P1

Diagnosis of Pulmonary Thrombo-embolism in Respiratory Intensive Care Unit

O. JHA, R. GUPTA, D. TALWAR

Pulmonary Medicine and Critical Care, Metro Center for Respiratory Diseases, Noida, UP (India)

OBJECTIVES: CT-pulmonary-angiography/VQ-scan (CTPA/VQS) and compression ultrasonography (CUS) arecurrently standard diagnostic methods for PTE and DVT respectively. Role of D-dimer as screening tool is notobjectively assessed for RICU patients with pulmonary and other co-morbidities where dyspnoea is commonpresentation at admission and they are at high risk to develop PTE due to immobility prior to and after admissionin the RICU. Due to patients respiratory condition it may not be possible to do definitive tests on all patients andmany times due to waxing and waning nature of respiratory symptoms repeating them may not be feasible insame patient many times. In current study using CTPA/VQS as gold standard we have analyzed the reliability of D-dimer and CUS positivity in evaluation of PTE in respiratory intensive care unit (RICU).

METHODS: All patients with respiratory and other co-morbidities with clinical suspicion of PTE (Well’s score > 6)and undergone CTPA and/or VQS were screened. The Study includes data from 41 patients (mean age 54.7±14.99)who had undergone CT-PA/VQS, CUS and D-dimer within 24-hour of interval. D-dimer and CUS results forCTPA/VQS positive and negative patients were compared.

RESULTS: The Demographics of CTPA/VQS positive (n=21) and negative (n=20) groups are comparable (Mean age52.3±15.00 vs. 57.2±14.95; p=0.305). Both group had similar prevalence of COPD (30%). Higher prevalence of otherrespiratory co-morbidities is found in CTPA negative group. D-dimer levels (3303±2472 vs. 2337±2341; p=0.217),positivity of CUS (22% vs. 17%, p=0.763) and adjusted D-dimer (90% vs. 80%; p=0.412) of the two groups was notsignificantly different.

CONCLUSIONS: D-dimer or CUS are not useful guide for evaluation of PTE in RICU setting in patients withrespiratory co-morbidities. Therefore there is need for low threshold for definitive tests (CTPA/VQS) to reliablydiagnose PTE cases in RICU patients in differential diagnosis of dyspnoea.

P2Physiological basis of Acid Base Disorders

DR. RAJIV GOYAL M.D. , (M.R.C.P.U.K.), CHAIRMAN AND HEAD

CENTRE FOR RESPIRATORY DISEASE, JAIPUR GOLDEN HOSPITAL, NEW DELHI

The internal metabolic environment of the human body is in a constant state of flux with complex checks andbalances which keep its chemical constituents within a narrow ‘normal’ range. Despite the enormous load of aciddue to catabolic activities the internal milieu is tightly controlled and the H+ ion concentration therefore the pH iskept within normal limits. The body is able to do this with help of certain buffer systems which are able to nullifythe effect of the additional acid load. Various disease states or organ malfunctions due to extrinsic stresses likepoisoning tend to induce changes in the metabolic environment by making it more acidic or alkaline. These areresisted by compensatory mechanisms which are primarily mediated through the lungs and the kidneys. Before weunderstand the physiological basis of these acid base disorders it is necessary to define few basic terms.

P3IMMEDIATE ECHOCARDIOGRAPHIC ASSESSMENT OF PAP IN PATIENTS ADMITTED WITH EXACERBATION OF COPDIN RICU

Kuldeep Saini, Deepak Talwar

Metro Centre for Respiratory Diseases, Noida, India

Objectives: PH is a well established complication of COPD, develops from disease related deranged structure-function relationship of lungs. This study correlates PAP assessed by immediate echocardiography in Indianpatients admitted with acute exacerbation of COPD with severity of COPD (spirometry) ,severity and duration ofcurrent exacerbation of COPD

Methods: PAP (systolic & mean) assessed by immediate echocardiography in 64 patients admitted with COPDwith acute exacerbation as per GOLD 2013 Guidelines at Metro Centre for Respiratory diseases wereretrospectively analyzed for their clinical symptoms, assessment of severity in the last one year’s using SPSSsoftware.

Results: Mean age 64.90+10.12 yrs and 15 (23.5%) were females. sPAP correlated with Pred post bronchodilatorFEV1 % (r=-0.321** ,p=0.010), severity of COPD (commonly seen C & D) (r=0.339** ,p=0.006), duration andseverity of current exacerbation (r=0.215, p=0.088) and (r=0.067,p=0.596) respectively.

Conclusions: PAP correlated with severity of COPD, not with severity and duration of current exacerbation ofCOPD in this study.

Clinical implications: As COPD is a progressive disease, investigations like PFT and serial Echocardiography shouldbe done to assess the progression and complications of associated PH. However repeat Echocardiography, onceexacerbation has resolved is likely to give valuable information regarding PAP.

P4Diagnosing bacterial peritonitis made easy by use of leukocyte esterase dipsticks

VIPIN GOYAL1, KIRAN CHUGH2, YUTHIKA AGRAWAL2,

1. Department of Chest and TB, S.H.K.M. Govt Medical College, Nalhar, Mewat, Haryana.

2. Departments of Biochemistry, PGIMS, Rohtak, Haryana, India

Introduction:

Spontaneous bacterial peritonitis (SBP) requires rapid diagnosis for the initiation of antibiotics. Its diagnosis isusually based on manual examination of ascitic fluid (AF) having long reporting time. AF infection is diagnosedwhen the fluid polymorphonuclear leukocyte (PMNL) concentration ≥ 250 cells/mm3.

Aims and objectives:

Aim was to evaluate the diagnostic utility of leukocyte esterase (LE) reagent strip for rapid diagnosis of SBP inpatients who underwent abdominal paracentesis and to calculate the sensitivity, specificity, positive, and negativepredictive values.

Materials and Methods:

The study was carried out on 103 patients with ascites. Cell count of AF as determined by colorimetric scale ofMultistix 10 SG reagent strip was compared with counting chamber method (PMNL count ≥ 250 cells/mm3 wasconsidered positive).

Results and Observations:

Of the 103 patients SBP was diagnosed in 20 patients, 83 patients were negative for SBP by manual cell count. AFculture was positive in 55% (11) of these cases. The sensitivity and specificity of the LE test for detecting neutrocyticSBP taking grade 2 as cut off were 95% and 96.4% respectively, with a positive predictive value of 86.4% and anegative predictive value of 98.8%. Diagnostic accuracy of LE test was 96.1%.

Conclusion:

There was a good correlation between the reagent strip result and PMNL count. In India, till date only two studieshave been published on the use of LE reagent strip in AF. It is a very sensitive and specific method for the promptdetection of elevated PMNL count, and represents a convenient, inexpensive, simple, and bedside method fordiagnosis of SBP. A negative LE test result excludes SBP with a high degree of certainty.

P5Comparison of Idiopathic Pulmonary fibrosis patients with and without pulmonary hypertension

Ashik.K, Suhail.N, Abdul Nazar.T, Lisha.P.V, Irshad.K

Department of Pulmonology MES medical college Perinthalmanna, Kerala, India

Background: Studies evaluating of phenotypic characteristics of IPF have not been reported in this region.Pulmonary hypertension (PH) may develop as an unrecognized complication of IPF leading to worse prognosis.There is debate on whether PH in IPF develops in end stage disease or as separate phenotypic entity

Aim: To compare the clinical and radiological profile of IPF patients with and without PH

Materials and methods:

Study design: Observational study

Inclusion criteria

IPF diagnosed according to the revised ATS/ERS/JRS/ALAT diagnostic criteria

Exclusion criteria

Patients with LV disease , IPF during exacerbation

Methods: All patients diagnosed as IPF were included. PH assessed using 2D-ECHOcardiography. Functional statusassessment was done by 6-MWT, PFT, ABG. A scoring system was used to grade fibrosis in HRCT Thorax

Results: A total of 24 IPF patients are included (15 males, 9 females). 8 patients had PH (6M, 2F). Mean age in PHgroup was 73.12 and in non-PH group was 60.44 (P value 0.004). Patients with PH had Grade 3MMRC dyspnoea orabove (P value 0.001).Mean 6MWT distance of patients with PH was 42.5 and without PH was 172.5mtrs (P value<0.001).Mean HRCT fibrosis score in patients with and without PH was 218.75.

Conclusion: PH in IPF shows a significant association with advanced age at presentation. Reduced 6MWT distancecorrelates with presence of PH. Higher MMRC dyspnoea grade are seen in those with PH. HRCT fibrosis scoredoesn’t show any significant association with PH

Clinical implication: PH is a significant worse prognostic factor in IPF. This study helps in identifying factorsassociated with PH so that such patients can be identified early and given appropriate care

P6Case report of cryptogenic organizing pneumonia (cop).

SUJIT REDDY CHINTHALA, SATISH CHANDRA, SUDHEER, CN PRASAD

Prathima Institute of Medical Sciences, Karimnagar, Telangana

OBJECTIVES: To report a case of cryptogenic organizing pneumonia presenting with fever, dyspnea and acuterespiratory failure. Cryptogenic organizing pneumonia is a clinical entity of unknown etiology. A prevalence of 6 to7 per 100,000 admissions has been reported.

METHODS: A 60 year male, nonsmoker, presented to our hospital with fever, dry cough, breathlessness grade IV(modified MMRC), progressing over 4 weeks. His PaO2 of 58.0 mm Hg, SpO2 of 79% on room air. Chest X-ray s/obilateral patchy alveolar airspace consolidation. HRCT chest s/o: Patchy ground-glass opacities in a subpleural andperibronchovascular distribution, bilateral basal airspace consolidation, small nodular opacities measuring 1-10 mmin diameter,noted,which is suggestive of COP.Transbronchial lung biopsy was performed which showed featuresconsistent with COP. Patient improved with initial NIV support, intravenous steroids later maintained on oralsteroids,presently on a gradual tailoff.

RESULTS: Histopathological examination revealed anastomosing plugs (‘buds’) of granulation tissue, the Massonbodies, that fill bronchiolar and extend into the alveolar ducts and spaces.

CONCLUSION: Patients presenting with acute or subacute features of fever and dyspnoea with above imagingfeatures should be evaluated for possibility of COP, simultaneously excluding various infective etiologies.

P7Diagnostic value of transbronchial lung biopsy in diffuse lung disease

Praveen BS, George Albert D’souza, Priya Ramachandran, Uma Devraj,

Department of Pulmonary Medicine, St Johns medical college, Bangalore, India

OBJECTIVE:

To understand the diagnostic value of transbronchial lung biopsy in diffuse lung disease.

METHODS:A retrospective review of our records was done between june 2012 to july 2014. A total of 57 TBLB wereperformed. All cases were reviewed for diagnostic yields.

RESULTS:Adequate samples were obtained in 54/57 TBLBs (94.7%). In total 5/57 TBLBs (8.7%) yielded bronchial mucosa,while 20/57 TBLBs (35.1%) showed chronic inflammation. Confirmed diagnosis was obtained in 34/57 patients; thetotal positive diagnostic rate was 59.7%. Diseases included adenocarcinoma 8/57 (14%), Non-specific interstitialpneumonia 5/57 (8.7%), Tuberculosis 6/57 (10.5%), Sarcoidosis 3/57 (5.3%), Usual interstitial pneumonia 2/57(3.5%), Brochiolitis obliterans with organizing pneumonia 2/57 (3.5%), Hypersensitivity pneumonitis 1/57 (1.8%),Small cell cancer 1/57(1.8%), silicosis 1/57(1.8%).

CONCLUSIONS:Our experience substantiates previous reports of the value of transbronchial lung biopsy in diffuse lung disease

P8Interstitial Lung Disease (Ild) In Rheumatoid Arthritis (Ra)-A Study Of forty seven cases.

S Bansal, D Talwar, S Joshi, R GuptaMetro Hospital and Institution, MCRD, L-94 sec 11, Noida

OBJECTIVESTo evaluate Interstitial Lung Disease (ILD) in the patients with Rheumatoid Arthritis (RA) and to assess pulmonaryfunction tests and High Resolution Computed Tomography (HRCT) findings.

MethodsAn unselected cohort of patients with a confirmed diagnosis of RA (satisfying the American College ofRheumatology (ACR) criteria ) and known lung disease were identified (n =47 ) and evaluated for RA lung diseaseactivity and severity. Outcomes included abnormalities determined by the HRCT findings of the lung, forced vitalcapacity (FVC) and diffusion capacity for carbon monoxide (DLco).

ResultsFour major HRCT findings were observed, nodules (n=27; 57.4%), Ground glass haze (n=20; 42.5%), Pleural effusion(n=12; 25.5%) and apical fibrobulla (n=10; 21%). Bronchiectasis was observed in 4 cases (8.7%) Dominant patternobserved were UIP (n=7; 14.8%), OP (n=5; 10.6%), NSIP (n=3;6.3%), Mixed (n=8; 17%). FVC was reduced in 80%(n=38) of patients in which 20 (42.5%) had mild, 15 (31.9%) had moderate and 3 (6.38%) had severe reduction inFVC. DLco was normal in 12 (25.5%) cases where as 16 (34%) had mild, 18 (38.2%) had moderate and 1 (2%) hadsevere reduction in diffusion capacity.

ConclusionPulmonary nodules are the most common pattern observed in our patients followed by ground glass haze. Pleuraleffusion is seen in one forth of our patients with RA-ILD. UIP, OP, and NSIP interstitial pattern is observed indecreasing frequency but mixed pattern is more commonly seen. Mild to moderate reduced FVC and DLco wasobserved in more than 80% of our pts. Pulmonary complications in RA are directly related to the severity ofpleural, parenchymal and airway involvement. Our study emphasizes that all patients with RA should undergoHRCT and PFT even with minimal respiratory symptoms so that more aggressive treatment can be justified inotherwise stable patients.

P9Title: A case of ILD with descending thoracic aorta aneurysm

Somnath Dash, K.V. Ramana Rao, Archana A.

GSL Medical College, rajamundry, Andhra Pradesh

A 46 year old female presented with shortness of breath and cough with expectoration since 2 months.She isknown hypertensive. she had history of amputation of distal phalynges due to gangrene. Patient is not a knowncase of tuberculosis. On clinical examination she was found to have hypopigmented macules on scalp with bilateralVelcro crackles on auscultation. On thorough investigations it was confirmed she was suffering from ILD withdermatological involvement and aneurismal dilatation of descending thoracic aorta. Though ILD’S arecommon,such presentation is rare and should be an eye opener to everyone.

P10

Title: A case of systemic sarcoidosis

Somnath dash, K.V.Ramana rao, Satish.B

GSL Medical college, Rajamundry, Andhra Pradesh

A 47 yr old male presented with dry cough and progressive dyspnoea. Patient is a known diabetic andhypertensive. He underwent cholecysectomy and biopsy from liver was obtained. It was confirmedhistopathologically as non caseating granuloma. Chest Xray and CT revealed features of sarcoidosis. Such kind ofasymptomatic presentation needs early and effective diagnosis for better management.

P11

Unusual presentation of Desquamative interstitial pneumonia: A case report

Dr. Santhosh V G, Dr. G.S. Gaude, Dr. Jyothi Hattiholi

Dr. Santhosh V G, Postgraduate in Department of Pulmonary Medicine, KLE University’s Jawaharlal Nehru MedicalCollege, Belgaum, Karnataka

Desquamative interstitial pneumonia (DIP) is a rare disease which was reported by Liebow et al. in 1965. Wehereby report a case of 46 year old male, nonsmoker with diagnosis of DIP and peripheral gangrene of fingers.Patient had presented with history of cough, repeated episodes of hypoglycemia and peripheral cyanosis of fingersinvolving both upper and lower limbs. Past history revealed, he was working in iron factory for last 25 years. Chestradiography showed the presence of non-homogenous opacity with air bronchogram in the left upper and midzone. Patient was treated with appropriate antibiotic coverage and other supportive treatment. Repeat chestradiography after 5 days showed no improvement and peripheral cyanosis persisted inspite of normal arterialblood po2. CT scan of thorax showed non homogeneous opacity with air bronchogram in left upper lobe.Bronchoscopy was normal and bronchialveolar lavage (BAL) fluid was negative for malignant cells and AFB. CTguided biopsy of lung was done, which showed alveoli filled with proteinaceous contents with plenty ofmacrophages containing brown pigment and fibrosis of interstitial tissue which was suggestive of DIP. He wastreated with steroids and supportive medication. Repeat chest radiograph showed radiological improvement withgood resolution. However peripheral cyanosis progressed to developed gangrene of fingers of both lower andupper limbs. The color Doppler study of arteries and venous system showed thrombus in the left cephalic andsubclavian vein, while other arteries and vessels had no evidence of thrombus. Patient was discharged andcontinued on oral steroids and oral anticoagulants.

Key words: Desquamative interstitial pneumonia, gangrene, CT guided biopsy.

P12

NITROFURANTOIN – INDUCED PULMONARY FIBROSIS: CASE REPORT

GIFTY MG, KISKU KH, MADHUSMITA M

Department of Pulmonary Medicine, Pondicherry Institute of Medical Sciences, Puducherry-605014IntroductionNitrofurantoin is a commonly used drug in the treatment and prevention of urinary tract infections. Many adverseeffects of nitrofurantoin have been documented, including aplastic anemia, polyneuritis, and liver and pulmonarytoxicity.

Case presentationWe describe the clinical history and the autopsy findings in a 60-year-old man with Interstitial Lung Disease ofunknown etiology. He had a history of recurrent urinary tract infections, treated with nitrofurantoin for fourmonths. He came to our hospital with progressively worsening breathlessness for 1 month. He was in respiratoryfailure and oxygen dependent and progressively worsened in spite of treatment with steroids and perfenidone. Hefinally died of respiratory insufficiency.

At autopsy there were features of organizing pneumonia. With the microscopic pattern bronchiolitis obliteransorganizing pneumonia and the history of long-term nitrofurantoin use, we concluded that this was a drug inducedpulmonary toxicity.

ConclusionThis case shows that the use of nitrofurantoin may cause severe pulmonary disease. Patients with long-term use ofnitrofurantoin should be monitored regularly for adverse pulmonary effects.

P13

A case series of connective tissue diseases in interstitial lung disease (CTD –ILD).

K.V.V. Vijaya kumar, T.Suresh babu, K. Venkataramana, A.Prem kumar

Government Hospital for Chest & Communicable diseases (GHCCD), Andhra Medical College, Visakhapatnam, AP,India.

Introduction: The connective tissue diseases (CTDs) are a group of inflammatory, immune-mediated disorders inwhich a failure of self-tolerance leads to autoimmunity and subsequent tissue injury. Involvement of therespiratory system, particularly interstitial lung disease (ILD), is common and is an important contributor tomorbidity and mortality. The radiographic findings and histopathologic appearances of ILD among the CTDs closelyresembles idiopathic interstitial pneumonias. However, close examination of radiographs, pathologic tissue andcollagen profile may offer clues to a diagnosis of underlying CTD. Corticosteroids and immunosuppressive agentsare often used.

Case Reports: Here, we present 3 cases of CTD –ILDs in which two were females and 1 male. Two were aged morethan 70 years. Collagen profile of these patients confirmed the diagnosis of dermatomyositis in one case (Ro- 52recombinant positive, increased CPK) , mixed connective tissue disorder in one case ( sRNP positive) , andrheumatoid arthritis in one case ( raised RF , anti CCP and CRP ). 2D ECHO in two patients showed moderate PAHand one case showed mild PAH. Among the three patients, dermatomyositis patient was died because of pneumo-mediastinum and due to vasculitis flare up. Another 2 patients were managed uneventfully for the present.

Conclusion: Lung disease is a common manifestation of the CTDs and may be a presenting feature. Subclinicaldisease is common. Clinically apparent disease is often slowly progressive but may present in an acute fashion,contributing to high morbidity and mortality. The diagnosis of idiopathic ILD should never be made without acareful clinical search for evidence of CTD.

P14

Correlation of GAP risk assessment system in Idiopathic Pulmonary Fibrosis at a tertiary care center

UNNATI DESAI, VINAYA KARKHANIS, JYOTSNA M JOSHI

Department of Pulmonary Medicine, T.N.M.C. & B.Y.L. Nair Hospital, Mumbai

Objective

Idiopathic pulmonary fibrosis(IPF) is a progressive IIP with poor prognosis. The GAP risk assessment system,consisting of the GAP index and staging system, is a clinical prediction tool that estimates prognosis in patientswith IPF. We studied the correlation of GAP risk assessment system in IPF.

Material & Methods

An observational study was conducted at a tertiary care center on 37 patients with IPF diagnosed on basis ofclinico-radiology and lung biopsy wherever required. Clinical characteristics, comorbidities, GAP score and GAPstage were noted at baseline. The survival of patients at one, two and three years was enquired for telephonically.

Results

Total thirty-seven IPF patients consisted of seventeen men and twenty women. There were eight smokers all men.31(84%) of these patients had associated comorbidities. Twelve patients had baseline six-minute-walk-distance(6MWD) less than 207meters of which nine (75%) died at 3year follow-up. All patients with pulmonaryhypertension died at 3 year follow-up. At one, two, three years follow-up 17(46%), 22(60%), 23(62%) patients diedrespectively. Patients classified into stages of GAP I, II, III consisted of 5, 17, 15 respectively. Of the GAP I patients20% died at 1 year, 40% died by 2year & 3year. Of the GAP II patients 35% died at 1 year, 47% died by 2year &3year. Of the GAP III patients 67%, 80%, 87% died at follow-up 1year, 2year and 3year respectively.

Conclusion

The mortality in our IPF patients as per GAP staging system was higher than noted in IPF cohorts internationally.Delayed diagnoses, comorbidities, lower 6 MWD; presence of pulmonary hypertension could be the reasons,necessitating their incorporation into future IPF staging systems.

P15

SEMIRIGID THORACOSCOPY: INITIAL EXPERIENCE FROM TERTIARY CARE CENTRE

ELAKYA.V, VENGADA KRISHNARAJ.S.P, ALLWYN VIJAY, SRIDHAR.R, KRISHNARAJASEKAR.O.R, CHANDRASEKAR.C

Government Hospital of Thoracic Medicine & Stanley Medical College

Objective: To assess the indications, efficacy and safety of semirigid thoracoscopy

Methods: Retrospective non randomized cohort study. Study population: All cases subjected to thoracoscopyduring March 2014 – august 2014. Technique: Semirigid thoracoscopy under conscious sedation and localanaesthesia. Variables like age, sex, indication, adhesion, loculations, visceral peel, no of biopsies, diagnosis,quantity of fluid, colour of pleural fluid were assessed. Site of study – Govt Hospital Of Thoracic Medicine,Chennai.

Results: Total number of cases is 45 - 38 cases male and 7 cases female.Mean age is 45.Indications noted wereempyema(22%), undiagnosed pleural effusion(31%) , non expanding lung(33%), hemorrhagic effusion(11%) and lungbiopsy(2%). 18 % of cases were diagnosed as malignancy and rest were due to benign causes. 4 out of 5 cases ofhemorrhagic effusion was malignancy.6 out of 10 cases of empyema were successfully drained.4 requireddecortications. Lung biopsy in a case of ILD shows hypersensitivity pneumonitis. Visceral peel was present in 47%of study population with high incidence (73%) in non expanding lung group. Prolonged air leak and visceral peelwere main reasons for non expanding lung group.

Conclusion:Semi rigid thoracoscopy is relatively easy to use and efficient in management of pleural diseases .It issafe with minimal complications

P16

ROLE OF FIBREOPTIC BRONCHOSCOPY IN SMEAR NEGATIVE RE-TREATMENT PULMONARY TUBERCULOSIS

NAVANEETHA KRISHNAN, G. ALLWYN VIJAY, S.P. VENGADA KRISHNARAJ, R.SRIDHAR, O.R. KRISHNARAJASEKHAR, C. CHANDRA SEKAR

BACK GROUND: Diagnosis of sputum smear –negative retreatment pulmonary tuberculosis patients can bechallenging and many patients being put on anti-tubercular treatment empirically, leading many time to

avoidable risk of drug toxicity, particularly retreatment cases. Fibreoptic bronchoscopy may provide a confirmativeand early diagnosis in such patients.

AIMS: To assess the role of fibreoptic bronchoscopy in the sputum smear – negative Retreatment pulmonarytuberculosis and compare the pre FOB sputum for LPA with FOB wash AFB culture by LJ medium.

MATIERIALS AND METHODS: This is prospective study. It was conducted on 52, clinically and radio logicallysuspected sputum smear –negative Retreatment Pulmonary Tuberculosis patients attending Government Hospitalof Thoracic Medicine, Tambaram, Sanatorium. Fibreoptic bronchoscopy was performed. Bronchial wash and brushsent for AFB smear and malignant cytology. Bronchial wash for AFB culture by LJ medium, post FOB sputum forAFB smear. All patients in this study given pre bronchoscopy sputum for LPA.

P18

Yield of Thoracoscopy in Undiagnosed Exudative Pleural Effusions

VIKAS MARWAH, AK RAJPUT, IM PANDEY, YADVIR GARG

Army Hospital (R&R), Delhi Cantt, India

An undiagnosed pleural effusion is often a difficult medical problem that needs histopathologic study for adefinitive aetiological diagnosis.

BACKGROUND AND AIMS:Medical thoracoscopy has received renewed interest in the recent past for diagnostic as well as therapeutic uses.In this study, we describe our experience with thoracoscopy for undiagnosed pleural effusions.

METHODS:In a retrospective analysis of thoracoscopic procedures, we performed between August 2013 and Aug 2014, yieldof thoracoscopic pleural biopsy for achieving a diagnosis in undiagnosed pleural effusions, defined as pleuraleffusions with adenosine deaminase (ADA) levels less than 40 IU/L and negative pleural fluid cytology formalignancy on three occasions was evaluated.

RESULTS:A total of 34 patients (25 males and 9 females; mean age years) underwent thoracoscopy. Overall diagnostic yieldof thoracoscopic pleural biopsy was 97.05% in patients with undiagnosed pleural effusions. Malignancy wasdiagnosed in 21 patients, tuberculosis was found in 09 patients, 03 patients had non-specific inflammation, andwas non-diagnostic in 01 patient. There were no major complications, only four patients had minor complicationlike subcutaneous emphysema (three patients) and prolonged air leak (one patient).Histologic diagnosis PrevalenceMalignant pleural effusion 21 (61.74%)Granulomatous lesion 09 (26.47%)Chronic non- specific inflammation 03 (8.82%)Non diagnostic 01 (2.94%)

CONCLUSIONS:Pleuroscopy is a safe, simple, and valuable tool in the diagnosis of undiagnosed exudative pleural effusion withminimal complication rates. In a tertiary care centre, thoracoscopy has shown more malignant pleural effusionsthan tuberculous signifying a changing trend.

P19

Bedside pleurodesis and digital suction device

S Khandelwal, K Ali, N Agarwal, A Z Khan

Department of Minimally Invasive and Robotic Thoracic Surgery

Medanta The Medicity, Gurgaon

Objectives: We present our experience of facilitation of conservation management of air leaks and malignantpleural effusion by bedside pleurodesis due to use of ThopazTM digital suction suction device thus avoiding surgeryand general anesthesia for very sick patients.

Methods: 52 patients unfit for general anaesthesia underwent bedside Talc pleurodesis for prolonged air leak ormalignant pleural effusion. Talc slurry with lignocaine was introduced via the drain and digital suction was appliedat 2 Kpas for 48 to 72 hours

Results: 48/ 52 patients underwent successful talc pleurodesis due to complete lung expansion. 8/48 patientsneeded 2 doses of talc over 4 days. Early mobilisation was facilitated by portable digital suction device. 2/ 52patients had small localised apical pneumothorax with no clinical significance. 4 patients with tuberculosis wereput on a flutter bag and discharged home. Drain was removed at follow up.

All patients had successful conservative management of clinical problem.

Referral rates have increased from Cardiac surgery, oncology, pulmonology and urology departments specificallyseeking medela digital suction device.

Conclusion: Use of ThopazTM digital suction device facilitates early expansion of lung and thus aiding in successfulbedside talc pleurodesis in very sick patients who are unfit for general anaesthesia

P20

Avoidance of surgery in secondary pneumothorax using digital suction device

S Khandelwal, K Ali, N Agarwal, A Z Khan

Department of Minimally Invasive and Robotic Thoracic Surgery

Medanta The Medicity, Gurgaon

Objective: We present our experience of facilitation of conservation management patients with secondarypneumothorax with air leaks by bedside pleurodesis due to use of ThopazTM digital suction device thus avoidingsurgery and general anesthesia for very sick patients

Methods: 18 patients with secondary pneumothorax with ICD with prolonged air leak, who were unfit for generalanaesthesia, underwent bedside Talc pleurodesis. Talc slurry with lignocaine was introduced via the drain anddigital suction was applied at 2 Kpas for 48 to 72 hours.

Results: 13/18 patients underwent successful talc pleurodesis due to complete lung expansion. 2/18 patientsneeded 2 doses of talc over 4 days. Early mobilisation was facilitated by portable digital suction device. 2/ 18patients had small localised apical pneumothorax with no clinical significance. 1 patient with tuberculosis was puton a flutter bag and discharged home. Drain was removed at follow up. All patients had successful conservativemanagement of clinical problem.

Conclusion: Use of ThopazTM digital suction device facilitates early expansion of lung and thus aiding in successfulbedside talc pleurodesis in very sick patients who are unfit for general anaesthesia

P21

Unusual Endobronchial Foreign Bodies

S Khandelwal1, K Ali1, N Agarwal1, S Khanna2, A Sharma2, T Piplani3, A Z Khan1

1Department of Minimally Invasive and Robotic Thoracic Surgery

2Department of Anesthesiology

3Department of Radiology

Medanta The Medicity, Gurgaon

Objective: We set out to present our experience of extracting unusual endobronchial foreign bodies.

Methods: A total of 11 cases were diagnosed roentogenographically and bronchoscopically at our hospital. Thesepatients consisted of 10 men and 1 woman with a mean age of 48.5 years (range 10 to 77 years). Symptoms onpresenting were usually cough, sputum, or chest pain. Three patients were not aware that they had aspirated aforeign body. Rigid bronchoscopy and retrieval of foreign body was performed in all the cases.

Results: The articles removed were betelnut, peanuts, denture, antihypertensive tablet, plastic button, coin, penspring. There were no severe complications during or after the endoscopic removal of the foreign bodies.

Conclusion: In conclusion, rigid bronchoscopy is useful for the diagnosis and treatment of endobronchial foreignbodies.

P22

Robotic & VATS Lobectomy for post tuberculosis Aspergilloma

S Khandelwal1, Kamran Ali1, N Agarwal1, S Khanna2, A Sharma2, T Piplani3, A Z Khan1

1Department of Minimally Invasive and Robotic Thoracic Surgery

2Department of Anesthesiology

3Department of Radiology

Medanta The Medicity, Gurgaon

Objective: We present a video of our experience of Robotic & VATS Resection of Aspergilloma using a DaVinci 4Arm robot. We also demonstrate a novel intraoperative technique to prevent spillage of aspergilloma into thenormal lung.

Methods: Between January 2012 to September 2014, 18 patients underwent surgical resection of Aspergilloma CTscan demonstrated an aspergilloma.

4 arm DaVinci Robot was used to perform the surgery. Intubation was done with double lumen tube into the non-operative bronchus with the patient in a lateral position with affected side down to prevent spillage. A Fogarty’scatheter was also introduced into the affected side (operative side). Fissure and hilum were exposed andstructures were stapled with endostaplers.

Results: Age group was 35 to 78 years (mean 48 years). 12 males and 6 females. Patients received antituberculousdrugs for at least 6 weeks. Voriconozole was given 2 weeks prior and continued for 3 months postop.

3 cases of robotics needed completion by VATS. 2 needed conversion to open due to bleeding and frozen hilum.

Mean operative time was 188 minutes. Mean blood loss was 558 mls. 6 patients received blood transfusion. ChestX-ray showed complete lung expansion.

One patient died with multi organ failure and fungal septicaemia on day 25.

Conclusion: Robotic and VATS Resection of Lung is technically possible with good clinical outcomes. Roboticsallows 3D visualization and 360 degree movement of endowrist. It gives good and accurate mobilization ofadhesions. Addition of anesthetic techniques like lateral double lumen intubation, Fogarty catheter preventspillage of aspergilloma into normal lung. In the background of tuberculosis, where the general feeling across thecountry is that VATS is not possible we have not only done these very complex cases by VATS but shown clinicalefficacy of resection by robotic thoracic surgery.

P23

VATS Decortication: The Indian experience

S Khandelwal1, Kamran Ali1, N Agarwal1, S Khanna2, A Sharma2, T Piplani3, A Z Khan1

1Department of Minimally Invasive and Robotic Thoracic Surgery

2Department of Anesthesiology

3Department of Radiology

Medanta The Medicity, Gurgaon

Objective: A retrospective case matched analysis of clinical outcomes of VATS drainage of empyema anddecortication of patients with tuberculous and non-tuberculous empyema.

Methods: 180 patients with empyema presented for surgical treatment over a four year period. The diagnosisconfirmed on CT scan included simple and loculated early and late stage empyema with or without cortices. Allpatients underwent VATS drainage of empyema and decortication to enable full expansion of trapped lung. GroupA consisted of 90 patients with tuberculous empyema and group B had 90 patients with non tuberculousempyema. Postoperatively patients had intrapleural antibiotic washouts till drain fluid was culture negative.Samples were sent for cultures, AFB cultures, histopathology, ADA analysis and TB PCR. Clinical and radiologicaldata was collected to show clinical outcomes at discharge and subsequent follow-ups. Data was analyzed usingSPSS 16.0 software.

Results: Group A & group B had similar demographics with relation to age, gender, duration of illness, clinicalcomorbidities. The age distribution in group A was 8-82 and group B was 14-80 years

Both groups had two conversion to open surgery (p<0.235).

All patients had good post operative outcomes. Percentage improvement in chest X-rays was 96% in both groups(p<0.235) and 100% at 3 months. Both groups had negative Intrapleural cultures at discharge (p<0.234). Onepatient in group A with Giant Bullous disease underwent lung volume reduction surgery. He subsequently hadprolonged air leak requiring indwelling drain. There was no statistical difference in hospital stay (mean 5 days,p<0.325).

Conclusion: VATS does have a role in the surgical management of patients with tuberculosis empyema. Besidesslightly longer operative time, the clinical outcomes are just as good as patients with pyogenic empyema. Presenceof suspected tuberculosis is not a contraindication for VATS decortication.

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Unusual presentation of anterior mediastinal mass - a case reportSrilata P. Naik, Jayaraj B S, Mahesh P A, Chaya S K.JSS Medical College, Mysore, Karnataka, India

IntroductionApproximately half of all mediastinal lesions are asymptomatic and are detected on chest radiographs taken forunrelated reasons. The absence of symptoms suggests that a lesion is benign, whereas the presence of symptomssuggests malignancy. In adults, 48 to 62 percent of lesions are symptomatic, whereas the percentage ofsymptomatic lesions is higher in children (58 to 78%). The most common symptoms are cardiorespiratory – inparticular, chest pain and cough. Other manifestations are heaviness in the chest, dysphagia, dyspnea, hemoptysis,signs of superior vena caval obstruction with facial swelling, and cyanosis. Recurrent respiratory infections are acommon complaint.

Case ReportA 28 year old female presented with multiple pigmented papules and macules over the extremities andinflammatory papules over the back with severe itching. She had no respiratory symptoms other than mild cough.The skin lesions were confirmed to be Prurigo nodularis on biopsy. Chest radiograph and CT thorax showed ananterior mediastinal mass enclosing the superior vena cava and right main bronchus. Mini thoracotomy and biopsyconfirmed Hodgkin’s lymphoma (nodular sclerosing type). Patient showed good response to standardchemotherapy.

ConclusionHigh degree of clinical suspicion is required as anterior mediastinal mass may have paucity of clinical symptoms atpresentation. Early diagnosis may help in improving the prognosis.

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Tracheal Lymphoma

YUNUS.A.S, R.NARASIMHAN, N.GEETHA, UMAMAHESHWAR.C

Department of Respiratory Medicine and Pathology

Apollo Hospital, Chennai, Tamil Nadu,

Primary pulmonary Non-Hodgkin’s Lymphoma (NHL), also known as Bronchial Associated Lymphoid tissue(BALT)lymphoma, is a rare extra-nodal lymphoma. They account for very small percentage of all lung malignancies. Wedescribe a case of a 73 year old male who presented with exertional dyspnea and foreign body sensation in throatwith a normal chest radiograph. Until date very few cases of BALT lymphoma involving the trachea have beendescribed.

CASE REPORT

A 73 year old Indian male, non smoker, diabetic and hypertensive presented with exertional dyspnea and foreignbody sensation in throat since 4 months to the outpatient department. Auscultation revealed bilateral inspiratoryrhonchi. He was found to have a subglottic growth on Indirect Laryngoscopy. Chest Radiograph was essentiallynormal. Computed Tomograph (CT) scan neck and thorax revealed a circumferential mural thickening withintraluminal mass and narrowing involving the left lateral, anterior and posterior wall of the trachea with multiplenodules extending up to the primary bronchus on either side. Bronchoscopy revealed a polypoidal endotrachealmass in the upper 1/3rd of the trachea. Multiple endobrochial biopsies were taken from the mass and tissue sentfor histopathology. Histopathology of the bronchial tissue showed dense aggregates of the lymphoid cells withfibrinous material within the pseudostrattified respiratory epithelium suggestive of Lymphoma. FurtherImmunohistochemistry analysis was done and B Cell BALT lymphoma confirmed. Patient was started on

Therapeutic Radiotherapy. Patient underwent repeat scan which showed reduction in the size of the mass andclinical improvement.

CONCLUSION:

Tracheal BALT lymphomas have an indolent behavior. The lesions are commonly missed on chest radiographsunless we have a high index of suspicion

P28

High Dose Rate Endobronchial Brachytherapy for Palliative Treatment of Lung Cancer – A Case ReportMuhammed Aslam N K , Rajeev Ram , Achuthan V , Manoj D K ,Rajani MPariyaram medical colleg , kannur , india

IntroductionHigh-dose-rate endobronchial brachytherapy (HDREB) is used in the treatment of endobronchial lung cancer forthe main purpose of symptom relief.

Case Report76 year old male ex-smoker presented with 1 month history of exertional dyspnea .His chest X-ray revealed leftperihilar homogenous opacity. CECT Thorax showed infiltrating mass (7cm) in left hilum with mediastinal invasionreaching up to 1.5 cm from carinal angle. Flexible video bronchoscopy showed proliferative growth partiallyoccluding the distal end of left main bronchus. Histopathology of bronchial biopsy showed squamous cellcarcinoma. Radiation oncology consultation done and posted for HDREB. An afterloading polyethylene catheterpassed through the bronchoscope. With Iridium -192 , a dose of 10 Gray was delivered using remote after loadingdevice. Repeat bronchoscopy done after 6 week showed significant reduction in size of mass. Patient gotsymptomatic relief and now he is on 6 cycles of chemotherapy.

ConclusionHDREB is an excellent modality for palliating malignant airway obstruction resulting in quality of life improvement,with a good tolerance, patient compliance, and low rate of severe complications

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Utility of fibreoptic bronchoscopy in a case of left lung collapse with Guillain Barre Syndrome and 5 months ofamennorheaDr P P JAIN1, Dr A S PANDEY2, Dr D A MODH3, Dr H V DESAI4, Dr S R Ghadiya5

IntroductionLung collapse due to thick mucus plug impaction in a mechanically ventilated patient with GBS is a difficult clinicalsequel to manage. Involvement of respiratory muscles in GBS hampers cough reflex and muco-ciliary clearancecausing formation and accumulation of mucous plugs, which may result in life threatening complications.

Case ReportThis case report highlights the importance of flexible fibre-optic bronchoscopy in consonance with N-acetylcysteine and Mesna (Sodium 2-mercaptoethanesulfonate) in the extraction of thick mucus plug from lungs.We had a 20-year-old female patient with GBS and 5 months of amenorrhea (pregnant patient) on invasiveventilator referred to us for left lung collapse. The Bronchoscopy findings were suggestive of impacted thick mucusplug in the left main bronchus with circumferential narrowing. Suction was applied after the instillation of N-acetylcysteine and Mesna. The procedure took 40 minutes and the O2 saturation was successfully maintainedabove 90%. Post bronchoscopy, the left lung expanded and arterial blood gas analysis showed markedimprovement.

ConclusionPrompt and timely intervention for lung collapse is required to manage patients of GBS with respiratorycomplications with pregnancy. Risk versus benefit ratio must be evaluated and hypoxia should be avoided toimprove maternal and foetal outcome. Use of Mesna and N-acetylcysteine enhances mucus plug breakdown andhelps in reverting collapse thereby, improving the prognosis of the patient.

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PREVALENCE OF LUNG CANCER IN A RELATIVELY NONSMOKING POPULATION VISITING CHEST & TB HOSPITAL,AMRITSAR

B. MALHOTRA, N. PANDHI, N.C. KAJAL, R. PRABHUDESAI, C.L. NAGARAJA

CHEST AND TB HOSPITAL, AMRITSAR

Prevalence Of Lung Cancer In a Relatively Nonsmoking Population Visiting Chest And TB Hospital , Amritsar.B.MALHOTRA, N. PANDHI, N.C. KAJAL, R. PRABHUDESAI, C.L. NAGARAJAChest and TB hospital, Amritsar-Punjab,India.OBJECTIVESLung cancer is the most common cancer worldwide. Smoking is the most common risk factor indevelopment of lung cancer. In patients who develop lung cancer without a smoking history, potentialenvironmental or inherited causes of lung cancer are unclear. In Punjab, majority of the population is nonsmokingdue to religious prohibitions and also smoking is banned by law in public places and institutions. Inspite of this weare getting quite a lot of lung cancer cases.METHODSThis study included 50 patients with proven diagnosis of lungcancer. They were divided into 2 groups-smokers and nonsmokers. They were compared according to theirdemographic characters like age, sex, occupation, smoking history, clinicoradiological findings andhistopathology.RESULTSIn our study of 50 patients, 48% were smokers whereas 52% were non-smokers. Mean ageof smokers was 62.25 years and that of nonsmokers was 56.15 years. All smokers were males. Amongstnonsmokers 46% were males and rest was females. 92% of the smokers exclusively smoked beedies whereas 8%smoked both cigarettes and beedies. 88% of the smokers had smoking index >300. Most smokers were labourersby occupation (50%) whereas 61% of the nonsmokers were unemployed. Most common symptom in smokers wascough (41%) whereas nonsmokers presented with cough and breathlessness (42%). Most common examinationand radiological finding in both smokers and nonsmokers was mass lesion. Most predominant histological type insmokers was squamous cell carcinoma(75%) and in nonsmokers was adenocarcinoma(69%).CONCLUSIONSFromthis study we have concluded that lung cancer is equally prevalent in both smokers and nonsmokers. Mostsmokers were males presented with squamous cell carcinoma whereas majority of the nonsmokers were femalesand presented at an earlier age than smokers with adenocarcinoma as the predominant histological type. Factorsleading to increased incidence of lung cancer in nonsmokers need to be further evaluated.

P31

MISDIAGNOSED CASE OF BRONCHIAL CARCINOID PRESENTING WITH REFRACTORY DYSPNOEA AND WHEEZE – ARARE CASE REPORT

S Meher ,P Dutta, R Manjhi, S Pothal

V.S.S MEDICAL COLLEGE BURLA

MISDIAGNOSED CASE OF BRONCHIAL CARCINOID PRESENTING WITH REFRACTORY DYSPNOEA AND WHEEZE – ARARE CASE REPORT

S Meher, P Dutta, R Manjhi, S Pothal

Department of Pulmonary Medicine,V S S Medical College ,Burla ,Odisha, India

BACKGROUND: Bronchial Carcinoid is a neuroendocrine tumour and constitutes 20-25% of all carcinoid tumours.They usually present with recurrent haemoptysis but can sometimes present as refractory wheeze andbreathlessness.

CASE REPORT: We report a case of 59 year male patient, teacher by occupation, presenting with graduallyprogressive dyspnoea over two years and occasional cough with scanty mucoid expectoration. He was a smokersince last 30 years, smoking 4-5 cigarettes per day. He was clinically diagnosed to have COPD and was put oninhalational formoterol and budesonide (800 microgram/day) along with inhalational tiotropium. On clinicalexamination, there was tachycardia, tachypnoea, SpO2 93% at room air. Auscultation of chest revealed diminishedvesicular breath sound and wheeze on left hemithorax. Spirometry demonstrated a restrictive pattern. ECGrevealed right axis deviation with first degree heart block. On chest X-Ray, left lung was found to be moreradiolucent in comparison to right. CT scan of thorax revealed a near complete cut off of left main bronchus due tointraluminal soft tissue mass with parenchymal infiltrate in the left upper and lower lobe without evidence oflymphadenopathy. Flexible bronchoscopy showed a tumour in the left main bronchus and biopsy was taken.Histology revealed uniform polygonal cells suggestive of bronchial carcinoid. Immunohistochemistry indicatedneuroendocrine differentiation of tumour cells with cytoplasmic positivity for Cytokeratin, Chromogranin A andSynaptophysin. Hence, a diagnosis of typical carcinoid tumour was established. Subsequently the patient wasreferred to thoracic surgeon and left pneumonectomy was performed.

CONCLUSION: Though carcinoid is an uncommon tumour of respiratory system, its possibility should be kept inmind in cases of refractory asthma or COPD.

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P33

A Rare Case Of Tracheal TumourA.M KHOJA, K S K GOUD, R.K JALAN, D L JAIN

Department of Respiratory Medicine, Ruby Hall Clinic, Pune, Maharashtra, IndiaBACKGROUND:Primary tracheal tumours either benign or malignant account upto less than 0.1% of all tumours. Benign tumoursare usually misdiagnosed as asthma or COPD and are usually diagnosed late. On contrary because of the rapidgrowth and hemoptysis malignant tumours are usually diagnosed a little early. Here we report a case of squamouscell carcinoma of trachea which was being treated as bronchial asthma for 6 months. The main objective ofreporting this case is to always keep a suspicion of tracheal tumour when an elderly male being treated for chronicairway diseases does not respond to the treatment.

METHODS:A 63 yr old male patient, nonsmoker, presented to us with complaints of severe orthopnea and cough since 6months. Physical examination revealed severe stridor and wheeze. He was being treated as bronchial asthma withno improvement in symptoms. HRCT showed an enhancing mid-tracheal mass lesion with collapse consolidation ofright lower lobe. Flexible bronchoscopy showed a lobulated mass arising from left lateral wall in the mid trachea,5cm away from the carina, blocking almost 90% lumen with mucopurulent secretions in right main bronchus.Electrocautery and snare was used to excise the whole mass and APC coagulation was done. Mass was sent forHPE.

Histopathological examination showed moderately differentiated Squamous cell carcinoma. Post-resection PET-CTwas done which showed uptake only in tracheal wall suggestive of residual mass, No distant metastasis.

CONCLUSION:Primary Tracheal tumours are very rare and slow growing and hence the diagnosis is often made very late. Mostlythey are treated either as asthma or COPD. The most common tracheal tumour being squamous cell carcinomafollowed by adenoid cystic carcinoma.The initial management in acute setting includes relieving the symptoms byresection of mass. Modern techniques for tracheal surgery include laryngotracheal, tracheal, or carinal resectioncombined with radiotherapy and have shown good outcome.

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P35

Lung adenocarcinoma in 32 year old male

Dr. P.M. Anbu Maran, Dr. B. Rajagopalan, Dr. T. Dhanasekar, Dr. Koushik Muthu Raja

Lung Cancer is a rare disease in patients under 35 years of age. It typically occurs in older patients with a history oftobacco use. This case concerns a 32 year old male with no history of tobacco use who complaints of hoarseness ofvoice, chest pain, dry cough, breathlessness grade II and loss of weight and appetite for two weeks. Chest x rayshowed left sided massive pleural effusion. Computerized tomography showed massive left sided pleural effusionwith complete collapse of left lung with numerous enhancing lobulated nodules in the left pleura. Patientunderwent left sided thoracentesis. Pleural fluid cytology suggestive of polymorphous cellular infiltrates with

atypical cells. Biopsy of left hilar mass showing features suggestive of adenocarcinoma. Unfortunately, despiteaggressive therapy, the patient’s disease progressed and he died within one week following chemotherapy. In thispaper we hope to illustrate the unique challenges in diagnosing and treating young patients with lung cancer.

P36

Title: Two cases presenting with common respiratory symptoms but uncommon diagnosisS K SAMANTA, S BARMAN, J JOSEPHFORTIS HOSPITAL, KOLKATA, INDIACASE 1A 20 year female

Right sided chest pain for 2 month Low grade intermittent fever for 15 days progressive SOB for 1 year with increasing severity for last 15 days

EXAMINATION: Features of right sided pleural effusion with tracheal displacement to right Sternal percussion - dull

INVESTIGATION:• Pleural fluid: hemorrhagic, exudative lymphocytic, low ADA, Malignant cells ~ negative• Pleural biopsy ~ chronic inflammatory cells.• Serum alfa fetoprotein and beta-HCG ~ normal

FURTHER EVENTS:• ICTD for severe SOB with drainage of 4.6 liters of fluid over 9 days.• Right antero-lateral thoracotomy

“Large mediastinal mass adherent to right lung, pericardium, chest wall, diaphragm with thickenedpleura”.

HISTOPATHOLOGY:• “Tumor with nests, cords, trabeculae of Polygonal cells with round oval nuclei, prominent nucleoli, Mitotic

figures seen”.IMMUNOHISTOCHEMISTRY:

• Expressing Cytokeratin, EMA, CK7,P63,TTF-1 and immunonegative for HMB-45, S-100 protein, CD-20.FINAL DIAGNOSIS:

Malignant clear cell tumor of the lung with a Myoepithelial phenotype

CASE 2:A 45 year old, male smoker

• Exertional SOB for 1 year• dull aching chest pain for 6 months• Low grade intermittent fever for 1 month

EXAMINATION:• Dull percussion note left hemithorax with ↓ Vesicular breath sound & ↓ Vocal resonance

CHEST RADIOLOGY:Large heterogenous SOL in whole left hemithorax

TRU-CUT BIOPSY:• Tumour cells are bland, monomorphic, hardly any mitotic activity, arranged in vague fascicles, stroma is

markedly collagenous & contain hyalinized vessels”.IMMUNOHISTOCHEMISTRY:

• CD 34 positive, negative for Cytokeratin, EMA, S-100 protein.THORACOTOMY:

• Well circumscribed, encapsulated lobulated mass measuring 19 x 13 x 10 cm attached to pleura by apedicle with part of lung tissue adherent to it.

HISTOPATHOLOGY:

• compatible with solitary fibrous tumour of pleuraFINAL DIAGNOSIS:

• Solitary Fibrous Tumor of Pleura with intraparenchymal extensionCONCLUSION: Sometimes common symptoms can be presentation of rare diseases

P37

CASE OF TRACT CARCINOMADr.s.trivedi, Dr.m.pawar, Dr.madhuri.g, Dr.s.singh

Objectives: To evaluate a 60 yr old female patient, operated case of Ca breast 20 yrs back for metastasis.shepresented with left sided chest pain, progressive breathlessness, swelling in lateral chest wall and back.

Methods: 1) Thorough history taking revealed Ca breast 20 yrs back, h/o massive pleural effusion on left drainedvia icd 4 months back, 1 month h/o swellings in lateral chest wall & back.2) examination revealed dull note onpercussion on left side, icd scar, swellings in chest wall.3) cxr & CT scan thorax to visualize mass.4) usg abdomen tor/o metastasis.5) FNAC of swellings.

Results:1) CT scan revealed pleural effusion left & pleural based mass.2)usg abdomen showed no metastasis.3)FNAC of both swellings showed highly cellular picture consisting of poorly differentiated malignant cells withconvoluted nuclei s/o metastasis from Ca breast.

Conclusion: case of tract carcinoma at intercostal tube drainage & pleural fluid aspiration site due to metastasisfrom old operated Ca breast..

P38

Multiple small nodule and medistinal lymph node with minimal pleural effussion cause tubercular misdiagnose asCa lung

Author-Harendra yadav-1 A Agrawal-2 A Jaiswal-3 R K Diwan-4 a Srivastava-5

1-senior resident NITRD Delhi 2-junior resident NITRD Delhi 3-Senior chest physician NITRD 4-Senior thorasicsurgeon NITRD Delhi 5-Senior pathologist CHS Diagnostics Delhi

Introduction- Pulmonary tuberculosis is a common disease in India. India is the highest TB burden country in theworld, accounting for one fifth of the global incidence-an estimated 1.9 million cases annually. Tuberculosis has alots of presentation. It can present like pleural effusion, mediastinal lymph node, pulmonary nodule, sputumpositive pulmonary tuberculosis. In India most of the time lung cancer is misdiagnosed as pulmonary tuberculosis.But in some cases like multiple pulmonary nodules is misdiagnosed as Ca lung. Lung carcinoma is rare under 40years of age.

Case description- A 40 year old female came to our department with the chief complaint of low grade fever from 7days and left side chest pain from 5 days. Chest x-ray was done outside and it showed left sided costophragnicangle blunting. USG guided pleural fluid was aspirated and sent for biochemistry and cytology. It was lymphocyticpredominant but cytology revealed adenocarcinoma. Further investigation was done like USG whole abdomen,mammography, PAP smear, transvaginal USG and CT scan thorax. But these investigations were normal. After thatPET scan was done and it revealed multiple small nodules in left upper lobe with mediastinal lymph node. Openlung biopsy was done and sent for histopathology. It showed multiple necrotizing granulomas. Patient is not havingprevious history of antitubercular treatment and registered under DOTS category-1.Discussion- Tuberculosis is one of the deadliest disease in the world. Extra-pulmonary tuberculosis is commonamong children and women. Pulmonary tuberculosis is common adults and elderly. Multiple small nodule is a rarepresentation of pulmonary tuberculosis. It is missed on chest x-ray. It is diagnosed on HRCT scan. Forhistopathology VATS guided biopsy or open lung biopsy should be done. There are lots of diseases which can

present multiple lung nodules like sarcoidosis, silicosis, military tuberculosis, lung mets. Most common cause ofmultiple pulmonary nodule is lung metastasis.Conclusion-HRCT scan of thorax is the basic investigation for diagnosis of multiple pulmonary nodule. Forhistopathology VATS guided biopsy or open lung biopsy can be done.Key words- Pulmonary TB, Adenocarcinoma, Multiple nodule

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TOPIC NAME:- Posterior mediastinal mass presenting as paraparesisDR IBRAHIM SIDDIQUE,DR.LAVINA MIRCHANDANI,DR JAYALAKSHMI T.K,DR GIRIJA NAIR,DR ABHAY UPPE,DRAPARNA IYER

INSTITUTION:-DR DY PATIL HOSPITAL AND RESEARCH CENTRE NERUL, NAVI MUMBAI

ADDRESS:-102 LAKE VIEW APARTMENT OPP BANDRA LAKE STATION ROAD BANDRA [W] MUMBAI 50

EMAIL ID:-SIDDIQUEMOHAMEDIBRAHIM@GMAIL.COM

Schwannoma are slowly growing , benign nerve sheath tumours that rarely cause symptoms and are usuallydetected on routine radiographic imaging

Ten percent schwannomas grow across the adjacent intervertebral foramen and extend across the spinal clumn inan hour glass or dumbbell shape .Thus

Spinal dumbbell schwannoma is a rare disorder having incidencebeing 3.75 per 10 million.

We report a case of a 27 years old male who came with progressive weakness in lower limb leading toparaplegia over a period of one month .A chest X-ray done as routine evaluation revealed a posteriormediastinal mass confirmed by taking lateral chest x-ray. Hence MRI of spine was done which revealedhour glass or dumbbell shaped tumour.FNAC done showed spindle cell neoplasm confirmingschwannoma. Complete surgical resection of tumour was done within 3 days of diagnosis Thusradiography is a vital diagnostic tool in the detection of these silent tumours and early diagnosis andcomplete surgical resection gives excellent prognosis

P40

Title – Non Hodgkin’s Lymphoma presenting as a chest wall mass

Authors – DR ABHIJIT AHUJA, DR SINDHU KAMATH, DR JAYALAKSHMI TK, DR LAVINA MIRCHANDANI, DR MUGDHABHIDE, DR APARNA IYER, DR ABHAY UPPE, DR GIRIJA NAIR

Institution- D Y Patil Hospital & Research Centre, Nerul, Navi Mumbai

Background-

Malignant lymphoma presenting as a chest wall mass is not common.1

Lymphoma comprises 2% of primary chest wall tumors & is mutually an extension of mediastinal disease.

Only 5% of Non-Hodgkin’s Lymphoma present in Anterior Mediastinum.

Most commonly seen are large, irregular, anterior & superior mediastinal masses.

Associated with large pleural effusions, pericardial effusions, pulmonary parenchymal changes.

Prevalence of anterior mediastinal mass is more in adults (65%) as compared to children (28%)

Case report-

A 47 year old Male, Farmer, addicted to Tobacco chewing ½ packet/ day for 40 years , without any co-morbiditiescame in OPD with complains of tender swelling over chest wall, breathlessness, chest pain, cough & low gradefever since 2 months. Local examination of the swelling revealed the size being 5x2x1cm, shape was irregular,tender, mobile, skin over the mass was tense & not warm on touch. Respiratory system examination revealedreduced breath sounds, left infrascapularly. Chest X-ray showed left sided CP angle blunting with homogenousopacity in the left lower lobe, silhouetting with left heart border & diaphragm. High Resolution ComputedTomography showed a large lobulated heterogeneously enhancing lesion in the anterior mediastinum –prevascular compartment extending to superior mediastinum. USG guided biopsy revealed Non HodgkinsLymphoma. Patient was referred to Onco surgery for further management.

Conclusion –

This case is a rare presentation of Non Hodgkins Lymphoma presenting as a chest wall mass.

Reference:

1Annuls of thoracic surgery 2006 April: 81(4): 1214 - 1218

P41

Bronchial carcinoid:Rare cause of Hemoptysis. A case report

Vishal CHOPRA, Don Gregory MASCARENHAS, Aditi, Ashrafjit CHAHAL, Prabhleen KAUR, Shiyas MOHAMMED

Department of Chest & Tuberculosis(TB), Govt medical college, Patiala , Punjab

Introduction: Carcinoids are neuroendocrine tumours. General prognosis for patients with this neoplasm is quitefavorable if diagnosed early.

Case report: A 32 year old male, manual labourer by occupation presented with recurrent episodes of cough, rightsided pleuritic chest pain and blood in sputum off and on for last 8 years. He had receive anti-tuberculosis therapy

twice based on Chest X-ray findings.Respiratory system examination revealed impaired percussion note in rightinfrascapular and infra-axillary area along with diminished breath sounds as well as vocal resonance in the same

areas.PA view chest X-ray revealed homogenous opacity in right lower lung field with elevated right hemi-diaphragm and a positive silhouette sign with right heart border. Sputum for AFB was negative. Contrast enhancedcomputed tomography of chest performed, showing collapse of right middle and lower lobes with minimal pleural

effusion on the same side and non-significant mediastinal lymphadenopathy. Bronchoscopy revealed a welldefined mass in right main bronchus. Biopsy on histopathological examination suggested a diagnosis of carcinoid

tumour.

Discussion: Carcinoids are most commonly found in the small intestine (26%), respiratory system (25%) andappendix (19%).The severity and variety of symptoms depend on the size of the carcinoid pulmonary tumor and

the production of hormones. Bronchial carcinoids are mostly located centrally and produce symptoms and signs ofbronchial obstruction such as localized wheeze, non-resolving recurrent pneumonitis, cough, chest pain, and fever.

Most of these symptoms were present in our case.The primary and most effective treatment for all pulmonarycarcinoid tumors is surgical resection.

Conclusion: Due to the lack of characteristic symptoms, diagnosis of pulmonary carcinoid is delayed.Pulmonologists should be vigilant to suspect carcinoid in cases of lobar collapse. Earlier the diagnosis is made,

more are the chances for radical treatment and hence favourable prognosis and outcome.

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A study on lung cancer in smokers and non smokers in a tertiary care center

Verma A,Shamim S,Mitra S

Department Of Pulmonary Medicine, Calcutta National Medical College,Kolkata

Objective:

To study the epidemiology , clinical and radiological profile of lung cancer patients with comparison of theseparameters among smoker and non smoker lung cancer.

Methods:

Study was undertaken among admitted lung cancer patients in a medical college of Kolkata during the period Sept2013 – Aug 2014. 160 lung cancer patients with smoking habits and 14 lung cancer patients without h/o smokingwere admitted during the study period. To facilitate comparison between profile of smoker and non smokers 30patients with lung cancer were selected randomly from the smoker group .Thus the sample size is 44; smokers -30and non smoker 14.

Results:

Overall non smokers were only 8% among the total lung cancer patients admitted .

Mean age( 59 ± 8.86) of smoker lung cancer is significantly high(p<.05) than that of non smoker(54.21 ± 13.82).Male preponderance noted among smokers(96%) and non smokers are mostly female(71.4%).commonestoccupation is skilled work (60%) in smoker lung cancer and home making (71.4%) in non smoker lung cancer.Cough(63%), dyspnoea(47%) haemoptysis(57%) and wheeze(23%) were common symptoms in smokers with lungcancer whereas cough(93%), dyspnoea(43%), hemoptysis(43%) were common in non smokers .Smokers with lungcancer radiologically presented with pleural effusion(46.7%), collapse(30%), mass lesion(30%)and Mediastinallymph nodes(53%) whereas nonsmokers presented with pleural effusion(57%) collapse(14.3%) mass lesion(35.7%)and mediastinal lymph node(21.4%). Histologically Squamous cell ca(63.3%) is prevalent significantly amongsmokers whereas Non small ca(57.2%) were significantly prevalent among non smokers.

Conclusion:

1) Prevalence of non smoker lung cancer is very low in our cohort of patients2) Smoker and non smoke lung cancer are different in several aspects in epidemiological clinical and

radiological perspective .

Commonest histological type in smokers with lung cancer is squamous cell ca and in non smokers it is nonsmallcell ca

P43

Concurrence of Lung Malignancy and Tuberculosis – A case report

DR.B.NITHILAVALLI, DR.K.ANUPAMA MURTHY, DR.R.KARTHIKEYAN

DEPT OF RESPIRATORY MEDICINE, PSG IMS&R, COIMBATORE, TAMILNADU, INDIA; 97906-51384;nithila76@gmail.com

Abstract:

A 54 year old male presented with productive cough, right sided pleuritic chest pain and streakyhemoptysis of one month duration.

On examination he was hemodynamically stable. General examination revealed a right supraclavicularlymph node of 2.0 x 1.0 cm. CXR showed right lower zone non- homogeneous opacity. Sputum for acid-fast bacilliwas negative. Bronchoscopy revealed no endobronchial lesions and broncho-alveolar lavage was inconclusive.FNAC of the lymph node was suggestive of granulomatous lymphadenitis, CT-Thorax revealed a heterogenousenhancing irregular lesion of 3.0 x 1.0 cm in right lower lobe with minimal effusion. A possibility of malignant lesionwith an ipsilateral cervical node metastasis was considered. Since the patient was not willing for invasiveprocedures, excision biopsy of the lymph node was done. Biopsy revealed granulomatous inflammation s/otuberculosis and was negative for malignancy. Patient was initiated on anti-tuberculous treatment. During reviewCXR revealed increasing right pleural fluid. Pleural fluid cytology revealed atypical cells suspicious of malignancy.VATS biopsy of the right lower lobe lesion was done and it revealed adenocarcinoma lung with infiltration intopleura-stage IV lung malignancy.

