key: cord-0078216-ez3bkfnn
authors: nan
title: TB AND OTHER CHEST INFECTIONS
date: 2022-03-03
journal: Lung India
DOI: 10.4103/0970-2113.341105
sha: 95e3d3cac3774c7279a10963af18c8a7859741f1
doc_id: 78216
cord_uid: ez3bkfnn

nan

Background: Among the involvement of solid viscera by Tuberculosis in the abdomen, involvement of spleen is rare. Globally, 15-20% of newly diagnosed TB cases were extrapulmonary, out of which 3-5% comprised abdominal TB, in which splenic involvement was rare. Case Study: This is a case of a middle aged South Indian Diabetic male who presented with left hypochondriac pain of 15 days duration and diagnosed to have multiple splenic abscesses on evaluation. Conservative management failed and splenectomy was done and sent for histopathological examination which showed granulomatous lesions suggestive of Koch's etiology with CBNAAT being negative. Other organ involvement was not detected. Discussion: Spleen can be involved by tuberculosis either as a part of disseminated TB or as isolated splenic TB. It can occur in both immunocompetent and immunosuppressed individuals. There is no specific feature to diagnose splenic TB clinically and is usually recognised on imaging or on histopathological examination of splenectomy specimen.

The possibility of splenic tuberculosis should always be suspected in a case of splenic abscess, particularly when there is a component of immunosuppression in the patient.

by Fridericia formula), arrhythmias and other possible adverse events along with the clinical outcome in terms of mortality, morbidity, sputum conversion and stoppage of the regimen were assessed and managed according to the Programmatic Management of DRTB (PMDT) 2019 guidelines. Results: Total of 6 (12%) patients (two males and four females) out of total 50 had developed QT prolongation between the days 4 to 10 during the first 2 weeks of initiation of the regimen. Four patients had grade 1 and two patients had grade 2 severity of QT prolongation without any clinical symptom and electrolyte imbalance. The regimen was temporarily stopped for 4 days in 1 out of 6 patients who had QT interval > 500 milliseconds. Clinical improvement and sputum conversion were noted in 99% of the patients. Conclusion: BDQ containing regimen is effective in DRTB patients though may produce asymptomatic QT prolongation in limited number of patients. However, more studies are recommended to generalize these findings to the community.

Chest Clinic, Chapra, Bihar, India. E-mail: drallaguraja@gmail. com Background: Tuberculosis has been a major public health concern which has led to 1.5 million deaths worldwide. Tuberculosis and pneumonia are two lung disorders that often exist concomitantly. After mycobacterium tuberculosis is cured, TB patients often stay at risk of developing pneumonia due to major complications like residual anatomic changes and impaired lung functions. Methods: A prospective observational study conducted in Bihar region was conducted between September 2021 to December 2021. A total of 100 pulmonary tuberculosis (PTb) patients who had been newly diagnosed in the last two years were randomly selected for this study. The hazard ratios and the incidence rates of pneumonia were calculated by sex, comorbidity and age. Results: The findings of this study showed that the incidence of pneumonia in the PTb patients were higher by 1.9 folds. It was also found that the risk for pneumonia was greater for men as compared to women, however, lower in cases of young adults. The risk of pneumonia is also aggravated for asthmatic patients. Among PTb patients who are comorbid with asthma, pneumonia had 2.5 folds higher chances of occurrence than an average PTb patient. Another assessment of risks of respiratory health for asthmatic patients showed a 2-fold elevated risk of pneumonia. These risks are however lesser in comparison to patients of heart diseases. Conclusion: Lung infection with tuberculosis presents a chronic consumptive disorder leading to higher chances for acute pneumonia.

Background: Tuberculosis is caused by Mycobacterium Tuberculosis. There are many factors that plays a role in delayed presentation and treatment initiation in pulmonary tuberculosis patients which leads to increased morbidity and mortality. This study aims at finding out these factors of delay. Thus early diagnosis and treatment is possible in order to decrease the tuberculosis burden of the country. Method: It's a cross-sectional study with study size of 150 patients. After taking consent from the patients, basic information of the patient were noted. Clinical history along with the duration were recorded, past medical history, drug history for both past and present illness; smoking and alcohol consumption habits were recorded. Specific questions related to the study like education, medical knowledge, job, drug history, medical records, and previous investigation records were asked and the duration for each and every hospital visit and also for investigations and the reason for time delay between the onset of symptoms and the diagnosis of tuberculosis and the initiation of treatment in the form of patient delay, doctor delay and treatment delay were assessed. Results: The mean duration of patient delay was 56 days and doctor delay was 21 days. Mean diagnostic delay was recorded as 70 days with negligence and symptomatic management as the most common causes of patient delay and doctor delay respectively. Conlusion: If these delays were addressed as early as possible, it reduces the morbidity and mortality in pulmonary tuberculosis patients. Thus making India a TB free nation.

showed a 2x2cm firm non-tender lymph node without any sinus tract or raised local temperature in the right supraclavicular region. She had cystic non-tender swellings with normal local temperature measuring approx 5x3cm on right and 4x2cm on left chest wall. CECT Thorax showed soft tissue lesion at RUZ (43X52 mm) directly extending to anterior chest wall, cystic lesions in both upper anterior chest wall and left encysted effusion. Pleural fluid study and FNAC from lymph node were nondiagnostic. Histopathologocal Examination of USG guided TruCut biopsy of chest wall swelling showed necrotizing granulomatous inflammation and growth of Mycobacterium tuberculosis on 3rd week in MGIT 960 culture. Discussion: She was diagnosed as disseminated Tuberculosis and subsequently put on anti TB therapy. So Tuberculosis can present as lung mass with chest wall invasion. Conclusion: Patients presenting with mass lesion in Chestx-ray should also be evaluated for Tuberculosis as it is potentially curable. High clinical suspicion and proper workup is necessary to confirm the diagnosis and rule out neoplasia. Department of Respiratory Medicine; Christian Medical College, Vellore, Tamil Nadu, Background: There is relative resistance of the thyroid gland to TB infection. Some possible protective factors are, thyroid capsule, high iodine levels, bactericidal action of colloid and thyroid hormones and abundant vascular supply. Thyroid involvement more commonly occurs as part of disseminated spread as in this case, where there was mediastinal lymphadenopathy. Case Study: A 62 year old nurse, Diabetic, presented with epigastric pain with loss of weight for 3 months. On evaluation, her TSH was low, CT Thorax showed bulky mediastinal nodes with right paratracheal being 16mm and thyroid nodules. USG Neck showed TIRADS4 nodule in left lobe of thyroid. EBUS TBNA was done from stations 4R and 7, ROSE showed granulomas. Cell block revealed granulomas with no conspicuous necrosis and hence steroids were started, with Sarcoidosis as the possible etiology. Meanwhile, left lobe of thyroid FNA smears showed patchy necrosis and stain for AFB was positive. Pathologists then reviewed the TB stain of the mediastinal nodes FNA smears and AFB were detected. Steroids were stopped and she was started on ATT with which she had clinical and radiological improvement. Discussion: The occurrence of isolated mediastinal lymphadenopathy decreases with increasing age. In her case, the incidentally detected thyroid nodules with low TSH levels and loss of weight prompted an early FNA which led to the diagnosis of Tuberculosis.

Conclusion: Tuberculosis of the thyroid gland is rare even in high prevalent countries. However, those with thyroid hormone abnormalities and nodules must proceed with FNA or biopsy.

Vasavi Cheguri, Arti D. Shah, Kusum V. Shah, Bhavesh Patel E-mail: vasavicheguri011@gmail.com Background: Tuberculosis (TB) is one of the top 10 causes of death worldwide. India is not only estimated to have the highest burden of TB cases, but also MDR TB cases. This study is undertaken to study the role of CBNAAT in establishing an effective diagnosis of pleural tuberculosis. Objective: To study the detection rate of MTB in pleural fluid with CBNAAT. 1) To study biochemical profile of pleural fluid.

2) To find out Rifampicin resistance in pleural effusion. 3) To compare the ADA levels of pleural fluid with CBNAAT results. Methods: 1) We are going to analyze the medical records of patients having pleural tuberculosis reporting to the Respiratory Medicine Department, Dhiraj Hospital.

2) Diagnosis will be done on the basis of biochemical evaluation of pleural fluid, AFB smear and CBNAAT.

3) Detailed Statistical analysis of results is done. Results: Here, out of the 90 samples, 12 samples were detected to have MTB. Out of these 12, about 92 % (n=11) had MTB sensitive to rifampicin whereas only one sample (8%) had MTB resistance to rifampicin. Out of all the Pleural effusions with ADA value 40 U/L and above, 7(13.33%) cases were diagnosed with CBNAAT, 5 (8.77%) cases were diagnosed as tuberculosis even though ADA value less than 40 U/L. Conclusion: We concluded that CBNAAT should be used in routine initial work up as it can offer definitive diagnosis and also can be helpful in solving the problem of delay in diagnosis and detecting drug resistance.

Deepak Bhanushali, R. K. Rathod, Sanjay Mutyepod, Durgesh Deshmukh Shri Vasantrao Naik Government Medical College, Yavatmal, Maharashtra, India. E-mail: djsbhanushali@gmail.com Introduction: The aim of this study is to estimate the prevalance of Tuberculosis in COVID-19 patients and to find out the incidence of COVID-19 in Tubercular patients. Enhanced screening of patients will enable prompt detection, early isolation and initiation of treatment, thereby reducing the morbidity and mortality in TB and COVID-19 patients. Methods: This is a prospective observational study conducted at 1000 bedded teaching hospital with a standalone 500 bedded DCH. Study subjects were divided into 2 groups. In group A, 1085 COVID positive patients were screened for Tuberculosis. In group B, 430 notified Tubercular patients were screened for COVID -19. Results: Of 1085 pts in group A, 17 (1.5%) pts were newly detected as tuberculosis Out of 17, 10 (58.8%) were PTB, 7 (41.2%) were EPTB In EPTB, 4 (23.5%) had pleural effusion, 2 (11.7%) had TBM and 1 (5.8%) had miliary Tuberculosis. 1 (5.8%) pt of Covid-TBM co-infection died during treatment. Of 430 TB pts in group B, 7 (1.6%) were detected COVID-19 positive. Of these 7 COVID-19 positive patients, 6 (85%) required <10 days of hospitalisation, while 1 (15%) required >10 days of hospitalization with no mortality. Conclusion: Significant proportion of COVID-19 patients were detected to be Tubercular and vice versa.Hence Bi-directional screening of Tuberculosis and COVID-19 should be strengthened at all the health care facilities in India. E-mail: drpriya2005smailbox@rediffmail.com Background: In India, the prevalence of Latent TB infection (LTBI) is estimated to be around 40%. Various formulations of PPD (Purified protein derivative) are available for TST, for diagnosis of LTBI, which may give variable responses in various populations. The commercially available PPD in India is by Arkray Healthcare. It is unclear if this product may have a similar sensitivity compared to other internationally accepted tuberculins (Tubersol). Objective: To compare the bio-equivalency of TUBERSOL and Arkray, and to assess the performance of the two TSTs with the IGRA QFT Gold plus (fourth generation tests). Blood sample was collected for QFTtest.Both the TSTs were placed in the right and the left volar aspect of the forearms and 48 hrs later, the subject came back to the study site for reading. Results: Among the 512 subjects who were tested with both TST1 (Tubersol) and TST2 (Arkray diagnostics, 139 (27%) subjects tested positive for TST1 (>=10mm), whereas 203 subjects (39.6%) tested positive for TST2. There was good agreement between the two tests with k= 0.75 (95% CI 0.6-0.93). However, there was poor agreement between both the TSTs with QFT Gold Plus ( Fourth generation QFT), with kappa value of 0.196 for Tubersol and 0.172 for Arkray. Conclusion: The IndianTST (Arkray diagnostics) has shown good agreement with the internationally accepted Tubersol. However there was poor agreement between the TSTs and QFT Gold plus test.

Background: Disseminated tuberculosis (TB) is defined as lymphohematogenous dissemination of Mycobacterium tuberculosis. The multiple organ involvement in disseminated TB can mimic various diseases including metastatic cancer making the diagnosis of TB difficult. Frequent false negative results necessitate, repeating samples for histopathology and microbiological evaluation. Case Study: 19-year-old immunocompetent female with no comorbidities presented with generalised weakness, fever, loss of appetite and loss of weight, bilateral lower limb weakness and swelling over skull of one month duration. Chest x-ray showed mediastinal widening. CT thorax showed mediastinal lymphadenopathy. PET Scan showed anterior mediastinum mass extending to right paratracheal region (SUV MAX 15.7), multiple lytic sclerotic lesions in bone (frontal bone, vertebrae, iliac bone, scapula, sternum, ribs) all showing SUV MAX more than 10, reported as Lymph Node Metastases and metabolically quiescent pulmonary metastasis. Bence Jones protein came negative. Prevertebral abscess and mediastinal mass biopsy sent for CBNAAT showed MTB detected rifampicin resistance not detected. Patient underwent corpectomy with fusion. She gradually improved with Anti tubercular drugs. Discussion: Disseminated TB is defined as tuberculous infection involving the blood stream, bone marrow, liver, or two or more non-contiguous sites. The various extra-pulmonary TB (EP-TB) involvement with multiple negative microbiologic tests in immunocompetent patient leads to various differential diagnoses including: multiple myeloma, metastatic cancer, lymphoma and fungal infection. Conclusion: Tuberculosis should be considered in differential diagnosis of patients in endemic areas even when PET shows metabolically active lesions. Differential diagnosis should be thoroughly ruled out. Delay in treatment leads to poor patient outcome. Guntur Medical College, Guntur, Andhra Pradesh, India. E-mail: drgowtham1995@gmail.com Background and Aims: MDR tb has become a major challenge for control in young females. The aim of this study was to asses the patterns of drug resistance, outcomes & risk factors of MDR-TB among young females aged <30 years attended Government Fever Hospital, Guntur, Andra Pradesh, India. Methods: A retrospective, observational, hospital based study conducted from January 2019-December 2020. Department of Pulmonary Medicine, Grant Government Medical College, Mumbai, Maharashtra, Background: Linezolid is an oxazolidinone class of drug, a part of group B 2 nd line AKT, Forms the important component of MDR/XDR TB treatment. However, it causes serious adverse effects which affect patient compliance & hinder in therapy to a larger extent. To effectively deliver the available treatment regimen and ensure patient compliance, it is important to manage ADRs more efficiently.

1. To study the various ADRs of linezolid in drug resistant TB patients and its association with demographic factor and comorbidities 2. To study the Average duration taken to produce the side effect, role of early recognition of ADRs and reduction of dose /withdrawal of the drug and its effects. Methods: Patients on linezolid containing regimen over one year period were screened. 34 patients were found to have developed linezolid induced ADRs. They were further studied with above mentioned aims and objectives. Results: Of the 230 drug resistant TB patients screened, 34 patient developed Linezolid induced ADRs like Peripheral neuropathy, optic neuritis, bicytopenia, blackening of teeth in decreasing frequency. Age, female gender, low body weight, preexisting DM, concomitant use of Cycloserine were found to be the common factors associated with ADRs. Most of the patient had to stop/or reduce the dose. Symptoms improved mostly once drug was stopped / reduced the dose at the earliest. Conclusion: Early recognition of ADRs and action is associated with better patient compliance to DR-TB treatment and also early replacement in case Linezolid has to be discontinued. Department of Respiratory Medicine, Tirunelveli Medical College and Hospital, Tirunelveli, Tamil Nadu, India. E-mail: dr.karthik1992@gmail.com Background: Tuberculous meningitis (TBM) is the severe form of infection caused by Mycobacterium tuberculosis, resulting in death or disability in more than half of those affected. TBM needs to be diagnosed and treated early as it is associated with high mortality and severe morbidity especially in endemic countries like India. The aim of this study is to do situational analysis of diagnosis and treatment outcome of TB meningitis in tertiary care hospital. Methods: It's a cross-sectional study with sample size of 50 patients. After obtained consent from the patients, basic information of the patient were noted. The patients were evaluated clinically and investigated with routine blood investigations. Lumbar puncture was done and CSF analyzed. CT/MRIbrain was taken for all patients. All diagnosed Patients were started on ATT regimens based on the standard FDC treatment regimens by NTEP. After completion of ATT patients were categorized as asymptomatic with or without persistent neurological sequel. Results: All patients were treated with standardized FDC regimens and most of the patients received ATT for 9 months (83%). The treatment outcome with the standard FDC regimen showed a treatment completed in 72%, lost to follow up in 12% and mortality rate of 16%. Among the Cinically and radiologically diagnosed patients, 70% completed treatment and 18% reported to have persistent neurological deficit. Conclusion: Duration of antituberculosis treatment regimens about 9 months had a better outcome and early diagnosis of TBM and early initiation of ATT was the most important factor for deciding the outcome in TB Meningitis. Department Respiratory Medicine Shri Sathya Sai Medical College and Research Institute, Kanchipuram, Tamil Nadu, India. E-mail: abiraminallathambi@gmail.com Aim: To assess the lung function abnormality and differentiate the pattern in patients with Pulmonary Tuberculosis (PTB) sequelae who were treated for PTB a decade ago. Methods: It is a cross-sectional descriptive study conducted in a tertiary care hospital with a total of 80 patients with PTB Sequelae who were treated for PTB 10 years ago, who were assessed with Spirometry and DLCO. Patients with active pulmonary tuberculosis patients, extra-pulmonary tuberculosis patients, and severe respiratory distress were excluded. Results: Of the 80 patients, the mean age was 52.6±12.2 years, 50 patients were male and 30 patients were female, Mixed pattern was the most common one which was seen in 33 (41.2%) patients, followed by an obstructive pattern in 20 (25%) patients and restrictive pattern in 19 (23.8%) patients and 8 (10%) had Normal pattern, 20 subjects (25%) had small airway obstruction disease and 15 (18.8.6%) patients had severe DLCO. Among subjects with restrictive pattern (n=19), 7 (36.8 %) had severe restriction. Conclusion: PTB has a significant effect on lung function even after a decade post successful completion of treatment. Routine use of spirometry and early identification of these patients will decrease the burden of post Tuberculosis sequelae in India and also around the World.

