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   Table of Contents - Current issue
Coverpage
April-June 2022
Volume 11 | Issue 2
Page Nos. 87-194

Online since Friday, April 8, 2022

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EDITORIAL  

Quality and errors in the intensive care unit Highly accessed article p. 87
Harish Mallapura Maheshwarappa, R Sidharth
DOI:10.4103/ijrc.ijrc_55_22  
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REVIEW ARTICLES Top

Potential application of probiotics in attenuating the link between COVID-19 and mucormycosis Highly accessed article p. 95
Rohan Kumar Polamarasetty, P Divya
DOI:10.4103/ijrc.ijrc_132_21  
COVID-19 has caused a significant amount of mortality and morbidity worldwide. It has paved the way for a plethora of complications including increase in the incidence of some previously rare diseases. Mucormycosis is one such opportunistic infection that has gained prominence in certain developing countries, especially India, during the pandemic. It is a life-threatening condition that requires to be managed promptly. Rampant use of steroids, immunomodulators, and antibiotics for the treatment of COVID-19 has led to hyperglycemia such as state, immunosuppression, and gut dysbiosis. All these conditions in addition to the local tissue damage mediated by the severe cytokine storm in the later stages of the disease are the key culprits for this upsurge. There is evidence promoting the potential use of probiotics for the prevention as well as the treatment of COVID-19. They boost and regulate the native immunity of the individual, simultaneously reducing the dependence on steroids and other immunomodulators. This can help prevent the development of opportunistic infections such as mucormycosis in COVID-19 patients. This article correlates the beneficial effects of probiotics in improving the individual's immune status to halt the probable mechanism by which mucormycosis can develop in individuals with COVID-19
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Strengthening the delivery of essential services for tuberculosis care during the ongoing coronavirus disease-2019 pandemic Highly accessed article p. 101
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/ijrc.ijrc_159_21  
The ongoing coronavirus disease-2019 (COVID-19) pandemic has changed the dynamics of the health sector. The purpose of the current review was to explore the relationship between COVID-19 and tuberculosis (TB), the impact of COVID-19 on TB, and identify the strategies that can be adapted to contain both infections effectively. An extensive search of all materials related to the topic was carried out on the PubMed search engine, and a total of 44 articles were selected based on their suitability with the current review objectives. Keywords used in the search include COVID-19 and tuberculosis in the title alone only. The findings of the report and research articles have reported that people with COVID-19 infection who have co-infection with TB are more likely to have poor outcomes, including death, compared with people who have only COVID-19 infection. Considering the public health magnitude of TB, we cannot undermine the importance of regular screening, preventive, diagnostic, and therapeutic activities that target TB disease, as it will save millions of lives. In conclusion, as we continue our fight against the COVID-19 pandemic, there is an immense need to maintain services directed toward the prevention and control of TB. The policymakers should explore all the options that will enable the implementation of joint strategies for the better containment of both the infections without compromising the safety of health professionals.
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ORIGINAL ARTICLES Top

Role of LENT score in prognosis of malignant pleural effusions p. 106
Yellapu Gayatri Devi, Preethi Koyyana, Vathada Nookaraju, Balla Padmaja, Pudi Mounika, Papayagari Alekya
DOI:10.4103/ijrc.ijrc_119_21  
Background: Detection of exfoliated malignant cells in the pleura, i.e., malignant pleural effusion (MPE), is an advanced form of the disease with poor outcome and limited survival in both primary lung and nonlung primary carcinomas. LENT score, the first validated prognostic score, was developed to predict such survival in MPE. The aim of the study is to assess the role of LENT score to predict the survival in MPE along with Eastern Cooperative Oncology Group Performance Status (ECOG PS) score. Materials and Methods: A prospective observational study was conducted on 30 patients who presented with MPE. LENT score along with ECOG PS was calculated, and survival prediction at 1, 3, and 6 months was done using receiver operating characteristic (ROC) analysis. Results: Out of 30 patients, 22 had primary lung and 8 had nonlung primary malignancy. Fourteen patients were in the high-risk group (LENT score 5–7), 15 in the moderate-risk group (LENT score 2–4), and 1 in the low-risk group (LENT score 0–1). Overall median survival was 45 days. Analysis of the area under the ROC curve for LENT and ECOG PS score at predicting survival at 1 month (0.763 vs. 0.855), 3 months (0.889 vs. 0.938), and 6 months (0.920 vs. 0.976) showed no significant difference though ECOG PS was slightly better as a prognostic variable. Kaplan–Meier survival analysis with log-rank test showed that there is a significant difference in survival between the risk groups based on LENT score (Chi-square 20.5469, P ≤ 0.0001). Conclusion: Both LENT and ECOG PS scores are equally good at predicting survival rates in MPE; however, the LENT score is potent, easy to compute, clinically applicable up to the point and helps in guiding treatment selection.
