Bleomycin induced pneumonitis: a case successfully managed with high-dose steroids

Bleomycin is a chemotherapeutic agent used in a number of solid organ malignancies.1-3 It accumulates in the skin and lungs resulting in skin ulceration and associated pulmonary toxicity. Its use is somewhat limited due to its significant pulmonary adverse effects with bleomycin induced pnemonitis (BIP) as the commonest and most dreaded complications. The overall incidence of pulmonary toxicity is as high as 10% and it is fatal in 1-2%.3,4 We present a case of BIP which was successfully managed by the aggressive use of high dose steroids with complete resolution

Wegener\u27s granulomatosis: a diagnostic challenge

Wegener\u27s Granulomatosis (WG) is a necrotizing granulomatous vasculitis that primarily involves small vessels in the body. Patient usually presents in the fourth to fifth decade. The clinical presentation is variable; however, majority of patients (90%) seek medical attention for nasal and sinus symptoms with or without lower respiratory symptoms of cough, dyspnoea and haemoptysis. The typical form of WG tends to involve the triad of upper and lower respiratory tract and the kidneys; while involvement of other organs like ocular, cutaneous, rheumatological, neural, gastrointestinal and lower genito-urinary tract is occasionally seen. A limited form with clinical findings isolated to the upper respiratory tract or lungs, occur in approximately one-fourth of cases. We present a case of Wegener\u27s Gmnulomatosis in an eighty five year old lady who presented with an acute pneumonia-like illness. She underwent an extensive work-up to reach a definitive diagnosis

Recent Advances in Decontamination of Chemical Warfare Agents

The recent turmoil and volatile situation in many countries and the increased risk of terrorist activities have raised alarm bells for the field of defense against toxic chemical/materials. These situations poses threats to society as terrorists can take advantage of such situations to strike and cause public mayhem. A number of chemicals have the potential of being used as chemical warfare (CW) agents. CW agents could immediately kill or incapacitate the affected individuals even when they are present in very low concentration. CW agents should be removed quickly to minimize their deleterious health effect. There is no single decontamination system that can be used against all types of chemical warfare (CW) agents. The review briefs about different decontamination processes and approaches for chemical decontamination and also discusses about various decontamination products available globally.Defence Science Journal, 2013, 63(5), pp.487-496, DOI:http://dx.doi.org/10.14429/dsj.63.288

Clinical characteristics, management and outcome of major pulmonary embolism: an experience from a tertiary care center in Pakistan

OBJECTIVE: To evaluate the clinical characteristics, risk factors, management and outcome of major pulmonary embolism (PE) in a tertiary care center of Karachi. METHODS: Medical records of all patients who underwent a spiral CT scan of the chest for suspected pulmonary embolism were reviewed between January 2000 and June 2007 at the Aga Khan University Hospital, Karachi. Patients having evidence of major pulmonary embolism on spiral CT scan were selected. RESULTS: A total of 30 patients (10 males, 20 females) with mean age 52 +/- 14.59 years were identified who fulfilled our predefined criteria for major pulmonary embolism. Risk factors for thromboembolism were identified in 22 (73%) patients, prolonged immobilization in 8 (27%) and recent surgery in 8 (27%) patients being the commonest. All patients were symptomatic on presentation. Tachypnea and tachycardia were present in 27 (90%) patients. Refractory hypoxia was present in 18 (60%) patients and 3 (10%) were hypotensive on presentation. On spiral CT scan, 8 (27%) patients had embolus in the main pulmonary trunk, 26 (87%) patients in main right pulmonary artery and 20 (67%) patients had left main pulmonary artery embolus. Echocardiography was done in 22 (73%) patients with the findings of right ventricular dysfunction in all of them. All patients except one were treated with anticoagulation with either heparin infusion or low molecular weight heparin. In addition, thrombolytics were given in 7 (23%) patients and five (17%) underwent surgical embolectomy. Four (13%) patients died during hospitalization with a total of 26 (87%) surviving till hospital discharge. CONCLUSION: Major pulmonary embolism is an uncommon but potentially life threatening entity. Early diagnosis and aggressive therapy improves the clinical outcome

Chest radiographs in acute pulmonary embolism.

Background: Pulmonary embolism (PE) is a serious clinical entity carrying significant morbidity and mortality. Clinically, it is a difficult condition to diagnose and remains under treated condition in Pakistan due to non-availability of objective tests and lack of awareness among physicians. This study was conducted to determine the chest radiographic presentation in known cases of acute PE presenting to a tertiary care hospital. Methods: Hospital records of patients with a diagnosis of acute PE were reviewed from June 2000 until June 2004. Fifty diagnosed cases of acute PE on Spiral Computed tomography (CT) of the chest demonstrating an intraluminal-filling defect were selected. Two chest physicians reviewed the chest radiographs obtained during that hospitalization. In case of discrepancy, a radiologist made final interpretation. Results: The chest radiograph was interpreted as normal in only 18% of patients with acute PE. The most common chest radiographic abnormalities were cardiac enlargement (38%), pulmonary parenchymal infiltrates (34%), atelectasis (26%), pleural effusion (24%), and pulmonary congestion (24%). Other rare findings were elevated hemi diaphragm (14%), pulmonary artery enlargement (14%), and focal oligemia (8%). Conclusions: Cardiomegaly is the most common chest radiographic abnormality associated with acute pulmonary embolism. Chest radiography is not useful in making the diagnosis of acute pulmonary embolism. Its major role is in identification of alternative disease processes that can mimic thrombo-embolism

Variables predictive of outcome in patients with acute hypercapneic respiratory failure treated with noninvasive ventilation.