Background: COVID-19 pandemic had adverselyaffected the services of National TB Elimination Programme (NTEP).which ultimately led to psychological distress among pulmonary tuberculosis patients. Methods: ACross-sectional, hospital-based study which included 361 Pulmonary Tuberculosis patients.Three predefined questionnaireswere used for the analysis:1. Semistructured questionnaire to evaluate anxiety-related to et al) . 2.Patient Health Questionnaire, (PHQ-9) for depression and 3. The Fear of COVID-19 Scale (FCV-19S) questionnaire (Griffith, et al) .

Results: Among the 361 of the Pulmonary Tuberculosis patients, 13%(n=47) hadCOVID-19 infection. Younger age group,18 to 30 years constituted majority of the study subjects i.e.,61%(n=220) and majority of them had drug resistant tuberculosis 66% (n=165, p=0.002). Out of the total subjects 69%(n=250) were drug resistant.The proportion of anxiety,fear and depression due to COVID-19was found in 49% (n=177), 23% (n=83), 67% (n=247) of the subject respectively. Delay in initiation of antitubercular treatment was found in 58% (n=210) of the study population, among which majorityi.e.,69% (n=172, p=0.011) were with drug resistance tuberculosis. The trend analysis of the psychological distress showed peak in accordance with the COVID-19 pandemic. Conclusion: Most of the drug resistant pulmonary tuberculosis patients had delay in initiating the antitubercular treatment during the pandemic. Preponderance of younger age group was seen in the pulmonary tuberculosis patients and majority of them had drug resistant pulmonary tuberculosis. Depression was the predominant psychological distress among the study subjects during the pandemic.

Department of Pulmonary Medicine, Burdwan Medical College and Hospital, Bardhaman, West Bengal, India. E-mail: s.raghulraj@gmail.com Background: The management of MDR-TB with multiple drugs in the regimen in a case of coagulation defect is not well-documented in literature. A number of anti-TB drugs can cause haematological abnormalities. Case Study Case 1: A 30-year-old diabetic male born of a consanguineous marriage with combined Factors V and VIII deficiency mild severity disease with similar history among his sisters, presented with fever, weight loss, anorexia, productive cough with recurrent haemoptysis for 3 months. His chest radiograph showed right middle and lower zone patchy infiltrates. He was treated with FFP for haemoptysis. He was diagnosed as rifampicin resistant TB on sputum CBNAAT and treated with Shorter MDR regimen (PMDT 2019). Case 2: A 16-year male born of a non-consanguineous marriage with severe Haemophilia B with similar illness among his family members, presented with haemoptysis and fever for a month. Radiologically he had right middle and lower lobe consolidation with cavitary lesion and was diagnosed as rifampicin resistant TB on CBNAAT. After starting the shorter all oral regimen with Bedaquiline, he developed hepatotoxicity two months later which was managed by withholding the regimen for 2 weeks and restarted. He received factor VII administration throughout the treatment as before. Discussion: Some of the anti-TB drugs such Linezolid, Pyrazinamide, Rifampicin, Isoniazid in the order of frequency can cause haematological abnormalities which should be administered with caution and close monitoring. Conclusion: MDR-TB can be treated safely in a patient with coagulation factors deficiency under close supervision and regular follow-up to avoid risk of bleeding. Department of Respiratory Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, Background: NTM mainly exist in the environment as saprophytes. One of them is Mycobacterium chimaera, an environmental contaminant. It is an opportunistic pathogen. Respiratory infections may develop through inhalation of aerosolized particles containing the pathogen, usually in immunocompromised patients and who have a history of cardiac bypass surgery and have been on ECMO. Case Study: A 60 year old male presented with history of fever, productive cough and shortness of breath on and off for last 5 years. He had taken ATT twice for smear positive pulmonary TB with partial resolution of symptoms and recurrence. On detailed evaluation, his sputum smear was positive for AFB, CBNAAT was negative and AFB culture showed growth of Mycobacterium chimaera. Patient was started on a regimen of clarithromycin, rifampicin and ethambutol. Discussion: M. chimaera is mainly a water-borne NTM of Mycobacterium avium complex (MAC) group. It is transmitted through inhalation of aerosolized particles containing the pathogen. It has been mainly reported following open heart surgery requiring ECMO due to the use of contaminated heater-cooler units. It is an indolent infection causing disseminated disease. Clinical features are often non-specific. Conclusion: NTM is a rare entity but should be focused upon in certain clinical situations. NTM like M. chimaera can remain clinically dormant for years and therefore making the diagnosis timely is a challenge.

Background/Introduction: Most studies of nosocomial pneumonia have focused on ventilated ICU patients. There has been a paucity of studies of HAP outside ICU. Previous studies have identified an incidence ranging from 1.6 to 3.67 cases per 1,000 admissions for non-ICU HAP; however, few studies have reported the risk factors for HAP and outcomes outside the ICU. Aims/Objectives: To determine the incidence of non-ICU HAP, to elucidate the risk factors for the same, estimate mortality and to find out the determinants of poor outcome. Methodology: Patients admitted to ward with no features of pneumonia at admission were included and followed up on a daily basis for development of HAP. Lower respiratory specimens were collected to determine the etiology. They were followed up with regard to length of hospital stay, need for ICU care, need for mechanical ventilation and in-hospital mortality. Multivariate regression analysis was done to find out the risk factors associated with occurrence of HAP and determinants of poor outcomes in HAP. Results: 1377 patients were admitted within the study period of which 431 with stay of < 48 hours were excluded. 114 patients developed HAP giving an incidence of 12%. The risk factors associated with the development of HAP were > / = 2 hospitalisations in the previous year, diabetes mellitus and group D COPD. Risk factors for poor outcome included prior carbapenem use, HAP with NF-GNB and past history of CVA. 11 patients with HAP expired during the hospital stay giving a crude mortality rate of 10%. Conclusion: The incidence of non-ICU HAP in pulmonary wards was 12%. Crude mortality rate was noted to be 10%. Well defined risk factors were identified for development of HAP as well as poor outcomes in HAP.

Pulmonary mucormycosis: Incidental finding in case of dengue with type 1 diabetes mellitus Shubhra Srivastava JN Medical College, AMU, Aligarh, Uttar Pradesh, Background: Pulmonary Mucormycosis is uncommon but serious opportunistic fungal infection caused by fungi of Mucor genus through spores inhalation. Risk factors are diabetes mellitus, hematologic malignancy, transplant and moderate to severe COVID. Here we present a case of 18year female, with new onset diabetes mellitus with dengue, finally diagnosed as a case of pulmonary mucormycosis. Case Study: 18-year female with high grade fever, dry cough, presented in diabetic ketoacidosis (new onset diabetes). Blood investigations revealed metabolic ketoacidosis, leucocytosis, thrombocytopenia, HbA1C of 14.4, ketone and glucose in urine examination, dengue serology positive. She was admitted in ICU under broad spectrum antibiotics, insulin infusion and platelet transfusion. Chest X-ray suggested bilateral inhomogeneous nodular opacities. Chest computed tomography showed multiple groundglass nodules and focal consolidation. Bronchoscopy done for nonresolving pneumonia suggested crusting at opening of right lowe lobe apical segment. Biopsy taken which resulted in diagnosis of pulmonary mucormycosis. Patient started on oral Posaconazole (300mg) along with insulin to manage diabetes and currently under follow-up. Discussion: In our case hyperglycemia, ketoacidosis, dengue all act to suppress innate immune response and provide facultative environment for fungal proliferation. Diagnosis based on both histopathology and cultures. Our patient is young age and clinically/vitally stable, so we started Posaconazole (300mg) while majority of published studies recommended liposomal amphotericin-B. Conclusion: Pulmonary mucormycosis can even occur in young age with new-onset type 1 diabetes mellitus. Background and Aim: Tuberculosis is one of the most common causes of death in the world. Drug resistance has become more common in previously treated patients, who were treated irregularly or with improper regimens and doses. Previous TB treatment is an important risk factor for developing DR-TB. So goal of this study is to look the clinico-microbiological profile, treatment outcomes, and follow-up of patients who were registered for DRTB and IRL at Puducherry tuberculosis unit. Materials and Methods: This study included 73 patients who were treated for drug-resistant tuberculosis at DRTB/IRL during 2014-2020. Their clinical condition, microbiological parameters, drug resistance pattern, laboratory profiles, and radiological results were taken into consideration. Patients with favourable and unfavourable outcomes (completed treatment, cured, failed) were followed up using random sampling method. Patients followed up at home or in hospital and their current clinical findings, sputum smear status, and radiological data were recorded. Results: 73 patients were included with mean age of 43.83±15.20 years. Treatment outcomes of patients as follows: 57 patients cured (78.08%), from the cured patients 16% were died during follow up period, 1.4 % completed treatment, 4.1% died before completing the treatment, 4.1% were lost to follow up and 2.7% had treatment failure. Conclusion: Treatment success outcomes occurred more than 3/4 th of cases, which is higher than the WHO of at least 75% success rate. There were 16% patients who died during the follow up period of study, which resulted an unfavourable outcomes.

Background: The burden of multidrug-resistant (MDR) tuberculosis (TB) is increasing and threatening worldwide. An estimated 480,000 people developed MDR-TB globally in 2014. However, only an estimated 26% (123,000 people) were notified and even fewer (111 000, ∼23%). The number of MDR/ Rifampicin Resistant TB cases in India is 124000(9.1/lakh), Considering the effectiveness of shorter regimen for the treatment of MDR-TB patients we have planned this study to assess the effectiveness of shorter regimen among MDR-TB patients at rural tertiary care centre of North India. Methods: A hospital based prospective, longitudinal study of a moxifloxacin based directly observed regimen was done between January 2020 to June 2021. The treatment given of 4-6 months of intensive phase and 5 month continuation phase. Patients were monitored using liquid culture after treatment completion. Results: This study reveals that 76% patients were cured and 24% patients failed to cure, among all the patients. Treatment outcome was found significantly associated with smoking and previous history of ATT as inadequately treated (P < 0.05). Conclusion: Mean age of study participants was 31±15.11 years with 59% were male and 41% were female. Most common age group was 18-45 years with 72% patients. Treatment outcome was negatively associated with smoking and previous inadequate treatment for tuberculosis. Most common adverse effect observed was Gastro-Intestinal intolerance. Department of Pulmonary Medicine, Chalmeda Anandrao Institute of Medical Sciences, Karimnagar, Telangana, India. E-mail: vsaikrishnarao2274@gmail.com Background: ATT forms the mainstay of treatment of pulmonary tuberculosis. However, these drugs cause rare but serious side effects,RIFAMPICIN is the most studied drug to cause thrombocytopenia and agranulocytosis but isoniazid induced thrombocytopenia are rare. Case Study: A 24yr old male patient presented to ER with complaints of bleeding from nose, blood in stool and rash all over the body since 3days.He was on CAT 1 ATT for sputum positive pul TB since 3months,presented with thrombocytopenia, ATT was immediately withheld and was investigated for cause of anemia and thrombocytopenia, thrombocyte suspension was given until a normal thrombocyte count was obtained, After several start-stop trails, first R AND H were identified as the possible cause of thrombocytopenia and were removed from regimen. The patient is treated with altered regimen of ATT drugs. Discussion: ATT induced thrombocytopenia and anaemia are rare and serious side effects of anti TB drugs. Drug induced thrombocytopenia is a frequent condition. George et al collected case reports and defined the 4 standard criteria to explain the association between the drugs and thrombocytopenia. Conclusion: Although (H) induced thrombocytopenia has been defined previously there have been very few cases reported so far to knowledge but early identification of the offending drug can prevent serious complications and save lives. Department of Pulmonology, Chalmeda Anand Rao Institute of Medical Sciences, Karimnagar, Telangana, India. E-mail: vsaikrishnarao2274@gmail.com Background: Before the availability of anti TB treatment, laryngeal involvement was considered as a grave prognostic sign suggestive of severe disease and was seen in nearly one third of cases. Post availability of anti TB treatment the incidence of laryngeal TB has reduced to less than 1%. Case Study: A 51years old male came to OPD with complaints of fever, cough, loss of appetite and weight since 3months and change in voice,hoarseness of voice, odynophagia since 10days and he was investigated with Chest X Ray, Hrct Thorax, Blood Investigations, Ent Examination, Sputum Examination And Bronchoscopy Was Done. Discussion: Laryngeal TB classically develops due to bronchogenic spread which is frequent in sputum smear positive pulmonary TB and most commonly involves the posterior glottis. This results in localized edema, grauloma, or ulcerations. Incidence of laryngeal TB mostly seen in 40s and 50s and age ranging from 25yrs to 75yrs.Apical TB with laryngeal involvement though rare can be managed with anti TB treatment. Conclusion: Laryngeal TB is less common in comparison to Laryngeal TB secondary to Pulmonary TB with early diagnosis the response to treatment is satisfactory. E-mail: drjagmohan99@gmail.com Background: Nocardia is a gram-positive, weakly acidfast, filamentous bacteria belonging to Actinomycetes. Currently about 30 species of Nocardia have been described which can cause disease in humans. Among them, Nocardia asteroides is responsible for about 70% of the infections Nocardiosis occurs most commonly inimmunocompromised patients. Nocardiosis primarily effects lungs (75-80%) and the other organs that can be effected are brain, skin and rarely kidney and liver. CASE REPORT: A 42-year-old male presented with fever, productive cough with episodes of hemoptysis and breathlessness from one week and altered sensorium and tremors since 3 days. He was a chronic alcoholic, with history of binge drinking from 1 month and stopped since 3 days. He did not have any other significant past, personal or drug history. On examination, he was conscious but drowsy. He was febrile with body temperature of 1020F, pulse rate was 124beats/min, respiratory rate was 28 cycles/min and Blood pressure was 114/70mmHg. His O2 saturation was 88%. On systemic examinations, fine crepitations were heard in all the areas of right lung. Other systems examinationwas unremarkable. His blood investigations revealed TLC-17,250cell/mm3. Other investigations (Hb, platelet count, RBS, RFT, LFT, FBS, PPBS, HbA1C) were normal. VCTC was negative. Chest x-ray showed non-homogenous opacities, infiltrations and two thin walled cavities in right lung upper and middle zone. Differential diagnosis of community acquired pneumonia or pulmonary tuberculosis in alcohol withdrawl state was made and patient was started on Inj. Linezolid (600mg bid), Inj.meropenem (1g tid) and bronchodilators. 4hrs after admission, patient became tachypneic and his oxygen saturation was not maintained on oxygen face mask. Then patient was intubated and kept on ventilator. Despite broad-spectrum antimicrobial therapy, patient's condition was deteriorating. ATT was planned to start but several sputum samples collected and tested for the presence of acid-fast bacilli, were negative. Sputum for Gene Xpert was also negative. Sputum Gram stain revealed Gram positive thin branching filaments. Modified Ziehl-Neelsen staining showed branching Acid fast bacilli consistent with the morphology of Nocardia species (Figure 3 ). Culture and sensitivity of tracheal aspirate identified the organism as Nocardia. Tablet Cotrimoxazole (160/800mg DS tablets bd) was added to meropenem. Patient improved clinically and radiologically and was discharged after 15 days and advised to continue Cotrimoxazole for 9 months. Patient is coming for follow up and is doing well. cxr showed right upper mid and lower zone opacity with cavity Sputum Gram stain revealed Gram Modified Ziehl Neelson staining showed positive branching filaments branching Acid fast bacilli. Conclusion: Pulmonary nocardiosis, though a well recognized entity, is often missed due to its clinic radiological similarities with tuberculosis. Our report emphasizes that a high level of clinical suspicion is required in patients without risk factors. In a patient with pneumonia if the lung infection responds poorly to antimicrobial therapy for community acquired pneumonia, pulmonary nocardiosis should be considered and a careful search for evidence of the organism is necessary.

Dennis Simon 1 , Jayant B. Chauhan 2 1 Department of Pulmonary Medicine, Baroda Medical College, Vadodara, Gujarat, India, 2 Department of Pulmonary Medicine, Baroda Medical College, Vadodara, Gujarat, Background: TB is the most common and serious opportunistic infection in HIV positive patients and the initial manifestation of AIDS in 50% of cases in developing countries. This research aims to analyse the adverse events reported by patients with HIV/TB coinfection and taking both ATT and HAART and to determine the sociodemographic and clinical profiles. Methods: This was a time bound study done in a tertiary hospital. All HIV TB coinfected patients (>18 years) on ATT and HAART were included in the study. Patients were examined for any drug reactions and blood examination was done and followed up every 3 months for six months. Results: A total of 50 TB/HIV co-infected patients were taken for the study. • Mean age of the patients was 38 years (25-50years). • 82% were male. • BMI of around 18 is more prone to have tuberculosis.

(62%) • Drivers and urban group were commonly affected.

(44%) • Abdominal (70%), neurological and dermatological complaints were seen most commonly after ART initiation. • Most common chest Xray findings were infiltrates in upper zone followed by lower zone. • TB IRIS seen in 6% of the patients. • Zidovudine and Rifampicin are the drugs causing haemolysis. • Tenofovir, Protease Inhibitors and Rifampicin are the nephrotoxic drugs. • Nevirapine, efavirenz, Ritonavir, Rifampicin, Isoniazid, pyrazinamide are the hepatotoxic drugs • Streptomycin caused SNHL in two patients Conclusion: Improvements in both ATT and ART drugs is needed to shorten the duration of TB treatment, with no drug-drug interactions, and very minimal toxicities so that treatment for both diseases can be optimized.