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Clinicodemographic Profile of Tropical Pulmonary Eosinophilia in a Tertiary Care Institute of Bihar p. 112
Manish Shankar, Md Arshad Ejazi, Satyadeo Choubey, Dinesh Kumar
DOI:10.4103/ijrc.ijrc_138_21  
Background: Tropical pulmonary eosinophilia (TPE) is a type of eosinophilic lung disease, and it is associated with a hypersensitivity response to Wuchereria bancrofti and Brugia malayi's microfilariae. Any systemic data regarding its clinical, demographic, and radiological profile in patients of this part of the world are sparse. This study aimed to study the clinical and demographic profile of TPE patients in this geographical area. Materials and Methods: This is a prospective observational study done over 1 year period in patients with TPE-like features in a tertiary care center of Bihar. After appropriate clinical and blood examination, absolute eosinophil count (AEC), serum total immunoglobulin E (IgE), spirometry, filarial antigen, and filarial antibody and chest radiology were done. Results: Among 77 cases of TPE, 54 were male (70.1%) and 23 were female (29.9%), in a ratio of 2.35:1. The majority of cases 43 (55.9%) were found in age less than 30 years. Most of our participants were students 28 (36.4%), homemakers 19 (24.7%), and farmers 17 (22.1%). The most common clinical feature was cough 77 (100%). Filarial antibody was raised in all (100%) while antigen was positive in 96.1%. Chest radiology was normal in 71.4%. Mean AEC and IgE ± standard deviation were 6730.71 + 4671.12 and 7983.14 ± 7279.60 kU/L, respectively. Spirometric findings were mild restriction 25 (32.5%). Conclusion: The prevalence of TPE is supposed to be higher in endemic areas. The patient should be evaluated in detail if having raised eosinophil count (>3000/mm3) with increased IgE level (>1000 kU/L) along with suggestive clinical features. Timely diagnosis and treatment can cure the disease and prevent its complications.
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Clinico – Bacteriological profile of community-acquired pneumonia patients at tertiary care center of North India p. 117
Prashant Yadav, Ashish Kumar Gupta, Aditya Kumar Gautam, Adesh Kumar, Shivam Priyadarshi, Dhiraj Kumar Srivastav
DOI:10.4103/ijrc.ijrc_145_21  
Background: Pneumonia is an acute inflammation of the pulmonary parenchyma, and its etiology can be the infective or noninfective origin. It is the sixth-leading cause of death from infectious disease in the United States, yet Indian epidemiological data were lacking on this subject. Materials and Methods: A hospital-based prospective observational study was done from January 2019 to June 2020. One hundred and twenty-five patients with community-acquired pneumonia (CAP) who met the inclusion and exclusion criteria during the study period were included in this study. In all patients, routine investigations and three sputum samples and two blood samples from two different sites for culture were taken on the 1st day of admission before starting the antibiotics. Results: Out of the 125 study participants, 80 (64%) were male, and 45 (36%) were female. The mean age of the study participants was 50.5 ± 17.2 years. Cough (99%) was the most common symptom. Chronic obstructive pulmonary disease (COPD) (25.6%) and asthma (25.6%) were the most common comorbidities. Absolute neutrophil count is the single best predictor of mortality in admitted patients of CAP (area under the curve [AUC] of 0.975) followed by total leukocyte count (AUC = 0.963) and neutrophil lymphocyte ratio (AUC = 0.925) and CRB-65 = Confusion, Respiratory rate, Blood pressure, 65 years of age and older (CRB 65 score) (AUC = 0.922) in predicting mortality in CAP. Overall bacterial growth was seen in 91 (72.8%) cases, among 74 (59.20%) Gram-negative and 17 (13.6%) were Gram-positive. Conclusion: Klebsiella pneumoniae was the most common bacteria isolated from all samples. Most of the isolates in our study were resistant to cotrimoxazole and ertapaenem, and these antibiotics should not be given as empirical antibiotics in patients of CAP.
