"Mushroom cloud": a giant left ventricular pseudoaneurysm after a myocardial infarction due to myocardial bridging – a case report

Left ventricular pseudoaneurysm is an uncommon complication after transmural myocardial infarction, occurring when a free wall rupture is contained by adhesions of the overlying pericardium preventing acute tamponade. In this report, an unusual case of a 61 year-old male with a giant apical left ventricular pseudoaneurysm after an unnoticed myocardial infarction is presented. On coronary angiogram myocardial bridging of the distal left anterior descending artery was judged to be the infarct related lesion. The echocardiographic diagnosis allowed for a timely surgical intervention which resulted in the patient's full recovery

Paradoxical tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) in HIV patients with culture confirmed pulmonary tuberculosis in India and the potential role of IL-6 in prediction

Background: The incidence, manifestations, outcome and clinical predictors of paradoxical TB-IRIS in patients with HIV and culture confirmed pulmonary tuberculosis (PTB) in India have not been studied prospectively. Methods: HIV+ patients with culture confirmed PTB started on anti-tuberculosis therapy (ATT) were followed prospectively after anti-retroviral therapy (ART) initiation. Established criteria for IRIS diagnosis were used including decline in plasma HIV RNA at IRIS event. Pre-ART plasma levels of interleukin (IL)-6 and C-reactive protein (CRP) were measured. Univariate and multivariate logistic regression models were used to evaluate associations between baseline variables and IRIS. Results: Of 57 patients enrolled, 48 had complete follow up data. Median ATT-ART interval was 28 days (interquartile range, IQR 14–47). IRIS events occurred in 26 patients (54.2%) at a median of 11 days (IQR: 7–16) after ART initiation. Corticosteroids were required for treatment of most IRIS events that resolved within a median of 13 days (IQR: 9–23). Two patients died due to CNS TB-IRIS. Lower CD4+ T-cell counts, higher plasma HIV RNA levels, lower CD4/CD8 ratio, lower hemoglobin, shorter ATT to ART interval, extra-pulmonary or miliary TB and higher plasma IL-6 and CRP levels at baseline were associated with paradoxical TB-IRIS in the univariate analysis. Shorter ATT to ART interval, lower hemoglobin and higher IL-6 and CRP levels remained significant in the multivariate analysis. Conclusion: Paradoxical TB–IRIS frequently complicates HIV-TB therapy in India. IL-6 and CRP may assist in predicting IRIS events and serve as potential targets for immune interventions

Predictors of unfavorable responses to therapy in rifampicin-sensitive pulmonary tuberculosis using an integrated approach of radiological presentation and sputum mycobacterial burden

INTRODUCTION: Despite the exalted status of sputum mycobacterial load for gauging pulmonary tuberculosis treatment and progress, Chest X-rays supplement valuable information for taking instantaneous therapeutic decisions, especially during the COVID-19 pandemic. Even though literature on individual parameters is overwhelming, few studies have explored the interaction between radiographic parameters denoting severity with mycobacterial burden signifying infectivity. By using a sophisticated approach of integrating Chest X-ray parameters with sputum mycobacterial characteristics, evaluated at all the three crucial time points of TB treatment namely pre-treatment, end of intensive phase and completion of treatment, utilizing the interactive Cox Proportional Hazards model, we aimed to precisely deduce predictors of unfavorable response to TB treatment. MATERIALS AND METHOD: We extracted de-identified data from well characterized clinical trial cohorts that recruited rifampicin-sensitive Pulmonary TB patients without any comorbidities, taking their first spell of anti-tuberculosis therapy under supervision and meticulous follow up for 24 months post treatment completion, to accurately predict TB outcomes. Radiographic data independently obtained, interpreted by two experienced pulmonologists was collated with demographic details and, sputum smear and culture grades of participants by an independent statistician and analyzed using the Cox Proportional Hazards model, to not only adjust for confounding factors including treatment effect, but also explore the interaction between radiological and bacteriological parameters for better therapeutic application. RESULTS: Of 667 TB patients with data available, cavitation, extent of involvement, lower zone involvement, smear and culture grade at baseline were significant parameters predisposing to an unfavorable TB treatment outcome in the univariate analysis. Reduction in radiological lesions in Chest X-ray by at least 50% at 2 months and 75% at the end of treatment helped in averting unfavorable responses. Smear and Culture conversion at the end of 2 months was highly significant as a predictor (p2 zones, were 3.05 (95% CI: 1.12–8.23) and 1.92 (95% CI: 0.72–5.08) respectively. Patients without cavitation, zonal involvement 2 zones and 3+ smear grade individually and independently forecasted a poorer TB outcome. The interaction model revealed that Zonal involvement confined to 2 zones, without a cavity and smear grade up to 2+, constituting “minimal disease”, had a better prognosis. Radiological clearance >50% along with smear conversion at the end of intensive phase of treatment, observed to be a reasonable alternative to culture conversion in predicting a successful outcome. These parameters may potentially take up key positions as stratification factors for future trials contemplating on shorter TB regimens