Patient was initiated on chemotherapy and ATT continued. This case has been reported for theconcurrent existence of tuberculosis and malignancy in the same patient.

Discussion:

Clinical diagnosis of co-existing tuberculosis and malignancy is often challenging. Lymphadenitis of variousetiologies causes a delay in diagnosis in malignancy patients; it may also lead to overstaging in the TNM system.This case also highlights the need of exploring pleural and parenchymal lung opacity in spite of biopsy provenlymphadenitis.

Conclusion:

The clinicians need to be aware of the protean manifestations of tuberculosis and malignancy andmaintain a high index of suspicion for simultaneous and / or misleading presentations.

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A CASE REPORT ON BRONCHOALVEOLAR CARCINOMA PRESENTING AS NON-RESOLVING CONSOLIDATION

GIFTY MG, KISKU KH, MADHUSMITA M

Department of Pulmonary Medicine

Bronchoalveolar carcinoma presenting as non-resolving consolidation is an uncommon presentation. The typicalpresentation of bronchoalveolar carcinoma is asymptomatic (solitary nodule) and remains without symptoms evenas disease disseminates. We report a case of bronchoalveolar carcinoma presenting as non-resolving consolidationin a 45 year female with productive cough (bronchorrhoea), exertional breathlessness and physical examination

revealing the features of left lower lobe consolidation on x-ray chest, with subsequent CT of the chest and biopsyrevealed bronchoalveolar carcinoma. Patient had a good performance score and was managed conservatively

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SPINDLE CELL SARCOMA OF THE LUNG: CLINICAL, RADIOLOGICAL AND HISTOPATHOLOGICAL FEATURES OFTHREE CASES

ANANTHA R, SANTOSHAM R, MADHUSMITA M, KISKU KH

DEPARTMENT OF PULMONARY MEDICINE

The frequency and clinical features of lung spindle cell carcinoma (SpCC) are unknown. Hence we retrospectivelyreviewed the records of 45 patients with lung cancer over 3 years and re-examined the clinical, radiological andhistopathological features of three patients of Spindle Cell Sarcoma. Thus the incidence of SpCC was 6.6% of alllung malignancies in our hospital. All three patients were females and non-smokers. The age of the patients was34, 43 and 56 years. The SpCC was initially detected by routine chest X-ray examination in all cases. Two wereperipheral tumors and one was a central tumour with total lung collapse. One patient had a surgical resectionother two cases were treated by chemotherapy. The survival period was 7 and 16 months for two patients. Onepatient for whom surgical resection was done is still under our follow up 15 months after surgery. Histologically, allthe three SpCC consisted of only malignant spindle cells with hyperchromatic nuclei and mitotic figures.

These results suggest that SpCC of the lung shows no differentiation. In summary, the present study showed thefrequency (6.6%) of SpCC of the lung of all lung malignancies. Clinical features of the three SpCC are described

P46

Present trend of carcinoma lung in our hospital setup

AJIT.H

Institution..vydehi institute of medical sciences and research centre bangalore Karnataka india

Objective-Lung cancer is most commonly diagnosed major cancer in the world and it is the most common cause ofmortality in both males and females.Recently there is a change in histopathological presentation of lung carcinomaamong males and females in western world based on change in trend of cigarette smoking.

Present study is conducted to study the recent change in trend of Histopathological presentation of lung cancers inAdult male and female.

Methods-Prospective study of lung carcinoma was conducted by using histopathological diagnosis.Weanalysedpatients coming to our hospital (vydehi institute of medical sciences and research centre)for the period of 2 years(from august 2012 to august 2014).Correlation was done between age, sex and histopathology.Results wereanalysed using chisquare test and logistic regression analysis.

RESULTS-During this period of 2 years 40 lung cancer patients were diagnosed in the department of pulmonarymedicine (vydehi institute of medical sciences and research centre, Bangalore). Out of 40 patients small cellcarcinoma was detected in 10% of patients, squamous cell carcinoma 45% of patients and adenocarcinoma 35%out of which 22.5% were males and 12.5% of females , and large cell carcinoma were found in 10% patients.allfemale patients(5/40 i.e., 12.5% ) had adenocarcinoma.

Conclusions-In our hospital setup we found squamous cell carcinoma is predominant type of lung cancer amongmales.But adenocarcinoma is showing raising trend.

P47

Epidemiology & clinicoradiological profile of lung cancer patients presenting in a tertiary care centre

AP KANSAL ,Nancy GARG, Don Gregory MASCARENHAS, Shiyas MOHAMMED, Kiran.N, Anand Kumar BANSAL

Department of Chest & TB, GMC, Patiala, Punjab

Introduction: Lung cancer has varied patterns in its epidemiology and histology.

Objective: To study the epidemiological , clinicoradiological & histological pattern of lung cancer presenting to ourdepartment over one year period.

Method & Materials : 67 patients suspected of lung cancer on symptomatology & Chest Xray(CXR) were subjectedto sputum examination, CT Scan of chest, followed by interventions like FNAC of the lesions and bronchoscopy toprove the diagnosis .

Results : In our study of 67 patients, 53 were males, 14 were females. Median age was 59. 9 years, youngest being26 years & oldest 95 years. All 14 females were non-smokers but had exposure to biomass fuel. Among males, 20were non-smokers & 33 smokers. Chief complaint was cough in 60 cases(89%) ,breathlessness in 12 cases(18%),loss of appetite/weight in all cases. 18 patients were put on AntiTubercular Treatment(ATT),merely on basis of CXR(89%) or pleural effusion(11%).

CXR had varied presentations ,most common being pleural effusion(22.4%) , unilateral homogenousopacity(21%),and hilar enlargement(12%). Most common findings in CT chest were peripheral mass(34.3%), centralmass(20.9%), consolidation(15%), pleural effusion(11.95%),bilateral nodules(5.97%), Cannonball secondaries in 2cases, SOL , Pancoast tumour & Lymphangitis carcinomatosis in 1 case each. Histological patterns included poorlydifferentiated NSCLC in 29 cases(45.3%).,squamous cell carcinoma(SCC) in 28 cases(43.8%), adenocarcinoma in 5cases(7.8%), large cell carcinoma & mesothelioma in one case each. Most of the patients were in stage 3 or stage 4lung cancer.

Conclusion: Lung cancer has equally high incidence among non-smokers , SCC still being most common histologicalvariant. Patients shouldn’t be put on ATT merely on CXR basis without microbiological/histological evidence.

P48

P49

Abstract : TITLE : - “ The Changing Face of TBNA ”

Transition From Conventional TBNA (c-TBNA) TO EBUS-TBNA With ROSE

Retrospective Analysis of 150 cases from a tertiary care hospital in New Delhi, India.

AUTHORS:- Nafees Ahmad KHAN, Nevin Kishore, Ajay LALL, Ashish JAIN, Vikas MITTAL, Jaya KUMAR, Nitin DAYAL,Amit SINGH, Akansha SHARMA,

Objectives :- To retrospectively analyze the diagnostic efficacy of EBUS-TBNA with ROSE compared to that ofconventional TBNA done by the same operators in our department over a 18 month period .

Material and methods : A retrospective analysis of case records of 150 consecutive patients with mediastinal orhilar lymphadeopathy who underwent TBNA were included of which the first 75 cases were done by conventionalTBNA method and 75 cases were done by EBUS TBNA with ROSE

Results were compared in terms of diagnostic efficacy, no of lymph node stations punctured, no of total puncturesper patient, representative and non representative samples and final diagnosis.

Results: - 150 cases records were analyzed - 75 (c-TBNA ) and 75 (EBUS- TBNA with ROSE )

Commonest LN station in both groups was 4R ( 52 % in c-TBNA and 50 % in EBUS –TBNA

Percentage of Representative samples was 47 % (137/292) c-TBNA vs 68 % ( 183/269) EBUS –TBNA

No of Diagnostic Punctures was 36% (106/292 ) c-TBNA vs 53% (144/269) EBUS –TBNA

Diagnostic yield was 72 % (54/75) c-TBNA vs 95 % (71/75 ) EBUS-TBNA

Conclusion :-

1- Starting an EBUS programme at our hospital improved the diagnostic efficacy of FNA of Mediastinal andHilar LN from 72 % (c-TBNA ) to 95 % (EBUS TBNA with ROSE)

2- Total no of punctures in both groups was comparable ( 292 vs 269 )3- Percentage of Representative samples was higher in the EBUS Group ( 68 % vs 47 % )4- The most common diagnosis was granulomatous inflammation in both the groups.

P50

A RARE VARIETY OF LUNG CARCINOMA IN A FEMALE MIMICKING MASSIVE PLEURAL EFFUSION

Prof. ATIN DEY, Dr. PALASH NANDAN DHARA, Dr. SAYANTAN SAHA

R.G.KAR MEDICAL COLLEGE & HOSPITAL

A 40 years old housewife presented with gradually progressing right sided chest pain for one year, increasingdyspnoea for 4 months and weight loss of four kgs. in last two months. The clinical findings & CXR was suggestiveof right-sided massive pleural effusion. Computed tomography (CT) scan of the thorax showed a large patchilyenhancing mixed density lesion having both solid & cystic component involving Rt. Lung, with minimal pleuraleffusion. CT-guided tru-cut biopsy from the mass revealed Spindle cell neoplasm. However, onimmunohistochemistry tumour cells

P51

Comparison of Diagnostic yield of fiberoptic bronchoscopic procedures in the evaluation of bronchogeniccarcinoma

Mahendra KUMAR, Sanjay GEHLOT, Mahesh MAHICH, Baname WAANBAH, Ravi PANWAR

Department of Respiratory Medicine,

R.N.T. Medical College (Udaipur, Rajasthan)

Objective: Aim of the study was to assess the diagnostic yield of bronchial washing, brushing, biopsy, and TBNA inbronchogenic carcinoma.

Design: Retrospective analysis.

Method:-Present study was carried out in 100 cases of bronchogenic carcinoma, proved either by Bronchialwashing, brushing, biopsy or TBNA. Bronchoscopy was done by flexible fiber-optic video bronchoscope at 280bedded TB & Chest hospital, Bari attached with R.N.T medical College, Udaipur.

Results: Out of 100 cases, 80 were of central lesion in which diagnostic yield of endobronchial biopsy was highesti.e. 92.5% , followed by brushing (75%) and washings (65%) respectively.In peripheral lesion (20 cases) , yield ofbronchial brushing was higher than washings. TBNA (Trans-bronchial needle aspiration) was done in 18 patientsand were found positive in 77.77%.

Conclusion: The overall diagnostic yield of flexible bronchoscopy procedures can be increased if conventionalTBNA performed together.

P52

A rare case of broncholithiasis: Removal by flexible video bronchoscopy

Mahendra KUMAR, Ananda DATTA, Ravi PANWAR, Mahesh MAHICH, Baname W.D. WAANBAH, Hemant SHARMA

Department of Respiratory Medicine, R.N.T. Medical college, Udaipur

Background: Broncholithiasis is a rare medical condition that needs to be considered in the differential diagnosis ofbronchial obstruction. Broncholiths originate from calcified material in peribronchial lymph nodes eroding into thetracheobronchial tree. Flexible bronchoscopy plays an important role in the diagnosis of broncholithiasis, but itstherapeutic application is still controversial. We report a case of broncholith removal with the help of flexible videobronchoscope without any complications.

Case report: A 45 year old male, farmer, chronic smoker was admitted with the complaint of cough withhemoptysis and low grade fever, off and on since 8 months. He had similar episodes in past and was diagnosedpreviously as a case of recurrent left upper lobe pneumonia. He never received antitubercular treatment. Clubbingwas the only finding in the general physical examination. Chest auscultation revealed diminished breath soundover left infraclavicular region. AFB smear and malignant cytology of sputum were negative. Gram’s and KOHstain revealed no pathogenic organism. Mantoux test was 4 mm. Chest x-ray showed left upper and mid zonehomogenous opacity with calcified lesions with bilateral hilaradenopathy. CT thorax showed calcified density inlingular bronchus. Flexible video bronchoscopy revealed a loosely attached greyish white broncholith in thelingular segment. We successfully removed broncholith with a toothed forceps. Patient was stable and had noepisodes of hemoptysis after the procedure.

Discussion: Usually rigid bronchoscopy with Nd-YAG laser photocoagulation or cryotherapy is used for saferemoval of broncholiths. Flexible bronchoscopy can be a promising tool in removal of broncholiths that are notincarcerated in the bronchial wall.

P53

A rare case of cavitating primary adenocarcinoma of lung

M.L. VED, Mahendra KUMAR, Ravi PANWAR, Ananda DATTA, Baname W.D. WAANBAH, Mahesh MAHICH, SanjayGEHLOT

Department of respiratory medicine, RNT medical college, Udaipur

Background: Adenocarcinoma is one of the most common histologic types of lung cancer which rarely cavitates.We report a case of cavitating primary adenocarcinoma.

Case report: A 65 year old male, contractor, chronic smoker was admitted with complaint of dry cough, low gradefever for last six months with occasional streaky haemoptysis. He was having dull aching pain on back of chest inright side. Physical examination revealed pallor and clubbing. Tenderness was present over right interscapularregion. Diminished breath sound was present over same region on auscultation. Other system examinationsrevealed no abnormality. Routine blood test showed microcytic hypochromic anemia. Biochemical tests were

normal. Chest x-ray showed peripheral cavitating mass lesion eroding posterior part of ribs in the right mid zone.Smear and culture of induced sputum did not reveal any pathogen. CECT chest revealed right upper posteriorpleural based cavitating mass lesion of size 5.9×4.9 cm with posterior rib erosion. USG guided FNAC was suggestiveof adenocarcinoma. Bronchoscopic study was inconclusive. Transthoracic tru-cut biopsy was performed.Histopathological examination and immunohistochemistry for EGFR & TTF-1 confirmed the diagnosis. Patient wasthen referred to the oncology department.

Discussion: Overexpression of epidermal growth factor present in neoplastic cells cause rapid tumor growth thatexceeds blood supply, favoring central necrosis and cavity formation. This case is interesting because cavitatingprimary adenocarcinoma of lung is rare.

P54

Pancoast tumour – a case report

DR.VEENA REDDY VANKAYALA, Prof. Pradyut waghray ; Dr. A.V.N.Koteswara Rao ; Dr.Venkateswara ReddyTummuru ; Dr. Sowmya ; Dr. Chetan Rao ,Dr.Harish , Dr.Rikin; Dr. Aditya ;Dr. Krishna Chaitanya ,

Prof Ramakrishna Reddy.G *, Dr.Chandrakanth Reddy^

Dept of Pulmonary Medicine, S.V.S Medical College, Mahabubnagar, Telangana.

Introduction: Pancoast tumour , also called pulmonary sulcus tumour or superior sulcus tumour is a tumour ofpulmonary apex. They account for less than 5% of all bronchogenic carcinomas. It is a type of lung cancer definedprimarily by its location situated at the top end of either the right or left lung . Clinically patient presents with thecharacteristic symptoms of severe pain in the shoulder radiating toward the axilla and/or scapula and along theulnar distribution of the upper arm, atrophy of hand and arm muscles and obstruction of the subclavian veinresulting in edema of the upper arm , horners syndrome.

Case report :

65 yr old male patient came to pulmonary medicine op with complaints of giddiness, and left sided pleuritic chestpain from 2 months ,radiating to left hand , absence of sweating on left side of face. General examination showedclubbing and wasting of hypothenar muscles. Opththalmological examination showed horners syndrome withreverse ptosis. X ray chest showed a mass with 1st and 2nd rib erosions. CECT chest showed a contrast enhancingmass with first 2 rib erosions.pt was diagnosed as having pancoast tumour. CT guided biopsy showedadenocarcinoma of lung. patient was referred to oncologist for further management.

P55

A rare case of cardiac angiosarcoma of right atrium with pulmonary metastases

Dr.G.AMBERNATH, Dr.Sai P Haranath, Dr.Meenakshi Swain*, Dr.Manasa, Dr. Baisakhi Chandra

Dept of Pulmonary Medicine, Apollo Hospitals, Hyderabad, Telangana

* Dept of Pathology, Apollo Hospitals, Hyderabad, Telangana

BACK GROUND

primary malignant cardiac tumors are extremely rare but their associated mortality is very high. Cardiacangiosarcoma, originates from mesenchymal tissue and endothelial subepicardium. Although angiosarcmoaconstitutes 31% of all malignant cardiac tumors, it is rare and prompted us to report this case.The diagnosis ofangiosarcoma is often delayed because early signs may be absent and generic. Indicative symptoms of potential

cardiac disease are exertional dyspnoea, chest pain, cough, syncope, arrhythmias, pericardial effusion leading totamponade and pleural effusion which occur late in the progression of angiosarcoma. Right atrial presentation isthe most common and the most difficult to diagnose.

CASE DETAILS

A 30 year old male from Tanzania presented to our hospital with complaints of chest pain since four months ,cough, haemoptysis ,shortness of breath & diminished vision in the left eye since admission.Chest radiographshowed marked cardiomegaly with right atrium (RA) & right ventricle (RV) enlargement. Echocardiographyshowed large hollow cystic mass attached to RA & RV. MRI chest with contrast showed irregular mass in the rightlateral wall with pedunculated & nodular areas in the RA anterior wall .PET-CT showed metabolically activeskeletal & bilateral lung lesions suggestive of metastases and non-avid RA lesion possibly angiosarcoma arisingfrom RA with pulmonary, skeletal & hemorrhagic brain metastases. Pulmonary metastasectomy by video assistedthoracoscopic surgery showed lung parenchyma with multiple tiny tumor nodules suggestive of angiosarcoma &multiple nodules in favour of metastasis. Immune-histochemistry showed CD31 & CD34 positive tumor cells.Thepatient has been treated with chemotherapy & radiation and has a good quality of life for the last 6 months .

P56

A rare case report of Low Grade Fibromixoid sarcoma in Anterior Mediastinum

Dr.Q.H.Ansari, Dr. Meenakshi Swain*,Dr.Avinash Dal#, Dr.G.AMBERNATHDept of Pulmonary Medicine, Apollo Hospitals, Hyderabad, TSDept of CTVS, Apollo Hospitals, Hyderabad, TS* Dept of Pathology, Apollo Hospitals, Hyderabad, TSBACK GROUNDLow Grade Fibro Mixoid Sarcoma (LGFMS) is a rare neoplasm commonly affecting young adults and typicallyarising in the somatic soft tissue of the proximal extremities. Its occurrence with in the thorasic cavity in theanterior mediastinum is exceedingly rare.CASE DETAILSA 52 year old woman, presented to OPD with c/o cough with expectoration since 10 days. On evaluation, CXR PA &lateral view showed well defined soft tissue dense shadow with convex outer margin not silhouting the cardiacborder in the anterior mediastinum in the hilar and supra hilar region. CECT chest showed well defined round masslesion in anterior mediastinum measuring 45 x 52 mm with moderate degree of non-homogenous enhancement &necrotic areas on post contrast study. FNAB showed non specific bland spindle cells. PET CT scan whole body didnot reveal any distant metastasis. Wide local excision of the mass lesion was done through median sternotomy andsent for histology for definitive diagnosis and on HPE showed hyalinised tumor cells arranged in loosely cellularmixoid and collagen rich areas and are composed of spindle to stellate cells, features consistent with LGFMS.Patient was treated with radiation to prevent recurrence. After surgery and radiotherapy,patient wasasymptomatic and leading a good quality of life for the last two months.

P57A rare case of extraskeletal Ewings sarcoma originating from the parietal pleura

Dr.HARISH KUMAR G.,Prof.Pradyut Waghray,Dr.ANV Koteshwar rao,Dr.Venkateswara Reddy.T,Dr.Veena,Dr.chetan Rao,Dr.sowmya,Department of pulmonary Medicine,Svs Medical College,Mahbubnagar,Telangana

Introduction: Extra skeletal Ewing Sarcoma (EES) is a rare entity which predominantly occurs in adolescents andyoung adults. It usually arises from the soft tissues of the trunk or the extremities,the most frequent sites ofoccurrence are the chestwall, the para vertebral region and the lower extremities. EES is associated with reciprocaltranslocation between chromosomes 11 and 22.

The case report:A 16years old male patient who presented to the ER with complaints of fever,right sidedhypochondriac pain,shortness of breath since 10days

Physical examination revealed tenderness at right hypochondriac region on palpation,dull note felt on percussionon right infrascapular, infra-axillary area and decreased breath sounds on rigt infrascapular and infra-axillary area

Cxr,suggestive of Right sided homogeneous opacity silhoutting right dome of diaphragm with oblitreration of rightcostophrenic and cardiophrenic angleUltrasound suggestive of irregular heterogenously hyperechoic lesion measuring 4*5 cms noted in the right pleuralspace arising from supradiaphragmatic region taking no flow on color doppler with moderate pleural effusion

CT chest suggestive of irregular heperdense region noted in the pleural space arising from parietal pleuraobscuring the daiphragm in its superior aspect and causing erosion of adjacent rib with moderate collection ofpleural fluid

Pleural fluid analysis: Exudative effusion and negative for malignant cells

Pleural Biopsy using Abraham’s needle: Pleural based mass suggestive of pleural ewings sarcoma

CT guided biopsy of mass: Suggestive of pleural ewings sarcoma

Conclusion: As a conclusion EES should be considered in the differentialDiagnosis of any patients but especially in adolescents or young adults, with a soft tissue mass of the trunk or theextremities, though it is a rarest possibility

P58

A rare case report of Secondary Pulmonary Amyloidosis.

G.NageswarRao, M.Venu, R. Ramakrishna, B.Surya kumari, N.Balakrishna.Department of Pulmonary medicine, Katuri Medical College & Hospital, Guntur-17, India.

Introduction:Amyloidosis is a systemic disease caused by extracellular deposition of insoluble fibrillar proteins. It can beidiopathic (primary form) or associated with various inflammatory, hereditary, or neoplastic diseases (secondaryform). Pulmonary amyloidosis may be part of a widespread process that involves many organs, or it may belocalized to the airways and lung parenchyma.Case scenario:

A 40 year old female presented with a two months history of progressive dyspnoea, productive cough, andweight loss. She suffered from several episodes of respiratory infection in preceding months that improved afterantibiotic therapy. She had a past history of military tuberculosis treated well ten years ago. She was not ahypertensive and diabetic.

Upon admission, physical examination showed an ill looking patient who was thin and pale. Her bloodpressure was 100/70 mmHg, her pulse 100 beats/min, respiratory rate was 26 breaths/min and pulse oxymetrysaturation was 94%.There was cervical lymphadenopathy. Chest auscultation revealed diffusely scattered cracklesand polyphonic rhonchi bilaterally. A physical examination of the heart and abdomen revealed no abnormalfindings. Routine blood investigation showed moderate anaemia and elvated serum creatinine (1.8mg%). She wasnon-reactive for HIV, HBV and HBC. Her sputum for acid-fast bacilli and fungi was negative. A chest radiograph andcomputed tomography (CT) on the thorax showed multiple calcified nodular opacities of varying sizes withirregular contours, and were diffusely and bilaterally distributed. Spirometry demonstrated a moderate

restriction. Arterial blood gas analysis was normal. Echocardiography revealed a normal ejection fraction with nomyocardial or valvular abnormalities. Bronchoscopy showed no abnormalities and bronchial washings disclosedonly chronic inflammatory changes. CT guided transthoracic core needle biopsy and excisional biopsy of cervicallymph nodes was done. Biopsy sections examined under light microscopy showed intense eosinophilic material.The diagnosis of amyloidosis was confirmed by the presence classical green birefringence in congo red stainedsections viewed under polarized light. This was further fortified by immunohistochemistry positive for serumamyloid A protein.Conclusion:

Secondary amyloidosis is a rare systemic complication of pulmonary Koch’s. Tuberculosis is still the mostcommon cause of secondary amyloidosis (AA form) followed by chronic suppurative lung diseases in developingcountries. Several cytokine like IL-1, IL-6 and TNF-α stimulate hepatic synthesis of serum amyloid A precursorduring tuberculosis inflammation. It should be considered in the differential diagnosis of calcified pulmonarynodules due to malignancy, baritosis, alveolar lithiasis and granulomatous diseases.

P60An Atypical Presentation of Pulmonary EmbolismM.M. MODI, R.K. JALANDepartment of Respiratory Medicine, Ruby Hall Clinic, Pune, Maharashtra, India

OBJECTIVES :

Pulmonary Embolism is the most common preventable cause of death in the world. Post-operative deep veinthrombosis from the pelvic veins is the most common cause. Cardiac Atrial myxomas are an extremely rare causefor pulmonary embolism. 75% of myxomas are located in left atrium. Right atrial myxomas are extremely rare. Wereport a rare case of pulmonary embolism due to fragmentation of an atrial myxoma in an usual location in rightatrium. The main objective of reporting this case is to consider such diagnosis when all other common causes ofpulmonary embolism are ruled out as timely surgical resection is the treatment of choice to prevent fatalconsequences such as sudden death.

METHODS :34 yrs old male patient, smoker, presented with history of right sided chest pain and breathlessness since 15 days.Chest X- Ray - Right pleural effusion and Right lower lobe consolidation. Diagnostic thoracentesis - Exudativepleural effusion. Patient was diagnosed as having syn-pneumonic effusion and started on antibiotics . After 21 daysof treatment repeat chest x- ray showed no reduction in pleural effusion and consolidation. Patient was referred tous for further management. HRCT- Thorax with Pulmonary Angiography - Dense calcific plaque in right descendingartery. 2- D Echo - Large mobile mass measuring 3.9 X 1.6 cm in Right atrium, prolapsing across mitral valve .Cardiac MRI - Mass in right atrium with heterogenous contrast uptake. Mid- Sternotomy and CP bypass showed afreely floating mass in the right atrium with 2 attachments , one near anterior lip of coronary sinus and other justabove the opening of IVC into RA.

Mass was completely excised and sent for HPE - Stellate cells surrounded by abundant loose myxoid stroma withareas of infarction- consistent with Atrial Myxoma.

CONCLUSION :Right atrium is a very rare site for atrial myxomas, which can rarely cause fragmentation and lead to pulmonaryembolism.

P61ABSTRACT

Successful Non- Surgical Management Of Acquired Benign Tracheo- Esophageal FistulaA.M. KHOJA , R.K. JALAN, D.L. JAIN, K.A. PATIL, KSK GOUD, B. SIDDESH

Department of Respiratory Medicine, Ruby Hall Clinic, Pune, Maharashtra, India

INTRODUCTION :Tracheo-esophageal fistula (TEF) are a rare entity which can either be congenital or acquired. Acquired TEF areseen in adults and are most commonly due to malignancy. Benign TEF are rare and are most commonly attributedto post intubation injuries. Till date,surgical correction for management of benign TEF has been most commonlyemployed. Tracheal stenting with self expanding metallic stent (SEMS) has been mostly reserved for palliativemanagement of malignant TEF. Here, we report a case of benign TEF caused due to high tracheostomy cuffpressure which was successfully managed non – surgically by tracheal stenting.

METHODS :54 yrs old male patient with history of Road traffic accident and subsequent Diffuse axonal injury was admitted inthe hospital since 2 months . He underwent tracheostomy 45 days ago and had Ryle’s tube in situ since 2 months.He was referred to us with complaints of regurgitation of Ryle’s tube feeds and purulent secretions through thetracheostomy site since 10 days. Examination and X- ray findings were suggestive of aspiration pneumonitis. Hewas posted for bronchoscopy which showed a large trachea-esophageal fistula in the upper part of the trachea. Asthe patient was unfit for surgical closure of the fistula due to poor neurologic status, he underwent trachealstenting with a SEMS for closure of the fistula.CONCLUSION :

Benign TEF is a rare entity and can be successfully managed by non – surgical interventions like tracheal stenting

P62A case report on pulmonary alveolar microlithiasis

Suman Kumar Jagaty, Pravati Dutta, Rekha Manjhi, Sudarsan Pothal,

Madhumita Nayak, Paresh Chandra Mohanta

Department of pulmonary medicine, VSS Medical College, Burla, Odisha, India.

Background: Pulmonary alveolar microlithiasis is a rare inborn error of calcium metabolism with unknownetiology and familial association in which concretions composed of calcium and phosphorus collect in alveolarspaces.

Case Report: A 42 year old male non smoker weaver presenting with 6 months history of fever,cough with mildexpectoration and dyspnea on exertion was diagnosed as miliary tuberculosis by a local physician for which hewas taking antitubercular treatment.His general physical examination was unremarkable with vitals beingnormal.Respiratory system examination revealed bilateral fine inspiratory crackles in axillary area.His laboratoryparameters and Pulmonary function test were normal and sputum was negative for acid fast bacilli.Chest X-rayshows bilateral diffuse micronodular shadows (sand-storm pattern) predominant in middle and lowerzones.Presence of diffuse calcified micronodular opacities with lower lobe and subpleural predominance andseptal thickening on high resolution computed tomography of chest confirmed the diagnosis of Pulmonaryalveolar microlithiasis.

Conclusion: Pulmonary alveolar microlithiasis being a rare disease with unknown etiology has burdened thepatient with unnecessary doses of anti-tubercular treatment because of its resemblance to miliary tuberculosison chest X-ray.Patients due to delayed diagnosis ultimately progress to end stage lung disease necessitating lungtransplantation. So attempt for earlier diagnosis and finding the etiology is all that needed.

P63

Title: Kartagener Syndrome

Subject: Abstract for poster presentation about a case of Kartagener Syndrome

Presenter: Dr.M.Sharanya G.S.L.Medical College, Rajahmundry,A.P.

Objective: To discuss the signs, symptoms, clinical evaluation, diagnostic investigations and treatment aspects ofKartagener Syndrome

Methods: A 20 year old female came to the Pulmonology O.P. with a complaint of cough with mucoidexpectoration , breathlessness and common cold like symptoms since 3 months. Patient claimed to have had ahistory of similar illness recurrently since childhood.

Result: Investigative workup revealed that the patient had Situs inversus , Bilateral Brocheichtasis and Chronic para-sinusistis. The patient was diagnosed to have Kartagener Syndrome.

Conclusion: The frequency of Kartagener syndrome is 1 case per 32,000 live births. Situs inversus occurs randomlyin half the patients with primary ciliary dyskinesia; therefore, for every patient with Kartagener syndrome, anotherpatient has primary ciliary dyskinesia but not situs inversus.

Hence I would like to present a poster for representation of the basic text of the summary, with the use of figures,graphs and tables, as well as references, so to facilitate visual communication about Kartagener Syndrome.

P64A rare cause for stridor in an elderly maleDr.Madhusudhan.Y, Dr Vishnu Sharma.M, Basavaraj.S.A.J.Institute of Medical Science, NH-66 , Kuntikana, Mangalore ,Karnataka- India 575004 madhu4788@gmail.comINTRODUCTION:

Stridor is most often due to upper airway obstruction. Any intra thoracic lesion leading to tracheal obstruction can be arare cause for stridor.CASE REPORTAn 80 year old male patient presented with progressive dysphagia since 3months, hoarseness of voice since 4 weeks

and noisy difficulty in breathing (stridor) since 10 days. He had loss of weight and appetite. He had no chest pain,cough, sputum, hemoptysis or fever. He had no neurological symptoms. He was a chronic smoker.ENT examination showed left vocal cord palsy. No other local abnormalities were seen in the throat. Respiratorysystem examination was normal. Chest X-ray did not reveal any obvious lesion which could account for stridor.Contrast enhanced CT scan of chest revealed soft tissue density shadow in upper part of esophagus at the level of D1 –D4 vertebra. Fat plane around trachea and esophagus was lost and the lesion was seen invading the trachea fromposterior aspect narrowing the tracheal lumen. Upper GI scopy showed a fleshy growth in the upper end of esophagusand biopsy from the lesion was taken. Biopsy revealed moderately differentiated squamous cell carcinoma.Bronchoscopy showed a lesion invading the trachea from posterior aspect occluding the tracheal lumen almostcompletely which lead to stridor.

CONCLUSION:Consider and evaluate for intra thoracic causes for stridor when ENT evaluation is normal. Carcinoma in the upper endof esophagus can invade the trachea and can lead to stridor.

P65A rare presentation of spontaneous acquired diaphragmatic hernia – case report.B.Bhushan, N.C.Kajal, A.Gupta, S.GuptaTB and Chest Department, Government Medical College, AmritsarBackgroundDiaphragmatic hernias represent a weakness that can evolve into a localized defect, allowing abdominal structuresto protrude. Spontaneous diaphragmatic rupture is one of the rarest thoracoabdominal emergencies, and is harderto detect in patients without visceral damage. A sceptical approach is key to the diagnosis of this condition.Case Report

A forty-six year old male patient presented with chest pain on left side and dyspepsia for the past two months,associated with few episodes of vomiting. Chest radiograph showed lesion mimicking a cavity in the left lower zoneoverlying cardiac shadow with a surrounding area of collapse(Figure 1). Initially, he had presented to a generalpractitioner, where he was misdiagnosed as a case of pulmonary tuberculosis and was prescribed anti-tuberculardrug treatment The findings led to a provisional diagnosis of spontaneous acquired diaphragmatic hernia, whichwas later confirmed on contrast enhanced tomography scan. Patient was referred to the cardiothoracic surgerydepartment.ConclusionThe presentation of diaphragmatic rupture is often a result of herniation of abdominal contents into thorax.Spontaneous Diaphragmatic Rupture (SDR) describes the rupture of the diaphragm due to increasing pressure in theabdominal cavity and chest wall without any direct trauma. It is difficult to diagnose SDR in the absence of visceralorgan injury or herniation. The diagnosis may be delayed by a few days or even several years as the symptoms arenon-specific. Diagnostic procedures for traumatic diaphragmatic ruptures include: chest x-ray, CT scan, ultrasound,Magnetic Resonance Imaging (MRI), Upper GI contrast studies, laparoscopy and thoracoscopy. However chest x-rayhas only a diagnostic accuracy for diaphragm injuries of just 25-50%. The management of SDR is surgical.

P66

Early stages of scleroderma- A case reportDr.N.Snigdha,Dr.N.Gopi chand,Dr.D.sudeena,Dr. C. Suma lathaSiddhartha medical college, Vijayawada, Andhra Pradesh, India.

ABSTRACT

Introduction: Scleroderma or systemic sclerosis (SSc) is a clinically heterogeneous, multi-system autoimmunedisorder characterized by endothelial dysfunction, dysregulation of fibroblasts resulting in excessive production ofcollagen and autoantibody formation with profound abnormalities of the immune system.Incidence ofscleroderma is about 9-19 per million populations. Pulmonary involvement like Interstitial Lung Disease(ILD) andPulmonary arterial hypertension(PAH) are common and occurs in all SSc subsets. Progression of lung disease inSSc is variable and difficult to predict.

Case Report: A 30 year old female home-maker presented with shortness of breath and dry cough since 3months.On general examination she has pallor, skin showed shiny ,light hide bound skin over extensor aspect offorearm and front of legs. Salt and pepper pigmentation over both ears, microstomia, digital pitting scars areseen. Respiratory examination reveals bilateral normal vesicular breath sounds with basal fine end inspiratorycrepitations. Chest X-ray PA view,2-D Echo are normal, Electrocardiography shows sinus tachycardia. HighResolution computed Tomography shows peripheral ground glass pattern in basal segments and bilateral lowerzones which is consistent with nonspecific interstitial pneumonia(NSIP). Spirometry showed restrictive pattern.Complete hemogram shows microcytic hypochromic anemia. She is positive for serum antinuclear antibodies , antiscl70 antibody and negative for anticentromere antibody. Endoscopy shows erosive antral gastritis. Bariumswallow shows delayed filling of barium in lower 1/3 of esophagus. Liver Function Test’s and Renal Function Test’sare within normal limits. She is diagnosed to have diffuse type of systemic sclerosis.

Discussion: PAH and ILD are most common pulmonary manifestations in Systemic sclerosis, with ILD of NSIP morecommonly associated with diffuse subset.PAH can occur in these patients secondary to ILD. Early diagnosis wouldenable us to prevent progression to severe forms of pulmonary fibrosis. However the outcome may vary. Steroidsand antineoplastic drugs like cyclophosphamide , methotrexate, mycophenolate remain main stay of treatment.Anti-fibrotic drugs like D-penicillamine have a role.PAH is managed on drugs like sildenafil or bosentan.

P67Unusual presentation of Right sided Bochdalek Hernia in an adultRavi Bhaskar, Alok Chandra, Tariq Mahmood, Rajneesh Shrivastav, Neha AgrawalMoti Lal Nehru Medical College and Swaroop Rani Nehru Hospital, Allahabad, India

Introduction: Bochdalek hernia is a type of congenital diaphragmatic hernia resulting from failure of closure ofposterior pleuro- peritoneal membrane by 8th week of gestation. It primarily manifests in neonates and infants. It israre in adults and accounts for about 0.17% to 6% of all diaphragmatic hernias. As 80%-90% occur on left side,right sided presentation is exceedingly rare in an adult with only about 20 cases reported in literature.Case presentation: A 24 year old male presented with gradual onset breathlessness on exertion for 3 months andpain over epigastrium for 1 day. Patient was non-smoker. General and systemic examinations were within normallimits. On auscultation, air entry was decreased on right side of chest. Chest X-Ray PA view(fig 1) revealed that rightdiaphragm was exceptionally high. USG abdomen showed epigastric location of right kidney with eventration ofright hemidiaphragm. Barium follow-through showed that hepatic flexure of large bowel loops and ileal loops werehigher up in position under the right dome of diaphragm. CECT Thorax and Abdomen(fig 2) confirmed the presenceof small bowel, right colon, right kidney and right lobe of liver in thoracic cavity causing mass effect on right lung.Patient underwent short lateral thoracotomy and herniated organs were moved back to abdominal cavity anddefect was closed. Postoperative course was uneventful and patient had no symptoms on follow up.Conclusion: Bochdalek hernia occurs in about 1 in 2,200 to 12,500 live births and is a rare finding in adults. Rightsided hernias are rare because right pleuroperitoneal cavity closes earlier and liver buttresses the diaphragm.

P68INTRAPULMONARY SOLITARY FIBROUS TUMOR OF LUNG PRESENTING AS PANCOAST TUMOR.

Dr VIPUL KUMAR, Dr K B GUPTA, Dr RITU AGGARWALPt BD Sharma Post Graduate Institute of Medical Sciences

INTRODUCTION

Intrathoracic solitary fibrous tumors (SFT) are the rare mesenchymal tumors, commonly arising from the pleura.Inward tumor growth into the lung parenchyma is infrequent while totally intra-pulmonary localized fibroustumors without histological continuity with visceral pleura have been described rarely. These tumors are threetimes more likely to arise from visceral than parietal pleura with variable morphological presentation.

CLINICAL DETAILS

45 year old female presented with right side chest pain since two months. CECT revealed hypo dense mass lesionof size 58mm x 66mm x 61mm in apical and posterior segment of right upper lobe showing heterogeneousenhancement with central non-enhancing or necrotic area. CT guided biopsy of the lesion revealed replacement ofnormal lung parenchyma by haphazardly distributed fibroblast like cells embedded in matrix of variable densitywith low mitotic activity. On immunohistochemistry, tumor cells were positive for CD34, vementin and negativefor cytokeratin, smooth muscle antigen consistent with the diagnosis of SFT.

DISCUSSION

SFTs account for 8% of benign intrathoracic tumors and 10% of pleural tumors. Most of the patients areasymptomatic and lesion is detected incidentally on routine chest radiograph. The diagnosis is usually madehistopathologically either by CT guided lung biopsy or surgical resection. As these lack distinctive histologicalfeatures, immunohistochemical examination is very important for their diagnosis. Although CD34 is expressed byvarious cell types such as hematopoietic progenitor cells and mesenchymal tumor cells, its detection along withvimentin and absence of cytokeratin in cells from a pleural tumor excludes the diagnosis of mesothelioma and ofmost other pleural tumors such as carcinomas, fibrous histiocytomas, fibromatosis, fibrosarcomas, and synovialsarcomas. The treatment of choice is surgical resection either through VATS or open thoracotomy depending onthe size.

P69CATAMENIAL HAEMOPTYSISDr.MOUNIKA.V*, Dr. H.V.PRASAD MALLA **, Dr.P.SUBBARAO***,

DEPARTMENT OF PULMONARY MEDICINE, KONASEMA INSTITUTE OF MEDICAL SCIENCES &RESEARCHFOUNDATION, CHAITANYANAGAR, NH-214,AMALAPURAM, ANDHRA PRADESH-533201.

BACKGROUND: The monthly periodicity of the symptoms led to the coining of ‘’CATAMENIAL”( In Greek-monthly).Thoracic endometriosis can involve the lung parenchyma causing catamenial haemoptysis or it mayinvolve the pleura causing pneumothorax. We present a case of catamenial haemoptysis associated with pelvicendometriosis.

CASE REPORT: A 25 yr old multiparous women was presented with recurrent episodes of haemoptysis at the timeof menstruation since 6 years. She had no fever, cough, weight loss, family H/O TB. Physical Examination wasunremarkable. Her chest radiography was normal and microscopy for mycobacterium tuberculosis was negative.Mantoux test 20 mm induration with BCG scar present. CT scan of chest was carried out on the 2nd day ofmenstruation with normal study. Fibre optic bronchoscopy showed normal endobronchial appearences.Considering the history of haemoptysis during menstrual periods, pulmonary endometriosis was diagnosed.

DISCUSSION:Endometriosis is a common gynecologic disorder with peak prevalence between 30 to 45 years of age. Only 10 -25% of women with endometriosis are presenting with gynecological symptoms. It is most commonly found inpelvis and only rarely in sites such as umbilicus or lungs. Pulmonary endometriosis gives rise to symptom ofcatamenial haemoptysis.The etiology of pulmonary endometriosis is unknown, but the theories of haematogenous spread and coelomicmetaplasia are plausible. The diagnosis is often presumptive, based on clinical history of cyclical haemoptysis atthe time of menstruation. Other diagnostic aids include endometriotic plaques on bronchial washings andendometrial tissue on lung biopsy. Imaging technique of choice is CT scan of chest during days of menstruation andin mid cycle.

P70Hereditary Hemorrhagic Telangiectasia presenting as recurrent Haemoptysis

Dr.Rajesh Kumar B, Dr.S.V.Ghorpade, Dr.Vinit Niranjane, Dr.Gyan S Mishra.

Dept. Of Pulmonary Medicine, Govt. Medical College, Nagpur, Maharashtra.

Introduction: Osler-Weber-Rendu syndrome is a rare hereditary, autosomal dominant disease characterized by alocal angiodysplasia. Patients usually have nasal and gastrointestinal bleeding and characteristic mucocutaneoustelangiectasia associated with Arteriovenous malformations in the viscera commonly lungs, brain and liver.

Case report: 48yrs old male patient presented with recurrent haemoptysis, had recurrent epistaxis in past andoperated for brain abscess previously. He also had multiple cutaneous telangiectasias in face, chest and hands.During evaluation CT Thorax and CT Pulmonary Angiogram were done, which showed multiple pulmonary A-VMalformations bilaterally.

Discussion: Epistaxis caused by spontaneous bleeding from nasal mucosal telangiectasia is the most commonmanifestation of this disease; about 80% of the patients have recurrent epistaxis. Cutaneous manifestations aremacular telangiectasia, which affect the face, lips, nose, tongue, ears, hands, upper body and feet. Pulmonary A-Vmalformations caused by direct communication between the pulmonary vein and artery by means of a thin-walledaneurism. They are usually multiple and bilateral, common in lower lobes, the treatment of choice is embolizationof vessels. Cerebral manifestations like Brain abscesses, Ischemic strokes, Bacterial encephalitis may occur due topulmonary A-V malformations. Cerebral malformations occur in about 28% cases. Gastrointestinal tract bleeding iscaused by mucosal telangiectasia in GIT. Liver involvement may cause congestive heart failure, hepaticencephalopathy, and portal hypertension with oesophageal varicose veins. Our patient fulfilled three criteria forthe diagnosis of HHT. Pulmonary A-V Malformations were occluded by multiple Coil Embolization. After CoilEmbolization, his Orthodeoxia improved dramatically.

Conclusion: Hereditary hemorrhagic telangiectasia should be suspected in a case of recurrent haemoptysis.Awareness must be created about this disorder and its genetic nature to enhance early diagnosis and appropriatemanagement. Diagnostic facilities for this disorder should be made available at specialised centres in India.

P71Atypical presentation of achalasia cardia

B S Behera, P Dutta, R Manjhi, S Pothal

Department of Pulmonary Medicine,V S S Medical College ,Burla ,Odisha, India

Background:- Achalasia is defined as failure of organised peristalsis in esophagus and failure of relaxatiuon at thelevel of lower esophageal spincter. It is a disease of unknown etiology.

Case report:- A 62 yr old male presented with history of low grade fever and cough for the past one year. Nohistory of hemoptysis. He had history of dysphasia, regurgitation or vomiting. These symptoms were mild so heconsulted either a local physicain and sometimes was on some home remedies, but his symptoms were not relivedon medications. He is non diabetic and non hypertensive. His physical examination was normal. On examination ofrespiratory system tubular bronchial breath sound was found over left mammary, upper interscapular& lowerinterscapular areas. His laboratory parameters showed a raised TLC count with rest of the blood parameters werewithin normal limits. Chest X-ray showed widening of mediastinum with a patch of consolidation in the left upperzone. CT scan of chest revealed a dilated and tortous bowel loop with a dilated loop of esophagus in thorax withhiatus containing food particles with consolidation of the left upper zone. Barium swallow was performed whichshowed a dilated and tortous esophagus. On Upper GI endoscopy the diagnosis of achalasis cardia was confirmed.His respiratory symptoms subsided with antibiotics there was also radiological improvement of the consolidation.He was referred to cardiothoracic department for further management.

Conclusion:- Achalasia remains an elusive diagnosis. The diagnosis is often delayed in asymptomatic patients as inthe present case.

P72AN UNUSUAL CASE OF MILIARY INFILTRATES

Dr.HAJI, Dr.KRISHNAMOORTHY,Dr.SANGAMITRA,Dr.MATHAN,Dr.RAHMAN,Dr.JEYAKUMAR

DEPARTMENT OF THORACIC MEDICINE,

TIRUNELVELI GOVT MEDICAL COLLEGE AND HOSPITAL,TIRUNELVELI(TAMILNADU)

ABSTRACT:

Carcinomatosis is described as a condition in which multiple carcinomas develop simultaneously, usually afterdissemination from a primary source. They are forms of metastasis and whether they spread in a general manneror in a defined pattern, they will still be a form of disseminated cancer. Miliary carcinomatosis is similar to militarytuberculosis in terms of their radiographic appearance. They are characterized by a pattern of metastases whichare not only nodular but also small in sizes.Usually presents late .We have described a 59 year old Female a caseof military carcinomatosis whose primary was papillary carcinoma of thyroid.Her thyroid had been removed andwas started on palliative chemoradiation.

P73

P74Ascending aortic aneurysm with left lung atelectasis

Dr.Dishan.Y, Dr.Yuvarajan S, Dr.Bency Koickal Thomas

Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India

ABSTRACT

Pulmonary atelectasis may be caused by endobronchiallesions or by extrinsic compression of the bronchus.However, lung collapse due to compression from a thoracic aneurysm is uncommon.

We report a 52 yr old male patient who has pulmonary atelectasis due to an extrinsic compression from theascending thoracic aortic aneurysm. He came with complaints of breathlessness for past 1 year. He was a nonsmoker and non alcoholic. On examination of chest ,breath sounds reduced on left side of chest. Chest xrayshowed enlarged cardiac shadow with left sided volume loss, following which 2D echo was done which showedright atrium and right ventricle enlargement with moderate pulmonary artery hypertension and aortic aneurysmwith bicuspid aortic valve. CT thorax showed dilated ascending aorta and anomalous left brachiocephalic vein,joined with left atrium directly and compression of pulmonary trunk between ascending aneurysm and anomaliesvein. Also narrowing of left main bronchus by left pulmonary artery and anomalous vein. Apical segmentatelectasis with patchy hyperinflation was also noted in left lung. Bronchoscopy showed carina shifted to left sidewith narrowing of left main bronchus. No evidence of endobronchial obstruction at the level of left main bronchus.Patient was referred to CTVS for the opinion regarding definitive surgical management.

P75A rare anterior mediastinal paraganglioma-a case report.

Anandeswari P, Ramesh.P.M, Chitrakumar.A. Gangadharan.V

Govt. Kilpauk Medical College&GTHTM,Chennai, Tamil Nadu, India.

Case report: 40 yrs. male, pest controller, presented with hoarseness of voice-5 years, weight loss, breathlessness-3 months. He was chronic smoker and alcoholic-20 years. On examination there were dilated veins over leftanterior chest wall. Examination of respiratory system revealed normal breath sounds with occasional wheeze withimpaired to dull note over the left infraclavicular and left mammary region. His blood counts were normal. Chest XRay PA view revealed a large well circumscribed homogenous opacity with left border abutting the lateral chestwall and right border extending up to right mid clavicular line. Left lateral view revealed obliteration of retrosternalspace. Echo revealed moderate pericardial effusion. CT Chest revealed a well-defined hyper dense lesion inanterior mediastinum extending from lower neck to anterior pericardium abutting the anterior chest wallcompressing and displacing trachea and vascular structures. CT guided biopsy revealed nests of small round to ovalcells separated by richly vascular thin stromal cells separated by dysmorphic stroma with focal calcification.Neuron specific enolase was strongly positive suggestive of paraganglioma. Immunohistochemical markers showedweak to moderate activity of synaptophysin and chromagranin. Patient was discharged and referred to surgicaloncology department for further management.

Discussion: Paraganglioma are rare, highly vascular, extra adrenal neuroendocrine tumors. First described by VonHaller in 1743 involving various body sites(Abdomen-85%, Thorax-12%, Head&Neck-3%). <1% seen in mediastinum.Anterior mediastinal paraganglioma arise from paraganglias associated with parasympathetic system located inhead and neck and extends into anterior mediastinum. They are asymptomatic, seen in older people, identifiedincidentally and serve chemoreceptor function. Diagnosis is usually made by biopsy and immunohistochemistry. Sofar only about 34 cases have been reported in the literature. Ours is another interesting case presented for its rareincidence.

P76ABSTRACT

Early Detection Of The Rare Entity Pulmonary Alveolar ProteinosisM.M MODI,B.SIDDESH, R.K JALAN, K S K GOUD.

Department of Medicine, Ruby Hall Clinic, Pune, Maharashtra, India300OBJECTIVES: 142Pulmonary alveolar proteinosis (PAP) is a rare syndrome characterized by pulmonary surfactant accumulation within the alveolar spaces with a reported prevalence of 0.1 per 100000. It occurs in an individual with distinct clinicalforms of which primary (idiopathic) represents the vast majority of cases, secondary form due to underlying lunginfections, haematological malignancies and inhalation of mineral dusts and insecticides, congenital form due tomutations in the genes encoding for the granulocyte- macrophage colony stimulating factor receptor and very fewwith surfactant gene mutations.Here we report a case of secondary PAP who was successfully treated with total lung lavage which is accepted asthe most effective treatment for advanced cases. The main objective of presenting this is to increase awarenessregarding this rare disease as early detection and prompt treatment increases the survival where if delayed leadsto death.METHODS: 99A 30 year old male patient, smoker, presented with complaints of productive cough with whitish expectoration

along with breathlesness on exertion from 3 months and fever on and off from 8 days. Patient had history ofworking in blast mines and fertilizer Company. On ausculatation the patient had fine inspiratory crepitations allover lung fields. Chest X ray showed bilateral reticulo- nodular shadows. HRCT Thorax showed crazy paving patternalong with ground glass opacities and reticulo- nodular shadows. Bronchoscopy with transbronchial lung biopsywas done which was consistent with PAP. Patient had pneumothorax post biopsy for which intercostal drain wasinserted.lavage patient was put on invasive ventilation. he developed ventilator associated pneumonia and died due tosepsis.

CONCLUSION: 28PAP is a rare entity which can be confused with many conditions. Early diagnosis and appropriate treatmentimproves the life expectancy and quality of life of such patients.

P77

P78

A CASE OF TRACHEOESOPHAGEAL FISTULA PRESENTING WITH RECURRENT LRTI’S

P.sireesha,G.P.vignan kumar

Postgraduate,department of pulmonary medicine,narayana medical college,Nellore,Andhra PradeshINTRODUCTION:Tracheoesophageal fistula (TOF) is a congenital or acquired communication between trachea andoesophagus.These can often lead to severe and fatal pulmonary complications.Among the acquiredcauses,malignancy is the most common cause of tracheoseophageal fistula.The second most common cause is theendotracheal cuff related trauma.

CASE REPORT:Here we report a case of 45 yr old male who presented with increased cough onfoodintake,breathlessness and recurrent LRTI’S.Past history of insecticide poisoning with prolonged intubation waspresent.Investigated with routine laboratory tests.CBP was normal.Chest xray showed a pneumonic patch.Furthurwork out with bronchoscopy revealed a Tracheoseophageal fistula.case was planned for surgical repair of thefistula.

P79

Title abstract for oster presentation: Skin associated lymphoid tumour

Name of author: Saurabh P borgaonkar

Dr vasantrao pawar medical college , nashik. india

A 28/M ,case of pleural effusion on cat 1 since 1 month. Pleural fluid was exudative and also was on oral steroids.Presented to us with fever,cough with white frothy sputum ,dyspnea , oedema over hand ,arm . Pleural tappingwas done , it was exudative with ADA 29.cytology negative for malignancy. TLC Venous doppler was done for rightarm suggestive of thrombus in axillary vein and brachilal vein. USG suggestive of multiple LN withsplenomegaly.CECT thorax shows mediastnal widening with right pleural effusion. Supraclavicular LN biopsysuggestive of monotonous population of lymphoid cells. Biopsy could not be done due to deranged PT INR.Meanwhile his oedema increased and neck vein engorged,odema on face and periorbital region.he developedreddish skin papule on face and chest ,biopsy was done suggestive of monotonous population of atypical lymphoidcell suggestive of SALT. Skin biopsy Block was sent for IHC but unfortunately patient succumbed. ADA are sensitiveand specific for diagnosis TB pleurisy. Incidence of thrombosis is 6.5% with NHL and 4.5% for HL. Incidence ofpleural effusion with NHL is between 6 to 50% and with HL is 7 to 21%.

Result lymphoma presenting with pleural effusion then developing into thrombosis.

Conclusion not every exudative pleural effusion is tubercular.

P80

P81Kikuchi Fujimoto disease--a case report

Dhamodharan P, Chella Raja C, Chitrakumar.A. Gangadharan V

Govt. Kilpauk Medical College&GTHTM, Chennai, TN , India

Case report: 13 year old female from villupuram district in Tamil Nadu presented with swelling over the left side ofneck -1 month, fever, headache and projectile vomiting - 1 week. On examination she was febrile and anemic.Examination of cardiovascular and respiratory system were normal. There were multiple, mobile, tender, firmlymph nodes over left side of neck each measuring 2 x1.5 cms. X ray and CT of chest-Normal. USG abdomen and CTabdomen-Normal. CT Neck revealed multiple enhancing bulky lymph nodes with central areas of necrosis overboth submandibular, deep cervical, left posterior cervical, left supraclavicular and left retroclavicular areas. MRIBrain revealed features suggestive of raised ICT. CSF analysis suggested chronic inflammatory pathology. Excisionbiopsy of node reported as necrotizing lymphadenitis with immunohistochemistry positive for CD3+, CD43+, CD8+and CD68+ suggesting Kikuchi. After 6 months she developed node on same side and it was also confirmed asKikuchi’s disease by biopsy and immunohistochemistry.

Discussion: Kikuchi-Fujimoto’s disease is a benign self limiting cervical lymphadenitis with fever and otherconstitutional symptoms. It should be differentiated from lymphoma, tuberculosis and SLE which presents withmultisystem and multinodal involvement. It was first described in Japan by Dr Kikuchi in 1972 and independentlyby Y. Fujimoto. The mean age of was between 20-30 yrs and occurs predominantly in young female due tononspecific, hyper immune reaction to a variety of infections, physical, chemical and neoplastic agents.Confirmation is done by histopathological examination of excision biopsy showing expansion of the paracortexwith phagocytic histiocytes and immunohistochemistry showing positive for CD3, MAC 387, CD68, CD43, CD45RO,CD8, CD4,CD11b and CD11c. Treatment involves supportive, NSAIDS and corticosteroids. Since then only 23 caseshave been reported and ours is a very rare and interesting case and hence we are presenting it.

P82IDIOPATHIC CD4 LYMPHOCYTOPENIA

P.ANAND K.RAJARAJAN, S.P.VENGADAKRISHNARAJ, G.ALLWINVIJAY, R.SRIDHAR, O.R.KRISHNARAJASEKHAR,C.CHANDRASEKAR

STANLEY MEDICAL COLLEGE

Introduction

Idiopathic CD4 lymphocytopenia(ICL) is defined by CDC as a clinical condition in patients with depressed numbersof circulating CD4 T lymphocytes (<300 cells/μl or <20% of total T cells) at a minimum of two separate time pointsat least 6 weeks apart, with no laboratory evidence of infection with human HIV-1 or HIV-2, and the absence of anydefined immunodeficiency or therapy associated with depressed levels of CD4 T cells.

Case ReportA 28 Years male admitted with C/o Cough with sputum – 3 months, Breathlessness - 15 days , left sided

chest pain, No other significant positive history. On general examination, he is pallor. With no clubbing, nogeneralised lymphadenopathy, Vitals are stable. Respiratory system examination revealed normal vesicular breathsounds on both sides, with decreased breath sounds on both infrascapular regions.

Investigations : CBC – Hb - 7 .6 g,WBC- 8,700 / cu mm DC - Neutrophils – 84.4% Lymphocytes –13.3 % Mixed - 2.3 % . HIV 1& 2 – non reactive ,HBsAg - negative , HCV - negative,Mantoux – 0mm, Sputum AFB – negative. X-ray revealed bilateral pleural effusion.Pleural Fluid Analysis showed AFB –Positive .ATT was started.

Since the patient condition did not improve despite ATT and Since lymphocyte count is very low, CD4count was done and it came as 186 cells/cu.mm. Patient gradually showed improvement. His CD4 countafter 6 weeks was 205 cells/cu.mm

ICL in an immunocompetent adult is very rare. ICL patients are susceptible for various opportunistic infections.Cryptococcal infections were the most prevalent infections in ICL patients (26.6%), followed by mycobacterialinfections (17%), candidal infections (16.2%), and VZV infections (13.1%). Because of sustained CD4 T lymphocyte

depletion, the lack of serological evidence of HIV infection, and the absence of any immunodeficiency orimmunosuppresive therapy associated with T cell depletion, our patient met the existing criteria for ICL.

ConclusionIn treating patients with tuberculosis who are slow to respond, complete hematological workup may be necessaryto find out conditions like idiopathic lymphocytopenia.

P83TITLE:LONG TERM FOLLOW UP OF A CASE OF PULMONARY ALVEOALAR MICROLITHIASIS (PAM): A CASE REPORTAuthor 1:SHIVALINGASWAMY SALIMATH3rd year Post graduateDepartment of Pulmonary MedicineJSS Medical College Hospital, Mysore

Author 2:DR. JAYARAJ B SProfessor and HeadDepartment of Pulmonary medicineJSS Medical College Hospital, Mysore

Author 3:DR. MAHESH P AProfessorDepartment of Pulmonary medicineJSS Medical College Hospital, MysoreINTRODUCTION:PAM is a rare disease of unknown pathogenesis, characterized by widespread laminated calcospherites in alveolarspaces. PAM is an autosomal recessive disease caused by mutations of SLC34A2 gene, encoding a sodiumphosphate cotransporter. There is a need for long term progression and survival data in India.CASE REPORT:

We present an 8 year follow-up of a 52 year old female with pulmonary alveoalar microlithiasis.Patient presented with exertional dyspnoea and cough in 2006. Chest radiograph had typical “sandstorm

appearance”. HRCT showed diffuse infiltrates and “Black pleura sign”. BAL showed microliths and BAL cytologyshowed multiple calcospherites.COURSE OF DISEASE OVER 8 YEARS:

The progression of various clinical, radiological, spirometric and biochemical parameters are presented.She underwent BAL 6 times in initial 2 years and clinically improved for 6 years. Last two years showed progressivedeterioration in clinical, spirometric and radiologic parameters with corpulmonale.FOLLOW UP:Patientcharacteristics:

2006 2008 2010 2012 2014

Dyspnoea(MMRC grade)

3 1 2 3 3

FVC in litres(%Pred)

1.93(66) 1.50(59.6) 1.43(62.4) 1.20(50.2) 1.05(46)

FEV1 in litres(%Pred)

1.28(59.6) 0.97(45.3) 0.97(50.2) 0.77(38.2) 0.64(34)

FEF25-75 in litres 1.03(36.4) 0.57(20.7) 0.58(22.0) 0.42(16) 0.29(12)

(%Pred)Serum Ca+2

(mg/dl)9.8 9.0 8.8 9.0 9.5

Chest X-Ray(Zones)

4 4 5 6 6

Pulmonary arterysystolic pressure(mmHg)

15 18 30 48 55

Conclusion:Further studies are necessary to identify markers for progression and better treatment modalities to delay theprogression of the disease.

P84Pulmonary Thromboembolism - A Rare Combo!!!Dr.Javid Abdullah1, Prof.Dr.Meenakshi, Dr.Subramanian, Dr.Vishwambhar, Chettinad Health Institute,Kelambakkam, Chennai.Background:Most cases of pulmonary embolism occur as a result of thrombus originating in the lower extremity. Many patientswho develop venous thromboembolism are found to have an inherited risk factor due to abnormal levels of orfunctional abnormalities in coagulation factors.Case Report:34 year old male presented with sudden onset chest pain and breathlessness, family history negative for PTE andDVT. Blood investigations revealed elevated D dimer and aPTT. CT Pulmonary angiography revealed a saddleshaped non enhancing, intraluminal filling defect noted in the bifurcation of main pulmonary artery, extending tosuperior and inferior pulmonary artery branches in both sides. Doppler study showed a thrombus in shortsaphenous vein. Further workup revealed Antithrombin III deficiency -49.1% (normal- 83-128%), lupusanticoagulant 1(screen) -93.2 s (normal- 28-48 s), lupus anticoagulant 2 (confirm)-64.6 s (normal 28-40 s). Ratio(LA1/LA2) - 1.44 (>2 - strong presence, 1.5-2 -moderate presence,1.3-1.5- weak presence, < 1.3 normal).Homocysteine-22µmol/L(normal-3.7-13.9µmol/L) Anticardiolipin Ab-negative, protein C & S - normal. Factor Vleiden assay normal. Thereby establishing a diagnosis of pulmonary thromboembolism with multiple etiologicalfactors

DISCUSSIONHereditary antithrombin deficiency is estimated to occur in about 1 in 2,000 to 3,000 individuals with PTE. Severalstudies have shown a good relation between homocysteinemia and thrombovascular disease. Antiphospholipidantibodies (APLA) have been reported in 2-5% of the general population. Combination of these 3 etiologicalfactors has not been commonly reported.CONCLUSIONCo existence of hyperhomocystinemia, antithrombin deficiency and lupus antibody (APLA) in pulmonarythromboembolism is a rare entity. This case is reported for its rarity.

P85MEDIASTIASTINAL MASS PRESENTING AS THYMIC CARCINOID

Dr.AVINASH R GANDHARE, Dr.S.V.GHORPADE Dr.S.H.MESHRAM, Dr.V.NIRANJANE, Dr.G.MISHRA, Dr.P.GHOLAPGOVERNMENT MEDICAL COLLEGE AND HOSPITAL, NAGPUR

Introduction - Thymic carcinoids are unusual and rare tumors, and prognosis is difficult to predict. We herebyreport a rare case of primary neuroendocrine carcinoma of the thymus which had an aggressive behavior andpatient died within 6 months.

