Dilemma in the diagnosis of mediastinal adenopathy in the South Asian population-role of CT guided biopsy, mediastinoscopy and video-assisted thoracoscopy (VATS)

The diagnosis of mediastinal adenopathy is a dilemma amongst treating physicians especially in South Asia. This is because although tuberculosis is endemic in this region, many a times lymphoma and sarcoidosis cannot be excluded. Often patients are being treated with medications without a confirmed diagnosis. The Video-assisted thoracoscopy (VATS) has revolutionized the way mediastinal adenopathy is diagnosed and managed in this part of the world

Ruptured hydatid cyst presenting as pneumothorax.

Patients with echinococcus infection are mostly asymptomatic. The documented rates of simple pneumothorax in Patients with pulmonary hydatidosis ranged from 2.4% - 6.2%. We report a case of a forty-year-old male Patient who was referred to our hospital for management of recurrent pneumothorax. A video assisted thoracoscope (VATS) was first introduced which showed a large amount of pus in the pleural cavity and a perforated hydatid cyst. The VATS was converted to an open thoracotomy and decortication was done with removal of the ruptured hydatid. The Patient made an unremarkable recovery and was discharged after one week with empyema tubes. The empyema tubes were gradually removed over a period of six weeks. An extraordinary number of management options for pulmonary hydatid disease have been offered. This case report highlights surgical treatment as the management opti

How VATS has changed the management of spontaneous pneumothorax in the 21st century

Objective: To determine the outcome of patients having undergone Video Assisted Thoracoscopic Surgery (VATS) for spontaneous pneumothrox in terms of hospital stay, complications and recurrence. Methods: The netrospective study included the review of 39 cases who had presented with spontaneous pneumothorax at the Aga Khan University Hospital, Karachi, Pakistan, between January 2001 to November 2008 and had undergone video assisted thoracoscopic surgery (VATS). Results: The duration of hospital stay (had a range of 3 to 9 days), and the length of chest tube in place (a range of 2 to 8 days), 2 (5.1%) patients developed recurrence after VATS while 3 (7.6%) patients developed bleeding post operatively requiring transfusion and 2 (5.1%) patients developed atelectasis requiring bronchoscopy. Conclusion: Compared with figures for thoracotomy data from other studies, it was seen that the length of hospital stay and chest tube placement with VATS was less than that for thoracotomy, and the overall cost as well as post-operative pain was also low. The rate of recurrence was however comparable to that after thoracotomy

On pump coronary surgical revascularization in a patient with chronic immune thrombocytopenic purpura

We performed on-pump coronary artery bypass graft surgery on a 54-year-old female, known case of chronic Idiopathic Thrombocytopenic Purpura (ITP), hypertension and dyslipidaemia who had presented to us with progressive exertional shortness of breath and chest pain. The decision of going on with CABG was made after two weeks of preoperative treatment with prednisolone. Her platelet counts pre-operatively and on the 4th post-operative day were 135 x 10(9)/L and 32 x 10(9)/L. She had an unremarkable post-operative recovery, without requiring whole blood or platelet transfusions. We recommend preoperative steroid treatment in patients with chronic ITP undergoing CABG

Asymptomatic presentation of giant bulla of the left apical and anterior segment of the left upper lobe of the lung with near complete atelectasis of the remaining left lung

Giant bullae may be found in association with emphysema. They present as pockets of entrapped air which grow as the surrounding lung retracts away. As they do not take part in gas exchange and merely occupy space, their presence leads to severe impediment of mechanical ventilation in the adjacent lung parenchyma. Patients may present with dyspnoea, exercise intolerance and a feeling of pressure in the chest. The case of a 54 year old gentleman is presented, who was found to have a giant bulla occupying his left hemithorax on a routine chest X-ray. The patient remained asymptomatic despite the large size of the bulla and was treated with surgical resection via thoracotomy i.e. Bullectomy which is the treatment of choice. If left untreated the condition can be complicated by pneumothorax, infection and a slow progression to malignant changes

Subclavian steal syndrome secondary to subclavian artery thrombosis in a patient with homocysteinemia and its successful treatment

Subclavian steal syndrome (SSS) is a rare condition. It results from subclavian artery (SA) stenosis proximal to the origin of the vertebral artery. It is characterized by cerebral ischaemia with associated symptoms of vertebrobasilar hypoperfusion and/or symptoms of brainstem or arm ischaemia. We describe a case of a 35 year old male who presented with persistent vertigo for two months, blue discoloration and pain in the left fingers for two weeks. A diagnosis of SSS was made and patient was treated with a gortex graft from the arch of the aorta to the second portion of the left subclavian artery. Treatment is aimed at restoring permanent antegrade blood flow to the affected vertebral artery. This abolishes vertebral basilar symptoms and other manifestations of SSS. Several modalities exist, however surgical correction is the treatment of choice

Congenital diaphragmatic hernia presenting in the sixth decade mimicking pneumonia

Congenital diaphragmatic hernia presentation in adults is extremely rare. Patients who present with late diaphragmatic hernias complain of a wide variety of symptoms and diagnosis can be difficult. We report a case of a 64 year old male who presented with a six month history of cough, shortness of breath and weight loss. The most common strategy to treat a Bochdalek hernia is via a thoracotomy or laparotomy or both. In our patient the repair was performed with a thoracotomy

Mediastinal seminoma presenting as superior vena cava syndrome and tracheal obstruction

Malignant germ cell tumours of the mediastinum are rare, presenting mostly in young males. These are bulky tumours, mostly intrathoracic, infiltrating into adjacent structures early in the growth process. Patients may present with symptoms of compression. Occasionally, mediastinal adenopathy and superior vena cava (SVC) syndrome may occur. We discuss a case of a 19 year old boy with six weeks history of progressively worsening shortness of breath and mid-sternal chest heaviness and one month history of swelling of the face and upper limbs. The entire face and upper extremities were grossly oedematous with engorged veins suggesting SVC syndrome. CT scan chest showed a large mediastinal mass 18 x 24 cm extending from the superior mediastinum to the mid pericardial area. The trachea was extrinsically compressed to almost 80% at its distal portion. Mass was resected completely. Post operative course was unremarkable. The final histopathology showed a fibrotic mass with no viable tumour. Surgery followed by radiation therapy has been the usual initial treatment with multimodal chemotherapy showing remarkable results

Tuberculous pericardial abscess with impending pericardial effusion and cardiac tamponade

The case of a 59 year male with acute tuberculous pericardial abscess who presented with cough, dyspnoea, haemoptysis, signs of Tamponade and a large Pleural Effusion is reported. Performing Pericardiocentesis did not improve his symptoms hence he was subjected to surgery. Acute tuberculous pericardial abscess was the diagnosis made after histopathology which was successfully managed with sternotomy along with drainage of pus

Synovial sarcoma of the lung presenting late with compression of mediastinal structures and its successful resection: A case report.

Synovial sarcoma accounts for 5-14% of all soft tissue tumours. We present a case of 35 year-old male who presented with five months history of progressively increasing shortness of breath and cough. On evaluation, there was no air entry on the left side. CAT scan chest showed a large necrotic mass involving the entire left hemi-thorax. The tru-cut biopsy of this mass was done and it showed synovial sarcoma. The entire tumour along with the lung and the pericardium was removed completely. The Patient had an uneventful recovery and was discharged home in 10 days with follow-up for adjuvant chemotherapy. Due to the rarity of this disease, no guidelines for the treatment are available. Main existing treatment includes surgery followed by either radiation, chemotherapy or both. Synovial sarcoma should be considered in the differentials of an adolescent or adult male Patient presenting with a mass in the thorax