UAPM Journal of Respiratory Diseases and Allied Sciences
UAPM Journal of Respiratory Diseases and Allied Sciences is the official publication of the United Academy of Pulmonary Medicine (UAPM). This journal is published twice a year in both print and online formats in the English language since 2024 and features cutting-edge clinical information in the multidisciplinary specialty of Respiratory Medicine. The journal also features studies and scientific information related to basic sciences, and allied systems of pulmonary Medicine. The main aim of the journal is to disseminate scientific information related to respiratory diseases for the better well-being of mankind. This print journal publishes editorials, original articles, review articles, meta-analyses, case reports, etc., apart from radiology imaging, clinical images, brief communications, letters to the editors, book reviews, and other information related to the respiratory system. The manuscripts are accepted on the basis of significance, scientific merit, and applicability. Authors are requested to base their reports on the basis of original work carried out by themselves or with their colleagues. Title: UAPM Journal of Respiratory Diseases and Allied Sciences Frequency: Twice a year E-ISSN: 3107-4189 Owner: United Academy of Pulmonary Medicine Publisher: United Academy of Pulmonary Medicine Chief Editor: Dr Ramakant Dixit Copyright: United Academy of Pulmonary Medicine Starting year: 2024 Subject: Respiratory Medicine and allied subjects Language: English Publication format: Print + online Phone Number: 0145-2692257 Email ID: editor_uapmjournal@yahoo.com Mobile Number: 9413040257 Website: https://uapmjournal.in/index.php/uapmjrdas/index Address: C/O Daulat Ram Dixit 60-A Block O, Chandravardai Nagar Ajmer, 305001, Rajsthan.
United Academy of Pulmonary Medicine (UAPM)
Critical Care Medicine: The Journey Back to the Bedside
Critical care medicine is a relatively new specialty that has been growing over the past seven decades. The specialty has come a long way from the bag-ventilation of polio patients to the modern intensive care units. Over the years, with more understanding of physiology, critical care now means intervening less while monitoring the patient more closely. The article touches upon the evolution of the specialty and the Indian context; and the opportunities artificial intelligence may bring in the coming decades.
Critical care, History of medicine, Current updates in intensive care.
Assessment of Respiratory Function and Exercise Capacity Among Persons Having Occupational Exposure to Silica Dust
Background: Silica inhalation at the workplace remains a major public health concern, particularly in developing countries where large numbers of workers are engaged in mining, stone crushing, stone cutting, and drilling activities. Prolonged inhalation of silica dust can result in progressive pulmonary fibrosis, leading to deterioration in lung function and a decline in exercise capacity. While radiological assessment plays an important role in disease evaluation, measurements of pulmonary function and functional exercise capacity provide additional insight into the physiological impact and severity of silica-related lung disease. Methods: Workers exposed to silica dust were selected as study subjects over the time period of two years. Clinical history and examination in detail, along with chest radiography, spirometry, and six-minute walk test (6MWT), etc were done and results were correlated with chest x-ray findings. Results: The mean age of participants was 47.19 ± 11.18 years, and 78.08% were male. The mean duration of silica exposure was 14.64 ± 6.76 years, with 68.49% exposed for more than 10 years. Dyspnoea (98.63%) and cough (93.15%) were the predominant symptoms. Mean pre-bronchodilator FEV₁ and FVC were 46.32 ± 17.35% and 52.15 ± 16.54%, respectively, indicating severe ventilatory impairment. The mean six-minute walk distance was 263.41 ± 94.88 meters, with significant exercise-induced oxygen desaturation from 95.11 ± 1.66% to 92.34 ± 2.61%. Chest radiographic severity showed significant correlations with spirometric impairment (p <0.001), and reduced exercise capacity (p <0.001). Conclusion: Workers exposed to silica dust demonstrate significant impairment of respiratory function and exercise capacity. Pulmonary function testing and six-minute walk testing are valuable tools for assessing disease burden and should be incorporated into routine occupational health surveillance programs.
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Losing the Voice to the Lungs: Ortner’s Syndrome in Pulmonary Vascular Disease
Ortner’s syndrome, also known as cardiovocal syndrome, is a rare clinical condition marked by left recurrent laryngeal nerve palsy. It is most commonly caused by mechanical compression or traction of the nerve between the aortic arch and the pulmonary artery, typically triggered by underlying cardiovascular diseases like aortic aneurysms or mitral stenosis. In 1897, Norbert Ortner elucidated the association between left recurrent laryngeal nerve palsy and severe mitral valve stenosis, which leads to hoarseness of voice. Although it was originally described in association with severe mitral stenosis, the syndrome may arise from several other causes. These include compression of the nerve by vascular conditions such as aortic aneurysm, aortic dissection, and pulmonary hypertension. We present a case of Ortner’s syndrome in a 41-year-old man, characterized by dysphonia from left recurrent laryngeal nerve compression, secondary to severe pulmonary arterial hypertension and embolic pulmonary occlusion. This case emphasizes the need to carefully consider cardiac causes in patients with vocal cord dysfunction and supports the use of a comprehensive, team-based approach to diagnosis and treatment.
Ortner’s syndrome, Dysphonia, Pulmonary hypertension, Cardio-vocal syndrome.