Department of Pulmonary Medicine, Government Medical College, Vadodara, Gujarat, India. E-mail: dennis.k.simon@gmail.com Case History: A 52-year-old male who had past history of asthma for 10 years admitted to our hospital. He had complained productive cough with brown plugs and slight fever for a month followed by blood in sputum for 7 days. Diagnosis: HB 8g/dl; Total count: 20,000/cumm; Blood eosinophils: 10% on differential count; Absolute eosinophil count: 2500 IU/ml Sputum for smear and Gene X-pert: MTB not detected Aspergillus specific IG E: 81 IU/ML Stool routine examination: No parasites, ova, or cyst C ANCA: Negative Imaging: Chest radiographs reveal a solid round mass within a cavity in the right upper lung field and few pulmonary infiltrates. HRCT Thorax showed features suggestive of aspergilloma; Multiple cysts, cavities and central bronchiectasis were also found. Sputum for fungal culture: Aspergillus Fumigatus Others: positive precipitin reaction for aspergillus He was diagnosed with possible ABPA, and the mycetoma may be pulmonary aspergillosis. Haemostatic drugs like ethamsylate were given intravenously 250mg thrice daily for 10 days; Proper bed rest was given. Haemoptysis subsided after that. He had administrated antifungal agent, Tab Itraconazole 200 mg twice daily continuously for 6 months. Discussion: Aspergillus infection usually, results from saprophytic growth within pre-existing cavities. Controversially, in this case, multiple cysts and cavities may be caused by aspergillus infection, which is extremely rare. We suppose that cysts and cavities might be formed by the check valve mechanisms. Outcome: Multiple cysts and cavities were all disappeared and the patient responded very well and there were no further episodes of haemoptysis too.

Background: Rasmussen's aneurysm is an inflammatory pseudo-aneurysmal dilatation of a branch of pulmonary artery adjacent to a tuberculous cavity which if ruptures, though uncommon, can cause life threatening massive hemoptysis. Case Study: A 57-year old male with DM presented with productive cough since 1 month and hemoptysis since 5 days around 50ml daily. No history of pulmonary tuberculosis or other illnesses. CT pulmonary artery angiogram showed large pseudoaneurysm with AV fistula arising from the right lateral basal segmental artery, 3.3x5.6x4.9cm, causing compression of the adjacent bronchus and collapse consolidation of the adjacent lung. Aberrant origin of the right subclavian artery from the aortic arch and Bovine aortic arch and few enlarged partially necrotic lymph nodes in paratracheal and para esophageal regions were also noted. This was suspected to be secondary to infective etiology ?Rasmussen's aneurysm ?Mycotic aneurysm. Patient underwent pulmonary artery pseudoaneurysm embolization with vascular plug. Patient was started on first line anti-Tuberculosis Treatment along with antibiotics and was also advised for right lower lobectomy and AV fistula excision. Discussion: Rasmussen's aneurysm occurs from progressive weakening of the wall from adjacent cavitatory tuberculosis and granulation tissue and fibrin subsequently replaces the tunica adventitia and media, causing thinning of arterial wall, pseudoaneurysm formation and subsequent rupture and hemorrhage.

Life-threatening massive hemoptysis can arise from a pseudoaneurysm of pulmonary artery or its branches contiguous to a tuberculous cavity. Such pathology should be differentiated from a bronchial source of bleeding by urgent CTA and may require emergency endovascular management techniques.

Mdr regimen in Coimbatore, Tamil Nadu: A retrospective study

Department of Thoracic Medicine, Coimbatore Medical College Hospital, Coimbatore, Tamil Nadu, India. E-mail: jeswynrobert@ yahoo.in

The global incidence of MDR-TB is 3.4% in new cases and 18% in previously treated cases. However, information about management and clinical outcomes of patients on shorter MDR regimen is scarce and hence the need for this study. Methodology: This is a 3-year retrospective cohort study of 129 patients on shorter MDR drug regimen registered in Coimbatore district. Patients demographic details, BMI, comorbid status, HIV status and other clinic-social characteristics data were taken.Clinical outcomes were cured, died, lost to follow up, treatment completed, treatment failure, Treatment regimen change. Association between clinical outcomes and factors associated were studied and analyzed. Results: Among 129 patients, majority were male, age group between 41-60 years. The outcome was-52 patients got cured, 27 patients died, 19 patients treatment completed, 19 patients lost to follow up, 5 patients had treatment failure, and treatment regimen was changed in 7 patients. There were no significant difference in outcomes with BMI, Rural vs Urban, Old Vs new case. Cured rates were significant among non-smokers, non-alcoholic, nonhypertensive patients. Death rate was significant among smokers. Treatment completed was significant among non-smokers, non-alcoholic. Conclusion: Better outcomes in Patients on shorter MDR drug regimen is seen among non-smokers, non-alcoholics, non-diabetics and non-hypertensive patients.

College and Sir JJ Group of Hospitals, Mumbai, Maharashtra, India. E-mail: bavithrra.muthu@gmail.com Background: Mycobacterium avium complex (MAC) is a ubiquitous pathogen, widely distributed in the environment including water, soil and animals. It is an uncommonly encountered clinical pathogen, primarily causing pulmonary infections in patients with underlying lung disease or disseminated disease in immunocompromised hosts. Sporadically, extra-pulmonary infections have been documented of the liver, spleen, skin, soft tissue and lymph nodes. Breast abscess due to MAC in an immunocompetent patient has not been reported yet. Case Study: A 40 year old female presented with complaints of pain and swelling initially in the left breast, later in right side also, with no co morbidities, married, multipara, with regular cycles. Ultrasound of breast was suggestive of bilateral duct ectasia with intra ductal echogenic masses with thick walled abscess. Pus aspirate culture showed growth of Mycobacterium intracellulare susceptible to Amikacin, Clarithromycin, Linezolid, Imipenem. She is being treated with Clarithromycin, Rifampicin, Ethambutol and Amikacin. Patient was evaluated for other immunocompromised states like anemia, chronic kidney and Liver disorders.CD4 count was also done. All reports were normal. Discussion: It is important to consider rare infections also such as MAC in immunocompetent patients, regardless of symptoms and the severity. Conclusion: Rare infection if timely diagnosed, will lead to effective treatment and cure.

Department of Respiratory Medicine, Pramukhswami Medical College, Karamsad, Gujarat, India. E-mail: rahulahir4438@ gmail.com Background: Emergence of drug resistance and development of multidrug-resistant tuberculosis has become a significant obstacle for tuberculosis (TB) control. As rifampicin-resistance is an important indicator for drug-resistant-TB, rapid diagnosis of tuberculosis and detection of rifampicin-resistance are essential for knowing the magnitude of problem and early management of drugresistance-TB. Cartridge-based-nucleic-acid-amplificationtest (CBNAAT) is an essential investigation which help us in early diagnosis and treatment of tuberculosis patient according to rifampicin-susceptibility. Methods: Total 297 microbiologically confirmed cases of pulmonary tuberculosis registered for treatment under RNTCP (now NTEP) during study period were included and their sputum reports were evaluated for study. Results: We had enrolled 297 patients who were microbiologically confirmed cases of pulmonarytuberculosis. Majority of patients were in the age group of 18-30 years (37.4%) and predominant were male (62.3%). About 90 (30.3%) patients were previously treated under NTEP, out of them 65 patients had completed treatment and rest 25 patients were defaulter. Amongst 297 patients, 7.08% patients had concurrent seropositive-illness(HIVpositive). AFB was detected in sputum microscopy in 263 patients (88.55%). According to the Sputum CBNAAT result, 15(5.05%) patients were resistant to rifampicin. Among rifampicin-resistance cases 60% were in age group of 18-30 years and 93.3% had past history of tuberculosis out of which 78.8% had defaulted treatment in past which statistically significant (p-value:<0.05). Conclusion: Patients with past history of tuberculosis are at high risk of developing MDR. Rifampicin-resistance cases are more prevalent in male, younger age and treatment defaulter in our study.

Department of Pulmonary Medicine, Andhra Medical College, Visakhapatnam, Andhra Pradesh, India. E-mail: aswinikovvada@ gmail.com, Background: The incidence, mortality and morbidity of lung abscess was high in the pre-antibiotic era but with the advent of powerful antibiotics there is fall in both. With the emerging antibiotic resistance and change in the trends of bacteriological profile causing lung abscess, it is the need of time to reevaluate lung abscess profile. Aim: The study aimed to determine the clinical, radiological and bacteriological profile of lung abscess. Methodology: The study was a retrospective study conducted in the department of pulmonary medicine, Andhra medical college, Visakhapatnam during October 2020 to October 2021. Demographic, clinical, radiological, bacteriological, antibiotic sensitivity and treatment data were collected from the hospital (GHCCD) data and analysed. Results: 92 adult cases of lung abscess were included, and with a male to female ratio of 6.6:1. The most common predisposing factor was an unhygienic oral cavity in 28% of cases with alcohol ingestion being the most important risk factor in 22% of cases. The most common organism found in lung abscess cases was Klebsiella pneumoniae, and they were sensitive to ceftazidime. Conclusion: Our study shows that Klebsiella pneumoniae should be considered an important pathogen in communityacquired lung abscesses and all the available parameters should be used in treating lung abscess cases so that there is good outcome.

Department of Pulmonary Medicine, Andhra Medial College, Visakhapatnam, Andhra Pradesh, India. E-mail: aswinikovvada@ gmail.com Background: Life threatening hemoptysis in patients with pulmonary aspergilloma should be managed by surgical resection but may have poor prognosis. Case Study: A 52year old male patient with past history of type 2 diabetis mellitus and chronic renal failure and using Anti tubercular treatment since3 months presented with chronic hemoptysis. Clinical presentation and workup revealed a left lung Aspergilloma, with chest x ray and CT chest showing thick walled cavitory lesion with intracavitory soft tissue mural nodule on the upper lobe of left lung and FNAC showing Aspergillus. In view of recurrent and massive hemoptysis patient was referred to CT surgery department and underwent thoracotomy with left superior lobectomy. Histopathological examination of specimen showed hyphae with septa. The patient had postoperatively controlled pleural effusions. Discussion: Type 2 diabetis mellitus and chronic renal failure are risk factors for Aspergillus infection because of the immunocompromised state when chronic hyperglycemia and hyperuricemia occur. Pulmonary Aspergilloma has poor prognosis after surgery. Removing aspergilloma of the lung cavity and maintaining blood glucose and urea levels can provide good prognosis. Conclusion: Pulmonary Aspergilloma that involves only one lung lobe has a good prognosis after surgery.

Department of Respiratory Medicine, Government Medical College, Bhavnagar, Gujarat, India. E-mail: yeshakakak@gmail.com Background: Tuberculosis is a major cause of ill health, one of the top 10 causes of death worldwide and the leading cause of death from a single infectious agent. Faster reduction in TB incidence and death requires prompt diagnosis using highly sensitive diagnostic tests including Drug Resistant TB in country. Gastric aspiration has been applied in pediatric population for suspect TB cases. These study was carried to find diagnostic role of Gastric aspirate in adults. Methods: Retrospective study conducted at Government Medical College Bhavnagar from May 2019 to November 2021. 230 Patients taken in the study were classified into: 1. Those who have sputum production with radiologically active lesion but sputum smear negative for AFB. 2. Those patients who have neurological deficits and very sick patients who cannot bring out sputum. 3. Those who have a radiological significant lesion without sputum production. Patients were kept NBM overnight before the procedure. Evaluation of gastric aspirate fluid was done by AFB smear and CBNAAT method. Of the 79 patients enrolled, KatG mutation was seen in 48(61%) patients and InhA mutation was seen in 27(34%) patients and InhA and KatG was seen in 4(5%) patients. 60(76%) patients were detected with primary monoresistance whereas 19(24%) patients were previously treated PTB patients. Positive treatment outcomes were seen in 70(88.6%) patients, and Negative treatment outcomes were seen in 9(11.39%) patients. CKD and history of previous treatment to TB was associated with statistically significant poor treatment outcomes. Conclusion: As per Drug resistance profile studied, the commonest mutation found was Kat G. Though Kat G resistance is associated with High level of resistance, there was no statistically significant difference in the treatment outcomes of those patients. Hence to achieve better outcome emphasis should be on improving treatment adherence, treatment of adverse events, comorbidities and close follow up. 

Department of Respiratory Medicine, Dr. D. Y. Patil Medical College and Research Centre, Pune, Maharashtra, Background: Tuberculous lymphadenitis (TL) will be the initial differential diagnosis in a patient with the enlarged lymph node in developing countries like India. Fine needle aspiration cytology (FNAC) and Ziehl Neelsen (ZN) smears were lacking both sensitivity and specificity in detecting Tuberculosis. The goal of the present study is to see how well the CBNAAT (Cartridge Based Nucleic Acid Amplification Test) performed in detecting MTB and RIF resistance directly from a TB suspected lymph node tissue. Aim: The present study aimed at a detailed clinical profile evaluation and also to assess the role of CBNAAT in the diagnosis of suspected/proven cases of tubercular cervical lymphadenitis to significantly improve the accuracy and rapid diagnosis of Tuberculous lymphadenitis. Methods: Study was conducted in Dr Dy Patil medical college which included 100 suspected/proven cases of TB Cervical lymphadenopathy(TBLN),a detailed clinical history and evaluation was carried out, all patients underwent FNAC and excisional biopsy was done in inconclusive cases of FNAC and detailed analysis was done. Results: Fever was the most common symptom followed by loss of appetite/weight, Jugular group of lymph nodes are most commonly involved. FNAC-CBNAAT had a good sensitivity(74.29%) and also specificity(68.18%), whereas excisional biopsy had a very good sensitivity(94.4%) and specificity(100%) in inconclusive cases of FNAC. Conclusion: CBNAAT has a high sensitivity and specificity, allowing it to be used to better diagnose, manage, and treat suspected TBLN patients. Excisional biopsy should be considered of all inconclusive/negative reports in patients who are strong suspects of tubercular lymphadenopathy particularly in endemic countries like India.

Department of Pulmonary Medicine, Chandigarh, Background: ABPA is a complex immunological pulmonary disorder caused by hypersensitivity to antigenic products released by Aspergillus fumigatus colonizing the tracheobronchial tree in bronchial asthma and cystic fibrosis patients. ABPA is often misdiagnosed as tuberculosis caused by Mycobacterium tuberculosis in a high TB burden country like India but rarely co-infection is seen. Case Presentation: Here we report a 48 year old male suffering from Childhood Bronchial Asthma with diagnosed and treated ABPA in remission (2019). He presented with dyspnoea, wheezing and cough for a week in 2021.The total IgE was raised (1802 IU/ml) and found to be >50% from the previous baseline (85.6 IU/ ml). Serial chest x-rays revealed fleeting opacities. Thus he was diagnosed as ABPA exacerbation (ISHAM-ABPA working group criteria) and started on oral itraconazole and prednisolone and followed up. Despite adequate treatment he continually deteriorated and after 2 months he was admitted with increased dyspnea. CECT chest revealed multifocal ill-defined confluent cavitatory patches of consolidation with air fluid levels. Sputum examination was inconclusive. Bronchoscopy was done and BAL AFB stain was positive. Anti-tubercular treatment was started with continuation of the treatment for ABPA. On follow up marked clinical and radiological improvement were noted after the completion of 6 months. Conclusion: Very few cases of co-infection of both the diseases have been reported so far although the occurrence of ABPA in other structural lung diseases including scars of old healed pulmonary tuberculosis is known in literature.

Department of Pulmonary Medicine P. D.U. Civil Hospital, Rajkot, Gujarat, Background: A 58 year old, male patient,chronic smoker, farmer by occupation known case of chronic obstructive pulmonary disease (COPD) since 2 months and hypertension since 2 years with metastatic squamous cell carcinoma of lung on chemotherapy referred from private hospital to our department with breathlessness, dry cough and bilateral chest pain since 4-5 days. Objective: To Highlight RSV Superinfection In Lung Carcinoma Case. Methods: Patient was on chemotherapy for metastatic squamous cell carcinoma of lung. Then he developed above mentioned symptoms and patient's throat swab was taken for RTPCR in which all possible respiratory pathogens had tested among which Human RSV (type a and b) was detected. Results: To which, according to antibiotic sensitivity report, intravenous and oral antibiotics administered. Although being dangerous superinfection, eventually patient improved clinically and haematologically and got discharged. Conclusion: Timely intervention is necessary to avoid the chance of superinfection in lung carcinoma patients due to immunocompromised state.

Himanshu Saini Department of Pulmonology, Max Superspeciality Hospital, Saket, New Delhi, India. E-mail: hsainiprivate@gmail.com Sarcoidosis is a systemic multisystem inflammatory disorder of unknown etiology characterized by the presence of non-caseating granulomas. Despite its long history, this disease remains enigmatic. Unidentified etiology and the multisystemic nature of the disease have made it more complex.In this case report we describe two patient with new-onset, biopsy confirmed sarcoidosis in the setting of COVID-19 pneumonia and we propose that the noncaseating granulomas in this case are due to sarcoid immune reaction to SARS-CoV-2. Earlier one case of sarcoidal granulomas mimicking scar sarcoidosis in a patient diagnosed with COVID-19 has been reported and one case of dermatologic manifestation, biopsy confirmed sarcoid-like reaction in the setting of COVID-19 pneumonia has been reported. Multiple etiological factors are known for a mediastinal mass. Lymphadenopathy due to several causes, neoplasms and various cystic mass lesions contribute to a major percentage. However, fungal infection presenting as a mediastinal mass is rarely reported. Invasive fungal infections are encountered often in immunosuppressive conditions. But, herein we present two cases of mediastinal masses in young immune-competent adult hosts.