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Correlation of Radiological Findings on High-Resolution Computed Tomography Chest in Vaccinated and Unvaccinated COVID-19 Patients from Eastern India p. 124
Roopak Dubey, Kamal Kumar Sen, Asim Mitra, Humsheer Singh Sethi, Rohit Arora, Mayank Goyal
DOI:10.4103/ijrc.ijrc_148_21  
Background: In this coronavirus disease-2019 (COVID-19) pandemic, safe and effective preventative vaccines are essential to contain the pandemic, which has had severe medical, economic, and societal consequences, despite some people still becoming infected after receiving immunisation. Methods: A total of 200 patients were examined and split into two groups: (1) 100 consecutive COVID-19-positive cases who had been vaccinated and (2) 100 consecutive COVID-19-positive patients with no vaccination. At the time of the scan, the patient's vaccination status was noted. Results: The computed tomography severity score (CTSS) of unvaccinated individuals was found to be considerably greater than that of partly or fully vaccinated patients (median 13 vs. 7, P < 0.001). Completely vaccinated individuals had a considerably lower median CTSS than partly vaccinated patients (6 vs. 9, P < 0.001). Conclusions: Individuals should be thoroughly vaccinated to avoid major lung disease. As a result, stronger dedication and motivating efforts should be made worldwide to improve the COVID-19 vaccination program.
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Effects of flipped classroom learning in acquisition and retention of cardiopulmonary resuscitation skills among entry-level health professional students: A single-blinded randomized controlled trial p. 128
Madhura Reddy, Ramesh Unnikrishnan, Selvam Ramachandran
DOI:10.4103/ijrc.ijrc_149_21  
Context: Inhospital cardiac arrests are provided with immediate life support care, but outhospital cardiac arrest does not receive bystander resuscitation immediately. These delays are due to several reasons; education and type of training received are among them. Objective: The objective of this study was to evaluate the effects of flipped classroom learning (FCL) in the acquisition and retention of knowledge and skills of cardiopulmonary resuscitation (CPR) among health professional students. Methods: A randomized control trial was performed among entry-level health professional students with no background knowledge and skills on basic life support (BLS) and CPR who were equally divided into the flipped classroom (intervention group) and lecture-based classroom (LC) (control group). The BLS and CPR were taught through didactic lectures and hands-on practice to both the groups. The intervention group received the self-study material in a video module before the lecture and hands-on practice. The study was implemented in three phases – intervention phase, follow-up at 1 month, and 2 months. Knowledge was assessed using multiple-choice questions and skills through direct observation and a checklist throughout all the phases. Results: Sixty-one participants completed the study. Mean difference in scores for knowledge and skills between the LC and flipped classroom groups increased immediately after intervention but was not retained on follow-up at 1 and 2 months, and is not statistically significant. However, a significant difference was observed in knowledge and skill scores within the group across different phases (P < 0.001). Conclusion: We did not find an additional benefit of FCL over LC learning.
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Prognosis, survival, and clinicopathological characteristics of small cell lung cancer with pleural fluid p. 135
Filiz Cimen, Melike Aloglu, Sevim Düzgün, Aysegül Senturk, Sükran Atikcan
DOI:10.4103/ijrc.ijrc_155_21  
Objective: While malignant pleural effusion (MPE) is generally observed in non-small cell lung cancer (SCLC) patients, its prevalence in SCLC has not been reported. Methods: Patients over 18 who were admitted to our hospital between January 2015 and December 2019 and diagnosed with SCLC histologically were retrospectively studied. Demographic data, tumor location, tumor stage, pleural fluid characteristics, radiological findings, and overall survival were recorded from hospital records. Results: Our study included 59 patients (48 [81.4%] men and 11 [18.6%] women), with a median age of 67. Forty-seven (79.7%) patients had a history of smoking. The patients had median tumor standardized uptake values (SUV) max levels of 11.9, a tumor diameter of 6 cm, and a follow-up period of 7 months. Protein levels in pleural fluid of the metastasizing group were significantly higher than in the nonmetastatic group (P = 0.049). In the univariate model, age, N stage, pleural fluid glucose, and pleural fluid protein levels were found significantly efficient in predicting disease-free survival (P = 0.008, P = 0.001, P = 0.001, and P = 0.026, respectively). In the multivariate reduced model, N stage, pleural fluid glucose, and pleural fluid protein levels were found independent predictive factors for disease-free survival (P = 0.000, P = 0.000, and P = 0.009, respectively). Conclusions: MPE is common at presentation (11%) in patients with SCLC and may be associated with reduced survival. Additional studies are needed to assess the treatment-adjusted survival rate in the MPE setting.