Clinical Efficacy of Bedaquiline-Containing Short-Course Regimens in Multi-Drug-Resistant Tuberculosis: Experience from Central Rajasthan
Background: Multidrug-resistant tuberculosis (MDR-TB) continues to pose a critical threat to global public health, with India bearing nearly one-fourth of the world’s total burden. The emergence of bedaquiline-containing regimens has significantly improved treatment outcomes in MDR-TB due to enhanced bactericidal activity and shorter treatment duration. Objectives: To evaluate the efficacy and treatment outcomes of a bedaquiline-containing short-course regimen in multidrug-resistant tuberculosis (MDR-TB) patients at a tertiary care center in Central Rajasthan. Methods: This observational study was conducted among 100 MDR-TB patients registered at our center. Patients underwent detailed pre-treatment clinical, radiological, biochemical, and microbiological evaluation. Demographic details, co-morbidities, socioeconomic status, addiction history, and previous anti-tuberculosis treatment (ATT) exposure were recorded. We initiated patients on a short-course bedaquiline regimen and followed them according to the Programmatic Management of Drug-Resistant Tuberculosis (PMDT) guidelines. Treatment outcomes were categorized as cured, treatment completed, treatment failure, loss to follow-up, regimen change, or death. Sputum conversion, clinical improvement, radiological response, and adverse drug reactions were also assessed. Results: Most patients (64%) were aged 21 to 50, the economically productive years, with a mean age of 34.97 ± 12.46 years. Males constituted 71% of the study population. Most patients were underweight (70%), and pulmonary tuberculosis was present in 92% of cases. Previous history of ATT was observed in 42% of patients. Smear conversion was achieved in 71% of patients, while radiological regression was noted in 62%. Complete clinical improvement occurred in 53% of cases. Final treatment analysis indicated a cure rate of 67%, with 11% died, 10% were lost to follow-up, 8% required regimen modification, and 4% experienced treatment failure. Adverse drug reactions were observed in 37% of patients, most commonly gastrointestinal symptoms and dermatological manifestations. Conclusion: The bedaquiline-containing short course regimen demonstrated favorable treatment outcomes with acceptable safety among MDR-TB patients. Shorter treatment duration, improved cure rates, and manageable adverse effects support the wider implementation of bedaquiline-based regimens in the programmatic management of MDR-TB in India.
Multidrug-resistant tuberculosis, MDR-TB, bedaquiline, short course regimen, treatment outcome, drug-resistant tuberculosis.
The Air We Exhale: Deciphering the Role of Fractional Exhaled Nitric Oxide (FeNO) in Airway Diseases
Fractional exhaled nitric oxide (FeNO) is an important indicator of type 2 inflammation, which is frequently utilized in the assessment and treatment of asthma. It is measured in exhaled breath and provides a simple, quick, and reproducible assessment of airway inflammation status. Elevated FeNO levels are strongly associated with eosinophilic airway inflammation. It represents the synthesis of nitric oxide in the airway epithelium, which is mainly caused by inducible nitric oxide synthase under the influence of cytokines like IL-4 and IL-13. FeNO is utilized in the assessment of symptoms in patients presenting with cough, wheezing, and dyspnoea. It plays a key role in phenotyping asthma, particularly in identifying the eosinophilic asthma phenotype, which is typically T2 high and steroid responsive. FeNO measurement is also valuable in predicting medication response, as it evaluates the possible reaction to anti-inflammatory drugs, mainly inhaled corticosteroids (ICS). Furthermore, it helps in guiding treatment changes in a step-wise manner, including stepping up or stepping down the ICS dose. FeNO is useful in assessing asthma control, especially in determining whether poor control is due to airway inflammation when other contributing factors such as rhinosinusitis, anxiety, gastroesophageal reflux, obesity, and ongoing allergen exposure are present. Additionally, variations in FeNO levels may serve as a helpful supplementary tool for identifying acute complications following lung transplantation. Emerging evidence in fractional exhaled nitric oxide (FeNO) has expanded its potential role beyond asthma, demonstrating its utility in evaluating conditions such as obstructive sleep apnoea, rhinoviral infection, and radiation pneumonitis. However, values may be impacted by things like smoking, illnesses, respiratory maneuvers, airway caliber and food. Standardized testing guarantees reliability. For the best possible care, FeNO should be read in conjunction with clinical results and other studies.
FeNO, Type 2 airway inflammation, Asthma.
Shadows of Doubt: When Lung Adenocarcinoma Mimics Interstitial Lung Disease
Lung adenocarcinoma commonly presents as a peripheral pulmonary mass; however, atypical presentations mimicking interstitial lung disease (ILD) are rare and diagnostically challenging. We report a case of a 67-year-old female presenting with subacute respiratory symptoms and diffuse interstitial changes on imaging, initially suggestive of ILD. Bronchoscopic evaluation was inconclusive, but transbronchial lung biopsy confirmed adenocarcinoma. This case highlights the importance of considering malignancy in atypical ILD presentations and underscores the role of early tissue diagnosis in selected cases.
Adenocarcinoma lung, Interstitial lung disease, Transbronchial lung biopsy.
A Case Report and Literature Review of Achalasia Cardia Presenting as Difficult-to-Treat Asthma
Background: Achalasia cardia is a rare neurodegenerative disorder characterized by impaired esophageal peristalsis and failure of the lower esophageal sphincter to relax. Patients often present with dysphagia, regurgitation, or chest pain. However, atypical presentations can mimic respiratory disorders, particularly asthma, leading to diagnostic delay and inappropriate treatment. Case Presentation: We report the case of a 67-year-old male, non-smoker, who presented with recurrent exacerbations of bronchial asthma. Despite being on optimal bronchodilator therapy with both inhaled and oral corticosteroids for an adequate duration, he showed no clinical improvement. On further evaluation, barium contrast studies revealed features suggestive of achalasia cardia. Surgical intervention was advised; however, the patient deferred and was kept on follow-up. Conclusion: This case highlights achalasia cardia as an uncommon but important differential diagnosis in patients with difficult-to-treat or refractory asthma. Early consideration of esophageal motility disorders in such scenarios may prevent misdiagnosis, unnecessary prolonged asthma treatment, and allow timely targeted therapy.