Case 1: A 28-year gentleman, with history of cough and exertional dyspnoea, who was found to have a mediastinal mass on CECT Chest associated with right lower lobar consolidation and pleural effusion. He was evaluated elsewhere, where TBLB was done which was suggestive of granulomatous inflammation (AFB -ve). He was started on Anti-Tubercular Therapy, but without improvement. In that condition, he was referred to us and we planned mediastinal mass biopsy. Thoracotomy & biopsy of the mediastinal lesion was done, which proved it to be mucormycosis. Case 2: A 29 years young gentleman, presented with progressively worsening dysphagia, was evaluated with a CECT Chest, which showed mediastinal mass. EBUS FNAC was initially attempted, but failed to provide anything conclusive. A VATS Biopsy was then done, which was reported as invasive aspergillosis. Both these patients were treated with antifungals and showed clinical as well as radiological disease resolution. In Endemic areas empirical treatment of mediastinal adenopathy with anti tubercular drugs is a common practice. The Gold standard is to obtain enough tissue to achieve a correct diagnosis. In conclusion, Mediastinal lymphadenopathy due to fungal infections are rare and merit further study.

Department of Pulmonary Medicine, Osmania Medical College, Hyderabad, Telangana, India. E-mail: sreejapulmo@gmail.com Background: Cutaneous tuberculosis occurs rarely in spite of high and increasing prevalence of tuberculosis world wide.it is reported as <1% of all cases of tb. Diagnosis is difficult as it resembles many dermatological diseases. Case Study: A 75year female presented with a single, large swelling over left cheek since 4months, complaining of discharge of pus since 15days. On examination, a single, well-defined, size 10x10cm, erythematous swelling, firm to hard in consistency present over left malar region with surface telangiectasis, central crusting, skin is non pinchable, not fixed to underlying structures. nasal mucosa is normal, deviated left nasal fold. chest x-ray is normal, Mantoux test was positive, Dermascopy revealed arborizing vessels, punch biopsy showed keratin plugging in epidermis, dermis showed necrotizing granulomas with plasma cells, epitheloid histiocytes and Langhan's cells around blood vessels, adnexa extending into subcutis. The patient was managed with Anti-tuberculous drugs for 6 months. Conclusion: Some forms of cutaneous TB indicates an immunocompromised state or severe underlying infection that may be fatal, lupus vulgaris can be complicated by development of squamous cell carcinoma or other skin cancers in the scar 25-30yrs later in up to 10% patients. Department of Pulmonary Medicine, Government Medical College, Thrissur, Kerala, India. E-mail: das302867@gmail.com Background: Tuberculosis, is an ancient disease continues to remain even today as a major public health problems in developing world. HIV infected individuals co-infected with mycobacterium tuberculosis have an increases annual risk of 5-15% for developing active tuberculosis. Aim: 1. To study the radiological presentation of pulmonary tuberculosis in HIV Patients. 2. To study the radiological presentation of tuberculosis in HIV infection in relation to CD4 cell count. Methods:Informed consent excluding their personal details is taken from the patients.Their blood reports and microbiological status will be checked, chest x ray and CD4 cell counts are collected and later the results are analysed. Results: This study showed that 42.5% patients have CD4 cell counts between 150 and 300.And 20% patients have involvement of middle / lower lobe. We observed that predominant radiological pattern of pulmonary tuberculosis in HIV positive patients was pulmonary infiltrates which was in 57.8% patients. In patients with CD4 counts <200 we found that most common radiological pattern was infiltrates, miliary pattern and fibrosis. And on the other hand normal x ray, infiltrates, pneumothorax,mediastinal lymphadenopathy and cavity was seen in patients with CD4 >200. Discussion: In a south Indian study by Mahesha Padyana et al (1) found that in patients with CD4 <200 most common patterns infiltration (39%) followed by consolidation (30%) and cavity in 11%. And lymphadenopathy. In patients with CD4 >200, infiltrates (37.5%) followed by cavity (25%) and miliary 25%. Bilateral 68.5%, mid and lower zones or all zones involvement commonly seen. Conclusion: In our study, most common radiological presentation of tuberculosis was parenchymal infiltration. In CD4 <200 group infiltrates, miliary pattern and fibrosis predominant. In CD4 >200 normal xray, infiltrates, pneumothorax, mediastinal lymphadenopathy and cavity predominant. Department of Pulmonary Medicine, Osmania Medical College, Hyderabad, Telangana, Background: Oral cavity is an uncommon site of involvement of Tuberculosis. In oral cavity, tongue accounts for nearly half the cases. Case Study: A 64 year old male presented with complaints of difficulty in swallowing, hoarseness of voice, ulcer over tongue, loss of appetite and loss of weight. Biopsy revealed pseudo epithelial hyperplasia that was mistaken for malignancy. PET CT revealed hypermetabolic fibro cavitary disease which raised the suspicion of tuberculosis and sputum for AFB was done which turned positive and to rule out possibility of malignancy of tongue repeat biopsy of the tongue ulcer was done which showed granulomas with caseous necrosis and diagnosed as tongue tuberculosis and started on antituberculous chemotherapy and patient improved. Discussion: Tuberculosis of oral cavity even as secondary form is uncommon Conclusion: Tuberculosis should always be a differential diagnosis in a case of ulcer of tongue and deeper biopsies are advised for ulcers of tongue as superficial biopsy may not reveal the etiology due to epithelial hyperplasia. Department of Pulmonary Medicine, Osmania Medical College, Hyderabad, Telangana, Background: Hydatid disease is a parasitic infection caused by echinococcus granulosus. Thoracic hydatid cysts are rare even in endemic areas. 60 % cases affect right lung and 80% cases occur in lower lobes. Case Study: A 30 year old female presented with left sided chest pain, shortness of breath and cough with expectoration. Examination findings and chest X ray were suggestive of left upper lobe mass. CT chest revealed cystic mass lesion suspicious of hydatid. Ultrasound abdomen was normal. Pre operatively patient was medically treated with albendazole. Pericystectomy and capitonage was done. On follow up patient had symptomatic and radiological improvement. Discussion: Hydatid disease is a zoonotic parasitic disease with global existence. Though it can involve any organ, liver and lungs are the most commonly involved organ. Patients remain asymptomatic for a longer period as the cyst grows slowly. Diagnosis is usually based on radiology supported by serological testing. Surgery is the treatment of choice of pulmonary hydatid cyst but in inoperable cases or in cases where surgery is contraindicated, medical therapy with benzimidazoles compounds may be tried. Conclusion: Though hydatid disease of lung is common in lower lobes, it can occur in upper lobes also.Timely surgery along with medical management can cure the disesase thereby preventing the complications.

Tamsha Rajkumar Osmania Medical College, Hyderabad, Telangana, Introduction: Tuberculosis and lung cancer are common diseases that cause substantial morbidity and mortality worldwide. Although the two rarely occur together, a relationship has been established between them. Case Report: A 60 year old male presented with left sided chest pain, shortness of breath and cough with expectoration. Examination findings and chest radiography were suggestive of left upper lobe cavity. CT chest revealed large cavitory lesion with irregular nodular wall thickening. Patient was diagnosed as sputum AFB and CBNAAT positive tuberculosis. Further in view of thick walled cavity and suspicion of malignancy, sputum for malignant cells was sent which showed presence atypical cells. Bronchoscopy was done and patient found to have squamous cell carcinoma. Discussion: Pathogenesis of coexisting tuberculosis and lung cancer remains controversial. Tuberculosis and lung cancer are able to mimic each other sometimes with clinical and radiological features. Both diseases are independent of each other and develop simultaneously or sequentially. Conclusion: Differentiation of lung tuberculosis from neoplasm, according to the clinical and radiological findings can be challenging. In the changing scenario tuberculosis can coexist with malignancy as well. When CT shows irregular thick walled cavity even if it is a case of tuberculosis, malignancy could not be ruled out in such instances. Hence bronchoscopy is advisable in such cases for diagnosis of coexisting malignancy. Department of Pulmonary Medicine, Osmania Medical College, Hyderabad, Telangana, Background: PTB is often under appreciated as a cause of chronic lung disease. Objectives: To find the correlation of CT chest with dyspnoea and spirometry in patients with post tubercular sequalae. Methodology: CT scoring and spirometry was done in 50 patients with PTB sequalae. Results: CT chest showed 80% cases with fibrosis ( score of 1 in 12%, 2 in 28%, 3 in 20%, 4 in 10%, 5 in 4%, 6 in 6%), 48% cases with cavity ( score of 1 in 10%, 2 in 18%, 3 in 6%, 4 in 6%, 6 in 6%, 8 in 2%), 66% with bronchiectasis ( score of 1 in 10%, 2 in 26%, 3 in 12%, 4 in 10%, 5 in 6%, 6 in 2%), 18% with nodules ( score of 1 in 6%, 2 in 12%), 8% with consolidation ( score of 1 in 4%, 2 in 2%, 4 in 2%), 12% with aspergilloma ( score of 1 in 4%, 2 in 4%, 4 in 4%).

On Spirometry 40% cases had obstructive pattern,24% had mixed pattern and 10% had restrictive pattern,where as 26% had normal pattern.The total morphological score and total lung score has got a statistically significant correlation with the grades of dyspnoea and the ventilatory defect. Conclusion: CT and spirometry can be used in the routine evaluation of post tuberculosis cases. In HIV group-INH monoresistance-5 (25%), rifampicin monoresistance -4(20%), MDR-4(20%), MDR with FQ -3 (15%), XDR -2 (10%), and others (RIF+ FQ, INH + FQ)-2 (10%) There is no significant difference between HIV and non-HIV group in the pattern of drug resistant tuberculosis. Conclusion: Even though association of HIV and MDR TB was not established in the study, keeping in mind high prevalence of HIV-TB coinfection monitoring of drug resistance should be given utmost importance to improve outcome and success of national strategic plan. ICD insertion. Pleural fluid analysis was suggestive of extrapulmonary TB and the patient was subsequently started on anti-tubercular therapy (ATT). During the course of illness, he developed gross ascites, chylous in nature. Ascitic fluid analysis revealed to be of tuberculous etiology for which ATT was sufficient. Gradually, patient responded well to treatment with resolution of his symptoms. Discussion: Tuberculosis has consumed millions of people each year. It also involves the gastrointestinal system and is the sixth most frequent site of extra-pulmonary involvement. One manifestation of abdominal tuberculosis is ascites. Etiologies of chylous ascites vary across different parts of the world, tuberculosis and filariasis accounting for a majority of cases in India. Conclusion: Among patients with diagnosed pulmonary or extra-pulmonary TB, tuberculosis should be kept as an important differential diagnosis for chyloascites, especially in developing countries, so as to avoid delay in diagnosis and initiate appropriate treatment at the earliest.

Background: TB and COVID 19 have similar presentation. This study Aims to identify the problems and difficulties faced by TB patients during COVID 19 pandemic and Lockdown. Methods: A 35 Questionnaire based study where a total of 100 diagnosed TB cases in DOTS OPD were asked regarding the difficulties faced by TB patients for Diagnosis of TB and starting treatment, and also the ease of availability of consultation, anti TB drugs, Investigations and counselling during the period of pandemic and lockdown. Results: Out of 100 patients diagnosed with TB, 42% were COVID 19 suspects, 38% had symptoms for <1month which helped in early diagnosis of TB. 6% patients had symptoms for > 6 months. 27% patients faced problems getting diagnosed, of which 51.8% had travel difficulty, 29.6 % -financial, 18.5 % -lack of health care access, 19% of the patients had no access to high protein diet during lockdown. 31% of patients had side effects due to AKT, Vomiting 74%, 16% Itching, 9.6% Joint pains. 57% patients required admission. All patients were satisfied about counselling regarding disease and treatment course. Patients reported for follow up after 6.7 days on average. Conclusion: TB patients faced difficulties during COVID 19 pandemic. 

Background: The emergence and spread of FQ Resistant strains of M.TB poses a serious threat to TB control. The mutation in gyrA, gyrB loci, marRAB and SoXRS loci are the mechanism of resistance development. The annual India TB report shows 27.4% of 2 nd line LPA report testing FQ drug resistance. Methods: Normal routine investigations with sputum and involved areas specimens were sent for AFB, CBNAAT and LPA in a time period of 2 years. Results: A total of 662 MDR patients were enrolled of which 212 were FQ resistant on 2 nd LPA report. 59.20 % of FQ resistant cases were in the age group 16-29 Approximately 48 % and 22.4 % of FQ resistant patients had a history of exposure to drug sensitive and MDR patients respectively. Conclusion: The prevalence of FQ resistance is increasing recorded 33.3% which has increased from the previous records. There are still hidden cases misdiagnosed as a case of drug sensitive TB having underlying FQ resistance.

Department of Respiratory Medicine, Dr. D. Y. Patil Medical College and Hospital, Dr. D. Y. Patil University, Pimpri, Pune, Maharashtra, Introduction: Takotsubo cardiomyopathy (TTC) is an acute syndrome characterized by reversible ventricular dysfunction in the absence of significant coronary artery disease. Case Report: 15 years old female diagnosed as sputum smear positive pulmonary tuberculosis (outside) was started on Antitubercular drugs, as her symptoms worsened; she was admitted for further management. On admission her pulse rate: 150beats/minute, BP: 100/90mmhg, Blood Investigation and other parameters were normal, ECG-sinus tachycardia, Troponin Inegative, 2D echo: LVEF-60%, mild pericardial effusion and was continued on Antitubercular treatment and other supportive management. After 14 days of admission, due to persistent sinus tachycardia, repeat ECG: sinus tachycardia with ST segment depression, repeat Troponin I :129, repeat 2D Echo showing apical, apico-septal, mid-septal, apicoantero-lateral, mid-antero-lateral segments are akinetic, dilated LV, mild pericardial effusion, LVEF -25%. Discussion: Revised Mayo Clinic diagnostic criteria for TTC diagnosis includes Transient dyskinesis of LV midsegments,Regional wall motion abnormalities beyond a single epicardial vascular distribution,Absence of obstructive coronary artery disease or acute plaque rupture,New electrocardiographic abnormalities or modest troponin elevation,Absence of pheochromocytoma and myocarditis. In our patient, all 5 criteria were met. Conclusion: We report a rare case of Takotsubo cardiomyopathy accompanied by pulmonary tuberculosis suggesting that pulmonary tuberculosis may be a cause of Takotsubo cardiomyopathy.

Background: Cryptococcosis is an opportunistic fungal infection usually found in immunocompromised patients; particularly prevalent in those with Human Immunodeficiency Virus/Acquired Immunodeficiency Syndrome (HIV/AIDS) and usually in disseminated form. Patients of isolated pulmonary cryptococcosis present with non-specific clinical signs and symptoms.The rarity of this entity makes it difficult to recognize and diagnose. Case Study: We present a case of a 67-year-old male with recently diagnosed diabetes, who presented with the complaints cough for 3 months, breathlessness for1 month and hemoptysis for 10 days prior to admission. The X ray chest showed homogenous opacity in left upper zone with normal routine blood and sputum investigations. His CT chest showed left upper lobe non resolving dense consolidation. Bronchoscopy was normal and BAL showed growth of Cryptococcus neoformans. To confirm diagnosis we did the CT guided biopsy of lesion and it showed granulomatous inflammation with staining positive of Cryptococcus. Fungal cultures of sputum and blood were negative. MRI brian was normal. There was no other evidence of disseminated cryptococcal disease. Antifungal treatment with oral fluconazole was started. The patient is on regular follow up and completed 6week therapy till date and the plan is to complete a six-to twelve-month course of therapy. Conclusion: Isolated pulmonary Cryptococcal disease is a rare entity with difficult to diagnose due to non-specific clinical presentation. Non resolving lung lesion should investigate for all possible causes including rare infections despite granuloma on biopsy for proper management.

Background: Rasmussen's aneurysm is an inflammatory pseudo -aneurysmal dilatation of branches of pulmonary artery adjacent to a tuberculous cavity. Massive hemoptysis from the rupture of a Rasmussen's aneurysm is an uncommon yet life threatening complication of cavitary tuberculosis. Case Study: 35 years male non-smoker presented with complaints of cough and massive hemoptysis since 7 days with 80ml per episode and 4-5 episodes per day. He had history of tuberculosis and treated with antitubercular therapy in 2010 later diagnosed with multi drug resistant tuberculosis in 2015 and treated till 2018. On examination pallor was present and bronchial breathe sounds heard on right side. Routine investigations revealed anemia. Sputum bacterial and fungal culture-negative, AFB-positive. CECT Thorax: Large thick walled cavity with hypodense content mixed with air foci in right upper and middle lobes with ground glass opacification in right middle lobe and fluid attenuating collection adjacent to right upper lobe. Bronchoscopy showed no active sites of bleeding. CTPA revealed pseudoaneurysm arising from right pulmonary artery. He was treated with antifibrinolytics, PRBC was transfused and referred for pulmonary artery embolisation. Discussion: Massive hemoptysis in TB can be caused due to bronchiectasis, aspergilloma or vascular complications of which 90% arise from bronchial artery. Rasmussen's aneurysm is a rare cause of massive hemoptysis arising from the pulmonary artery found in 5% of cases. Conclusion: The disease rarity hinders its suspicion, so early investigation and diagnosis is a must to explore the therapeutic options and save the life of a patient. E-mail: rasmitha9@gmail.com Introduction: Paecilomyces lilanicus is an extremely rare emerging fungus that rarely causes invasive pulmonary infection, with cases sporadically reported in immuno compromised patients.