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The association between serum vitamin D deficiency and chronic obstructive pulmonary disease exacerbation p. 140
Farnoosh Ebrahimzadeh, Milad Bahrami, Fariba Rezaeetalab, Fatemeh Taheri Asl, Mobina Sadat Mirvahabi, Zeinolabedin Kafa, Farzaneh Akbari
DOI:10.4103/ijrc.ijrc_157_21  
Introduction: Chronic obstructive pulmonary disease (COPD) is a progressive disease characterized by irreversible airway obstruction and impaired pulmonary function. Acute exacerbation is responsible for the majority of COPD mortality and morbidity. This study aimed to evaluate the association between serum Vitamin D deficiency and COPD exacerbation. Materials and Methods: This cross-sectional study was conducted on 80 COPD patients who were hospitalized for severe acute exacerbation in Imam Reza Hospital, Mashhad, Iran, in 2016–2017. Subjects were excluded if they were taking corticosteroid, calcium, phosphorus, or Vitamin D supplements. Immunocompromised patients and cases with underlying cardiovascular, liver, or renal diseases, metabolic syndrome, cancers, electrolyte imbalance, and any diseases related to Vitamin D metabolism and absorption were also excluded. A blood sample of 3 ml was taken from each participant to measure 25-hydroxyvitamin D (25OHD) level, up to 24 h after hospitalization. The severity of the disease was assessed by forced expiratory volume in 1 s obtained from spirometry tests, and hypoxemia level using O2 saturation. Results: The lower levels of mean serum 25OHD were significantly associated with the increased number of exacerbations (P = 0.01). Hypoxemia levels and the mean serum 25OHD level were found to have a significant association as well (P = 0.01). However, no significant relationship was observed between the mean serum 25OHD level and the duration of hospitalization (P = 0.1). Conclusions: Serum Vitamin D deficiency was associated with increased COPD exacerbation and poor clinical outcomes. Therefore, Vitamin D supplementation should be considered to reduce the risk of COPD exacerbation.
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Effect of respiratory muscle stretch gymnastics on exercise capacity in the elderly – A randomized control trial p. 145
Anjali Chandrakant Awachat, Prajakta Sahasrabudhe, Parag Sancheti, Ashok Shyam
DOI:10.4103/ijrc.ijrc_163_21  
Background: Aging is associated with structural degeneration and functional limitations in the respiratory system, reducing exercise capacity. Respiratory muscle stretch gymnastics (RMSG) is used to improve the function of lungs and respiratory muscles with some success in various populations. Materials and Methods: Eighty-four individuals in the age group of 60–70 years were randomly allocated to the experimental and control group. Individuals in the experimental group were put on a 4-week RMSG supervised program. Distance covered in incremental shuttle walk test (ISWT), maximal inspiratory pressure (MIP), and quality of life (QoL) were the outcome measures for the study. Results: There was an improvement in distance covered in ISWT, MIP, and scores of World Health Organization QoL-BREF (WHO QoL-BREF) questionnaire of subjects in the experimental group (P = 0.000) as compared to the control group. Conclusion: Prescription of RMSG for 4 weeks was beneficial in improving exercise performance, maximal inspiratory muscle strength, and QoL in elderly individuals.