Achalasia cardia, Bronchial Asthma, esophageal motility disorder
Pulmonary Sequelae of Moderate to Severe Atypical Pneumonia Caused by SARS - COV-2 Virus
Background: Survivors of moderate to severe COVID-19 pneumonia frequently exhibit persistent pulmonary abnormalities, but the longitudinal radiological and biochemical evolution remains unclear. Methods: This observational study included 50 patients with moderate to severe COVID-19 pneumonia. Clinical symptoms, inflammatory markers, and serial chest CT scans were evaluated from day 1 to 180. CT patterns and severity scores were analyzed to assess temporal changes and post-COVID pulmonary sequelae. Results: The mean age was 52.4 ± 13.4 years, with male predominance (62%). Acute symptoms resolved within 30 days; however, breathlessness and fatigue persisted in 74% and 40% of patients at 6 months. CT imaging showed progressive resolution of ground-glass opacities and consolidation, while fibrotic-like changes, particularly parenchymal bands, reticulations, and traction bronchiectasis, increased over time, despite a significant decline in CT severity score (16.24–4.84). Inflammatory biomarkers normalized earlier than radiological findings, indicating persistent structural remodeling. Conclusion: Moderate to severe COVID-19 pneumonia is associated with lasting fibrotic-like lung sequelae, highlighting the need for structured long-term follow-up.
COVID-19 pneumonia; post-COVID lung sequelae; chest CT; pulmonary fibrosis; parenchymal bands; traction bronchiectasis
Primary Tuberculous Parotitis with Facial Nerve Palsy: A Rare Presentation
Parotid tuberculosis is a rare and often overlooked cause of chronic parotid swelling, particularly when accompanied by atypical features such as facial nerve palsy. Given its clinical and radiological resemblance to neoplasms, this case underscores the necessity of ruling out tuberculous parotitis when evaluating chronic parotid swellings in tuberculosis-endemic areas. Early use of FNAC combined with molecular diagnostic techniques such as Truenat or GeneXpert allows for timely and accurate confirmation, enabling prompt initiation of antitubercular therapy. Timely treatment not only prevents unwarranted parotidectomy but also improves the likelihood of recovery from associated facial nerve dysfunction. Ultimately, heightened clinical awareness and early diagnostic evaluation are crucial for optimizing outcomes in this rare condition.
Tuberculous parotitis; Facial nerve palsy; Granulomatous
Narcolepsy in a Young Adult Initially Misdiagnosed as Depression: A Case Report
Narcolepsy is a chronic neurological sleep disorder characterized by excessive daytime sleepiness (EDS) and rapid eye movement (REM) sleep related phenomena such as cataplexy, hallucinations, and sleep fragmentation. Owing to significant overlap with psychiatric symptoms, particularly depression, narcolepsy is frequently misdiagnosed, resulting in delayed treatment and impaired functional outcomes. We report the case of a young adult male who presented with an 18-month history of severe daytime sleepiness, declining academic performance, and reduced motivation. He was initially diagnosed with major depressive disorder and treated with fluoxetine for six months without clinical improvement. Detailed sleep history later revealed episodes of cataplexy and hypnagogic hallucinations. Overnight polysomnography excluded obstructive sleep apnoea, and Multiple Sleep Latency Test (MSLT) demonstrated a mean sleep latency of four minutes with three sleep-onset REM periods, fulfilling ICSD-3 diagnostic criteria for narcolepsy type 1. The patient was started on modafinil therapy, resulting in marked improvement in alertness and academic performance within two weeks. This case highlights the importance of maintaining a high index of suspicion for narcolepsy in young patients with persistent fatigue unresponsive to antidepressants. Early recognition and appropriate sleep evaluation are essential to prevent prolonged misdiagnosis and ensure timely management.
A Study of Functional Changes of the Right Heart in Patients of COPD Acute Exacerbation with Respiratory Failure
Background: Chronic obstructive pulmonary disease (COPD) is a common and treatable disease characterized by progressive airflow limitation and tissue destruction. COPD has considerable effects on cardiac functions, primarily by affecting the pulmonary vasculature and then the right ventricle, along with the left ventricle. During acute exacerbations, hypoxemia and hypercapnia may contribute to pulmonary hypertension and right ventricular (RV) dysfunction, which adversely affect prognosis. Methods: A prospective observational study was conducted on 61 patients admitted with acute COPD exacerbations to the respiratory intensive care unit (ICU) over a period of 6 months at a tertiary care hospital. After applying exclusion criteria, 56 patients were included. All underwent arterial blood gas (ABG) analysis, spirometry, and transthoracic echocardiography to assess RV systolic pressure (RVSP), pulmonary artery systolic pressure (PASP), right atrial size, RV ejection fraction (EF), fractional area change (FAC), and tricuspid annular plane systolic excursion (TAPSE). Clinical status was assessed with the modified Medical Research Council (mMRC) scale, COPD assessment test (CAT), BODE index, and GOLD ABCD tool. Results: Severe COPD patients exhibited higher PaCO₂ (72.6 ± 5.3 vs. 55.2 ± 3.5 mmHg), lower PaO₂ (56.5 ± 2.96 vs. 64.2 ± 4.6 mmHg), increased right atrial area (33.3 ± 6.5 vs. 21.5 ± 5.2 cm²), and elevated PASP (45.3 ± 3.5 vs.30.2 ± 2.3 mmHg) compared to moderate COPD. TAPSE was reduced, indicating RV dysfunction, and correlated positively with PaO₂ and negatively with PaCO₂. Conclusion: COPD exacerbations were strongly associated with pulmonary hypertension and RV dysfunction. Echocardiographic evaluation of pulmonary pressures and right heart parameters provides essential prognostic information and should be integrated into COPD management.