A 19 year old female had complaints of dry cough, fever, easy fatigue, loss of appetite & weight. Her chest x ray revealed bilateral lower zone consolidations. Patient was started on ATT. Patient developed left sided pneumothorax. Tube thoracostomy was performed and later patient was subjected for bronchoscopy. Bronchial wash was sent for analysis. Bronchial wash was not only positive for MTB but Paecilomyces lilanicus was grown in all 4 fungal culture bottles. Patient completed full course of ATT for 6 months & 2 weeks of oral voriconazole. After 2 months patient was free of symptoms & chest CT after 6 months showed marked improvement. Conclusion: This case confirms co infection of pulmonary tuberculosis & paecilomyces lilanicus which was never reported before. We believe that tuberculosis is serving as an immuno compromised state in this patient. We also believe this case highlights the importance of paecilomyces lilanicus as an emerging infection and can be used for early & prompt diagnosis in future. E-mail: drtaruntiwariofficial@gmail.com Background: Pulmonary tuberculosis among elderly is often diagnosed late due to fewer symptoms and most of the cardinal symptoms such as malaise, fever, cough and progressive weight loss are often attributed to advancing age by patients and seeking medical advice late. Objectives: This study was planned to confirm various aspects related to Pulmonary tuberculosis among elderly. Methods: 104 patients of more than 65 years of age, newly diagnosed cases of Pulmonary tuberculosis were included in this study and compared with 100 cases of newly diagnosed cases of Pulmonary tuberculosis in 18-45 year age group. Results: At the time of presentation, elderly Pulmonary tuberculosis cases in comparison to younger control group had far more advanced disease radiologically( 30.7 % as compared to 22 % cases). Radiological distribution, however was similar in both the groups. Elderly Pulmonary tuberculosis cases had radiological disease in upper and mid zones in 53.8 % cases and mid and lower zone in 21.1 % cases, respectively. In comparison to younger age groups extrapulmonary tuberculosis is more common among elderly and Pleural effusion, abdominal tuberculosis, miliary tuberculosis being commoner among elderly patients whereas Tuberculous lymphadenopathy and Potts spine was less common in elderly patients. Conclusion: In order to arrive at a diagnosis it is necessary that one must go into the detailed history of symptoms, the order of occurrence and their duration as physical signs may be minimal in uncomplicated pulmonary tuberculosis cases. Thus, Pulmonary Tuberculosis has got a variable clinico radiological presentation in elderly patients and there should be a high index of suspicion for pulmonary tuberculosis while investigating and treating elderly patients presenting with respiratory symptoms. P.D.U Govt. Medical College, Rajkot, Gujarat, India. E-mail: aidomoyong2019@gmail.com Background: Sarcoidosis is a chronic granulomatous condition of unknown etiology having multisystem involvement with a varied clinical presentation and is a diagnosis of exclusion. Pulmonary involvement is common with parenchymal involvement and bilateral hilar lymphadenopathy but rarely with unilateral pleural effusion. we describe such a case in the following report.A 75 year old male ceramic worker ex smoker presented to our department with complaints of cough with copious expectoration,fever, anorexia with discolouration of skin for over 2 months with aggravated complaints since past 8 days. Methods: Left pleural tapping was done and reports suggestive of a transudative picture patient had a palpable left supraclavicular node and was worked up accordingly with sputum, blood reports and imaging studies where sputum for AFB was negative and sputum CBNAAT was negative,chest x-ray revealed bilateral hilar lymphadenopathy. Patient had bilateral subcentrimetric lymph nodes on ultrasonography of neck and CECT thorax suggestive of sarcoidosis more likely than neoplastic etiology. Serum ACE levels were normal. Bronchoscopy guided biopsy of lung lesion revealed non caseous granulomatous lesion. Results: A diagnosis of Sarcoidosis with lymphangitic spread was made. Both TB and SARCOIDOSIS share remarkable similarities clinically and radiologically and diagnosis becomes an enigma. In India, the prevalence of Sarcoid is 10-12 per 1000 new registrations yearly and diagnosis requires appropriate clinical, radiological and histopathological correlation. Corticosteroids remained the mainstay of treatment with other supportive medications. Conclusion: Diagnosing Sarcoid in high TB burden countries pose a significant challenge. However it is now increased with availability of diagnostic modalities and negating the later remains important because of its high prevalence. Department of Pulmonary Medicine. E-mail: hina_2412@yahoo. com Background: Tuberculosis is a serious contagious major health problem at both national and international level. Spontaneous pneumothorax complicating pulmonary tuberculosis is a well-recognized complication and is a medical emergency but is scantily reported in the literature. This may account for the limited information on its epidemiology. Patients are often treated without treating the underlying cause. Case Study: Single case study. Discussion: Pulmonary tuberculosis has repeatedly described as frequent cause of Secondary Spontaneous pneumothorax. The frequency of secondary spontaneous pneumothorax complicating the course of TB has been studied little, figures range from 0.6-1.4%. These figures, although appearing to be very low, can be important if we keep in mind the 9.5 million new cases that the WHO reports are produced in the world every year. 80% of these occur in developing countries. Inspite of TB being frequent cause of secondary pneumothorax, very few series, with very few patients, have been reported. The frequency of presentation, the clinical therapeutic management & prognosis of these patients have been poorly studied. Conclusion: Pulmonary tuberculosis may present as spontaneous pneumothorax with acute severe dyspnea and may be missed with a catastrophic outcome. Although presentation may be confused with that of the other causes of acute dyspnea, a high index of suspicion, thorough history and careful examination clinches the diagnosis and the response to treatment is often rewarding. Morbidity and mortality from this curable disease is thus reduced. Background: Fungal colonisation of airways in Post TB patients, can lead to a spectrum of diseases based on the immune response of the host. Allergic Bronchopulmonary Aspergillosis, Aspergillus Tracheobronchitis, Chronic Pulmonary Aspergillosis (Aspergillus nodule, Aspergilloma, Chronic Cavitary Pulmonary Aspergillosis (CCPA), Chronic Fibrotic Aspergillosis (CFPA), Subacute Invasive Aspergillosis (SAIA)) and Invasive Pulmonary Aspergillosis (IPA) are the diseases of this spectrum. Methods: A cross sectional observational study was conducted over 100 patients of post TB lung diseases like fibrosis, bronchiectasis, fibro-cavitary disease and obstructive airway disease. Clinico-microbiological profile was studied to make an observation of the individual diseases of the spectrum of Aspergillus infections. Results: Of the 100 patients who were studied, 63 met the inclusion criteria. 41 (65%) were men, and 21 (33.3%) were Diabetics. Chronic pulmonary Aspergillosis (CPA) 34 (53.9%) was the most common manifestation followed by Allergic bronchopulmonary Aspergillosis 14 (22.2%). 8 (12.6%) had simple colonisation of fungal hyphae without disease and Invasive pulmonary Aspergillosis was seen in 7 (11.1%). Among the 34 CPA patients, CCPA was seen in 12 (35.2%), CFPA 8 (23.5%), SAIA 6 (17.6%), simple Aspergilloma 6 (17.6%) and Aspergillus nodule in only 2 (5.8%) patients. Conclusion: Chronic pulmonary Aspergillosis was the most common disease from Aspergillus among Post TB patients. Diabetes was associated to invasive forms of Aspergillosis, Invasive Pulmonary aspergillosis (IPA) and subacute invasive pulmonary aspergillosis (SAIA). Department of Pulmonary Medicine, Bombay Hospital, Mumbai, Maharashtra, Background: This study was undertaken to evaluate the sensitivity of GeneXpert Ultra and AFB smear as compared to the gold standard MGIT culture for detection of MTB in pulmonary and extra pulmonary specimens. Methodology: During the study period, June 2019-May 2021, 100 cases were prospectively evaluated which had MTB complex growth on MGIT culture. The results were compared with AFB smear microscopy and GeneXpert Ultra. Results: 58 samples were pulmonary TB and 42 were extrapulmonary TB. In the study, AFB smear had an overall sensitivity of 50% with sensitivity of 68.9% in pulmonary TB and 23.8% in extra pulmonary TB. The sensitivity of GeneXpert Ultra overall was 93% with a sensitivity of 98.5% in pulmonary specimens and 85.7% sensitivity in extrapulmonary specimens. The sensitivity of GeneXpert Ultra on smear positive samples, pulmonary as well as extrapulmonary was 100%. The sensitivity of Ultra on smear negative TB is 86%, with a higher sensitivity of 95% in pulmonary TB as compared to 81% in extrapulmonary TB. The most common extrapulmonary TB was lymph node TB in which the sensitivity of GeneXpert Ultra was 87.5%, followed by spinal TB in which the sensitivity was 70%. The sensitivity of GeneXpert Ultra on pleural TB was 77.8% and on CNS TB was 100%. Conclusion: GeneXpert Ultra is a rapid and highly sensitive test for tuberculosis case detection and simultaneous detection of rifampicin resistance. Our study confirms that GeneXpert Ultra will help in early diagnosis of paucibacillary TB, TB-HIVcoinfection, paediatric TB and extrapulmonary TB.

Iram Syed, Praveen Waghmare, Amita Nene, P. S. Tampi Department of Pulmonary Medicine, Bombay Hospital, Mumbai, Maharashtra, Background: Analysis of clinical characteristics, common pathogenic bacteria and their antibiotic susceptibility in chronic kidney disease(CKD) patients on hemodialysis has become increasingly important for treatment and prognosis of lung infections. Methodology: The present prospective study investigated the pathogen distribution and drug resistance of lung infections in hemodialysis patients. 125 hemodialysis patients with pulmonary infection were analyzed. Results: In our study, the most affected age group was 61-80 years and majority patient's samples (sputum/BAL) were positive for pathogenic organisms. Out of 91 patients with positive pathogens, 76 (83.5%) showed bacterial growth (13.6% grampositive; 47.2% gramnegative) and 15 were positive for fungi (12%). The most common isolated pathogen was Klebsiella pneumoniae. The results of the drug sensitivity test suggested that Gram-negative bacilli had low resistance rates to piperacillin-tazobactam, imipenem and amikacin, while Gram-positive cocci had a low resistance rate to vancomycin. All resistance rates of the pathogens to other common antimicrobials were >50%. Among fungal species, Candida albicans and Aspergillus were isolated. The resistance rate for candida to fluconazole was more than 50% and for other antifungal drugs such as Itraconazole, Amphotericin B, Caspofungin was less than 50%. Conclusion: We conclude that lung infections in hemodialysis patients were largely caused by gramnegative bacteria and were often multidrug resistant. Results of this study demonstrate that microbiological examination of sputum/BAL sample should be performed as early as possible and effective antimicrobial agent should be chosen according to drug sensitivity results to improve outcome of this vulnerable population. Department of Pulmonary Medicine, Osmania Medical College, Hyderabad, Telangana, India. E-mail: nikhila.samalas@gmail.com Background: Mucormycetes was previously called as zygomycetes which causes mucormycosis/zygomycosis Pulmonary Mucormycosis is a relatively uncommon but an important opportunistic fungal infection in immunocompromised person. The main risk factors are diabetes mellitus, hematologic malignancies and organ transplantation. It is the second most common form of mucormycosis, accounting for more than 30% of infections. This form has a high mortality (40%-76%). History: A 40 years old male, diabetic presented with cough with expectoration and fever since 1 month. Chest x-ray and CT chest revealed right upper lobe thick walled cavity. Evaluation: Patient was investigated for sputum analysis for Acid Fast Bacill, Gene-Xpert,bacterial and fungal culture sensitivity which were inconclusive. Later Bronchoscopy was done which revealed right upper lobe bronchus corrugated mucosa present,B3 segment obstructed by mass lesion which bleeds on touch,bronchial brushings and washings and biopsy taken.Bronchial brushings and washings showed negative for culture sensitivity while bronchial biopsy revealed chronic inflammation with necrosis and ulcerations showing fungal eliments consistent with zygomycetes. Thus the diagnosis of pulmonary mucormycosis was retained and treatment with amphotericin B was started. Conclusion: Pulmonary mucormycosis is a rare but emerging fungal infection with a high mortality rate. Proper and immediate treatment can significantly improve the prognosis. College and Dr. R N Cooper Hospital, Juhu, Mumbai, Maharashtra, India. E-mail: saurabhmandilwar@gmail.com Background: India has the highest burden of Tuberculosis and Drug resistant TB in the world. The WHO Global TB report 2021 estimates that India contributes 27% (2.6 million) and 25% (49679) of TB and Multidrug resistant TB (MDR-TB) respectively. The treatment of MDR-TB is highly challenging mainly due to the potential adverse drug reaction (ADR) associated with the second line drugs. Aim: The study aims to determine the frequency of side effects of the drugs in patients of MDR-TB. Methods: A prospective observational descriptive study was conducted among confirmed Pulmonary and Extra pulmonary MDR-TB patients. Total 40 newly diagnosed MDR TB patients between June 2021 and November 2021 attending our OPD were enrolled in the study. ADR during the treatment were recognized and confirmed with appropriate laboratory investigations. Results: Among 40 patients 70% have completed 3 months of treatment and developed ADR noticed i.e. Peripheral neuropathy was seen in 15, GI disturbances/ nausea and vomiting in 10, arthralgia in 9, visual disturbances in 4, headache in 3, hepatitis in 2, convulsions in 1, hearing loss QTc prolongation in ECG in 1, renal impairment in 1, oral ulcers 1, giddiness in 1, skin rashes in 1 Conclusions: 25% patients had ADR requiring change or stoppage of drugs and 75% patients were successfully managed despite occurrence of adverse drug reactions. MDR TB can be cured and successfully managed despite of occurrence of minor or major ADR with appropriate combination of drugs, timely intervention and aggressive strategy. Department of Respiratory Medicine Gandhi Medical College and Hospital, Secunderabad, Telangana, Introduction: Presumptive tuberculosis is defined as patient presenting with cough with expectoration > 2weeks, fever, weight loss, night sweats, hemoptysis and associated with changes in chest radiograph. Aim: To study the role of light emitting diode fluroscent microscopy and catridge based nucleic acid amplification test in presumptive patients negative by ziehl neelson staining technique. Objectives: 1. To make sputum collection technique standardized one, to identify missed cases.

To study the efficacy of LED microscopy and CBNAAT in comparison to ZN staining technique and to know rifampicin sensitivity. Methodology: This is a prospective cross sectional study conducted on 100 presumptive TB patients with negative ZN staining technique. The detailed history was taken and clinical examination was done. the blood samples were collected for routine investigations. The sputum samples were further subjected to LED microscopy and CBNAAT. And following results were obtained. Results: In the following study, out of 100 patients, 74 (74%) were males, 26(26%) were females. Hemoptysis was present in 21% of the patients while 79% did not report it. Smoking was present in 39% of the patients, 61% did not have the habit.54% of the patients had diabetes while 46% did not have it. The sensitivity and specificity of CBNAAT is 100% and 88.64% respectively. The PPV and NPV of CBNAAT is 54.55% and 100% in the study conducted. Conclusion: CBNAAT is superior than LED microscopy and ZN staining technique and additionally gives rifampicin sensitivity. So it helps in case detection and starting of early treatment, thereby decreasing the burden of the disease.

Rahul Jain, Rajendra Saugat, Gunjan Soni, Manak Gujrani E-mail: aolrahul28@gmail.com Background: Tuberculosis can involve almost every organ in the body.Tuberculosis of nose, nasopharynx and para nasal sinuses is extremely rare even in countries where the incidence of tuberculosis is very high. Case Study: A 38-year-old immunocompetent female patient presented with shortness of breath, nasal congestion, occasional epistaxis and left sided facial swelling for last 6 weeks. Her ESR was 45 mm/h, MT was 16mm, RFT and LFT were normal. Her two consecutive sputum smear were negative for AFB. X-ray chest was normal, X-ray of the para nasal sinuses showed increased soft-tissue density and mucosal thickening in left maxillary antrum. The CECT of the para nasal sinuses showed ill defined soft tissue attenuation area measuring approx. 29*25*35 mm in left maxilla. Patient referred for endoscopic sinus surgery followed by Caldwell luc procedure and excision of mass. Biosy of nasal mass revealed epitheliod cell granuloma along with multinucleated langhans giant cells, areas of casseous necrosis consistent with tubercular inflammation. Patient was referred for DOTS. Discussion: Nasal tuberculosis is rare even in developing countries like India. Nasal tuberculosis commonly occurs in females and the median age of occurrence is mid 40 years. Nasal tuberculosis is usually unilateral as in our case, but in one-third cases it is bilateral. Conclusion: We believe that though nasal tuberculosis is a rare clinical entity, it should be considered as one of the differential diagnosis of patients with granulomatous lesion of the nose. High degree of suspicion is the key to diagnose the disease.

Department of Respiratory Medicine, MS Ramaiah Medical College, Bengaluru, Karnataka, Objectives: Aspergillus is a ubiquitous mold, which causes a wide spectrum of illnesses. Pulmonary disease is caused mainly by Aspergillus fumigatus. Pulmonary aspergillosis is a common infection in the immunocompromised, but it is also seen in patients with chronic debilitating diseases who require corticosteroids and/or immunosuppressive therapy. The aim of this work was to focus on the diagnosis of invasive pulmonary aspergillosis (IPA), with the use of a relatively new test, Galactomannan assay. Methods: We report a case series of 6 patients with suspected fungal infection over the course of 2020-2021. The diagnosis of IPA was obtained by use of galactomannan assay. Patients underwent routine sputum examination, and when indicated, bronchoscopy. Sputum and/or BAL fungal cultures were negative for all patients.

The patients mean age was 48.3±12 years. The most common clinical presentation was cough with expectoration. Comorbidities included past history of pulmonary tuberculosis (1), severe COVID-19(1), HIV infection (1), chronic kidney disease (1) and diabetes mellitus (2). Galactomannan levels were obtained in BAL in five patients, and serum in one patient. All patients were given voriconazole. Outcome was favourable in all patients. Conclusion: Galactomannan is a polysaccharide cell wall component of Aspergillus species which is released during fungal growth. ELISA is capable of detecting galactomannan levels at concentrations as low as 0.5ng/ mL. It is a non-invasive test with high specificity that can be used both for diagnosis as well as for monitoring of patients. Serum galactomannan levels, though diagnostic, become positive later in the disease. BAL galactomannan provides an early diagnosis.