Case Reports- A 45 yrs. old married female farmer was admitted with complaints of breathlessness for 3 months,multiple joints pain for 3 months, generalized weakness for 3 months and retrosternal chest pain for 1 month. X-ray chest showed mass in left hemithorax. Computed tomography scan (CT scan) thorax revealed mass in left

hemithorax which appeared to arise from superior mediastinum. CT scan guided fine needle aspiration cytology(FNAC) from the mediatinal mass revealed small cell neuroendocrine tumors. CT scan guided biopsy showedneuroendocrine carcinoma with possibility of thymic carcinoid. Patient was advised surgical excision for whichpatient was unwilling. Patient was then started on chemotherapy vincristine, doxorubicin and cyclophosphamide.

Discussion- Neuroendocrine neoplasms of the mediastinum form part of a family of tumors characterized bygenotypic, immunophenotypic and functional properties of neuroendocrine differentiation. Such tumors compriselesions derived from; elements within the thymus, paraganglionic nests, misplaced embryonal structures withinthe mediastinum and rarely from aorticopulmonary or aorticosympathetic paraganglia or from ectopic orsupernumerary parathyroid glands.

Neuroendocrine Carcinomas of the thymus may be asymptomatic or have signs and symptoms of rapidly growingmediastinal mass. One third of patients may have endocrine symptoms, Multiple Endocrine Neoplasia (MEN) -type1 syndrome, polyarthropathy, proximal myopathy, peripheral neuropathy, hyperparathyroidism, inappropriateantidiuretic hormone secretion, Eaton-Lambert syndrome, and hypertrophic osteoarthropathy. They are notassociated with myasthenia gravis, hypogammaglobulinemia, or the carcinoid syndrome

Conclusion- Primary neuroendocrine tumors of the thymus are rare aggressive tumors associated with poorsurvival. Surgical resection of the tumor remains the treatment of choice because the experience with adjuvanttherapy has been unsatisfactory.

P86AETIOLOGY OF HEMOPTYSIS IN PATIENTS PRESENTING IN DEPARTMENT OF PULMONARY MEDICINE, MEDICAL

COLLEGE HOSPITAL, THIRUVANANTHAPURAM.

Dr Smitha P.S, Dr Anithakumari .K, Dr Ronald Win , Dr Sanjeev Nair

INTRODUCTION

Hemoptysis is defined as coughing up of blood originating from the lungs or tracheobronchial tree. The materialand amount produced varies from mere blood streaking of expectorated sputum to massive volumes of pure blood.Massive hemoptysis has been variably defined according to the volume ,but Bronchiectasis, pneumonia andmalignancy are the main causes of hemoptysis. The frequency of each disease as a cause of hemoptysis varies indifferent series, according to the geographical areas implies a life threatening process requiring immediateevaluation and treatment.

AIM OF STUDY

To determine the proportion of patients presenting with different aetiologies of hemoptysis in Department ofPulmonary Medicine in Medical College Hospital, Thiruvananthapuram for a period from February 2013 to august2014.

MATERIAL AND METHODOLOGY

Study design-Descriptive study.

Study Period-From February 2013 to August 2015.

Assessment include sputum AFB, Sputum Cytology, Chest X-ray, CT chest, Bronchoscopy.

All patients were advised to do sputum AFB and chest X ray, if diagnosis was uncertain

CT chest and bronchoscopy with tissue diagnosis was done .All patients are assessed for one month after dischargefrom hospital.

RESULTS AND DISCUSSION

Total 265 cases of hemoptysis were analysed. Till now, analysis had shown Post TB bronchiectasis – 26.79%,Pneumonia—20.37%, Bronchiectasis—13.58% Malignancy—13.58%, Smearpositive pulmonary TB—9.43%,Aspergilloma—3.39%, c/c bronchitis --3.37%, ABPA—4%, lung abcess 2% and other causes –3.57%.

Massive hemoptysis was present in 11 patients and main etiology was post TB bronchiectasis.

Bronchial artery embolisation done in 12 patients

Lobectomy was done electively in one patient. There were death of 5 patients while in IP care due to massivehemoptysis.

P87Is inhaled budesonide useful in bronchiectasis?

S K Singaraju1, E P Chelluri2.

1. Resident, Post-graduate department of Pulmonary medicine, Shadan Institute of Medical Sciences &Research Centre, Hyderabad, Andhra Pradesh.Phone number: +918897565555

Email: drsaiskrishna@yahoo.com

2. Head, Post-graduate department of Pulmonary medicine, Shadan Institute of Medical Sciences &Research Centre, Hyderabad, Andhra Pradesh.

Address for the correspondence:ceprasad@hotmail.com

Background. Role of inhaled steroids in bronchiectasis is controversial. None of the previous studies examinedeffect of inhaled corticosteroids on post bronchodilator reversibility in bronchiectatic patients. Effect of inhaledbudesonide 400 mcg/day on ventilatory functions of 23 consecutive bronchiectatic patients was studied.

Subjects and Methods: Bronchiectasis was diagnosed by clinical & imaging criteria. Randomized into two groups.Study group (n=12) inhaled budesonide 400 mcg/day through spacer while Controls (n=11) received placeboinhaler. Both groups received amoxicillin & physiotherapy. Spirometry was performed at 7-day intervals at thesame hour of the day. FEV1, FVC, PEFR, FEF 25-75% and “salbutamol reversibility” were tested as per ATSguidelines. Percent change in FEV1, FVC, PEFR, FEF 25-75% and FEV1 reversibility at 0,7,14, and 21 day wereanalyzed by Student “t” test.

Results:

Study group

Time FEV1 FVC FEV1 “Reversibility”

Day O 1.58+/- 0.67 1.94+/-0.97 8.18+/-7.3

Day 7 1.59+/-0.74 1.94+/-0.80 11.27+/-11.63

Day 14 1.61+/-0.8 2.07+/-0.93 11.79+/-15.48

Day 21 1.66+/-0.76 2.12+/-0.87 6.44+/-4.95

Control group

Day 0 1.28+/-0.48 1.45+/-0.65 5.92+/-8.93

Day 7 1.35+/-0.45 1.63+/-0.65 4.75+/-3.79

Day 14 1.38+/-0.5 1.72+/-0.72 4.82+/-5.90

Day 21 1.48+/-0.46 1.79+/-0.78 3.33+/-5.46

No statistically significant change between study and control groups.

Conclusion:

The present small study, though the results are not statistically significant, shows a trend of improved“reversibility” of FEV1 in the budesonide treated bronchiectatic subjects.

P88Tracheal diverticulum : a rare cause of chronic cough

S D GABHALE1, S JAIN2

, N JOSHI3, S P AGNIHOTRI4

DEPT. OF RESPRATORY DISEASES AND TUBERCULOSIS, INSTITUTE OF RESPIRATORY DISEASES, S.M.S. MEDICALCOLLEGE, JAIPUR, RAJASTHAN

Introduction :

Tracheal diverticulum is a rarely encountered entity, It is an out pouching of tracheal wall progressing as an airfilled paratracheal cyst. Most cases are asymptomatic, however they can act as a reservoir for secretions withsecondary chronic infections of the tracheobrochial tree. We herein report a case of tracheal diverticula thatpresented with chronic cough.

Case report :

A 40 year old female nonsmoker presented with recurrent cough since 1 year. atient had no improvement onantituberculosis treatment. Chest x-ray revealed left lower lobe consolidation, CT chest revealed left lower lobeatelectasis. Fiber optic bronchoscopy showed an opening in left posterior wall of trachea, air bubbles andsecretions were coming from opening. Barrium contrast study of the case showed no oesophageal communication.Diagnosis of tracheal diverticulum was made causing recurrent respiratory infection.

Conclusion :

This malformation is a rare anomaly with two types, the congenital and the acquired one. It must be included intothe differential diagnosis of recurrent respiratory infection.computed tomography scans (with thin section andreconstructed images) seem the proper imaging. Bronchoscopy can also visualize the diverticulum althoughsometimes the connection with trachea can't be detected. Most cases are asymptomatic and need no specialtreatment. A possible danger of repeated respiratory infections and insufficient intubation and/or ventilation mustbe in mind.

P89

A case of systemic sclerosis with atypical chest presentation

Dr. K.NAGA CHAITANYA , Dr. S.V. PRASAD , Dr. T.V. RAJIV

MNR MEDICAL COLLEGE AND HOSPITAL

BACKGROUND – Systemic sclerosis is a relatively uncommon condition with an average annual incidence of 6-12patients per million population. The disease is most prevalent between 30 and 50 years of age with femalepreponderance(7:1).

Systemic sclerosis is characterized by progressive fibrosis of skin and multiple organs. Parenchymal lunginvolvement is very common in these patients , lung fibrosis being the most common pattern of abnormality.

This current case is unique in that a male patient with cavities in the lung is unusual in Systemic sclerosis.

CASE REPORT - A 48-year-old man came to Pulmonary medicine OPD , with the complaints of breathlessness ,cough , haemoptysis, generalised weakness since 6 months. He was diagnosed earlier as a case of Bronchialasthma and later as PTB and was started on ATT since 10 days.

On examination, his skin was smooth, shiny, thick, hard and hidebound with pigmentary alteration of 'salt andpepper' appearance on limbs, and trunk . Hands and fingers appeared tight and digital ischaemia was present(atrophy, ulceration )

Examination of the respiratory system showed restriction of chest movement and reduced expansibility of chestwall on right side. Decreased Vesicular breath sounds and Crepitations are present on right side of chest .After corroborative investigations the positive findings were:TLC 18000cells/mm3. CUE – albumin +. CXR - showedcavities in right lung . Bronchoscopy – showed mucus plug in right intermediate bronchus. BAL –NAD.CT-CHESTshowed cavities in right UL, consolidation with cavities in right LL . Serology was non-reactive (negative ANA,Antitopoisomerase antibody, Anticentromere antibody ). Upper GI endoscopy – Sliding hernia, erosivegastritis.ECG – sinus tachycardia. 2decho – mild PAH.

DISCUSSION -Systemic sclerosis is a systemic and complex collagen vascular disease of unknown etiologyThe AMERICAN COLLEGE OF RHEUMATOLOGY (ACR) criteria for the diagnosis of systemic sclerosis.One major criteria / two or more minor criteria for diagnosis.

Major criterion : Proximal scleroderma Minor : 1.Sclerodactyly

2.Digital pitting scars/loss of substance from the finger pad3.Bibasilar pulmonary fibrosis

Serologic specificity of the disease is the presence of ANA ,directed against cellular nuclear enzymes, like DNAtopoisomerase -1 (anti –Topo 1 ) and RNA polymerase, as well as centromeric proteins (anticentromere Ab) .Antitopoisomerase antibody is positive in 20-70% of cases.

In this case though the serology was negative as he fulfilled one major and two minor criterias , we diagnosed himas a case of Systemic sclerosis.

Pulmonary fibrosis is the most common radiographic finding, present in 20%–65% of patients.The histologicpattern is of usual interstitial pneumonia.

CONCLUSIONIt is an unusual presentation because of its rare occurrence in male and presentation as cavities in lung. This case

highlights the wide variety of presentations in connective tissue disorders and importance of thoroughinvestigation in connective tissue diseases

P90A rare case of haemoptysis with Pulmonary artery thrombosis

Dr Subash Immanuel G , , Dr Richa Gupta, Dr D J Christopher

Christian Medical College, Vellore, Tamil Nadu, India

Hughes Stovin syndrome (HSS) is a rare and life threatening disorder characterized by pulmonary artery aneurysm(PAA) and thrombosis. So far, less than 30 cases have been reported in literature.

We report a case of Hughes Stovin syndrome presented with haemoptysis, pulmonary artery aneurysm andthrombosis.

A 19 year old male presented with complaints of cough, dyspnoea with intermittent haemoptysis of 4 monthsduration. His general and systemic examination was unremarkable. His routine blood examination was normal.Connective tissue disease, vasculitis work up and sputum AFB smear were negative. Radiology revealed normalchest x-ray; however, CT pulmonary angiogram (CTPA) showed pulmonary artery aneurysm with intra muralthrombus in bilateral lobar and segmental pulmonary arteries.

With above investigations, differential diagnosis of Behcet’s disease and Hughes Stovin syndrome wereconsidered. Our patient had no complaints of oral or genital ulcers and Pathergy test was negative. Hisophthalmology examination was normal and HLA B51 was negative which ruled out the possibility of Behcetsdisease. He was diagnosed to have Hughes Stovin syndrome and improved on treatment with Immunosuppressantand corticosteroids.

Hughes Stovin syndrome was first described in 1959 as a combination of deep venous thrombosis, cerebral venoussinus thrombosis and PAA . It is considered to be a variant of Behcets disease. Diagnosis is made on the basis ofclinical history and imaging studies for detection of PAA. Initial management of HSS involves corticosteroids andimmunosuppressive drugs. Anti-coagulants are contraindicated due to risk of life threatening rupture of aneurysm.Surgical resections may be the option in patients with localised aneurysm.

We conclude that in young patients with haemoptysis and normal initial work up, CTPA and Doppler studies shouldbe considered to look for rarer causes like HSS which if left undiagnosed can be potentially life threatening due toaneurysmal rupture.

P91Aortic aneurysm – a rare cause of ortner’s syndrome

DR. JYOTI PATNAIK, DR. H.K.SETHY, DR. T. MOHANTY, DR. G.PANDA, DR.M.R.DASH, DR. S.PRADHAN, DR. B.P.TRILOCHAN, Dr. BIJAYA KUMAR MEHER

Department of pulmonary medicine, scb medical college & hospital,cuttack, Odisha,India

OBJECTIVE: To study the cause of hoarseness of voice in a 60yr old male

METHODS: detailed history, physical examination, routine blood test, chest x-ray, bronchoscopy, HRCT Thorax,echocardiography, CT-angiography

RESULTS: A 60yr old man presented with hoarseness of voice and was found to have left vocal cord paralysis and amedistinal widening on chest X-ray. Fibre optic laryngoscopy & bronchoscopy showed absent movement of leftvocal cord. A HRCT scan of thorax and CT Angio Aortogram revealed fusiform aneurysmal dilatation of the arch ofaorta possibly compressing left recurrent laryngeal nerve.ortner’s syndrome or cardio-vocal syndrome

CONCLUSIONS: Hoarseness of voice is a very common condition andunderlying causes vary from reversible benign causes to life-threatening malignancies. Unilateral recurrentlaryngeal nerve injury is most commonly caused by surgical trauma or a malignant tumor. Ortner’s syndrome is arare disorder characterised by left recurrent laryngeal nerve palsy secondary to a cardiovascular cause. Cardiovocalsyndrome was originally described in 1897 by Nobert Ortner in three patients with severe MS. He explained thathoarseness was caused by compression of the left recurrent laryngeal nerve by the enlarged left atrium. Later ithas been encountered with other mediastinal structures causing mass effect and in many cardiac conditions forexample, congenital heart diseases, mitral valve disorders, ventricular and aortic aneurysms, atrial enlargementand in iatrogenic conditions. Chest radiograph is usually ordered as the first imaging study which can give hints ofthe underlying condition and direct further studies. CT is useful for evaluating the mediastinum and especially theaortopulmonary region.

P92Title: Tracheobronchopathia osteochondroplastica (TO) – only case series from India

Dr. Jebin Roger S, Dr. Prince James, Dr. Richa Gupta, Dr. D.J Christopher

Christian Medical College, Vellore

Introduction: Tracheobronchopathia osteochondroplastica (TO) is a rare benign disease of unknown etiologycharacterized by cartilaginous or bony outgrowths in the tracheobronchial tree. We present first and largest caseseries of 8 cases of TO from India.

Case Presentation: Out of 13,700 bronchoscopies done from year 2004 to 2014 at Christian Medical College ,Vellore , India, we diagnosed 8 cases of TO. Male to Female ratio was 6:2 with a mean age of 48 years (range 29-58 years) at the time of diagnosis. The most common symptoms were cough (100%), dyspnea (50%) andhemoptysis (43%). CT thorax showed multiple beaded calcified nodules in the tracheobronchial tree in 7 cases.Bronchoscopy showed diagnostic typical appearance of multiple irregular hard nodules in trachea, sparing theposterior membranous wall. In 6 cases, bilateral main bronchi were also studded with TO nodules. Bronchoscopicbiopsy of these nodules gives hard gritty feeling of cutting hard structure. Bronchoscopic biopsies showedcalcifications, cartilage and lamellar bone formation in respiratory mucosa. In one patient, TO presented as rightupper lobe endobronchial growth, for which she underwent right upper lobectomy. Out of 8 cases, one patientalso had active TB and received ATT. The rest of the patients were put on symptomatic treatment.

Discussion: Bronchoscopy remains the gold standard for identifying TO with typical findings of multiple irregularnodules in tracheobronchial tree, sparing the posterior wall of trachea. Though the course of disease remainsbenign, some cases may present with airway obstruction, post-obstructive pneumonia, atelectasis, and difficultintubation. The treatment of TO varies from symptomatic management, endobronchial treatments to operativedebulking surgeries depending on the severity of airway obstruction.

Conclusion: TO is a rare benign disease and Bronchoscopy is the most important tool to detect TO. Awareness ofthe condition among physicians is important to identify this rare disorder of the tracheobronchial tree.

P93Bilateral Congenital Cystic Adenomatoid Malformation with Tuberculosis in an adolescent: a rare presentation

DR. J. PATNAIK, DR. H.K. SETHY, DR. T. MOHANTY, DR. G. PANDA, DR. M.R. DASH, DR. S. PRADHAN, DR. BPTRILOCHAN, DR. DIBYA PRAKASH ACHARYA

Dept. of Pulmonary Medicine, SCB Medical College, Cuttack, Odisha.

IntroductionCongenital cystic adenomatoid malformation (CCAM) of the lung is a rare developmental anomaly of tracheo-bronchial tree beyond terminal bronchioles. Incidence 1 in 25,000∼30,000 pregnancies. The lesion is usuallyunilateral. Most cases are diagnosed antenatally or in neonates/infants who present with severe respiratorydistress or pulmonary infections. Occasionally, CCAM remains unrecognized until adolescence or adulthood.Recurrent bacterial infections are frequent feature of CCAM.

Case SummaryA 14 year old female presented with the complains of Fever for 4months low grade, intermittent, with evening riseof temperature, not a/w chills, rigor. Cough for 4months with scanty mucoid expectoration. Chest examinationrevealed diminished breath sounds at left anterior chest. Sputum for AFB- negative. Chest x ray showed non-homogenous opacity over left hemithorax. Patient was started on Anti Tubercular Therapy CAT I DOTS. Sheimproved with ATT. CXR PA View showed multiple cystic lesions; opacities in the previous radiograph had cleared.HRCT Thorax :Left Lung showed multiple large cystic lesions, largest of size 14.4 * 6.6 cm Type I CCAM .Right Lungshowed multiple small cystic lesions largest size 1.2* 1 cm Type2 CCAM.A diagnosis of bilateral CCAM in adolescentsecondarily infected with Tuberculosis was hence made.

DiscussionCCAM is an abnormality characterised by a hamartomatous multicystic mass of pulmonary tissue with an abnormalproliferation of bronchial structures.Type I CCAM most common includes multiple large cysts (>2 cm in diameter)Type II CCAM has multiple small cysts, less than 2 cm in diameter.Type III CCAMs are a solid mass consistingmultiple adenomatoid microcysts, less than 0.5 cm in diameter. Radiograph: Multiple air filled cysts Diagnosticmethod of choice is the HRCT. Lobectomy is the treatment of choice.

Unusual bilateral involvement Left Lung Type1 Right Lung type2 CCAM and Tubercular superadded infection inadolescent makes it a rare presentation.

P94Spontaneous esophagopleural fistula:a rare case report

DR J.PATNAIK,DR HK SETHY,DR T.MOHANTY,DR G PANDA,DR MR DASH,DR S.PRADHAN,DR BP TRILOCHAN

DR JYOTIRMAYA SAHOO.

Dept of Pulmonary medicine,SCB Medical college and hospital ,cuttack,Odisha.

INTRODUCTION:-Esophagorespiratory fistula (ERF) is an uncommon condition despite the anatomical proximity ofthese structures.Malignany of esophagus,lung and mediastinum is recognized as the most common cause.BenignERF is very rare and may be due to trauma and infections.Here we report a rare case of spontaneousesophagopleural fistula.

CASE REPORT:-A 34 year old male was admitted to scb medical college,cuttack,odisha complaining of right sidechest discomfort and regurgitation of food particles during feeding.He has known psychiatric(bipolar ) disordersince last 7years on antipsychotic medications.He had no smoking history.No previous operative history.Nomedical history like diabetes mellitus,hypertension,tuberculosis or hepatitis.On physical examination diminishedbreath sound in right IAA,ISA and lower inter scapular area.Dull note on same area.Rest of the right hemithorax isnormal resonant note and normal breath sound.All routine investigations are WNL.Chest x ray revealed ahomogenous opacity with straight upper boarder in right lower zone.Diagnostic tap was dry.On usg thorax therewas minimal collection in right pleural space.On CT Thorax there was a suspicious connection between esophagusand pleural space.On oral contrast administration the contrast moved to pleural space.On barium swallow study

barium passed into pleural space.On upper GI endoscopy there was fistulous opening in esophagus that connectsto right pleural space.So final diagnosis is Spontaneous esophagopleural fistula.Finally patient was operated(closure of EPF and reconstruction of esophagus ) and patient is doing well now.

Tissue biopsy was taken and it was nontubercular. DISCUSSION:-Spontaneousesophagopleural fistula is a very rare condition.Spontaneous rupture of esophagus occurs due to sudden raise ofitraesophageal pressure .usual complains of patients are retrosternal chest pain and vomiting.On chest x rayreveals as pleural effusion,hydropneumothorax or pneumothorax.CT thorax helps to find any mediastinalinvolvement.Conservative management with ICT drainage of pleural space and finally definite surgery required.

P95A RARE CASE OF LEFT UPPER LOBE LESIONAUTHORS – DR SANJEEV MEHTA, DR SWAPNIL THORVE, DR ANURATI MEHTA, DR KARISHMA BHATIACASE: 28 YEAR ASYMPTOMATIC FEMALE REFERRED FOR LEFT ZONE OPACITY PERSISTENT SINCE 5 YEARS.INVESTIGATIONS: HRCT CHEST REVEALED LARGE, WELL ENCAPSULTED, LEFT UPPER LOBE MASS 7.1 x 4.5 CM WITHECTOPIC CALCIFICATION, INDENTING THE TRACHEA AND SUPERIOR MEDIATINAL STRUCTURES WITHOUTINFILTRATING THEM. FNAC REVEALED LYMPHOID CELLLS. CT GUIDED BIOPSY REVELAED CASTELMAN’S DISEASE.TREATMENT: COMPLETE SURGICAL EXCISION OF THE MASS. UNEVENTFUL RECOVERY. SURGICAL SPECIMENCONFIRMED THE DIAGNOSIS.DISCUSSION: CASTLEMAN’S DISEASE OR ANGIOFOLLICULAR LYMPH NODE HYPERPLASIA IS A RARE DISORDERCHARACTERISED BY BENIGN PROLIFERATION OF LYMPHOID TISSUE (CERTAIN B CELLS).WHILE NOT OFFICIALLY A CANCER, OVERGROWTH OF LYMPOID CELLS RESEMBLES A LYMPHOMA. TWO CLINICALENTITIES HAVE BEEN DESCRIBED, UNICENTRIC (CONFINED TO A SINGLE LYMPH NODE STATION) OR MULTICENTRIC(GENERALISED, WITH MORE AGGRESSIVE CLINICAL COURSE, USUALLY WITH HIV INFECTION). FOURHISTOPATHOLOGICAL SUBTYPES HAVE BEEN DESCRIBED, HYALINE-VASCULAR, PLASMA CELL, PLAMABLASTIC ANDMIXED. PREOP DIAGNOSIS IS DIFFICULT AND FINAL SUBTYING IS USUALY ON THE POST OP SPECIMEN.WHILE RADIATION, STEROIDS, ANTIVIRAL DRUGS, CHEMOTHERAPY AND IMMUNOTHERAPY ARE TREATMENTOPTIONS, THE BEST CURE, IN UNICENTIRIC DISEASE, IS COMPLETE SURGICAL EXCISION.

OUR CASE IS IMPORTANT AS IT HIGHLIGHTS A RARE CONDITION THAT IS OFTEN MISSED OR CONFUSED WITH TBOR LYPHOMA. HIGH INDEX OF SUSPICION AND AGGRESSIVE APPROACH TO MANAGEMENT IS NEEDED.

P96Title: The oxidative stress determined through the levels of antioxidant enzymes and the effect of N-acetylcysteinein aluminium phosphide poisoning.

MANISH GUTCH, AVINASH AGARWAL, ROTO ROBO, NIRDESH JAIN

Department of Internal medicine, King George’s medical university, Lucknow, India

ABSTRACT

Objectives: The primary objective of this study to determine the serum level of antioxidant enzymes and tocorrelate them with outcome in patients of aluminium phosphide (ALP) poisoning and secondly, to evaluate theeffect of N-acetylcysteine (NAC) given along with supportive treatment of ALP poisoning.

Design: We conducted a cohort study in patients of ALP poisoning hospitalized at tertiary care center of North-India. The treatment group and control group were enrolled during the study period of one year from May 2011 toApril 2012.

Interventions: The oxidative stress was evaluated in each subject by estimating the serum levels of the enzymesviz. Catalase, superoxide dismutase (SOD) and Glutathione reductase (GR). The treatment group comprised of thepatients who were given NAC in addition to supportive treatment (magnesium sulphate and vasopressors, ifrequired), while in control group only supportive treatment was instituted. Primary end point of the study was thesurvival of the patients.

Measurements and Results: The baseline catalase and SOD were reduced, however GR level was not reducedrather was increasing with due time, and more so in treatment group. The baseline catalase (p =0.008) and SOD (p<0.01) levels were higher among survivors than to Non-survivors. But, no association of outcome with baseline GRlevels (p =0.064), but the levels on day 1 was associated with outcome (p =0.017).Out of total, 31(67.4%) expiredand 15(32.6%) survived. Survival rate was 45.8% (11/24) in treatment group and 18.2% (4/22) in controls (p =0.045).Among who expired, the mean duration of survival was 2.92±0.40 days in test group and 1.82±0.33 days in control(p=.043).

Conclusions: This study suggests that the baseline level of catalase and SOD have reduced in ALP poisoning, butbaseline GR level has not suppressed, rather is increasing with due time, and more so in treatment group. NAC

along with supportive treatment has improved survival in ALP poisoning

P97Pulmonary arteriovenous malformations with recurrent stroke late diagnosed but well managed!!!

N.D.Gondaliya, R.M.Kshatriya, N.V.Khara, R.P.Paliwal, S.N.Patel.

Dept of Respiratory Medicine, Pramukhswami Medical College, Karamsad 388325,Gujarat.

Introduction: PAVMs is an abnormal communication between the pulmonary artery and vein being congenital inorigin; it may be acquired in several conditions. Approximately 70% cases of PAVMs are associated with HereditaryHemorrhagic Telangiectasia(HHT). Presenting symptoms include dyspnea, easy fatiguability and rarely hemoptysis.Approximately 4% to 12% develop complications like paradoxical embolism and stroke. Contrast enhancedpulmonary angiography (CTPA) is the gold standard test. Treatment of choice is therapeutic embolization and lungsurgery. We report a case here as was managed as chronic obstructive pulmonary disease (COPD) for 5 years andlater diagnosed as PAVMs with stroke.

Case report: A 62 year female patient presented with exertional dyspnea and easy fatiguability for 5 years whichexacerbated since 10 days with inability to speak since 2 days. On examination cyanosis,clubbing and crepitationswere present over right lung. Neurological examination revealed Opercular syndrome (Trigemino-lingio-facio-buccal apraxia). She was on treatment for COPD for 5 years and had cerebrovascular stroke(Left frontal lobe) 3years back. On investigatigating blood report showed hypoxemia and polycythemia. Where as chest X-ray showedright lower zone opacity with CTPA showing complex pulmonary arterio-venous malformations in the right middle,lower and left upper lobe largest being 12.1 mm. CT scan of brain suggested acute infarct in right temporal lobe.Contrast echocardiography showed 'extracardiac right to left shunt'. Finally she was diagnosed as PAVMs withparadoxical brain embolism. Angioembolization was done and anticoagulant therapy started with supportivetreatment and patient is better now.

Conclusion: Uncommon disorder like PAVMs can be misdiagnosed and managed as chronic obstructivepulmoanary disease. So it is worth to investigate in detail in patients with unexplained hypoxia, cyanosis, clubbingand recuurent stroke. For earlier diagnosis of PAVMs and better outcome, emphasis should be placed on amultidisciplinary approach and inclusion in differential diagnosis.

P98

Prospective Study around Etiology of Mediastinal Lymphadenopathy using TBNA in a tertiary care centerA. Prabhu, R. Chawla

Indraprastha Apollo Hospital, New Delhi, India

Objectives:To find diagnostic yield in various etiology of mediastinal lymphadenopathy in a tertiary care center

Method:Following a meticulous,clinical and radiological assessment, bronchoscopic TBNA was performed in allpatients. Other procedures performed were Bronchial Biopsy and BAL.

Result:The most common etiology found in our study was Tuberculosis in 43 patients (41%) followed byGranulomatous Inflammation, mostly Sarcoid, in 31 patients (29.5%). Lowest prevalence was for Lymphoma (foundin 1 patients only) – 1%. There were 7 (6.7%) cases of Malignancy and Fungal in 8 patients (7.6%). Our study couldnot find the final diagnosis in 15 patients (14.3%) due to lack of conclusive evidence.

A sufficient specimen was obtained in 87 out of 105 patients and TBNA could establish a diagnosis in these cases.Overall yield of TBNA was 82.86% and the diagnostic yield of TBNA was 68.57%. Coming to specific yields, highestcame from malignancy and lymphoma (100%) and lowest yield came from necrotizing/AFB (Tubercular etiology)[58.1%]. Granulomatous Inflammation (Sarcoid) diagnosed patients gave a yield of 64.5% while patients diagnosedwith Fungal during TBNA gave a yield of 87.5%.

Conclusion: We recommend that TBNA is a reliable, safe and relatively cheap investigational method with gooddiagnostic accuracy. Especially for endobronchial lesions, it may obviate the need for more invasive surgicalprocedures. We also learnt multiple sampling of nodes, rapid onsite cytology method and optimizing interactionsat every step may prove to be most cost effective measures. EBUS TBNA is not very practical owing to high costespecially in developing country like India. So the novel approach to be recommended is to first performconventional TBNA and refer only inconclusive cases for EBUS procedure.

P99Effect of oral Zileuton in acute asthma – a prospective, randomized, double blinded study.

Shahul Hameed ABOOBACKAR, Rahul MAGAZINE, Bharti CHOGTU

Kasturba medical college, Manipal, Karnataka, India

Objective: 5- Lipoxygenase inhibitors are well established in the management of chronic asthma. However, verylittle is known about their role in acute asthma. Our objective was to study the efficacy of oral Zileuton in acuteasthma.

Methods: We conducted a prospective, randomized, double blinded study whereby 80 patients aged 18 to 65attending the outpatient department or emergency department under Pulmonary Medicine unit of KasturbaMedical College, Manipal with a primary diagnosis of acute asthma were admitted and randomly assigned toreceive either 600 mg of oral Zileuton or placebo at enrolment and again after 12 hours, with twice dailyadministration thereafter in addition to the standard therapy for acute asthma. The peak expiratory flow (PEF) wasmeasured at baseline, at 6 hours, 12 hours, 24 hours and 48 hours following administration of the study drug andthen at discharge. Additionally, PEF was measured between 8 – 10 am during the morning following admission. Theprimary endpoint was the difference in PEF between the Zileuton and placebo groups at the various time pointsfollowing treatment. The secondary endpoint was the need for rescue medications by patients in each group.

Results: Data of all 80 enrolled patients were analysed at the end of the study. It was found that patients receivingZileuton had significantly higher PEF values than patients receiving placebo (p = 0.007). The higher PEF values weresustained over the entire hospital stay. Moreover, the need for rescue medications in the Zileuton group weresignificantly lesser (p = 0.049) in comparison with the placebo group. No adverse effects were reported during thestudy.

Conclusion: Additional administration of Zileuton results in greater improvement in lung functions in acute asthmathan that attained by current standard treatment.

P100Asymptomatic Achalasia cardia presenting with bilateral bronchiectasis

Shahul Hameed ABOOBACKAR, Aswini Kumar MOHAPATRA, Manu Mohan K

Kasturba medical college, Manipal, Karnataka, India

Introduction: Achalasia is a disorder of oesophageal motility characterised by aperistalsis of oesophageal body, andimpaired relaxation of lower oesophageal sphincter. Most cases of Achalasia are symptomatic and usually presentwith dysphagia, nasal regurgitations and heart burns. The oesophageal dysmotility can predispose to repeatedaspirations, resulting in recurrent pneumonias and bronchiectasis. We present a case of asymptomatic achalasiacardia which presented initially as a pulmonary complication. Asymptomatic achalasia presenting with bilateralbronchiectasis is extremely rare.

History and physical examination: A 25-year-old female, presented with chronic expectorative cough andexertional shortness of breath since 10 years with recent aggravation. She had undergone multiple hospitaladmissions for recurrent pneumonias in the past. There was no past history of pulmonary tuberculosis. Generalphysical examination was normal. Respiratory system examination revealed bilateral diffuse coarse crepitations.Examination of other systems did not reveal any abnormality.

Investigations: Routine blood investigations were normal. Chest radiograph showed bilateral bronchiectaticchanges, predominantly over the right mid-zone and left lower zone. Sputum Ziehl-Neelsen staining for acid fastbacilli was negative. High resolution computerised tomography (HRCT) of thorax revealed cystic bronchiectasisinvolving right upper lobe and middle lobe segments, left lingular segments and anterior medial basal segment ofleft lower lobe, along with dilatation of the entire extent of esophagus and smooth narrowing at gastroesophagealjunction. Upper gastrointestinal endoscopy showed inflammatory changes with minimal ulcerations along thelower esophagus. Barium swallow study showed dilated thoracic oesophagus with narrowed gastroesophagealjunction. Oesophageal manometry showed high pressure at the level of lower oesophageal sphincter andconfirmed aperistalsis along the lower esophagus.

Management and outcome: She was offered surgical management (Heller’s myotomy), but she declined and hersymptoms persisted on follow up.

P102

Title : INSULINOMA PRESENTING AS ADULT-ONSET SEIZURE DISORDER

Name: Dr VENKATESH MALALI , Dr SHIVKUMAR B.G , Dr SHASHIKANTH M

Institution: JJM MEDICAL COLLEGE, DAVANGERE.

INTRODUCTION: Once diagnosed with a refractory seizure disorder, patients often receive aggressive andescalating pharmacotherapy. Toxic and metabolic causes of seizures should always be considered as they arepotentially curable, and may be fatal if untreated .We describe a case of insulinoma who presented with recurrentseizures.

METHOD: A 62 year old female presented to ED with H/o of generalised tonic clonic seizures. She was a knownepileptic since one year on multiple anticonvulsants.On enquiry she gave H/o dizziness and excessive sweating prior to each seizure episodes and was mainly inmorning and before meals. Patient claims feeling better after meals. No significant past medical and family historyand denied addiction.O/E -Patient was well built, drowsy, PR=80/min, BP=130/80 mm Hg, bilateral pupil 3-4 mm equally reactive tolight. Systemic examination was normal except drowsiness with no focal neurodeficits. Brain imaging and EEGincluding routine hematological investigations were normal except RBS-38mg/dl. She was started on dextroseinfusion and anticonvulsant. During hospital stay she developed repeated hypoglycemia and seizure episodes. Soshe was further investigated and evaluated for cause of hypoglycemia.

Investigations revealed FBS-30 mg/dl, S.insulin-6.96 uU/ml (normal < 6 uU/mL). Serum C-peptide-2.2ng/ml(normal< 2 ng/mL),HbAlc-<4.CECT Abdomen was done suggestive of 1.5 cm enhancing mass at head-neck junction of

pancreas. So working diagnosis of pancreatic insulinoma with hypoglycaemic seizures was made. She underwentenucleation of the nodule at higher centre and became asymptomatic. Histopathology revealed well differentiatedneuroendocrine tumour.

CONCLUSION: A high index of suspicion for a rare cause like insulinoma is warranted for non diabetic patientspresenting with intractable seizures with hypoglycemia not responding to anticonvulsant treatment, which isamenable to complete cure.

P103Unilateral hyperlucent lung: Common and uncommon causes presenting in the department ofpulmonary medicine at GMC, Patiala, from january 2014 till date .

VIDHU MITTAL , URVINDERPAL SINGH, ADITI, SUNIL KUMAR, MURLI

Department of Pulmonary Medicine, Govt. Medical College, Patiala,Punjab, India

Abstract:

Unilateral hyperlucency is described as darker appearance at one side due to increased X-raytransmission. This radiologic appearance may be due to technical impropriety, chest wall abnormalities andincreased air volume and decreased pulmonary vascularization on that side. In diagnostic approach tounilateral hyperlucency, soft tissues, lung volumes, air trapping existence, pulmonary vessels sizes and lunghilum should be carefully evaluated.

Objectives:

1. To recognize a unilateral hyperlucent lung on chest radiography and computed tomography (CT).

2. To describe the common causes of a unilateral hyperlucent lung on chest radiography and CT and tounderstand the pathophysiology of certain conditions.

3. To list an appropriate differential diagnosis in case of a unilateral hyperlucent lung and to provide atargeted diagnosis when certain associated radiological signs are seen.

P104DIAGNOSIS BY TRANSTHORACIC PERCUTANEOUS FNAC IN PERIPHERAL LUNG LESIONS.

Dr.Keyur Patel, Dr.Nasim Mondal, Dr. Savita Jindal, Dr. Nalin T. Shah, Dr. Kusum V.Shah

Department of Pulmonary Medicine, BJMC, Ahmedabad, Gujarat- India.

INTRODUCTION:

Lung cancer is most commonly diagnosed cancer world wide Transthoracic Percutaneous FNAC of lung is rapid andsafe diagnostic tool.

AIM:

To Assess a role of Transthoracic Percutaneous FNAC and to determine the sensitivity and specificity of FNAC withUSG and CT guided aids in peripheral lung mass.

METHODS AND MATERIALS:

A study of 50 patients, conducted in Aug 2013 – Aug. 2014 in age group of 30-90 years in both the sex. The sampleswere taken by the pathologist with the radiologist. At first, ultrasound was used. If lesion well visualized,aspiration performed otherwise CT was chosen for image guidance.

RESULTS:

The FNAC were positive for malignancy in 27 (54%) cases, hemorrhagic aspiration 10(20%) cases, Suspicious ofmalignancy in 6 (12%) cases, inflammatory infiltrate in 3 (6%) cases, inadequate aspirate in 3 (6%) cases,granulomatous lesion in 1 (2%) cases. Most common malignancy was Adenocarcinoma (44.44%) followed bysquamous cell carcinoma (15%), Non-small cell carcinoma (15%), carcinoma (4%), small cell carcinoma (4%) NonHodkin’s Lymphoma (4%) and poorly differentiated 15% . Prevalence, sensitivity, specificity, positive predictedvalue. Negative predicted value, and Accuracy observed 80%, 82.5%, 100%, 100%, 58.82% and 86% respectively.The details of results will be discussed in study.

CONCLUSION:

Transthoracic FNAC for peripheral lung lesions is a safe and efficient method for cytological diagnosis. It has highSensitivity Specificity, Positive Predicted Value and Negative Predicted Value.

P105Erasmus syndrome associated with broncholithiasis, bronchoesophageal fistula and active pulmonarytuberculosis: A rare case report

Paulo Varghese Akkara, George Albert D’souza, Priya Ramachandran, Uma Devraj,

Department of Pulmonary Medicine, St Johns medical college

Background: Erasmus syndrome describes the association of generalised progressive systemic sclerosis followingexposure to silica with or without silicosis. Silicosis and progressive systemic sclerosis coexisting in the samepatient were published from western and Indian literature. We are reporting a case of 38-year-old female quarryworker who developed silicosis and systemic sclerosis complicated by broncholithiasis, bronchoesophageal fistulaand active pulmonary tuberculosis. To our best of knowledge, this is the first case report of coexistence of Erasmussyndrome with broncholithiasis, bronchoesophageal fistula and active pulmonary tuberculosis

Case Report: A 38-years-old female, quarry worker presented with history of fever, cough, and breathlessness of 3months duration. All her symptoms worsened in the last 2 weeks and developed cough on swallowing.Examination findings revealed thickening of skin and microstomia suggestive of scleroderma. Signs s/o right sidedlung fibrosis was also present. Her sputum was positive for acid fast bacilli (AFB). RA factor was negative and ANAwas positive. Skin biopsy consistent with scleroderma. CECT showed multiple calcific lymph nodes with fibroticchanges, centrilobular nodules with tree in bud pattern along with reticular opacities consistent with ILD.Bronchoscopy showed distorted bronchial anatomy and multiple broncholiths and fistulous opening. Barium studyshowed the presence of bronchoesophageal fistulas. The patient was started on anti-tubercular therapy along withmanagement of scleroderma and oral feeds through nasogastric tube as patient refused any further invasivemanagement.

Conclusion: This is the first case report of coexistence of Erasmus syndrome with broncholithiasis,bronchoesophageal fistula and active pulmonary tuberculosis

P106TITLE- To Assess the Knowledge of RNTCP in Post Graduate Students

AUTHOR(S) –Dr Aparna Iyer, Dr Bhumika Madhav , Dr Girija Nair, Dr Abhay Uppe, Dr Jayalakshmi T.K, Dr LavinaMirchandani, Dr Mugdha Bhide

INSTITUTION-Dr D.Y.Patil Hospital and Research Centre, Sector 5 , Nerul, Navi Mumbai - 400706. Maharashtra .

Background-Causes of MDR/XDR Tuberculosis are improper regimen, inadequate treatment and Default. RNTCPhas protocol on evidence based regimens which intend to cope with these difficulties and ensure propermanagement.Awareness regarding the need for doctor to imply the RNTCP protocol needs to be ensured forsuccess of the programme. PG students are the future of a country's medical care system; hence awareness shouldbe created at an early stage.

Aim- Evaluation of sensitisation and awareness regarding RNTCP protocol among PG students.

Method-PG students who attended the RNTCP sensitisation programme were subjected to a set of questionnaireto assess their knowledge.

Result-Following were the most common answers.

Awareness in Students PercentageAware of RNTCP 100%Source- Study Course/Sensitisation /Televisionadvertisement

60%/30%/10%

RNTCP Categories 50%Category III was scraped off 36%Category IV/V existed 40%Category1 Regimen 70%Category2 Regimen 46%Definition of MDR Tuberculosis 66%Definition of XDR Tuberculosis 46%Diagnosis of MDR Tuberculosis 55%Diagnosis of XDR Tuberculosis 46%Persistent cough> 2 weeks for AFB examination 26%HIV- TB National Programme 16%Dots Principle:-Common Answer-Early Detection, Prevents Relapse, Free of Cost

Rare Answer-Ensures compliance

HIV-TB Co infection- Common Answer- Anti Koch Treatment should be started 2 weeks prior to antiretroviralTreatment

Awareness Score Card –100% students said they benefited from the sensitization programme.

Conclusion- Regular Intradepartmental RNTCP sensitisation programme will create better awareness among PGstudents about the RNTCP protocols, hence reducing the rate of MDR / XDR tuberculosis.

P107Clinical Audit of a Community Respiratory Centre in Bangladesh

Kamrun Nahar, GM Monsur HABIB,

President, Primary Care Respiratory Group, Khulna, Bangladesh

A clear shifting of respiratory diseases from communicable to non-communicable (NCD) sector is observed duringlast decade in the developing countries of South East Asia. Asthma, COPD, Allergic Rhinitis, Bronchiectasis etc areimposing huge burden on primary care health service in Bangladesh where these respiratory NCDs are wellmanaged. Aim of this study is to examine the power of primary care respiratory service by analyzing a clinical auditof a CRC in Bangladesh.

Method: We have selected one of the 15 CRCs in the southern part of Bangladesh under the GARD-WHOrecognized project “Better Breathing Bangladesh”. We analyzed clinical audit report of CRC to examine the powerof service for improvement of respiratory NCDs. Study period was from 19 September 2013 to 19 September 2014.

Result: A total of 4366 patient was registered and all the medical records were saved in software “Doctors Guide”in the CRC. The distribution of disease was: Asthma 2736, Allergic Rhinitis 263, High probability of Asthma 335(symptom based diagnosis, not confirmed reversible airway obstruction due to age i.e. under-7 children), transientBHR 108, UACS 45, COPD 499, bronchiectasis 17, Chronic Bronchitis 13 and others 350. Co-morbidities are alsorecorded in the audit among them, GERD, AR, ACOS, Pregnancy, Rheumatoid Arthritis, visual, hearing and cognitiveimpairment are also recorded to set up the target of care for the coming year in the centre.

Conclusion: Respiratory NCDs are common in South East Asia and its care need to invest all the efforts to primarycare rather than secondary or tertiary care health service. Primary care respiratory services should be updated andempowered for the better service through continuous clinical audit and developing appropriate Clinical PracticeGuidelines (CPG).

P108RARE CASE OF ALVEOLAR MICROLITHIASIS

R A S KUSHWAHA, RAJIV GARG, SANTOSH KUMAR, S K VERMA, ASHWINI KUMAR MISHRA, NEHA KAPOOR.Pulmonary alveolar microlithiasis (PAM) is an uncommon chronic disease characterized by calcifications withinthe alveoli and a paucity of symptoms in contrast to the imaging findings. It occurs sporadically and it isregarded as an autosomal recessive lung disease. A 21 years old male, Non Smoker, presented to us with chiefcomplaints of non progressive exertional breathlesness since childhood. He had no other significant history andno abnormality was detected on physical examination. Chest X Ray PA view showed bilateral diffuse nodularshadows more on lower lung fields. Spirometry was suggestive of restrictive lung disease. CT Thorax showedbilateral multiple fine nodular lesions with basal predominance, intra and interlobular septal thickening in bothlung fields. Foci of calcification noted in both lung fields, pericardium and mediastinal pleura. There was clinico-radiological dissociation as the patient was quite asymptomatic despite significant radiological findings. AHRUSG of the scrotum was done which revealed calcification of the testes. Hence,a provisional diagnosis ofpulmonary alveolar microlithiasis was made. Pulmonary alveolar microlithiasis (PAM) is a rare disease ofunknown etiology characterized by the widespread intra-alveolar deposition of laminated calcispherites in thelung. Most patients are between the ages 30 to 50 years at the time of diagnosis. It is often diagnosedincidentally following a chest radiograph. The aetiology and pathogenesis are obscure. Technitium 99 scan isdiagnostic. Most patients remain symptom-free for many years despite extensive radiological changes. There isa striking contrast between the paucity of signs and symptoms and the marked radiographic features. Patientseventually develop dyspnoea on exertion that limits their physical activity. Eventually respiratory failure andcorpulmonale supervene. Survival of 10-20 years is characteristic. So far no reversible treatment of this disorderis known. We report this rare and interesting disorder in an asymptomatic young adult.

P109Acute onset rapidly progressive multisystem Granulomatosis with polyangiitis(Wegener’s Granulomatosis)requiring plasmaphersis

JAIN R.S., MATHUR R.S., KADAM S.J.

Abstract

Granulomatosis with polyangiitis (Wegener’s Granulomatosis) is a rare idiopathic autoimmune multisystemvasculitis characterised by necrotising granulomatous inflammation and pauci-immune vasculitis involving smalland medium size blood vessels.

Here we present a case of a 21 year old male who had a 4 day history of cough, fever and haemoptysis followed byepistaxis. Granulomatosis with polyangiitis was diagnosed by CT guided lung biopsy and p-anca being positive.Patient had a rapid progressive involvement of renal system in spite of giving pulse cyclophosphamide and oralsteroids. Renal biopsy showed focal necrotising glomerulonephritis with crescents. Patient required plasmaphersisto which he responded.

P110A CASE REPORT OF CONGENITAL PULMONARY AIRWAY MALFORMATION

DR NALINI GHANATE, DR.A.SATHYA PRASAD, DR.PRASHANTHY, DR.VIJAY, DR.SUBBA RAOMAMATA MEDICAL COLLEGE AND HOSPITAL, KHAMMAM

Introduction: Congenital pulmonary airway malformation (CPAM), previously known as congenital cysticadenomatoid malformation (CCAM), is a rare developmental anomaly of the lower respiratory tract with areported incidence between 1:25,000 and 1:35,000.It is a multi-cystic mass of segmental lung tissue with abnormalbronchial proliferation and is considered part of the spectrum of bronchopulmonary foregut malformations. Wereport a case of CPAM in a 6year old child with recurrent infections.

Case report: A 6-year-old boy born of secondary consanguineous marriage presented with high grade fever andcough with expectoration of 15 days duration. Past history revealed admission in NICU at birth for respiratorydistress and similar complaints at the age of four. Physical examination revealed decreased breath sounds and endinspiratory crackles in right upper part of chest. Finger clubbing was absent. Laboratory investigations showedanemia and neutrophilic leukocytosis. Mantoux test was negative. A chest radiograph showed multiple cysticlesions in the right upper lobe. Computed tomography (CT) showed organized multiple cystic changes withsurrounding consolidation in the right upper lobe. He was treated with antibiotics and referred to pediatricsurgeon. Surgical resection was done and biopsy revealed congenital pulmonary airway malformation.

Conclusion: Early recognition and surgical intervention of CPAM is essential in view of complications like recurrentinfections and bronchogenic carcinoma. It is usually diagnosed in fetal or neonatal life. Serial ultrasonographicevaluation, fetal lung mass size, and fetal echocardiography are needed for management of antenatally detectedcases .We report this case for its rarity.

P112Primary pulmonary hypoplasia masquerading as cystic bronchiectasis in an adult.

K.V.V. Vijaya kumar, K. Preethi, Ch.R.N. Bhushan Rao, K.Venkataramana,

Government Hospital for Chest & Communicable diseases (GHCCD) , Andhra Medical College,Visakhapatnam,AP,India.

Introduction : Primary pulmonary hypoplasia is an intrinsic defect in the process of lung developmentwith an incidence of 1-2 cases for 12000 live births. Congenital anomalies are increasingly diagnosedin the adulthood as they mimic other thoracic pathology or remain asymptomatic in the childhood.We report a case of right sided primary pulmonary hypoplasia masquerading as cystic bronchiectasis.

Case report : A 30 year old nonsmoker male patient presented with complaints of cough ,expectoration which is more on left lateral position , shortness of breath and right sided chest pain of1 month duration. He had similar complaints since 16 years and was being treated under theprovisional diagnosis of right total lung cystic bronchiectasis of congenital etiology. Chest examinationrevealed loss of lung volume with diminished breath sounds and coarse crepitations on right side.Chest radiograph showed cystic changes and ipsilateral mediastinal shift on right side with

compensatory hyperinflation on left side. Spirometry showed severe obstructive and severerestrictive abnormality. HRCT chest showed multiple thin and thick walled intercommunicating cysticareas connected to lobar bronchi which had decreased calibre on the right side. 2D ECHO showedsitus solitus with dextro position of heart. Bronchoscopy revealed multiple blind pouches at thedistal end of right main bronchus with narrowing of lumen of right lobar bronchi. CTPA showed smallcalibre of right main pulmonary artery (16mm) , lobar and segmental arteries than left side.

Conclusion : Prognosis depends on integrity of remaining lung and presence of associated congenitalmalformations. Pulmonary hypoplasia should be kept in mind as a differential diagnosis in cases ofcongenital cystic brochiectasis.

P113

Myth and Truth of Patient Satisfaction Surveys in Teaching hospital

AP KANSAL, Kiran N, Nancy GARG, Kamal Deep, Sudesh Kumari, Varinder SINGH Bamrah

Department Of Chest & TB, GMC, Patiala, Punjab

Introduction: The primary goal of hospital is to provide best possible health care to patients. Where it is the rightof every patient to demand best possible care, it is the duty of every staff member of the hospital to deliveroptimum efforts to the entire satisfaction of the patient and its assessment will give us an opportunity to findloopholes in our services and future ratification.Measuring and reporting of impartial patient satisfaction survey ismajor issue .

Method & Materials:The patients admitted over year were randomly selected in three groups,one group wasinterviewed by health professional or hospital staff, one by volunteers, and third was by patient satisfactionquestionnaire. Patient satisfaction is assessed regarding the outpatient department services, waiting time,facilities, and perception about the performance of staff, appointment system, behavior and knowledge of staff,cleanliness and any other suggestions of patients.

Observations Out of 3342 patients admitted in year in department, 2978 agreed for survey and average scores in

three groups are shown in graph.

It is seen survey becomes partial when hospital staff interviews, while similar results are observed withquestionnaire or when third person like independent body or volunteers are used to assess.

Conclusion: Patient satisfaction survey in country like India with limited literacy is best done with help ofvolunteers or independent body which make it less partial and more realistic

P114Right lower zone opacity on chest Xray: Rule out eventration of diaphragm

AP KANSAL, Don Gregory MASCARENHAS, Prabhleen KAUR, Shiyas MOHAMMED, Nancy GARG, Anand KumarBANSAL

Department of Chest & TB, GMC, Patiala, Punjab

Introduction: Eventration of diaphragm is characterised by elevation of right or left leaf of diaphragm abnormallyhigh into the chest. Usually its congenital, rarely can be acquired. Left side eventration is more common than rightsided.Asymptomatic cases are managed conservatively. We report three cases of right lower zone opacities onchest Xray(CXR), which eventually proved to b cases of eventration of diaphragm.

Case series:

Case1: 80 year old non-smoker male presented to us with dry cough for two weeks, right sided chest pain for3days.there was no h/o ATT or trauma in the past.GPE was unremarkable. On chest examination, trachea wascentral. Chest movements were reduced on right ISA, IAA,IMA. Breath sounds as well as Vocal Fremitus/VocalResonance were reduced in corresponding areas.CXR showed RLZ opacity. Right lateral Xray showed raised righthemidiaphragm. Lab investigations & ECG were normal. Fluoroscopy showed reduced movement of righthemidiaphragm .sniff test showed no paradoxical movement. CECT chest proved it to b a case of eventration.

Case 2: 65 year old female presented to us with generalised weakness & exertional dyspnoea. GPE wasunremarkable. On chest examination, trachea was central. Chest movements were reduced on right ISA, IAA,IMA.Breath sounds as well as Vocal Fremitus/Vocal Resonance were reduced in corresponding areas.CXR showed RLZ

opacity. Right lateral Xray showed raised posterior end of right hemidiaphragm. Fluoroscopy, sniff test & CECTchest proved it to b a case of eventration

P115Title : Genetic Dissection of Birt Hogg Dube' syndrome in an Indian family

Authors: Anindita Ray1, Suman Paul2, Susmita Kundu2, Bidyut Roy1, *

Address: 1Human genetics Unit, Indian Statistical Institute, 203 B.T. Road, Kolkata 700108

2 R. G Kar Medical College & Hospital, Kolkata - 700004

*corresponding author, Bidyut Roy, email:broy@isical.ac.in1Anindita Ray,anindita.2486@gmail.com

Introduction and Objectives: Birt Hogg Dube' syndrome (BHDS,MIM 135150) is a rare genetic disorder whichfollows autosomal dominant mode of inheritance with incomplete penetrance. BHDS may predispose to three typeof manifestations - kidney neoplasms, cutaneous fibrofolliculomas and/or lung cysts or pneumothorax,. It is amonogenic disorder, mapped to a gene encoding a 579 amino acid protein – Folliculin (FLCN) at chromosome17p11.2. We encountered a family, in Kolkata, with spontaneous pneumothorax and lung cysts in two members ofthe family but absence of skin lesions and renal tumors. Genetic studies were performed in the 8 individuals of a 3generation family from Kolkata, India.

Methods: Genomic DNA was isolated from venous blood from all 8 individuals of the family. Bidirectional DNAsequencing of all 14 exons of FLCN gene was done to identify mutations. Also high-resolution CT scan wasperformed in 4 individuals (two of them with pneumothorax and two phenotypically normal individuals) of thefamily.

Results: Genetic analysis revealed presence of a heterozygous “C nucleotide” deletion in the hypermutable poly-cytosine (poly-C) tract in exon 11 leading to a possible truncated protein. This mutation was found in two affectedmembers along with 4 other members with no lung or renal complications in the family. CT scan for thephenotypically normal member (age: 28yrs) of the family but having this mutation, revealed presence ofparacardiac lung cysts without any symptoms of BHD. We also checked for this mutation in 14 healthy unrelatedcontrol individuals but none of these controls carried this mutation.

Conclusion: Our results confirmed presence of deletion mutation in poly C8 tract at exon 11 which is a mutationalhot-spot for patients with BHDS. This study gives the first genomic insight in an Indian family with BHDS,correlating the mutation hotspot with radiological findings.

P116Thymomic myasthenia gravis with solely bul bar invol vement- a rare case report.S.harikrishnan, A.sundararaj aperumal, A.mahilmaran, D.ranganathan.,Institute of thoracic medicine, madras medical college, Chennai, Tamilnadu, Indi a.

Introduction:Overall incidence of thymoma is approximately 0.15/10,0000/yr. Thymoma is usually a rare begin tumor fromanteri or mediastinum. About 1/3rd of cases were di gnosed during myastheni a evaluation.1/3rd duringasymptomatic mass evaluation,1/3rd as obstructi ve features.Myasthenia gravis is the common paraneoplasticsyndrome associated with thymoma.Ocular weakness is most typical usual present ation with or without limbinvol vement,while early or isolat edoropharnygeal or limb weakness is less common.

Case report :

40 yr old male manual labour, evaluated in otol aryngol ogy for dysarthria for past 3 months,reffered topulmonol ogy for abnormal chest X-ray fi ndi ng- medi astinal wideni ng.patient had nasal speech and gavehistory of recurrent nasal regurgitation,occasional dysphagia and dry cough with no ocular or limb weaknesssymptoms. Necessary investigations were done.CECT chest confi rmed anterior medi astinal mass.CT gui dedFNAC was done- reported as thymoma with metaplastic squamous cells.Neurophysician opi nion obtained -reported as decremental response in repeated nerve stimulation test which confi rmed Myastheni agravis.Patient referred to surgery with consent. Cardiothoracic surgeonstaged the tumor as stage-I thymoma during surgery . Histopathol ogical examinati on of resected tumour showstype-B2 thymoma(WHO classification) without evi dence of malignancy.

Conclusion:Thymoma is a rar e tumor but its association with myasthenia gravis is well reported. Main stay oftreatment of thymoma is surgical removal.if it is associated with myasthenia gravis surgery should be electivewith adequate preoperative assessment such as avoidance of immunosuppressive drugs, adequate respiratoryfunction, in which FVC > 2 liter is mandatory or else plasmapheresis/IVIg shoul d be carried out. We report endthis case because despite of being a manual laborer by occupation patient had a rare presentation of only bulbarinvolvement without ocular and limb muscular involvement.

P117

P118Pediatric mucoepidermoid carcinoma

DR. MEHTA N, Dr. SHETH V, DR.RAMI K, DR.GHANCHI F,

DR.CHATTERJEE I

Shri M.P.Shah Government medical college, Jamnagar, India

8 year old male child was referred to chest medicine department for recurrent respiratory tract infectionsfor 2 year needing frequent treatment with antibiotics and decongestives. He had also been given short courseAnti TB treatment for the same complaints.

On Examination: At time of consultation He was afebrile, had quite breathing, but was pale andunderweight and had no chest symptoms .Auscultation revealed less aerated right lower chest. There was neitherdigital clubbing nor any chest deformity. Other systemic examination was unremarkable. Except 10 gm/dl Hb hishematological, microbiological and biochemical reports were normal. His Chest X ray(PA view) [Figure 1] showedwell outlined homogenous right lower zone opacity obliterating right dome and right cardiac border with sparedright costophrenic angle. Similar opacity with varying size was present in the previous Chest X rays. He wassuspected to have right intermediate bronchus occluding pathology with collapse of middle lobe and lower lobeand recurrent post obstruction infection. FOB(fiberoptic broncho scopy) revealed intermediate bronchusoccluding, smooth surfaced tumor, that on CT scan was found infiltrating adjoining lung parenchyma. FOB guidedbiopsy was negative for carcinoma and carcinoid. He was advised surgical treatment and underwent bilobectomy.The tumor turned out to be Mucoepidermoid Carcinoma. Post operatively he has been asymptomatic and doingwell after 9 months.

Conclusion: Recurrent RTIs with variable response to anti infective measures and iso-positioned chestopacity is an alarming state of bronchus occluding pathology and endoscopic examination clubbed with CTscan are irreplaceable definitive diagnostic tools, directing further timely management.

P119Pneumonic Carcinoma

DR. SHETH V, DR.RAMI K, DR.UDACHANKER G, DR.GHANCHI F, DR CHATTERJEE I

Shri M.P.Shah Government Medical College, Jamnagar, India

60 year old lady was referred to chest medicine department for recurrent intermittent cough, trivial hemoptysisand transient spells of fever for 7 years.

On Examination: On evaluation she reported to have mucoid expectoration and feeling short of breath on briskwalk for last one year. At time examination her resting pulse, respiratory rate, body temperature and bloodpressure were normal. She had audible crepitation on left lung field. She did not have digital clubbing or enlargedlymphnodes. Her sputum microbiology and cytology reports were inconclusive while hematological, biochemicaland urine analysis were normal. HIV, ANA, CEA were negative. Her chest X-rays(PA view) (Figure 1) showedprogressive multicentric pneumonic shadows left lung in right middle zone and left mid zone lower zone. Herbreast examination and abdominal sonology were normal. She was suspected to have Broncho Alveolar Carcinoma(BAC) with remote possibility of immunogenic inflammatory pneumonia and was further evaluated by HRCT chestand FOB(fiberoptic bronchoscopy) At bronchoscopy frothy secretion was found oozing from left bronchi and rightupper lobe bronchus. However BAL, and transbronchial biopsy from left lower lobe were non diagnostic. Forfurther confirmation Trans thoracic lung biopsy from left upper lobe was carried out. Histopathologicalexamination of biopsy sample confirmed BAC.

Conclusion:

Slowly progressive multicentric pneumonic shadows with recurrent chest symptoms and variable response to anti-infectives is a suspect scenario of BAC especially in non smokers. High index of suspicion and timely furtherevaluation with interventional investigations can lead to specific diagnosis.

Figure 1: Chest X rays(PA view)showed progressive multicentric shadow

P120A rare case report on pulmonary langerhan’s cell histiocytosis or histiocytosis x

DR.ADITYA REDDY. VANGALA, Prof. Pradyut waghray**, Dr.A.N.V.Koteswara rao**, Dr.v.veena**, Dr. Chetan**,Dr. Sowmya **, Dr. Harish **, Dr. Rikin**, Dr. Krishna chaitanya**.prof. k.p.a.chandrashekhar #

prof. ramakrishna reddy gaddam^

** dept of pulmonary medicine,s.v.s.medical college, mahabubnagar,a.p # dept of pathology, s.v.s.medical college, mahabubnagar,a.p ^ dept of radiology, s.v.s.medical college, mahabubnagar,a.p

We report a case of pulmonary langerhans cell histiocytosis in a 57 yr old male chronic smoker presented with 1month h/o productive cough,chest discomfort ,joint pains & dyspnea gr-3. And he reported coughing up a fewmouthfuls of blood over the previous 10-15 days. Chest radiography revealed cystic changes and nodules in the midand lower zones with infiltrations. BAL,Endobronchial biopsy unremarkable. Trucut lung biopsy proved.