The Heterogeneity of COPD: A Comprehensive Review of Clinical Phenotypes
<a href="https://uapmjournal.in/index.php/uapmjrdas/Current understanding of the epidemiology and pathogenesis of chronic obstructive pulmonary disease (COPD) is limited by difficulties in defining and classifying the different phenotypes that make up this complex group of disorders. COPD is a multi-factorial and heterogeneous disease and not every patient responds to all available drugs. In order to approach this heterogeneity, an attempt to group patients with similar characteristics that could be associated to a differential clinical outcome has been done by using the term clinical phenotype. Such in-depth phenotyping can pave the way for personalized treatment regimens, ensuring that the most suitable therapies are provided. A phenotype can be broadly defined as ‘any observable characteristic of an organism,’ while a COPD phenotype can be more specifically defined as ‘a single or combination of disease attributes that describe differences between individuals with COPD as they relate to meaningful outcomes (symptoms, exacerbations, response to therapy, rate of disease progression, or death).’ Identifying such phenotypes (also described as phenotypic traits) allows grouping of patients according to their prognostic and therapeutic characteristics. Early classification of the COPD subtype will facilitate superior healthcare provision and early intervention where it is most required. The various phenotypes and associations of COPD that has been recognised in recent literature includes Emphysema phenotype, Chronic Bronchitis, Asthma-COPD overlap phenotype, Frequent Exacerbator phenotype, COPD with Bronchiectasis, Combined pulmonary fibrosis with Emphysema, COPD with Obstructive sleep Apnoea, Tuberculosis associated COPD, Respiratory Bronchiolitis with interstitial disease, HIV associated COPD, Obese COPD, nonsmoker phenotype, etc. In the recent years, clinicians also proved that the heterogeneity of COPD is associated with different clinical outcomes including symptoms, exacerbations, and responses to recommended therapy, decline of lung function and death etc.">Current understanding of the epidemiology and pathogenesis of chronic obstructive pulmonary disease (COPD) is limited by difficulties in defining and classifying the different phenotypes that make up this complex group of disorders. COPD is a multi-factorial and heterogeneous disease and not every patient responds to all available drugs. In order to approach this heterogeneity, an attempt to group patients with similar characteristics that could be associated to a differential clinical outcome has been done by using the term clinical phenotype. Such in-depth phenotyping can pave the way for personalized treatment regimens, ensuring that the most suitable therapies are providChronic obstructive pulmonary disease (COPD) is a complex and heterogeneous condition whose epidemiology and pathophysiology remain incompletely characterized, partly due to challenges in accurately defining and classifying its diverse subtypes. COPD arises from multiple interacting factors, and affected individuals show marked variability in clinical manifestations, disease progression, and response to available therapies, making a uniform treatment approach ineffective. To address this variability, the concept of clinical phenotyping has emerged, aiming to categorize patients into subgroups with shared characteristics that are associated with distinct clinical outcomes. Phenotyping provides a framework for understanding disease heterogeneity and supports the implementation of personalized therapeutic strategies. Broadly, a phenotype refers to any observable characteristic of an organism. In COPD, a clinical phenotype is defined as a single feature or a combination of disease-related attributes that differentiate patients in terms of clinically relevant outcomes such as symptom burden, exacerbation frequency, response to treatment, rate of lung function decline, and mortality. Identification of these phenotypic traits enables prognostic stratification and guides targeted management. Early recognition of COPD subtypes may facilitate timely intervention and improved healthcare delivery. Recent literature has identified several clinically relevant phenotypes, including emphysema-predominant COPD, chronic bronchitis, asthma–COPD overlap, frequent exacerbator phenotype, COPD with bronchiectasis, combined pulmonary fibrosis and emphysema, COPD with obstructive sleep apnoea, tuberculosis-associated COPD, respiratory bronchiolitis with interstitial lung disease, HIV-associated COPD, obesity-related COPD, and COPD in non-smokers etc. Emerging evidence indicates that such phenotypic diversity significantly influences symptoms, exacerbation risk, therapeutic response, lung function decline, and survival.ed. A phenotype can be broadly defined as ‘any observable characteristic of an organism,’ while a COPD phenotype can be more specifically defined as ‘a single or combination of disease attributes that describe differences between individuals with COPD as they relate to meaningful outcomes (symptoms, exacerbations, response to therapy, rate of disease progression, or death).’ Identifying such phenotypes (also described as phenotypic traits) allows grouping of patients according to their prognostic and therapeutic characteristics. Early classification of the COPD subtype will facilitate superior healthcare provision and early intervention where it is most required. The various phenotypes and associations of COPD that has been recognised in recent literature includes Emphysema phenotype, Chronic Bronchitis, Asthma-COPD overlap phenotype, Frequent Exacerbator phenotype, COPD with Bronchiectasis, Combined pulmonary fibrosis with Emphysema, COPD with Obstructive sleep Apnoea, Tuberculosis associated COPD, Respiratory Bronchiolitis with interstitial disease, HIV associated COPD, Obese COPD, nonsmoker phenotype, etc. In the recent years, clinicians also proved that the heterogeneity of COPD is associated with different clinical outcomes including symptoms, exacerbations, and responses to recommended therapy, decline of lung function and death etc.
COPD, Clinical phenotypes, Disease heterogeneity.
