oral steroids and cyclophosphamide. She responded well to the treatment and discharged. Though antisynthetase syndrome is a rare disease, we should keep in mind when patients presenting with interstitial Lung disease. Patients presenting with ILD have guarded prognosis