P12118 F-FDG PET in Benign Pulmonary Diseases

KETAKI UTPAT, MAKARESH YADAV, VINAYA KARKHANIS, SANDIP BASU, JYOTSNA M JOSHI

Department of Pulmonary Medicine, T.N.M.C.& B.Y.L. Nair Hospital, Mumbai

Objective18 F-Fluorodeoxyglucose (FDG)-positron emission tomography (PET) is emerging as an important non-invasiveinvestigation in benign conditions. We studied its utility in the diagnosis and monitoring of various benignpulmonary diseases.

Materials and methodsAn observational study was conducted on 47 consecutive patients with benign lung diseases.FDG PET scan wasperformed at baseline and repeated after therapy in necessary cases. The findings of FDG scan were correlatedwith clinical, histopathological and radiological findings.

Results

47 patients of benign pulmonary diseases were included in the study. Pulmonary tuberculosis(16), tuberculousmediastinal lymphadenopathy (5),sarcoidosis (9)- type 1(1), type 2(3) and type 3(5), IIPs (9)-IPF (5) and NSIP (4), CTDrelated ILD (1), alveolar proteinosis (1), silicotuberculosis (2), tropical pulmonary eosinophilia (2), pleural hydatid disease(1), diffuse panbronchiolitis (DPB (1). All patients showed increased FDG uptake in areas showing lesion on HRCT.Additional uptake was noted in 2 patients. Repeat FDG scan after treatment showed improvement in all patients which

was consistent with clinico radiologic and/or spirometry findings.Findings of FDG PET scan in patients of pulmonarytuberculosis matched well with microbiological findings in all but 2 patients. 4 patients with mediastinallymphadenopathy showed favourable response on FDG PET on antituberculous therapy. All ILD patients had bilaterallow grade FDG uptake. Unusual intense FDG uptake was seen in 2 cases in areas of honeycombing. Comparison of FDG-PET scans with clinic-radiological correlation in silicosis, DPB and hydatidosis showed consistent findings at baseline andafter therapy.

Conclusion

FDG-PET scan can be used as an important adjunct non invasive investigation in diagnosing and monitoring ofvarious non-malignant lung conditions by assessing metabolic disease activity along with microbiology andcomputed tomography.

P122Traumatic Diaphragmatic Hernia

Dr.Rajeshwari, Dr.K.RameshKumar I/C Professor Department of Pulmonary MedicineGovt. General and Chest Hospital, Hyderabad

OBJECTIVES: The estimated rate of occurrence of congenital diaphragmatic hernia varies from 1:2000 to 1:4000live births. Though thousands of such cases are reported during infancy, few reports describe adult patientsdiagnosed with Bochdalek hernia. Usually, these hernias become evident during the neonatal period, throughsymptoms and signs of respiratory distress. However the most frequent symptoms found in adult patients areslight respiratory and digestive symptoms. It is also possible for these hernias to be asymptomatic. Here we reporta case of mild dyspnea within a traumatic posterolateral diaphragmatic hernia. Evaluation of 50 years old malewith one month history of shortness of breath without any previous respiratory complaints.

METHODS: A 50-year-old male patient was admitted to our department with a one month history of slightdyspnea. The discomfort was greatly obvious after heavy physical work, but could be alleviated by taking a rest. hedenied having other symptoms such as chest pain, abdominal pain, dysphagia, vomiting, and dyspepsia. There washistory of penetrating trauma and surgery. Upon physical examination we inspected nothing characteristic exceptthe remarkable decrease of breathing sounds and increased bowel sounds in the left hemithorax. Computedtomography(CT) Chest showed herniation of stomach, splenic flexure and peritoneal fat in left hemithorax. Defectof about 65 cm was seen in the left diaphragm

RESULTS: Sputum for gram stain, culture and sensitivity and sputum for AFB: No growth found. Blood group: “o”positive. Ultrasound Abdomen Nothing abnormality detected. HIV: Non reactive. Ultrasound chest radio opacitywhich seen in radiograph is not appreciated on ultra sound. PFT moderate restriction. No significantbrochodilation.

CONCLUSION: For Bochdalek hernias, correct diagnosis and early treatment is significant to avoid the occurrenceof serious complications.

P123Familial Spontaneous pneumothorax and lung cysts in an Indian family associated with Folliculin gene mutation.

AUTHORS: S. PAUL, A. RAY, B. ROY.

INSTITUTION: R.G Kar Medical College, Kolkata- 700004, India; Indian Statistical Institute , 203 ,Barrackpore trunkroad ,Kolkata – 700108; Indian Statistical Institute , 203, Barrackpore trunk road, Kolkata – 700108.

Approximately 10% patients of spontaneous pneumothorax have positive family history. Birt–Hogg–Dubesyndrome (BHD) is one of the cause of familial pneumothorax. BHD syndrome is associated with hamartomas of

skin, renal cancer and spontaneous pneumothorax. However there have been reports of isolated spontaneouspneumothorax and lung cysts in patients of BHD syndrome in the absence of other manifestations . Mutation inFolliculin gene (FLCN) on chromosome 17 has been reported to cause BHD syndrome.

A 32 year old non-smoker female presented with left sided spontaneous pneumothorax . Her sister hadpreviously suffered from recurrent pneumothorax (twice). High Resolution CT (HRCT) scan of chest of both thesisters revealed multiple lung cysts. We decided to evaluate these patients of familial pneumothorax and identifyany genetic basis for their disease.

After getting informed consent , genetic study of the FLCN gene was performed in 7 family members. Wesubsequently screened willing family members by HRCT scan of chest for any lung abnormality. One of the siblingof the index patient did not wish to participate in the study.

Physical examination and abdominal CT scan was done to rule out any skin and renal involvement. Geneticsequencing revealed Cytosine - deletion mutation in hypermutable region of exon 11 of FLCN gene in the indexcase, her 3 siblings, her mother and her son. HRCT scan of the patient’s brother showed lung cysts whereas her sonhad normal lungs.

For cystic lung disease with an undetermined etiology, or familial pneumothorax, it is necessary to consider thepossibility of BHD syndrome. Pulmonologists should be aware that BHD syndrome can occur as an isolatedphenotype with pulmonary involvement.

P124

A rare case report of churg-strauss syndrome and loefflers syndrome in the same patient

Dr.J.SOWMYA , Prof.Pradyut waghray, Dr.A.V.N.Koteswar Rao, Dr.K.Surender Reddy , Dr.Venkateswara reddy T,Dr.Veena, Dr.Harish, Dr.Chetan, Dr.Aditya, Dr.Krishna Chaitanya, Dr.RikinDept of Pulmonary Medicine, SVS medical college, Mahbubnagar,TS

BACK GROUNDChurg-strauss syndrome is a systemic disorder characterized by asthma, transient pulmonary infiltrates, hypereosinophilia and small vessel vasulitis.It is also called “allergic angitis and granulomatosis or eosinophilicgranulomatosis”. It may involve multiple organ systems including lungs, heart, skin, GIT, nervous systemLoefflers syndrome is characterized by migrating lung infiltrates and by eosinophilia.Diagnosis is based on theradiographic picture and eosinophilia.it is most likely an allergic reaction in the lung to foreign antigen mainlyparasites.

CASE SCENARIOA 40 yr old male patient came to the OPD with the complaints of cough with sputum, SOB ,fever since 3 months,pain abdomen since 1 month, headache since 15 days. On general examination skin lesions were seen. Chest x rayPA view showed bilateral migratory pulmonary infiltrtates. CBP showed increased WBC count with eosinophilicpredominance of 64%, AEC,IgE were elevated. Stool for ova and cyst showed large number of stongyloides ,giardia lambia larvae. Sputum and BAL for cytology showed increased number of eosinophils .Skin biopsy showedeosinophilic predominant small vessel vasculitis with granulomas. P-ANCA is elevated. Patient responded well withcorticosteroids, albendazole and Diethyl carbamazine.

P124LAM PRESENTING AS PNEUMOTHORAX COMPLICATED BY ACINETOBACTER SPECIES - A RARE CASE REPORTAUTHOR NAME-SWAPNIL CHAUDHARIGUIDED BY- BABAJI GHEWADEABSTRACT-

18 year old female presented with complaints of Breathlessness & Cough with mucoid expectoration – 3 monthsPatient was started on Cat I DOTS from PHC on September 2013 based on chest X- Ray (Sputum for AFB – Negative), but no symptomatic relief was presentShe got admitted under us on November 2011 with complaints of Fever & Breathlessness-15 days, Right sided chestpain – 2 daysClinical examination and chest x-ray suggestive of RIGHT SIDED PNEUMOTHORAX & Consolidation in Left mid &lower zone & ICD Tube was inserted in the 4th intercostal space in mid – axillary line.

Hb-10, TLC-14000(P-86%,L-10%,E-3%M-1%) LFT & KFT – WNL Sputum Culture & Sensitivity- No growth of pathogenic organisms (2 mucopurulent samples)- Negative

for AFB ELISA & HBsAg– Non Reactive ABG was suggestive of Type I Respiratory Failure Pleural fluid ADA-32, Culture & sensitivity- No growth seen , occasional RBCs seen, Triglyceride-31 mg/dl,

Cytology- suggestive of Acute Mixed Leucocytic Exudation HRCT thorax- Bilateral Ground Glass Opacities With Air Bronchogram & Reticular Thickening In

Interstitium with right sided pneumothorax Serum LDH – 1135 IU/L (200-400) ANA – 10.2 (< 20 u/l) Serum calcium – 7.9 mg/dL SerumACE-Negative 24 hour urinary protein – 0.5 g BAL culture & sensitivity – Growth of Acinetobacter species BAL Cytology – Benign epithelial cells in inflammatory & hemorrhagic background TBLB was suggestive of Type II pneumocyte proliferation & hemorrhage, smooth muscle proliferation

around airways most likely possibility is Resolving Adult Respiratory Distress Syndrome

P125

Title: Dysphagia and dysarthria with cavitary lung lesions: A Case Report

Satyajeet SAHOO, Subhra MITRA

Calcutta national medical college & hospital, Kolkata, India

CASE: Lesions affecting the posterior parapharyngeal space involving the 9th to 12th cranial nerves with Hornersyndrome is called Villaret’s syndrome. Etiologies include parotid gland tumor, nasopharyngeal tumors,parapharyngeal abscess and aneurysms of internal carotid artery. We report this case of 42 year immune-competent housewife presenting with high grade fever, headache and neck pain for 25 days with inability to takefood and difficulty in speech for 10 days. She was admitted in a local hospital 20 days back, where she wasdiagnosed meningitis and put on intravenous antibiotics. During the previous hospitalization she developed coughand dyspnoea with CXR showing bilateral pleural effusions and patchy opacities in lower zones. There were nocomplaints of haemoptysis or chest pain. On examination she had decreased appetite with BMI of 15 kg/m2. Shewas dysarthric, dysphagic and febrile. Her respiratory rate was 26/min with scattered crepitations. Horner’ssyndrome was noticed on right side. CNS examination showed right lateral rectus paralysis and lower motorneuron palsy of 9th, 10th, 11th and 12th cranial nerves bilaterally. Meningeal signs were absent. She was put on ryle’stube feeding and intravenous antibiotics. MRI brain revealed prevertebral (upper cervical) abscess. Sputum forGram stain and culture showed growth of Staphylococcus aureus. CECT thorax showed minimal bilateral pleuraleffusion and multiple bilateral nodules with cavitations in some of them. A week later she had become afebrile,her neck pain had subsided, she was taking soft diet and put off ryle’s tube. She is under follow-up with someimprovement in speech, though her tongue remains atrophic and weak.

DISCUSSION: We present this case of staphylococcal abscess of prevertebral space complicated with Villaret’ssyndrome with hematogenous spread to lungs which presented to our department with unusual features ofdysphagia and dysarthria with multiple cavitating lesions and bilateral pleural effusions.

P126Title: Invasive pulmonary aspergillosis (IPA) in liver transplant recipient(LTR) – a case

report.R CHOPRA, A TAKALE, V PANDHARKAR

Grant Medical Foundation’s Ruby Hall Clinic, Pune, Maharashtra, India

Objectives:IPA post liver transplant is a devasting complication with high mortality(40-90%) despite newer antifungal agents.Rapid and reliable diagnosis may improve the outcome. This is an interesting case, with late onset IPA in a LTRbeing presented.

Methods(case report):A 45 years old, post HCV liver cirrhosis, underwent liver transplant in 2011 and now presented in 2014 with cough,fever and haemoptysis since 2 wks prior. He has been on steroids and cyclosporine based immunosuppressivedrugs. CXR and CT scan showed macronodules, consolidation, cavity, halo and crescent signs.

WBC count and renal functions were normal. BAL showed branching hyphae and culture grew green colonies of A.fumigates. Galactomanan index was high. IPA diagnosis was confirmed. Treated with incremental doses ofliposomal Amphotericin B(total 2.5 gms) followed by oral Voriconazole. Clinical and CT scan resolution wassatisfactory.

Results(discussion):With changed epidemiology and better immunosuppressive drugs, late onset IPA in post liver transplant isreported frequently. Our patient developed IPA as late as 3 yrs after liver transplantation. Characteristics CT scanfindings in IPA patients, cavity and patchy consolidation, halo and crescent signs, were present and this alsodescribed in retrospective analysis of 2150 liver transplant cases. Though mortality is high, some trials documentedbetter survival with combination antifungal treatment with liposomal Amphotericin and Voriconazole. Our patientreceived liposomal Amphotericin followed by Voriconazole with good result.

Conclusion:IPA is uncommon but severe complication in LTR and has high mortality. Quick diagnosis of IPA with typical CT scanfindings and culture was made in our patient. Results with liposomal Amphotericin and Voriconazole weresatisfactory.

P127

P128A Rare Encounter With Hemoptysis

Dr. Natraj. M, Dr. N. Meenakshi, Dr. S. Subramanian, Dr. Thirunavukarasu,Chettinad Hospital And Research Institute, Rajiv Gandhi Salai, Kelambakkam, Chennai

IntroductionRhinosporidiosis is a chronic granulomatous disorder caused by Rhinosporidium seebri. Molecular biologicaltechniques have more recently demonstrated that this organism is an aquatic protistan parasite. It is groupedunder the class Mesomycetozoea. This disease is endemic in Sri Lanka and India, predominantly South India.Case ReportHere we present a case report of a 70 years old male patient who presented with multiple episodes of hemoptysisfor one month duration (10 – 15 ml per episode, frank blood), progressive dyspnea, cough with expectoration(mucoid, not foul smelling ) associated with loss of weight and appetite for the last one month. Patient is a knownsmoker for more than 40 years. Patient was a bus driver by occupation. Chest X ray PA view and CT thorax for thepatient were normal. Routine blood investigations revealed no significant abnormality. Initial nasal examinationrevealed only congested turbinates and deviated nasal septum but Direct Nasal Endoscopy revealed reddishgranular mass seen occupying right nasopharynx. The mass was surgically removed. Histopathology report wasconsistent with the diagnosis of rhinosporidiosis. Patient was asymptomatic after surgery.

P129An Unsusal Cause of Fungal Pneumonia.S.dharmic, V.suryanarayana, M.harishSree balaji medical college and hospital,Chennai,india

A 65 year old female, known asthmatic on steroids intermittently, with no other co-morbidity presented withfever, breathlessness and cough with mucoid expectoration of ten days duration. Bilateral crepts were heard inauscultation. She was maintaining saturating well in room air. Blood investigations revealed leucocytosis with

neutrophilic predominance. CT chest showed multiple patchy consolidations of the right upper, middle and lowerlobes with ground glass appearance and enlarged mediastinal lymph nodes. Work up for retrovirus andtuberculosis was negative. Sputum for KOH mount was negative. Sputum showed gram negative bacterial growthand she was started on antibiotics. Meanwhile patient went for Type II respiratory failure and was intubatedfollowed by tracheostomy in view of prolonged ventilator support.In spite of high end antibiotics, weaning off the ventilator was not possible. Bronchoscopy showed pus along withflakes in the right lateral basal bronchus. Bronchial wash sample grew Curvularia species. Fluconazole 150mg ODwas added. Serial imaging of the chest showed resolution of the consolidation. She was weaned off the ventilatorand was comfortable on room air.

Discussion: The genus Curvularia (filamentous fungi) contains some 35 species which are mostly subtropical andtropical plant parasites. Three ubiquitous species have been recovered from human infections, principally fromcases of mycotic keratitis; C. lunata, C. pallescens and C. geniculata. Clinical manifestations of phaeohyphomycosisinclude sinusitis, endocarditis, peritonitis and disseminated infection.Pneumonia caused by Curvularia in an immune competent patient is very rare and if diagnosed and treated early,will respond well to first line drugs like azoles. This case report highlights a unilateral fungal pneumonia withdramatic clinical improvement post treatment once the rare causative organism was identified.

P130Progressive allergic fungal rhinosinusitis with stable lingular bronchiectasis

Sindhoora Rawul1 , Prasad E Chelluri2 , SK Sistla3, Fahad Aleem1, Sai Singaraju1

Background: Allergic fungal rhinosinusitis with or without asthma has been mentioned in literature. Criteria fordiagnosis have been proposed without a consensus. We report one such case in a 59 year old lady with recurrentrhinopulmonary allergy with progressive nasal and sinus disease since year 2006 and stable non-progressivelingular bronchiectasis.

Methods:Clinical assessment, Imaging(X-ray,CT:PNS,Chest,Brain),Echocardiogram,Spirometry,EEG, Eosinophilcount,Serum Chemistry (VitaminD,Calcium,Thyroid, Immunology), Specific IgE, Total IgE,Sputum examination, FESSin June2013,histopathology of nasal mucosa. Patient refused skin prick test and bronchoscopy.

Results: On examination: postnasal drip, crackles in the left infraaxillary and paracardiac areas. CT PNS: left sideturbinate hypertrophy,maxillary sinusitis with polyps, CT chest: left lingular segmental bronchiectasis with patchof consolidation, eosinophil count increased(24%), total IgE: 4574 IU (Lab Normal 400 IU), Specific IgE toaspergillus,candida markedly increased, Echocardiogram normal,Spirometry:mild airflow obstruction without anymoderate or severe episodes since 4years,Histopathology:profuse eosinophilic infiltraton, no bony changes, nofungal elements,Sputum examination revealed fungal elements,CT brain normal,EEG: temporal lobe epilepsy.

Conclusion: A case of fungal rhinosinusitis with turbinate hypertrophy, maxillary polyps, high eosinophil counts andtotal IgE with highly elevated specific IgE to aspergillus and candida, mild airflow obstruction with reversibility andlingular bronchiectasis is presented. The unusual feature being stable lung disease while rhinosinusitis wasprogressive.

Treatment: Nasal, inhaled, oral steroids, bronchodilators and Itraconazole

Clinical implications: Any patient of rhinosinusitis with or without asthma should be screened by tests of allergyand lung function for early diagnosis of allergic fungal disease.

P131An unusual case of invasive Aspergillus pseudomembranous and obstructive tracheobronchitis withoutinvolvement of lung parenchyma in a immunocompetent patient.

Dr Ramesh S.Pal, Dr Sonam Spalgais, Dr Amit Kumar, Dr U C Ojha

department of pulmonary medicine esi pgimsr basaidarapur new delhi india

A 19 years aged young female presented with cough, mild expectoration since 3 month and life threateninghemoptysis since 1 week. She was non diabetic, not suffering from any chronic illness, not on any cytotoxic andimmunosuppressive drugs.Immune status was evaluated in terms of HIV status, hepatitis B, IgA, IgG, C3,C4complement components and were found normal. CECT thorax revealed segmental collapse of left lower lobe.Videobronchoscopy showed tiny nodules in trachea and left lower lobe bronchi. Dark brown intra luminal threadymaterial was visualized and taken out in piecemeal. Direct smear KOH preparation shows fungal elements. Biopsyfrom nodules shows chronic non specific inflammation. Repeated sputum KOH preparation also showed fungalelements and culture revealed Aspergillus flavus. Serum Galactomannan was positive. Thus a conclusion is made ofInvasive Apergillus Tracheobronchitis. Patient received intravenous Voriconazole for one month than switchover tooral Voriconazole for next two months. Her hemoptysis was stopped and improved clinically and radiologically.Repeat Serum Galactomannan become insignificant.

Discussion

The finding of Aspergillus spp. in respiratory tract samples in critically ill patients should not be routinely discardedas colonisation, even in presumably immunocompetent hosts like the case mentioned above. However risk factorsfor the development of invasive aspergillosis in critically ill patients include neutropenia, haematologicalmalignancy and immunosuppressive treatment. But, invasive disease can occur in the absence of these risk factors.

Figure1

Vediobronchoscopic view of left lower lobe showing luminal obstruction

Figure 2

Vediobronchoscopic view of left lower lobe showing brown thready structure protruding through lumen

Figure3

Bronchial wash from left lower lobe showing brownish sediment

P132

SOUVENIER in the ICD BAG

Dr Kumar Utsav, IInd Year Resident, BJMC, AhmedabadDr Savita Jindal, Asst. Professor, BJMC, Ahmedabad

BACKGROUND: Pleural effusion is common in INDIA. The importance of this case study is how a clinician can beeasily misled by Age of the patient, past AKT, when clinically symptoms are not prominent.

CASE HISTORY: An 80 year old male patient presents to O.P.D. with chief complaints of Breathlessness slowlyprogressive over the period of 2 years. Cough with expectoration over a period of 2 years, Generalised weaknessover 5 days. Pt has a past history of AKT and has been a smoker but left smoking since 10 years. CXR: Massive U/Lpleural effusion, An ICD was placed in situ. Pleural fluid assessment was not leading anywhere, neither werePleuroscopy and CECT Thorax

RESULTS: Incidentally, one day patient mentioned something crawling in ICD BAG. It was a full grown worm ofA.Lumbricoides. It was extracted from ICD BAG& sent for MICROBIOLOGICAL assessment. Pt was given TabAlbendazole 400mgSTAT. 2 days later stool R/M and parasitic examination was sent for, came negative forova/cysts/eggs. Tab Prednisolone (5mg) 5-0-5 was started. Pt was regularly followed up, was healthy, lost to followup at 6 months.

CLINICAL IMPLICATIONS: Seeing the age and presentation of patient, correlating with Past history of the patientone can easily make a mistake of presuming above case to be tuberculosis induced pleural effusion or malignanteffusion, but like every lock has a different key, every case is to be looked OBJECTIVELY. This is perhaps rare casewith uncommon presentation of parasitic infestation where a fully grown worm is roaming freely in pleural cavity.

P133Isolated pulmonary cystic lesion? Always suspect hydatidosis.D.N.Prajapati, R.M.Kshatriya, N.V.Khara, R.P.Paliwal, S.N.Pateldepartment of respiratory medicine, pramukhswami medical college, karamsad388325, gujarat, india.Introduction: Hydatidosis is caused by echinococcus granulosus. Humans maybe infected incidentally as intermediate host by accidental consumption of soil,water or food contaminated by fecal matter of an infected animal. Lung is the 2most commonly affected organ following liver. The symptoms depend on thesize and site of the lesion. There are very few reported cases of isolated lunghydatidosis. For hydatidosis, serology and imaging are diagnostic tools. Surgicalremoval and/or chemotherapy are the mainstay of treatment. Here we discuss acase of persistent left lower lobe lesion with history of operated left breastcarcinoma.Case report: A 36 years old female presented with 1 month history of coughwith yellow expectoration, dyspnea and left sided chest pain, with history oftrace hemoptysis before 1 month. Patient was a known case of infiltrating ductalcarcinoma of left breast operated before 3 years and had cystic lesion in leftlower lobe of lung confirmed on CT scan. Physical examination revealeddullness to percussion and diminished breath sounds over left lower chest.Blood reports showed eosinophilia with normal leukocytes. Chest radiographwas interpreted to have a left lower zone round opacity (possibly metastatic)which was increased in size as compared to previous x-rays and on ultrasoundit was found to be a cystic lesion with fluid collection. So diagnostic fluidaspiration was performed and surprisingly hooklets of ecchinococcus werefound on microscopy. Abdominal ultrasound was nomal including liver. Patientwas referred for surgical intervention and underwent left lower lobectomy. Therewere no complications in the postoperative period and no recurrence of thedisease.Conclusion: Pulmonary hydatidosis should always be considered as adifferential diagnosis when dealing with a cystic lesion on radiology in our

country.

P134Co-existence of ABPA and aspergilloma in same individual: a rare entity.

URVINDERPAL SINGH, VIDHU MITTAL, ADITI, SUNIL KUMAR.

Government Medical College, Patiala,Punjab,India.

ABSTRACT

Coexistence of allergic bronchopulmonary aspergillosis (ABPA), a hypersensitivity disorder to Aspergillusantigen, and aspergilloma, in same individual is of rare occurrence. Aspergilloma is a fungus ball caused bysaprophytic overgrowth of Aspergillus species in a cavitatory or cystic lung disease. However, tissue necrosis andinvasion of blood vessels does not occur. We hereby present a case of a 42 years old male who was diagnosed as acase of ABPA with co-existing aspergilloma.

P135Clinicoradiological and laboratory profile of Allergic bronchopulmonary aspergillosis ( ABPA) patients presentingto a tertiary care centre

AP KANSAL, Kiran.N, Shiyas MOHAMMED, Don Gregory MASCARENHAS, Nancy GARG, Hardik JAIN

Department Of Chest & TB, GMC, Patiala , Punjab

Introduction: ABPA is an idiopathic inflammatory lung disease characterized by an allergic inflammatory responseto the colonization of Aspergillus or other fungi in the lung.Objective: To study the clinicoradiological and laboratory profile of ABPA patients presenting to our departmentfrom August 2013 to July 2014.

Method & Materials : Patients diagnosed as ABPA based on Rosenberg Patterson criteria were retrospectivelystudied and analysed.

Results: In our study of 61 patients, 35(57.3%) were males, 26(42.7%) were females. Median age was 32.8 years,youngest being 7 years & oldest 84 years. Cough was the commonest presenting complaint present in 57(94.4%)followed by breathlessness in 51(83.6%), haemoptysis in 8(13%) patients. History of asthma was present in44(72.1%) patients. History of anti tuberculosis treatment was present in 11(18%) patients, all of them beingprescribed ATT in the peripheral health centres merely on the basis of Chest X-ray(CXR).

Fleeting opacities was present in chest X-rays in 14(22.9%) patients.On HRCT, 54(84.5%) patients has centralbronchiectasis , consolidation/mucus plugs in 4(6.5%) and normal in 3(4.9%) patients. Total and specific IgEagainst aspergillus antigen was high in all 61 patients.

Discussion : 70% of ABPA patients have a history of asthma.Keeping a high suspicion and evaluating on the lines ofABPA is necessary in bronchial asthma patients especially when they are poorly controlled on regular asthmatreatment. CXR lesions are nonspecific when serial X-rays are unavailable. Patients shouldn’t be put on ATT merelyon CXR basis without being properly evaluated for ABPA especially in asthma patients .

P136BILATERAL HYTADID CYST OF THE LUNG

Dr. RJESWARI G, Dr.RAMESH KUMAR, Dr. SARTAJ HUSSAINDepartment of Pulmonary Medicine, Osmania Medical College, Hyderadad

A 17 years girl presented with the chief complaints ofCough with expectoration - 3 monthsShortness of breath - 3 monthsL side chest pain - 3 months

Past history - Relatively healthy without any co-morbiditiesTreatment history – no history of worm infestations, no history of handling pets.

Cough with expectoration, sputum moderate in quantity, mucoid,non foul smelling, aggravated on lyingdown to left side, no diurnal variation

Shortness of breath, gradual in onset ,progressive, aggravated on lying down to left side, no history oforthopnea

Left sided chest pain, dull aching in nature, no history of radiation of pain, increases on lying to left side No history of wheeze or hemoptysis History of sputum being salty 15 days ago

On examination Vitals – stable; upper respiratory tract – normal; examination of chestInspection: deviation of trachea to the right side; Palpation : TVF decreased over the L hemi thorax.

P137A rare case report of disseminatedcryptococcosis in immunocompetent hostDr.G.AMBERNATH, Dr. Ajit Vigg, Dr.S.Gourishankar,*Dr.S.V.N.Anuradha*Dept of Pulmonary Medicine, Apollo Hospitals, Hyderabad, TS*Dept of Pathology, Apollo Hospitals, Hyderabad, TS

BACK GROUNDCryptococcosis is a defining opportunistic infecton for AIDS, and is the second most common AIDS defining illness.The distribution of Cryptococcus neoformans is worldwide and it is mostly seen in soil. Cryptococcosis is believedto be acquired by inhalation of the infectious propagule basidiospore from the environment. Pulmonarycryptococcosis with dissemination to brain in immunocompetent host is rare, which prompted us to report thiscase as a poster presentation.

CASE SCENARIO

A 59 year old gentleman,presented to ER in a state of altered sensorium, shortness of breath of grade II MMRCscale, low grade, intermittent fever associated with chills, cold and dry cough for the past 10 days and had a briefexposure to pigeon bird droppings over a period of 1month prior to development of these symptoms.Was a knownhypertensive,not a diabetic and also not on any immunosuppresants.TLC counts 26,000 cells/mm3,ESR 30mm atfirst hour. CXR PA view showed RLL consolidation. CT scan chest with contrast evidenced soft tissue densitylesion in the antero-lateral segment of right middle lobe suggestive of segmental consolidation. BAL on PAS stainshowed budding yeast cells of Cryptococcus in mucinous background. CT guided biopsy of lung tissue from RML onHPE showed necrotic tissue and encapsulated budding yeast cells with morphological features consistent withCryptococcus.MRI of brain with contrast study showed evidence two descrete large irregular thick walled ringenhancing lesions in rt capsulo-ganglionoic area with significant peri-lesional edema causing midline shift. patientresponded well to amphotericin-flucytosin combination therapy followed by oral fluconazole for six months.Patient on repeat MRI brain and CT chest showed significant resolution at four months.

P138Association of serum vitamin-D concentrations with pulmonary disorders: Tuberculosis, COPD and BronchialAsthma.

GAYATHRI B, SUJATHA R, NEHA GHALIB

PSG Institute of Medical Sciences and Research, Coimbatore, India.Objectives:Vitamin-D is classically associated with bone and mineral metabolism, but the identification of vitamin-D receptor(VDR) in many human cells suggests a role for vitamin-D in extra-skeletal diseases. Several cross-sectional studieshave associated lower vitamin-D status and decreased lung function. The present study was designed to find outthe association of serum vitamin-D concentration with pulmonary disorders like Tuberculosis, COPD and BronchialAsthma.Methods:A retrospective data collection of serum vitamin-D concentrations was performed between September 2013-March 2014, for the patients attending the out-patient and in-patient clinics of PSG hospitals, out of which vitamin-D levels of patients having the diagnosis of Tuberculosis, COPD and Bronchial Asthma were segregated andanalysed. Serum 25-OH Vitamin-D levels were measured by electrochemiluminescence. Normal serum referenceinterval was 30-70ng/mL. The objective of the study was to determine the vitamin-D status in patients with thesepulmonary diseases. Vitamin-D levels of 20 - <30ng/mL was classified as vitamin-D insufficiency and levels

<20ng/mL were classified as vitamin-D deficiency(VDD). VDD was further classified based on Lips classification asmild (10-<20ng/mL), moderate (5-<10ng/mL) and severe (<5ng/mL).Results:The mean age of the study group was 62.85±15.64 years. Of the total 28 pulmonary cases, 12 (43%) had severevitamin-D deficiency, 2 (7%) had moderate deficiency, 5 (18%) had mild deficiency. Among the 14 tuberculosispatients, (36%) 5 patients had severe vitamin-D deficiency. There were also 5 severe vitamin-D deficiency casesamong the 10 respiratory failure cases.Conclusion:Vitamin-D improves lung function by regulating inflammation, inducing anti-microbial peptides and its action onmuscle. Vitamin-D deficiency has been associated with lowered lung function in COPD and Bronchial Asthma, andalso in tuberculosis infections.The reduced levels of serum 25-OH Vitamin-D in pulmonary diseases suggest optimization of serum vitamin-Dlevels to improve the lung function among the general population.

P139Title: A study on bode index as a predictor of severity in patients with Chronic Obstructive Pulmonary Disease.Author: Dr. Manik MahajanCo-authors: Dr. Stani Francis(Prof & Head), Dr. Arti Shah(Asso. Prof),

Dr. Parth Shah (Asst. Prof).Designation: 2nd Year Resident, Respiratory MedicineInstitute: Department Of Respiratory Medicine, SBKS Medical College & Research institute, Piparia, Vadodara.

Introduction:

Chronic Obstructive Pulmonary Disease (COPD) as defined by the Global initiative for chronic obstructive lungdisease is a disease state characterized by airflow limitation that is not fully reversible. According to WHO, COPDwas the 6th major cause of death in 1990 and is estimated to be the 3rd major cause by 2020. The present studyhas been undertaken to determine the factors other than the lung function that affect the outcome in COPDpatients. The original BODE index ,body-mass index (B), degree of airflow obstruction (O) , dyspnea (D), exercisecapacity (E), measured by the six-minute–walk test, is a simple multidimensional grading system which is superiorto FEV1 alone for prediction of mortality and hospitalization rates among COPD patients.Aims & Objectives:To study the outcome of COPD patients by using BODE Index.Method:It is prospective observational study.Total 50 adult patients with symptoms suggestive of COPD and who attended respiratory medicine department,SBKS & MIRC were included.The study was done to evaluate the BODE index as a predictor of hospitalization and severity in patients withCOPD.Results: A total 50 COPD patients were enrolled in the study. 17 patients who had mild COPD with (BODE scorebetween 0 – 2). 16 patients had moderate (BODE score of 3 – 5) and 17 patients had severe COPD (BODE scoremore than or equal to 6). The average age of participants in the study was 56.01yrs. Among the COPD patients,BODE index was found to increase with age. The average BMI of the patients in this study was 21.58kg/m2. TheBMI was found to be significantly lower in patients with COPD.Conclusion: BODE index is reliable method to predict hospitalization and the severity in patients with COPD andwhich is relatively inexpensive.Keywords: COPD; BODE Index

P140Integrated Dose Counters: Technical Aspects and Functional SpecificationsV NAIK1, G MALHOTRA2, K ROTE2, DR J GOGTAY1

1 Medical Services, Cipla Ltd., Mumbai, India

2 R&D Centre

IntroductionCurrently there is no accurate test whereby the patient can estimate the number of doses remaining in apressurized metered dose inhaler (pMDI). As a result patients may underuse or overuse the pMDIs therebyincreasing the cost or the risk of not receiving the correct dose, respectively.Cipla’s dose counter is integrated into the pMDI and shows the number of puffs remaining in the inhaler with itsuse. It has been designed to satisfy the USFDA’s guidance on “integrated dose counters”, as well as meeting theneeds of patients and physicians.

Design Features

The dose counter is integrated with the canister thus maintaining count integrity while minimizing interferencewith airflow and aerosol generation. No additional force is required to use a pMDI with a dose counter.The counter starts slightly above label claim doses in order to take care of doses lost in priming and re-priming. Thelast 40 doses are in red color, indicating the need to obtain a new pMDI, at position “0” the user knows that thedevice is empty. However the pMDI is functional even beyond this point thus confirming with US FDAs guidancethat even partially therapeutic dose could be lifesaving.

Accuracy

Accuracy of count is a critical parameter and Cipla’s dose counter includes delivery of a dose without the possibilityof jamming the valve and displacement-driven design which eliminates the possibility of under-counting.

In vitro tests

Robustness has been confirmed by various in vitro studies including temperature cycling (hot, cold), drop testing,transportation, contamination analysis, robustness testing, counting accuracy, and actuation force analysis.

Conclusion

Cipla’s dose indicator potentially provides reassurance and adds confidence on the usage of pMDIs, thus improvingadherence to treatment and enhancing the effectiveness of aerosol drug delivery by pMDIs.

P141Profile of sensitivity to pollen allergens in the bronchial asthma patients attending a tertiary care hospital in Jaipur,

India by skin prick testingR SEHAJPAL1, S KOOLWAL2

INSTITUTE OF RESPIRATORY DISEASES, SMS MEDICAL COLLEGE, JAIPURObjective : To determine the profile of sensitivity to pollen allergens in the bronchial asthma patients attending atertiary care hospital in Jaipur, India by skin prick testing .

Methods: Skin test reactivity for 20 pollen allergens was studied by skin prick testing, using buffer saline asnegative control and histamine phosphatase as positive control in 100 stable bronchial asthma patients ..Immediate cutaneous responses were recorded at 20 minute after allergen challenge. Pollen antigens wereselected based on the local aerobiological calendar.

Results :Fifty seven percent of the patients had a significant positive reaction( >+2). 57.7% of the males and 56.3 %of the females were found to be allergic to pollens.Pollen allergy was more common in urban population(64%)andin the occupational groups it was common in office job workers (66.6%), shopkeepers(66.6%)and students(60.7%).Family history was positive in 40% of the patients. .Twenty three percent of the patients had positive reaction tosingle pollen , 17 % to two pollens and 24% to three or more pollen.Tree pollen were the most common allergen inthe study population and among them Holoptelea integrifolia was the commonest pollen .Amaranthus spinosus

was the commonest weed pollen and Pennisetum typhoides was the commonest grass pollen having significantpositive reaction by SPT.

Conclusion: Airborne pollens are important causal factor of allergic diseases such as asthma . Thereforeidentification of these pollens is important. Knowledge of profile of sensitivity may be useful to cliniciansmanaging patients suffering from respiratory allergies and allergen‑specific immunotherapy could be a viableoption for these patients.

P142Understanding perception of COPD among doctors at different specialty levels in India: a face-to-face survey

Dr. ISHPREET KAUR, Dr. BHUMIKA AGGARWAL, Dr. JAIDEEP GOGTAYCipla Ltd., Mumbai, India (for all three authors)

Objective:COPD in India remains highly under-recognized and under-treated despite high prevalence and diagnosis usuallydoes not occur until loss of significant lung function. This survey aimed to identify the existing barriers to an earlyand proper diagnosis and treatment of COPD in India by exploring the attitudes, beliefs, and knowledge of Indiandoctors w.r.t. COPD.

Methods:A cross-sectional study involving data collation through a questionnaire and face-to face interviews was conductedin 91 randomly selected physicians (primary care physicians & internal medicine specialists) and pulmonologistsfrom 8 Indian cities.

ResultsThe response rate to the written questionnaire was 59.34% (54 out of 91). Majority of the doctors (57.4%) reportedthat COPD patients usually visit them at severe stages. Lung function testing is not routinely performed anddiagnosis is largely symptom and history based - 44% physicians denied performing spirometry to make a diagnosisof COPD. About 35% of physicians believed that COPD occurs only in smokers.

The most commonly reported challenges to diagnosis of COPD were a) spirometry related- access (22.22%),interpretation (27.77%), patients’ unwillingness (44.44%), affordability issues (29.62%); b) doctor related-inadequate training on COPD diagnosis (11.11% ) and c) patient related-lack of awareness about the disease.Doctors’ perceived barriers to the treatment of COPD included difficulty in explaining COPD to patients (38.88%)and poor compliance to treatment (42.59%).

Conclusion:Lack of awareness about COPD, its symptoms and its implications contribute significantly in preventing people atrisk from reaching out to doctors. Inadequate use of or access to spirometry and the belief that COPD is a smoker’sdisease are important barriers to diagnosis. A large scale study will help to further understand the physician andpatient perceptions. Educational and awareness programs are needed both for doctors and patients to helpaddress the awareness-gap, under-diagnosis and under-treatment associated with COPD.

P143Inspiratory flow rates using In-check Oral in patients of obstructive airway diseases in Indian population

DR. ISHPREET KAUR, DR. JAIDEEP GOGTAY, DR. BARDAPURKAR SUHAS,DR. BARNALI BHATTACHARYA, DR. S. RAJU, DR. SHAILESH JAIN

Introduction:The patient’s inspiratory flow has to be adeqaute to activate the dry powder inhaler or breath-actuated inhalerand to guarantee optimal pulmonary drug deposition. Peak inspiratory flows (PIFs) are dependent on the patient'sinhalation effort and device resistance. Optimal inspiratory flow rates may not be achieved in few patients,especially in children or elderly COPD patients. PIFs >60 l.min-1 are generally accepted to be the optimal flows formost of the devices, while PIFs < 30 l.min-1 are believed to be insufficient.

Methods:

The present study measured PIF rates in patients (n=178) with asthma including children and with COPDincluding elderly. PIF was measured using the In-Check Oral (Clement Clarke International Ltd, Harlow, UK). Thehighest value of the three attempts was recorded.

Results:The mean (± SD) PIF was 201.89 (±82.74) l.min-1 and 134.78 (±61.85) l.min-1 in patients with asthma (n=132; meanage=35.88 years) and COPD (n=46; mean age=64.54 years), respectively. Paediatric (≤12 years) asthma (n=22,mean age=7.98) and severe COPD patients (n=34, mean age=64.41) demonstrated a mean (± SD) PIF of 124.54(±50.68) l.min-1 and 124.70 (±60.46) l.min-1, respectively; these subgroups representing two ends of the spectrumwith the lowest PIF values. The lowest PIF recorded was 40 l.min-1 in 3 patients (2 elderly severe COPD patients and1 paediatric asthma patient). PIF correlated positively with FEV1% (r=0.53). PIF showed a strong positive correlationwith age till 12 years (r=0.60) while for 13 to 84 years it showed a moderate negative correlation (r= -0.50). PIFcorrelated positively with height (r=0.51) and negatively with severity of asthma and COPD.

Conclusion:The present study demonstrates the ability across all age groups, including children and elderly patients, togenerate sufficient inspiratory flow, irrespective of the severity of asthma or COPD.

P144Abstract

Title –ECG and ECHO correlation in COPD patients in Tertiary health care centre.

Authors-Dr Nikhilesh Pasari, Dr Ashok Bajpai, Dr Bhupendra Jain.

Sri Aurobindo Institute Of Medical Sciences & PG Institute Indore,India

Objective-To observe correlation in ECG and ECHO findings with COPD severity.

Methods- A prospective study of 80 patients( pts) over a period of 7 months Jan 2014 to July 2014 are recruited atSri Aurobindo Institute Of Medical Sciences Indore in Dept of Pulmonary Medicine and detailed history, clinicalevaluation,spirometry,2D Echo & ECG obtained.

COPD severity is categorized based on GOLD Guidelines and data were analysed by Fisher’s Exact Test and p<0.05considered significant.

Results-We found that maximum number of pts was of grade 2 (42.50%) among which significant associationbetween presence of P pulmonale and COPD grading was observed. ECG changes (P pulmonale) were observed.

Grade 1 COPD 0% pt. was having P pulmonale while in

Grade 4 91.66% ,pts were having the same. (P<0.001)

Signifiacant association with echo findings was observed that maximum Grade 4 COPD pts were having moderatePAH. (P<0.007) while Cor pulmonale was present in 50% of cases in grade 4 COPD ( p<0.005)

Conclusion-Stages of COPD is significantly proportional to ECG changes & Echo findings in COPD pts.&consider as a non invasive and easily available screening tool.

P145

A rare cause for Hypercapnic respiratory failure

Dr Janso KOLLANUR, Dr Vishnu SHARMA M., Dr.Alka BHAT, Dr Harsha D. S.

Department of Respiratory Medicine, A. J. Institute of Medical Sciences, Kuntikana, Mangalore, 575004.

INTRODUCTIONHypercapnic respiratory failure can be a manifestation of neuromuscular weakness due to various causes.

CASE REPORTA 55 year old female presented with breathlessness of 8 months duration increased since 1 week. There was nohistory suggestive of asthma or COPD neither did she give any occupational exposure. Thyroidectomy was done 12years back and she was on thyroxine 100mcg daily.

On examination she was conscious, oriented, had pulse rate of 96/min, respiratory rate of 32/min and oxygensaturation of 82% with room air. Chest examination revealed normal vesicular breath sounds with bilateral basalcrepitations and few scattered rhonchi. Thyroid function tests were within normal limits. Chest x-ray showedbilateral basal infiltrates. ABG showed metabolic alkalosis with hypercapnic respiratory failure.

Despite adequate bronchodilators, antibiotics and NIV, patient did not improve. She developed focal seizures oneday after admission. On further enquiry patient gave history of 3 episodes of seizures 3 months back. CT head wasnormal. Nerve conduction study showed mild asymmetrical sensory motor axonal peripheral neuropathy. Serumcalcium level was 4.4mg/dl. Vitamin D3 level was 13.65ng/ml, parathormone level was 139.7pg/ml and urinecalcium was 4.1mg/dl. A diagnosis of Post thyroidectomy hypothyroidism, hypocalcaemia withpseudohypoparathyoidism with hypercapnic respiratory failure secondary to hypocalcaemia was made. She madeuneventful recovery with calcium supplementation and other supportive treatment.

CONCLUSIONThis case report aims to highlight the fact that neuromuscular weakness secondary to electrolyte imbalance canlead to Hypercapnic respiratory failure and should be considered in differential diagnosis of causes for Hypercapnicrespiratory failure.

P146Effect of oral montelukast in acute asthma

B CHOGTU*, S HAMEED1, R MAGAZINE1

Department of Pharmacology, Department of Pulmonary Medicine1, Kasturba Medical College, Manipal University,Manipal, Karnataka-576104, India

Objectives: Montelukast is used in prophylaxis of asthma. Studies have shown that it has a beneficial effect inasthma exacerbations. Hence, the study was done to evaluate the effect of oral montelukast as an add on therapyin patient with acute severe asthmaMethodology: It was a randomised, prospective study conducted in department of Pulmonary Medicine. Afterobtaining Institutional Ethics Committee clearance, the patients presenting to emergency triage from September2012 to March 2014 with a primary diagnosis of acute exacerbation of asthma requiring hospitalisation, wereincluded in the study. Informed consent was taken from the patients prior to inclusion. History, physicalexamination and laboratory investigations were recorded as per the proforma. Baseline peak expiratory flow rate(PEFR) was measured. All patients received standard treatment for asthma exacerbation and were randomisedinto 2 groups. Patients in group1 and group 2 received a placebo tablet and oral montelukast 10mg respectively atbaseline. The investigational medications were continued once daily till the patient was discharged from thehospital. Nebulised salbutamol 2.5 mg was given as rescue medication. PEFR values, details of rescue medication

and vital signs were recorded at 6 hours, 12 hours, 24 hours and 48 hours of drug or placebo administration and atdischarge. The data was analyzed using SPSS software v20.0.Results: Of the total enrolled patients, 50 were randomized to placebo group and 40 patients to the montelukastgroup. Repeated measures ANOVA was used to compare the mean change in PEFR. The values at the various timepoints between the two groups were not statistically significant (p=0.189). However, the patients in themontelukast group required significantly lesser number of rescue medications than the placebo group (p=0.049).Conclusion: Montelukast decreases the need for rescue medication in acute severe asthma.

P147

Title: Co-relation between risk factors of asthma and severity of the disease.Author: Dr. Rahul PANDYA.Co-authors: Dr. Stani FRANCIS, Dr. Arti SHAH, Dr. Parth SHAH.Introduction: Asthma is a major cause of chronic morbidity and mortality throughout the world and asthma’sprevalence has increased considerably over past 20 years, mostly young adults. Globally asthma affected 235 to330 million people in 2011, out of which 70-80% patients belong to developing countries. India has an estimated15-20 million asthmatics, with prevalence rising more in recent decades. Worldwide, the economic costs associatedwith asthma exceed those ofTB and HIV/AIDS combined.

Aims & Objectives: To analyse the pattern of asthmatics in terms of environmental factors, indoor environment,ETS (Environmental Tobacco Smoke), occupational exposure, obesity, socio-economical status and correlate themwith severity of their asthma.

Methods: It is a prospective, observational type of study. 50 diagnosed patients of asthma were included in thestudy and their detailed clinical history was taken. Severity of the asthma was calculated based on frequency ofasthma attacks, PFT values and FEV reversibility.

Result: Out of 50 patients, the severity of asthma was as below:

Co-existing allergic conditions were found in 30 asthmatics, while 40 had exposure to indoor or outdoor triggers.Conclusion: Severity of asthma was more with sedentary life-style, lower socio-economical status, occupationaltriggers, and indoor environmental triggers. Asthma was severe in smokers and ever-smokers. Presence of co-existing other allergic conditions resulted in poor prognosis of asthma.

P148

Effect of Inhaled Anticholinergic Drugs on Intraocular pressure In Chronic Obstructive pulmonary diseasepatients

YADAV PRASHANT, CHAUDHRI SUDHIR, KUMAR ANAND, VERMA SANJAY, KUMAR AVDHESH

GSVM Medical College, Kanpur, Uttar Pradesh, India

Objective: The objective of this study is to know the effect of inhaled anticholinergics (Tiotropium/ Ipratropiumbromide) on intraocular pressure in COPD patients and to evaluate their safety in potential glaucoma patients.

Glaucoma is frequently seen in patients with chronic bronchitis who require treatment with nebulized Beta2agonists and ipratropium due to accidental instillation in eyes. Significance of anti cholinergic drugs used asinhalers by Chronic Obstructive Pulmonary Disease (COPD) causing raised intraocular pressure is unknown.

Methods: Initially 132 patients were included. 14 patients were excluded because on initial examination they hadhyper mature senile cataract. 10 patients were excluded because they were not co-operative with the studyprotocol. Included patients were divided into 70 patients (study group) who received Ipratropium or Tiotropiumwith formetrol and fluticasone as Metered dose Inhaler (pMDI) and 38 patients(control group) took formetrol withfluticasone without ipratropium / tiotropium. General ophthalmic examination, and Gonioscopy was done as pre-treatment. Intra-ocular pressure measurement done in all patients before starting treatment, 2 hours after firstdose and thereafter weekly for four weeks.

Results: Out of 108 patients, 73 were males and 35 were females. Mean age of patients was 64 years. Out of 70patients (study group) 13 showed increase in intraocular pressure (IOP), 57 did not show any change. Themaximum increment was 4mmHg. In Control group 33 out of 38 did not show any change in IOP, only 05 showedincrement of IOP. The maximum increment was 2 mmHg.

Conclusion: The inhaled anticholinergics all by Metered Dose Inhalers did not lead to any significant change inintraocular pressure (IOP) after 2 hours, 1st, 2nd, 3rd and at 4th week of starting treatment. All values of intraocularpressure are within normal clinical range.

P149Correlation of spirometry with impulse oscillometry, body plethysmography and DLCO

VANJARE N, KODGULE R, RASAM S, BHOSALE S, SALVI S

Chest Research Foundation, Pune, India

Background: Spirometry, Impulse Oscillometry (IOS), Body Plethysmography (BP) and DLCO are tools that measuredifferent aspects of lung function. However, there is inadequate knowledge about the correlation between theparameters measured by these tests.

Aim: To study the correlation of spirometry indices with values measured by IOS, BP and DLCO.

Methods: In this ongoing study 4 healthy, 9 asthma and 10 COPD patients underwent IOS, BP, spirometry andDLCO according to the international guidelines. Correlations between values obtained by IOS (R5, R20, and R5-20),BP (sGawtot, sGaweff, RV, TLC), spirometry (FEV1, FVC, FEF25-75%) and DLCO were analyzed using Pearsons’scorrelation.

Results: R5, R5-20 and DLCO correlated with FEV1 (r=-0.55, -0.61 and 0.87, all p<0.05) suggesting that small airwayresistance increased and DLCO decreased linearly with reduction in FEV1. The correlation of FEV1 was highest withsGawtot and sGaweff (r=0.96, p<0.01 for both). FVC correlated with all the measured parameters suggesting thatFVC is reflective of overall lung function (all p<0.05). Small airway parameter FEF25-75% correlated best withsGawtot and sGaweff (r=0.911 and 0.914, both p<0.01) and also correlated with R5 and R5-20 (r=-0.5 and p<0.05for both). Neither FEV1 nor FEF25-75 correlated with R20 (p>0.05). sGawtot and sGaweff correlated best withFEF25% (r=0.95, p<0.01 for both).

Conclusion: sGaw reflects more distal airways than R5 and R5-20. FEV1 majorly reflects small airway obstructionand FVC is a measure of overall lung function. DLCO decreases linearly as FEV1 decreases.

P150Can Impulse Oscillometry and Body Plethysmography differentiate response to two salbutamol doses?

VANJARE N, KODGULE R, RASAM S, BHOSALE S, SALVI S

Chest Research Foundation, Pune, India

Background: Impulse Oscillometry (IOS) and Body Plethysmography (BP) are more sensitive in differentiatingbetween mean percentage responses to sequentially increasing bronchodilator doses. However, whether IOS andBP can differentiate bronchodilator response between single doses of different strengths of bronchodilator is notknown.

Aim: To study the effect of 100 and 400 mcg of salbutamol on Impulse Oscillometry and Body Plethysmographyparameters?

Methods: In this ongoing study, 9 asthma and 10 COPD patients were randomized to receive either 100 mcg or400 mcg of inhaled salbutamol in a cross-over manner. Impulse Oscillometry to study resistances at 5 Hz, 20 Hzand 5-20 Hz (R5, R20 and R5-20), body plethysmography to study specific airway conductances -sGawtot andsGaweff and spirometry to study FEV1 and FEF25-75 was done before and 30 min after drug administration. Withingroup changes were analyzed by paired t-test and the within-group changes were analyzed using independent t-test and ANCOVA.

Results &Conclusion: R5, R20, R5-20 and FEF25-75% showed maximum differentiation between two doses. Allparameters showed significant change after bronchodilation with 100 and 400 mcg of salbutamol (Table 1)

Table 1: Mean percent change (MPC) in asthma &COPD

Mean percent change (MPC) in asthma

ParametersMPC100 mcg

Stddev

MPC400 mcg

Std.dev

FEV1 26.8 17.35 30.63 19.83FEF25-75% 39.69 48.71 71.18 38.94sGawtot 52.03 26.6 40.36 90.65sGaweff 59.81 23.86 50.7 6.25R5 -18.28 34.06 -26.86 36.84R20 -7.6 19.29 -18.44 17.09R5-20 -23.72 59.61 -30.96 74.98Mean percent change (MPC) in COPD

ParametersMPC100 mcg

Stddev

MPC400 mcg

Std.dev

FEV1 16.31 13.5 14.07 15.82FEF25-75% 7.9 16.27 18.92 33.48sGawtot 43.25 21.48 50.4 51.08sGaweff 46.82 30.18 49.65 51.26R5 -9.2 21.33 -14.78 17.03R20 -16.31 15.73 -10.37 16.55R5-20 -19.41 23.76 -22.67 23.94

P151

Confidence, usability, preference, satisfaction and errors with use of Revolizer®: A single dose dry powder inhaler(SDDPI) for patients with obstructive airway disease (OAD).

SK RAJAN1, S SHRIVASTAVA1, I BUBNA1, SP JADHAV2, PV LONDHE2, JA GOGTAY2

1Bhatia General Hospital, Mumbai, India, 2Cipla Ltd. Mumbai, India

Objective: Optimal management of obstructive airway disease depends on adequate drug delivery to the airways. Thechoice of device therefore becomes pertinent. Ease of use should be given careful consideration when prescribing adevice to patients. The objective of this study was to assess the confidence, usability, preference, satisfaction anderrors associated with the use of Revolizer®, a single dose dry powder inhaler (SDDPI) in India.

Methods: 100 participants [50 healthy and 50 with obstructive airway disease (OAD)] of 18 years and above wereenrolled in the study. At visit 1, the technique of using the device was explained and demonstrated twice by theinvestigator. Participants then repeated the procedure until they achieved three consecutive correct attempts. At visit2 (two days later), participants made a single attempt before receiving demonstration from the investigator. They thenrepeated the steps until three consecutive correct attempts were made. At both visits, time taken to achieve threeconsecutive correct attempts was noted. The number and type of errors were recorded. The participants were asked toanswer a questionnaire at both visits.

Results: 100 participants (54 women, 46 men) with a mean (SD) age of 42 (+14) years were enrolled in the study. Themean time taken for three consecutive correct attempts at visit 1 was 3.75 (2.10) minutes and at visit 2 was 3.07 (1.32)minutes (p<0.001). Patients who made critical errors were 38 and 28, while non critical errors were 49 and 38 at twovisits respectively. Most of these were device independent. Out of 48 patients who were using an inhaler device, 78%preferred Revolizer ® over their current device.

Conclusion: Revolizer®, a SDDPI is easy to use and scores high on confidence, preference and satisfaction in patientswith OAD.

P152Usability, confidence, preference, satisfaction and errors with the use of spacers: a combined analysis of results fromthree studies

S SALVI 1, S RAJAN2, SP JADHAV3, PV LONDHE3J GOGTAY3

1Chest Research Foundation, Pune India, 2Bhatia General Hospital Mumbai, India, 3Cipla Ltd., Mumbai, India

Objectives: Errors with the use of pressurized metered-dose inhalers (pMDIs) reduces lung deposition and increases thelocal and systemic side effects. The use of a spacer reduces these errors. The objectives of these studies were to assessthe usability, confidence, preference and satisfaction with the use of three spacers (Zerostat, Zerostat V and Zerostat VT)in three different but identically designed studies.

Methods: The three studies were open-labelled, prospective and single center conducted in healthy volunteer andpatients with mild asthma and COPD. The study consisted two visits. In these two study visits , the patients were trainedto use the device at visit 1 and again at visit 2, and the average time taken for three consecutive correct attempts wasreported (primary endpoint). The secondary endpoints included number and type of errors (critical and non-critical), andscores on usability, confidence, preference, and satisfaction questionnaires.

Results: A total of 90 participants (30 participants per study, 1:1 healthy volunteers: patients with asthma/COPD)completed these studies. The average time taken for three consecutive correct attempts in patients with asthma/COPD inthe three studies decreased at visit 2 (2.99, 4.65 and 1.91 minutes) from visit 1 (3.58, 4.99 and 2.23 minutes), respectively.The critical and non-critical errors also decreased at visit 2 from visit 1. Overall reduction in the scores at visit 2 was alsoobserved on the usability, confidence, preference and satisfaction questionnaires.

Conclusion: Zerostat, Zerostat V and Zerostat VT spacers are easy to learn, understand and operate. This highlights thefact that the spacer devices can be recommended for all patients finding difficulty in using a pMDI.

P153Evaluation of efficacy and safety profile of Fluticasone/ Formoterol (FF) combination versusBudesonide/Formoterol (BF) combination administered through a pressurized Metered Dose Inhaler (pMDI) inpatients with moderate to severe persistent asthma- : A randomized controlled trial.

A BALKI1; S DALAL2; A SINGH3; S BARDAPURKAR4; S BALAMURUGAN5; B SINGH6; R MEHTA7; SURYAKANT8; SBHARGAVA9; B TRIVEDI10; A ARYA11; S PAPINWAR12; S CHANDRATRE 13; B MUTHA14; K PODDAR15; P.PHOPALE16; A VAIDYA 16; J GOGTAY16.

1Chest Care Hospital, Nagpur, India; 2Ashray Chest Center, Vadodara, India; 3Asthma Bhavan, Jaipur, India;4Shree Nursing Home, Aurangabad, India; 5Dr.Balamurugan's Chest Clinic, Chennai, India; 6Surya ChestFoundation, Lucknow, India; 7Dr. Mehta's Allergy, Asthma Care And Research Center, Indore, India; 8ResearchDepartment, India; 9Gyanpushp Research Center For Chest And Allergy Diseases, Indore, India; 10Nashik HealthCare And Research Centre, Nashik, India; 11Center For Chest Diseases, Delhi, India; 12 Dr. Papinwar Hospital,Aurangabad, India; 13Shatabdi Super Speciality Hospital, Nashik, India; 14Mutha Hospital, Nashik, India; 15Chest,Asthma And Allergy Clinic, Kolkatta, India; 16Cipla Ltd India.

Objective:Combination of an inhaled corticosteroid (ICS) and long-acting beta agonist has become the mainstay oftreatment of asthma when not controlled by ICS alone. A number of combination inhalers are already available,but there is scarce data on the combination of FF in a single inhaler. Hence, this study was conducted to evaluateefficacy and safety of FF 125/6 mcg pMDI combination versus BF 200/6 mcg pMDI combination in patients withmoderate to severe persistent asthma.

Method:This was a double blind, prospective, active controlled, parallel group, multicenter study, with a 2-4 weeks run-in period during which patients received budesonide 100 mcg, 2 puffs twice daily. 232 patients, symptomaticwith ICS alone, were randomized to receive either of the active treatments at a dose of 2 puffs twice daily for12 weeks.. Levosalbutamol was provided as rescue medication. Spirometry and subject diary assessments wereperformed at 2, 4, 8, and 12 weeks. Adverse events (AE) were assessed at all visits.

Results:232 patients (117 - FF and 115 - BF group) were enrolled, out of which 59% were males and average age was 41years. Both FF and BF produced a statistically significant improvement within group in mPEFR from baseline to12 weeks (48.07L/min and 49.03 L/min respectively (p<0.005) and the difference between the two groups wasnot significant (p>0.005) (difference of -0.96 L/min, 95% CI: -2.38L to 0.46L). Improvement was observed frombaseline in FEV1, evening PEFR, nighttime symptoms and rescue medication within both group at all treatmentvisits. BF reduced day time symptom scores over FF (p=0.0326). There was no difference observed in frequencyof AE.

Conclusion:This study showed comparable efficacy and safety data of FF to BF in terms of primary & secondary endpoints.

P154Comparison of a novel fixed dose combination (FDC) of nebulized formoterol/budesonide with pMDIformoterol/budesonide FDC in patients with severe to very severe COPDS SALVI1; H PANDYA2; A GHOSAL3; R DHAR4; S WALANJ5; N BOYILLA6; V DESHMUKH7; B TAYADE8; V NANGIA9;S JADHAV10; P PHOPALE10; A VAIDYA10; J GOGTAY10

1Chest Research Foundation Pune, India; 2Sheth LG Hospital and AMC Met Medical College, Ahmedabad, India;3National Allergy Asthma Bronchitis Institute Kolkata, India; 4Fortis Hospital Kolkata India; 5Ethika ClinicalResearch Center Kalwa India; 6Axon Hospitals Hyderabad India; 7Nagpur Chest Centre Nagpur India; 8NKP SalveInstitute Of Medical Sciences & Lata Mangeshkar Hospital, Nagpur India; 9Fortis Flt. Lt. Rajan Dhall Hospital NewDelhi India; 10Cipla Ltd., India.

Objective:To evaluate efficacy, safety and tolerability of 20 mcg/1mg of FB neb with 6/200 mcg of FB pMDI in patientswith severe to very severe COPD

Method:In this open-label, prospective, active-controlled, parallel group, 6 weeks, multicentre study, patients wererandomised (2:1) after 2 weeks of run-in period to receive either FB neb or FB pMDI, with a non-static spacer,twice daily for 6 weeks. Combination of ipratropium 40 µg & levosalbutamol 50 µg, 2 puffs, thrice daily wasprovided in run in period. Levosalbutamol 50 µg pMDI was provided as rescue medication.Primary efficacyparameter was difference in mean change in trough FEV1 at the end of 6 weeks. Others included FVC, FEF25-75and subject diary assessment at the end 2, 4 and 6 weeks.

Results:113 patients (96.43% males) were randomized, with a mean age 62 ± 9.11 years. Data of 94 patients with a meanbaseline post bronchodilator (PB) FEV1% predicted 35.91% with reversibility 10.44% was analyzed. At the end of6 weeks, the difference in the change in trough FEV1 between FB neb and FB pMDI was not significant (30 ml,95% CI (-0.05L, 0.11L) (p=0.42)). Similar results were seen for PB FEV1, FVC and FEF25-75. There was a trendtowards significance in the PB FEF25-75 at week 6 vs baseline in FB neb group (p=0.05) but not in the FB pMDIgroup. Use of rescue medication and adverse events were similar in both groups..