An Unexpected Twist: Paradoxical Pleural Effusion during Pott’s Spine Management
Paradoxical pleural effusion refers to the appearance or worsening of a pleural effusion during anti-tubercular therapy (ATT), despite initial clinical or radiological improvement. It can manifest as a new or enlarging effusion, often contralateral to the primary disease focus. Paradoxical reactions are well-recognized complications of ATT, most commonly described in lymph node and central nervous system tuberculosis. Paradoxical pleural effusion, particularly in extrapulmonary TB such as spinal disease, is rare and under-reported. We describe the case of a 34-year-old female with thoracic spinal tuberculosis who developed a right-sided pleural effusion three weeks after initiation of ATT, despite a normal baseline chest X-ray. The case emphasizes the importance of recognizing this immune-mediated phenomenon to avoid unnecessary changes in therapy or invasive diagnostic procedures.
Pott spine, Paradoxical response, Anti-tuberculosis therapy.
Bronchoscopy: The Last Hope When Radiology Fails to Illuminate, A Case of Subglottic Stricture
Background: Subglottic stricture is a rare cause of upper airway obstruction in adults and is often misdiagnosed as asthma or chronic obstructive pulmonary disease due to nonspecific symptoms and normal routine imaging. Case Presentation: A 55-year-old female presented with progressive shortness of breath and wheezing for three months. Routine blood investigations, chest radiography, and contrast-enhanced computed tomography of the thorax were unremarkable. Spirometry revealed flattened inspiratory and expiratory limbs on the flow–volume loop, suggestive of fixed airway obstruction, with a reduced FEV₁/FVC ratio and preserved forced vital capacity. Flexible bronchoscopy subsequently demonstrated a subglottic stricture, confirming the diagnosis. Conclusion: This case emphasizes the importance of recognizing spirometric patterns of fixed airway obstruction and the role of bronchoscopy in diagnosing subglottic stricture when routine imaging is normal. Early identification allows appropriate management and improved outcomes.
Excessive Dynamic Airway Collapse: An Unusual Cause of Refractory Cough
Expiratory central airway collapse (ECAC) is characterized by excessive narrowing of the central airways during expiration. Excessive dynamic airway collapse (EDAC), a subtype of ECAC, involves inward bulging of the posterior membranous tracheal wall with preserved cartilaginous rings and its clinical presentation closely mimics asthma and chronic obstructive pulmonary disease. EDAC is frequently underdiagnosed with spirometry and chest imaging and often requires dynamic bronchoscopy, which remains the diagnostic gold standard. We report a 63-year-old non-smoker female with hypothyroidism, treated pulmonary tuberculosis, coronary artery disease status post percutaneous transluminal coronary angioplasty, and obstructive airway disease, who presented with a three-month history of troublesome productive cough, exertional dyspnea (mMRC grade 2). Physical examination revealed bilateral polyphonic wheeze. Spirometry showed a mixed ventilatory defect with moderate obstruction and no reversibility. Despite treatment with bronchodilators and antibiotics, symptoms persisted. High-resolution computed tomography of the chest findings was not helpful in making a sound diagnosis and warranted further evaluation. Cardiac evaluation was normal. Flexible bronchoscopy performed under conscious sedation revealed significant expiratory collapse of the posterior tracheal wall, confirming EDAC. This finding explained the patient’s refractory symptoms and poor response to conventional therapy. Continuous positive airway pressure was initiated as a pneumatic stenting measure, resulting in significant symptomatic improvement. This case shows that dynamic airway disorders should be considered in patients with persistent cough and wheeze, and that bronchoscopy plays a key role in making an early and accurate diagnosis and guiding proper treatment.
Broncho-Pleuro-Cutaneous Fistula at Intercostal Chest Drain Site in a Patient having Silicotuberculosis
Burst or Bluff: A Bulla Masquerading as Tension Pneumothorax in a 2-Year-Old Child
This case highlights the diagnostic challenge of differentiating between a pneumothorax and a congenital pulmonary bulla, particularly in a malnourished paediatric patient presenting with chronic respiratory symptoms. Despite initial management with intercostal drainage under the impression of pneumothorax, the absence of lung expansion prompted further imaging, which confirmed congenital bullous disease. Definitive surgical management with an 80 mm linear stapler resection resulted in marked clinical improvement. Early consideration of bullous lung disease in children with atypical or non-resolving pneumothorax is essential to avoid unnecessary interventions and to ensure timely surgical correction for favourable outcomes.
Giant bullae, Pneumothorax, Linear Stapler Resection
Primary Pulmonary Synovial Sarcoma: A Rare Lung Tumor
Pulmonary synovial sarcoma is an uncommon lung tumour when compared to other lung malignancies. The diagnosis of primary pulmonary sarcoma is usually made after ruling out the common primary lung malignancies and metastatic sarcomas. Metastatic pulmonary synovial sarcoma is more common than primary synovial sarcoma. The usual presentation will be cough, chest pain, breathlessness and radiologically a mass in the lung. Histopathological examination and immunohistochemical staining of the biopsy sample are needed to confirm the diagnosis; if possible genetic study should also be done. Considering the rarity of this tumour, we report a case of a 66-year-old female with a huge right lung mass with ipsilateral pleural effusion, which was diagnosed as primary pulmonary synovial sarcoma by USG-guided lung biopsy.