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Risk factors, clinical profile, and management outcome of patients with isolated subsegmental pulmonary embolism: A single-center experience from North India p. 149
Arif Rehman Sheikh, Farzana Manzoor, Sanaullah Shah
DOI:10.4103/ijrc.ijrc_1_22  
Background and Objective: The clinical profile of patients with isolated subsegmental pulmonary embolism (SSPE) remains understudied and underreported. To describe the clinical particulars of patients with SSPE, we aimed to compare clinical signs and symptoms, risk factors, lab parameters, and short-term mortality between patients with isolated SSPE and those with proximal pulmonary embolism (PE). Materials and Methods: We prospectively studied all patients with objectively confirmed PE over 4 years. Depending on the location of the most proximal pulmonary artery in which emboli were detected, patients were divided into two groups: (a) isolated SSPE and (b) proximal PE. Different clinical and laboratory parameters were compared between the two groups. Results: One hundred and fifty patients were enrolled during the 4-year study. Twenty-three (15.3%) patients were diagnosed with isolated SSPE. Compared to proximal PE, patients with SSPE are younger, are more likely to have active malignancy, less likely to have dyspnea, and more likely to have chest pain, are hemodynamically stable with a lesser prevalence of hypoxemia and hypocapnia. Patients with isolated SSPE have shorter hospital stays and lower 30-day mortality compared to proximal PE. Conclusion: Patients with isolated SSPE have a mild clinical presentation, lesser laboratory abnormalities, and a favorable short-term outcome compared to patients with proximal PE.
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Risk factors and a novel score (CARI-65) predicting mortality in COVID-19 patients p. 154
Suhail Mantoo, Afshan Shabir, Umar Hafiz Khan, Tajamul Hussain Shah, Farhana Siraj, Nazia Mehfooz, Muzaffar Bindroo, Syed Mudasir Qadri, Ajaz Nabi Koul, Mushtaq Ahmad, Fayaz Ahmad Sofi, Sonaullah Shah, Rafi Ahmed Jan, Asma Shah, Faizan Wani
DOI:10.4103/ijrc.ijrc_3_22  
Purpose: The rapid spread of severe acute respiratory syndrome coronavirus-2 infection resulted in an exponential increase in hospitalizations and mortality. We aimed to explore the determinants of mortality and formulate a score that can predict mortality in patients hospitalized due to coronavirus disease 2019 (COVID-19). Materials and Methods: In this retrospective study, 1024 COVID-19 patients hospitalized between March 2020 and October 2020 were included. Patient demographics, underlying comorbid illnesses, clinical features, vital signs at admission, disease severity, and laboratory parameters, were collected from hospital medical records and analyzed to derive risk factors for in-hospital mortality and formulate a mortality prediction score. Results: The median age of the study population was 56 years (interquartile range [IQR], 45–65) and was significantly higher in nonsurvivors than in survivors (62 [IQR 55–70] vs. 52 [IQR 40–65]; P = 0.001). Hypertension and diabetes were the most common associated comorbid illnesses seen in 50.5% (n = 518) and 29.1% (n = 299) of patients, respectively. The presence of altered level of consciousness (C), azotemia with serum creatinine >1.5 mg/dl (A), respiratory rate >25/min (R), interleukin-6 >25 pg/ml (I), and age ≥65 years were independent predictors of mortality. A six-point COVID-19 mortality prediction score, “CARI-65,” was developed using variables predicting mortality in multivariate regression analysis. The CARI-65 score ≥3 had a sensitivity and specificity of 87.1% and 57.3%, respectively, and positive and negative predictive values of 42.52% and 92.45%, respectively, in predicting mortality. Conclusion: This study demonstrated various demographic, clinical, and laboratory parameters that predict mortality in hospitalized COVID-19 patients. We also proposed a simple risk stratification score to predict mortality in hospitalized COVID-19 patients, so that effective triaging of patients can be done to utilize health-care resources efficiently.