Conclusion:FB neb is as efficacious, safe and well tolerated as FB pMDI and can serve as an alternative treatment option inpatients with severe to very severe COPD who are unable to use handled inhalers.

P155

TITLE: D-dimer level in acute exacerbation of COPD.AUTHOR: P.PERIWAL, A.K SINHA, K. SAINI, D.TALWARINSTITUTION: Pulmonary Medicine and critical care, Metro centre for respiratory diseases, Noida, Uttar Pradesh, India.

INTRODUCTION: Acute exacerbations of COPD are associated with increased airway inflammation, causing imbalance inthe endothelial- coagulation system, resulting in a potential prothrombotic stimulus. D-dimer is a marker of fibrinturnover but is also used as a predictor of pulmonary thromboembolism (PTE) in the absence of sepsis and trauma. It iselevated in a number of inflammatory conditions including acute exacerbations of COPD.

METHODS: D-dimer levels of 27 consecutive known cases of COPD with acute exacerbations admitted in Respiratory ICUwere evaluated, their values were adjusted for age (defined as age * 10 in patients 50 years or older) and statisticalanalysis of the data was done.

RESULTS: Of the 27 patients admitted with acute exacerbation of COPD, 66.66% were male and 33.33% were female. Themean age of the admitted patients was 66.81+/-9.8 years. The mean D-dimer level in these patients was 3107.9 +/-2882.7 ng/ml. 26 patients were >= 50 yrs of age. The mean age-adjusted D-dimer cutoff was 675.7+/-91.8 ng/ml. All thesepatients underwent MDCT thorax and that revealed no evidence of PTE or pneumonia.

CONCLUSION: D-dimer level is elevated upto 4.6 times in acute excacerbations of COPD and is not a useful screening testfor PTE.

CLINICAL IMPLICATION: D-dimer cannot be used as a screening tool for pulmonary embolism in COPD with acuteexacerbation. Futher studies are required to evaluate the D-dimer cutoff value that can be used to screen PTE in thepatients of COPD exacerbation.

P156TITLE: - Adequacy of inhaler technique in COPD & asthma patients attending a tertiary care hospital in NaviMumbai.

AUTHORS: - Dr. Akanksha Das, Dr. Jayalakshmi T.K., Dr. Girija Nair, Dr. LavinaMichandani, Dr. Mugdha Bhide.

OBJECTIVES: - Chronic obstructive pulmonary disease (COPD) & asthma are major concerns to health care system.Improper inhaler device used (Metered dose inhaler/ Dry powder inhaler) is one of the major causes associatedwith inadequate control of the disease. This study was performed to evaluate the inhaler technique amongpatients and to investigate factors associated with improper use and whether age or gender was associated withpoor inhaler technique.

Methods:- A cross-sectional study of all patients who visited chest out- patient department with asthma or COPDover a 6 months period in a tertiary care hospital in Navi Mumbai. Information was collected about demographicdata and inhaler technique was assessed using a standard checklist.

Results: - There were 107 patients, 71 with asthma and 36 with COPD. Inhaler techniques of 95% of patients werefound to be inadequate in some form or the other as per check- list Of all the patients interviewed, only about60% of patients recalled, that demonstration was done by doctors or other health care professionals. Twelvepercent were instructed by pharmacists and remaining followed their friend’s or relative’s suggestions along withinsert literature.

Conclusion: - The inhaler technique is inadequate among most patients. On every visit patient’s inhaler techniqueshould be observed and adequate suggestions should be given to correct any deficiencies.

P157An Observational Study Of Risk Factors For Hospitalization Of Chronic Obstructive Pulmonary DiseaseExacerbation And Their Outcome

DR. S. BARMAN, DR. S. K. SAMANTA, DR. A. DATTA, DR. P. BISWAS

Department of Pulmonary Medicine, Fortis Hospitals Kolkata

ObjectivesBy 2020 chronic obstructive pulmonary disease will be fifth leading cause of disability and third leading cause ofdeath worldwide. By 2030, fourth leading cause of death. If risk factors of hospital admission can be identifiedpreventive measures can be taken to affect outcome and reduce the economic burden. This study aimed to studyrisk factors associated with acute exacerbation, study the quality of life and evaluate the ultimate outcome ofthese patients.

MethodUsing a preformed structured questionnaire; relevant blood parameters including C-reactive potein, Pulseoxymeter, Spirometry, Echocardiography, arterial blood gas analysis to assess risk of exacerbations and outcomeinlast one year.

ResultsOf 60 patients included in study, majority are above 60 years (56.6%) with male predominance (80%) and 17patients (28.3%) died during hospitalization. Advancing age (p value < 0.001), smoking status (p value < 0.001),duration of symptoms (p value < 0.004), FEV1 (GOLD grade p value < 0.001), past hospitalization (value < 0.018),

Body mass index(p value < 0.005), Dyspnea scale (p value < 0.001) were statistically significant relating toexacerbations whereas sex is found to be statistically insignificant (p value 0.857).

ConclusionIdentification of risk factors of exacerbation helps respiratory specialists to extend their expertise to broaderdiagnostic and treatment. But the study has limitation of hospital based Barkesonian bias.

P158Number of pack year smoked increases frequency of COPD exacerbation per yearMohit Bhatia, J.K.Samaria, Ganeshee Lal SharmaDepartment of TB chest and respiratory diseases S.S. hospital IMS BHU Varanasi.

Objective:Smoking is the most important risk factor involved in pathogenesis of COPD. Quantification of the risk due tosmoking has done in form of pack per year (1). We investigate effect of increase quantity of risk factor (pack years)on the frequency of COPD exacerbation per year.

Method:We evaluated 50 patients of COPD and classify them in 4 groups according to number of pack year smoked.

Group- 1(o pack years, the non-smokers), group-2 (1-10 pack years), group-3(11-20 pack years), and group-4 (>20pack years). We excluded group-1 from our study as some of non-smokers had other risk factors like exposure tobiomass fuel etc. which are difficult to quantify. We obtain record of total number of exacerbation of COPD in lastone year for all the patients included in study. Obtained data was analysed statistically.

Results:In our study we found that mean value for group-2 was 0.12 (with standard deviation of + 0.35), for group-3 it was1.25(with standard deviation of + 1.0) and in case of group-4 it was 1.55(with standard deviation of + 1.5). Numberof pack per year has significant positive correlation with frequency of COPD exacerbation per year (f-value= 4.203,p-value= 0.024).

Conclusion:As the numbers of pack year smoked increases risk of exacerbation of COPD increases.

References:1.Cigarette Calculator - American Cancer Society www.cancer.org › Stay Healthy › Tools and Calculators ›Calculators

P159Agreement between the spirometry criteria and peak expiratory flow rate criteria in diagnosing bronchialasthma – a prospective observational studyRishabh Priyadarshi, Seshadri Varadarajan, Suganya, A SureshSundaram Medical Foundation, ChennaiObjective:To compare the spirometry criteria (post bronchodilator reversibility of 200 ml plus 12% in FEV1 and/or FVC – GINA& ATA/ERS) and peak expiratory flow rate criteria (post bronchodilator reversibility of 60 L/mt or 20% - GINA 2013)in diagnosing bronchial asthma.Study period: October 2013 to July 2014Materials and Methods:The spirometry (Ganshorn spirometer) reports of all patients during the above period were collected. Peak flowrecording (pre and post bronchodilator) using Wright’s peak flow meter, was done additionally during thespirometry tests and was mentioned in the reports.

The reports of those patients who showed positive bronchodilator response in PEFR (GINA) and those withsignificant FEV1 (GINA &ATS/ERS) and/or FVC (GINA &ATS/ERS) reversibility were isolated. The sensitivity andspecificity of PEFR method in diagnosing asthma was calculated in comparison with the spirometry method.Results:There were 258 spirometry reports during the above period and all the reports had the documentation of pre andpost peak expiratory flow rates (PEFR) measured simultaneously. Sixty six out of 258 reports showed positivebronchodilator response in FEV1 and/or FVC, which means 66 (25.6%) patients’ reports were consistent with thediagnosis of asthma. PEFR reversibility was seen in 33 (12.8%) patients’ reports. Twenty one out of 33 PEFR positivepatients were also positive for spirometry criteria (FEV1 and/or FVC reversibility) and the remaining twelve patientswere positive for PEFR criteria alone.

FEV1 and/or FVC positive (DISEASE) FEV1 and/or FVC negative(DISEASE)

PEFR positive (TEST) 21 12PEFR negative (TEST) 45 180

PEFR in comparison with spirometry as a gold standard showed,Sensitivity: 31.8%Specificity: 93.75%Positive predictive value: 63.6%Negative predictive value: 80%Though the PEFR reversibility has a good specificity, it seems to have a poor sensitivity in diagnosing asthma.Hence further testing with spirometry would still be required for the confirmation of asthma in patients withabsence of PEFR reversibility.Conclusion:Peak expiratory flow rate (PEFR) measurement, though a simple method in a resource limited setting, is a doubtfulparameter in asthma diagnosis.

P160FeNO and serum IgE do not correlate with asthma assessment tests in Indian untreated severe asthma patientsAuthors: Mayuri Johari, Deepak TalwarMetro Centre for Respiratory Diseases, Noida, IndiaObjectives: Severe asthma patients demonstrate chronic inflammatory changes in the airway , severity beingascertained by assessment scores. FeNO and Serum IgE are well-establisehd markers of atopic inflammation. Thisstudy correlates FeNO and total serum IgE with asthma assessment scores in 50 adult untreated Indian patientswith severe asthma. Smokers and ex-smokers were excluded from the study.Methods: 50 untreated patents of asthma satisfying the latest WHO criteria for adult severe asthma, attendingoutpatient clinic of Metro Centre for Respiratory diseases were retrospectively analyzed for their clinicalsymptoms, assessment scores and atopic biomarkers in the last two years using SPSS software.Results: Severity assessment of asthma was done with asthma control test (ACT) in 34 patients and asthma controlquestionnaire (ACQ) in 16 patients, and FeNO and Serum total IgE done in all patients included in the study. Themean ACT score was 13.44 + 3.71and mean ACQ score of 3.07 + 1.59. The mean FeNO was 62.09 + 52.96 parts perbillion(ppb) and the mean IgE value was 540.54 + 705.12 IU/ml. The cut-off value for FeNO to be considered asraised was 50ppb and 168 IU/ml for serum total IgE. There was inverse relationship of FeNO and Serum total IgEwith Asthma control test(ACT) and Asthma Control Questionnaire(ACQ)(p>0.05)Conclusions: FeNO and serum total IgE do not correlate with ACT and ACQ scores in adult severe asthma patients.

Clinical implications: Severe asthma, caused by varied etiologies, may be atopic or non-atopic phenotype. Westernstudies show improvement in the assessment scores and atopic biomarkers corticosteroid treatment. However, inview of lack of data in severe untreated asthma, studies are required to correlate these variables in this subset ofpopulation.

P161

FeNO and serum IgE do not inter-correlate in untreated severe asthma in adult Indian patients.Authors: Mayuri Johari, Deepak TalwarMetro Centre for Respiratory Diseases, Noida, IndiaObjectives: Both serum IgE and FeNO are biomarkers of atopic inflammation, which is a hallmark of asthmaticairways. This study inter-correlates FeNO and total serum IgE in 50 adult untreated Indian patients with severeasthma. Patients with a history of smoking were excluded from the study.Methods: 50 untreated patents of asthma satisfying the latest WHO criteria for adult severe asthma, attendingoutpatient clinic of Metro Centre for Respiratory diseases were retrospectively analyzed for their clinicalsymptoms, assessment scores and atopic biomarkers in the last two years using SPSS software.Results: FeNO and Serum total IgE were done in all patients included in the study. The mean FEV1 was1.85 + 0.67liters and FeNO was 62.09 + 52.96 parts per billion(ppb) with a mean IgE value was 540.54 + 705.12 IU/ml.According to the standard cut-off values, FeNO was raised in 23 patients (more than 50ppb), 13 patients hadborderline raised values (between 25 to 50 ppb) and 12 patients showed normal values (less than 25 ppb). Totalserum IgE was raised in 36 patients (more than 168 IU/ml) and normal in remaining 14 patients with a mean of79.57 IU/ml. FeNO and total serum IgE showed negligible inter-correlation (r= 0.02, p>0.05).Conclusions: FeNO and serum total IgE do not inter-correlate in adult untreated severe asthma patients.

Clinical implications: While both serum IgE and FeNO are markers of atopic inflammation, studies show conflictingdata between the two variables. This could be due to varied etiologies of severe asthma including atopic or non-atopic phenotypes. However, in view of limited data in severe untreated asthma, studies are required to correlatethese variables in this subset of population.

P162To determine the prevalence pattern of aeroallergens in patients of Bronchial Asthma and Allergic Rhinitis

reporting to a tertiary care centre in western UP.

A Jain, M Saluja, S Singh, S Kumar, S R Yadav

Subharti Medical College, Meerut, India

Allergens have been associated with diseases such as BA (Bronchial Asthma) and AR (Allergic Rhinitis) which are ofmost concern, among the patients visiting the chest physicians. Exposure to various aeroallergens has directimpact on pathogenesis as well as outcome of BA and AR. Allergens responsible for respiratory allergies (BA & AR)are found to be different from place to place as echoed in various Indian and international studies. This study isbeing done in Meerut district of western province of Uttar Pradesh to find out the major prevailing aeroallergensleading to respiratory distress.

Objective: To determine the prevalence pattern of aeroallergens in patients of BA and AR reporting to tertiary carecentreSubharti Medical College inwestern UP.

Methods: It is a prospective study in which a cohort of 20 patients were assessed who were diagnosed as a case ofBA or AR clinically or by pulmonary function test. These patients were subjected to skin prick test after takingwritten and informed consent.

Results: Among the total cohort 13(65%) were females, 7(35%) males. In relation to age wise distribution maximumpatients were in age group 20-29 yrs(7 pts, 35%) and minimum in 60 yrs and above with 1 pt(5%). In relation todisease status 11 had BA followed by 5 AR and 4 had mixed disease. Distribution of aeroallergens in maximumpositivity in age groups were observed as; pollens 46 (97%significant) in age group 30-39, fungi 17 (94.4 sig) in 0-19yrs, insects 15 (100% sig)in 20-29yrs & 30-39yrs, dusts 11 (100%sig) in 20-29yrs, dander 6 (100% sig) in 20-29 yrs,feathers and fabric 5 (83.3% sig) in 20-29yrs. House dust mite was found to be positive in 70%(sig) of the totalcohort group with maximum in 20-29yrs.

Conclusion: The study concludes that most of the patients allergic belong to female gender. High allergenicity wasobserved in BA. Most of the patients had polysensitisation and the age group most vulnerable was 20-29yrs.

Education of patient regarding avoidance of allergens help in reduction of symptoms and morbidity and increasingthe overall health status.

P163Revolizer®: The Next Generation Novel Single Dose Dry Powder Inhaler

V Naik1, G Malhotra2, P Rege2, V Mhapsekar2, B Aggarwal1, J Gogtay1

1 Medical Services and

2 R & D Centre, Cipla Ltd, Mumbai, India

IntroductionDry powder inhalers (DPIs) are breath-actuated devices which do not require propellants and eliminate the needfor co-ordination and cold-freon effect associated with the use of metered dose inhalers. The Revolizer® - a novel,single dose DPI, is the result of a development program to address the critical requirements of an ideal inhalationdevice. It was developed using computational fluid dynamics simulation and enables visual, gustatory and acousticfeedback mechanism to assure patients of having taken their medication correctly. It is designed to be used withdry-powder capsule formulations and is currently available in India, Sri Lanka, Nepal, UAE, Dominican Republic,Lebanon, and South Africa.

Performance of the RevolizerRevolizer shows a high drug deposition at flow rates of 30, 45 and 60 L/min. The Revolizer has medium airflowresistance and uses an optimized dispersion system to ensure effective de-agglomeration of the inhalationpowder. Revolizer gets activated at inspiratory flow rates of approximately 44 L/min.

Design features of the RevolizerThe long and narrow mouthpiece of the Revolizer leads to a straight air path and a laminar exiting airflow whilecreating turbulence in the tubular capsule chamber, thus facilitating easier evacuation of the drug particles at allangles of holding the device. The design of the capsule chamber and the baffles inside ensure maximum drugdelivery to the lungs. The transparent medication chamber provides visual confirmation, the vibration sound of thecapsule whirring in the chamber gives an audio feedback, and the taste of the lactose (excipient) confirms doseinhalation.

ConclusionThe Revolizer has been designed to achieve optimal efficacy and to deliver doses consistently with minimalinstruction. It can be used for delivering a variety of inhaled medications including bronchodilators, corticosteroidsand their combinations.

P164Severity, risk factors and comorbid conditions in newly diagnosed smoking and non-smoking COPD patients:theSCOPEstudyDr R. Kacker1,Dr A. Dalal2, Dr R. Palaniappan31.Dr Rajeev Kacker - Sr Consultant Pulmonary, Critical Care & Sleep Medicine, Regency Hospital,India2.Dr AlpaDalal - HOD Pulmonology, Jupiter Hospital, India3.Dr Ramanathan Palaniappan -Prof & HOD, Department of Pulmonary Medicine, PeelameduSamanaiduGovindarajulu Hospitals,IndiaObjective:Survey of newly diagnosed COPD PatiEnts (SCOPE)in India,to gain insights on theirhealth status.Method:

This survey conductedin7 cities of Indiainvolved 47 pulmonologists, who recordedsymptoms, risk factors, lungfunction, previous respiratory ailments, inhaler use, history of exacerbations, hospitalizations, comorbidconditions and COPD assessment test (CAT) score for consecutive newly diagnosed COPD patients.Results:Data was obtained on 247 newly diagnosed COPD subjects, mean age (± SD) 59.91 (± 11.53) years, majority 209(84.6%) males with 75.7%reportingcurrent or past history of smoking.Of the non-smokers, 24.29% reported biomass exposure.Average FEV1% predicted was 50.30 (± 18.96) and average FEV1/FVC% was 60.38 (± 20.30), indicating a higherdegree of airflow limitation. Cough (97.57%), dyspnea (95.45%), sputum (92.41%) were the most commonsymptoms followed by wheezing (82.51%) and chest tightness (85.59%). Average CAT score (± SD) was 21.26 (±7.68). Approximately 31%, 28% and 22% of all patients reported biomass exposure, living close to highway/industrial areas and occupational exposure (cotton mills/ chemicals industry etc.), respectively.History of respiratory ailments included asthma (29.96%), tuberculosis (15.38%) and allergic rhinitis (5.73%). 45.9%patients were using inhalers, of whom 67.44% did not have a good inhaler technique and 59.77% reported poorcompliance with therapy.On an average, there were 1.96 exacerbations and 0.79 hospitalizations in the last 1 year. Hypertension, diabetesmellitus, osteoporosis, depression was reported in 33.2%, 17.81%, 7.69% and 6.88% of the COPD patients.There was no significant difference between symptoms, clinical presentation, co-morbidities, number ofexacerbations and CAT assessment in smokers and non-smokers.Conclusion:The SCOPE survey highlightsthat newly diagnosed COPD patients attending a chest physician’s clinic in India, are atan advanced stage of COPD with comorbid conditions. Many of themare non-smokers showing symptoms, co-morbidities and exacerbation frequencysimilar tosmokers.

P165Clinical effectiveness of anticholinergic tiotropium bromide as an add on therapy in patient with severe bronchialasthma: A randomized control trial.

Dr. Santhosh V G, Dr. G.S. Gaude, Dr. Jyothi Hattiholi, Postgraduate in Department of Pulmonary Medicine, KLEUniversity’s Jawaharlal Nehru Medical College, Belgaum, Karnataka

Introduction: Some patients with severe asthma remain symptomatic despite maximum recommended treatment.Tiotropium bromide, a long acting inhaled anticholinergic agent might be used as an effective bronchodilator insuch patients.

Aim: To evaluate clinical effectiveness of anticholinergic tiotropium bromide as an add on therapy to the usualstandard therapy in severe Asthma patients.

Methodology: In a randomized single blinded study involving 60 patients, aged more than 18 years with severeAsthma, the patients were randomized into two groups. The study group received addition of 18mcg of Tiotropiumonce daily, while both the groups were continued on standard therapy as per GINA guidelines. Improvement inlung function test, clinical symptom and quality of life by mini asthma quality of life questionnaire (AQLQ) weremonitored at 4, 8 and 12 weeks.

Results: A total of 30 patients were included in each group. Baseline characteristics were identical in both thegroups with a mean age of 41.5±11.87 years. At 12 weeks, the mean (±SD) change in FEV1, FVC and PEFR frombaseline was greater in Tiotropium group as compared to the control group, with a difference of 0.71±0.36 L (p˂0.001), 0.75±0.40 L (p˂ ˂ 0.001) and 0.73±0.47 L (p -AQLQ was statically better in the Tiotropium group (p ˂0.001). There was no difference in the number ofexacerbations during the study period between the two groups. No serious adverse events were noted with theuse of Tiotropium.

Conclusion: The addition of once-daily Tiotropium to severe asthma treatment, including a high-dose inhaledcorticosteroid plus a long-acting β2-agonist, significantly improves lung function and quality of life in patients withinadequately controlled, severe asthma.

P166Pulmonary Function test in patients of Allergic Rhinitis

Jinesh Shah, Ajay Akkara, Stani Akkara

Smt. B. K. Shah Medical Institute and Research Centre

Introduction: It is a known fact that there is a close relationship between allergic rhinitis (AR) and bronchialasthma (BA). However very rarely do pulmonologists and ENT surgeons cross refer patients or look for signs ofconcomitant disease, especially in the absence of symptoms or complaints in a given patient. Aim: To find thestatus of pulmonary function in patients of allergic rhinitis. Materials and methods: All patients of allergic rhinitispresenting to our institute were investigated for pulmonary functions tests (PFT) over and above their routinework up and treatment. The findings of PFT were collected, tabulated and analysed. Results and Discussion: Atotal of 20 cases were included in the study during the three month period of the study. Majority of the cases werefemale and the commonest age group of presentation was in the fourth decade of life. Only 6 of the cases hadnormal PFT. 2 of the cases had a history consummate with BA and manifested as severe obstructive and restrictivedisease. Rest of the cases had varying degrees of obstruction and restriction on PFT. These results were as percontemporary literature. Conclusion: All cases of allergic rhinitis should also undergo work up for BA to detect subclinical and pre clinical stages of the disease.

P167Clinical profile of diseases causing chronic airflow obstruction in a tertiary care centre in India

AUTHORS: SS GUPTA, A SRIVASTAVA, S TRIPATHI

Department of Pulmonary Medicine, Era’s Lucknow Medical College & Hospital, Lucknow, India

OBJECTIVES: To evaluate the profile of patients with chronic airflow obstruction with an aim to establish a cause-effect relationship between various disorders vis-a-vis chronic airflow obstruction.

MATERIALS AND METHODS: A total of 100 OPD and in-patients from the Department of Pulmonary Medicine withchronic airway obstructive disorders were included. Demographic profiles and environmental and occupationalexposures were noted. Clinical features and spirometry results were used to confirm the diagnosis.

RESULTS: Majority of patients had COPD (68%) followed by bronchial asthma (19%) and bronchiectasis (13%).Major etiology of COPD and bronchiectasis was smoking (70.6% and 53.8% respectively). Age of bronchial asthmapatients was lowest (29.74±4.78 years), followed by those suffering from COPD (non-smokers) (55.00±10.67 years),bronchiectasis (58.46±9.02 years) and COPD (60.67±6.64 years). Majority of patients of COPD due to smoking(100%) were males. COPD owing to non-smoking reasons was more common in females who were exposed tobiomass fuel smoke. A total of 11 (55%) COPD (non-smokers) patients had a history of ATT intake. No significantassociation between occupation and different types of chronic airflow obstruction (CAO) was observed. Pulmonaryfunctions were significantly more impaired in bronchial asthma patients as compared to other groups.

CONCLUSION: In this study, COPD was the most common chronic airway obstructive disorder. Risk of CAO washigher in smokers or those having exposure to biomass fuel smoke. Pulmonary functions of patients with different

types of CAO showed a different trend

P168

A study of pulmonary function assessment in patients with allergic rhinitis.

Authors -ANUSHANALAMOTHU, B.VIDYASAGAR, B.P.RAJESH, B.J.ARUN

DEPARTMENT OF PULMONARY MEDICINE,

Institute :J.J.M.M.C, DAVANGERE, KARNATAKA, INDIA

ABSTRACT:

Objectives: a)To assess the pulmonary functions of patients with allergic rhinitis. b) To demonstrate thepresence of airflow obstruction and post-bronchodilator reversibility and to correlate with severity of allergicrhinitis in these patients.

Material and methods: 50 patients presenting with allergic rhinitis over a duration of 1year (from Dec 2012- Dec2013) were enrolled in our study .All the patients were evaluated with complete history, clinical examination,blood investigations, spirometry (FVC,FEV1,FEV1/FVC,FEV25-75%) pre and post bronchodilator inhalation. Thedegree of airflow obstruction and reversibility were assessed and correlated with severity of allergic rhinitis.

Results: : In our study of 50 patients with AR- obstructive flow pattern was observed in most of the patients-27(54%) with reversibility in 17(63%). Among the patients with obstruction(n=27) - small airway obstruction withreversibility was demonstrated in 10(37%) patients and large air way obstruction with reversibility in 7(26%)patients. Majority of the patients presented with moderate-severe AR-34(68%)vs mild AR-16(32%).). Lower airwayobstruction was more frequent 19(56%) in patients with moderate- severe AR(n=34) compared to patients withmild AR(n=16) - 8(50%).The mean baseline FEV1(% predicted)was 74.14±20.42% and it tend to decrease withseverity of AR(P<0.004).The mean baseline FEF25-75%(%predicted)-54.76±24.64 and the flow rates tends todecrease with severity of AR(P<0.01).

Conclusions: According to our study the prevalence of asthma in patients with allergic rhinitis was high. Smallairway obstruction was found to be predominant and there was significant post-bronchodilator reversibility.Theflow rates tend to decrease with severity of AR. Asthma and allergic rhinitis should not be treated as two seperateclinical entities. Patients with allergic rhinitis should be evaluated for lower airway obstruction to initiate a safeand effective combined treatment strategy for both upper and lower airway.

P169ISOLATED PULMONARY MUCORMYCOSIS PRESENTING AS FATAL SEVERE ASTHMASANTOSHAM R, ANANTHA R KISKU KH, MADHUSMITA MDepartment of Pulmonary Medicine, Pondicherry Institute of Medical Sciences, Puducherry-605014Pulmonary mucormycosis is an uncommon disease caused by zygomycetes. It occurs predominantly inimmunocompromised host. Isolated pulmonary mucormycosis is extremely rare. We report a case of pulmonarymucormycosis presenting as acute severe asthma and consolidation with no other site of involvement andunderlying risk factors

We report a 30 year old female who presented with altered sensorium – 1 day, wheeze, breathlessness and feverfor 10 days. Her chest xray showed non homogenous opacity in the right lower zone. She was a known asthmaticnot on regular treatment. She had no other comorbidities. She was found to have CO2 narcosis and was treated asacute severe asthma with ventillatory support. She died of respiratory insufficiency and her post mortem lungbiopsy showed mucormycosis

P170IS COPD THE BREEDING GROUND FOR PULMONARY TUBERCULOSIS ?

AP KANSAL, Kamal Deep, Prabhleen KAUR, Shiyas MOHAMMED, Anand Kumar BANSAL, Varinder SINGH Bamrah

Department Of Chest & TB, GMC, Patiala, Punjab

INTRODUCTION : Both chronic obstructive pulmonary disease (COPD) and tuberculosis (TB) primarily affect thelungs and are major causes of morbidity and mortality worldwide. COPD and TB have common risk factors such assmoking, low socioeconomic status and dysregulation of host defence functions. COPD is a prevalent co-morbidcondition, especially in elderly with TB but in contrast to other diseases known to increase the risk of TB

AIM AND OBJECTIVES: To study Profile of Geriatric Patients having Pulmonary tuberculosis and COPD and their corelation .

METHOD AND MATERIALS: This study was conducted on 500 geriatric patients with different respiratory problemspresenting in Department of Tuberculosis and Respiratory Diseases, Govt. Medical College, Patiala. This was aperforma based study. A proforma was used to seek biodata, clinical history and relevant investigations. All thecases were subjected to detailed physical examination and specific investigations and final diagnosis was made.Newly diagnosed Pulmonary tuberculosis were checked for history of COPD, smoking and corticosteroid use .

RESULTS : This study shows 372 (74.4%) males and 128 (25.6%) with different respiratory problem.243 weresmokers or have smoked in past.116 were having COPD. 147 cases were diagnosed to have pulmonary tuberculosis ,124 males and 23 females. Out of 147 cases of pulmonary tuberculosis 79 had history of smoking, 15 had history ofbiomass fuel exposure, 58 had history of inhaled ICS use with mean duration of use 4±3.2 and 54 were previouslydiagnosed as COPD.

CONCLUSION: Keeping a high suspicion and regularly monitoring for the development of pulmonary TB in COPDpatients are necessary,as majority are receiving oral corticosteroids and have history of smoking.

P171Intranasal Fluticasone vs Oral Montelukast in the management of NasoBronchial Allergy

Dr Apar JINDAL, Dr Meenakshi N., Dr Subramanian S.Department of Respiratory Medicine, Chettinad Hospital and Research Institute, Kelambakkam, Chennai, India

Introduction:Both asthma and rhinitis are considered to be inflammatory disorders of the airway as per the “one airwayhypothesis”. Thus it follows that a therapeutic approach targeting one site may significantly improve the other.

Aim:To compare intranasal fluticasone and oral montelukast for - symptom control of asthma and allergic rhinitis (nasaland non nasal), reduction in acute exacerbations and adverse effect profile.

Methodology:120 Patients of Bronchial Asthma (GINA) and concomitant Allergic Rhinitis (ARIA) in the age group of 15 to 65 yearswere randomized into 2 groups receiving intranasal fluticasone propionate 200mcg and oral montelukast 10mgrespectively, for a period of 60 days, and neither of the drugs for the following 30 days. During study periodAsthma was treated with fluticasone/salmeterol 125/50 mcg via Metered Dose Inhaler for all patients. At each visit(Day 0, 30, 60 and 90) asthma and allergic rhinitis control was evaluated by symptom score questionnaire.

Results:The baseline characteristics were comparable in both the groups. There was better asthma control in thefluticasone group at Day 60(p = 0.001) and 90 (p = 0.041). At day 60 the control of nasal and non-nasal symptomsof allergic rhinitis was better in fluticasone group (difference of mean -2.324, p = 0.000 & -1.369, p = 0.028respectively). There were more adverse effects noted with Montelukast, most common being headache and GIdisturbances (18.9% and 13.2% respectively). Adverse effects with fluticasone were nasal irritation (9.3%) and

throat irritation (7.1%). At day 60 the Odds Ratio for Acute Exacerbation of Asthma for fluticasone versusmontelukast was found to be 0.325(p = 0.098).

Conclusion:The present study demonstrates the superior efficacy and better safety profile of intranasal fluticasone Propionateover oral montelukast, in control of Asthma and Allergic Rhinitis symptoms in patients with Nasobronchial Allergy.

P172Title- BODE index as a prognostic tool in COPD patients.

Authors- Dr Kapil Jangid,Dr Ravi Dosi ,Dr Ravindra Chordia ,Dr Ashok Bajpai , Dr Satish Motiwale.

Sri Aurobindo Institute of Medical science & PG Institute Indore, India

Objective: - We hypothesize that BODE index is good prognostic tool in COPD patients.

Methods: 100 pt over 2 year period at Sri Aurobindo Institute of Medical science indore in department ofpulmonary medicine recruited in study and demographics, clinical evaluation, spirometry, peripheral oxygensaturation, body composition, 6-minute walking distance, dyspnea, and quality of life measurements wereobtained and BODE score is calculated at 0 month (baseline) and after 1 yr of follow up of 51 patients.3 groups as per BODE score severity were made & patient were followed accordingly. P <0.05 considerd significant& paired t test applied.

Results-Baseline of BODE 1 - 19 pts (patients) were in BODE 1

2 pts worsen to BODE 20 pt was in BODE 3

Baseline of BODE 2 - 7 pts were in BODE110 pts worsen to BODE 2 (p <0.001)1 pt was in BODE 3

Baseline of BODE 3 - 0 pt was in BODE 15 pts improved to BODE 27 pts remain in BODE 3

We obtain that 6 min walk distance significantly improved in BODE 2 & BODE 3 (p < 0.003 & p<0.012)FEV1 was not significant with either of BODE index. Patients addicted to both smoking and alcohol were moredecrease in 6MWD (P 0.136) also decline in FEV1 (P 0.866).

Conclusion- BODE index strongly determine prognosis of COPD patients and be should consider as a surrogatemarker in assessment of COPD patients as compared to FEV1.

P174AIRWAY HYPERRESPONSIVENESS IN CHRONIC ASTHMATICS

Dr. Jenam Mehta, Dr. J M Phadtare, Dr. N N Ramraje

Department of Pulmonary Medicine, Grant Government Medical College, Mumbai-8

ABSTRACT

50 mild to moderate asthmatic patients were assessed for airway hyper responsiveness by direct method usinggraded concentrations of histamine.The youngest was 18 years, the oldest 51 years ,the mean age being 34years.44% were males and 56% females. Bronchial challenge tests were positive in 90% of mild to moderateasthmatic patients. 62% of the asthmatics had an associated nasobronchial allergy as documented by X ray PNS.There was significant linear correlation of PC20 levels with FEV1, .There was no significant correlation of PC20 levelswith serum Ig E levels.

P175CONSOLIDATED REPORT OF THE PULMONARY FUNCTION TEST CHECK UP CAMPS FOR MUMBAI TRAFFIC POLICEJAIN S., MOHANTY K.C., BENDRE S.S., SAI H., BALAKRISHNAN R.K. J. SOMAIYA MEDICAL COLLEGE & RESEARCH CENTRE, MUMBAIINTRODUCTION-URBANISATION IS ASSOCIATED WITH AN ENORMOUS INCREASE IN VEHICULAR TRAFFIC EMITTINGEXHAUST AND POLLUTION OF THE ATMOSPHERE.SO2,NO2,CO,SUSPENDED PARTICLE PLAYS A KEY ROLE INOVERALL ATMOSPHERIC POLLUTION AND MOTOR VEHICLE EMISSION CONSTITUE THE MOST SIGNIFICANTSOURCE OF ULTRAPARTICLE IN AN URBAN ENVIRONMENT.TRAFFIC POLICE ALL EXPOSED TO POLLUTANT MORETHEN 8 HRS AS OCCUPATIONAL HAZARDAIM- DETERMINE THE PULMONARY FUNCTION TEST OF TRAFFIC POLICEPERSONALMETHOD-MEDICAL CHECK UP WAS DONE ON 1455 TRAFFIC POLICE PERSONNEL AT 12 MULTISPECIALITY MEDICAL CHECK UP WITH CO-OPERATION OF ADDITIONAL COMMISSIONER OF POLICE DRAWING THEPOLICEMEN FROM EASTERN,WESTERN SUBURB,CENTRALMUMBAI, .PFT WAS CARRIED OUT AS A PART OFCOMPLETE MEDICAL CHECK-UP RESULTS ARE AS FOLLOWSRESULT-OF 1455 POLICEMEN ALL PERFORMED THEPFT. 210 (15%) WERE FEMALES AND 145(10%) WERE SMOKERS. 250(17%) HAD AIRWAY OBSTRUCTION, OF WHICH204(14%) HAD MILD OBSTRUCTION,45(3%)HAD MODERATE OBSTRUCTION AND ONE POLICEMAN HAD SEVEREAIRWAY OBSTRUCTION . MACHING INDIAN STANDARDS OF SPIROMETRY. NO POLICEMAN DEMONSTRATEDRESTRICTIVE PATTERN. AVERAGE DURATION OF WORKING HOURS WAS 8 HOURS PER DAY.CONCLUSION-OURRESULT SUGGEST THAT EVEN AFTER EXPOSURE TO ENVIROMENTAL POLLUTION PFT CHANGES WERE NOT MUCHAS EXPECTED .MOST OF THEM HAD MILD AIRWAY OBSTRUCTION WHICH CAN BE CONTROLLED BY BREATHINGEXCERCISE AND USING FACIAL MASK. INTRODUCTION OF UNLEADED PETROL, LOW SULPHUR DIOXIDE CONTENTDIESEL AND IMPLEMENTATION OF BHARAT III EMISION NORMS HAS PROBABLY PLAYED A MAJOR ROLE INPREVENTING DEVELOPMENT OF ABNORMAL LUNG FUNCTION.

P176ROLE OF SPUTUM EOSINOPHILS CORRELATION WITH SPIROMETRY DURING ACUTE EXACERBATION AND

REMISSION IN BRONCHIAL ASTHMA AND COPDP.RAVIKMC

OBJECTIVES:-The presence of eosinophilia has been considered typical asthmatic inflammation where asneutrophils,macrophages and lymphocytes are the most significant inflammatory cells found in the airways ofpatients with COPD.The aim of the present study is to compare the eosinophils in sputum of pts with asthma andCOPD.

MATERIALS AND METHODS:-30 pts presenting with airway disorders were prospectively studied in the year 2012-2014 they were evaluated with spirometry and sputum for eosinophil count during exacerbation and remission.

RESULT:-Out of 30 pts, 20 were COPD and 10 were bronchial asthma.In the bronchial asthma group 9 out of 10 hadsputum eosinophilia(90%) and 1 pt didn’t. (Mean level during exacerbation- 13.2).In remission 8 pts had sputumeosinophilia 2 pts didn’t.(Mean level - 3.8). In the COPD group out of 20, 18 had sputum eosinophilia and 2 ptsdidn’t.(Mean level in COPD exacerbation-9.8),during remission 3 patients had sputum eosinophilia,17 ptsdidn’t.(Mean level during remission -1.5).

CONCLUSION:-There was no difference in the occurrence of sputum eosinophilia during exacerbation in bronchialasthma and COPD.But mean level of eosinophilia is more in asthma than COPD.During remission sputumeosinophilia was more common in asthma than COPD

P177CONSOLIDATED REPORT OF THE PULMONARY FUNCTION TEST CHECK UP CAMPS FOR MUMBAI TRAFFIC POLICEJAIN S., MOHANTY K.C., BENDRE S.S., SAI H., BALAKRISHNAN R.K. J. SOMAIYA MEDICAL COLLEGE & RESEARCH CENTRE, MUMBAIINTRODUCTION-URBANISATION IS ASSOCIATED WITH AN ENORMOUS INCREASE IN VEHICULAR TRAFFIC EMITTINGEXHAUST AND POLLUTION OF THE ATMOSPHERE.SO2,NO2,CO,SUSPENDED PARTICLE PLAYS A KEY ROLE INOVERALL ATMOSPHERIC POLLUTION AND MOTOR VEHICLE EMISSION CONSTITUE THE MOST SIGNIFICANTSOURCE OF ULTRAPARTICLE IN AN URBAN ENVIRONMENT.TRAFFIC POLICE ALL EXPOSED TO POLLUTANT MORETHEN 8 HRS AS OCCUPATIONAL HAZARDAIM- DETERMINE THE PULMONARY FUNCTION TEST OF TRAFFIC POLICEPERSONALMETHOD-MEDICAL CHECK UP WAS DONE ON 1455 TRAFFIC POLICE PERSONNEL AT 12 MULTISPECIALITY MEDICAL CHECK UP WITH CO-OPERATION OF ADDITIONAL COMMISSIONER OF POLICE DRAWING THEPOLICEMEN FROM EASTERN,WESTERN SUBURB,CENTRALMUMBAI, .PFT WAS CARRIED OUT AS A PART OFCOMPLETE MEDICAL CHECK-UP RESULTS ARE AS FOLLOWSRESULT-OF 1455 POLICEMEN ALL PERFORMED THEPFT. 210 (15%) WERE FEMALES AND 145 (10%) WERE SMOKERS. 250 (17%) HAD AIRWAY OBSTRUCTION, OF WHICH204(14%) HAD MILD OBSTRUCTION, 45 (3%) HAD MODERATE OBSTRUCTION AND ONE POLICEMAN HAD SEVEREAIRWAY OBSTRUCTION. MACHING INDIAN STANDARDS OF SPIROMETRY. NO POLICEMAN DEMONSTRATEDRESTRICTIVE PATTERN. AVERAGE DURATION OF WORKING HOURS WAS 8 HOURS PER DAY.CONCLUSION-OURRESULT SUGGEST THAT EVEN AFTER EXPOSURE TO ENVIROMENTAL POLLUTION PFT CHANGES WERE NOT MUCHAS EXPECTED .MOST OF THEM HAD MILD AIRWAY OBSTRUCTION WHICH CAN BE CONTROLLED BY BREATHINGEXCERCISE AND USING FACIAL MASK. INTRODUCTION OF UNLEADED PETROL, LOW SULPHUR DIOXIDE CONTENTDIESEL AND IMPLEMENTATION OF BHARAT III EMISION NORMS HAS PROBABLY PLAYED A MAJOR ROLE INPREVENTING DEVELOPMENT OF ABNORMAL LUNG FUNCTION.

P178Triple drug therapy in patients with COPD: a survey of prescription practices in India

DR A HASAN1, DR P PRABHUDESAI2

1Deccan College of Medical Sciences and Care Institute of Medical Sciences, Hyderabad, India2Lilavati Hospital & Research Center, Mumbai, India

Objective:Recent guidelines recommend the use of triple therapy (Long acting β2 agonists [LABA] + long acting muscarinicantagonists [LAMA] + inhaled corticosteroids [ICS]) in patients with advanced chronic obstructive pulmonarydisease (COPD). Triple drug therapy finds a place in the prescribing practices of physicians in India, especially in themoderate and severe stages of COPD. This survey was designed to understand the ground realities of COPDpractice in India in terms of triple drug therapy.Methods:The data for this survey was obtained through a questionnaire from those respiratory physicians across India whoroutinely manage COPD patients.Results:Two hundred respiratory physicians participating in the survey reported that on an average COPD patientscomprised 26.1% of all their patients. According to the survey, 35% [95% CI: 31.3 - 39.8] of patients with COPD werereceiving the three drugs in combination. A concurrent administration of [ICS+LABA] fixed dose combination andLAMA was the most preferred line of treatment by respiratory physicians for prescribing triple drug therapy inpatients with COPD. Eighty percent of the physicians agreed that using triple drug combination in a single inhalercould simplify therapy (especially for patients with comorbidities), improve compliance, reduce overall cost oftherapy and improve efficacy. 48.7% of those physicians who did not prescribe the three drugs in a single inhaleradmitted to lack of data about the combination as the primary factor for reluctance to prescribe the combination.Patients with severe (51%) or moderate to severe (39%) COPD were more likely to be prescribed triple drugtherapy.Conclusion:

This survey provides insight into the fact that respiratory physicians in India frequently employ triple therapycomprising LABA, LAMA and ICS in patients with COPD. They also acknowledged that using triple therapy in a singleinhaler helps improve efficacy, compliance and simplifies treatment regimen.

P179Title

COPD-6 a screening device to detect obstructive airways disease in patients with respiratory symptoms from aprimary care centre in India.

AUTHORS

1. Dr Shobhit Bansal MBBS (Presenting Author); Metro Hospitals & Heart Institute; L-94, Sector-11, Noida,Delhi NCR, India-201301.

2. Dr. Vidya Nair, MD; Metro hospital & heart Institute; L-94, Sector-11, Noida, Delhi NCR, India-201301.3. Mr. Abhijit Vaidya, MSc, abhijit.vaidya@cipla.com; MSc; Medical Service (Clinical Research Division), CIPLA

Ltd., Mumbai Central, Mumbai, Maharashtra, India-400008.4. Dr. Deepak Talwar , dtlung@hotmail.com, MD; Metro Hospitals & Heart Institute; L-94, Sector-11, Noida,

Delhi NCR, India-201301.

INTRODUCTION AND BACKGROUND

Despite rising mortality and health care costs COPD and asthma remains the most undiagnosed diseases due tolack of required infrastructure in primary care hospitals.

AIMS AND OBJECTIVES

To evaluate clinical equivalence in terms of sensitivity, specificity and reliability of COPD-6 device in comparisonwith pneumotach spirometer in detecting patients with obstructive airway disease with respiratory symptoms.

Methods

This was a descriptive, cross-over, prospective study which included 60 participants. Screening was donesequentially with COPD-6 device and pneumotach spirometer. The validity and specificity of the COPD-6 device indetecting obstruction was determined using standard formulas, and the sensitivity, specificity, positive predictivevalue (PPV) and negative predictive value (NPV), were calculated. We also estimated the area under the ROC(Receiver-Operating Characteristic) curve of the FEV1/FEV6 ratio (measured with the COPD-6) in the discriminationof the obstruction, using the FEV1/FVC <0.7 quotient obtained with spirometry as the gold standard.

Results

There were 29 participants detected to have obstructive airway disease. The kappa index was 0.66 when anFEV1/FEV6 cut-off point of <0.7 was used as gold standard. The ROC AUC was 0.88. To detect obstruction, if the cut-off point of FEV1/FEV6 for COPD-6 was <0.70, the sensitivity, specificity, PPV and NPV were, 65.5%, 93.5%, 90.5%and 74.4% respectively. For a cut-off point of <0.76, they were 76.9%, 95.2%, 96.8% and 69%, respectively.

Conclusion

COPD-6 is a moderately accurate device to detect airway obstruction in patient with respiratory symptoms.Greater accuracy is observed when cut-off point is 0.76.

P180Bird Fancier’s Lung - usefulness of ImmunoCAPtechnology to measure IgG precipitating antibodiesagainst avian antigensAuthors and affiliations:S KHAN, S R CHOWDHURY, S GHOSH, A SENGUPTA, B GHOSH and SRAMASUBBANDepartment of Allergy & Immunology, Apollo Gleneagles Hospital, Kolkata, IndiaDepartment of Pulmonary Medicine, Apollo Gleneagles Hospital, Kolkata, IndiaDepartment of Intensive Care Unit, Apollo Gleneagles Hospital, Kolkata, India

OBJECTIVES: Bird fancier's lung is a hypersensitivity pneumonitis (HSP) involving thepulmonary interstitia in response to avian droppings or antigens on bird feathers. There islittle data on the usefulness of serum specific IgG antibodies and whether a cut-off valuecan be determined at different stages of the disease.METHODS: A retrospective analysis was done on suspected HSP patients with datacollected from radiologic analyses, absolute eosinophil count, total IgE levels and avianspecific IgG antibodies using ImmunoCAP (Thermo Fisher Scientific) with Ge91 (pigeonserum, feathers and droppings). Six-point calibration was done using ImmunoCAP IgGcalibrators and serum analyzed at 1 in 100 dilution. Different cut-off levels of AvianPrecipitins IgG were analyzed including negative and positive predictive values. Thecurrent cut-off for significant exposure determined from previous studies is 10 mgA/L.RESULTS:23 patients (10 males, 13 females) with a mean age of 49.9 years (range 20-66 years)between June 2013 to May 2014 were studied. Dyspnea and cough were present in 100%of patients. Mean absolute eosinophil count was 277 (n=11) and mean total IgE was 877kU/L (range 40-2810, n=7). Specific IgE to Aspergillus fumigatus done in 6 patients werenegative (range 0.03-0.28 kUA/L, manufacturer recommended cut-off 0.35). Elevenpatients (47.8%) had high values of avian precipitins from 30.3 to >200 mgA/L, of which 6patients in the acute phase with extensive honey combing on HRCT had very high levelsat >200 mgA/L. Five patients had levels in the intermediate range 30.3-68.1 mgA/L, ofwhich only one patient did not have significant changes on HRCT. 12 patients withoutsignificant lung involvement had mean (± SD) value at 16.74(± 8.34) mgA/L. Cut-off valueat 10mgA/L would yield sensitivity (Se) at 100% but very low specificity (Sp) at 16.67%;cut-off value 20mgA/L, Se 100% Sp 58.33; and at 30mgA/L Se 100% Sp 91.67% PPV91.67 NPV 100%.CONCLUSIONS:Use of the ImmunoCAP Ge91 avian precipitin technology proved helpful to clinicians andwe recommend a higher cut-off at 30mgA/L with concomitant HRCT findings to determinesignificant antigen exposure. Patients with acute HSP had levels >200 mgA/L. The actualcut-off of avian precipitins for subacute and chronic stages of the disease remains to bedetermined.

P181Use of ImmunoCAP technology to measure Aspergillusfumigatus specific IgE and IgG precipitating antibodies (precipitins)in the management of ABPAAuthors and affiliations:S KHAN, S R CHOWDHURY, S GHOSH, A SENGUPTA, B GHOSH, S RAMASUBBAN, DDepartment of Allergy & Immunology, Apollo Gleneagles Hospital, Kolkata, IndiaDepartment of Pulmonary Medicine, Apollo Gleneagles Hospital, Kolkata, IndiaDepartment of Intensive Care Unit, Apollo Gleneagles Hospital, Kolkata, IndiaDepartment of Medicine, Apollo Gleneagles Hospital, Kolkata, India SEN

Objectives:Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity pneumonitis in the lunginterstitium and terminal bronchioles induced by chronic exposure to moulds. We present ourexperience in using the quantitative estimates of specific IgE and precipitating IgG antibodiesagainst Aspergillus fumigatus using the automated ImmunoCAP method (Thermo FisherScientific) in the management of ABPA.Methods:A retrospective analyses was done on suspected ABPA patients who had total IgE (kU/L),specific IgE and IgG against Aspergillus fumigatus (m3 IgE and m3 IgG) blood tests doneusing ImmunoCAP (fluoroenzyme immunoassay), including skin prick tests on some patients.Criteria for ABPA were assessed using the Patterson or Agarwal criteria. Normative data onspecific IgE level for sensitization to Aspergillus fumigatus were calculated on patients withasthma without ABPA. Descriptive statistics and unpaired t-test was done using GraphPadPrism software.Results:71 patients (39 males, 32 females) with average age 53.4 years (age range 9-94 years)between June 2013 to May 2014 were evaluated for ABPA. 19 patients (26.7%) fulfilledcriteria for ABPA of which 11 had m3 IgG between 40-90 mgA/L, 5 between 90-200 mgA/L, 2had >200 mgA/L and one patient with skin test positive to 3 Aspergillus species but low m3IgG (18 mgA/L). The mean (SD) m3IgG value of the ABPA patients was 98.1 (56.38) ascompared with mean value of 58 patients with bronchiectasis but without ABPA 17.33 (SD9.68) (p<0.0001, 95%CI 64.85 to 96.66). Mean m3 IgE in the 8 patients was 13.32 kUA/L (SD22.77). Unpaired t-test to compare means between gender and m3 IgG (98.08 mgA/L vs90.15 mgA/L) and m3 IgE were non-significant (p=0.77 and 0.47 respectively). Of 65consecutive patients with asthma (without ABPA) as controls checked for sensitization toAspergillus fumigatus, 5 were sensitized (0.35-1.19 kUA/L) with mean total IgE 840.58 kU/L(SD 1129.39).Conclusions:Around 8% of asthmatics were sensitized to Aspergillus fumigatus in our study. The cut-offvalue of specific IgG against Aspergillus fumigatus at 40mgA/L for diagnosis of ABPA had100% sensitivity but specificity is much higher when the cut-off is 90mgA/L. The diagnosis ofchronic pulmonary aspergillosis appears more plausible at levels between 40-90mgA/L.

P182Title- Life Threatening Occupational Hazards

Author- Dr Nikhilesh pasari Dr Ashok Bajpai Dr B.Jain

Sri Aurobindo Institute Of Medical Sciences & PG Institute Indore, India

Toluene Inhalation is an important occupational health hazard in persons working in factories manufacturingpaint, pharmaceuticals& rubber .The present report describes an unusual case of toluene induced ALI threateninglife.

Key words:-Health, Lung injury, Toulene

REFERENCES

1) U.S Depart of labor occupational safety &Health Administration. Safety & Health topics; Toulene availablefrom:http://www.osha.gov/dts/chemicals/data/CH_272200.html.

2) Byrme A,Kirby, ZibinT,EnsmingerS.Psychiatric &Neurological effects of chronic solvent abuse. Can J Psychiatry1991;36:735

P183Effects of cotton dust exposure on the respiratory system in spinning mill workersSanthosh C, nageswari A D, srinath D, rajalakshmi R, aishwarya RSRM medical college hospital and research centre, chennai, indiaObjective -To estimate the prevalence of respiratory symptoms and to evaluate the pulmonary function changes in spinningmill and textile workers

Method -The study was conducted in the spinning mills in and around Tirupur district in Tamilnadu, at their workplace itself.The workers were asked to fill the modified ATS respiratory questionnaire along with necessary demographic datafollowed by spirometry. Chest symptoms and spirometric variables for all workers were analyzed.

Results –The study was conducted among 251 spinning mill workers. The median age group of the population was 21years(minimum – 17, maximum – 63). The gender distribution of the population was 142 males and 109 females. Amongthem 136 were local people and 115 were migrants from other states. Out of 251 workers, 18(7%) were in cardingdepartment, 106(42%) in spinning, 64(26%) in cone winding, 20(8%) in simplex and 43(17%) were from otherdepartments such as machine cleaning, technical support, drawing, and supervising.

Out of 251, 73(29%) were having respiratory symptoms, among the symptomatic 40(55%) were having chesttightness.

Among 251, 36(14%) were having obstruction in PFT (FEV1/FVC < 0.70), in which 20(19%) were working in spinningdepartment.

Out of 251, 114(45%) were having FEV1 <80%, among them 49(43%) were in spinning department.

Out of 251, 106(42%) were having FVC < 80%, in that 43(41%) were in spinning department.

Among 251, 208(83%) had PEF% < 80%, in that 116(56%) were in spinning department

Conclusion-In this study, chest tightness was the most prominent symptom which accounts for 55% of chest symptomatics.Workers in spinning department were having more obstruction (19%), reduced FEV1% (43%), FVC (41%) andreduced PEF% (56%) in spirometry.

Workers in the spinning department of textile mills require personal protective measures than those in otherdepartments to prevent respiratory ailments.

P184PROFILE OF PATIENTS PUT ON INTERCOSTAL DRAINAGE TUBE(ICD) IN A TERTIARY CARE HOSPITAL

AP KANSAL , Prabhleen KAUR , Don Gregory MASCARENHAS, Shiyas MOHAMMED , Nancy GARG

Department Of Chest & TB,GMC, Patiala , Punjab

Introduction : Chest tubes are used in pneumothorax, hemothorax, empyema and malignant pleural effusion(MPE)

Method and materials : A retrospective study was done of patients put on ICD in our department betweenNovember 2013 to july 2014

Results: Out of the 34 patients who were inserted a ICD, 27 were males and 7 were females .Youngest was a 17 yrold and oldest being 84 yrs with a median age of 42.9yrs. Most common(M/C) indication washydropneumothorax(38%) followed by pneumothorax(26.4%), empyema(17.6%) MPE(8.8%).most commonunderlying condition was pulmonary tuberculosis , both for hydropneumothorax and pneumothorax(56%)accounting for 64.7% of cases, followed by COPD(14.7%), trauma(5.9%) and malignancy(5.9%). Majority of patientswere manual labourers(50%) .2 pts were smokers . 13 pts had taken att prior to ICD insertion .only 3 patients cameout to be sputum positive for AFB .3 patients had AFB detected in their pleural fluid, all three being cases ofempyema .16 had right sided involvement and 18 had left sided involvement . Duration for lung expansion on anaverage was 5days for pneumothorax, & 7 days each for Hydropneumothorax(HPT) and empyema with the lattertwo requiring streptokinase injection in some cases(33%) for complete lung expansion. Pleurodesis wassuccessfully done in 11 out of 12 cases using 1.5gm single dose tetracycline intrapleurally(92%)

Discussion: Tuberculosis is still the major cause of pneumothorax(SSP), HPT & empyema in our part of country. ICDinsertion causes quick resolution of fluid/air & decreases morbidity. Tetracycline is a very effective agent forpleurodesis.

P185Silicotuberculosis : A case report

AP KANSAL, Prabhleen KAUR , Don Gregory MASCARENHAS, Kamal Deep, Nancy GARG, Varinder SINGH Bamrah

Department Of Chest & TB, GMC, Patiala , Punjab

Introduction: Silicosis, the most prevalent disease of all the pneumoconioses is caused by inhalation of crystallinesilica particles. Tuberculosis is notorious to alter its course and outcome.

Case Report: A 55 year old chronic smoker male presented to us with progressive breathlessness and productivecough for 3 months with loss of appetite for 1 month. There was no history of fever , chest pain or hemoptysis.Hewas a chronic bidi smoker for 30 years(pack year=30). He was a marble grinder for the past 30 years. On chestexamination, patient had bilateral rhonchi. Chest xray revealed multiple dense nodular shadows in both the lungfields. patient came sputum positive for acid fast bacilli. Pulmonary function tests showed obstructive pattern.HRCT showed multiple centrilobular nodules along with pleural thickening and multiple calcified lymph nodesalong with cavitatory lesion and consolidation in the bilateral upper lobes .Based on the clinicoradiological featuresand occupatinal exposure to silica , diagnosis of silicotuberculosis was made. Patient was put on anti tuberculardrugs for which he responded well clinically and radiologically.

Discussion: Silicosis is caused by prolonged exposure to silica dust. Silica particles absorb body iron and act as areservoir of iron. Mycobacteria are dependent on iron for growth and produce the iron chelators mucobactin.Hence silica-exposed workers are at increased risk for tuberculosis and other mycobacterium-related diseases. TBcomplicates silicosis and viceversa. Silicotuberculosis affects the parenchyma ,arteries and the veins. Synergisticeffect of silicosis and TB leads to proliferative fibrous reaction leading to end stage lung disease.

Conclusion: Active surveillance of the workers in industries causing silica exposure is required both pre-employment and post-employment periods to reduce the morbidity and mortality of silicotuberculosis.

P186Chronic hypersensitivity pneumonitis: a case series of 18 biopsy proven casesSANTOSH JHA,ANKUR AGRAWAL,PRAHLAD PRABHUDESAILilavati hospital and research centre,Mumbai,india.Objectives: 1)To retrospectively analyse the clinical features, radiological findings, spirometry and biopsy resultsof 18 patients of chronic hypersensitivity pneumonitis(HP)2)to compare pre and post treatment spirometry findings in these patients.Methods and materials: 18 cases of biopsy proven HP was retrospectively studied. history, spirometry andradiological findings were analysed. therapy was instituted and post therapy spirometry was compared to pretreatment finding.Results : Mean age was 46.2yrs. Exposure to pigeons was there in 15 patients. Most common symptom onpresentation was dyspnea on exertion and dry cough. Most common radiological findin was reticulonodularshadow on CXR and centrilobular nodules, interstitial thickening, ground glass opacity in chronic HP cases. Mostcommon spirometric finding was restriction and reduced DLCO. and most common histopathological findingswere multinucleated giant cells, ill defined granulomas. Post treatment spirometry was done after 1 years, whichshowed no significant improvement or deterioration in lung functions.Conclusion: Exposure to pigeons was most common etiological agent in our study, in 3 patients we couldnot findany cause.there was no significant improvent in spirometric values despite treatment with steroids, although therewas symptomatic improvement. More studies are required for elusive disease.

P187Bird Fancier Lung: Clinico-radiological presentation in 15 patients

MANDEEP SINGH, RAJ KUMAR, RAJENDRA PRASAD

National Centre for Respiratory Allergy, Asthma and ImmunologyVallabhbhai Patel Chest Institute, Delhi-110009, India

Category: for ICS - Dr. J. C. Kothari Young Scientist Award (3 Awards)

Objective: Bird fancier's lung (BFL) is a type of hypersensitivity pneumonitis occurring in response to avianantigens. The diagnosis is based on a combination of clinical, radiological and biopsy characteristics. The presentstudy was planned to highlight the clinico-radiological presentation in cases of bird fancier's lung.

Methods: The present study is a retrospective analysis of cases of BFL diagnosed in a unit of Vallabhbhai PatelChest Institute from 2013-14. The diagnosis of BFL was made as per criteria laid down by Mark Schuyler and YvonCormier. The clinico-radiological features of the subjects were analysed.

Results: There were a total of fifteen cases diagnosed with BFL during the study period comprising of twelvefemales and three males with a mean age of 54.93 ± 14.21 years. All studied subjects gave significant history ofexposure to pigeons and were non smokers. The period of symptoms prior to presentation varied from 1-8 years.The main symptoms on presentation were exertional breathlessness in 100% (15/15), cough in 93.3% (14/15). Onexamination, crepitations were heard in all patients and 73.33% (11/15) patients desaturated on 6MWT.Radiologically, diffuse centrilobular nodules, ground glassing- predominant in upper lobes, was each seen in 40%(6/15) cases, fibrosis with or without traction bronchiectasis in 40% (6/15) cases, honeycombing in 13.3% (2/15)cases. Pulmonary function testing showed mild obstruction in one, was completely normal in another case while inthe rest there was evidence of restrictive lung disease with reduced diffusion capacity in all except one case inwhich it was normal. Bronchoscopy showed ill defined granulomas in 60% (9/15) cases and chronic interstitialinflammation in all cases.

Conclusions: BFL can exhibit a wide range of radiological patterns and high index of suspicion must be maintainedand particular attention paid to detailed exposure history in every case of ILD.

P188Role of Adenosine Deaminase in the Diagnosis of Tubercular Pleural Effusion

Mehta A, Rohatgi A

Prashant Mehta, PG, Deptt. of Medicine LHMC & SSKH Delhi

Introduction: TB is common in India. ADA has recently become a valuable tool in diagnosing Extrapulmonary TB asdefinitive diagnosis of TB pleural effusion is difficult due to the low sensitivity and specificity of non invasive tests.

Objectives: This Study was undertaken to evaluate the role of ADA in the diagnosis of TB Pleural effusion wherediagnosis based on conventional Non- Invasive tests is difficult.

Methods: Patients with exudative Pleural effusions were taken for this study after relevant investigations. ADAlevels were estimated in Pleural fluid by Giusti’s method. ADA>40 U/L was considered diagnostic of TB. In additionL/N ratio > 0.75 in fluid was considered an additional supportive evidence .

Results: 50 cases were analysed of which 36 had TB effusion(group I) and 14 due to other causes(Group II :-Malignant- 5; CTD- 6; Hypothyroidism- 1; SynPneumonic- 1). Mean ADA was 134 U/L in Group I compared to 15.17U/L in Group II. Sensitivity, Specificity, Positive Predictive Value and Negative Predictive Value of ADA in effusionwas 100%, 86%, 95% & 100% respectively. L/N ratio was >0.75 in Group I as against None in Group II. Of 36 casesof TB effusion( Group I), 28 responded to ATT however the remaining were lost to follow up.

Conclusion: The performance of ADA in TB effusion is reasonably accurate and is hence a good diagnostic methodas it is simple, rapid, easily available with high sensitivity and specificity. However larger multicentric studies

would be advisable to further look into this.

P189Massive right sided haemorrhagic pancreatic pleural effusions :Case Series

Dr. N. Snigdha , Dr.N.Gopichand ,Dr.D.Sudeena,Dr.C.Suma lata

Siddhartha Medical College, Vijayawada, Andhra Pradesh,India.

INTRODUCTION: Pleural effusion occurs as a complication of pancreatic disorders like Acute pancreatitis,Pancreatic Abscess, Pseudocyst, Pancreatic malignancy,Chronic pancreatitis.It is usually bilateral but 22% accountfor left ,10% right sided. Diagnosis is established by demonstrating high levels of pleural fluid amylase. Here wepresent four different cases of right sided pancreatic pleural effusions.