Objective: To assess results with NIV in acute hypercapneic respiratory failure and to identify outcome predictors. Methods: This was a retrospective observational study on consecutive patients presenting with acute type II respiratory failure and meeting criteria for NIV use over a 5 year period. Patients presenting with haemodynamic instability, inability to protect their airway, malignant arrhythmias and recent oesophageal surgery were excluded. Univariate and Multivariate regression analysis was used to determine the impact on survival. A p value of \u3c 0.05 was considered statistically significant. Software used was SPSS 14. Results: Total numbers of patients included were 119; 52.9% were males. Mean age was 63.4 ± 11.9 years. Overall Survival to discharge rate was 76.5%, intubation rate was 12.6% and mean length of stay was 11.4 ± 10.9 days. Statistically significant improvements were observed in the pH and PaCO2 at 24 hours and 48 hours compared to baseline (7.28 v/s 7.37, p\u3c0.001; 74.2 v/s 65, p\u3c0.001). On multivariate regression analysis, sepsis at admission predicted mortality (adjusted Odds ratio 26.4; 95% CI 2.3, 304, p \u3c 0.009). A serum HCO3 \u3e 35 Meq/L (adjusted Odds ratio 0.9; 95% CI 0.83, 0.98, p \u3c 0.015) identified those less at risk for intubation. Conclusion: NIV was found to be both safe and effective in the management of acute hypercapneic respiratory failure. Sepsis and serum HCO3 at admission identified patients having poor outcome

A randomized, double-blind, placebo-controlled trial of oral montelukast in acute asthma exacerbation.

Background: Leukotriene receptor antagonists (LTRAs) are well established in the management of outpatient asthma. However, there is very little information as to their role in acute asthma exacerbations. We hypothesized that LTRAs may accelerate lung function recovery when given in an acute exacerbation. Methods: A randomized, double blind, placebo-controlled trial was conducted at the Aga Khan University Hospital to assess the efficacy of oral montelukast on patients of 16 years of age and above who were hospitalized with acute asthma exacerbation. The patients were given either montelukast or placebo along with standard therapy throughout the hospital stay for acute asthma. Improvements in lung function and duration of hospital stay were monitored. Results: 100 patients were randomized; their mean age was 52 years (SD +/− 18.50). The majority were females (79%) and non-smokers (89%). The mean hospital stay was 3.70 ± 1.93 days with 80% of patients discharged in 3 days. There was no significant difference in clinical symptoms, PEF over the course of hospital stay (p = 0.20 at day 2 and p = 0.47 at day 3) and discharge (p = 0.15), FEV1 at discharge (p = 0.29) or length of hospital stay (p = 0.90) between the two groups. No serious adverse effects were noted during the course of the study. Conclusion: Our study suggests that there is no benefit of addition of oral montelukast over conventional treatment in the management of acute asthma attack

Variables predictive of outcome in patients with acute hypercapneic respiratory failure treated with noninvasive ventilatio

OBJECTIVE: To assess results with NIV in acute hypercapneic respiratory failure and to identify outcome predictors. METHODS: This was a retrospective observational study on consecutive patients presenting with acute type II respiratory failure and meeting criteria for NIV use over a 5 year period. Patients presenting with haemodynamic instability, inability to protect their airway, malignant arrhythmias and recent oesophageal surgery were excluded. Univariate and Multivariate regression analysis was used to determine the impact on survival. A p value of \u3c 0.05 was considered statistically significant. Software used was SPSS 14. RESULTS: Total numbers of patients included were 119; 52.9% were males. Mean age was 63.4 +/- 11.9 years. Overall Survival to discharge rate was 76.5%, intubation rate was 12.6% and mean length of stay was 11.4 +/- 10.9 days. Statistically significant improvements were observed in the pH and PaCO2 at 24 hours and 48 hours compared to baseline (7.28 v/s 7.37, p \u3c 0.001; 74.2 v/s 65, p \u3c 0.001). On multivariate regression analysis, sepsis at admission predicted mortality (adjusted Odds ratio 26.4; 95% CI 2.3, 304, p \u3c 0.009). A serum HCO3 \u3e 35 Meq/L (adjusted Odds ratio 0.9; 95% CI 0.83, 0.98, p \u3c 0.015) identified those less at risk for intubation. CONCLUSION: NIV was found to be both safe and effective in the management of acute hypercapneic respiratory failure. Sepsis and serum HCO3 at admission identified patients having poor outcomes

Tracheal stenosis mimicking severe acute asthma.

Post-intubation tracheal stenosis is a rare but serious clinical entity that rarely develops when intubation is less than a week. These patients may remain asymptomatic for a variable period and are often misdiagnosed as asthmatic. The authors report a case of a middle-aged lady who was initially misdiagnosed as having acute asthma after brief tracheal intubation