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Pulmonary Rehabilitation Reduces the Sarcopenia Phenotype in Patients with Chronic Obstructive Pulmonary Disease p. 162
Abdulla Altamimi, Aesha Shuaeeb, Ahmed Yakout, Dana Hassouna, Huda Srouji, Maha AlQaydi, Mona Mohammed Mahmoud, Noor Alkindi, Qamar Kashmoola, Ragad Alkhatib, Rand Soudan, Roaa Abu Tawileh, Tahir Muhammad, Rizwan Qaisar
DOI:10.4103/ijrc.ijrc_20_22  
Purpose: Sarcopenia or age-associated muscle decline is common in patients with chronic obstructive pulmonary disease (COPD). Pulmonary rehabilitation (PR) is an effective tool in reducing COPD phenotype, but its effects on sarcopenia and functional capacity are poorly known. We aimed to assess the restorative potential of PR on skeletal muscle and physical capacity in COPD patients. Methods: We investigated the male COPD patients, 56–71 years old (n = 55), through clinical examination, laboratory investigation, and spirometry. All patients were evaluated at two time points, 1 year apart before and following the PR. Reduced handgrip strength (HGS), appendicular skeletal mass index (ASMI), and gait speed were considered the clinical indexes of Sarcopenia. Enzyme-linked immunosorbent assay were used to measure the circulating markers of inflammation (C-reactive protein [CRP]) and oxidative stress (8-isoprostanes). Results: At baseline, the COPD patients had low HGS and gait speed and elevated CRP and 8-isoprostanes levels. According to four internationally recognized criteria, these patients also had a high incidence of Sarcopenia. One year of PR partially restored the HGS, gait speed, CRP, and 8-isoprostanes levels (all P < 0.05). However, the ASMI values were insignificantly restored following PR. PR also reduced the incidence of sarcopenia in COPD patients. Among various criteria for sarcopenia, the international working group on sarcopenia yielded the highest incidence of sarcopenia in COPD patients. Conclusion: Altogether, our data show the therapeutic potential of PR in skeletal muscle, physical performance, and systemic health in patients with COPD.
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CASE REPORTS Top

Pulmonary alveolar proteinosis: Case report of rare diffuse lung disorder in pediatric age group p. 169
Vipulkumar Gandhi, Shashank Kadam
DOI:10.4103/ijrc.ijrc_130_21  
Nonspecific symptoms and variable clinical course are a few of the hurdles in diagnosing pulmonary alveolar proteinosis (PAP). Lack of accessible health care and efficient health infrastructure, including diagnostic and treatment facilities, are the major challenges for early detection and prompt management of PAP in developing countries such as India. A 6-month-old child was brought to the tertiary health care center for cough, dyspnea, and intermittent fever. The history of third-degree consanguineous parents was evident. The patient had a history of evolving respiratory complaints at the age of 4 months, for which she was hospitalized for 12 days. There was a relapse of similar symptoms within 2 weeks of discharge and required readmission. The patient was cyanosed with signs of severe respiratory distress. Chest X-ray revealed bilateral diffuse alveolar infiltration. High-resolution computed tomography imaging showed diffuse interstitial thickening with adjacent ground-glass opacities along with crazy-pavement appearance involving both lungs. With flexible bronchoscopy, bronchoalveolar lavage (BAL) was performed. Congenital PAP was confirmed with periodic acid–Schiff -positive proteinaceous extracellular globules on smear. The child was intubated and mechanically ventilated during a hospital stay to treat uncontrollable respiratory failure. The child succumbed on the 28th day of admission despite repeated therapeutic BAL procedures and systemic corticosteroids. The possibility of missed/delayed diagnosis of PAP is widespread in resource-limited health-care settings. Postnatal onset of PAP should be suspected in every child with chronic respiratory distress and failure to thrive with diffuse alveolar infiltrates.
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Drug-Resistant Pulmonary Tuberculosis Mimicking Lung Malignancy p. 173
Sunil Kumar, Sheena Taneja, Manish Advani
DOI:10.4103/ijrc.ijrc_146_21  
Pulmonary tuberculosis (TB) and lung malignancy can mimic each other in clinical presentation and sometimes in radiological imaging. Delayed or overdiagnosed of TB may cause a delay in treatment, unwanted adverse drug reactions, and increased morbidity. Here, we report an interesting case of conflict clinicoradiololgical presentation. In this case, the clinical features were consistent with infective etiology, while the radiological imaging favored lung malignancy. The final diagnosis of primary drug-resistant pulmonary TB was established based on GeneXpert in bronchial washing. The patient was put on treatment and follow-up under the national program. On follow-up, the patient showed clinical improvement in terms of symptoms resolution and weight gain. This case depicts the atypical presentation of drug-resistant TB and highlights the role of invasive procedures in clinicoradiological discordant cases of TB and malignancy.