Kamineni Academy of Medical Sciences and Research Center, Hyderabad, Telangana, Background: Tuberculous pleural effusion (TPE) is a second most common extrapulmonary manifestation of tuberculosis. TPEs are caused by delayed-type hypersensitivity to tuberculin-like antigens entering the pleural space after rupture of subpleural caseous foci. Interleukin-27(IL-27), a recently discovered heterodimeric cytokine, member of the IL-12 cytokines family, has been found to be involved in TPE and is mainly produced by active antigen-presenting cells under the stimulation of pathogen-associated molecular patterns binding to toll-like receptors and may provide a clue to the diagnosis. Objectives: To compare the efficacy of IL-27 with ADA levels in diagnosing TPE. Diagnostic efficacy of IL-27 in differentiating TPE from Non-TPE. Methods: Data was collected from 80 patients presenting to the Respiratory Medicine Department of KAMSRC with Pleural Effusions. All patients underwent necessary testing including serum, sputum and pleural fluid tests along with pleural biopsy. Results: Out of 80 patients, 34/40 patients with TB Pleural effusions had ADA levels >40U/L with a sensitivity and specificity of 85% and 90% respectively. 38/40 patients with TB pleural effusions had a P.F IL-27 >1500ng/L With a sensitivity and specificity of 95% each. Conclusion: Pleural fluid IL-27 is a new and better noninvasive biomarker in the diagnosis of TB pleural effusions when compared to ADA. IL-27 assessment can minimize the complications associated with pleural biopsy which is an invasive procedure.

Sutrave Sumeeth, M. G. Krishna Murthy, P. Eshwaramma, G. Ramulu E-mail: sumeethstrv29@gmail.com Background: One of the world's largest TB burden lies in India. TB can affect any organ or tissue. Most commonly involved extrapulmonary site is the lymphnode. The conventional methods include cytology, culture and AFB stain. LPA is molecular method to detect resistance to first line and second line ATT drugs. CBNAAT, also detects the presence of TB bacilli and Rifampicin sensitivity but in a very short time. Aim and Objectives: This study aims to determine the efficacy of CBNAAT in comparison with LPA and liquid culture in the evaluation of lymph node abscess. The objectives are to evaluate the frequency of drug resistance patterns. Methods: 50 cases with features of LN abscess on FNAC presenting at Gandhi hospital, secunderabad were included in the study. Each case was assessed with history, physical examination and investigations consisting of AFB stain, culture, LPA and CBNAAT. Results: The diagnostic accuracy of CBNAAT was 86% whereas culture and LPA had 78% and 88% respectively. AFB stain showed an accuracy of 58%. Rifampicin sensitivity was detected in 96%. Conclusion: CBNAAT is a better diagnostic option as it is equally efficacious when compared to LPA and Liquid culture in TBLN abscess. It also helps in clinical management by detecting Rifampicin sensitivity. It is a rapid, has minimal contamination risk, is not a biological hazard, and easy to use with minimal technical training. Department of Pulmonology, ASRAMS, Eluru, Andhra Pradesh, Background: India has high burden of both TB and HIV and faces second highest burden of HIV associated TB. Tuberculosis is one of the most common opportunistic infections and leading cause of death among people living with HIV (PLHIV). Isoniazid Prophylaxis Therapy (IPT) is recommended as an important strategy for prevention of TB among PLHIV and is therefore a key public intervention for TB prevention in PLHIV. Objective: To estimate the incidence of tuberculosis in PLHIV before and after implementation of IPT. Methods: Study was conducted for a period of 3 months (15-09-2021 to 15-12-2021) among PLHIV, West Godavari district, A.P. Data was collected from four Anti-Retroviral Therapy (ART) centres namely Eluru, Bhimavaram, Tadepalligudem, Tanuku and was compared with that of 2017. Results were expressed in the form of percentages and frequencies.

In the year 2017, before implementation of IPT, incidence of TB in PLHIV in West Godavari district was found to be 2.66 %. Whereas in 2021 that is after full implementation of IPT, incidence of TB in PLHIV is found to be 1.74%. Most of the TB cases after implementation of IPT were drug sensitive TB (95.64%). H mono/poly resistant TB was 1.24%. Rifampicin resistant TB was 3.12%. Conclusion: PLHIV are in contact with health services and it is an opportunity to provide prophylaxis and encourage adherence. IPT is found to be effective in reducing the incidence of tuberculosis in PLHIV and sets a platform for the success of Tuberculosis Preventive Treatment in other target populations.

Kakatiya Medical College, Warangal, Telangana, India.

Introduction: Tuberculosis is one of the most common chronic infections globally, especially in developing countries like India and is a leading cause of morbidity and mortality. Therefore, early diagnosis, and microbiological confirmation of pulmonary TB is important to break the chain of transmission. Methodology: It was an observational study conducted among 56 cases of presumptive tuberculosis whose sputum were negative on sputum AFB and CBNAAT. Cases with relative or absolute contraindication for bronchoscopy were excluded from study,BAL was collected and sent for analysis. Results: Mean age of study subjects was 50-69 years of age, majority were males 55.4% and 21.5% had past history of tuberculosis. Most common findings on chest X-ray was in non homogenous opacity (57%), cavities(14.3%). BAL AFB was positive in 19.6%, BAL culture was positive in 28.6% BAL. BAL sent for CBNAAT testing detected 46.4% mycobacterial TB, 11.5% mycobacterial TB with Rif resistance. 10 had past history diabetes,10 out of 7 diabetics were positive for tuberculosis in BAL.BAL cytology for malignant cells was positive in 4%. Sensitivity of BAL AFB-50%,Specificity-92.5%,PPV-72.7%,NPV-82.2%,Accuracy-80.4%.sensitivity for BAL CBNAAT-81.3%,specificity-65%,PPV-48.1%,NPV-89.7%,Accuracy-69.6%. Conclusion: Fibreoptic bronchoscopy is useful investigation in establishing accurate and early diagnosis of lower respiratory tract infections. Department of Respiratory Medicine, Gandhi Medical College and Hospital, Secunderabad, Telangana, India. E-mail: gayathri. m2012@gmail.com Introduction: Cryptococcal pneumonia is predominantly seen in immunosuppressed individuals and rarely in immunocompetent population. We report a case of middle age male with Cryptococcal pneumonia. History: A 45-year-old male farmer by occupation presented with shortness of breath for 2months, cough with sputum for 2 months associated with streaky hemoptysis, fever on and off for 1month, loss of appetite for 1 month, no history of SARS CoV 2, no h/o long term steroid usage and immunosuppression (HIV, malignancy) no significant family history. Presentation: Spo2-98%RA, Blood pressure and pulse rate were normal. Examination reveaed Decreased breath sounds in left infra scapular area. Rest systemic examination was normal. A study on role of pao2/fio2, total leucocyte count in predicting outcomes in community acquired pneumonia with respiratory failure Gandhi Medical College and Hospital, Secunderabad, Telangana, India. E-mail: gayathri.m2012@gmail .com, Introduction: Community-acquired pneumonia (CAP) is one of the most common serious infective diseases accounting for nearly 1% of all medical admissions and is an important cause of mortality and morbidity worldwide. Aims and Objectives: To assess the role of Pao2/Fio2, Total Leucocyte count in predicting the outcomes in Community Acquired Pneumonia with Respiratory failure. 1. To measure Pao2/Fio2 and Total leucocyte count in Community acquired pneumonia with respiratory failure. 2. To measure Absolute neutrophil count, Absolute lymphocyte count and its ratio. 3. To correlate Pao2/Fio2, Total Leucocyte count and Neutrophil Lymphocyte ratio in Community Acquired pneumonia with respiratory failure. Methodology: This is a prospective observational study in 44 cases of community acquired pneumonia with respiratory failure conducted in dept. of Respiratory Medicine, Gandhi Hospital, Secunderabad. Blood samples as well as clinical data were collected in a well-designed proforma from all the patients. ABG analysis was done with 5 litres of oxygen for analysis at the time of admission. Results: The mean Pao2/Fio2 was higher in survivors compared to non survivors (192.27 and 156.41 respectively) . The mean Neutrophil-Lymphocyte Ratio was lower in survivors compared to non survivors (6.86 and 12.11 respectively). Conclusion: It is suggested that Neutrophil-Lymphocyte Count Ratio (NLCR) and Pao2/Fio2 can be done in patients with CAP along with other severity scores to assess the prognosis and to consider treatment options. Department of Respiratory Medicine. E-mail: dryasarphc@gmail. com Background: The pulmonologist are faced with incidental radiographic findings of pulmonary nodules and deciding how to manage these findings is very important as the differential diagnosis of lung nodule is broad like neoplasms or infections or immune-mediated diseases etc. Case Study: A 56-year-old female presented with complaint of sever pain over the back side of the lower part of chest on both side, which were pleuritic in nature since one month. Had history of wheezing for which she took methylprednisolone tablets for 3 years. On examination tenderness over right infra scapular region and on auscultation bilateral basal crackles heard. Blood investigations and chest x ray were normal. Her HRCT chest showed multiple soft tissue density nodules in right middle and lower lobe and lingular segment of left upper lobe. Multiple pleural based consolidation in bilateral basal segments. BAL for CBNAAT detected Mycobacterium with no Rifampicin resistance. ATT was started and she improved symptomatically. Discussion: In our case, she had atypical presentations of PTB both clinically and radiologically. She was immunocompromised(steroid misuse). There many cases of TB where radiological findings are not typical of tuberculosis and may mimic a number of other diseases like lung metastases in our case. A tree-in-bud appearance and cavitation are known to be typical findings on CT; however, TB may also present as a pulmonary nodule that resembles pulmonary carcinoma. Conclusion: The immunocompromised patients may have atypical presentations of PTB both clinically and radiologically.

A rare case presentation of pancreatic tuberculosis mimicking pancreatic mass Sutrave Sumeeth, M. G. Krishna Murthy, G. Ramulu, V. Veena E-mail: sumeethstrv29@gmail.com Introduction: Tuberculosis is a leading public health problem, with India bearing one of the highest TB burden in the world. There is parallel increase in the cases of extra pulmonary TB along with rising burden of pulmonary TB. Despite the high prevalence of TB in developing countries, primary pancreatic TB is extremely rare, as pancreas is protected biologically due to presence of pancreatic enzymes that interfere with seeding of MTB. Case Report: 75 year male patient, with no comorbidities and no significant past history, came to OPD with complaints of loss of weight since 3 months, hiccups from 45 days, epigastric pain since 10 days and yellowish discolouration of eyes since 10 days. Investigations revealed obstructive jaundice with elevated lipases and amylases. CBP, ESR, serology and CXR were unremarkable.USG abdomen showed gastric antral thickening.UGI Endoscopy was done and it revealed polypoid ulcerated growth in periampullary area with mild luminal narrowing and a growth infiltrating proximal to ampulla suspecting pancreatic carcinoma with duodenal infiltration. Biopsy was taken which revealed well defined epitheloid cell granuloma, necrosis,giant cells and dense lymphohistiocytic infiltrates -suggestive of Tubercular inflammation. Patient was started on anti tubercular therapy and there was significant reduction in clinical symptoms during the course of therapy. Conclusion: Pancreatic mass in a patient from high prevalence of TB or in an immunocompromised patient, pancreatic tuberculosis should be considered. Direct HPE is the best test for confirmative diagnosis of pancreatic tuberculosis.

A comparative study on the sensitivity and specificity of pleural fluid cbnaat versus pleural fluid lymphocyte neutrophil ratio in a diagnosed case of pulmonary tuberculosis Indraneel Bose Department of Respiratory Medicine. E-mail: indraneel2992@ gmail.com Background: Tubercular Pleural effusion are one of most common causes of exudative pleural effusion in India.In a tubercular pleural effusion when lymphocyte:neutrophil ratio(L:N) more than equals to 0.75 is used in combination with ADA,the sensitivity,specificity,positive predictive value,negative predictive value for identification of TB were reported 88%,95%,88% and 92% respectively. CBNAAT had relatively low sensitivity(62%) compared to other pleural fluid markers but high specificity(98%) for diagnosing TB. Methods: All sputum positive(CBNAAT or AFB) pulomnary TB patients with pleural effusion attented NRS Hospital during 15 th December 2019 till 30 th November 2021 were taken as study population.Excluded from the study are---patients with <12 years age,Malignant Pleural Effusion and those unwilling to give consent for study.After effusion analysis,statistical data were entered into a Microsoft excel spread sheet and then analyzed by SPSS and Graph Pad Prism version 5.p-Value less than equals to 0.05 were considered statistically significant. Results: In Pleural fluid CBNAAT detected group,38.9% patients had L:N Ratio 0.5-0.6,50% patients 0.6-0.75 and 11.1% had >0.75.Pleural fluid CBNAAT detected patients had ADA < 35 in 5. 6%,35-40 in 5.6%,40-45 in 16.7% and >45 in 72.2% . Conclusion: Association of Pleural Fluid ADA vs CBNAAT as well as Pleural Fluid L:N Ratio vs CBNAAT were not statistically significant.CBNAAT though found negative,patients with ADA>40IU/L with Lymphocytic effusion(though L:N Ratio may not be >0.75) to be considered tubercular. E-mail: l.lalwani05@gmail.com Background: Management of Pulmonary Tuberculosis is largely limited to the bacteriological cure, but there is little information about the role of nutritional status on severity of pulmonary impairment after tuberculosis (PIAT) and the effect of PIAT severity on quality of life and exercise tolerance. Methods: A total of 150 adult PIAT patients with any chest complaints presenting to the outpatient department were enrolled prospectively and sequentially. The severity of PIAT was assessed by spirometry. Socio-economic status, the severity of dyspnea, nutritional status, quality of life and exercise tolerance were also assessed. Objectives: The severity of PIAT was correlated with nutritional status and clinical features. Results: Out of 150 enrolled patients, 19 (12.67%) had no impairment, 28 (18.7%) had mild impairment, 39 (26.0%) had a moderate impairment and 64 (42.7%) had severe impairment based on the value of FEV1 on spirometry. Patients with lower-socio-economic status tend to have a poorer nutritional status which was associated with increased severity of PIAT. Dyspnea severity was assessed using the MRC scale and found to be significantly worse in patients with severe impairment (p<0.01) and BMI is inversely associated with the same. 39/63 undernourished patients had severe PIAT. Half of the patients with adjusted FFMI of less than 16 kg/m2 had severe PIAT suggestive of positive and strong correlation. Quality of life score and exercise intolerance were significantly decreased with increasing severity of pulmonary impairment after tuberculosis (p<0.001). Conclusion: Patients with severe PIAT tend to have poorer nutritional status and severe PIAT is associated with decreased exercise tolerance and poor quality of life.

Institute of Thoracic Medicine, Madras Medical College, Chennai, Tamil Nadu, India. E-mail: dhanapulmo1995@gmail.com Introduction: Hydatid disease is a parasitic infection caused by Echinococcus granulosus (EG), characterized by cystic lesions in the liver, lungs, and rarely in other parts of the body. Lungs and liver are the most frequent sites involved. Simultaneous lung and liver cysts are observed in less than 10% of the cases. Case Report: A 44 year old male presented with complaints of abdominal pain and fever for two month and breathlessness for one month.Patient was complaining left sided chest pain on and off for past 15 days. He was admitted and evaluated for diagnosis and treatment.There was no significant finding on general examination On systemic examination,there was decreased breath sounds on left lower hemithorax and mild epigastric with right hypochondrial tenderness.Chest X-ray revealed a round and we'll defined mass in the left lung base and USG abdomen shows 9× 9.8 cm heteroechoic lesion in 7 th segment of Right lobe of liver.MRcholangiopancreatogram showed enlarged liver and a heterogenous intensity lesion involving segment 4,7,8 segment.The lesion shows solid cystic component with well defined capsule and similar intensity lesion involving the left lower lobe measuring 8.8x10 cm also visualized.Ultrasound guided cystic fluid was aspirated from the liver and sent for latex agglutination test found to be POSITIVE. Patient was given T.albendazole and treated surgically. Conclusion: Hydatid cysts can be treated by surgical or medical intervention. Surgical resection is the cornerstone for the treatment of hydatid cyst of lung and and is useful for the patient where cysts cause compression due to their large size. However,medical therapy is indicated in patients with primary liver or lung cysts that are inoperable, patients with cysts in two or more organs and peritoneal cysts.

Francis Ankita, Jayamol Department of Respiratory Medicine, Sree Balaji Medical College and Hospital, Chrompet, Chennai, Tamil Nadu, Background: Empyema thoracis is defined as, a collection of pus in the pleural space, between the visceral and parietal pleura. Empyema causes significant morbidity and mortality. Pleural empyema can be subdivided into 3 stages: exudative, multiloculated, and organizing. Clinical outcomes of Tubercular empyema are worse compared to those of non-tubercular empyema, because of protracted illness, presence of concomitant fibrocavitary lesions, high bacillary load, development of bronchopleural fistulae (BPF), and requirement for complicated surgeries.