Treatment Outcomes for Isoniazid-Resistant Pulmonary Tuberculosis Using a Shorter Regimen at a Tertiary Care Centre from the Western Part of India
Background: Drug-resistant tuberculosis has been associated with higher rates of morbidity and mortality. A global total of an estimated 4 lakh people with ‘multidrug resistant/rifampicin resistant’ tuberculosis (MDR/RR-TB) were detected and notified in 2023. In India, 63,929 MDR/ RR TB cases were diagnosed, with 23,019 patients diagnosed with isoniazid (H)-mono/poly drug-resistant tuberculosis (DR-TB). Objective: This study analyses the outcome of ‘Isoniazid Mono Resistance’ Tuberculosis patients and the adverse drug reaction (ADR) among those put on isoniazid (H) mono/poly regimen treatment. Method: ‘Isoniazid-mono-poly’ DR TB regimen duration is 6 to 9 months and started according to drug sensitivity testing (DST) among eligible patients. Follow-ups were done every two months for clinical, bacteriological and radiological parameters. Outcomes observed were cure, treatment completed, treatment failure, died, lost to follow-up, not evaluated, switch to another regimen and transfer out, etc., as per standard protocol. Results: 88 isoniazid-mono/poly patients were enrolled over the last two years. There were 62 male and 26 were females. Outcome for isoniazid mono/poly regimen was cure among 40 (45.5%), treatment completed in 34 (38.6%), lost to follow up in 2 (2.3%), treatment failure in 1 (1.1%), died in 9 (10.2%) and switched to another regimen in 2 (2.3%). The prevalence of katG mutation (High level Isoniazid resistance) was more than inhA (Low level Isoniazid resistance). A more favorable treatment outcome was observed among those with minimal/moderate lung disease compared to those with far advance disease with large cavitation (p = 0.029). This was also in line with better sputum conversion. Conclusion: Treating isoniazid ‘mono-resistant’ TB patients with levofloxacin, rifampicin, ethambutol, and pyrazinamide (LfxREZ) resulted in satisfactory outcomes and low toxicity. Ruling out the isoniazid drug resistance pattern is important for all bacteriologically confirmed TB cases.
Fungal Sensitization in Bronchial Asthma: Epidemiological Insights and Clinical Correlates from an Indian Cohort
Background: Fungal sensitization is increasingly recognized as an important contributor to poor asthma control and disease severity, particularly in patients with severe asthma. Data from Indian populations remains limited, necessitating region-specific epidemiological and clinical insights. Objectives: To determine the prevalence of fungal sensitization in patients with bronchial asthma and to evaluate its association with clinical severity, spirometric parameters, and immunological markers. Methods: This cross-sectional study was conducted in the Department of Respiratory Medicine at a tertiary care center in western India. About 70 diagnosed bronchial asthma patients aged ≥12 years were enrolled. Clinical assessment, spirometry with bronchodilator reversibility testing, skin prick testing for fungal allergens, absolute eosinophil count, and serum IgE levels were performed. Asthma severity scores were correlated with lung function and immunological parameters using appropriate statistical analyses. Results: Fungal sensitization was identified in 11 patients (15.7%). Aspergillus fumigatus was the most common sensitizing fungus (11.43%), followed by Mucor mucedo (5.71%), while no sensitization was observed to several other fungal species. Spirometric indices showed significant improvement post-bronchodilator, confirming reversible airflow obstruction. Fungal sensitization demonstrated a strong positive correlation with asthma severity and an inverse relationship with lung function parameters, particularly FEV₁/FVC. Absolute eosinophil count and serum IgE levels showed significant positive correlations with both fungal sensitization and asthma severity, highlighting an underlying IgE-mediated inflammatory mechanism. Conclusion: Fungal sensitization, especially to A. fumigatus, is present in a significant subset of asthma patients and is associated with increased disease severity and impaired lung function. Early identification of fungal sensitization, along with immunological profiling, may aid in better phenotyping and targeted management of bronchial asthma in the Indian setting.
Psychogenic Cough, Substance Abuse and Intellectual Disability- A Diagnostic Dilemma?
Psychogenic cough, substance abuse, and borderline intellectual functioning are distinct clinical entities that may coexist, complicating diagnosis and management. This case report explores the clinical presentation, diagnostic challenges, and therapeutic approach in an adolescent male exhibiting all three conditions simultaneously, emphasizing the importance of multidisciplinary evaluation.
Asthma in School Children: Assessment of Prevalence And Risk Factors Among Rural and Urban Settings from the Western Part of India
Background: Asthma in children remains a significant global public health challenge, contributing extensively to paediatric hospitalizations, increased healthcare utilization, missed school days, and reduced caregiver productivity, apart from the problem of underdiagnosis and undertreatment of asthma. This study aimed to assess the prevalence of asthma in school children aged 5 to 15 years in urban and rural areas of the western part of India. Methods: The study was conducted to assess the prevalence and associated risk factors of asthma among school-going children aged 5 to 15 years in urban and rural regions. The cross-sectional survey included 6,959 children, with 4,553 from urban schools and 2,416 from rural schools. Data collection was based on a modified version of a standardized and validated questionnaire developed by the Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh. Results: Among urban children, 645 (14.2%) were found to have different allergic disorders, with a higher prevalence among females (15.9%) compared to males (11.3%). The rural population showed a lower overall prevalence of allergic disorders (5.1%), again with female predominance (6.1 vs. 4.2% in males). In urban children, asthma was present in 26% of those with allergies compared to just 0.8% among non-allergic peers. 44.7% of rural children with allergic conditions had asthma, compared to 1.2% among those without allergic conditions. In urban areas, asthma was diagnosed in 8.7% of children with environmental tobacco smoke exposure compared to 5.9% in rural children. 278 (6.1%) urban children reported biomass fuel exposure, with an asthma prevalence of 4.3% (n = 8). 48.7% (n=1177) of rural children were exposed to biomass fuel, with an asthma prevalence of 6.03% in the exposed group. Conclusion: The prevalence of allergic disorders was significantly higher in urban children compared to their rural counterparts. The overall prevalence of asthma was markedly higher among children with allergic conditions. Exposure to environmental tobacco smoke was found to be a significant risk factor for asthma in both urban and rural populations. Biomass smoke exposure was significantly associated with increased asthma prevalence among rural female children.