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Hepatopulmonary syndrome and portopulmonary hypertension coexisting in a case of wilson's disease cirrhosis: “Double trouble” p. 176
V V. S. S. Sagar, Sourya Acharya, Gajendra Agrawal, Samarth Shukla, Sunil Kumar, Chitturi Venkata Sai Akhil
DOI:10.4103/ijrc.ijrc_150_21  
Wilson's disease is one of the infrequent causes of hepatic failure with a wide clinical spectrum. Hepatic and neuropsychiatric manifestations are the most common, whereas atypical presentations were also reported as the complications of hepatic failure such as hepatopulmonary syndrome (HPS) and portopulmonary hypertension (POPH). These are considered pulmonary complications of hepatic disease with underlying complex pathology and various vasoactive substances such as endothelin 1 and nitric oxide on the pulmonary blood vessels. HPS usually presents with breathlessness and central cyanosis. The triad of HPS comprises dilatation of pulmonary vasculature, intrapulmonary shunting, and hypoxia, whereas POPH causes vasoconstriction and vascular remodeling leading to increased resistance in pulmonary blood vessels and subsequent right ventricular dysfunction. In this case report, we highlight two antagonistic pathological processes coexisting in the same patient.
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Chilaiditi sign - An unusual finding in a patient with pulmonary tuberculosis p. 181
Amiya Pandey, Hemant Kumar, Natasha
DOI:10.4103/ijrc.ijrc_151_21  
Chilaiditi sign refers to gas in between the right dome of the diaphragm and liver, after excluding the symptoms and signs of intestinal perforation. In our case, the patient was diagnosed with pulmonary tuberculosis. His chest radiography revealed the presence of gas under the right dome of the diaphragm with no abdominal symptoms, revealing a rare entity, i.e., Chilaiditi sign.
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Rehabilitation journey of a COVID-19 survivor from hospitalization to follow-up: A case report of progressive lung fibrosis p. 183
Anulucia Augustine, Shruti Prabhakaran Nair, Mansi D Darji, Vrushali Panhale
DOI:10.4103/ijrc.ijrc_16_22  
Progressive lung fibrosis, an enduring complication of COVID-19, affects lung function adversely, fatigue levels, exercise tolerance, and health-related quality of life, affecting more than 50% of the confirmed cases. Furthermore, the number of post-COVID survivors is steadily increasing, stipulating a need for early, safe, and effective post-COVID pulmonary rehabilitation (PR). A 62-year-old male diagnosed with viral pneumonitis with severe lung fibrosis post-COVID infection exhibited severe exercise intolerance during hospitalization. An 8-week supervised, structured PR program led to early weaning from oxygen support and improved patient's functional outcomes. Amelioration in the patient's clinical status was demonstrated by a 50% reduction in his fatigue levels and a three-fold change in his functional capacity. This case study highlights the importance of early initiation of PR in optimizing patient's health status and reducing any further functional limitations.
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A case of un-ruptured hepatic hydatid cyst: A rare cause of eosinophilic pleural effusion p. 187
Sunil Kumar, Jimit Nitin Mistry, Sheena Taneja, Manish Advani
DOI:10.4103/ijrc.ijrc_19_22  
Cystic echinococcosis in humans is caused by incidental ingestion of water or food contaminated by embryonated eggs of Echinococcus granulosus. Pleural involvement in hydatid disease occurs through transdiaphragmatic spread or intrapleural rupture of a liver or lung cyst. In rare circumstances, a hydatid cyst may accompany pleural effusion. Here, we report a rare case that presented to us with right-sided gross pleural effusion. On evaluation, a large hydatid cyst was found in the left lobe of the liver without any sign of intrapleural or transdiaphragmatic rupture. The pleural fluid was exudative, eosinophilic, and had raised adenosine deaminase. This case depicts the rare presentation of disease and highlights the importance of clinical examination.
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SHORT COMMUNICATION Top

Recommendations for the use of face masks among children to contain coronavirus disease-2019 pandemic p. 190
Saurabh RamBihariLal Shrivastava, Prateek Saurabh Shrivastava
DOI:10.4103/ijrc.ijrc_25_22  
The coronavirus disease-2019 (COVID-19) pandemic continues to account for the disruption of health care and other welfare services. As the predominant mode of transmission of infection is through close contact or airborne mode, it is important to acknowledge that we should encourage the use of face masks in the community and workplace settings. Even though significant results have been attributed to face masks, we must realize that to optimize the impact, and we must ensure their appropriate usage, storage, cleaning, and disposal. To conclude, a face mask is an effective tool to reduce the incidence of infection among children and adherence to standard public health and infection control measures. However, the decision to wear face masks among children to stop the transmission of COVID-19 infection should be determined based on assessing the potential benefits, harms, and local epidemiological factors.
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