Coexistence of Pulmonary Thromboembolism, Pulmonary Tuberculosis and Granulomatosis with Polyangiitis: A flimsy triple dribble

Granulomatosis with polyangiitis (GPA) is a rare autoimmune disease with multi‐system involvement. It involves the upper respiratory tract, lungs and kidneys. A 36-year-old female patient presented with complaints of low-grade fever, dry cough and loss of appetite initially followed by dyspnea, purpuric skin lesions, right lower limb swelling with pain and redness. Her chest radiograph revealed right upper lobe cavitary lesion with consolidation in right lower lobe. Mycobacterium tuberculosis was detected in sputum and Broncho alveolar lavage (BAL) via Cartridge based nucleic acid amplification assay (CB-NAAT). Later, Computed Tomography Pulmonary Angiography (CTPA) revealed bilateral pulmonary artery thromboembolism. Furthermore, her C-ANCA was positive, serum creatinine was rising, urine microscopy had red cell casts and lower limb venous doppler revealed DVT. Histopathological examination of the skin lesion revealed vasculitis. Based on the above findings, diagnosis of GPA was comfortably made. Patient improved with pulse steroids, cyclophosphamide, anticoagulants and anti-tuberculous therapy (ATT). Keywords: Granulomatosis with polyangiitis (GPA), Pulmonary Tuberculosis, Pulmonary thrombo-embolism, deep venous thrombosis, vasculitis, c-ANCA

Pulmonary Alveolar Microlithiasis: A commonly misdiagnosed rare entity

Pulmonary alveolar microlithiasis (PAM) is an uncommon entity which can pose a diagnostic challenge. We report a 45-year-old female who was referred to the All India Institute of Medical Sciences, Bhopal, India, in 2017 with a two-year history of progressively worsening dyspnoea and dry coughing. She had been previously diagnosed with pulmonary tuberculosis elsewhere and prescribed antitubercular therapy; however, there was little improvement in her symptoms. Following referral, the patient was diagnosed with PAM based on high-resolution computed tomography findings and the abundance of lamellar microliths in a bronchoalveolar lavage sample. She was subsequently managed symptomatically and enrolled in a rehabilitation programme. Keywords: Calcinosis; Pulmonary Alveolar Microlithiasis; Pulmonary Tuberculosis; Misdiagnosis; Case Report; India

Thoracic Endometriosis Presenting with Bilateral Hydropneumothorax

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Recurrent episodes of pneumonia in a toddler: Don't forget chronic granulomatous disease

A 4-year-old boy presented with community acquired pneumonia, hepatosplenomegaly and bilateral cervical lymphadenopathy. The peripheral blood film showed significant monocytosis and bone marrow examination revealed multiple histiocytic granulomas. Presence of CD 68 positive granulomas supported by cytological findings enabled us to make a diagnosis of chronic granulomatous disease

Pulmonary tuberculosis presenting as diffuse alveolar hemorrhage: Believe it or not

Diffuse alveolar hemorrhage (DAH) has been rarely reported with pulmonary infections and even rarer with pulmonary tuberculosis (PTB). We hereby report the case of a 31-year-old male, a known case of ankylosing spondylitis, who presented with clinical and radiological features consistent with DAH. Initial partial improvement with steroids was followed by a microbiological diagnosis of tuberculosis (TB). Starting of antituberculous treatment was followed by complete clinical improvement. This leads to a thought-provoking possible association between the two pathologies, DAH and PTB, if any

Askin’s Tumour: Massive tumour with minimal symptoms

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Bilaterally enlarged parotids and sicca symptoms as a presentation of sarcoidosis: Pivotal role of aspiration cytology in diagnosis

Sarcoidosis is a chronic multisystem inflammatory disease of unknown etiology characterized by widespread noncaseating granulomas in various organs. The diagnosis of sarcoidosis is based on cytological, clinicolaboratory, and radiological findings, and requires careful exclusion of other granulomatous diseases especially tuberculosis. Involvement of parotid glands is uncommon. Presentation of sarcoidosis with sicca symptoms that include dryness of eyes and mouth is an even rarer phenomenon. We present a case of multisystemic sarcoidosis presenting with dryness of eyes and mouth along with bilateral enlargement of parotid glands. Fine-needle aspiration cytology (FNAC) smears showed epithelioid cell granulomas and multinucleate giant cells. Stain for acid-fast bacilli was negative. Careful cytological examination revealed crystalline structures inside the giant cells, which prompted us to evaluate the patient for sarcoidosis. This case report highlights the cytological features that can be useful in clinching the diagnosis of sarcoidosis in conjunction with clinicoradiological and laboratory findings in a clinically unusual case

Case of postural complex sleep apnea: effect of gravitational forces

We report a case of an elderly male with predominant obstructive sleep apnea and who developed or complex sleep apnea (CxSA) at the start of continuous positive airway pressure (CPAP) titration. This CxSA was more prominent in supine position, and he was not settling with either CPAP/bilevel positive airway pressure (PAP) in supine position. He finally settled with CPAP along with position therapy. This case highlights the importance of treating CxSA with basic PAP modes like CPAP along with positional therapy before switching to costlier therapies such as adaptive servo-ventilation