CASE REPORTS

Case1: A 36 year old alcoholic male came with shortness of breath (SOB), cough and chest pain on right side.Absent breath sounds present over right side. Chest X-Ray (CXR) PA views showed right massive pleural effusion.Thoracocentesis revealed hemorrhagic fluid which showed elevated amylase-59740 U/l. Contrast CT chest andabdomen showed pancreatic pseudocyst.

Case2:A 45 year male, alcoholic and smoker came with complaints of severe SOB.CXR PA view showed massiveright sided pleural effusion. On evaluation his serum amylase was 457 U/l, pleural fluid amylase was 14,830 U/l.Pleural fluid was haemorrhagic and showed malignant cells on cytology. Contrast CT chest and abdomen alongwith ultrasound abdomen confirmed malignancy involving head and neck of pancreas.

Case3:A 33 year male, alcoholic came with complaints of SOB.CXR PA view revealed massive right sided pleuraleffusion. On evaluation pleural fluid is haemorrhagic pleural fluid amylase was 14,486 U/l. Ultrasound abdomenand CT abdomen showed features of chronic pancreatitis.

Case4:A 38 year male presented with SOB. On evaluation he is found to be having massive right sided pleuraleffusion that is haemorrhagic. Pleural fluid amylase was 38,365U/l. Ultrasound abdomen revealed pancreaticpseudocyst.

Discussion: Pleuro-pulmonary complications secondary to pancreatic etiology are well known but rare. Theseeffusions are usually left sided but all the above 4 cases are right sided, heamorrhagic, showed elevated amylaselevels. Often the underlying pancreatic disease is missed due to lack of abdominal symptoms. The best modality fordiagnosis in these cases remains pleural fluid amylase. They often tend to recur after thoracocentesis.

P190Rare cause for pneumothorax in a young maleManjunath M, Vishnu SHARMA M, Alka BHAT, Harsha D SDepartment of Respiratory Medicine, A. J. Institute of Medical Sciences & Research Centre, Kuntikana, Mangalore,Karnataka.

INTRODUCTIONWhen a patient develops pneumothorax proper evaluation should be done to find the cause. Identifying the causewill help to prevent recurrences and is essential to treat the underlying disease.

CASE REPORTA 20 year male presented with complaints of sudden onset of dyspnea, left sided chest pain and cough with scantyexpectoration since 3 days. No other significant history. He had started smoking at the age of 15 years, dailysmoked two packs of cigarettes.Clinical examination revealed features suggestive of left sided pneumothorax. Chest X ray showed Left sidedpneumothorax with bilateral reticulonodular and occasional cystic lesions in both lower zones. Intercostal tubedrain was inserted. Routine blood investigations were normal. Sputum AFB smear was negative. In view ofradiological findings patient was empirically started on anti tuberculosis treatment. On further work up with HRCTshowed features suggestive of Pulmonary Langerhans cells Histiocytosis with left sided pneumothorax. He had anuneventful recovery.He was discharged with advice of smoking cessation and oral prednisolone 40mg/day. He was asymptomatic on 6month follow up and steroid was tapered and stopped after 6 months.

CONCLUSIONPulmonary Langerhans Cell Histiocytosis should be considered as a cause for pneumothorax in young smokerswhen chest radiography shows bilateral reticulo nodular or cystic changes. Complete work up with HRCT should bedone when cause of pneumothorax is uncertain.

P191CASE REPORT

Massive right sided hemorrhagic pleural effusion in a patient of Acute Necrotizing Pancreatitis - A rare case ofPancreatico-Pleural Fistula

BUDHRAJA AKSHAY, SHARMA KAPIL, TANDON SANJAY, MAQSOOD SHEEMA, JOSHI PRIYANKA, DAUSAGE CHIRAG

Peoples College of Medical Sciences & RC, Bhopal (M.P), India

ABSTRACT

Hemorrhagic pleural effusion in patients of acute pancreatitis is very rare and warrants the consideration fordiagnosis of pancreatico-pleural fistula. We report a case of 30 year old chronic alcoholic male with alcoholdependance with acute presentation of severe epigastric pain and respiratory distress for last 2 days. He was beingmanaged conservatively from past 3 months for acute necrotizing pancreatitis. On examination he had tachypnea,tachycardia and hypotension. Breath sounds were absent over the entire right hemithorax. Massive right sidedeffusion was confirmed radiologically. Pleural fluid examination revealed blood clots, protein of 4.9gm%,TLC=18000/mm3 with extensively hemorrhagic background. Pleural fluid AFB was negative and pleural fluidcultures were sterile and cytology was unremarkable. Serum Amylase and lipase were 101/1592 U/L respectively.Liver function test (LFT) were normal except Total protein of 4.9gm% and Albumin of 2.2 gm%. Serum Calcium was6.7mg%. Pleural fluid amylase was 1500U/L. PT/INR was within normal limits. Patient was managedprophylactically by pancreatic duct stenting even though ERCP failed to detect fistulous tract. After 30 days ofadmission, patient made complete recovery and was discharged in good health. He was followed later for upper GIendoscopy for removal of pancreatic duct stent. Pancreatico-pleural fistula is a clinico pathologico radiologicaldiagnosis requiring high index of suspicion and early MRCP(sensitivity-80%) to detect fistulous tract. ERCP may behelpful in detecting fistulous tract but a failure rate of 32% is reported. Duct stenting facilitates early drainage ofpancreatic fluids and promote healing. Surgical closure of tract is reserved for resistant cases.

P192A misdiagnosed case of malignant pleural effusion

Paresh Chandra Mohanta, Pravati Dutta, Rekha Manjhi, Sudarsan Pothal,Madhumita Nayak,Sasmita Meher

Department of pulmonary medicine, VSS Medical College, Burla, Odisha, India

Background: Malignant pleural effusion was on of the leading cause of exudative pleural effusion.Carcinoma oflung and breast and lymphoma accounts for 75% of malignant pleural effusion.In tuberculosis prevalent countrylike India it is sometimes misdiagnosed as tubercular pleural effusion.Case Report: A 70 year old smoker presented with chest pain for 1 month and breathlessness for 20 days.He wasmanaged as a case of tubercular pleural effusion and was put on ATT for past 3 months.He was not relieved ofhis symptoms despite of 3 months of treatment.On clinical examination features of massive pleural effusionwith pallor and not associated with clubbing and lymphadenopathy.Routine blood investigations revealed araised blood urea and creatinine.Chest X-ray suggestive of massive left pleural effusion.Pleural fluid analysisshowed a low ADA,exudative fluid and its cytology report showed TLC-4300 cells,DC-N-1%,L-86%,mesothelialcells 12%,macrophages 1% and enlarged cells with binucleate,trinucleate reactive/hyperplastic changes.CTthorax shows solitary nodule left lower lobe.On flexible thoracoscopy showed pleural adhesions and multiplepleural growth and biopsy from suspicious lesion revealed invasive squamous cell carcinoma.Conclusion: This case illustrates that in an elderly smoker presenting with pleural effusion, our first suspicionshould be to rule out malignancy.

P193An incidental finding of Pleural Lipomas:Case series

P.Ajoy kumar, C.Sumalata, N Gopichand, D.Sudeena

Department Of Pulmonology, Siddhartha Medical College, Vijayawada,A.P

Abstract

Introduction: Lipoma is a benign mesenchymatous tumour seen in subcutaneous parts of the body, its presence inpleura is a rare entity.They are incidentally found on chest x-rays or Computed tomographies.Here we present twocase reports of pleural lipoma, which are of intrapleural variety.

Case reports: Case 1:A 65 year old female patient came to chest OP with complaints of cough and shortness ofbreath.On examination she had decreased breath sounds and was dull on percussion on right infrascapular andinfra axillary region.She was then subjected to radiological investigations where a large intrapleural lipoma of 9.8cm x11.2 size tumour was observed.Case2:A 80 year old man was referred to chest OP for a lesion on the rightlower zone.When he was subjected to a CT chest plain,it was found to be a intrapleural tumour of 6x7cm.

Discussion:Pleural lipoma are extremely rare. They are of two types(1)hour glass or dumb bell lipomas(2)intrathoracic lipomas. According to their origin,they are calssified into various types endobronchial lipoma,diaphragmatic lipoma. Most patients are asymptomatic.The occurrence of symptoms depend on the size of thelipoma. Although the tumours were detected incidentally in a chest X-ray, CT scan has replaced conventional x-rayand ultrasound scan for accurate detection of thoracic lipomas. CT allows a definitive diagnosis when itdemonstrates a homogeneous fat attenuation mass (-50 to -150 Hounsfield units, or HU) which formed obtuseangles with the chest wall and displaced adjacent pulmonary parenchyma and vessels .Management includesclinical and radiological follow up.Follow up is done to see for malignant changes so that surgical intervention canbe planned accordingly.

CT scan of case no 1 Chest x-ray of case 2

P194RARE PRESENTATION OF PLEURAL MALIGNANT MESOTHELIOMA IN A PATIENT WITHOUT PRIOR EXPOSURE TOASBESTOSDR.K.VIJAY KUMAR, Dr.A.Sathya Prasad, Dr.Ganesh Chandra,Subba rao, Prashanti, NaliniMAMATA MEDICAL COLLEGE & HOSPITAL ,KHAMMAMBackground:

Most common primary tumor of pleura is malignant mesothelioma occurring commonly in age group of 5 th-7th

decade with male: female - 2.6:1 with exposure to asbestos constituting about >70% cause. spontaneous (nonasbestos exposure related) incidence 1/million/year. Here we present you one such rare case.

Case report: A 60 year old female Sandamma Kanakapudi came to OPD with c/o left sided pleuritic chest pain withSOB on moderate exertion with occasional dry cough with decreased appetite and sleep of 40 days duration and anon-smoker, non-alcoholic and agriculture labour by occupation without any exposure to any environmental riskfactor. Husband is also an agricultural labour who is non-smoker, non-alcoholic . Chest X-Ray PA view - Left U/Llesion confined to pleura with shagging borders & blunting of Costophrenic angle .USG guided TTNA in Left antAxillary line 4th ICS - Revealed large epithelial cells with increased N/C ratio strongly suggestive of epithelialmalignancy. correlate accordingly . CTguided pleural biopsy done at MNJ cancer institute suggestive of epithelialvariant of Mesothelioma

Conclusion: Our case high lightens the fact that we should widen our horizon in decision making with such patientin a country like India that can lead to early diagnosis resulting in better survival rate by effective treatment andfollow-up

P195

P196CASE REPORT

Spontaneous Pneumothorax and Myocardial Infarction in Marfan Syndrome without Valvular Heart disease

SHEEMA MAQSOOD,KAPIL SHARMA,PRIYANKA JOSHI,ST NAGDEOTE,AKSHAY BUDHRAJA

Dept. of Pulmonary Medicine, Peoples College of Medical Sciences,Bhopal

ABSTRACT :

Marfan Syndrome is a heritable disorder of connective tissue mainly affecting skeletal, cardiovascularand ocular systems. Lungs are rarely involved.We report a case of a 19 year old young adult with history ofprogressive dyspnea along with cough with expectoration with features of Marfan Syndrome. He also had pasthistory of ATT for pulmonary tuberculosis with same features of Marfan Syndrome in other siblings also. Ongeneral examination he was tall with long slender limbs (Dolicostenomilia), long fingers and toes (Arachinodactyly)and protruded sternum with scoliosis. On respiratory examination bilateral breath sounds were decreased withbilateral occasional crepts with tapping apex beat. Sputum for AFB was negative with HIV non reactive. During thehospital stay he developed MI confirmed by raised troponin levels and spontaneous pneumothorax. Chest X-Rayfollowed by CECT Thorax showed right upper lobe fibrosis with right lower lobe bronchiectetic changes along withleft sided hydropneumothorax. Pus was sent for AFB and DST was planned. Pus for AFB was positive. No valvularinvolvement on 2D-ECHO Heart. Patient was planned for ICDT insertion but he expired. Case opens our eyes inview that MI as such can be rare entity in Marfan syndrome but precipitating factors like chronic hypoxia in posttubercular pleuroparenchymal fibrosis with acute development of spontaneous pneumothorax (Amjadi K, AlvarezGG, Vanderhelst E,Velkeniers B, Lam M, et al: Chest 2007;132: 1140–1145.) can cause MI in marfan syndrome whichspares heart valves.

P197A study of pleural fluid adenosine deaminase levels in tubercular and other exudative pleural effusions at atertiary care center in U.P.

A AGARWAL, A JAIN , L SINGH, R TANDON, A CHAWLA, A SINHA

Shri Ram Murti Smarak Institute of medical sciences, Bareilly, U.P., India

Objective –

To study pleural fluid adenosine deaminase (ADA) levels in tubercular and other exudative pleural effusions.

Methods –

A prospective study was designed at SRMS Institute of Medical Sciences, Bareilly, U.P. to evaluate the importanceof pleural fluid ADA level in the diagnosis of tubercular pleural effusion and differentiating it from other causes ofexudative pleural effusion.

Results –

A total of 232 cases of pleural effusion were evaluated, of which 169 (72.85%) were observed to be exudativepleural effusion. Tuberculosis was diagnosed in 76 (45%) cases, malignancy in 32 (19%) cases and parapneumoniceffusion in 50 (29.6%) cases. 11 (6.5%) cases were found to be due to miscellaneous causes or remainedundiagnosed. Median ± SD values of ADA for tubercular pleural effusion, malignant pleural effusion andparapneumonic effusion were 62.37 ± 22.63, 24.12 ± 10.88, and 34.55 ± 20.45 U/L respectively. Our study showedthat 68 (89.5%) out of 76 cases of tubercular pleural effusion had ADA ≥ 40 U/L and only 3 (9.3%) out of 32 cases ofmalignant pleural effusion had ADA ≥ 40 U/L. For the diagnosis of tuberculosis the pleural fluid ADA ≥ 40 U/Lyielded 89.47% sensitivity and 72.04% specificity; the positive predictive value was found to be 72.34% and thenegative predictive value 89.33%.

Conclusion -

Pleural fluid ADA level can be used for differentiating tubercular effusions from other causes of non-tubercularexudative effusion. Moreover, it can reduce the diagnostic need of pleural biopsy for the diagnosis of malignancy.

P198A case of complicated parapneumonic effusion presenting as empyema necessitans

Dr. K.NAGA CHAITANYA , Dr. S.V. PRASAD , Dr. T.V. RAJIVMNR MEDICAL COLLEGE AND HOSPITAL , Sangareddy , Telangana

BACKGROUND : Empyema necessitans is an extremely rare condition developing secondary to infection bymycobacterium tuberculosis , staphylococcus , fusobacterium , actinomycosis . The following case report is of awrongly diagnosed and neglected parapneumonic effusion which went on to develop empyema necessitans

CASE REPORT : A 40 year old male presented with complaints of right sided chest pain , non productive cough anddyspnea on exertion for 1 month and a swelling in the axilla and back over the right chest for 10 days. Patient hadno history of haemoptysis or fever. He was treated 2 months back with injectables for 10 days for productive coughand fever. He had no history of contact with TB patient.There was grade 3 clubbing bilaterally and no cervical lymphadenopathy. Chest examination showed 7 * 8 cmswelling over the right chest extending from the back to the axilla. It was firm in consistency and mobile withwarmth and no tenderness. Skin over the swelling was smooth and had no discharging sinuses. There was nopalpable crepitus. Apart from the swelling ,the right hemithorax shows bulging with reduced respiratorymovements. Intercostal tenderness was present on palpation along with dull note on percussion in rightmammary, inter and infrascapular , infraaxillary areas. Absent breath sounds were present in the same areas.Rest of the chest was normal Blood investigations revealed TLC = 13200 cells/mm3 , negative for HIV and ESR was70 mm/1st hr. Chest xrays PA and lateral views revealed right sided moderate pleural effusion and adjacent softtissue swelling. USG revealed right loculated pleural collection which was aspirated. The aspirate was thick puswith ADA of 80 IU/dl , LDH – 1200 IU/dl , proteins 5.6 gm/dl , glucose 60 mg/dl. CT scan chest confirmedencapsulated pus in the right hemithorax and soft tissue swelling and no rib erosions. Soft tissue swelling wastreated by incision and drainage. Pus for culture was negative for any bacterial growth and for AFB stain patientwas posted for thoracoscopy and ICD was placed. Histopathology of pleural biopsy specimen revealedgranulomatous inflammation and epitheloid histocytes, lymphocytes and multinucleate giant cells. Culture waspositive for AFB.DISCUSSION: Empyema necessitans is an extremely unusual complication of empyema seen only inimmunocompromised patients and in neglected TB empyemas. Although accounting only for 10 % of empyemas,

Mycobacterium tuberculosis is responsible for 75 % cases of empyema necessitans causing an overall mortality of60 %

CONCLUSION: This case is being presented to highlight a rare condition and to emphasize on the fact that wrongand delayed diagnosis of TB is still a major problem in our country leading to increased morbidity and mortality.

P199GOVT. MEDICAL COLLEGE, NAGPUR

DEPARTMENT OF PULMONARY MEDICINE

Dr. Anuroop Shankar S., Dr.P.Gholap , Dr. S.H.Meshram, Dr.S.V.Ghorpade

A RARE PRESENTATION OF TENSION PNEUMATOCELE

ABSTRACT

INTRODUCTION

Pneumatocele are air filled lung cyst that occurs when bronchial injury or inflammation creates check valvemechanism for air entry in to the lung parenchyma. Underlying causes include severe pneumonia, blunt thoracictrauma, COPD, hydrocarbon ingestion with aspiration

CASE PRESENTATION

48 yrs old married farmer ,known case of type 2 DM ,presented with left side chest pain ,continous and graduallyprogressing its severity ,shortness of breath , fever for 15 days and sudden onset of swelling over left side ofchest.chest Xray and CT scan revealed tensed pneumatocele herniated in to the subcutaneous plane of chest wall.sputum revealed staph. Aureus. Condition was treated with CT Guided percutaneous catheter placement using apigtail catheter for decompression with good antibiotic cover.

DISCUSSION

Pulmonary pneumatocele are thin walled, air-filled cysts that develop within the lung parenchyma. They can besingle emphysematous lesion but can be multiple, thin walled cyst like cavities. Most often they occur as asequelae to acute pneumonia, commonly caused by staph.aureus. Complicated tension pneumatocele which isherniating to subcutaneous plane of chest wall is rare. It may cause cardio respiratory compromise. Sodecompression with pigtail insertion is necessary but it is difficult for this patient due to herniation. Patientexpired postoperatively due to cardio respiratory compromise.

CONCLUSION

A rare presentation of complicated tension pneumatocele herniating in to subcutaneous plane

P200Diagnostic efficacy of biochemical parameters in differentiating transudative and exudative pleural effusion

Bhavya S, Department of Respiratory Medicine

Regional institute of Medical sciences, Imphal

Abstract :

Objectives: To study the diagnostic efficacy of absolute level of pleural fluid cholesterol,pleural fluid and serumratio of triglycerides and bilirubin in differentiating transudative and exudative pleural effusion

Methods: A cross sectional study conducted in the Department of Respiratory Medicine, RIMS ,Imphal includedfifty six cases of pleural effusion with definite clinical diagnosis were classified as transudates and exudates . Thepleural fluid cholesterol (pf CHOL), Pleural fluid/serum triglycerides ratio (pfTRIG/s TRIG), pleural fluid /serumbilirubin ratio (p BIL/s BIL ) were compared with clinical diagnosis with regard to their usefulness for distinguishingbetween pleural exudates and transudates

Results:A total of 56 patients withb effusion who were definitively diagnosed were included in the trial andanalyzed. Out of which 36 and 20 cases are exudative and transudative respectively. The Pchol levelsdemonstrated a sensitivity of 89%, a specificity of 100%, The p/s TRIG ratio showed a sensitivity of 89, a specificityof 100%, p/s BIL ratio had a sensitivity of 100% and specificity of 80%. Combination of any two criteria had asensitivity and specificity of 100%

Conclusion:The pleural cholesterol level ,the pleural/serum triglycerides and bilirubin ratio can be utilized asunique and cost effective biomarkers in differentiating transudative and exudative pleural effusions.

P201CLINICO-LABORATORY PROFILE OF NON-MALIGNANT EXUDATIVE PLEURAL EFFUSION IN A TERTIARY CARE

HOSPITALDR.M.D.VARUNN, DR.K.SURENDRA MENON, DR.R.PAJANIVEL

DEPARTMENT OF PULMONARY MEDICINE, MAHATMA GANDHI MEDICAL COLLEGE AND RESEARCH INSTITUTEBACKGROUND: Pleural effusion remains the commonest pleural disease making a significant contribution to thepulmonologists. It is always a systematic approach which helps in arriving at an etiological diagnosis.OBJECTIVE: The study was designed to investigate the clinical and laboratory profile of non-malignant exudativepleural effusions.METHODS: Patients who were diagnosed to have pleural effusion over a period of 6 months (Jan-Jun, 2014) weresubjected to diagnostic pleurocentesis. Patients with pleural fluid protein of >3gms% were taken into study andwere analyzed retrospectively for symptoms, side of effusion and pleural fluid analysis of cell count, ADA, glucoseand culture. Cytology showing malignancies were excluded.RESULTS: Out of the study population of 65 patients, cough (99%) and breathlessness (97%) were the commonestpresentation, followed by chest pain (80%) and constitutional symptoms (46%). Based on the clinical features andradiology, 72% of patients had right-sided effusion. Tuberculosis was diagnosed in 44 patients, parapneumoniceffusion in 21 patients. 79% of patients diagnosed as tuberculosis had lymphocyte count of >80%. The mean ADA intuberculous pleural effusion was 68.83. Parapneumonic effusions had cell count of predominant polymorphs. 83%of the pleural fluids pyogenic cultures were sterile and the commonest organism in culture positive samples (17%)were staphylococcus aureus, streptococcus pneumonia. Majority of the isolated organisms were sensitive topiperacillin, ciprofloxacin, vancomycin, gentamycin and amikacin.CONCLUSION: Pleural fluid differential cell counts are helpful in narrowing the differential diagnosis but none aredisease specific. High lymphocyte proportions (>80%) with high ADA occur most frequently in TB, neutrophil-predominant pleural effusions are associated with acute processes like parapneumonic effusions. The sensitivitypattern from this study helped us with the empirical choice of antibiotics in cases of parapneumonic effusions.

Despite the high incidence of indeterminate diagnoses, the measurement of protein and cytological examinationmust be ordered routinely which plays an important role in arriving at the diagnosis.

P202Osteosarcoma presenting as multiple calcified metastases to lung and pleura: A rare case reportDr. K. Rajendra Kumar, Dr. S. Raghu, Dr. CH. Hanumantha Rao.Dept. Of pulmonary medicine, Govt. Fever Hospital / Guntur Medical College, Guntur, Andhra Pradesh, India.Abstract:Osteosarcoma is a most common primary bone tumor in children and adolescents, arising from primitive boneforming mesenchymal cells. The lung is the most common site of metastasis of osteosarcoma. Here we report acase of an 18years old male patient presenting with progressive breathlessness for last the 2months. Chest X-raysuggestive of extensive pleural calcifications and bilateral parenchymal lesions with right sided moderate pleuraleffusion. CT scan chest revealed multiple calcified metastatic nodules in both lungs and pleural calcification withright side pleural effusion. On examinantion, we found bony mass of left humerus which is of 3 months duration,punch biopsy of which revealed osteosarcoma. FNAC of pleural lesion is diagnostic of metastatic deposits.Osteosarcoma presenting as multiple calcified metastasis to lung and pleura is very rare that too within very shortduration.

P203Empyema secondary to submandibular gland abscess : a rare case report

K.BHARATH P.SWETHA K.SAILAJA H.N.SREEDHA RAO U.KIRAN KUMAR

Department of Pulmonary Medicine, Kurnool Medical College, Kurnool ,Andhra Pradesh,India

INTRODUCTION:Although empyema is frequently seen in general population,but this condition secondary to neckspace infection [submandibular gland abscess] and mediastinitis is rarely seen .Mortality in such conditionsreported to be 15 to 40% despite high antibiotic therapy and in some cases surgical intervention is required Wewould like to report a case of empyema secondary to submandibular gland abcess here.

CASE REPORT: A 38yr male presented to us with dyspnea,fever,purulent discharge from mouth,difficulty inswallowing both to solids and liquids since 15 days. History of large swelling in the left submandibular area withsevere pain,that gradually reduced after taking medication .On examination,a swelling of 2x2cm below the angleof mandible noted, which was tender, freely mobile. A small fistula [1x1 cm] noted in left retromolar area withpurulent discharge draining from itCXR revealed homogenous opacity left side with mediastinal shift to opposite side s/o pleural collection and CECTneck showed enlarged left submandibular gland with air and fluid collections and abcess is extending into rightside of neck through pretracheal space causing erosion & thrombosis of right IJV and retropharangeal space. CECTchest showed abcess is extending into anterior,posterior and middle mediastinum causing left empyema andlung fields were normal. With this imaging findings we suspect empyema secondary to submandibular infection.Pus was drained from left pleural cavity and patient is kept on broad spectrum higher antibiotics.The patientresponded well with complete expansion of lung and reduction of submandibular swelling

CONCLUSIONS : The term descending necrotising mediastinitis implies the infection started from a head and necksource, here from submandibular gland and extending into mediastinum. Infection from cervical region can spreadto pleural spaces and anterior mediastinum through pretracheal space, middle mediastinum through carotidspace, posterior mediastinum through retropharangeal or prevertebral spaces

P204Carcinoma Breast related Metastatic Pleural Effusion –

A Thoracoscopic Evaluation.

CHETAN B PATIL, RAKESH C GUPTA, RAMAKANT DIXIT, NEERAJ GUPTA, A GUPTA, P. PACHAR

Department of Respiratory Medicine, J.L.N Medical College, Ajmer.

Objective: Carcinoma Breast is one of the common malignancies that metastasize to lungs and pleura, here weevaluated four cases of Carcinoma breast that presented with recurrent massive pleural effusion, which showedmetastasis to the pleura, diagnosed by thoracoscopy.

Method: Carcinoma breast cases that presented to our centre with recurrent pleural effusion within a year ofdiagnosis, treated by surgery alone or with multimodal therapy. Pleural effusion in these cases remainedundiagnosed even after routine initial workup & pleural fluid cytology negative for malignant cells on threeoccasions. We performed thoracoscopy after informed consent, Thoracoscopic appearances of the pleura wererecorded and pleural biopsy was sent for histopathological analysis.

Results: All the four cases of Carcinoma Breast that presented with massive pleural effusion had hemorrhagicpleural fluid with hematocrit less than 50% of peripheral blood. Thoracoscopic view revealed edematous pleurae,grossly studded with multiple nodules of varying sizes forming grape like pattern which were hyperaemic andbleeds on touch, nodularity was seen even on the diaphragmatic pleura which is rarely involved in metastaticadenocarcinoma lung. Thin fibrinous adhesions were also noted. Pleural biopsy revealed metastatic deposits fromthe primary carcinoma breast.

Conclusion: Thoracoscopy should be considered in all cases of undiagnosed pleural effusion with backgroundhistory of Ca Breast without any evidence of local recurrence or pulmonary metastasis.

P205A RARE CASE OF DRUG INDUCED CHYLOTHORAX

BACK ROUND:DASATINIB IS USED AS A THERAPY FOR IMATINIB RESISTANT CHRONIC MYELOID LUEKEMIA.INITIALLY APPROVED STANDARD DOSE OF DASATINIB 70MG TWICE DAILY PRODUCES VARIOUS SIDE EFFECTS LIKEANAEMIA,HYPERTENSION,PERIPHERAL EDEMA ,DRY COUGH ,DYSPNEA, PLEURAL AND PERICARDIAL EFFUSIONS .

METHODS: I REPORT MY EXPERIENCE IN MANAGING A CHRONIC MYELOID LEUKEMIA PATIENT - FOLLOWINGIMATINIB FAILURE ,WAS TREATED WITH DASATINIB AT 140 MG DAILY FOR 3 MONTHS,DEVELOPED CHYLOTHORAXAS A COMPICATION.

RESULTS: MY PATIENT IS TREATED FOR CHRONIC MYLOID LEUKEMIA WITH DASATINIB 140 MG DAILY WHODEVELOPED CHYLOUS PLEURAL EFFUSION. THE PATIENT WAS MANAGED BY THERAPEUTIC PLEURAL TAPPING,REDUCED DOSE OF DASATINIB AND DIURECTICS. CHYLOTHORAX RESOLVED.

CONCLUSION:IN CONCLUSION ,CHYLOUS PLEURAL EFFUSION IS A RARE COMPLICATION OF DASATINIB .MANAGEMENT SHOULD BE DISCONTINUING DASATINIB / DOSE REDUCTION OF DASATINIB/ ALTERNATIVECHEMOTHERAPEUTIC DRUGS WITH DIURETICS OR STEROIDS. HENCE, PATIENTS ON DASATINIB SHOULD BE MADECLOSE FOLLOW UP TO MONITER THEIR SIDE EFFECTS AND FOR INITIATION OF PROMPT TREATMENT.

P206Giant solitary fibrous tumour of the pleura

GAURAV GUPTA, RISHABH RAJ, SUSHEEL BINDROO

Dept. of respiratory medicine, jaslok hospital and research centre, mumbai, India

Solitary fibrous tumour of the pleura is a rare primary pleural neoplasm. They usually arise from visceral pleura butmay also arise from parietal pleural. These tumours are usually asymptomatic and are incidentally detected.

Sometimes they may be associated with chest pain, shortness of breath and cough. Majority of these neoplasmsare benign and surgical excision provides excellent results.Here we are discussing a rare case who presented to us with complaints of breathlessness on exertion and loss ofweight since one year. Also he was having frequent episodes of hypoglycemia since one month though he was aknown case of diabetes mellitus. Chest Xray showed a homogenous mass occupying left hemithorax. Usg guidedbiopsy was done and a diagnosis of solitary fibrous tumor was made. Associated multiple episodes ofhypoglycemia were present (Doegge potter syndrome) which is seen in 5% of patients with solitary fibrous tumor.

P207Title-

Metastatic alveolar rabdomyosarcoma presented as massive pleural effusion.

Authors- M N BHAKARE, G P GODBOLE, A DIWAN, N H BHAKARE, M KULKARNI. Smt. Kashibai Navale medicalcollege & general hospital, Pune Maharashtra, India.

Introduction-

Rabdomyosarcoma is the commonest soft tissue sarcoma of adolescence. The tumor commonly occurs in the softtissues of the head & neck, genitourinary & extremities. Alveolar rabdomyosarcoma presenting as massive pleuraleffusion is extremely rare and presents diagnostic challenges, especialy in resource limited centers.Rabdomyosarcoma is an aggressive tumor with poor prognosis especially when diagnosed late.

Case presentation -

We present a case of 14 years female who was presented to us with left side massive pleural effusion, which wasprimarily diagnosed as tuberculosis & started with antituberculous treatment at another center. But after CTthorax & left axillary lymph node biopsy diagnosis was revised as metastatic rabdomyosarcoma with unknownprimary. Ascites developed within 2 weeks of admission.The bone scan showed no evidence of any skeletalmetastases. Due to unavailability, PET scan could not be done. Metastatic malignant cells were seen in both pleuralfluid & ascitic fluid. The patient failed to respond to chemotherapy & succumbed to the disease.

Conclusion-

Though very rare, alveolar rabdomyosarcoma may be present as massive pleural effusion. Usually bone metastasesare common, which were absent in our patient. So massive pleural effusion in teen aged patient should beinvestigated properly. We think this case will add knowledge for diagnosing alveolar rabdomyosarcoma.

P208Title: Profile of patients underwent inter-costal drainage in a medical college hospital

R Bansal, PK Sharma

Dr. Rajendra Prasad Government Medical College, Kangra at Tanda (HP) 176001

Objective: To study the profile of patients underwent Inter Costal Drainage (ICD) procedure by the authorMethods: Information of all the patients underwent ICD was recorded on an approved proforma. The data wasanalysed keeping objectives in mind.Result: A total of 101 patients were treated with ICD over the study period of 18 months by the author. Only 2 werefemales, 60 and 76 years old. Average age of male patients was 48.11± 15.86 years. Maximum 29% patients werewithin 50-59 years of age.Duration of ICD in place: Mean duration ± 1SD of ICD in place was 23.84±38.33 days; Mode duration = 6 days;Median duration = 14 days with a range of 2-251 daysPresenting complaints: Only Chest pain 19% and only shortness of breath (SOB) 15%. Chest pain with or withoutother complaints 43%, SOB with or without other complaints 36%, fever with or without other complaints 13%,

cough with or without other complaints 6%, incidental 3%, leakage from previous tube site 2% and 1 case wasiatrogenic.Provisional diagnosis: Pneumothorax 48% (Primary spontaneous 24%, Secondary spontaneous 23% and iatrogenic1%), Pleural Effusion 23%, Empyema 18%, Hydropneumothorax 9% and Hemothorax 1%Co-morbidity: On ATT 19%, Old Treated Case of TB 13%, Malignancy 9%, COPD 7%, Bullous lung disease 4%, Lungabscess 1%Final outcome: Expanded fully 60%, Expanded partially 15%, Pleural thickening 14%, Collapse lung 9% and Cortexformation 3%.Associated events: Readjustment 12%, Repeated flushing 4%, Surgical emphysema 4%, Pleurodesis 2%, Tissuegrowth 2%.Conclusion: ICD procedure is done almost exclusively in male patients of productive age groups withpneumothorax, they mostly present with chest pain with SOB and is mostly associated with tuberculosis.

P209PLEURAL FLUID BILIRUBIN- A NEW DIAGNOSTIC AID IN DIFFERENTIATION OF TRANSUDATES AND EXUDATES

ANANTHA R, KISKU KH, MADHUSMITA MDEPARTMENT OF PULMONARY MEDICINE, PONDICHERRY INSTITUTE OF MEDICAL SCIENCES, PUDUCHERRY-605014

The primary aim when investigating a pleural effusion is to establish the correct diagnosis with minimalinvestigation. The conventional method for classifying the pleural fluid as trtansudates and exudates is based onthe diagnostic criteria established by Light et al. The most frequently used Light’s criteria, though still considered asa gold standard; often misclassify a transudate as an exudate which has been proven by many studies

To evaluate the diagnostic accuracy of pleural fluid bilirubin and its ratio to serum levels in differentiating thepleural fluid into transudates and exudates

This study was conducted on 30 patients above 18 years of age who had symptomatic pleural effusions on whom adiagnostic thoracocentesis was performed after meeting the inclusion and exclusion criteria. The initial pleuralfluid analysis were gross appearance, biochemical parameters like LDH, protein, cholesterol, albumin, bilirubin andtheir serum values. The etiology of effusions were determined and the diagnostic accuracy of the bilirubin criteriawas compared with that of light’s criteria

In our study of 30 pleural effusions there were 7 transudative and 23 exudative effusions. There were 13tuberculous, 3 malignant and 7 parapneumonic effusions. The mean bilirubin concentration ratio in exudativeeffusions was 0.6 and in transudative effusions was 0.5. We found that the pleural fluid to serum total serumbilirubin ratio is a useful marker in differentiating transudates and exudates. The correlation of a bilirubinconcentration ratio of 0.6 or more with the presence of an exudate as determined by established criteria is highlysignificant and also helps in identifying false positives with that of the light’s criteria

P210Syringo-Pleural Shunt after fifteen years- A rare cause of Recurrent Pleural Effusion.

MANDILWAR SAURABH, PRAKASH K ASHISH, PRABHUDESAI PRALHAD, SHASHTRI B S

Lilavati hospital and research centre, Mumbai, India.

This is a case report of one of the rarest cause of recurrent pleural effusion because of syringe-pleuralshunt which after fifteen years has led to the said complication. The patient reported is case of post spinaltuberculosis who developed syringomyelia which itself is a rare sequelae of tuberculosis, has underwentsyringopleural (SP) shunting. After fifteen years of normal working of shunt, the patient developed recurrentpleural effusion. Thoracentesis both diagnostic and therapeutic has been done. The fluid repeatedly examined was

transudative and every effort to find out the cause was non-yielding. Computed Tomography (CT) done focusingthe shunt showed that it was in exact place. Pleural fluid was positive for Beta-2 transferrin. Video-assistedthoracoscopic (VATS) exploration done and it was found that distal tip of shunt was adhered with the lungparenchyma. The pleural biopsy was negative for any malignancy or tuberculosis. The effusion did not progressfurther after the dislodgement of distal tip from lung parenchyma.

Key words: Syringopleural shunt; Ventriculoperitoneal shunt; Pleural effusion; Thoracentesis; VATS; Beta-2Transferrin; Transcytosis; LDH-lactate-dehydrogenase; CSF-Cerebrospinal fluid; syrinx cavities.

P211VATS in management of Tuberculosis Sequelae

S Khandelwal1, Kamran Ali1, N Agarwal1, A Sharma2, S Khanna2, T Piplani3, A Z Khan1

1Department of Minimally Invasive and Robotic Thoracic Surgery

2Department of Anesthesiology

3Department of Radiology

Medanta The Medicity, Gurgaon

Objective: To present our experience of VATS for management of Tuberculosis and its sequelae in the chest

Methods: 130 patients with suspected tuberculosis presented for surgical treatment. The diagnosis includedsimple and loculated pleural effusions, early and late stage empyema with thick cortices, residual pulmonary cavitywith fungal ball, and pneumothorax with air leak.

Procedures performed were; adhesiolysis, decortication, lobectomy, resection of giant bullae, lung volumereduction surgery, bullectomy/ pleurectomy/ pleurodesis.

Results: Pleural effusions were treated with VATS (Uniportal and three ports) drainage. Empyema with thickcortices underwent VATS drainage followed by decortication of both visceral and parietal cortices. Two patientswith cavitatory lung lesions presented with haemoptysis underwent VATS lobectomy. Two patients presentedwith pneumothorax underwent VATS bullectomy and pleurectomy.

All patients had good post operative outcomes. Microbiological culture was negative before removal of drain.Radiological improvement with good lung expansion was seen. All patients continued antituberculous treatment.One patient with MDR TB needed treatment for 2 years. One patient with Giant Bullous disease underwent lungvolume reduction surgery. He subsequently had prolonged air leak requiring indwelling drain.

All patients with decortication were given post-operative intrapleural antibiotic washout till drain fluid is culturenegative. One patient who was 80 years old, presented with pneumothorax was treated withbullectomy/pleurectomy/pleurodesis had prolonged air leak and died due to secondary sepsis. One case requiredconversion to open surgery.

Conclusion: VATS does have a role in the surgical management of patients with tuberculosis. We can achieve goodsurgical results with minimal morbidity and mortality.

P212Use of Urobag in place of a conventional underwater chest drainage system in patients with air leaks after VATS

Kamran Ali, S Khandelwal, N Agarwal, A Z Khan

Department of Minimally Invasive and Robotic Thoracic Surgery

Medanta The Medicity, Gurgaon

Objective: Prolonged air leak from the parenchyma is a frequent complication of lung surgery leading to anincreased hospital stay. We wish to share our experience with the use of a Urobag with a non-return valveconnected to a chest drain, which works on the same principle as a Heimlich valve, as an alternative to underwaterchest drainage system in facilitating early discharge in patients undergoing VATS.

Methods: Between August 2013 to August 2014, 58 patients with persistent air leak after VATS done for varyingetiologies, were managed with application of a Urobag to the intercostal chest drain and discharged home early.

Results: The period of chest drainage varied from 3-11 days post operatively. There were no major complicationsexcept for clot obstruction of valve of the Urobag in 2 patients.

Conclusion: Urobag with its inbuilt one-way valve offers many advantages over the underwater seal system. Ithelps maintain a more negative intrapleural pressure and by being physiologically more effective than theunderwater drain which may occasionally increase the intrapleural pressure and diminish drainage. It is lightweight and easy to manage, thereby allowing early ambulation and discharge, apart from being cost effective andeasily available at all centres. In a country like India where cost of treatment is an issue use of urobag is a cheaperoption than urobag.

P213A study on pleural fluid eosinophilia in patients presenting with pleural effusion in RIMS, Imphal

Dr. Moirangthem Seilaja, Prof. W. Asoka SinghDepartment of Respiratory Medicine,

Regional Institute of Medical Sciences, ImphalObjectives:

To determine the prevalence rate, To determine the causes of pleural fluid eosinophilia, To explore its clinical importance, To evaluate the outcome of treatment.

Methods:A cross sectional study of 53 patients who presented in Respiratory Department of Regional Institute of MedicalSciences with pleural fluid eosinophilia was analysed from October 2012 to August 2014.Results:The prevalence rate found was 7.89. Out of 53 patients, 35 were males and 18 were females with age ranging from16 to 86 years. The causes were paragonimiasis: 15 (28.30%); tuberculosis: 10(18.87%); carcinoma: 8(15.09);parapneumonic effusions: 6(11.32%); pneumothorax: 5(9.43%); blood or air in the pleural cavity due to chest injury:4(7.55%); Meig’s Syndrome and amoebiasis: 1 each (1.89%) and others: 3(5.66%). It affected all adult age groups.Males are more affected. It affects more people from rural areas. Forty-seven(88.68%) cases showed exudativeeffusion. Absolute eosinophil count was raised in 36 patients.ConclusionsPleural fluid eosinophilia is mostly seen in males from rural areas affecting all age groups mainly caused byparasitic infestation, Paragonimus westermanii. Raised absolute eosinophilic count is seen in maximum cases. Thetreatable cases responded well to the treatment given specific for the disease. Eleven patients are being followedup in OPD with improvement.

P214A case series of pancreatic pleural effusions.

K.V.V.Vijaya kumar, K. Preethi, CH.R.N.Bhushan rao, K.Venkata Ramana

Government Hospital for Chest & Communicable diseases (GHCCD), Andhra Medical College, Visakhapatnam, AP,India.

Introduction: Chronic pancreatic pleural effusions are uncommon and often unrecognized clinical syndromewhich results from internal pancreatic fistulas and usually presents as exudative pleural effusion of unknowncause. The effusion frequently occurs without clinical evidence of pancreatitis but occasionally it may be associatedwith pseudocyst of pancreas.

Case reports: Here, we present three cases of chronic recurrent hemorrhagic pleural effusions of pancreaticetiology. All three cases were males among whom two were alcoholics and one was non alcoholic. Two casespresented as bilateral pleural effusions and one case presented as left pleural effusion of exudative etiology.Pleural and serum amylase levels were elevated in all three cases. One subject had associated erythema nodosumand another subject had coincidental finding of horse shoe kidney. Therapeutic ERCP was done in all three casesand there was complete resolution.

Discussion: Chronic pancreatic pleural effusion is usually recurrent and characterized by very high levels ofamylase in pleural fluid. Of several possible mechanisms involved, transdiaphragmmatic lymphatic transfer ofpancreatic enzymes, intrapleural rupture of mediastinal extension of pseudocyst and diaphragmatic perforationsare the most important. Enzyme rich effusions are more commonly left sided and often hemorrhagic andfrequently associated with pancreatic pseudocysts and if long standing may be complicated by broncho pleuralfistula.

P215Right sided massive pleural effusion secondary to Pancreatic pseudocysts and Pancreatico pleural fistula - An

Unusual PresentationDr.Anusha. M, Dr.Yugandhar.K , Dr.Bhanurekha.B , Dr.V.V.S.D.S.R.Sagar

Dr.Pinnamaneni Siddhartha Institute Of Medical Sciences &Research FoundationBackground:Pleural effusion on the right side, due to acute on chronic pancreatitis, is a rare manifestation. We are here withreporting an unusual case of Necrotizing pancreatitis with Pseudo pancreatic cyst presenting as Right sidedmassive Pleural effusion secondary to Pancreatico pleural fistula.Case Presentation:A 35 year old alcoholic male patient presented with grade – IV breathlessness with right sided chest pain, with ahistory of non-productive cough and pain abdomen on and off for six months.Chest x-ray PA view showed right sided massive pleural effusion, tube thoracotomy was done and 2 Lts ofexudative pleural fluid with markedly elevated amylase in pleural fluid (22450 IU/Lt) was obtained.Ultrasound abdomen, CT Chest and Abdomen, and MRCP showed acute on chronic pancreatitis with parenchymalfluid collections/pseudo cysts and fluid collection from tail of pancreas communicating with fluid in abdominallesser sac and tracking upwards medially towards midline in right sub diaphragmatic region, fluid seen in rightpleural cavity.Therapeutic Thoracoscopy was done and the locules ruptured and fluid drained. Pseudo cysts were managedconservatively. Conclusion:Massive right sided pleural effusion with high amylase levels and right sided Pancreatico pleural fistula is a very

rare condition and managed with tube thoracostomy and therapeutic thoracoscopy .

P216TOPIC NAME: PANCREATICO PLEURA FISTULA PRESENTING AS RECURRENT PLEURAL EFFUSION.Authours: Dr.R.Nedunchezhian, Prof.Dr.D.Ranganathan, Pror.Dr.A.Mahilmaran, Dr.V.SundarInstitution: Institute of Thoracic Medicine, Madras Medical College, Chennai-31.

Introduction:Pancreatic pleural effusion is due to accumulation of fluid in pleural space with high amylase content resultingfrom disruption of pancreatic duct.When pancreatic duct disrupts anteriorly results ascites and disruptsposteriorly results Pseudocyst and gives rise to retroperitoneal fistula which tracts through Esophagus or Aortichiatus gives rise to pleural effusion.Pleural effusion also occurs with fistula from Pseudocyst extending throughdome of diaphragm.Spontaneous resolution unlikely.Endoscopic Retrograde Cholangio Pancreatography isessential in both diagnosis and management.Partial disruption of main pancreatic duct is treated with panreaticstent placement.Complete disruption of Main pancreatic duct needs surgical correction

Case History: 43 yr old male,chronic alcoholic ,completed cat 1 ATT for 6month 10 yr back for sputum AFBnegative Pulmonary TB,admitted in Rajiv Gandhi Govt General Hospital Madras Medical College,as Left pleuraleffusion.History of Intrcostal tube drainage of pleural effusion done two times previously in private hospitalpresent. On examinatin left pleural effusion was present.USG&MRI abdomen done and reported as chroniccalcific pancreatitis with pseudocyst in tail of pancreas.Plueral fluid amylase reported as 34600 somaygiunits,serum amylse reported as 3640 somaygi units.Endoscopic retrograde cholangio pancreatographydone:Fistulous communication from pseudocyst to left side dome of diaphragm confirmed and pancreatic stentplacement done.patient uneventful during the hospital

Conclusion: Pancreatico pleural fistula a rare cause of recurrent pleural effusion has good prognosis with surgicaltreatement or pancreatic stent placement

Key words:pleural effusion,pancreatico pleural fisula,stent placement. presentationP217

Comparison Of Clinical diagnosis And Light's Criteria in Distinguishing Transudative and Exudative pleural effusions

G.Ramya, V.V.Ramana Reddy, Ganeswar behra, J.V.praveen, D.S.S.sowjanya, B.K.Prithvi

Department of pulmonary medicine, Maharajah’s Institute of Medical Sciences, NTR University of health Sciences ,Andhra Pradesh, India

OBJECTIVE: The delineation of pleural effusions as being either exudate or transudate is the initial and crucial stepin the diagnosis of pleural effusions. The aim of this study is to ascertain the role of clinical diagnosis in segregatingthe exudative and transudative pleural effusions and to compare with the Light’s criteria and serum-pleural fluidalbumin gradient (SAPA).

MATERIALS AND METHODS: Forty patients with pleural effusion admitted from August 2013 to August 2014 in ourinstitute were studied. Clinical examination, chest x-ray, Light’s criteria and serum-pleural fluid albumin gradientwere used to distinguish transudates and exudates.Further investigations like 2D echo ,pleural fluid culture,sputumfor AFB ,thoracoscpoic and bronchoscopic biopsies were done to confirm the diagnosis.

RESULTS: A total of 40 patients having pleural effusion were divided into 2 groups. Group I Transudates (n=10,25%), Group II Exudates(n=30, 75% ) based on SAPA, which is taken as gold standard. According to the Light’scriteria, there were 37( 92.5%) exudates and 3(7.5%) transudates. Out of the 37 exudates, 7 exudates on diuretictherapy were found to be transudates by clinical diagnosis and SAPA which were misdiagnosed as exudates byLights. With clinical diagnosis 29(72.5%) cases were classified as exudates and 11(27.5%) cases were classified astransudates. Light’s criteria misclassified 17.5% of cases whereas Clinical diagnosis misclassified only 2.5% of caseswhile differentiating transudates from exudates.

CONCLUSION: The discriminative value of clinical diagnosis appears to be superior to light’s criteria in thediagnostic separation of transudates and exudates. In conclusion, though light’s criteria is mostly recommended,coalesced use of clinical diagnosis improves the diagnostic confidence in distinguishing exudates andtransudates.In primary care where biochemical analysis were not available clinical diagnosis alone can beconsidered for treating the patients.

P218CLINICO MICROBIOLOGICAL PROFILE OF EMPYEMA THORACIS

DR.S.SOWMYAKAKATIYA MEDICAL COLLEGE

OBJECTIVES-comparing the clinical & microbiological profiles of patients with tuberculous and nontuberculousempyema.

MATERIALS AND METHODS-A prospective study of adult cases of nonsurgical thoracic empyema was performedover a period of 18 months. A comparative analysis of clinical characteristics, treatment modalities, and outcomes

of patients with tb and nontb empyema was carried out.

RESULTS-40 cases of empyema were seen during the study period, of which 18 (,45%) were of nontb etiology whiletb constituted 22(, 55%) cases. Among the nontuberculous empyema patients, pseudomonas 6( 15%) was themost frequent pathogen isolated. tb empyema was more frequent in younger population compared to nontb

empyema (mean age of 32.7 years vs. 46.5 years). Duration of illness and mean duration of chest tube drainagewere longer (48.7 vs. 23.2 days) in pts with tb empyema. Also the presence of parenchymal lesions and

bronchopleural fistula often requiring surgical drainage procedures was more in tb empyema pts

CONCLUSION-TB empyema remains a common cause of empyema thoracis in India. TB empyema differs fromnonTB empyema in the age profile, clinical presentation, management issues, and has a significantly poorer

outcome

P219Role of pleural fluid adenosine deaminase in etiological diagnosis of pleural effusion

Lokeswara Reddy .A, Yugandhar .P, Satya sri .S

ASRAM Medical college, Eluru, A.P

Abstract:

Objectives: To estimate ADA levels in pleural effusions and to find out diagnostic utility of ADA in etiologicaldiagnosis of pleural effusion.

Methods: This prospective study has been approved by our ethical committe.The study was carried out in 75patients in age group of 10-75years both Out and In patients in ASRAM hospital,Eluru with intial diagnosis of PLEFduring September 2013 –February 2014.After taking consent ,detailed clinical history,physical examination,routineinvestigations of all patients including ADA estimation by Galanti and Giusti colorimetric method was done.

Results:Total no. of Tuberculosis patients were 55 and in all of them pleural fluid ADA was more than 40 IU(mean66.4+29.3).In 10 cases proved to be Malignant the ADA was less than 40(mean17.3+2.64) where as patients withTransudative effusion were 7 and their pleural fluid ADA was less than 40(mean11+3.12).The mean ADA activity intuberculous pleural effusion is significantly high when compared to malignant and transudateeffusions(p<0.001).Based on this data we have taken 40 IU/L as cut off point in differentiating tuberculous andnon-tuberculous effusions with a sensitivity of 98.8% ,specificity 100% and positive predictive value of 100% eachfor tuberculous effusion.

Conclusion: Pleural fluid ADA is a very good parameter to differentiate tubercular from non tubercular pleuraleffusion. It is a simple,low cost investigation and should be considered routinely in all cases of pleural effusion.

P220A case of asymptomatic atraumatic rupture of spleen with pleural effusion in a diabetic patient.

A.B. SRIVASTAVA, B. WAANBAH

Department of Respiratory Medicine, RNT Medical College, Udaipur

Background: Atraumatic rupture of spleen is a condition associated with many disorders and it mainly presentswith abdominal pain in the left upper quadrant, hypovolemic shock and peritonitis. We report a case of left sidedpleural effusion due to atraumatic rupture of spleen without abdominal symptoms.

Case Report: A 68 yrs old male presented with progressive shortness of breath for 10 days. No history of trauma orsyncope or any unusual effort. He is a known case of Diabetes Mellitus on oral hypoglycaemics for the last 20 yrs.On examination the patient was afebrile and vitals were normal. Respiratory system examination showed findingsof pleural effusion on the left side. Pleural fluid was aspirated in four different sittings. It was about 2500ml inamount, hemorrhagic, exudative and showed PCV = 1.2%, ADA = 25.62U/L with cell count of 80 cells/cumm whichmainly included RBC, lymphocytes and few mesothelial cells. No malignant cells were found. CECT scan showedfree fluid collection in left pleural space and multiple hypodense lesion in spleen with peripheral enhancing lowattenuation fluid density collection in subcapsular region suggestive of splenic rupture.

Discussion: Atraumatic rupture of the spleen has been described in the medical literature as a clinical oddity withgrave consequences, if unrecognised and untreated. The true incidence of this condition is difficult to state as aMedline literature search revealed only 44 such case reports over the last 34 years. Symptoms can be subtle andthe condition may be mistaken for angina pectoris, myocardial infarction, pulmonary embolism, peptic ulcerationor pneumonia. In our case, conservative management was given, though we did not rule out the possibility of asplenectomy during the period. Patient was discharged after 2 weeks.

P221To study the therapeutic use of streptokinase in loculated empyemaDr. VIKASH KUMAR, Dr. G.V.SINGH, Dr. SANTOSH KUMAR, Dr. R.K.GUPTA, Dr. SANJEEV ANAND, Dr. ANKITDESHWAL, Dr. BHARTESH, Dr. SANTOSHS. N. Medical College, Agra

OBJECTIVE- to study the therapeutic effect of streptokinase in loculated empyema.

MATERIAL AND METHODS- Patients complaining of fever and dry cough, having clinical and CXR findingssuggestive of empyema will be evaluated by USG, and patients having loculated empyema will be considered forintrapeural instillation of streptokinase. In total, 30 lac IU of streptokinase will be instilled intrapleurally via

transthoracic route in three divided doses daily (diluted in normal saline) in duration of three days. Patients will beevaluated clinically and radiologically using CXR, before and after treatment. Pt. will be kept in follow-up, alongwith drugs according to the etiology of empyema, and monthly CXRs will be done to find out any recuurentempyema.

RESULTS- Atotal of 7 patients established to have loculated empyema were considered for intrapleural instillationof streptokinase, and all the 7 patients were cured as evident on serial CXRs done. In follow-up, none of the caseswas found to have recurrence of loculated empyema.

CLINICAL IMPLICATION- Patients having loculated empyema are difficult to treat, as there are loculations in pleuralcavity along with pus. Once intercostal drain is placed, it takes months to extubate such patients because ofloculations. In such patients, instead of putting ICD, intrapleural instillation of streptokinase via transthoracic routeby injection can prove to be a better treatment option as it will lead to early cure and lesser duration of hospitaladmission.

P222A rare case of left lower lobe pulmonary sequestration presenting as empyema

DR. CHETAN RAO.VADDEPALLY , Prof. Pradyut Waghray, Dr.A.N.V.Koteshwara rao, Dr. Venkateswara reddy.T,Dr.Rama Krishna reddy.G*,Dr. Veena , Dr. Harish, Dr. sowmya, Dr. Rikin, Dr. Aditya, Dr. Krishna Chaitanya.

Dept. of Pulmonary Medicine, S.V.S medical college, mahboobnagar, Telangana.

*Dept. of Radiology

Introduction : with an overall incidence of 0.15 to 6.4% of all congenital pulmonary malformations, pulmonarysequestration forms a rare disorder. The condition is characterized by aberrant formation of segmental lung tissuethat has no connection with the bronchial tree. It preferentially affects the lower lobes, predominantly the leftlower lobe. We hereby present a case of the rarer variety presenting as empyema.

The case report: A 35 yr old male was admitted with complaints of high grade , intermittent fever with chills andcough with expectoration and haemoptysis since the last 10 days. The patient gave history of recurrent episodes offever and cough since childhood.

Physical examination revealed a healthy appearing, well nourished man. On auscultation, there were decreasedbreath sounds on the left lower zones.

Total leucocyte count was raised and all other routine investigations were within normal limits. Chest X-rayshowed an ill-defined, homogenous opacity, occupying the left lower zone with obliteration of the CP angle.Ultrasound of the thorax revealed moderate pleural effusion. Diagnostic tap showed frank pus which was drainedwith ICD. After removal of ICD patient had an episode of massive haemoptysis. Subsequent contrast enhanced CTshowed heterogenous enhancing cystic mass lesion in the left lower lobe. A small arterial branch from theabdominal aorta supplying the mass lesion was visualized. Given the history and imaging features characteristic ofintra lobar sequestration, the patient was reffered to thoracic surgeon.

Conclusion : The diagnosis of sequestration can be easily missed in adults as many of the symptoms overlap withother pulmonary processes. The constellation of recurrent pneumonia and cystic lower lobe mass fed by ananamalous systemic arterial vessel are hallmarks of an intralobar bronchopulmonary sequestration.

P223A rare case of Thoracic Empyema – Double Trouble

Authors – Avik GHOSHAL, Koushik MUTHU RAJA.M, B.RAJAGOPALAN

Institution - Sri Ramachandra Medical College and Research Institute

Introduction: - Pleural space is always a riddle.Tuberculous empyema is rare compared to tuberculous pleuraleffusion and the pleural fluid is smear positive for acid – fast bacilli(AFB) unlike that in pleural effusion. Presence ofother systemic disease makes the etiological diagnosis more challenging. Here we present a case of empyema, AFBpositivity and suspected Adult Onset Still’s disease (AOSD) – all together.

Case Report:-

A 21 years female presented with complaints of breathlessness, chest pain and high grade fever. On detailedhistory patient revealed fever for 20 days-initially low grade intermittent, later high grade continuous. She hadpain with tenderness left lower chest, was febrile, toxic and breathless-MMRC grade III . She also gave history ofintermittent polyarthralgia and pink coloured rash over extremities, predominantly lower limbs, for nearly a year.Clinical examination revealed Right cervical lymphadenopathy. Chest X-ray revealed bilateral pleural effusion leftmore than right. Nearly 170ml of pus was aspirated from left pleural cavity. Pleural fluid analysis revealed Sugar-2,Protein-6, LDH-6066, ADA-221, with smear positive for AFB. Patient was started on Anti-tubercular therapy (ATT).Fever was not subsiding. Laboratory investigations revealed TLC-10200, S.Bilirubin-4.13(Direct-3.65), SGOT-1567,SGPT-942. Based on history of polyarthralgia and skin rash for a year and raised S.Ferritin concentration of 2047.7mcg/L (normal range 30 – 300mcg/L), patient was diagnosed with Adult Onset Still’s Disease. Patient was put onoral Steroids, Hydroxychloroquine and Hepatic safe ATT regimen. Her fever subsided and liver function normalised.

Conclusion:-

Adult Onset Still’s Disease is uncommon (incidence < 1/1,00,000 ) and characterised by polyarthritis, rash, feverand leucocytosis. The diagnosis is primarily a diagnosis of exclusion suggested by coexistent elevated level ofFerritin. Pleural effusion and even pleuro-pericardial effusion are less recognised components of AOSD. Wepresent this case as it may be a combination of tuberculosis with AOSD.

P224Spectrum of sleep disturbances in patients undergoing haemodialysis

KRISHNOJI RAO S, KRISHNASWAMY U, CHENNABASAPPA GK, MANTHA SP, ANEJA A

Departments of Respiratory Medicine and Nephrology

MS Ramaiah Medical College, Bangalore, Karnataka, India

Objectives: To study the spectrum of sleep disturbances in patients with End Stage Renal Disease (ESRD)undergoing haemodialysis.

Method: This cross-sectional study was conducted on 121 ESRD patients undergoing haemodialysis in M.S.Ramaiah Hospitals. After obtaining informed consent, patients were screened using a clinical proforma, EpworthSleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI).

Results: Out of 121 patients with ESRD included in the study, there were 34 (28.1%) females and 87 (71.9%) males,with age ranging from 20-81 years. Ninety seven (80.2%) patients were undergoing dialysis for more than 6 monthswhile 24 (19.8%) patients were undergoing dialysis for less than 6 months.

Ninety three (76.8%) patients reported sleep disturbances. These included excessive daytime sleepiness in32(34.4%), insomnia in 35(37.6%), restless legs in 17(18.3%) and various combinations of the above in 9(9.7%)

patients. Among patients with excessive sleepiness, symptoms suggestive of obstructive sleep apnea (snoring,witnessed apneas) were reported in 10 (31.2%) patients.

However, when the ESS and PSQI were administered, it was found that ESS was >10 in 61(50.4%) patientsqualifying them as excessively sleepy and PSQI score was >5 in 111(91.7%) which was indicative of poor qualitysleep.

Conclusion: This study shows that there is a high frequency of self-reported sleep disturbances among patientsundergoing hemodialysis, and the frequency further increases if validated questionnaires are administered. Thus,there is a need to routinely screen these patients for sleep disturbances and perform polysomnography todiagnose wherever indicated.

P225Sleep quality in patients with Hypercapnic Chronic Obstructive Pulmonary Disease by Polysomnography

K.Rajarajan, S.P.VengadaKrishnaraj, G.AllwynVijay, R.Sridhar, O.R.Krishnarajasekhar, C.ChandrasekarStanleyMedicalCollege, Chennai

Background:

COPD is fast emerging as global health problem and is the fourth leading cause of death among developedcountries. There are few studies on COPD establishing differences between functional parameters of the diseaseand sleep variables.

Objective:To describe the sleep pattern in COPD patients with Chronic Hypercapnic Respiratory Failure and to describe theinfluence of hypercapnia on the quality of sleep .

Methods:Patients enrolled in the COPD registry at Government Hospital Of Thoracic Medicine, Tambaram , with severestable COPD evidenced by FEV1< 40% by spirometry are included, Arterial Blood Gas analysis is done. Those withChronic Hypercapnic Respiratory Failure (Group A) are included in the study. Patients with similar degree ofobstruction without Respiratory Failure are used as comparision group (Group B). Overnight Polysomnography wasperformed in those patients and Pittsburg sleep quality index scoring is done. Data is analysed by standardstatistical methods.

P226BILATERAL TUBERCULOSIS OF AREOLA & NIPPLE–A RARE CASE

1) Dr Srikanth Ravoori, 2) Dr V.A.N.Raju, 3) Dr P.Subbarao

Department of Pulmonary Medicine, Konaseema Institute of Medical Sciences & Research Foundation, NH-214,Amalapuram, E.G. Dist, Andhra Pradesh-533201.

BACKGROUND: Though TB is common in India, Tuberculosis of Breast is an uncommon finding or may beoverlooked and treated commonly as Pyogenic Abscess. This is a case of TB of areola and nipple.

CASE REPORT:

A 25 yr unmarried woman presented with pain, fever, and discharge from nipples for last 7 yrs. There was nohistory of pulmonary tuberculosis, but her brother was treated adequately for sputum positive pulmonarytuberculosis 5 years back. Sputum AFB of the patient was negative but mantoux with 36mm induration with a BCGscar was noted. On physical examination, there were multiple healed scars present on both the breasts around theretracted nipples. Grayish white thick, cheesy discharge was expressed from both the nipples and examined forAFB by ZN staining which was found to be POSITIVE. Chest x-ray was normal. Patient is kept under DOTS andresponding well to treatment.