A 33 year old female presented with productive cough for 2 weeks with mucoid expectoration and malaise. On lung auscultation, reduced breath sounds were present over right infrascapular and infra axillary area. Chest X ray revealed right sided loculated pleural effusion for which USG thoracocentesis was performed, thick purulent pus was aspirated and sent for pleural fluid analysis. Pleural fluid reports were indicative of exudative pleural effusion, most likely TB. Patient was started on IV antibiotics and was planned for CECT Scan [ Figure 1 ] which revealed right loculated empyema with split pleura sign. Patient underwent Thoracoscopy which revealed nodularity [ Figure 2 ] with septation throughout the pleura, pleural biopsy sample was taken after which thick pus was drained and ICD inserted. Antitubercular therapy was started. Patient improved symptomatically. Discussion: The procedure of medical thoracoscopy in early management of multiloculated pleural empyema is safe, efficient and cost effective in developing countries where thoracic surgery facility is scarce. Conclusion: In the absence of clear septation, antibiotics plus simple drainage of pleural fluid is often sufficient treatment, whereas clear septation often requires more invasive treatment. Background: Tuberculosis (TB), caused by Mycobacterium tuberculosis is an infectious airborne disease and a major health problem world-wide A total of 1.5 million people died from TB in 2020 (including 214 000 people with HIV). Although the recent NTEP is the best till now but still the drug resistance patients are on rise. Some factors like poor training of DOTS providers, non availability of drugs, poor funding in the programme, improper counseling, increased distance from home to drug distribution center (>1 hour/50km ) could be some of the leading factors developing drug resistance. Methods: Study Design: Cross sectional, Observational Study Study Area: Nodal DOTS plus site and OPD /IPD of TB Hospital, Regional Institute of Respiratory Disease (RIRD), Lalghati, Bhopal (MP) Dept of Respiratory Medicine, GMC,BHOPAL. Results: In our study non-compliance to ATT drug intake on previous treatment, adverse drug reaction on previous treatment and mental health issues on previous treatment have statistically significant positive association interpreting as, with the ascent of these factors, incidence of MDR Tb will also increase. (p value <0.05) Whereas unobserved treatment and socioeconomic burden do not have any significant correlation but still possess risk factor in development of MDR TB.(p value >0.05) Conclusion: 1. Possible Factors related to patients which may lead to development DRTB mainly comprise of those which make them uncomfortable to drugs or poor counseling so such patients should be proper counseled about drug compliance and its adverse effects. Also there are patients who are regular defaulters or go into depression due to medications and social stigma such patients should be properly counseled and some government programmes be made up for their betterment and rehabilitation. Also such patients should be treated after hospitalizing them for longer duration in order to ensure compliance and avoid spread of infection in society. After taking written informed consent from the patient's attenders, we went ahead doing transthoracic biopsy from right upper lobe after his death which showed pulmonary aspergillosis. Discussion: Covid 19 associated pulmonary aspergillosis is commonly seen in immunocompromised individuals including uncontrolled diabetes mellitus, chemotherapy, h e m a t o l o g i c a l a n d o t h e r m a l i g n a n c i e s , o rg a n transplantation, and corticosteroid therapy. Conclusion: Our case report highlights the fact that COVID 19 infection may expose the patients to a greater risk of developing opportunistic co-infections even at presentation which may lead to worse outcomes. Respiratory clinician usually encounters patients with history of fever along with chest radiograph having bilateral lung nodules. In endemic areas like India usually tuberculosis is considered as the initial diagnosis. A falsely ascribed diagnosis may prove unfortunate as the underlying diagnosis is left unaddressed and the burden is amplified by avoidable potential side effects of antituberculosis drugs. We encountered a 30-year-old male patient with a rare cause of fever along with bilateral lung nodules. Details of the case will be further discussed.

tuberculosis since 2 months. He had history of MDR-PTB in May 2017, for which he was treated with kanamycin-based regimen for 21 months. His followup cultures of 15m,18m and 21m were positive and no clinical improvement. After gap of 3months patient reported to hospital and he was started on capreomycin-based regimen from June 2019. As sputum cultures of 21m and 24m were negative and he showed clinical improvement, AKT was stopped in May 2021. Patient again became symptomatic for which he was evaluated. As sputum smear and culture was positive, phenotypic-DST was done, which showed Resistance to Bedaquiline,Levofloxacin,Moxifloxacin, E t h i o n a m i d e , E t h a m b u t o l , Clofazimine,PAS,Pyrazinamide,Rifampicin,Isoniazid and sensitivity to Linezolid,Amikacin,Kanamycin a n d C a p r e o m y c i n . Pa t i e n t w a s s t a r t e d o n delaminid,amikacin,cycloserine,linezolid. Discussion: BDQ is part of all oral longer regimen in treatment of DR-TB. It is group A drug as per WHO Consolidated Guidelines for TB. Primary BDQ-resistance raises concern in DR-TB control programme. Early recognition of BDQ-resistance is important to achieve better treatment outcome and prevent spread of BDQresistance. Conclusion: Primary BDQ-resistance is important concern in management of DR-TB. Early detection and management of BDQ-resistance is core in preventing spread of BDQresistance.

Study on drug induced liver injury among drug sensitive tb patients who is on fixed drug combination of anti-tb drugs in a tertiary care centre S. Ramyadevi, S. Aravind, P. Arulkumaran, P. M. Ramesh Government Thiruvotteswarar Hospital of Thoracic Medicine, Govt Kilpauk Medical College, Chennai, Tamil Nadu, Background: Tuberculosis caused by susceptible mycobacterium tuberculosis strains is effectively treated by the fixed drug combination of anti TB drugs. However, most anti TB drugs are known to induce hepatotoxicity which may limit their adherence and hence lead to the development of mycobacterial drug resistance Aims and Objectives: The aim of this study was to assess the incidence of FDC induced hepatotoxicity, associated risk factors and outcome among drug sensitive tuberculosis patients in a tertiary care centre. Materials and Methods: This is a study done among new PTB and EPTB patients started on 4 fixed drug combination of anti TB drugs. After enrolling in to the study, blood samples taken from all the patients and asked to repeat after 1 week of starting 4 FDC. Those with Drug induced liver injury were admitted and details regarding associated risk factors collected. Rechallenging of non hepatotoxic drugs done and did further follow up of patients.

Results: There were 77(13.8%) cases of ATT-associated Drug induced liver injury among 557 patients diagnosed with active TB between FEBRUARY 2021 to JULY 2021.Among 77, 46(59.7%) male and 31(40.2%) female, > 40 years-57(74%), alcoholic -31(40.2%), GI disorder-18(23.3%), viral markers-3(3.8%). Rechallenging of non hepato toxic drugs done for all the patients then Regimen restarted for 16(20.7% among DILI, 2.8% among 557) and change of regimen needed for 61(79.2% among DILI, 10.9% among 557). The outcome of the study is among 557, treatment completed -290(52%) on treatment-200(35.9%) lost follow up-35(6.2%) died -38(6.8%). Among 61(regimen changed), treatment completed-32(52.4%) on treatment-20(32.7%) lost follow up-5(8.1%) died-4(6.5%). Among 16(regimen restart), treatment completed -9(56.25%) on treatment -5 (31.25%) lost follow up -1(6.2%) died -1(6.2%) Conclusion: There is a significant increase in drug induced liver injury among drug sensitive tuberculosis patients started on 4 fixed drug combination of anti-tuberculosis drugs. Risk factors like age >40yrs, chronic alcoholic, higher baseline LFT and GI disorders are more prone to develop drug induced liver injury. Hence LFT can be added as preliminary routine test for Drug sensitive TB patients and follow up LFT should be done after starting 4 fixed drug combination of Anti TB drugs. E-mail: tripathiawatansh@gmail.com Introduction: Pseudoaneurysm of the pulmonary artery (PAP) is a rare cause of hemoptysis with a wide array of aetiologies. This case report discusses our clinical experience of PAP associated with pulmonary mucormycosis (PM) in a COVID survivor. Case Report: A 58-year-old gentleman presented with a 1-week history of high-grade fever and progressive dry cough. Four weeks before his presentation, he was treated for mildly symptomatic COVID-19 infection with unusually high doses of steroids. On admission, a chest x-ray and CT chest showed a cavitatory lesion in the right lower lobe. He underwent a FOB with BAL and endobronchial biopsy, which were inconclusive. On day 5 of his hospital admission, he had an episode of massive hemoptysis leading to hemodynamic instability. CT showed an increase in the size of the cavity and a pulmonary angiogram showed the descending segmental branch of the right pulmonary artery traversing through the consolidative cavitating lesion with focal dilatation of the same measuring up to 1.5 x 1.9 cm. Consistent hemostasis couldn't be achieved after gluing an interlock coiling of pseudoaneurysm, hence he underwent video-assisted thoracic surgery for right lower lobectomy and stump ligation of the right lobar pulmonary artery. Lobectomy specimen on histopathology revealed large areas of necrosis with aseptate fungal hyphae. He responded well to antifungal therapy during follow on 4 th week post discharge. Conclusion: Mucormycosis is characterized by angioinvasion, vessel thrombosis, and subsequent tissue thrombosis. Pseudoaneurysm formation is rarely seen in PM and can be associated with fatal hemoptysis. Irrational use of systemic steroids in the management of COVID makes the patient more vulnerable to an otherwise rare disease.

Department of Pulmonary Medicine, JNMCH, AMU, Aligarh, Uttar Pradesh, India. E-mail: danishtbrd@gmail.com Background: Lung cavitation occurs in a variety of pathological processes that comprise of a wide spectrum of diseases, both infectious (Tuberculosis, Atypical Pneumonia, Cavitating bacterial pneumonias) and noninfectious (vasculitis, secondaries, Rheumatoid and sarcoid nodules).

Here we present a case of a 60 year old male who was a farmer by occupation, immunocompetent, and chronic smoker, who presented to our OPD, with complaints of yellowish discoloration of skin and eyes for the past 3 months, fever and cough for one and half months. Cough was associated with scanty expectoration, white to yellow in color, mucoid in consistency, non-foul smelling, not associated with haemoptysis. There was no history of previous ATT intake. Discussion: The routine blood investigations, mantoux test, AEC count, urine examination, sputum examination, c-ANCA, p-ANCA, RA factor, bronchoscopy, etc. were done but showed no specific abnormality. Repetitive cultures from sputum and BAL came out to be sterile. Chest X ray and CT scan revealed only multiple cavities in lung parenchyma without any particular lobe predilection. Despite extensive investigations, we could not establish a cause for the multiple cavities in lung. Hence, the patient was started on empirical antibiotics and symptomatic treatment was given. The patient responded to our treatment and improved clinically after 10 days of treatment. Radiologically there was significant resolution of cavities in chest X-ray taken after 3 weeks.

Jawaharlal Institute of Postgraduate Medical Education and Research, Puducherry, India. E-mail: vishnu1429@yahoo.com Background: Prostatic abscess is a complication of acute prostatitis and usually occurs in the 5th and 6th decades of life with immunocompromised status. Gram negative organism are the most commonly implicated. We herein describe a case of septic pulmonary emboli with origin from prostatic abscess. Case Details: A 52 Year old diabetic with uncontrolled sugars presented to emergency medicine in view of breathlessness, cough with expectoration, dysuria and fever for 2 weeks. He was tachypneic and hypoxic on room air. Chest x ray and subsequent CT showed bilateral multiple cavities involving all lobes of the lung with left side effusion.a feeding vessel sign was also noted. His blood investigations showed leucocytosis of 23 000 counts /mm3 with peripheral smear showing toxic granules and normocytic normochromic anemia and a blood sugars of 520 mg/dl with no ketone bodies. urine routine showed plenty of pus cells with granular material. USG abdomen and pelvis showed complex hypoechoic collection with thick septations and few areas showing moving echoes seen posteroinferior top bladder suggesting a prostate abscess. Suprapubic cystostomy and transperineal pigtail insertion done for ruptured prostatic abscess. Blood culture,sputum culture and exudate culture from prostate yielded E.Coli which was sensitive to cefoperzone and sulbactam and amikacin. Anaerobic culture showed Bacteroides uniformis and caccae sensitive to cefoxitin,chloramphenicol and imipenem. He was treated with sensitive antibiotics, fluid replacement and insulin. He improved clinically and radiologically and was subsequently discharged.

The origin of septic emboli should be meticulously searched and can be present in rare sites like prostate.

KaranKumar Waghmare, P. L. Meshram, V. V. Pujari, R. R. Hegde Grant Government Medical College Mumbai, Maharashtra, India. E-mail: karankumarw@gmail.com Background: Esophageal Tuberculosis is a rare Extrapulmonary tuberculosis accounting only 2.8 % of all cases of Gastrointestinal Tuberculosis. which are total of 1-3% of all Tuberculosis cases. Oesophageal tb usually occurs as a result of direct spread from mediastinal nodes. Commonly presents as Dysphagia,retrosternal pain with constitional symptoms as mild grade Fever, loss of weight and appetite. If not treated can complicate as perforation, fistula formation, aspiration pneumonia, fatal hematemesis and esophageal strictures. Early initiation of AKT can decrease emergence of such complications. Case Study: A 22-year old male with no comorbidities presented with dry cough,dysphagia,evening rise of fever with loss of weight since 1 month. Blood investigations revealed raised TLC with lymphocytosis, with an elevated ESR. Patient tested negative for HIV,HbsAg,HCV. Sputum CBNAAT -MTB Not Detected On CXR patient had bilateral Hilar Lymphadenopathy. On CT -Thorax -hilar Lymphadenopathy was confirmed with Normal lung parenchyma. of pyrazinamide, ethambutol and ethionamide resistance raise questions of continued inclusion of these drugs in shorter regimens in the absence of drug susceptibility testing-confirmed susceptibility. noted in both hemithorax extending upto neck.Computed tomography (CT) of thorax showed diffuse subcutaneous emphysema and pneumomediastinum with multiple cavities in right upper lobe and middle lobe. Volume loss with cavity communicating with pleura and subcutaneous tissue noted in left hemithorax. Sputum examination was positive for Acid -fast Bacilli. Patient was treated with high flow oxygen and antitubercular chemotherapy. Following which the subcutaneous emphysema gradually reduced and the patient improved both clinically and radiologically. He was discharged with the advice of anti-TB chemotherapy for 6 months. Discussion: Presence of air in the subcutaneous layer of skin is called subcutaneous emphysema. When it is secondary to any surgical procedure, it is called surgical emphysema and when cause is unclear, it is called spontaneous subcutaneous emphysema. It may be observed in association with pneumothorax or pneumomediastinum as a result of pathological changes in the respiratory tract. Spontaneous pneumomediastinum has been reported in several forms of pulmonary tuberculosis like miliary, silico tuberculosis and cavitary tuberculosis. Spontaneous subcutaneous emphysema from caverno pleuro subcutaneous fistula is rare. In our case the CT scan revealed a communication of pulmonary cavity to the subcutaneous tissue (caverno pleuro soft tissue fistula). The cavity was probably under tension that allowed passage of bronchial air through a tear to create subcutaneous emphysema. Subcutaneous emphysema carries no particular risk of its own. Additional high flow oxygen helps to correct hypoxia and denitrification of the blood which hastens reabsorption of subcutaneous air. Subcutaneous emphysema may be manually reduced by multiple skin incisions at the level of thoracic inlet or placement of subcutaneous drain. Department of Pulmonary Medicine, ASRAM, Eluru, Andhra Pradesh, Background: Aspergilloma is saprophytic colonization of parenchymal lung cavity by aspergillus. It is also referred to as mycetoma or fungal ball. It consists of both dead and living mycelial elements,fibrin,mucus,debris,inflammatory cells.Most aspergillomas are caused by aspergillus. fumigatus but some especially in patients with diabetes mellitus, caused by aspergillus.niger. Case Study: A 47 year old female presented with cough with scanty, mucoid expectoration, mild haemoptysis 5-6 episodes/day, dyspnea grade 2 mMRC-since 7 days.She had history of old pulmonary tuberculosis 20 years back, with no history of diabetes mellitus, bronchial asthma.On auscultation bilateral normal breath sounds,coarse crepts over left basal areas were heard.Active TB was excluded. Chest X-ray was suggestive of old TB sequelae.Movement of fungal balls within the cavities were appreciated by comparing chest CT scans taken in supine and prone positions. Discussion: Haemoptysis is typical manifestation of aspergilloma seen in 50-90% of patients.Aspergilloma in this patient was diagnosed by aspergillus.niger isolates from fungal culture of bronchial wash.Definitive treatment of aspergilloma is surgical resection.As there are multiple aspergillomas in this patient, surgical resection was not preferred.Itraconazole 200 mg twice daily was administered orally for 6 months.Patient improved symptomatically. Conclusion: In patients with history of cavitary lung disease, careful investigation should be carried out and fungal infection,especially aspergilloma should be taken into consideration. Aspergillus.niger as cause of aspergilloma should be taken into account.Itraconazole is found to be useful in symptomatic improvement of the patient. SMS Hospital, Jaipur, Rajasthan, Background: Tubercolosis has a worrisome connection with novel corona virus.Lingering respiratory symptoms in people who have recovered from Covid could well be mistaken as residual issues of Covid or secondary bacterial infections,missing TB diagnosis totally. Methods: A 28 year old female doctor by profession, initially asymptomatic tested Covid -19 positive as a part of contact tracing. On the 15 th day, she developed fever,dry cough and fatigue which persisted even after taking symptomatic treatment.Repeat Covid testing was negative.HRCT chest was normal.Sputum CBNAAT was negative and other relevant blood investigations were normal. On examination she was febrile and matted subcentimetric right cervical lyphnodes(LN) were palpable.Excision Biopsy of cervical LN was done and report suggested Kikuchi's disease.As a part of work up of Pyrexia of Unknown Origin,she undertwent 18-FDG PET whole body CT scan and showed mediastinal lymph node uptake(2R,4R LN station). Mediastinoscopic biopsy report showed tuberculosis and Gene Expert showed mycobacterium complex with Rifampicin resistance. Results: Based on clinical,radiological and laboratory findings,MDR LN tuberculosis was diagnosed.Patient wad started on MDR TB regimen and symptoms got improved. Conclusion: There is an increased likelihood of tuberculosis in post COVID patients due to many factors like lung inflammation,altered immunity and stress due to COVID,use of steroids and uncontrolled diabetes.Therefore active tuberculosis should be vigorously ruled out in any post covid patients with continuous fever.