Extensive dermatophytosis caused by Microsporum gypseum in an AIDS patient in Madras

[no abstract available

A Rare Case of Dapsone Induced Eosinophilic Pneumonia without Peripheral Eosinophilia

Eosinophilic lung diseases are a diverse group of pulmonary disorders which may result from different etiologies, including drug treatment. Dapsone, a sulfone drug useful for treating wide variety of infectious and inflammatory dermatological conditions including leprosy, has been described as a possible cause of eosinophilic lung diseases. We report a 40 year old female patient with leprosy who presented with respiratory symptoms and pulmonary infiltrates and was diagnosed as suffering from eosinophilic pneumonia which was managed successfully

Early Onset Chyliform Pleural Effusion-A Rare Case

Chyliform pleural effusion is turbid or milky from high lipid content without cholesterol crystals. Chyliform pleural effusion is a rare presentation than chylous or pseudochylous pleural effusion. The mean duration of the effusion to turn chyliform is 5 years. A 20 year old male presented with dry cough, left side chest pain and dyspnea on exertion and gives history of bilateral pleural effusion for which he had taken empirical antituberculous treatment. Chest radiograph showed bilateral pleural effusion more on left side. Thoracentesis done on left side revealed milky white coloured fluid with elevated cholesterol levels and Mycobacterium tuberculosis was detected and was not resistant to Rifampicin in cartridge based nucleic acid amplification test[CBNAAT] for pleural fluid. Contrast enhanced CT chest showed healed fibrotic lesion in bilateral upper lobe with bilateral pleural effusion with thickened pleura on left side. Patient diagnosed as chyliform effusion and treated with Intercostal drainage and antituberculous treatment. Less than 200 cases of chyliform have been reported in the medical literature of which microbiologically confirmed tuberculous chyliform effusion is rarely reported. Chyliform effusion rarely develops within one year and Tuberculosis presenting as Chyliform pleural effusion is a rare phenomenon

A case report of extramedullary plasmacytoma - Presenting as a chest wall tumour

Plasmacytoma refers to a malignant plasma cell tumor growing within soft tissue or within the axial skeleton. Plasmacytoma accounts for six percent of all primary chest wall tumours. A solitary extramedullary plasmacytoma is reported three percent of plasma cell disorders. A 65 year male patient presented with complaint of swelling in the back of right side of the chest noticed for one month, pain over the swelling and dry cough for two weeks. Physical examination revealed a diffuse, lobulated swelling in the back of right side of chest which is firm to hard in consistency. The chest radiograph showed a large extra-pulmonary opacity with well-defined medial margin and lateral margin merging with chest wall on right side and blunting of the right costophrenic angle. The histopathological examination of tru-cut biopsy section showed fragments of fibrocartilagenous stroma infiltrated by mononuclear cells with round to oval nucleus and eosinophilic cytoplasm and some foci showed plasmocytoid features with the intervening stroma shows proliferating capillaries thereby features suggestive of plasmacytoma. The specimen is positive for CD 138 by the immunohistochemistry analysis which is the hallmark for diagnosing plasmacytoma