DISCUSSION: In India the incidence of TB breast has been reported to be 0.63%to 4.5%. Bilateral breasttuberculosis is rare, TB of areola and nipple being rarest. Bilateral involvement holds for only 3% of patients withbreast tuberculosis. In most of cases histology contributes to diagnosis by identifying a granulomatous lesion withtypical caseous necrosis. The Gold standard for diagnosis of TB is Zeil Neelsen staining/culture, which is positive inour case. The differential diagnosis to be considered is carcinoma, although other diseases of the breast such asfatty necrosis, plasma cell mastitis, periareolar abscess, actinomycosis & blastomycosis should also be considered.

P227Pulmonary Mucormycosis Masquerading As Endobronchial Growth with Non Resolving Pneumonia

1) Dr Srikanth Ravoori , 2) Dr Mootha Vamsi Krishna

Department of Pulmonary Medicine, Konaseema Institute of Medical Sciences & Research Foundation,NH-214, Amalapuram, E.G. Dist, Andhra Pradesh-533201

BACKGROUND: Non resolving pneumonia has a wide range of etiology which needs extensive investigationsincluding bronchoscopy, radiological and microbiological tests. We present an unusual case of Non resolvingpneumonia

CASE SUMMARY: Patient is a 40 year old diabetic male, presented to us with complaints of chronic cough andfever of 4 weeks duration. He was evaluated elsewhere with chest X rays, CT SCAN which showed left lower lobeconsolidation. Sputum was sent for bacterial culture. He received antibiotics for K.pneumonia infection as persensitivity pattern. Despite 2 weeks injectable antibiotics he had persistant symptoms. Repeated sputumexamination for AFB was negative. Repeat CT scan showed persistent consolidation. At this juncture patient wasreferred to us. He was subjected to BRONCHOSCOPY. It revealed an endobronchial growth in left lower lobe mainbronchus, causing partial obstruction of lumen. Endobronchial biopsy has shown features of INVASIVEMUCORMYCOSIS. He received liposomal Amphotericin B 100 mg/day for 10 days with which clinical improvementwas noted and was followed by Posaconazole syrup. Patient had complete clinical, radiological improvement andconfirmed by resolution of endobronchial growth and normalization of airways. Posaconzole was continued tillcomplete radiological resolution.

CONCLUSION: We report a case of pulmonary mucormycosis presenting as endobronchial growth. We successfullytreated the patient with liposomal Amphotericin B and Posaconazole, avoiding surgery.

CLINICAL IMPLICATION: Diabetic patients with uncontrolled blood sugars presenting with non resolving pneumoniashould be investigated for fungal etiologies

P228TITLE: Endobronchial tuberculosis: case report.

AUTHORS: Dr.Bharat Bhushan, Dr.Ramesh Chander, Dr. N.C.Kajal, Dr. Rosy Aggarwal, Dr. Sandeep Gupta, Dr.Satish Duggal.

Department of Chest and TB, Government Medical College, Amritsar (Punjab), India

ABSTRACT

BACKGROUND : Tuberculosis remains major threat to mankind worldwide with India accounting for one-fifth ofglobal incidence. Endobronchial tuberculosis is disease of tracheobronchial tree with microbial andhistopathological evidence. It remains difficult to be diagnosed because of nonspecific clinical presentations withnormal chest skiagram and absence of acid fast bacilli in direct sputum smear oftenly. Accordingly patient remainsundiagnosed and source of infection to the family and community. Procedural investigations like fiberopticbronchoscopy are sometimes of great help in patients with strong suspicion of disease in country like India withhigh disease incidence.

Case Report : A 27yr married female presented with three months complaint of having fever, dry cough , right sidechest pain along with hemoptysis of fifteen days duration. There was no history of ATT previously. GPE and Chestexamination were normal. Hb7 g/dl, TLC7800, DLC N60,L40, ESR110mm, HIV non-reactive, Mantoux negative, CXRshowed no abnormality. Direct sputum smear microscopy was negative for AFB. FOB showed inflammation,hyperemia and ulceration with caseous material on bronchial mucosa of intermediate bronchus and adjoininglower lobe bronchus on right side. Brush-smear, broncho-alveolar lavage and post bronchoscopic sputumspecimen were taken. BAL centrifuge revealed AFB on direct smear. Cytology revealed lymphocyticpredominance. Post-bronchoscopic sputum and brush-smear were negative for AFB. Accordingly diagnosis of EBTBwas established. The patient was put on anti-tubercular chemotherapy (DOTS) along with oral prednisolone (1mg/kg). The patient improved markedly and the prednisolone dose being tapered during follow up.

Conclusion : EBTB is less frequently diagnosed because of non-specific clinical presentations, misleading normalradiological findings and low incidence of AFB positivity in routine sputum-smear. A high index of suspicion isrequired for its diagnosis, especially in high endemic regions like Indian subcontinent. Added proceduralinvestigations including FOB will help for early diagnostic yield.

Key words: Atelectasis, Endobronchial, cancer, complication, pneumonia, tuberculosis

P229ALTERNARIA ALTERNATA PNEUMONIA

A RARE CASE REPORT

Dr. V.Mounika, Prof. Dr.P.Subbarao, Dr.H.V.Prasad

Konaseema Institute of Medical Sciences & Research Foundation

Amalapuram, Eastgodavari, Andhrapradesh

BACKGROUND CASEREPORT

Alternaria alternata is a rare fungal organism, that usually Seen on dead and dying plant parts , house dust.

CASE REPORT

In this case report a 50 year-old female with a 10 year history of asthma and 4 year history of diabetes mellitus,presented with two months duration of right chest pain, cough with purulent sputum and streaky haemoptysis.Chest x-ray and CT chest showed non homogenous opacity in right mid zone.

Ultrasound guided Fine needle aspiration of right lung lesion revelead pus.The cytology of pus showed branchedseptate hyphae, and few hyphae are brown in colour and culture on sabouraud's dextrose agar showed colonies ofAlternaria alternata. The patient was treated with Amphotericin B and fluconazole. Patient was discharged afterresolution of symptoms.

DISCUSSION

ALTERNARIA fungus is a large universally occurring genus. Several form-species are found as saprophytes on deadand dying plant parts. Commonly found in house dust, carpets, textiles, and on horizontal surfaces in buildinginteriors and is one of the main fungal causes of allergy. Outdoors, it may be isolated from samples of soil, seedsand plants, and is frequently reported in air. Conidia of this fungus are easily carried by the wind. The large sporesize suggests that the spores from this fungus will deposit in the nose, mouth and upper respiratory tract causingnasal septum infections. It has also been associated with hypersensitivity pneumonitis

It is a common cause of extrinsic asthma includes, Baker’s asthma and Farmer’s lung . Acute symptoms includeedema and bronchospasms; chronic cases may develop pulmonary emphysema. Other diseases caused byAlternaria include mycotic keratitis, skin infections, and osteomyelitis

P230

P231

Validity of empiric anti-tubercular treatment in suspected extra-pulmonary TB patients in tertiary health care-Retrospective study

Dr. Avinash Chauhan(Presenting Author), Prof. Dr. Meena Hingorani, Prof. Dr. Tushar SahasrabudheDepartment of Pulmonary Medicine Padmashree Dr. D. Y.

Patil Medical College Hospital and Research Centre, Pimpri, Pune, Maharashtra, India.

OBJECTIVES:

To study the validity of empiric anti-tubercular treatment in suspected extra-pulmonary TB patients

METHOD:A retrospective case series study was conducted at Dr D.Y Patil medical college, Pune, Maharasthra. All casesdiagnosed and treated as EPTB from September 2013 to February 2014 were included. Data was retrieved from theRNTCP register. Details of clinical, laboratory and radiological records of the patients were retrived from respectivedepartments. Extra-pulmonary TB was defined as patients with TB of any organ other than the lungs according toWHO definition such as gastrointestinal (G.I), musculoskeletal and genitourinary systems. Lymphadenopathy andpleural effusion were excluded as their diagnosis is based on histopathological and ADA findings respectively. Allcases were registered on DOTS-CAT-1 and followed up after 3 months to evaluate the response to therapy.

RESULTS:Out of the 36 patients treated for EPTB, 19 patients were males and 17 were females and mean age was 30 yrs

(range 15-40). Most of the patients were unskilled workers and farmers. 60% patients were alcoholics. G.I andmusculoskeletal(joints) were the most common sites involved (80.5%).Common complaints were abdominal painand fever when G.I system was involved, and joint pain in case of musculoskeletal system. Among G.I patients,63.8% (12 patients out of 19) symptoms resolved at the end of 3 months and 36.2% (7 patients out of 19) patientsthere was no change in symptoms- 3 defaulted within 2 months due to no improvement in symptoms and 4 arecontinuing treatment inspite of no change in symptoms . Among musculoskeletal, 60%(6 patients out of 10)symptoms resolved and 40%(4 patients out of 10) patients there was no change in symptoms-2 defaulted within 2months due to no change in symptoms and 2 are continuing inspite of no change in symptoms. No additionaltreatment was taken either as alternative therapy or treatment for co-morbidity by the patients during 3 monthsperiod.

CONCLUSION:Our study shows that suspected extra-pulmonary patients must be investigated thoroughly for tuberculosis and allother differential diagnosis must be excluded before starting anti-tubercular treatment.

P232TITLE: Diagnostic value of PCR in sputum of patients with pulmonary tuberculosis

AUTHORS: SS GUPTA, A MEHROTRA, R SHARMA

Department of Pulmonary Medicine, Era’s Lucknow Medical College & Hospital, Lucknow, India

OBJECTIVES: To find out diagnostic utility of PCR in sputum of patients with pulmonary tuberculosis, to determinesensitivity and specificity of PCR in diagnosis of pulmonary tuberculosis, and to compare the results of PCR withsputum smear reports of Mycobacterium tuberculosis (MTB) by Ziehl-Neelsen (ZN) staining.

METHODS: The study group consisted of 65 out-patients with strong suspicion of active pulmonary tuberculosis onbasis of clinico-radiological evidence. 40 out-patients having non-tubercular respiratory disease during the sameperiod formed the control group. Sputum of all the patients was subjected to smear microscopy by ZN staining andPCR for MTB in MJ mini thermal cycler (BIO RAD UK) using IS6110 (123bp) primer for amplification. All patients weresubsequently followed clinico-radiologically.

RESULTS: Of the 65 cases, 40 were smear positive and 25 were smear negative for MTB. All smear positive caseswere PCR positive. Out of 25 smear negative cases, 14 were PCR positive. All 40 controls were PCR negative. All 54PCR positive cases responded to anti-tuberculosis therapy. The sensitivity and specificity of smear microscopy wasfound to be 61.5% and 100%, while that of PCR was found to be 83% and 100% respectively.

CONCLUSION: This study suggests that detection of MTB by a PCR based test could lead to rapid detection, earlytreatment, application of isolation procedures and also, investigation of contacts.

P233Deep Vein Thrombosis in a patient with Pulmonary Tuberculosis - A Case Report

KB GUPTA, VIPUL KUMAR, MOHIT AGGARWALPt B.D. Sharma Post Graduate Institute of Medical Sciences

INTRODUCTION: Deep vein thrombosis (DVT) is clinically observed and can be confirmed with laboratory methodsin 3-4% of patients with pulmonary tuberculosis (PTB). But the real incidence may be closer to 10%, because mostof the patients are thought to be clinically inapparent. The lack of awareness regarding the association is possiblyresponsible for the condition not being recognized and hence screening and treatment strategies have not beenstandardized.

CASE RECORD: A 25 year old male TB patient was admitted with painful swelling of left lower limb for last 5 days.On examination the leg was tender &signs of DVT were present. Color Doppler Ultrasonography of left limbshowed echogenic thrombus in lumen of left external iliac, common femoral, superficial femoral, popliteal,posterior tibial and anterior tibial veins. CT Angiogram chest showed no evidence of pulmonary embolism. Patient

was treated with subcutaneous low molecular weight heparin with an overlap of warfarin for 10 days. Repeat ColorDoppler ultrasonography done after 2 weeks of treatment of antithrombotics showed resolution of thrombus.

DISCUSSION : The thrombogenic potential of TB is not well known but can have serious consequences. Activationof endothelial cells occurs in response to numerous physiological stimuli and results in the expression ofendothelial proteins that change the normally non-thrombogenic internal surface of the vessel into athrombogenic surface with subsequent development of local thrombosis. Priming of vascular endothelium occursas a result of interaction between mycobacterial products and the host monocyte–macrophage system. It is alsopostulated that these changes result in hypercoagulable state predisposing to DVT. Prognosis of the DVT in PTBwas found to be good if ATT and LMWH were started simultaneously and earlier. We emphasize on early detectionof deep vein thrombosis, early start of prophylactic low molecular weight heparin in severe pulmonarytuberculosis

P234A RARE CASE OF PAROTID TUBERCULOSIS

P Dani, P Dutta, R Manjhi, S Pothal

Department of Pulmonary Medicine,V S S Medical College ,Burla ,Odisha, India

Background:- parotid tuberculosis is a rare form of extrapulmonary tuberculosis which usually presents as aunilateral parotid swelling or abscess. Only about 100 cases of parotid tuberculosis have been reported is theliterature. .

Case report:- The present case reports a 33yrs old male patient presented with swelling of left parotid area of 2 yrsduration which gradually is increasing in size. On excamination swelling was firm in consistency non tender with illdefined borders, which was not fixed to masseter or any underlying structure. Skin over the swelling was normal.Facial nerve was intact.Chest X-ray and other routine blood investigations were normal.USG guided FNAC andbiopsy of the swelling were suggestive of tubercular sialoadenitis. Z-N stain for AFB was negative. Patient improvedwith a course of ATT.

Conclusion:- In a case of parotid swelling the possibility of tuberculosis should be kept in mind even though it israre. The early diagnosis and suspicion is required to avert the need for surgery which may be a hazardousprocedure in a medically treatable condition.

P235Calcified subcutaneous cysticercosis in a treated pulmonary TB patient--a case report

Saravanan.M, Ramanujam.P., Chitrakumar.A., Gangadharan.V

Govt.Kilpauk Medical College/ GTHTM, Chennai, Tamil Nadu, India

Introduction: WHO designated cysticercosis as one of the 17 "neglected tropical diseases" worldwide. Encystmentof larval form of tapeworm in various tissues of body is called cysticercosis.Eventhough CNS is the most commonlyinvolved organ, subcutaneous cysticercosis is also reported in literatures.

Objectives: To highlight that calcified subcutaneous cysticercosis has to be considered in differential diagnosis ofcalcified lesions in chest xray

Case report: 70yrs non-diabetic male,agriculturist,pork eater,presented with complaints of cough andexpectoration for 2-3 weeks.10 yrs back,he was treated for pulmonary TB.On examination,there were multiplesubcutaneous small,multiple swellings all over the body.chest xray showed typical millet seed calcifications in softtissue areas and lung zones.xrays of abdomen and both lower limbs showed similar calcified lesions in soft tissue

areas.Excision biopsy of subcutaneous swelling revealed fibrocollagenous wall with foci of calcification.nocysticercosis demonstratable in specimen.sputum for AFB was negative.respiratory symptoms improved withantibiotics.

Discussion : Subcutaneous cysticercosis is a less common presentation of tapeworm infestation. Man is thedefinitive host. Pigs are the intermediate host.Humans get the infection when they ingest undercooked infectedpork meat which is harbouring the cysticerci. Biopsy and HPE demonstrating the cysticerci is the definitivediagnostic method. In FNAC, the presence of eosinophils, neutrophils, palisading histiocytes, giant cells in a typicalgranular dirty background should alert the cytopathologist of a parasitic infection . When characteristicmorphology is absent in histopathology specimen, mitochondrial DNA diagnosis is a powerful tool for a definitivediagnosis of cysticercosis. .Asymptomatic calcified subcutaneous cysticercosis can be left alone without treatment

P236Association between DVT and pulmonary TB-- a case series report

Saravanan.M, Ramesh.P.M, Chitrakumar.A, Gangadharan.V

Govt. Kilpauk Medical College /GTHTM, Chennai, Tamil Nadu, India

Introduction: India accounts for 1/3rd of global burden of Tuberculosis. Pulmonary TB is a risk factor for DVT.Thromboembolic complications associated with pulmonary TB had been reported in literatures with incidencevarying between 1.5 to 3.4%.

Objective: To analyze the epidemiological factors associated with DVT in pulmonary TB patients.

Methods: We did a case series study of 4 cases of smear positive pulmonary TB patients who developed DVT whileon treatment for pulmonary TB. All 4 cases reported to our hospital within a period of 2 months. All cases weresubjected to routine blood investigations, sputum for AFB, x-ray chest

Results: All the 4 patients were male smokers. Age of the patients ranged from 35 -- 53 yrs. Sputum positivitygrading was 2+ in 3 patients and 1+ in one patient. All the 4 patients had bilateral extensive lesions in chest x-ray.All the patients developed DVT within 4 weeks of diagnosing PTB. All were poorly nourished with low BMI. VenousDoppler USG confirmed the diagnosis of DVT in all 4 cases. All were treated with ATT, heparin and oral warfarin. All4 patients responded well to the treatment and no one developed pulmonary embolism in our study

Discussion: Pulmonary TB infection causes elaboration of IL-1,6 and TNF-α and release of pro-inflammatorycytokines resulting in a hypercoagulable state. Further rifampicin used in the ATT regimen alters the coagulant andanticoagulant protein balance resulting in hypercoagulable state. In our study, in all 4 cases, smoking, extensivelung disease leading to release of pro-inflammatory cytokines and patient’s poor nutritional and bed-riddenstatus contributed to the development of DVT..

Conclusion: In all severely ill pulmonary TB patients,we should be aware of development of DVT and earlyscreening for DVT and encouraging early ambulation in such patients will prevent life threatening pulmonaryembolism.

P237A case of paradoxical TB IRIS in NON-HIV TB cervical adenitis patient on ATT--a case report

Saravanan.M, Karthikeyan J.J., Chitrakumar. A. , Gangadharan .V

Govt. Kilpauk Medical College/GTHTM, Chennai, Tamil Nadu, India

Introduction: Paradoxical TB IRIS is an immunological reaction seen in HIV patients on ART while on treatment fortuberculosis, seen within 2 months of initiating ATT. It is characterized by enlargement of existing lymph nodes,appearance of new nodes, tuberculoma in brain, new lesions in lung and serositis. It poses a challenge to clinicianbecause it is difficult to distinguish between paradoxical reaction and treatment failure or drug resistance. Wereport a case of paradoxical TB IRIS in non-HIV female patient with TB cervical adenitis

Case report: A 33yrs female, non-HIV, non-diabetic, who presented with left cervical lymphadenopathy wasdiagnosed as TB cervical adenitis based on symptoms, mantoux positivity and excision biopsy. After 3-4 weeks ofstarting ATT, patient developed fever, chest pain,myopathy,arthritis and enlargement of existing node withabscess formation. CT chest revealed mediastinal adenopathy, pleuro-pericardial effusion and parenchymalinvolvement and presternal abscess collection. Aspirate from abscess was sent for AFB culture. Sputum for AFBwas negative. LFT was normal. Meanwhile, patient was continued ATT and treated with NSAID and steroid asclinical features were suggestive of IRIS. Fever subsided. Pleuro-pericardial effusion resolved. AFB culture reportcame as negative for Mycobacterium tuberculosis. Patient improved clinically and ATT was continued whereassteroid was stopped after gradually tapering the dose. Patient completed full course of ATT with resolution ofnodes.

Discussion: Paradoxical reaction during ATT treatment must be considered after careful exclusion of medicationnon-adherence, development of resistance and other similar conditions. The addition of short course of steroidmay be necessary to control severe form of reaction with or without drainage or surgical excision of lymph node toavoid fistula. .

P238Awareness of Tuberculosis among patients attending RNTCP at Siddhartha Medical College, Vijayawada

S.N. Mani devi. K , N.Gopichand , D.Sudeena

Department of Pulmonology , Siddhartha Medical College , Vijayawada , A.P.

Introduction:Tuberculosis is one of India's major public health problems. According to WHO estimates, India has the world'slargest tuberculosis epidemic. Public awareness about its causative organism, modes of spread, diagnosis,treatment, and prevention plays an important role in TB control. The present study was carried out to assessawareness of Tuberculosis among patients attending tertiary care hospital(Siddhartha Medical College)

Methodology:A cross sectional observational study was conducted among 100 patients taking treatment at Siddhartha MedicalCollege, Vijayawada using a preformed questionnaire. The questionnaire contains socio-demographic variablessuch as age, sex, religion, literacy status, and knowledge about symptoms, mode of transmission, aetiology,Investigations, prevention and treatment of tuberculosis

Results:Out of these 100 Patients 97% were aware that Tuberculosis is an infectious disease. Regarding symptoms only69% identified cough more than 2 weeks as an important warning sign for Tuberculosis. Regarding investigationsonly 69% were aware that sputum test was done for diagnosis of Tuberculosis. Only 60% knew DOTS as treatmentfor Tuberculosis. Only 56% were aware that Tuberculosis is most common in HIV individuals.

Conclusion:The current study revealed that although awareness regarding certain basic aspect of tuberculosis was adequate;however there is a great need to improve awareness about the symptoms and treatment of tuberculosis.

P239

Prevalence of extra pulmonary multi drug resistant tuberculosis among retreatment tuberculosis patient admittedin tertiary care hospital by using gene x pert assay

Dr. K. Maheswaran, S. P. Vengada krishnaraj, G. Allwyn vijay, J. Arivozhi, R. Sridhar, O.R Krishnarajasekhar, C.ChandrasekarInstitution.stanley.medical.college.chennaiBackground:

In 2012, out of the estimated global annual incidence of 8.6 Million TB cases, 2.3 million occurred in India, of which15% falls under extra pulmonary tuberculosis. India accounts for one fourth of global burden of tuberculosis.Because of human immunodeficiency virus infection incidence of extra pulmonary tuberculosis is raising,occupying 50% of tuberculosis in retro viral positive patients. Multi drug resistance among retreatment case is 12-17%; primary drug resistant is 2-3%. The X pert MTB/Rif test is a cartridge-based fully automated NAAT (nucleic acidamplification test) for TB case detection and rifampicin resistance testing, suitable for use in disease-endemiccountries. It provides results from unprocessed sputum samples in less than 2 hours, with minimal hands-ontechnical time. This Study where done to identify Multi Drug Resistance tuberculosis among extra pulmonarytuberculosis patient admitted in our hospital (Government Hospital of Thoracic Medicine tambaram), as similarprevious data unavailable in Tamil Nadu.

Study place: Government Hospital of Thoracic Medicine, Tambaram, Tamil Nadu.

Study period: Between March 2014 to August 2014.

Study design: prospective study

Methods and material:

Patient with extra pulmonary tuberculosis came for retreatments were chosen for my study to analyze drugresistance among them. Samples from extra pulmonary sites like lymph node, pleural fluid and abscesses weresend for gene x pert analysis in IRL Chennai

Results:

71 extra pulmonary tuberculosis specimen were subjected to gene x pert of which 10 where retroviral positive,among which pleural effusion occupies 43.6 %, lymph node tuberculosis 52.1 %, abscess 4.6%. Multi drug resistantwas diagnosed in 7 patients (9.8%), MTB detected in 50.7%, MTB not detected in 33.8%, 3 of the 71 samples (4.2%)was repeated because of indeterminate report. sensitivity of gene x pert in diagnosing MTB complex from variousspecimen includes 64.8% for lymph node aspiration, for pleural fluid it is 32.2% and for abscess is 50%.

Conclusion:

1. Compare to conventional culture methods for diagnosis of extra pulmonary MDR TB used previously;gene x pert method is quicker hence we are able to diagnose extra pulmonary MDR TB more easilyaccounting for its higher incidence in recent years in our institute.

P240TB presenting as right paratracheal mass.

Dr. Praveen.R, Dr. Yuvarajan.S, Dr. Kavitha devi. M

Sri Manakula Vinayagar Medical College and Hospital,Puducherry, India

Introduction:

Mediastinal tuberculous lymphadenitis is a rare disease in adults. Dysphagia as a presenting symptom is evenrarer. Dysphagia due to mechanical obstruction is usually related to malignant disease.

Case report:

Our case is a 56 year old lady who came with complaints of difficulty in swallowing for 2 months, cough withscanty mucoid sputum and loss of appetite for six months. Patient was initially evaluated at an outside hospitalwith chest x-ray, upper gastrointestinal scopy( Impression – mild oesophagitis) and treated with antacids. As thepatient did not have symptomatic improvement, came to our hospital, was evaluated with Chest x-ray whichshowed well defined homogenous opacity in right paratracheal region. Bronchoscopy was done and trans trachealneedle aspiration was taken which was suggestive of granulomatous lesion. C.T Thorax (plain and contrast ) wasdone which showed conglomerated mediastinal lymph nodes present. C.T guided needle aspiration of nodes donewhich was suggestive of non caseating granulomatous lesion. With a working diagnosis of sarcodosis / TBlymphadenitis, Mantoux was done, showed 15mm induration. Patient was started on Anti-tuberculous treatmentCAT -1, improved symptomatically. Follow up chest x rays were taken which showed regression in size of thehomogenous opacity and complete resolution of it after six months of Anti-tuberculous treatment.

P241EVALUATION OF MYCOBACTERICIDAL ACTIVITY OF SUPEROXIDIZED WATER ON CLINICAL ISOLATES OF

MYCOBACTERIUMDr Ritu Aggarwal, Dr Uma Chaudhary, Dr Vipul Kumar, Dr K B Gupta, Dr Nidhi GoelPt BD Sharma Post Graduate Institute of Medical Sciences, Rohtak (Haryana) INDIA

Objectives- In 2012, 8.6 million people fell ill with TB and 1.3 million died from TB. The main cause for concern isthe spread of MDR TB strains and HIV-TB co infection. Resistance to medication does not mean that at the sametime there is also a resistance to disinfectants. Careful disinfection in the everyday clinical environment is of greatimportance today and is a particularly effective measure for the prevention and breaking down of infection chains.In this context the methods of asepsis and active chemical antisepsis are currently becoming increasinglyimportant in terms of the prevention of transmission of infection. So, this study was conducted to investigate theactivity of superoxidized water on mycobacteria.

Methods- For clinical isolates of Mycobacteria and Mycobacterium tuberculosis H37Rv (NCTC 7416) were includedin the study. Suspension of the five mycobacterial strains was prepared in distilled water in six sets for each strain.Three set of tubes were used as test and were treated with SOW for a period of 05, 10 and 15 minutes. Remainingthree acted as control and was treated with D.W.

Results- Colony counts of all strains were reduced to zero within five minutes of treatment with SOW. Controltubes for all the organisms showed growth. Superoxidized water gave >5 log10 reduction of Mycobacterium sppwith five minutes of exposure in the absence of organic load.

Conclusion- Our study shows, significant reduction in mycobacterial load i.e >5 log10 in the absence of organic loadwithin 05 minutes of exposure with SOW. Such high level of disinfection has also been demonstrated by otherauthors. So, SOW can be a good alternative high level disinfectant for various health care purposes.

P242Comparative study of clinical and radiological features of pulmonary tuberculosis patients with or without diabetesmellitus

AUTHORS: J SIRCAR, SS GUPTA, AS SINHA, A VERMA

Department of Pulmonary Medicine, Era’s Lucknow Medical College & Hospital, Lucknow, India

OBJECTIVES: To compare the clinical and radiological similarities/dissimilarities between diabetic and non-diabeticpulmonary tuberculosis patients.

METHODS: The study group consisted of 65 new patients of pulmonary tuberculosis who were sputum smear foracid-fast bacilli (AFB) positive and were either known cases of diabetes mellitus (DM) or were recently diagnosedas having DM. The control group consisted of 65 new pulmonary tuberculosis patients who were sputum smear forAFB positive and did not have diabetes.

RESULTS: Of the 65 patients in the study group, 40 (61.5%) were newly diagnosed cases of DM and 25 (38.5%) wereold known cases of DM. Of these 25 patients, the duration of diabetes was ≤5 years in 5 (20%) and ≥5 years in 20(80%) cases. 2 (8%) of these 25 patients were on insulin therapy, 21 (84%) were on oral hypoglycemic therapy,while 2 (8%) were not taking any treatment for DM. Fifty-two (80%) out of the 65 diabetic patients were males.Grade and duration of fever, and lower zone lung involvement was significantly higher in diabetic patients.Incidence of cough and cavitary lesions was significantly higher in non-diabetic patients.

CONCLUSION: Male sex, old age and lower zone lung involvement are strong predictors of DM among pulmonarytuberculosis patients. As a significant number of patients were diagnosed to have DM on screening, routinescreening for DM should be made essential for pulmonary tuberculosis patients to help improve the treatmentoutcome and to prevent the emergence of multi-drug resistant tuberculosis.

P243ABPA - A MASQUERADER OF PULMONARY TUBERCULOSIS

DR.VARIKUTI SUBBARAO, DR.A.SATHYAPRASAD, DR.Ganesh Mohapatra, Dr Vijay, Dr Nalini, Dr PrashanthyMAMATA MEDICAL COLLEGE & HOSPITAL, KHAMMAM

Background: Allergic Bronchopulmonary aspergillosis is an idiopathic inflammatory lung disease characterized byallergic inflammatory response to the colonization of aspergillus. High degree of suspicion is required in order tomake its diagnosis since the presenting complaints are often non specific and overlap with other clinical situationslike pneumonias, bronchiectasis, pulmonary tuberculosis.The delay in diagnosis of ABPA often leads to significantmorbidity. The wide spectrum of this disease can be severe requiring lung transplantation. However, if diagnosedearly, it can be treated effectively to reduce future remission and progressive lung damage. We report one suchcase, who was treated with anti tuberculous drugs without any significant improvement.

Case Report: A 35 years old female with clinical history suggestive of bronchial asthma since childhood, presentedto us with unremitting symptoms of breathlessness, cough, expectoration, wheeze, fever, chest pain since 2 years.She was being treated outside with ATT, based on chest radiograph finding inspite of her sputum and bronchialwashings were being negative for AFB. Upon further evaluation she was found to have elevated total serum IgElevels, immediate skin hypersensitivity reaction was positive to aspergillus fumigatus antigen, with elevatedperipheral eosinophil count. All these findings, in addition to central bronchiectasis as seen on HRCT Thorax werefulfilling the Greenburger and Patterson criteria for the diagnosis of ABPA. She was treated with oral steroids,antifungal agents and followed upto 6 months with good clinical and radiological improvement.

Conclusion : Suspicion for ABPA should be maintained while managing any patient with bronchial asthma with anyseverity or any level of control and should not be misdiagnosed and wrongly treated for other pulmonary diseases.Here this case was diagnosed as per Greenberger and Patterson criteria.

P244Pulmonary tuberculosis presenting as organizing pneumonia-a case report

Karthiga.G, Chellaraja.C, Chitrakumar A, Gangadharan .V,

Govt. Kilpauk Medical College/GTHTM, Chennai, Tamil Nadu, India

Case Report: 18 years old unmarried female, housemaid by occupation presented with severe hypoxia (SpO2-82%)even with high flow oxygen, high grade fever with chills, dry cough and dyspnea at rest for 10 days duration. Therewas no past h/o tuberculosis /ATT intake. Clinically patient was febrile (102 F), dyspnoeic, tachypnoeic andtachycardia. Auscultation of chest revealed bilateral crepitation. Investigations done-Sputum AFB, widal, ANA, RA,HIV, blood urine C/S were negative; CRP positive; ESR 25/50mm. Chest X ray showed bilateral peripheral air space

opacities. CT chest revealed extensive lobar consolidation with GGO pattern predominantly involving lower lobe.Patient was treated with supportive care, antibiotics and steroids. After stabilizing patient general condition, FOBand DLCO were done. BAL revealed mixed cellularity with increased lymphocytes. Microbiological tests showedpositive for AFB and negative for fungal and NT culture. PFT showed severe restriction with reduced DLCO. Patientwas started on ATT category I with continuous O2 flow for 2 weeks. Hypoxia improved after 2-3 weeks of O2therapy. After 6 weeks of hospitalization with tapering steroids, patient improved clinically with minimalradiological improvement and discharged with an advice to continue ATT.

Discussion: Organising pneumonia is a type of pneumonia in which usual process of resolution has failed andorganization of inflammatory exudates occur in alveoli by fibrous tissue. Etiology of organizing pneumonia includesbacterial, viral, parasitic infections, connective tissue disorders, drugs, ionizing radiation and toxic fumes. It affectspeople of ages 40-60 years. It has no sex predilection. Patients usually present with flu like symptoms whichinclude dry cough, dyspnea, fever, weight loss and fatigue. Pathophysiology-delay in clearance of fibrinousexudates and granulation tissue which leads to intra alveolar accumulation of fibromyxoid connective tissueleading to organising pneumonia. Our case presented like organizing pneumonia due to tuberculosis, a very rarepresentation.

P245Case of Non-Tuberculosis infection mimicking Aspergiloma.

Dr. Abhinandan B. Mutha, Co-author- Dr. B. K. Mutha, Dr. S. Dugad, Dr. G. Kulkarni.

Case history- 50 years old female, came with C/O cough with expectoration, low grade fever & breathlessness onexertion since 6 months. Also C/O loss of weight and appetite.

Past history of Pulmonary Koch’s 25 years back, for which treatment was taken of which details were not available.No H/O DM, HTN, B.A.

No significant family and personal history.

O/E – patient was averagely built and nourished, vitally stable, no e/o pallor, cyanosis, clubbing, lymphadenopathy,oedema.

On Respiratory system examination- trachea central, B/L chest movements equal, B/L BS present, crepitationspresent in left infrascapular area.

CVS, CNS, PA – WNL.

CxR & HRCT Thorax – bilateral fibrocavitatory lesions with aspergiloma in left lower lobe.

Bronchoscopy done and BAL taken which was sent for AFB, Fungal & Pyogenic culture.

BAL AFB culture- Mycobacterium other than tuberculosis grown, which on identification revealed MycobacteriumAbscessus, which was sensitive to trimethoprim sulfamethoxazole, moxifloxacin, amikacin, clarithromycin,linezolid.

Treatment was given as per sensitivity report and patient responded well to treatment.

Fig 1 &2 are pre treatment, fig 3 is post treatment.

P246

Clinical and Bacteriological profile of Comminity Acquired Pneumonia among adult patientsAji Mathew Joseph, R N toshniwalDepartment of Pulmonary Medicine, Navodaya Medical College Hospital and Research Centre, Raichur, Karnataka,India.Objectives:

1. To assess the types of clinical presentation of Comminity acquired pneumonia (CAP)2. To study the associated risk factors and their outcome on the disease.3. To study the spectrum of organisms causing CAP4. To study the drug sensitivity pattern of the organisms isolated.

Methods:Etiology and clinical profile of 50 patients with CAP above 18 years were studied retrospectively from October 2012to November 2013. Data regarding clinical features, physical examination, chest xray, sputum samples for smearmicroscopy and cultures were collected in a preformed proforma and analysed.Results:The commonest mode of presentation was cough (96%), followed by fever (94%) and expectoration(86%).Allpatients had bronchial breathing and 70% had crepitations.The commonest risk factor was copd (20%) with amortality of 2%.,. Streptococcus pneumonia was the commonest pathogen(38%) followed by pseudomonasaeruginosa (18%) , staphylococcus aureus (12%), klebsiella pneumonia (8%).organisms were most sensitive tociprofloxacin (44%) followed by amikacin (32%), piperacillin tazobactum (28%),and amoxicillin clavulanic acid (26%)Conclusions:CAP was common in elderly (>50 years) .Incidence was more common in men .Commonest predisposing factor wascopd. Majority of the patients had cough with expectoration and fever followed by chest pain and dyspnea.Mostpatients had leukocytosis and sputum examination showed predominance of gram positive organisms.Streptococcus pneumonia was the commonest organism isolated which was most sensitive to fluoroquinolonesfollowed by aminoglycosides and broad spectrum pencillins with beta lactum inhhibitor.The mortality was high incopd patients.

P247Unusual presentation of tuberculosisN.G.KUNJIR, R. NARASIMHANDepartment of Respiratory Medicine, Apollo hospital, Chennai.

Hereby we report a case of 27 year old female, who presented with persisting moderate to severe left sided chestpain since last 3 weeks. Pain was localised to left infraaxillary and interscapular region and was not responding toanalgesics. She denied any other co-existing respiratory complaints or any constitutional symptoms. Breastexamination was normal. ECG showed sinus rhythm. Chest X ray and Plain CT scan chest revealed pleuro-parenchymal nodule in the left lower lobe region. She was referred to our hospital for further evaluation. ContrastCT chest was done which showed that nodule was localized to costal pleura and was associated with pleuralthickening. CT guided biopsy of the nodule showed perivascular round cell infiltrates. PET CT showedhypermetabolic soft tissue mass in left chest wall and FDG avid pleural nodules in left hemithorax region, withimaging differentials of Lymphoma or Askins tumour/PNET or Metastasis. Since suspicion of malignancy was high,she was subjected to open pleural biopsy. Left pleural nodule biopsy showed necrotizing granulomatousinflammation with few acid fast bacilli. We report this case to emphasis the fact that false positivity of PET CT inhigh prevalent countries like India should be always kept in mind while interpreting the results.

CONCLUSIONAll that glitters on PET, is not cancer.

P248

Spirometric analysis in post-tuberculois sequelae

BHATIA H, GUPTA P, MITTAL R, DASH DJ, CHHABRA SK

Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, Delhi

Background. In a substantial proportion of cases, treatment of tuberculosis does not ensure a completeanatomical and functional recovery and the patient is left with posttubercular sequelae. These sequelae lead tosignificant impairment of lung function that is responsible for significant morbidity and mortality. The presentstudy was carried out to explore the spectrum of spirometric abnormalities in patients presenting with Post-tuberculosis sequlae.

Methods: A retrospective analysis of spirometric patterns of cases diagnosed with posttubercular sequelae over aperiod of two years was carried out. Active tunerculosis was ruled out. The patients underwent spirometry fortheir functional assessment.

Results: There were 37 subjects (22 male and 15 females) with mean age of 44.78 ± 12.67 years. All the studiedsubjects confirmed pulmonary or pleural tuberculosis in the past with 4 (11%) patients having received treatmenttwice or more frequently. Majority had completed treatment or were declared cured (33/37) while 4 had defaultedat different stages. The main symptoms on presentation were cough with expectoration and breathlessness onexertion. Thirteen subjects (13/37,35%) had clinical history suggestive of bronchial asthma. Active tuberculosis wasruled out by sputum examination for acid fast bacilli by direct smear and culture. Spirometry revealed abnormalityin 27/37 (73%) subjects. It showed obstructive pattern in 7 (19%) subjects (6male/1female) restrictive pattern 11(30%) subjects (4male/7female) & mixed pattern 9 (24%) subjects (7Male/2Female) while it was normal in Normal10 (27%) subjects (4Male/6Female). Significant response to bronchodilator was observed in 14 (38%). Eightsubjects (8/37,22%) were smokers, out of whom 43% (3/7) had mixed abnormality, 43% (3/7) had airflow limitation& 14% ( 1/7) had restrictive pattern.

Conclusions: Functional abnormalities are common in tuberculosis after completion of treatment and result incontinued morbidity. The majority of patients had restrictive pattern followed by mixed patterns of abnormalities.

P249An Interesting Case of Tuberculosis with Intraoral Involvement

Dr Karl DM, Dr Ajit H, Dr Sivaraj AL, Dr Alamelu H, Dr Rajashekar MB, Dept of Pulmonary Medicine and DrRachna K, Dept of Oral Medicine & Radiology

Vydehi Institute of Medical Sciences & Research Centre and Vydehi Institute of Dental Sciences & Research CentreTuberculosis is still endemic to India. Mycobacterium tuberculosis’ ability to infect any part of the human body is afact. Tuberculosis of oral cavity is an uncommon entity because of the bacilli’s inability to penetrate the intactsquamous epithelium.

This case report is of a 63 year old farmer, a smoker for more than 35 years. He presented with complaints for thelast 3 months, which were: pain in the left side of the mouth, which was aggravated on opening his mouth, whiletalking and chewing food. Pain arose from an ulcerative lesion in the left buccal mucosa, which gradually increasedin size to involve the left angle of the mouth. For the last 1 month he also complained of progressive trismus. Healso gave history of productive cough with scanty, white, mucoid sputum, non-blood stained and intermittent, low-grade fever. He denied losing weight and claimed to have a normal appetite.

On clinical examination, he had fever of 101oF. Local examination showed an irregularly shaped solitary ulcer,about 2.5 cm x 3 cm, involving the left buccal mucosa, extending anteriorly to involve left commissure, leftmucocutaneous junction of lower lip and upper lip. Auscultation of his lung fields revealed bilateral scatteredcrepitations.

A punch biopsy of the ulcer was reported as caseating granulomatous inflammation while Ziehl-Neelson stainconfirmed the presence of acid-fast bacilli. Incidentally, his sputum was positive for acid-fast bacilli. A diagnosis of

pulmonary tuberculosis with intraoral involvement was made. He was started on RNTCP Category 1 antituberculartreatment.

This case illustrates an atypical presentation of tuberculosis and the diagnostic challenge clinician’s face. Indiabeing a high burden country for TB, our clinicians must continue to remain aware of this disease and keep it as adifferential diagnosis in any atypical medical scenario.

P250SPUTUM POSITIVE PULMONARY TUBERCULOSIS WITH HANSEN’S DISEASE(PURE NEUROTIC TYPE) - An Unusual

PresentationDr.Kiran, Dr.Krishnamurthy , Dr.Vijay kumar,Dr.Pramod kumar

OSMANIA MEDICAL COLLEGE ,GGCHBackground:Pulmonary koch’s with hansen’s, is a rare manifestation. We are here with reporting an unusual case of sputumpositive pulmonary tuberculosis with pure neurotic type of leprosyCase Presentation:

A 34 year old male patient presented with grade – I breathlessness , cough with expectoration since 2 monthsand inability to use left upper limb and tingling sensation of left upper limb for one month.Chest x-ray PA viewshowed left upper zone infiltrates, sputum for AFB 3+ and 1+Skin chip for AFB taken from right ear and left hand dorsum suggestive of pure neurotic type leprosy

Patient treated with anti tubercular treatment under RNTCP DOTS cat-1 and and hansen’s treatment under NLEPP251

Role of geneXpert in lymph node aspirates via EBUS in diagnosis of TB in evaluation of isolated mediastinallymphadenopathy

A.BHANOT, S.JOSHI, R.GUPTA, D.TALWAR

Pulmonary Medicine and Critical Care, Metro centre for respiratory diseases, Noida, Uttar Pradesh, India.

OBJECTIVE: To investigate the role of geneXpert in diagnosis of tubercular mediastinal lymphadenopathy fromreal-time endobronchial ultrasound and transbronchial needle aspiration (EBUSTBNA) material. EBUS-TBNA of themediastinal and hilar lymph nodes is now becoming a standard care that is safe and has a good diagnostic yield.GeneXpert assay has high sensitivity and specificity for identification of MTB in expectorated samples of lowerairways secretions. However, few performance data have been published to date on non-respiratory specimen inTBNA samples from mediastinal lymphnodes where the diagnosis of tuberculosis depends upon the cytologyfindings.

METHODS: We collected clinical, cytological, and microbiological data from 30 patients admitted to our centrefrom January-August 2014 with mediastinal lymphadenopathy. All patients underwent EBUSTBNA.

Performance of a single Xpert-MTB assay as compared to the cytology was evaluated against microbiologicallyconfirmed TB lymphadenitis. “Definite-TB” was defined as positive microscopy and/or culture with consistentclinical features.

RESULTS: A total of 30 patients with a mean age of 46.3 ± 17.3 years underwent EBUS-TBNA in whom mediastinalTB was clinically suspected. Xpert-MTB demonstrated an overall sensitivity for stain and/or culture positive TB of33% and specificity of 94.4%, PPV of 80% and NPV of 60%. Positive TBNA Cytology showed an overall diagnosticsensitivity of 75% for stain and/or culture positive TB patients but with a specificity of 27.8% , PPV of 41% and NPVof 62.5%.

CONCLUSION: Our study showed that although sensitivity of geneXpert in EBUS-TBNA material from mediastinallymphnodes (believed to be paucibacillary) is low but high specificity and high positive predictive values would

support the use of positive result to start empirical treatment in patients with pending microbiological data orjustify in its absence. Therefore we conclude that Xpert-MTB in EBUSTBNA aspirate provides a rapid, useful, andaccurate test to diagnose mediastinal nodal TB.

P252A STUDY OF 70 CASES OF PULMONARY TUBERCULOSIS IN HIV INFECTED PATIENTS

DR.HEMANT NAYI, DR.PRAGNESH PATEL, DR.SAVITA JINDAL, DR.NALIN T.SHAH, DR.KUSUM V.SHAH

Department of pulmonary medicine, BJ Medical college, Ahmedabad,

INTRODUCTION:

The emergence & pandemic spread of AIDS and HIV have posed the greatest challenge to public health in moderntimes. The rate of TB infection has been steadily mounting.

AIM

1. To study the relation b/w HIV infection & Pulmonary TB.2. To assess the clinical profile and outcome of pulmonary TB in HIV seropositive patient.3. To study the presentation of pulmonary TB in relation to CD4+ T Cell lymphocyte count among HIV

seropositive case.

MATERIAL AND METHODS

A study was carried out on 70 patients, from April 2013 to April 2014 in pulmonary medicine department, BJMC,Ahmedabad Gujarat.

RESULTS

1. 57 cases (82%) were males and 13 (18%) cases were females with Male : Female ratio 4:1. This suggeststhat males are commonly affected in HIV with TB than females.

2. As far as pulmonary TB is concerned, 43 cases (61.43%) had CD4+ T Cell count < 200/mm3 and 27 cases(38.57%) had CD4+ Cell ≥ 200.

3. In pulmonary TB Sputum smear for AFB was positive in 14 cases (19.99%) and Negative in 56 cases (80%)10 cases (14.28%) with CD4+ T Cell count ≥ 200.mm 3 had positive sputum smear for AFB as compared to4 cases (5.71%) with CD4+ T cell count <200 /mm3. Majority of these patients with positive sputum smearhad CD4+ T Cell count ≥ 200/mm3.Detail results will be discussed in case study.

CONCLUSION:

HIV and pulmonary TB co-infection may aggravate both conditions as both are intracellular organism and TB co-infection increase replication of HIV virus.

P253A survey of knowledge and attitude of general population about tuberculosis

Sivakumar Reddy P, Nageswari AD, Srinath D, Rajalakshmi R,Kavita Vani KSRM Medical college and hospital, Kattankulathur

Background: Tuberculosis is a major public health problem. Tuberculosis the most common opportunistic infectionin diabetes, hiv and aids, it has gained even greater importance. RNTCP depends on the passive reporting of thechest symptomatic patients to the health institutions. Therefore, it is important that the basic knowledge aboutthe disease and the availability of treatment is clear among the individuals in the community. Equally important isto assess the practices of the people to find out unhealthy practices.

Objectives: To assess the knowledge about symptoms, mode of transmission, causation, prevention and treatmentrelating to tuberculosis in a general population.

Study design: Cross-sectional.

Setting: Kanchipuram dist.

Participants: Individuals above 18 years and who are willing for answering tuberculosis questionnaire wereselected. A total of 350 patients were selected

Results: A total of 350 individuals with mean age of 43.02 years (Range: 20-70 years) were interviewed, out ofwhich 202(57.7%) were males and 148(43.3%) were females. One-fourth (24.6) of the individuals were illiterate.94.6% were aware about tuberculosis disease. cough with sputum (31.5%) was common symptom associated withtuberculosis. 27.7% of responders said TB is not contagious.51% responders thought TB is spread through coughing.59% responders believed TB is curable. When questioned about the social acceptance of tuberculosis, 16.3% saidthey will hide the disease. Only 13.9% responders had heard about TB through media. 22.5% responders had saidthat TB is associated with DM followed by HIV (19.9%) and both DM & HIV (20.5%).

Conclusion: Although knowledge regarding symptoms, mode of transmission and causation was fairly good,misconception like non contagious nature of disease still exist among the general population. despite advances inmedicine the stigma attached to tuberculosis is still prevalent.

P254PYRAZINAMIDE INDUCED CUTANEOUS LEUKOCYTOCLASTIC VASCULITIS

SINGH A, MISHRA M, JAIN V K, SHARMA A, NAYYAR P , KUMAR ADEPARTMENT OF RESPIRATORY MEDICINE, MAHATMA GANDHI MEDICAL COLLEGE & HOSPITAL, JAIPUR, INDIA

Cutaneous leukocytoclastic vasculitis is a small vessel Vasculitis localized to skin. There are any possible causes forthis pathological condition like infections, collagen vascular disorder, use of medications and malignancies. A 30year old male was diagnosed as left sided tubercular pleural effusion. He was put on daily anti-tubercular therapy,regimen comprising of isoniazid, ethambutol, rifampicin and pyrazinamide. After 1.5 months of initiation oftreatment patient presented to us with complaint of purpuric lesions that developed on bilateral lower legs. Thelesion first appeared over the both ankles and spread upwards upto the knees. Histopathically the lesion wasleukocytoclastic vasculitis. The lesions improved after the discontinuation of ATT. ATT was re-challenged one byone over next few days. The lesions reoccurred with Pyrazinamide. Thereafter pyrazinamide was withdrawn andremaining drugs were continued. Diagnosis of pyrazinamide induced leukocytoclastic vasculitis was made.

P255A Rare Case of Disseminated Tuberculosis - Laryngeal Tuberculosis with Lupus Vulgaris and PulmonaryTuberculosis

B.SriTeja, V.V.Ramana Reddy, Ganeswar behera, J.V.Praveen, D.S.Sowjanya, G.Ramya, B.K.Prithvi,P.V.V.BharadwajDepartment of Pulmonary Medicine, Maharajah’s Institute of Medical Sciences, NTR University of health sciences,India.

Laryngeal tuberculosis is a rare disease. It is almost always associated with pulmonary tuberculosis. Lupus vulgarisis a common morphologic form of cutaneous tuberculosis, but this type of association with laryngeal andpulmonary tuberculosis is rare.

CASE REPORT: A 46 yr old female patient presented to the department of Pulmonary Medicine with complaints ofdry cough, skin lesions over nose and lip, hoarseness of voice, dysphagia since 1year. On examination large skinlesions with crusting over plaques were present all over the nose extending onto the upper lip and filtrum.

INVESTIGATIONS:Chest X ray - a large nodular opacity of approximately 1x 1cm size in the left upper zone. Sputum for AFB - negative.Mantoux test - 25 mm of induration at the end of 72 hrs. ESR - 45 mm. CECT chest - a well defined nodular lesionwith central calcification and air lucencies in posterior segment of left upper lobe suggestive of pulmonarytuberculosis. Bronchoscopy showed yellow coloured crusts in the base of the both nostrils. Normal architecture ofEpiglottis, ariepiglottic folds, arytenoids, false cords and Vocal cords was lost, which were replaced by the thickproliferative granulomatous lesion. We proceeded with biopsy from the skin and epiglottic lesions.Histopathological examination revealed typical granulomatous tubercle with epitheloid cells, langhan’s giant cellsand a mononuclear infiltrate with minimal caseation suggestive of tuberculosis. Diagnosis of lupus vulgaris withlaryngeal and pulmonary involvement was made. The patient responded very well and the lesions in the lip, larynxand lung regressed with ATT.

DISCUSSION: A high index of suspicion and a thorough clinical examination of the pharynx and larynx is mandatoryfor not missing this diagnosis of laryngeal lupus. Therefore, efforts should be made to locate an active or inactivelesion elsewhere in the body.

P256MDR TB-Cold Abscess in Chest Wall—Secondary To Mediastinal And Pulmonary Tuberculosis In a HIV Patient

RAHAMAN TANZIL*, HARI PRASAD**, BHARGAV PRASAD **, VAMSI KRISHNA** SUBBA RAO***

DEPARTMENT OF PULMONARY MEDICINE, KONASEEMA INSTITUTE OF MEDICAL SCIENCES, CHAITANYA NAGAR,AMALAPURAM,EAST GODAVARI, ANDHRA PRADESH-533201.

INTRODUCTION: Tuberculosis is a major public health problem in India. Further it’s complicated by the spread ofHIV and increased drug resistance. There are very few reports of MDR-TB at extra-pulmonary sites from India. Wereport here about a rare occurrence of MDR-TB involving chest wall abscess.

CASE REPORT: A 35 year old, HIV positive male patient, initially presented with symptoms suggestive of PTB .Sputum for AFB was positive. We started him on ATT with CAT-1. After completion of ATT there was no relief insymptoms and developed left suprascapular lymphadenopathy, firm with matting. Chest x ray showed mediastinalwidening in addition to persistent pulmonary infiltrates. CECT chest showed multiple enlarged mediastinallymphnodes with peripheral rim enhancement suggestive of tuberculous lymphnodes. FNAC of cervicallymphnodes showed granuloma due to tubercular etiology. CAT 2 ATT was started.

While patient was in 5th month of CAT II ATT, he presented with complaints of large swelling over sternum. Onexamination, swelling of 8 X 8 cm in size, skin is shiny and fluctuation test was positive. Aspirated pus was sent forZN staining and DST. Z N staining positive 2+ for AFB. As patient had already received CAT I and was on CAT IItreatment, MDR TB was suspected. On L J medium, culture growth was seen after 3 weeks. DST done from the

growth showed Mycobacterium tuberculosis which is resistant to INH and rifampicin. MDR –TB wasconfirmed&CAT IV regimen started. Patient responded very well to the treatment with complete reduction in sizeof chest wall

DISCUSSION: MDR-TB is an emerging and alarming health problem. The actual treatment regimens for MDR-TB arecomplex, expensive, long term, associated with high rates of side effects and poor outcome, and high morbidityand mortality.pulmonary TB is the common mode of presentation of MDR-TB.

P257ATYPICAL PRESENTATION OF GENITO URINARY TUBERCULOSIS

KRISHNA KARTHIK *, HARI PRASAD**, BHARGAV PRASAD **, VAMSI KRISHNA** SUBBA RAO***

DEPARTMENT OF PULMONARY MEDICINE, KONASEEMA INSTITUTE OF MEDICAL SCIENCES, CHAITANYA NAGAR,AMALAPURAM,EAST GODAVARI, ANDHRA PRADESH-533201.

INTRODUCTION: Lymph nodes, pleura, and osteoarticular areas are common sites of extra pulmonary tubercularinvolvement but any organ can be involved. Genitourinary TB is the 2nd most common cause of extra pulmonary TBwith kidney being the most common site.

CASE REPORT: A 26 year old married woman presented with a 6 months history of recurrent episodes of increasedfrequency of micturation and dysuria. She has anorexia, weight loss, fatigue ,evening rise of temperature andirregular periods since 1 yr.On examination chest was clear, per abdomen a suprapubic mass of 7 × 8cm wasfound, which diminished in size on micturition.Urine AFB was negative.CT abdomen showed B/L enlarged kidneyswith hydroureteronephrosis, bladder wall thickening with patulous vesicoureteric junctions. Multiple calcificationsin peritoneal cavity, hydrosalpinx and retroperitoneal lymphadenopathy. Bladder biopsy revealed caseous necrosissugessestive of tuberculosis cystitis.

DISCUSSION: Genitourinary TB complicates 3-4% of pulmonary TB cases & constitutes 30 % of extra pulmonarydisease. Involvement of the bladder is usually secondary to renal infection and is found in nearly one-third of thepatients Chronic inflammation causes reduced compliance and capacity manifesting as frequency of micturition.The common presentation is irritative voiding symptoms, renal mass, hematuria,sterile pyuria,etc. In our case thewomen had a suprapubic swelling which is a rare presentation of genitourinary tuberculosis.

P258

P259Initial sputum smear grading as a factor to predict treatment outcome in new sputum smear positive pulmonary

tuberculosis

Don Gregory MASCARENHAS, Vishal CHOPRA, Prabhleen KAUR, AP KANSAL

Department of Chest & TB, GMC, Patiala, Punjab

Introduction: Sputum positivity is used as a basis for initiating antitubercular treatment(ATT) under RNTCP. Thoughsputum smear grading is done, its not used to modify ATT regimen

Objective: To assess the association between the initial sputum smear grading and treatment outcomes in newsputum smear positive pulmonary tuberculosis patients.

Method & Materials : 500 patients who were started on RNTCP Category 1 ATT on sputum positive basis in ourdepartment were analysed for sputum conversion and cure in relation to their initial sputum grading. In our study,we considered scanty and 1+ as low grade sputum smear specimen and 2+ as well as 3+ as high grade sputumsmear specimen.

Observations: Majority of the patients belonged to the age group of 21-40 years. The mean age was 36.6 years,68.6% being males and 31.4% being females. The initial sputum smear grading was scanty in 29(5.8%) cases, 1+ in158 (31.6%) cases, 2+ in 143( 28.6%) cases and 3+ in 170(34%) cases. Sputum conversion rate at 2 months wasinversely related to initial sputum grading(p=0.0005) and age. At the end of treatment, a cure rate of 85.8% wasaccomplished. cure rate was high in patients with initial low sputum grading(p=0.045),age 60 years or less(p=0.0255) and in patients who had sputum conversion at 2 months(p<0.001). There was a high default rate inhigh initial sputum grading group(7.66%) and in patients who had persistent sputum positivity at 2 months ofATT(12.72%).Death rate was high in initial high grade group(p=0.08) and patients >60years (p=0.0004).Failurerate was high in initial high grade group and in those with low SCR at 2 months of ATT (p=0.0004)Conclusion: Initial sputum grading, sputum conversion rate and advancing age appear to be strong predictors oftreatment outcome in new sputum positive patients put on category 1 ATT. In patients with initial high bacterialload(2+ and 3+), advanced age (>60 years ), a modification of current RNTCP regimen (which as of now, has aunified chemotherapy regimen irrespective of initial bacteriological load ) and greater vigilance is called for.

P260The Sternoclavicular Joint Involvement: A Rare Presentation Of TuberculosisVishal CHOPRA, Don Gregory MASCARENHAS, Prabhleen KAUR, Parul MRIGPURI

Department of Chest & Tuberculosis(TB), Govt Medical College, Patiala , Punjab

Introduction: The involvement of the sternoclavicular joint in TB is rare and have been reported in 1-2% of all casesof peripheral TB.

Case report: A 43 year-old woman presented with the left sternoclavicular joint swelling which was graduallyincreasing in size since 4 months. The swelling was associated with pain that radiated to the left side of neck andaggravated with bending and turning. She gave a history of low grade fever especially in the evening. There was nohistory of cough, expectoration, weight loss or dyspnea.Local examination of the sternoclavicular joint revealed a rounded swelling about 7cm in diameter. The overlyingskin was shiny and red. The swelling was immobile, non tender and fixed to underlying tissue. The localtemperature was normal. Patient gave past history of uveitis, since 6 years for which patient was on oral and localsteroids off and on. There was no evidence of any cervical or axillary lymphadenopathy. There was no historysuggestive of involvement of any other organ system.The haematological investigations were within normal limits. Mantoux test was strongly positive (18*18mm). CTscan revealed cortical erosions at medial end of left clavicle and along left lateral margin of sternum with

associated soft tissue component. FNAC of the swelling revealed a chronic granulomatous pathology and alsoshowed the presence of AFB which is very rare. Patient was put on antitubercular treatment and responded well.

Discussion: Extrapulmonary tuberculosis presenting with involvement of the skeletal system accounts forapproximately 1 to 4% of cases. Tuberculosis of sternoclavicular joint has been reported in 1-2% of all cases ofperipheral tuberculosis and 1- 9% of septic arthritis. Differential diagnosis for swelling at the sternoclavicular jointcan be due to sternoclavicular hyperostosis, condensing osteitis, septic arthritis, tumor, rheumatoid arthritis,ankylosing spondylitis, osteoarthrosis or Tietze syndrome The diagnosis of tuberculosis should be considered inevery patient with involvement of sternoclavicular joint. The features of any monoarticular arthritis, cold abscess,positive tuberculin skin test, epidemiological risk factors or chest Xray abnormalities consistent with healed oractive pulmonary tuberculosis.

Conclusion: A high index of suspicion of TB is to be maintained in swellings at unusual sites even if they lacksystemic features of tuberculosis as in this case.

P261Non resolving pneumonia: A clinicopathologic dilemma

DR P.SHARMA, DR S. MOTIWALE

Department of Respiratory Medicine, Shri Aurobindo Institute of Medical Sciences, Indore, India.

Background: Pneumonia showing a slow resolution of radiologic infiltrates and/or clinical symptoms inspite ofgiving adequate antibiotic therapy ,has been defined as non-resolving pneumonia .The term “unresolvedorganizing or protracted pneumonia” was first coined by Amberson in 1943. Approximately 10% - 15% ofnosocomial pneumonias ultimately converts into non resolving or slowly resolving pneumonia and delayedtreatment may lead to rise in its mortality by 3-5%. The common causes of non-resolving pneumonia are incorrectdiagnosis, inadequate and irrational antibiotic therapy, impaired host defence, atypical organisms, resistantpathogens, non-infectious causes, and tuberculosis and endobronchial lesions.

Case report: We report a case of 53 yr old female admitted in SAIMS with the presenting complaints of fever withchills and rigors since four months and cough with minimal expectoration since fifteen days. She reportedshortness of breath, pain in chest and generalized bodyache since ten days. Patient was febrile( temperature was1020 F) with remarkable pallor. Fibreoptic bronchoscopy showed right lower lobe inflammed mucosa with retainedpurulent secretions. Bronchoalveolar lavage/ culture sensitivity showed growth of Pseudomonas aeruginosa whichwas sensitive to- Amikacin , Imipenem , Tobramycin and Colistin. During hospital stay course, patient was treatedinitially with antibiotics like Piperacillin - Tazobactum combination along with Levofloxacin for 7 days then startedon injection Gentamicin and Imipenem for 10 days.Significant clinical improvement was noticed by 7 days and thenthe patient was discharged on tablet Faropenem for 2 weeks, and on follow-up, she became alright.

Conclusions: Non-resolving pneumonia has always been referred as an area of clinical dilemma by pulmonologists.Its early diagnosis by fibreoptic bronchoscopy and rational treatment is mandatory for its treatment.

P262Study of Tuberculosis with Diabetes Mellitus

DR. POOJA SHARMA, DR. RAVI DOSI

Department of Pulmonary Medicine, SAIMS, Indore, India

OBJECTIVES: To analyze presentation of Pulmonary Tuberculosis with Diabetes mellitus in terms of clinical andradiological pattern.

METHODS: The study includes 100 cases, among these, 50 are diabetic patients with sputum positivetuberculosis and 50 are non-diabetic patients with sputum positive tuberculosis visiting SAIMS Hospital ,Indoreduring the study period (July 2012 to June 2014).

RESULTS: There was male preponderance, 76% males in diabetic group and 80% in non diabetic group withmajority of the patients in the age groups more than 40 years in diabetic and less than 40 years in non-diabeticgroup. Weakness and cough were predominant symptoms with 94% and 90% in diabetic group, and 70% and 90%in non- diabetic group respectively. Mean FBS was 201.55 ± 67.34 mg/dl and mean PPBS was 268.94 ± 93.93 mg/dl.Cavitary lesion was more common in diabetic group. There was a linear relation between the duration of diabetesmellitus and the development of tuberculosis. Poorly controlled hyperglycemia is associated with development oftuberculosis. Lower lung field tuberculosis was more common in diabetics.

CONCLUSIONS: All the diabetics with abnormal weight loss, unexplained cough or sudden increase of insulinrequirement should have sputum examination and chest x-ray done thus helping in early diagnosis and treatment.

P263Comparison of rate of sputum conversion in smokers and non-smokers on DOTS Category I under RNTCP

Kandala Venu, Srikar Darisetty, Raghudeep Palla, Mateenuddin Saleem, Laxman Babu

Department of Pulmonary Medicine, Kamineni Institute of Medical Sciences, Narketpally, Telangana, India.