Esophageogastroduodenoscopy was done -longitudinal esophageal friable ulcers were seen,Biopsy taken

On 2 monthly f/u Dysphagia was resolved along with all other complains. Conclusion: Along with conventional symptoms, Dysphagia is also common presenting complain in oesophageal tuberculosis. CB-NAAT along with histopathology is mainstay for diagnosis. Early starting of AKT remains best management and for preventing complications

The co-relation between malnutrition and active TB has been based on various observational studies. Malnutrition is associated with risk of relapse and low treatment response rates of TB. In general population, diets rich in fruits and vegetables is seen having low risk of lung function decline and asthma.It has also been seen that asthma is difficult to control in obese patients.it has also been observed that obese and overweight children have higher risk of development of bronchial asthma as compared to normal weight individuals.Majority of COPD patients have malnourished or under nourished state known as pulmonary cachexia syndrome and is associated with a decline in functional status and unfavorable prognosis.The present study was done to assess nutritional status of patients with Pulmonary Tb, bronchial asthma and COPD and to co-relate nutritional status with disease severity in these patients. Methods: this is a cross sectional study done in 50 patients each of sputum AFB positive pulmonary TB, bronchial asthma and COPD. These patients underwent anthropometric measurements alongside biochemical parameters (i.e Hb, S. albumin) and 24 hour calorie intake(via oral questionnaire). The nutritional status was co-related inter-disease as well as with disease severity. Results: There is a significant difference seen in all the three groups of patients for BMI with lowest BMI seen in TB patients.Tb patients were found to have a significantly lower Waist-Hip Ratio as compared to COPD (p=0.041) patients.Tb patients were found to have a significantly lower MUAC as compared to Asthma (p<0.001) or COPD (p<0.001) patients.More than 3/4 th of TB patients had anaemia which was significantly higher than Asthma and COPD patients (p<0.001).both COPD (p=0.004) and TB (<0.001) patients had a significantly lower calorie intake as compared to Asthma patients. Conclusion: patients with TB had more severe malnutrition as compared to asthma and COPD. Asthma patients had prevalence of obesity with more waist/hip ratio. The 24 hour calorie intake was significantly lower in patients of Pulmonary TB and COPD as compared to bronchial asthma suggesting the disease related cachexia and need of nutritional supplementation.A rare case of MDR PTB with primary bedaquiline resistance in the society Dnyaneshwar V. Dhobale, P. L. Meshram, V. V. Pujari, R. R. Hegde Grant Government Medical College Mumbai, Maharashtra, Background: XDR-TB is defined as resistance to at least isoniazid,rifampicin plus any of fluoroquinolones and any one of the second-line injectable anti-TB drug. A single case of primary BDQ-resistance is reported from Taiwan,Alver till date. BDQ is diarylquinoline which targets mycobacterial ATP synthase. It is bactericidal drug with mean terminal t1/2 of 5.5months. E-mail: amrutraj@haystackanalytics.in Background: The epidemiology of tuberculosis (TB) is a dilemma today. With an increasing option of treatment choices, the specter of drug resistance (DR) is also rising. Newer drugs offer a much-needed option in patients who have highly resistant TB. Today's methods of identifying DR, however, are limited. Several national and international authorities now recommend the use of whole-genome sequencing for TB drug profiling. Methods: TB whole-genome sequencing (WGS) was performed for over 500 samples. The data was analyzed using the OmegaTB genomic analysis. DR of newer drugs or unique profiles that would not be identified easily through current testing methods were identified and further described. Results: Among these samples, the profiles of samples that show resistance to newer drugs or unique patterns are showcased to exemplify samples that would not be easily identified through standard diagnostic profiles. Conclusion: WGS is inherently comprehensive. It is a single-test solution for the complete profiling of TB. It can identify drug-resistance conferring mutations even to newer drugs. As evidence for newer mutations grows, this test can be used to identify those as well. Several countries have shown the benefits of using TB WGS. We demonstrate its utility in an Indian context. E-mail: rkumarjkl@gmail.com Tuberculosis (TB) is an ancient human disease caused by Mycobacterium tuberculosis which mainly affects the lungs and thereby pulmonary manifestations are the most common way of presentation. Mycobacterium tuberculosis is a pathogen that infects humans with no reported environmental reservoir as such but it has mastered the art to survive and persisted through the human generations from ancient times till date. Drug resistant Tuberculosis has been known from the time anti-TB drugs were first introduced. The era of modern effectively treatable tuberculosis began in 1952 and it was since then that various drug resistant strains started coming into light for which arose the need of both treatment and control programs. In 2016, World Health Organization guidelines conditionally recommended standardised shorter 9-12-month regimens for multidrug-resistant (MDR) tuberculosis (TB) treatment. We conducted a prospective study of a shorter standardised MDR-TB regimen in Tertiary centre Objective:

• To assess the clinical outcome in patient of Multidrug Resistant Pulmonary Tuberculosis taking shorter injectable regimen. • To assess the radiological outcome of patient of Multidrug Resistant Pulmonary Tuberculosis put on shorter regimen. • To assess the microbiologic conversion of patient of Multidrug Resistant Pulmonary Tuberculosis taking shorter injectable regimen. ·• To study the adverse effect profile of patient of Multidrug Resistant Pulmonary Tuberculosis taking shorter injectable regimen. Design :Prospective Observational Study of MDR-TB patients treated with a standardised 12 month regimen including gaitifloxacin, clofazimine, prothionamide,ethambutol, and pyrazinamide throughout, supplemented by kanamycin and isoniazid during an intensive phase of a minimum of 4 months. Patients were enrolled on the basis of inclusion and exclusion criteria of shorter injectable regimen. Patients were followed at the end of intensive phase,extended intensive phase, and continuation phase and assesses clinically,radiologically,microbiologically. Results: In our study,our patients were mainly belonged to the younger group ( 24 patients, age group 11-20 years ),and 35 (67%) patients were female, 23 (43%) patients out of 53 patients were successfully treated, while regimen was changed for 17(32%) patients,out of which 5 patients regimen changed due to serious adverse effect reaction and and 12 patients had additional resistance. 9 patients died during the treatment, 2 were lost to follow up. Grade 3 adverse event was noted in 8 patients (15%). None of the patients were seropositive. The most common radiologic finding was patchy consolidation (n=40, 75%). And most of them had single parenchymal lesion (n=32, 60%.) BMI of the patient of 28 (53 %) belong to the underweight category. Conclusions: Overall success with a standardised shorter MDR-TB regimen was moderate with considerable treatment failure and amplification of fluoroquinolone resistance. When introducing standardised shorter regimens, baseline drug susceptibility testing and minimising missed doses are critical. High rates globally with lower lung field tuberculosis

Shadan Institute of Medical Science, Affiliated to Kaloji Narayana University of Health Sciences, Hyderabad, Telangana, Background: Lower lung field TB is a primary pulmonary Tuberculosis M.C in adults. In areas of high tuberculosis transmission, this form of tuberculosis is seen in adolescence with impaired immunity which is extremely rare & secondary spontaneous pneumothorax is a well-known complication of pulmonary tuberculosis (TB), particularly in patients with advanced TB, but its presentation in adolescence is rare. Case Report: A 18 yr female presented with complains of fever low grades since 1 month progressed to high grade since 2 days, cough with expectoration since 1 month, loss of appetite since 1 month,shortness of breath grade 2 MMRC since 5 days. On examination she was febrile temp 102 F, RR was 20/ min, SPO2 95% RA Respiratory examination revealed bilateral coarse crepitation's with increase vocal resonance in bilateral infrascapular & infraaxillary area CXR revealed right side minimal pneumothorax with bilateral mid & lower zone consolidation which was of 7 days back. Hrct was done which showed resolution of pneumothorax with left lower lobe consolidation & cavity with tree in bud appearance in right lower lobe. Thus the pneumothorax resolved on its own without any intervention. Sputum CBNAAT was done which showed MTB detected with no resistance & was started on ATT. Conclusion: The lower lung field tuberculosis is very uncommon in adolescence age group & leading to secondary spontaneous pneumothorax is an extremely rare complication. Introduction: Novel coronavirus disease started in December 2019 and declared pandemic on march 11 2020. Viral pneumonia increases patients susceptibility to bacterial and fungal infections and those who were admitted to ICU had a higher probability of infection.

Case Report: A 33yr old female came to the hospital with chief complaints of cough with expectoration associated with streaky haemoptysis and generalised weakness since 20 days. There was a h/o hospital admission for covid and patient was on NIV support. Patient was denovo diabetic. On examination pallor present and decreased breath sounds in bilateral infrascapular and infraaxillary areas. Investigations: Chest X ray showed bilateral mid and lowerzone non-homogenous opacities. Sputum for AFB,CBNAAT and KOH were negative. Sputum culture & sensitivity showed streptococcus. HRCT chest was done which showed multiple cavitary lesions in bilateral lung fields. Bronchoscopy was done and washings showed branching septate hyphae on KOH mount suggestive of aspergillosis. Patient was started on antifungals and symptomatic improvement was seen. Conclusion: Pulmonary aspergillosis is a serious complication in postcovid patients and high index of clinical suspicion and focused diagnostic approach is essential for early diagnosis and treatment which may improve the outcome.

Sri Manakula Vinayagar Medical College and Hospital, Madagadipet, Puducherry, India. E-mail: madhan.s21@gmail.com I n t r o d u c t i o n : S u b c u t a n e o u s e m p h y s e m a a n d pneumomediastinum occur frequently in critically ill patients in association with alveolar rupture, blunt or penetrating trauma, soft-tissue infections, or any condition that creates a gradient between intra-alveolar and perivascular interstitial pressures. Subcutaneous emphysema in a case of pulmonary tuberculosis may be present because of associated secondary spontaneous pneumothorax or may be iatrogenic following chest tube insertion for pleural pathology. Subcutaneous emphysema in a case of pulmonary tuberculosis in the absence of these conditions are sparsely reported. We report one such case of pulmonary tuberculosis that presented with subcutaneous emphysema without Pneumothorax. Case Report: A 49-year-old male who is farmer by occupation presented with complaints of chest pain, radiating to back and jaws with swelling over the chest for past three days which progressed to involve whole chest, neck, arm and face over the next few days. There was history of low-grade fever and cough with expectoration for the past 1 month. On examination of the chest, Crepitus was present over the chest and neck on palpation. Cavernous type of breathing was present in left infraclavicular area. Chest X-ray revealed heterogenous opacity involving entire left hemithorax, few fibrotic strands along with cavity noted in left upper zone and subcutaneous emphysema Department of Respiratory Medicine, GSVM Medical College, Kanpur, Uttar Pradesh, India. E-mail: 199304appykanaujia@ gmail.com Background: Shorter regimen for MDR /RR resistant patients was started in 2018 by RNTCP based on WHO recommendation in 2016. As per NDRS survey Success rate with injectable shorter MDR-TB in 2018 & 2019 was 60% and 57% respectively. Methods: This was a hospital based study on patients registered on shorter regimen for MDR TB. Patients was analyzed in terms of sputum conversion time, rate of sputum conversion. Outcome analysis at the end of therapy was done as per NTEP guidelines. Results: Among 420 MDR TB patients, 213 enrolled on shorter regimen out of which 200 were included after getting consent. 40 patients were switched over to all over longer regimen and 53 either defaulted or died or not submitted sample. Out of 107 patients,75% were negative,8.4% were positive &14.9% didn't submit sample at 3 rd month. 54.3% were turned negative, 4.9% patients were positive and 39.5% didn't submit sample on completion. Out of 166, sputum culture was negative in 46.38% and 48.70% at the end of third and 6 th month of therapy. Out of 200 patients, 26.5% were cured, 12% completed treatment, 20% converted into all oral longer regimen (32 during IP & 8 during CP),12 % were lost to follow-up,26% died while 3% not evaluated. Conclusion: Among 200 patients registered on shorter regimen,77 patients completed shorter regimen. Out of these 77, 53 were cured and 24 were treatment completed. Success rate of shorter regimen in our study after transfer of 40 patients to longer regimen would be 48.12% (77/160). College and Hospital, Lucknow, Uttar Pradesh, Introduction: The joint of feet including ankle, talocalcaneal and mid-tarsal, Tenosynovitis, and bursitis arising from TB are rare, so isolated tubercular ankle bursitis is a rare presentation of extrapulmonary tuberculosis, might not be seen in all forms of tuberculosis affecting this joint. Radiological investigations can help in accurate, timely diagnosis for safe and definitive management. Chemotherapy remains the mainstay of treatment. Case Study: A 14-year-old female patient, presented with pain ankle joint for 3 months and was misdiagnosed as arthritis and had received multiple courses of antiinflammatory medication. Discussion: X-Ray left ankle joint showed soft tissue swelling on the lateral aspect of the ankle and osteopenic changes. MRI was done of the left ankle joint showed the fluid collection in the ankle joint. USG guided aspiration of abscess done from the left ankle joint and send for Culture and CBNAAT. Mycobacterium Tuberculosis was detected. The patient was advised of Anti-tubercular treatment under DOTS Cat-1. Conclusion: Osteoarticular tuberculosis of the Ankle Joint is a rare form of extrapulmonary TB. Early diagnosis and treatment are essential to prevent joint destruction. Adjuvant surgery is often required to establish the diagnosis and in the treatment of patients with deformity and destruction of articular cartilage owing to delayed presentation. E-mail: maheshwariaditi213@gmail.com Background: Aspergillus is saprophytic fungi found in soil, water, decomposing organic matter. Among aspergillus species, A.fumigatus is the most common pathogen. Pulmonary aspergillosis can occur in different forms depending on architecture of the lung, host immune status. These are: simple colonisation, saprophytic aspergillosis, hypersensitivity reaction, semi-invasive or chronic necrotizing pulmonary aspergillosis (CNPA) or invasive aspergillosis. Here we report a case of CNPA. Case Report: A 60yr old female presented with complaints of chronic productive cough from last 4 years, on and off fever and chest pain since last 2 months. Patient had no history of asthma, cystic fibrosis, diabetes, pulmonary tuberculosis. Viral markers were negative. Patient had COPD due to biomass exposure. CECT chest reveled bilateral multiple cavities with fungal ball. TEC was normal. Serum total IgE, IgE and IgG for Aspergillus fumigatus were raised. FOB showed edematous and hyperemic left upper lobe bronchus with thick purulent secretions and Bronchoalveolar lavage was positive for aspergillus culture. Based on clinical and laboratory findings patient was diagnosed with CNPA. Discussion: CNPA is characterized as insidious infection that leads to progressive cavitatory lung disease and chronic respiratory symptoms for more than one month. The spores of aspergillus are deposited in the host lungs, resulting in extensive and progressive lung damage with no vascular invasion or dissemination to other organs. CNPA does not require a preexisting cavity. Conclusion: The diagnosis requires a high index of suspicion as prognosis depends on the promptness of treatment and on the nature of the underlying lung disease.

Tuberculosis -The master impersonator, two cases of pulmonary tuberculosis mimicking diffuse cystic lung disease

National Institute of Tuberculosis and Respiratory Diseases, New Delhi, India. E-mail: docvinayv@gmail.com Background: Multiple cystic lung diseases are a group of uncommon disorders that pose a diagnostic challenge to the physician. Cystic lung disease as the initial presentation of tuberculosis is atypical and very rare. Case Presentation: We present two immunocompetent cases of pulmonary tuberculosis who presented with multiple cysts in the lung parenchyma. The diagnosis was confirmed by the transbronchial lung cryobiopsy in first case and by analysis of bronchoalveolar lavage fluid in the second. Both had spontaneous pneumothorax which was treated with chest drain and pleurodesis. Both showed an excellent response to Anti-tubercular therapy and steroids. Discussion: TB with multiple lung cysts on presentation is less frequently reported. The pathogenesis of cyst formation in the lung due to TB is unclear, but few mechanisms are postulated: a) Interstitial air leakage due to tubercle rupture, b) Chronic granulomatous inflammation of bronchioles and caseating necrosis of the bronchiolar walls leading to dilated bronchioles by check-valve mechanism, c) Poor drainage of necrotic lung parenchyma along with bronchiolar obstruction. The extent and outcome are dicey while cysts are reversible in few cases. Conclusion: Tuberculosis is a heterogeneous disease with a myriad clinical presentation. Cystic lung lesion as an initial presentation of PTB is rare and should be considered as a possible cause of acquired cystic lung disease in a high TB burden country like India. If diagnosed and treated on time, we can prevent complications and improve the outcome.A rare case of Ovarian TB with elevated CA 125 levels mimicking ovarian cancer E-mail: meghasmangal1111@gmail.com Introduction Perioperative diagnosis of ovarian tb is often difficult d/t confusion with ovarian cancer. Female who present with ascites, adnexal mass, elevated CA125 are presumed to have ovarian cancer. This can lead to radical surgery with associated morbidity. Case Report-27 F presented with abdominal pain and distension with no fever, weight loss. CA125 level was 426. Ct s/o left adnexal cystic lesion with abdominal and right supraclavicular lymph nodes, moderate ascites, peritoneal soft tissue densities. Mantoux negative, ascitic fluid cytology was lymphocytic with no malignant cells. Ovarian cancer was highly suspected. Explorative laparotomy with omental biopsy and left oopherectomy done. Frozen section showed granulomas with military granular deposit over omentum. She was started on ATT and is under regular follow up.Conclusion-CA125 levels lack specificity with elevated levels encountered in benign and malignant condition. There are few discriminative features s/o tb than ovarian ca as smooth peritoneal thickening and dirty omentum on Ct s/o tb compared to nodular thickening s/o cancer. Diagnostic laparoscopy/laparotomy should be performed with aid of frozen section in case of discrepancies.