School children, allergic conditions, environmental tobacco smoke, biomass fuel, prevalence of asthma..
An Assessment of Tracheal Index and Thoracic Cage Ratio in patients with Chronic Obstructive Pulmonary Disease
Introduction: Chronic obstructive pulmonary disease is a heterogeneous lung condition characterized by chronic respiratory symptoms due to abnormalities of the airways and/or alveoli that cause persistent, often progressive, airflow obstruction. Objectives: The present study was undertaken to assess the tracheal index and the thoracic cage ratio in patients with COPD. Methods: Male COPD patients diagnosed in accordance with GOLD guidelines were included; all study subjects had with smoking history of ≥ 20 pack years and age ≥ 40 years. Patients who had any evidence of coexisting lung disease other than COPD were excluded. Patients having comorbid systemic disorders were also excluded. High-resolution CT scans were obtained without using any contrast. Tracheal Index, defined as the ratio of transverse/anteroposterior diameter at a plane 1-cm above the aortic arch, was analyzed. A tracheal index is < 0.67 was considered as Saber-sheath trachea. In the present study, the thoracic cage ratio was evaluated at two planes: carina and 5 cm below the carina. Results: A total of 40 COPD patients completed the study. Their mean age was 59.86 ± 9.46 years. Mean smoking history of 37.67 ± 12.26 pack years. Total duration of illness due to COPD was a mean of 14.58 ± 4.86 years. Their FEV1/FVC ratio varied from 0.49 to 0.66 and the resting oxygen saturation was 87.6 to 95.6%. Saber Sheath Trachea was assessed in 14 patients, thoracic cage ratio > 0.75 at Carina was seen in 5 patients, and Thoracic Cage Ratio > 0.75 at 5 cm below Carina was found in 11 patients. Tracheal Index had significant correlations with age, duration of illness, pack years and FEV1/FVC Ratio. Thoracic Cage Ratio at carina and that 5 cm below carina had significant correlations with age, duration of illness, pack years and FEV1/FVC Ratio Conclusion: HRCT was observed to be a useful imaging modality to detect characteristics of pulmonary hyperinflation – Tracheal index and the thoracic cage ratio. These parameters had significant correlations with the severity of the disease.
COPD, HRCT, Tracheal index, Thoracic cage ratio, Lung hyperinflation, Saber Sheath Trachea, Airways disorders
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Correlation of 5-Repetition Sit-to-Stand Test with Borg Dyspnoea Scale and GOLD Spirometric Classification in Patients with COPD
Background: Chronic obstructive pulmonary disease (COPD) is a major global health problem associated with significant morbidity and mortality. Functional assessments such as the “5-repetition sit-to-stand test (5STS)” may serve as accessible tools to estimate disease severity, especially in resource-limited settings. This study assesses the relationship between the 5STS and the Borg dyspnoea scale, along with the GOLD spirometric classification, in Indian patients diagnosed with COPD. Methods: In this cross-sectional study, 71 stable COPD patients from a tertiary care center in Mumbai were evaluated. Participants underwent spirometry, 5STS, and dyspnoea assessment using the modified Borg scale. Patients were also classified according to the GOLD spirometric classification. Statistical correlations and comparisons were performed using Spearman’s correlation, ANOVA, and post-hoc Tukey tests. Results: Participants had a mean age of 65.7 ± 8.3 years, with males comprising 80.3% of the study population. The mean 5STS completion time was 14.98 ± 3.64 seconds. The 5STS demonstrated a strong positive correlation with the Borg dyspnoea scale (r = 0.857, p < 0.001). ANOVA revealed significant differences in 5STS times across GOLD spirometric categories (p < 0.001). Cronbach’s alpha demonstrated high reliability of 5STS in reflecting symptom severity (0.829). Conclusion: The 5STS test shows a strong correlation with established COPD severity indices and is a reliable, inexpensive, and rapid assessment tool. It holds potential as a surrogate marker for disease severity in resource-constrained settings.
Chronic obstructive pulmonary disease, 5-Repetition sit-to-stand test, Borg dyspnoea scale, GOLD spirometric classification, Functional exercise capacity.
Phantom Tumor of the Lung: A Radiological Masquerader of Pulmonary Mass Lesion
Background: Phantom tumor, also referred to as a vanishing tumor or pseudotumor, is a rare radiological entity characterized by localized transudative pleural fluid accumulation within a pulmonary fissure, most often associated with congestive heart failure. Its mass-like appearance on chest radiographs can closely mimic pulmonary neoplasms, potentially leading to unnecessary diagnostic procedures if unrecognized. Case Presentation: We describe a 68-year-old male with a history of ischemic heart disease who presented with acute-onset breathlessness, orthopnea, and bilateral pedal edema. Chest radiography revealed a well-defined, homogeneous opacity in the right mid-zone, raising suspicion of encysted pleural effusion within the horizontal fissure. Electrocardiography demonstrated tachycardia with a right bundle branch block, while echocardiography revealed severe left ventricular systolic dysfunction. Following initiation of intravenous diuretic therapy for decompensated heart failure, repeat chest radiography subsequently showed complete resolution of the opacity, confirming the diagnosis of a phantom tumor. Conclusion: Phantom tumor should be considered in elderly patients with congestive heart failure presenting with fissural opacities on chest radiographs. Rapid radiological resolution after diuretic therapy is pathognomonic and aids in avoiding unnecessary investigations and interventions.
Phantom tumor, Interlobar effusion, Congestive heart failure.
Treatment Outcome Analysis of Drug-Sensitive Pulmonary and Extrapulmonary Tuberculosis Among HIV Positive and HIV Negative Patients and their Correlation with CD4 Counts
Background: WHO guidelines recommended daily therapy in HIV-TB co-infected individuals. The study was aimed at comparing treatment outcomes of standard drug-sensitive anti-tuberculosis regimen in HIV seropositive and HIV seronegative patients with tuberculosis and their correlation with CD4 counts. Material & methods: The present observational and prospective study of 236 HIV-negative and 154 HIV-positive patients was conducted over two years. All the patients included in the study were reviewed regularly to enquire the compliance, symptom improvement and outcome analysis. Results: Among HIV-negative patients, pulmonary TB was more common, while among HIV-positive patients, extrapulmonary TB was observed more frequently. Notably high treatment success rate (82.6 vs. 65.5% at the end of treatment, p-value 0.002) and low mortality rate (8.0 vs. 20.1%, p-value 0.002) were observed among HIV-negative patients. Higher CD4 counts among HIV-positive patients was found to be noteworthy after 6 months treatment (194.85 vs. 288.18, p <0.001). Those HIV individuals who died had inadequate improvement in CD4 counts. Conclusions: Overall, HIV negative patients did better on the daily DOTS regimen than HIV positive patients in terms of treatment completion and success rates, treatment failure as well and mortality. Improvement in CD4 counts after treatment was statistically significant and indicates the effectiveness of combined ART and DOTS in tuberculosis treatment.
Tuberculosis, HIV infection, Treatment outcome.
Isolated Primary Tuberculosis of the Pectoralis Major Muscle
Skeletal muscle tuberculosis is an extremely rare form of extrapulmonary TB, accounting for <1% of all cases, even in TB-endemic countries. We present the case of a 45-year-old female with isolated involvement of the right pectoralis major muscle, presenting as a painful, gradually enlarging anterior chest wall swelling. Computerized tomography scan revealed a soft tissue lesion within the muscle, and fine needle aspiration cytology from the lesion confirmed tuberculosis with granulomatous inflammation and acid-fast bacilli. The patient responded completely to standard anti-tuberculosis therapy. This case highlights the importance of considering tuberculosis in the differential diagnosis of soft tissue swellings at any site of body in endemic areas.
Tuberculosis, Muscular TB, Pectoralis major, Extrapulmonary TB, Chest wall swelling.
A Challenging Case of Ethambutol-Induced Optic Neuritis Manifesting with Perioptic Cystic Changes Diagnosed by Optic MRI
A 51-year-old female with a diagnosed case of Pott’s spine has been on regular antitubercular treatment for the last 9 months and presented with complaints of progressive blurring of vision for the past 3 months. Ophthalmological examination revealed decreased visual acuity and bilateral retro-orbital pain on gentle compression of the eyeballs. This case highlights the role of MRI in the early detection of optic neuritis and demonstrates that early discontinuation of ethambutol can lead to favourable outcomes by preventing irreversible optic nerve damage.
Tuberculosis, Optic neuritis, Ethambutol, Pott’s Spine, Adverse drug reaction.
Deep Vein Thrombosis, Pulmonary Thromboembolism, and Pulmonary Infarction: All in one in a Young Male Patient with Pulmonary Tuberculosis
Pulmonary tuberculosis (PTB) is a known pro-inflammatory state that can predispose individuals to thromboembolic events. We present an uncommon case of a young male with active PTB who developed deep vein thrombosis (DVT), pulmonary thromboembolism (PTE), and pulmonary infarction as complications during the disease course. This case underscores the critical need for prompt identification of thromboembolic events in patients with tuberculosis, the diagnostic value of Doppler and CT pulmonary angiography, and the successful use of anticoagulation alongside modified ATT in achieving favourable outcomes.
Pulmonary tuberculosis, deep vein thrombosis, pulmonary thromboembolism, pulmonary infarction, hypercoagulability, anticoagulation, CT pulmonary angiography, Doppler ultrasound, ATT modifications, venous thromboembolism.
When Bullae Deceive: A Rare Case of Vanishing Lung Syndrome Misdiagnosed as Pneumothorax
Background: Vanishing lung syndrome (VLS), also referred to as giant bullous emphysema, is an uncommon form of lung disease in which massive bullae replace a substantial portion (typically more than one third) of the hemithorax, leading to compression of surrounding healthy lung tissue. It typically occurs in young male smokers but may also arise in non-smokers with biomass exposure, making diagnosis and management particularly challenging. Case Presentation: We describe a case involving a 51-year-old non-smoking woman with long-term exposure to biomass fuel, who presented with dry cough, chest discomfort, and gradually worsening shortness of breath. An initial chest X-ray was interpreted as a left-sided pneumothorax, for which an intercostal chest drain was placed; however, clinical and radiological improvement was not achieved. Subsequent high-resolution computed tomography revealed a large emphysematous bulla occupying the left lower lobe and causing a contralateral mediastinal shift, findings consistent with vanishing lung syndrome. The patient underwent successful surgical management via left posterolateral thoracotomy and bullectomy, resulting in marked clinical improvement. Conclusion: This case highlights the critical need to distinguish vanishing lung syndrome from pneumothorax, particularly in individuals with non-traditional risk factors like prolonged biomass smoke exposure. Early recognition and surgical intervention can lead to substantial symptomatic and functional recovery.
Vanishing lung syndrome, Pneumothorax, Mimic, Giant bullous emphysema, Biomass exposure, Bullectomy, Hyperlucent lung.