AIM AND OBJECTIVES:

1. To assess and compare the rates of sputum conversion in smokers and non smokers on DOTS category I(RNTCP) after 2 months of therapy.

MATERIALS AND METHODS:

A prospective study was conducted in our institute between the periods of August 2012 to January 2014 amongpatients who were newly diagnosed as sputum smear positive for AFB using LED microscopy (Auramine staining)after fulfilling the inclusion and exclusion criteria. A total of 100 subjects were studied. (55 smokers, 45 nonsmokers). Amongst these, 5 subjects were lost to follow up, 5 subjects died during the study period. The remaining90 subjects (48 smokers, 42 non smokers) were followed up. The data was tabulated and analyzed after 2 monthsof therapy.

RESULTS:

SPUTUM SMEAR POSITIVITYINITIATION OF THERAPY AFTER 2 MONTHS OF THERAPY

SMOKERS (N = 48) 48 (100%) 22/48 (45.8%)NON SMOKERS (N = 42) 42(100%) 3/42 (7.14%)

The Chi Square test was used to analyze the data. Chi square value = 8.47,

P value < 0.05

CONCLUSION:

The response of subjects to ATT was better in non smokers when compared to smokers. Hence, it is advisable forpatients with pulmonary tuberculosis to quit smoking to enhance the efficacy of therapy and hence, to control thespread of tuberculosis in the community.

P264Outcome of chemotherapy in lung cancer : Effect on quality of life & reasons of default among patients

AUTHOR(S) - DR TARUSHI SHARMA, DR BABAJI GHEWADE

INSTITUTION- Jawaharlal Nehru medical college, Sawangi(meghe),Maharashtra,India

ABSTRACT

OBJECTIVES-The objective is to study the outcome of chemotherapy in lung cancer patients in form of Survival &Quality of life and investigate the factors that contribute to low rate of acceptance and adherence tochemotherapy.

METHODS- A prospective study of lung cancer patients admitted in AVBRH,SAWANGI who had taken atleast onecycle of chemotherapy was performed from Sept 2013 to Sept 2014. FACT-L questionnaire was used to measureQol(Quality of life) in patients who completed the course of chemotherapy.

RESULTS- A total of 20 patients were included in the study. The ages ranged from 20 to 70 years.Only 3(15%)patients completed the course of chemotherapy.An increase in Qol score was seen in these patient. 17patients(85%) dropped out of chemotherapy during the treatment. 9(53%) of these defaulted due to inadequatefunds to procure chemotherapy.5 (30%)patients switched to alternate form of medication and the rest 3(17%)discontinued due to non tolerance of the side effects of treatment.

CONCLUSION- Lack of funds to procure chemotherapy was the major factor responsible for default amongpatients. In patients completing the chemotherapy, significant improvements were seen in Qol. In past few years ,little progress has been made in treatment of lung cancer patients in form of increased survival. As a result, theeffect of chemotherapy on Qol becomes important while discussing the benefits of treatment with patients.

P265Disseminated tuberculosis in an immunocompetent host: A rare entity

AUTHOR(S)- DR TARUSHI SHARMA, DR BABAJI GHEWADE

INSTITUTION- Jawaharlal Nehru medical college, Sawangi(meghe),Maharashtra,India

ABSTRACT

OBJECTIVES- Disseminated tuberculosis with liver and spleen involvement in an immunocompetent host is a rareentity today, not frequently diagnosed and reported. We report a case of 22 year old female which was diagnosedas a case of Disseminated tuberculosis and started on antitubercular therapy & responding well.

METHODS-Patient was referred to our hospital as a suspected case of malignancy from PHI. A detailed history ofpatient was taken and physical examination done. Routine blood investigations such as CBC and serumbiochemistry were ordered .Radiological investigations included chest Xray, HRCT Thorax and USG abdomen.Sputum smear for AFB and USG guided FNAC was done along with bone marrow examination before arriving onfinal diagnosis.

RESULTS-A final diagnosis of disseminated tuberculosis was made based on investigations & clinical findings. Thepatient was started on category-I antitubercular drugs.Gradually patient improved symptomatically and repeatradiograph after 1 month showed good radiological improvement.

CONCLUSION- Disseminated tuberculosis is a potentially lethal form of tuberculosis arising from hematogenousdissemination of Mycobacterium tuberculosis bacilli. Disseminated tuberculosis is rare, particularly inimmunocompetent people. Diagnosis is often difficult due to variable clinical presentations,poorly sensitive smearsand diverse radiologic findings. Although positive chest radiographic findings or a positive tuberculin skin test may

support the diagnosis, negative results however do not exclude extrapulmonary tuberculosis. A high index ofclinical suspicion is needed and antimycobacterial therapy should be administered urgently to prevent anotherwise fatal outcome. 1-2 % of all cases of tuberculosis in immunocompetent patients

FIGURE- On Admission, Chest X-Ray PA view showing diffuse nodular opacities of variable sizes

P266Outcome of Cat IV ATT from DOTS-plus site: Govt Fever Hospital, Guntur, Andhra Pradesh, India.

Dr. K. Rajendra Kumar, Dr. S. Raghu, Dr. M. Venkata Rao, Dr. N. Bhaskara Rao, Dr. S. Lakshmi Kumari, Dr. CH.Hanumantha Rao.

Dept. of Pulmonary Medicine, Guntur Medical College/Govt Fever Hospital, Guntur, Andhrapradesh, India.

Abstract:

Introduction: India is one of the high burden countries for tuberculosis as well as drug-resistanttuberculosis. Standardized treatment regimen (STR) for management of multi-drug resistant tuberculosis (MDRTB)has been approved by RNTCP national DOTS-plus committee. Objective: Study was done at Government feverhospital / Guntur medical college, Guntur, to know the effectiveness, adherence and the outcome of DOTS-plus.Methodology: A total of 106 patients who were confirmed to have MDRTB and came for pre-treatment evaluationwere enrolled in to this prospective study conducted from October 2009 to March 2012. Patients were treatedwith DOTS-plus and were followed up mainly on out-patient basis. Results: At the end of 3rd month 61 (57.5%)patients were culture converted and at the end of 6th month 68 (64%) patients were culture converted. At the endof treatment, 57 were cured, 25 defaulted, 13 failed, 11 died. 5 failure cases were converted to extensively drugresistant (XDR) TB during the treatment. 92 patients were complained of adverse drug reactions (ADR) and changeof medication needed in 13 (12%) patients with severe ADR. Conclusion: The treatment outcome results ofpatients treated with DOTS-plus was not up to the mark. Defaulters are main obstacle to the success of DOTS-plus.Patient as well as family counselling, close attention to the timely recognition and treatment of ADRs will improvethe adherence to the treatment and thus the cure rate.

P267Childhood tuberculosis presenting as multiple rib osteomyelitis: A rare case reportDr. K. Rajendra Kumar, Dr. S. Raghu, Dr. CH. Hanumantha Rao.Although tuberculous infection of bone is fairly common i.e., 15% of all tuberculosis, tuberculous osteomyelitis ofthe rib shaft is rare. Rib involvement occurs in approximately 5% of all bony tuberculosis and in 0.1% of alltuberculosis cases. And tubercular parietal chest wall abscess is also a rare form of extrapulmonary TB. Thoughbony tuberculosis is common between 2 to 10 years of age, rib involvement is common between 20 to 30 years ofage. We report a case of 3 year male child presented with chest pain, fever and posterior chest wall swellings.Chest X ray revealed osteolytic lesions of multiple ribs and homogenous opacity in right mid and lower zones.Computed tomographic findings suggestive of multiple rib osteomyelitis with extension into the both chest walland right hemithorax. FNAC of chest wall lesion suggestive of cold abscess formation. The pathogenesis,differential diagnoses and management for rib osteomyelitis were reviewed and briefly discussed.Key words: childhood tuberculosis, rib osteomyelitis, chest wall abscess

P269Tuberculous Dactylitis (Spina Ventosa) In A 17 Year Old Girl - A Rare Entity

SR YADAV, M SALUJA, S TANEJA, K CHOUDHARY, K LOCHAB

Subharti Medical College, Meerut , India

Vertebral tuberculosis is the most common form of skeletal tuberculosis and it constitutes 50% of all cases ofskeletal tuberculosis. The less common sites of skeletal tuberculosis are mandible, tempromandibular joint, sculland metacarpals and phalanges. Tuberculous infection of metacarpals, metatarsal and phalanges of hands andfeet is known as tubercular dactylitis. Tuberculosis of the short tubular bones quite uncommon after the age of 5years.

Here we present a case of 17yrs. girl who presented with swelling of left middle finger since one month which wastender, non-mobile with slight increase in local temperature. Patient was previously treated by private doctors andantibiotics were given to her which gave no relief to her. Her detailed history was took which was insignificantexcept of family history of extra pulmonary TB in her sister. She was admitted and entire work up was doneincluding general blood tests, urine, montoux test, sputum examination, USG abdomen, and X-ray of chest and lefthand.

All the test reports were with in normal limits, montoux test was strongly positive and X-ray of left hand wassuggestive of spondylarthropathy- juvenile RA. Patient RA factor was tested and was found to be negative. Patientwas subjected to FNAC from her swelling which was suggestive of tuberculosis and Z-N staining of smear revealedacid fast bacilli (grade1+), hence a diagnosis of Tuberculous Dactylitis was made.

Patient was put on ATT according to her weight; dramatic improvement was seen as all her symptoms subsided.Size of swelling also decreased to normalcy.

P270Pulmonary Tuberculosis presenting as Pneumomediastinum with Subcutaneous emphysema: A RarePresentation

K.BHARATH , P. SWETHA, K.SAILAJA, H.NAGASREEDHAR RAO, U. KIRAN KUMAR

Department Of Pulmonary Medicine, Kurnool medical college

Back ground: Pneumomediastinum may develop due to (i) mediastinal sepsis from gas forming organism ortraumatic disruption of large gas containing organs or damage to alveoli and to bronchioles, allowing gas to leaktowards the mediastinum. Chest pain, tachypnea, cyanosis and respiratory failure are seen. Pulmonarytuberculosis presenting as Pneumomediastinum with subcutaneous emphysema without Pneumothorax is rare.

Patient and methods: A 65 year old male patient presented with Acute onset of dyspnea with cough and swellingof chest wall, neck and face. Patient also complained of chest pain and change in voice two days duration. Historyof intermittent fever, shortness of breath, cough, Loss of weight and appetite for 2 months duration. Examinationof respiratory system reveals palpable crepitus all over the front and back of neck, chest wall and both upper limbsupto to the tip of fingers. Emergency chest X ray showed features suggestive of air in subcutaneous planes. HRCTrevealed Fibrobronchiectactic changes in left upper lobe, pleural thickening, Pneumomediastinum and no evidenceof Pneumothorax. Sputum for AFB was positive. Patient was started on ATT and high flow Oxygen. Completeresolution of the subcutaneous emphysema was noted at the end of one week. There was no recurrence ofpneumomediastinum thereafter.

Conclusions: It is said that in both tuberculosis and bronchiectasis, local airway obstruction with distal air trappingcan cause alveolar rupture and subsequent Pneumomediastinum. Conservative treatment is indicated in majority.

The present report describes a self limiting case of Pneumomediastinum with subcutaneous emphysema a rarecomplication of pulmonary tuberculosis.

P271ATYPICAL PRESENTATION OF DISSEMINATED TUBERCULOSIS IN AN IMMUNOCOMPETENT PATIENT

DR.PRASANTHY REDDY CH,dr.A Sathya prasad,dr.M ganesh,dr nalini G,dr vijay kumar K,dr subba rao VMamata medical college and general hospital

Introduction: Disseminated tuberculosis refers to involvement of 2 or more non contiguous sites. it is rare inimmunocompetent host

Case report: A 30 year old female presented to out patient department with bleeding per vagina and lowerabdominal pain since 3 months with no past history of tuberculosis. on further evaluation chest x ray pa viewshowed ill defined opacities in right lower zone. Sputum for AFB was negative. Fibre optic bronchoscopy was doneand bronchial washings and brushings for AFB were positive. Dilatation and curettage was done and menstrualblood for AFB stain was positive. Ultrasound abdomen revealed bilateral hydronephrosis. urine for AFB negative.Patient was started on anti tubercular therapy. Patient improved symptomatically after intensive phase of therapy.

Conclusion: This is an atypical presentation of disseminated tuberculosis in an immunocompetent host wherediagnosis was achieved and confirmed

P272Association of tuberculosis with deep venous thrombosis

DR.TARUN SHARMA, DR.K.N.MOHAN RAO

rajarajeswari medical college and hospital, bangalore, india

Introduction: Tuberculosis (TB) is one of the most devastating curable infectious diseases and persists as a majorcause of morbidity and mortality in India. India accounts for almost one-third of the global burden of TB.Respiratory infections have been documented to increase the risk of venous thromboembolism. There is alsoevidence that there is a hypercoagulability state in TB, which may be attributed to the increase in plasmafibrinogen and factor VIII, and reactive thrombocytosis. There can also be stasis due to local compression of veinsby lymph nodes or immobility due to respiratory compromise. There is also evidence regarding endothelialdysfunction in tuberculosis, which may be a result of bodily reactions to Koch's Bacillus, or the use of Rifampin.Being able to affect all the three components of the Virchow's triad, TB could be a significant risk factor for venousthromboembolism.

Objective: To highlight occurrence of DVT in severe pulmonary and extrapulmonary TB.

Method: We report 5 cases of pulmonary and extrapulmonary TB associated with venous thromboembolism whopresented to our department. A 45 year-old male who had DVT, a 60 year-old male that developed deep venousthrombosis later in the course of the disease, a 20 year old male who presented with effusion and later developedDVT and massive pulmonary embolism, a 25 year old woman with disseminated TB and DVT with pulmonaryembolism, and a 32 year old male with pulmonary TB and DVT.

Conclusion: There is a strong association between inflammation induced by TB and a hypercoagulable state.Therefore, the occurrence of DVT or pulmonary embolic episodes should be considered in patients with TBparticularly those with poor response to treatment. The treating doctor’s awareness of this phenomenon whiletreating severe forms of TB is important for early diagnosis and starting anticoagulation to prevent fatal outcomes.

P273An Interesting Case of Tuberculosis of the Left Breast

Dr Ajit H, Dr Karl DM, Dr Sivaraj AL, Dr Alamelu H, Dr Rajashekar MB, Dept of Pulmonary Medicine and DrSabaretnam M, Dept of Endocrine & Breast surgery

Vydehi institute of medical sciences and research centre Bangalore KarnatakaTuberculous breast abscess continues to be an uncommon presentation in developing countries wheretuberculosis is an endemic disease. It still poses a clinical challenge with its presentation being similar to breastcarcinoma and pyogenic breast abscess. Its incidence in developing countries is: less than 4% of mammarydiseases.

This is a case report of a 28 year old housewife who presented to our hospital with complaints of: left breast lumpfor the last 8 months that gradually progressed from 1.5 cm x 1.5 cm to 8 cm x 6 cm on presentation associatedwith intermittent pain to touch and lifting heavy weights. It was not associated with menstrual cycles, which wereregular. She gave no history of respiratory symptoms, constitutional symptoms, comorbidities or past surgeries.

Her general physical and systemic examination was unremarkable. Breast examination revealed diffuse firmswelling palpable in the upper-inner quadrant of the left breast extending into the upper part of the lower leftquadrant which was 8 cm x 6 cm, immobile and adherent to the chest wall with an area of cystic consistency.There were no signs of breast tenderness and nipple discharge. There were no palpable axillary and supraclavicularlymph nodes. Routine investigations and CXR-PA were unremarkable. Purulent fluid aspirated showed: occasionalacid-fast bacilli (AFB) on Zeihl-Neelson stain. Multiplex DNA TB-PCR was positive for Mycobacterium tuberculosis.However, AFB culture report is awaited. She was started on RNCTP Category-I ATT for Tuberculous breast abscess.

P274Quantitative assessment of MDR positives among MDR suspects during the period of six months

K.V.V. Vijaya kumar, S. Vinay kumar, G.Sambasiva rao, A.Prem kumar

Government Hospital for Chest & Communicable diseases (GHCCD), Andhra Medical College,Visakhapatnam,AP,India.

Background: Multi Drug Resistant tuberculosis (MDR-TB) is an increasing global problem with most cases arisingfrom a mixture of physician error and patient noncompliance during treatment of susceptible tuberculosis. Thereshould be strong suspicion of drug resistance in persons with a history of prior treatment or treatment failurecases. We have tried to ascertain the number of MDR-TB cases in MDR suspect patients

Objectives: To identify the number of MDR positives among MDR suspects who are subjected to culture and drugsusceptibility testing ( C-DST) laboratory at GHCCD, a teaching hospital of Andhra Medical College, from 3 northAndhra Pradesh Districts(Srikakulam, Vizianagarm and Visakhapatnam)from January 2014 to June 2014 as perPMDT suspect criteria 2012.

Methods: Two sputum samples ( early morning and spot ) are taken from the cases with the above criteria andsent to C/DST laboratory at GHCCD , Visakhapatnam. Line probe assay (LPA) is used for the rapid DST.

Results: The results of first 3 months are as follows- Out of total 932 MDR suspects, 58 were MDR positive. Among932 suspects ,3 were failures(none of them were found to be MDR), 1 was a contact of MDR-TB(found to be MDR),396 suspects were smear positive at time of diagnosis, retreatment(40 were found to be MDR), 129 suspects wereany smear positive follow up results(9 were found to be MDR), 159 suspects were smear negative at diagnosis ofretreatment case(3 were found to be MDR), 244 suspects were HIV-TB coinfected group(5 were found to beMDR).The entire data will be projected during platform presentation.

P275Correlation of CD4 count with respect to opportunistic infections (OIs)

K.V.V. Vijaya kumar, L.Haritha kumari, G. Sambasiva Rao, A.Prem Kumar

Government Hospital for Chest & Communicable diseases, Andhra Medical College, Visakhapatnam, AP, India.

Background: human immunodeficiency virus pandemic is among the greatest health crisis ever faced by humanity.Morbidity and mortality in HIV disease is due to immunosuppression leading to life threatening opportunisticinfections during the natural course of the disease. The most common OI among them being the pulmonary orextra pulmonary tuberculosis. This study was aimed to asses prevalence and CD4 correlates of OIs among adult HIVinfected patients attending Government Hospital for Chest & Communicable diseases, a teaching hospital ofAndhra medical college, Visakhapatnam.

Objective: To correlate CD4 count with respect to OIs in HIV infected patients.

Methodology: Cross sectional study was conducted on 200 adult HIV infected patients attending GHCCD, ARTcentre from September 2013 to july 2014. Patients OIs status determined through clinical diagnosis, laboratoryinvestigations and clinical data obtained from medical records. CD4 count was assessed by using flow cytometry.

Results: Preliminary results of the study of 200 HIV infected patients included 64.5% males, 35.5% females. Out of200 seropositives 82.5% were between 15-45 years and 17.5% were greater than 45. Tuberculosis carrying themajor burden of OIs i.e 89% of which 42.5% pulmonary tuberculosis, 44.5% extra pulmonary tuberculosis and 2%disseminated tuberculosis. The entire study data would be projected at the time of presentation.

P276Massive hemoptysis in a pulmonary Koch’s patient: A case report of Rasmussen’s aneurysm

AP KANSAL, Don Gregory MASCARENHAS, Kamal Deep, Prabhleen KAUR, Hardik JAIN

Dept. of Chest and TB, GMC, Patiala.

Introduction: Massive hemoptysis is a serious complication of Pulmonary Koch’s. We present a case report of apatient of massive hemoptysis which was later proven to be a case of Rasmussen’s aneurysm.

Case report: A 52 year old male patient, manual labourer by occupation, presented to us with persistent cough andprogressive breathlessness since 7 months, fever since 1 month and massive hemoptysis since 2 days. He hadcompleted RNTCP Cat I anti-tubercular treatment one month ago. He was a chronic smoker and type 2 diabetesmellitus patient on irregular treatment. On chest examination, rhonchi were present over all lung fields along withcrepitations in right infraclavicular and mammary areas. Chest X ray showed bilateral diseased lung withheterogenous opacity in right upper zone. Hb was 9.5 gm%, TLC 10,600/mm3, platelet count 2.2 lakh/mm3, RFT,LFT and BT/CT/PT-INR were normal.

Patient came sputum positive for AFB and LPA showed resistance to Rifampicin and Isoniazid. He was treated withDOTS PLUS regimen and symptomatically for hemoptysis. But hemoptysis was persistent. CECT chest showedbilateral emphysematous changes and consolidation with cavity formation in right upper lobe. Multidetectorcomputerised tomography angiography revealed a pseudoaneurysm in one of the segmental branches ofpulmonary artery in right upper lobe cavity, suggestive of Rasmussen’s aneurysm. Patient was referred forembolisation.

P277HEPATOTOXICITY AS AN ADVERSE EFFECT WITH FIRST LINE ANTI-TUBERCULAR AGENTS: A PROSPECTIVE STUDY

AP KANSAL, Shiyas MOHAMMED, Kiran N, Kamal Deep, Hardik JAIN, Komal BHATTI,

Department Of Chest & TB,GMC, Patiala , Punjab

Introduction: The incidence of Anti-tuberculosis drug induced liver injury( ATLI) during standard multi-drug TBtreatment has been reported varying from 2.0% to 28.0% according to different populations and definitions.

Material and methods: Present study was conducted on 200 patients (100 in cat I and cat II) presenting toDepartment of TB and Chest Diseases and Department of biochemistry, Government Medical College, Patiala. Liverfunction tests were performed before initiating the treatment and thereafter every month till the regimencontinued (6 months in Cat-I and 8 months Cat-II).Results: In the present study, out of total 114 patients with ADRs, 33 developed raised liver enzymes (SerumBilirubin, SGOT, SGPT) due to ATT and it was second most common ADR after gastrointestinal side effects. It wasobserved that it was found more in females (n=18) as compared to males (n=15), in patients on cat I (n=18) ascompared to patients on cat II (n=15). Most common age group affected was in range of 40-60 years. Weight bandwhich was affected the most was of less than 40 kg. Patients with moderately advanced lesion on CXR were mostcommonly affected.

Discussion: Out of total 10 patients who required their regimen to be changed due to various adverse effects,hepatotoxicity accounted for 5. Predicting who will be at an increased risk for ADRs to first-line TB therapy canassist in identifying the patients who require closer monitoring to prevent potential morbidity, hospitalization andmortality .Therefore, close monitoring of patients is crucial to ensure that the adverse effects of drugs arerecognized as soon as possible by health care personnel

P279TUBERCULOSIS AND LEPROSY CO-INFECTION: A RARE CASE IN THE MODERN ERA.

Dr. Priti Meshram, Dr. Rohit Hegde, Dr. N N Ramraje (Professor & Head)

Department of Pulmonary Medicine. Grant Govt. Medical College & sir J J Group of Hospitals, Mumbai.

Introduction:

The concommitant occurrence of both tuberculosis and leprosy in a singal individual,the oldest reportedmycobacterial diseases, is not rare. Tuberculosis and Leprosy have been diagnosed together since antiquity.However, since the Industrial revolution of the 16 th century, there has been a steady decline in Leprosy thoughTuberculosis has now reached epidemic proportions. The decline has been partly explained due to some studiesshowing that Tuberculosis provides protective immunity against Leprosy. Hence, there is very infrequent reportingof the occurrence of these infections together in modern medicine.

Case Report:

We report one such case a 18 yr old male diagnosed as borderline lepromatous leprosy with type 2 reaction, wholater developed pulmonary tuberculosis. The patient had received steroids for his Lepra reaction for 9 mths priorto becoming symptomatic with respiratory complaints. On investigating, patient had bilateral infilates with Rtsided hydropneumothroax which was respiratory complaints. On investigating, patient had bilateral infiltates withRt sided hydropneumothorax which was treated with Intercostal drain insertion. His sputum was also screened forMDR TB. He was sensitive to both INH and Rifampicin. The patient was treated with both AKT and MBMDT andsteroids for his Type 2 Lepra reaction.

Conclusions:

The use of steroids in leprosy (for treating Lepra reactions and neuropathy) warrants screening of individual fortuberculosis including Multi drug resistant TB. Multi-drug therapy for leprosy may lead to acquired drug resistancefor Rifampicin, which is mainstream of anti-tubercular therapy. Hence awareness is necessary for screening anddiagnosing tuberculosis, especially MDR TB in patients who infected Leprosy and are on steroids.

P280Persistent upper lobe pneumonia- a case report

A YADAV, D BHATTACHARYYA, CDS KATOCH, T AJAI KUMAR, SAFIA AHMEDDept of Respiratory Medicine, Military Hospital CTC, AFMC, Pune

Non resolving pneumonia is a challenging, interesting and intriguing puzzle for the clinician to unravel. We treatedone such unusual case in our hospital recently. The patient was a 31 year old soldier who presented withcomplaints of cough with mucoid expectoration, breathlessness (mMRC grade II), intermittent fever, new onsetwheeze and 10 kg weight loss of one year duration. The complaints were associated with episodic exacerbations onexposoure to dust and cold. He gave history of treatment for tuberculosis a year back. Examination revealedbilateral polyphonic expiratory wheeze. At this point a differential diagnosis of collagen vascular diseases,cryptogenic organising pneumonia, sarcoidosis, hypersensitivity pneumonitis and chronic eosinophilic pneumoniawas entertained. Investigations revealed an eosinophilia of 58% and AEC of 4,350/cumm. Chest x-ray showedbilateral upper zone peripheral non homogenous opacities with air bronchograms. HRCT chest showed multifocalperipheral airspace opacities in bilateral upper lobes. Pulmonary function testing revealed obstruction withsignificant reversibility and mild diffusion defect. Bone marrow biopsy showed increase in eosinophilic precursorswith no atypical/blast cells. The diagnosis of chronic eosinophilic pneumonia was confirmed by fibre opticbronchoscopy which showed 10% eosinophils in broncho alveolar lavage and eosinophilic infiltration ontransbronchial lung biopsy. The patient was managed with oral corticosteroids (tab prednisolone 1mg/kg), inhaledcorticosteroids and long acting β2-agonists, which led to prompt clinical improvement and resolution of upper lobeopacities, which is a hallmark of the disease. Considering his clinico-radiological presentation in conjunction withhistopathological examination reports, the final diagnosis of Chronic eosinophilic pneumonia with adult onsetasthma was made. At follow up after 3 months, patient was asymptomatic with normal chest x ray on a taperingsteroid regime.

P281PREVALENCE OF CARDIAC COMORBIDITIES AND ITS RELATION TO SEVERITY STAGING OF CHRONIC OBSTRUCTIVE

PULMONARY DISEASEDr.VINEETH ALEXANDER, DR.R.PAJANIVEL ,DR.K.SURENDRA MENON, DR.ARUN PRASATH

DEPARTMENT OF PULMONARY MEDICINE, MAHATMA GANDHI MEDICAL COLLEGE AND RESEARCH INSTITUTE

INTRODUCTION: Complexity of COPD and mortality from the disease is increased by co morbidities andexacerbationsOBJECTIVE: This study was conducted with aim to find the prevalence of cardiac co morbidity in COPD and itsrelation to severity staging of COPD.METHODS: The study was done in the Department of Pulmonary medicine for 1 year. The study subjects were allthe patients which were previously diagnosed and newly diagnosed of COPD. The selected patients were subjectedto Pulmonary Function Test, assessment of blood pressure, electrocardiography and echocardiography. Thestatistical analysis was done to assess the cardiovascular status and its relation to severity staging of COPD.RESULTS: On the basis of GOLD guidelines there were 5(11.4%), 13(29.5%), 16(36.4%) and 10(22.7%) mild, moderate,severe, and very severe COPD respectively. Right axis deviation, p-pulmonale, T-wave inversions, dominant R-wave, persistent S-wave in electrocardiography were present in 45.5%,52.6%,40.0%,33.3%,36.4% of severe and54.5%, 36.8%, 60.0%, 58.3%, 63.6% in very severe cases of COPD. In echocardiography, right atrium and ventricledilatation, left ventricular dysfunction, tricuspid regurgitation, and regional wall motion abnormalities werepresent in 55.6%, 46.15%, 50.0%, 37.5% of severe and 38.9%, 53.85%, 33.3%, 62.5% of very severe cases of COPD.All the cases of mild and moderate COPD had mild (30-50mmHg) Pulmonary artery systolic pressure (PASP). Insevere COPD, 5(19.2%), 10(76.9%) and 1(20.0%) had mild (30-50mmHg), moderate (50-70mmHg) and severe(>70mmHg) PASP respectively. In very severe COPD, 3(11.5%), 3(23.1%) and 4 (80.0%) had mild (30-50mmHg),moderate (50-70mmHg) and severe (>70mmHg) PASP respectively. In severe COPD 7(29.2%), 5(62.5%), 3(30.0%)and 1(50.0%) had normal, pre hypertension, stage 1 hypertension, stage 2 hypertension respectively. In severeCOPD 3(12.5%), 6(60.0%), 1(50.0%) had normal, prehypertension, stage 2 hypertension respectively.CONCLUSION: Prevalence of cardiac co morbidities has a linear relationship with severity of COPD with severe andvery severe COPD associated with cardiovascular diseases. Early detection of cardiac complications in COPD casesgive time for early interventions

P282OCCURRENCE OF ATOPIC MANIFESTATIONS IN PULMONARY TUBERCULOSIS SEQUELAE

T. VIVEKKAKATIYA-MEDICAL-COLLEGE

OBJECTIVES-Mycobacterium tuberculosis has been shown to suppress allergic airway disease driven by type 2helper T cells in animal models.In this study we investigated development of allergic airway disease in pulmonarytuberculosis (PTB) sequelae pts presenting with airway obstruction.

MATERIALS AND METHODS-Twenty one pts with a past history of PTB without any past history of airway disorderpresenting with SOB and/or wheeze were prospectively studied from july 2013 to july 2014.They were evaluated byspirometry, total serum IgE levels, sputum for eosinophil count and absolute eosinophil count (AEC).Othersystemic manifestations of atopy were also taken into account.

RESULTS-Out of the 21 pts,12 pts had reversible and 9 had irreversible airway obstruction.Out of the 12 reversiblepts,10 had elevated serum IgE(mean IgE-1150.3IU/L),8 had sputum eosinophilia and 8 high AEC(mean AEC-431.6).Out of the 9 irreversible pts,4 had elevated IgE(mean-450 IU/L),no pt had sputum eosinophilia and 2 hadelevated AEC(mean-314).4 pts among the reversible group presented with other systemic manifestations of allergylike rhinitis(3) and dermatitis(1).

CONCLUSION-Our study does not support the hypothesis that PTB supresses atopy (manifestations).On thecontrary atopic manifestations occur with an increasing incidence after PTB,but larger prospective experimentalstudies are needed before excluding possibility of relationship.

P283Bronchoscopic diagnosis of Tuberculosis: A stitch in time saves nine

PASHA MD, MANTHA SP, ANEJA A, PRASHANTH D, HALAPPA S, KRISHNASWAMY U

M.S.Ramaiah Medical College, Bangalore, India

Objective:

To report a case of actively caseating type of endobronchial tuberculosis presenting as community acquiredpneumonia. (CAP)

Case report:

A 31 year old immune competent patient with no co-morbidities had presented to another hospital with history ofpersistent productive cough, high grade fever, wheezing and dull left sided chest pain since one month. She hadbeen treated with multiple courses of broad spectrum antibiotics including cephalosporins and Piperacillin-Tazobactum. She was referred to us after 1 month of the above treatment in view of persistent high fever andopacities on serial chest radiograms. On evaluation in our hospital, sputum analysis was negative for Acid FastBacilli (AFB) and did not grow any organism on culture. Respiratory system examination revealed reduced breathsounds, rhonchi and coarse crepitations all over the left hemi-thorax. A diagnosis of non-resolving pneumonia wasmade and bronchoscopy was performed. It revealed tenacious cheesy material lining the entire left bronchial tree.Endobronchial biopsy was taken and BAL fluid was sent for Gram stain, culture and AFB smear.

BAL and post-bronchoscopy sputum were positive for AFB (+++) and no other organism was grown on culture.Endobronchial biopsy report was also consistent with tubercular pathology. Patient was started on anti-tuberculartherapy (ATT).Oral steroids were also given in view of the extensive endobronchial component to preventfibrostenotic sequelae. Patient came for follow up after 1 month of ATT and had improved clinically andradiologically. It is planned to repeat the bronchoscopy after completion of intensive phase.

Conclusion:

This case highlights importance of timely performance of bronchoscopy in patients with pneumonia who havepersistent unilateral wheeze and exhibit sub-optimal response to treatment for CAP.

P284

P285

P286MDR-Pott’s Spine: The hidden danger

DR.SAURABH SINGH, DR.MEDHA BARGAJE, DR.ANITA ANOKAR, DR.RAM DEOSKAR.

Department of Pulmonary Medicine, Bharati Vidyapeeth Deemed University Medical College and Hospital,Pune-43, India.

Background:

Tuberculosis (TB) of the spine (Pott’s disease) is the most common and dangerous form of skeletal TB infection.The exact incidence and prevalence of spinal tuberculosis in most parts of the world are not known.

Case report:

We report MDR Potts spine in two previously treated TB cases.

1. A 34 years man was diagnosed for lumbar spine tuberculosis based on MRI and biopsy with initial isolation ofMycobacterium TB monoresistant to streptomycin. Despite 1 year of treatment with first line drugs, clinical andradiological progression warranted repeat spinal abscess drainage and was found to have MDR M. tuberculosiscomplex. Patient is being treated with 2nd line drugs and followed up.

He had sputum positive pulmonary, lymph node and shoulder joint tuberculosis 13 years back and was treated. (2HRZE, 12HRE).

2. A 20 years woman, with lymph node TB (biopsy proven) and Potts spine (radiology based) received(2HRZE+6HRE+9HR) was on regular treatment with symptomatic and radiological improvement in spinal TB andlymph node regression. She showed clinical and radiological deterioration while on treatment (18 months). Hence,tissue biopsy obtained and MDR M.tuberculosis complex was grown on culture. The patient was put on DOTScategory 4 under RNTCP.

Both the patients showed symptomatic improvement after 6 months with satisfactory radiological response ofproperly supervised treatment with adverse effects prominently due to aminoglycosides. Both the patients arefollowing up with our department regularly.

Conclusion:

In India, with increasing incidence of MDR TB, stress should be given on obtaining tissue sample formycobacterial culture and sensitivity. This is important in order to diagnose MDR cases early and promptly treatthe otherwise disabling spinal tuberculosis with correct regimen.

H-Isoniazid, R-Rifampicin, Z-Pyrazinamide, E-Ethambutol, MDR- Multidrug Resistant,RNTCP- Revised National TB Control Programme.

P287Additional yield of cases of tuberculosis from household contact screening of newly diagnosed sputum smearpositive tuberculosis patients.

M. GUPTA, A.A. SAIBANNAVAR

RCSM Government Medical College, Kolhapur, India

Objectives: Aim of present study was to assess prevalence of tuberculosis among household contacts of newlydiagnosed sputum positive tuberculosis index cases. Secondary objective was evaluation of risk factors inhousehold contacts for acquiring tuberculosis disease; and also evaluation of various characteristics of index caseswhich influence transmission of disease to household contacts.

Methods: 521 household contacts of 133 newly diagnosed sputum smear positive tuberculosis patients which wereregistered for RNTCP at the DOTS centres of DTC, Kolhapur from July 1, 2013 to February 28, 2013 (8 months) wereincluded in the study. Household contacts with symptoms suggestive to TB subjected to sputum AFB examinationand X ray Chest PA view. Presence of risk factors in suspected contacts was also recorded

Results: 18 contacts out of 521 (3.45%) had symptoms suggestive of TB. Out of them 8 (44.44%) were female and10 (55.55%) mere male. Mean age of symptomatic contacts was 43 years. In 5 contacts, sputum AFB came outpositive. In one of the contact, sputum AFB was negative, but chest X ray was suggestive of TB. This resulted in4.51% (6 cases) secondary yield of tuberculosis cases.

Conclusions: Although additional yield (4.51%) is very modest, but the effort put in to detect these cases is veryminimal. Also, lead time is obtained in these cases by means of early diagnosis. Household contact screening fortuberculosis cases is a very promising tool for case detection. Therefore, it can prove to be an important method toboost case detection rate for tuberculosis.

P288Tuberculosis of the thyroid gland. a rare case report

DR. KRISHNACHAITANYA PANYAM**,, Prof. Pradyut Waghray**, Dr.A.N.V.Koteswara rao**,Dr. VenkateswaraReddy T**, Dr.v.veena**, Dr. Chetan**, Dr.Harish**, Dr. Sowmya**, Dr. Aditya**, Dr. Rikin**.Prof. k.p.a.chandrashekhar #

Dr.suresh kumar reddy.g ^

* DEPT OF PULMONARY MEDICINE,S.V.S.MEDICAL COLLEGE, MAHABUBNAGAR,A.P # DEPT OF PATHOLOGY, S.V.S.MEDICAL COLLEGE, MAHABUBNAGAR,A.P ^ DEPT OF GENERAL SURGERY, S.V.S.MEDICAL COLLEGE, MAHABUBNAGAR,A.P

Abstract.We report the case of a 54-year old female patient with tuberculosis of the thyroid gland. She presented to the

pulmonology o.p with h/o swelling at the neck region since 2months,evening rise of temp,cough with mildsputum,loss off appetite&weight since 30 days in jan 2014.All routine investigations were unremarkable.

Sputum&BAL are negative for AFB. FNAC of thyroid-Features suggestive of nodular goiter. Specimen- caseatinggranulomatous lesion. On ATT for 6 months. Doing well.

P289

SIDS WITH PULMONARY TUBERCULOSIS WITH BILATERAL PNEUMOTHORACIES

Introduction : A case of SIDS on ART and Cat-1 ATT for Pulmonary Tuberculosis presenting with Pneumothorax.During treatment developing contraletaral Pneumothorax.

Discussion : Cases of SIDS ,quite commonly present with PCP. Quite a few of such cases developPneumothorax,even biletaral ones, which have been known to enhance mortality in such cases.

A YOUNG patient with SIDS on ART , presented with features suggestive of PULMONARY TUBERCULOSIS. He wasinvestigated and was found to be SPUTUM POSITIVE.There were no other co-morbidities. CAT 1 was started andthe patient was discharged. Within the next 2 months the patient presented again with history of chest pain anddyspnoea since last 5 days. Xray chest PA view suggested a Left Pneumothorax.Vitals were normal and , again , onother comorbidities were noticed. ICD under water seal was done and the patient was continued on CAT 1 andSulfa-Methoxazole –Trimithoprim, Ceftriaxone and other supportive treatment. Within a span of 5 days , thepatient , developed , Pneumothorax on Right Side. ICD under water seal was done on and the medical treatmentcontinued as required. Patient’s respiratory parameters kept on deteriorating and he expired within 10 daysdespite adequate treatment.

P290

Title: IL-1β & IL-12p70 cytokine secretion in Tuberculosis patients

Author: Nazish Fatima, Mohammad Shameem, Nabeela, Haris M Khan, Asma Roohani

Institute: Department of Microbiology, Jawaharlal Nehru Medical College, A.M.U, Aligarh.

Introduction: Tuberculosis (TB) remains a significant public health problem with an estimated one-third of theworld’s population being infected. If TB control is not improved, 1 billion people will be infected by 2020. Cytokinesplay a major role in protection against Mycobacterium tuberculosis infection and regulate the immune responsesat a cellular level. The discovery of biomarkers for TB treatment response is therefore important for both clinicalpractice and clinical trials of new anti TB drugs.

Objectives: To determine the levels of IL-1β & IL-12p70 in the serum of TB patients.

Materials and Methods: The study was conducted in the Deptt. Of Microbiology, J.N.M.C., A.M.U, Aligarh.Cytokines levels were measured in 76 serum samples from tuberculosis patients of whom 30 were new TB cases,24 under-treatment, 22 were MDR TB cases, 44 were pulmonary and 36 were extra-pulmonary TB cases by ELISAkit (Diaclone France) along with 20 healthy BCG vaccinated controls. A complete clinical, radiological & treatmentdata was collected.

Statistical analysis was done by using sigma plot 10.1.

Results: The serum levels of IL-1β & IL-12p70 were significantly higher in new & MDR TB cases (P<0.001). Duringtreatment IL-1β & IL-12p70 remained low or unchanged. IL-1β & IL-12p70 showed no significant variations accordingto the site of involvement in Pulmonary vs. Extra-pulmonary TB cases.

Conclusions: The above findings are encouraging as they support the concept of host biomarkers IL-1β & IL-12p70

for the prediction of differential TB treatment responses. This concept, if validated, could lead to the developmentof clinical interventions and accelerate the conduction of TB clinical trials.

P291DIAGNOSTIC ACCURACY OF COMBINED PLEURAL FLUID ADENOSINE DEAMINASE AND LYMPHOCYTE/NEUTROPHIL RATIO IN TUBERCULAR PLEURAL EFFUSION

Dr. ANIRUDDHA UDUPA K , Dr S Vinod Kumar, Dr Manju R and Dr. H.Nandeesha

Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India

Increased pleural fluid adenosine deaminase (ADA) activity is classically associated with tuberculous pleuraleffusion. However, increased activity can also occur in a number of other diseases and this may negatively affectthe diagnostic utility of ADA measurements and decrease its specificity for the diagnosis of tuberculosis (TB). Thepresence of ADA in pleural fluids reflects the cellular immune response in the pleural cavity and in particularly, theactivation of T lymphocytes. Different disease entities are typically associated with the presence of particular typesof leukocytes.

OBJECTIVE: To evaluate efficacy of combined use of ADA activity and lymphocyte/neutrophil ratio for diagnosingtuberculous pleural effusion.

METHODS: Biochemistry, cytology, and microbiology studies were performed on 164 consecutive pleural fluids.ADA and differential cell counts were determined on all exudative effusions.

RESULTS: Pleural fluid ADA activity at a level of ≥40 U/L, the sensitivity=95.5%, specificity=93.4%, positiveprediction value=94.4%, negative prediction value=94.7% and efficacy= 94.5 %. It was statistically significant (pvalue<0.001). When the additional requirement of a lymphocyte/neutrophil ratio of ≥0.75 was included, hadsensitivity=95.45, specificity=100%, positive prediction value=100%, negative prediction value=97.45 andefficacy=97.5.

CONCLUSION: 1. ADA is a highly sensitive diagnostic marker of tubercular pleural effusion, 2. Combined pleuralfluid ADA and Lymphocyte /neutrophil ratio increases diagnostic accuracy in tubercular pleural effusion patientscompared to pleural fluid ADA alone.

P292Role of Non invasive Ventilation in the Management of Acute Respiratory Failure

Dr. Srinivas Banoth, Dr S Vinod Kumar and Dr Manoj Kumar Panigrahi

Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India

Objective: To assess the effect of Noninvasive ventilation (NIV) and to identify the factors associated with theoutcome in NIV among patients with acute respiratory failure.

Study Design: Descriptive study

Methods: All the patients with acute respiratory failure requiring NIV were enrolled in the study. We had collectedserial clinical and arterial blood gas parameters at baseline, one hour and four hours. These parameters includerespiratory rate, heart rate, mean blood pressure, PH, PaO2, PaCO2 and PaO2/FiO2 ratio.

Results: A total of 122 patients presented with acute respiratory failure during the study period and 82 patientsfulfilled the inclusion criteria were enrolled in the study. The study included 54(65.9%) male and 28 (34.1%) female.It showed significant decrease (p < 0.05) in respiratory rate, heart rate and PaCO2 at one and four hour andsignificant increase (p < 0.05) in PH at one and four hour compared to baseline values after NIV application. Theoverall NIV success and failure rates in our study were 82.92% and 17.07% respectively. NIV was most successful inpatients with COPD (92.1%) and bronchiectasis (90.9%) with failure rates of 7.89% and 9.1% respectively. Allpatients of pneumonia with COPD failed the NIV trial. In our study, it was observed that the duration of thehospital stay was significantly higher in patients with bronchiectasis with corpulmonale (9.41±4.47 days) thanCOPD with corpulmonale (5.26±2.25 days)(P <0.05).

Conclusion: Noninvasive ventilation is an effective modality in preventing endotracheal intubation in acute(hypercapneic) respiratory failure with possible exception of pneumonia. The duration of the hospital stay wassignificantly higher in patients with bronchiectasis with corpulmonale than COPD with corpulmonale.

P293Aortic Aneurysm presenting as a Posterior Mediastinal Mass- a case report

Dr Bhumika Madhav, Dr Aparna Iyer, Dr Girija Nair, Dr Abhay Uppe, Dr Jayalakshmi T.K, Dr Lavina Mirchandani, DrMugdha Bhide

Dr D.Y.Patil Hospital and Research Centre, Sector 5, Nerul, Navi Mumbai - 400706. Maharashtra India.

Background- Descending Aortic Aneurysm is one of the rare causes of Posterior Mediastinal masses.The sources ofposterior mediastinal masses are usually neurogenic tumors, cysts, malignancy, paraspinal abscess orlymphadenopathy .Prompt recognition and earlier identification of thoracic aortic aneurysm upon routinescreening is necessary since it can be catastrophic. Descending aortic aneurysm mimicking a posterior mediastinalmass is a rare presentation.

Case Report- A 65 yr old male was referred in view of chest xray findings patient was posted for cataract Surgery.Patient was asymptomatic. Patient denied of any respiratory complains. He was non diabetic, non hypertensive.Respiratory system examination was suggestive of breath sounds reduced in the infrascapular area with a fewcrepts. On cardiovascular examination a mid systolic murmur was heard.

Chest X Ray showed a well defined rounded opacity seen in the Left Lower Zone with rounded regular margin notobscuring the cardiac border or diaphragm. A rim of calcification seen in lower part of the opacity. Thoracic lesionhas its caudal end visible below the dome of diaphragm. Thoraco abdominal sign was positive. High ResolutionComputer Tomography was suggestive of fusiform thoracic descending aortic aneurysm with eccentric muralthrombosis with impending rupture with a small abdominal aortic aneurysm with mural thrombosis within withbilateral renal artery ostial stenosis.

Conclusion-Aortic Aneurysm can present as Posterior Mediastinal opacity or an Anterior Mediastinal Opacitydepending on the site of aneurysm- ascending or descending aorta.

P294A CASE REPORT OF RARE PLEURAL TUMOUR MIMICKING MALIGNANT MESOTHELIOMAM.L.VED, MAHENDRA KUMAR, MINI GARGRNT MEDICAL COLLEGE, UDAIPURBackground: Solitary fibrous tumour of pleura(SFTP) represent 5% of all pleural tumours.It resemble malignantmesothelioma in clinicoradiological presentation.It is mostly benign and localised,tumour though rare but stillpresent in community.So need to be kept in differential diagnosis as its treatment is completely different frommalignant tumours.

Case Report:A 65 years old ,non smoker female presented with right side chest pain,cough,exertional dyspnoeafor one month.On examination,clubbing was present.Respiratory system examination reveals decreased intensityof breath sound in right suprascapular region.Other system examination were normal.Xray showed multiple softshadows in right upper and mid zone.`CT reveals multiple nodular pleural masses and thickening in right upper andmid zone with mild pleural effusion suggestive of malignant mesothelioma more likely than benign.Pleural fluidexamination and percutaneous fine needle aspiration cytology reports were inconclusive.The diagnostic dilemmawas overcome by histopathology examinationof tissue taken by video thoracoscopy and confirmed to be SFTPfrom immunohistochemistry staining.

Discussion:SFTP originates from submesothelial mesenchymal layer of pleura.These are most common pleuraltumours after malignant mesothelioma.Unlike malignant mesothelioma,SFTP is not associated with tobacco smokeor asbestos exposure.SFTP is associated with two paraneoplastic syndromes:1)Pierre Marrie Bamberger Syndrome2)Doege Potter Syndrome.Radiolologically,diffuse pleural involvement without loss of volume is unlikely formalignant mesothelioma and other malignant pleural effusion.The treatment of malignant pleural tumour andbenign sftp is entirely differentand it is treated by en bloc resection.Its survival is excellent(96%).One should havehigh suspicion of SFTP in such presentation for early diagnosis and treatment to improve quality of life of patient.

P295

CASE OF POST HEMOPTYSIS LUNG COLLAPSE IN A PATIENT OF PULMONARY TUBERCULOSIS

A.B. SRIVASTAVA, DINESH KUMAR SHARMA, PRIYANK JAIN

RNT MEDICAL COLLEGE, UDAIPUR

Background: Endobronchial obstruction by blood clot following massive hemoptysis is an unusual cause of lungcollapse. It is seen in variety of clinical conditions but very few cases are reported in pulmonary tuberculosispatient. We are presenting such a case of smear positive pulmonary tuberculosis female.

Case Report: A 20 yrs old female admitted with productive cough and fever for one month and one episode ofhemoptysis 2 days back. On examination the patient was anaemic and respiratory system examination revealedcoarse crepitations in left interscapular region. Chest x ray was normal and sputum examination for AFB waspositive.

During hospitalization, 2 days later patient had another episode of massive hemoptysis in night with sudden onsetof dyspnoea. By next morning dyspnoea relieved to some extent and on examination vitals were normal.Respiratory system examination and chest x ray were suggestive of complete collapse of left lung. Routine bloodinvestigations were normal including BT & CT except low blood hemoglobin level. Patient was stable and SpO2 was95%, so managed conservatively.

Subsequent chest x ray after 3 days showed partial expansion of left lung. On fiberoptic bronchoscopy there werefew patches of blood clots adherent to wall of left main bronchus and CECT Thorax showed a cavity in left upperzone posteriorly. There was no hemoptysis thereafter and patient was referred for category I under DOTS.

Discussion: Pulmonary collapse due to an endobronchial obstruction by blood clot following hemoptysis is seen inbronchiectasis, tuberculosis, mitral stenosis, pulmonary infraction, sarcoidosis, bronchial carcinoma and postoperative patients. Lung collapse is diagnosed by clinical examination and radiology. Blood clot is confirmed bydirect endoscopic visualisation. Stable patient are managed conservatively until clot resorbs, and inhaemodynamically unstable patients clot is removed urgently by way of lavage, suctioning, or bronchoscopy.

P296

A CASE REPORT OF DEEP VEIN THROMBOSIS IN SMEAR POSITIVE PULMONARY TUBERCULOSIS PATIENT

A.B. SRIVASTAVA, PRIYANK JAIN, DINESH KUMAR SHARMA

RNT MEDICAL COLLEGE, UDAIPUR

Background: An association between tuberculosis induced inflammation and hypercoagulable state is well known.Venous thromboembolism (VTE) is a rare complication of extensive pulmonary and disseminated tuberculosiswhich can cause a potentially life threatening event. Undiagnosed pulmonary thromboembolism may be one ofthe cause of sudden unexplained death in patient of tuberculosis with clinically asymptomatic DVT. Here we reporta case of extensive pulmonary tuberculosis with DVT without any other risk factor

Case Report: A 15 years old girl with constitutional symptoms of pulmonary tuberculosis for 2 months, also havingleft leg pain and edema since 12 days was admitted. Her chest x ray showed bilateral extensive pulmonarytuberculosis and sputum examination for AFB was also positive. On routine blood investigation hemoglobin was9.8 gm% and platelet count was 4.93 lakh/cumm, ESR was 35mm/hr. DVT was suspected on clinical grounds andcolor Doppler confirmed thrombosis of left lower limb veins. Anti-tubercular therapy was started and anticoagulation therapy and related blood investigations were planned meanwhile patient absconded.

Discussion: VTE may occur at presentation or later in the course of pulmonary tuberculosis. Elevated plasmafibrinogen coupled with decreased Antithrombin III , reactive thrombocytosis, platelet hyperaggregation andprotein S deficiency favor the development DVT in pulmonary tuberculosis as inflammatory cytokines produced byinflammatory cells in tuberculosis such as IL-6, TNF-α which are responsible for reactive thrombocytosis and downregulation of protein S. These hematological parameters worsen during the first 2 weeks of therapy in most of thecases, but normalize after a month of anti tuberculer therapy. Association between DVT and rifampicin is alsopresent.

Our report emphasise the need of clinical suspicion of DVT in cases of extensive pulmonary tuberculosis.

297

THE UTILITY OF SINGLE SITE CONVENTIONAL TRANSBRONCHIAL NEEDLE ASPIRATION (C-TBNA) IN PATIENTS WITHDIAGNOSIS OF BRONCHOGENIC CARCINOMAS AND MEDIASTINAL LYMPHADENOPATHIES WITHOUT ROSE

DR. MAHENDRA KUMAR, DR.MAHESH MAHICH ,DR.BANAME WAANBAH, DR.RAVI PANWARRNT MEDICAL COLLEGE, UDAIPUR

Introduction : Transbronchial needle aspiration of mediastinal structures was described by Schiepatti in 1949, butits use with flexible bronchoscopy was described and systematized by Wang in 1978. Currently the usefulness of C-TBNA lies mainly in its effectiveness as a diagnostic tool and in the mediastinal staging of bronchial carcinoma. It isa simple technique to learn, with a short learning curve, and has proven to be cost effective, despite which it hasalways been underused.

Objective : To analyze the utility of C-TBNA for diagnosis.

Patients and methods : Retrospective observational study. All the TBNA was performed in suspected cases ofbronchogenic carcinoma having mass presentation with or without mediastinal or hilar adenopathies on CTThorax. We did C-TBNA by single site puncture technique with a 19G needle without the facility of ROSE.

Result : We performed C-TBNA in 21 patients (19 male, 2 female). 16 cases were true TBNA, 4 were EBNA and 1ETNA was done. The overall diagnostic yield was 90.47% in our cases. Out of that, 15 cases (71.42%) wereconfirmed as malignancy, 2 cases (9.52%) were Tuberculosis, 2 were non diagnostic, 1 case (4.76%) Non HodgkinsLymphoma and 1 case was non specific inflammation. We did the single site puncture in these cases at 4R (13), 7(5),10R (2), 11R (2), and 4L (1) for confirmation of diagnosis. Peri-procedural complications included 2 cases of chestpain on puncture by needle, 1 minimal pneumothorax and 1 was needle stuck at lower end of scope.

Conclusion : C-TBNA is a clinically useful, cost effective technique with minimal complications. It could thereforebe performed on a regular basis during diagnostic bronchoscopy of such patients.

P298Chyluria and Recurrent Chylothorax cause - Idiopathic Lymphatic dysplasia syndrome

Authors-

PRAKASH K ASHISH , MAMNOON FATIMA, PRABHUDESAI PRALHAD, SHASTRI B S.

Institute – Lilavati Hospital and Research Centre, Mumbai, India.

Abstract-

This is a case report of one of the rarest cause of recurrent left sided pleural effusion which was basically recurrentchylothorax. The patient reported is case of lymphatic duct dysplasia which has led to said problem. He also hadhistory of chyluria in 2005 for which he was operated. He had post operative complication of shrunken kidney.Patient after being asymptomatic for such long period has presented to us with recurrent chylothorax. Weinvestigated with computed tomography, PET-CT, magnetic resonance imaging and finally with lymphoscintigraphyand came to the conclusion that it was the lymphatic duct abnormality which has initially presented with chyluriaand after being operated for that has presented with chylothorax. We ultimately did pleurodesis and thoracic ductligation through VATS (videoscopic assisted thoracic surgery).

Key words: chylothorax; idiopathic lymphatic dyslpasia; Pleural effusion; Thoracentesis; positron emissiontomography-CT; computed tomography; lymphoscintigraphy; LDH-lactate-dehydrogenase; chyle. VATS-videoscopic assisted thoracic surgery

P299No scope without bronchoscope in abnormal chest x- ray

Dr.J.SOWMYA , Prof.Pradyut waghray, Dr.A.V.N.Koteshwar Rao, Dr.Venkateswar reddy T, Dr.Veena, Dr.Harish,Dr.Chetan, Dr.Aditya, DrKrishna Chaitanya, Dr.Rikin

Dept of Pulmonary Medicine, SVS medical college, Mahabubnagar,TS

INTRODUCTION: Flexible bronchoscopy has evolved in recent years to be the first choice of investigation inradiologically abnormal cases for both diagnostic and therapeutic purposes.

AIM: To evaluate the yield of fibreoptic bronchoscopy in our institute over a period of 18 months.

TYPE OF STUDY: Observational study

MATERIALS AND METHODS:

The study was conducted in 200 patients with abnormal chest x rays in whom it was indicated and were subjectedto bronchoscopy. All the findings and complications were noted , materials taken were sent for pathological andmicrobiological examination.

RESULTS AND DISCUSSIONS:

Out of 200 patients 130 patients were males with in the range of 14-75 yrs. Following findings were observed.Plenty of thick secretions in 85 pts(42.5%), Extraluminal compression in 15 pts(7.5%), Intraluminal growth in 3pts(1.5%), Anatomical variations in 4 pts(2%) Post intubatioin tracheal stenosis in 1 pt(0.5%), Visible fungal ball in 3pts(1.5%) , Blood clot in1 pt(0.5%), Endobronchial TB in 2pts(1%), Nodules in the airways in 4(2%), Paralysis of vocalcords in 3pts(1.5%), Air leak in 2 pts(1%), Icd in the bronchus visible through bronchoscope in 1 pt(0.5%), Fibroticchanges in airway walls in 9pts(4.5%), Black coloured patches in 6 pts(3%), Foreignbodies in 14 pts(7.5%), Activebleeding in 10 pts(5%), Inconclusive in 30 pts (15%).

CONCLUSION: Disease was found in 89.1% cases in bronchoscopy .Thus flexible bronchoscopy should be theinvestigation of choice in abnormal chest x rays

P300PULMONARY MUCORMYCOSIS MASQUERADING AS ENDOBRONCHIAL GROWTH WITH NON RESOLVINGPNEUMONIA

MOUNIKA.V*, VAMSIKRISHNA.M* , J ** , DR.P.SUBBARAO *** .

DEPARTMENT OF PULMONARY MEDICINE, KONASEEMA INSTITUTE OF MEDICAL SCIENCES

NH-214, CHAITANYA HEALTH CITY, AMALAPURAM, ANDHRA PRADESH-533201

BACKGROUND: Non resolving pneumonia has a wide range of etiology which needs extensive investigationsincluding bronchoscopy, radiological and microbiological tests. We present an unusual case of Non resolvingpneumonia

CASE REPORT: Patient is a 40 year old diabetic male, presented to us with complaints of chronic cough and feverof 4 weeks duration. He was evaluated elsewhere with chest X rays, CT SCAN which showed left lower lobeconsolidation. Sputum was sent for bacterial culture. He received antibiotics for K.pneumonia infection as persensitivity pattern. Despite 2 weeks injectable antibiotics he had persistent symptoms. Repeated sputumexamination for AFB was negative. Repeat CT scan showed persistent consolidation. At this juncture patient wasreferred to us. He was subjected to BRONCHOSCOPY. It revealed an endobronchial growth in left lower lobe mainbronchus, causing partial obstruction of lumen. Endobronchial biopsy has shown features of INVASIVEMUCORMYCOSIS. He received liposomal amphotericin B 100 mg/day for 10 days with which clinical improvementwas noted and was followed by posaconazole syrup. Patient had complete clinical, radiological improvement andconfirmed by resolution of endobronchial growth and normalization of airways. Posaconzole was continued tillcomplete radiological resolution

CONCLUSION: we report a case of pulmonary mucormycosis presenting as endobronchial growth. We successfullytreated the patient with liposomal amphotericin B and posaconazole, avoiding surgery.

CLINICAL IMPLICATION: Diabetic patients with uncontrolled blood sugars presenting with non resolvingpneumonia should be investigated for fungal etiologies

P301A COMPARITIVE STUDY OF SPIROMETRIC PATTERNS IN OBESE AND NON-OBESE ASTHMATICS

Dr.VARGHESE LOUIS, DR.K.SURENDRA MENON, DR.R.PAJANIVEL

DEPARTMENT OF PULMONARY MEDICINE, MAHATMA GANDHI MEDICAL COLLEGE AND RESEARCH INSTITUTE

BACKGROUND: The incidence of obesity and asthma has increased by 75% in recent decades and this has ledclinicians to investigate potential links between the two medical conditions. There is an increased annual risk ofasthma if associated with antecedent obesity.

OBJECTIVES: The aim of this study was to estimate pulmonary function parameters in obese and non-obeseasthmatics, and to observe the relation between obesity and spirometric patterns in asthma.

METHODS: The study was carried out in the Out-Patient Department of Pulmonary Medicine in our institute. Theparticipants (n=90) included all patients above sixteen years of age of both sexes with signs and symptoms ofAsthma,. BMI was measured in all subjects using height/weight2 and waist circumference measured incentimetres. Spirometric parameters studied were FEV1 and FVC and derived parameters based on pulmonaryfunction tests, before and after bronchodilator therapy. Data was then analysed using statistical tests.

RESULTS: Of the total 90 patients studied, 77 (85.5%) had post-bronchodilator therapy reversibility of obstructivepattern on spirometry. Of these 27(37.1%), were classified as obese based on BMI measurements (p=0.05), and32(42.6%) were classified as obese based on waist circumference (p=0.018). These values were statisticallysignificant. These patients were also found to have a restrictive pattern on spirometry assessment, as shown by aFVC less than 80% recording (p=0.05).

CONCLUSION: Based on the present descriptive study, the following factors were determined: There is a significantcorrelation between asthma and obesity. Waist Circumference helped us identify more Obese asthmatics thanBody Mass Index. Obese Asthmatics had a more Restrictive pattern on spirometry compared to Non- ObeseAsthmatics.

P302

Aortic Aneurysm presenting as a Posterior Mediastinal Mass- a case report

Author(s)–Dr Bhumika Madhav, Dr Aparna Iyer, Dr Girija Nair, Dr Abhay Uppe, Dr Jayalakshmi T.K, Dr LavinaMirchandani, Dr Mugdha Bhide

Institution-Dr D.Y.Patil Hospital and Research Centre, Sector 5 , Nerul, Navi Mumbai - 400706. Maharashtra India.

Address- 43/1, RCF Row Houses. Sector-6, Vashi, Navimumbai, Maharashtra 400703

Background-

Descending Aortic Aneurysm is one of the rare causes of Posterior Mediastinal masses.The sources of posteriormediastinal masses are usually neurogenic tumors, cysts, malignancy, paraspinal abscess or lymphadenopathy.Prompt recognition and earlier identification of thoracic aortic aneurysm upon routine screening is necessarysince it can be catastrophic. Descending aortic aneurysm mimicking a posterior mediastinal mass is a rarepresentation.

Case Report-

A 65 yr old male was referred in view of chest xray findings patient was posted for cataract Surgery. Patient wasasymptomatic. Patient denied of any respiratory complains. He was non diabetic, non hypertensive. Respiratorysystem examination was suggestive of breath sounds reduced in the infrascapular area with a few crepts. Oncardiovascular examination a mid systolic murmur was heard.

Chest X Ray showed a well defined rounded opacity seen in the Left Lower Zone with rounded regular margin notobscuring the cardiac border or diaphragm. A rim of calcification seen in lower part of the opacity. Thoracic lesionhas its caudal end visible below the dome of diaphragm. Thoraco abdominal sign was positive. High ResolutionComputer Tomography was suggestive of Fusiform thoracic descending aortic aneurysm with eccentric muralthrombosis with impending rupture with a small abdominal aortic aneurysm with mural thrombosis within withbilateral renal artery ostial stenosis.

Conclusion-

Aortic Aneurysm can present as Posterior Mediastinal opacity or an Anterior Mediastinal Opacity depending on thesite of aneurysm- ascending or descending aorta.

P303

Diagnostic yield of various techniques 0f Fibreoptic video bronchoscopy in diagnosing lung cancer

Dr.VEENA REDDY VANKAYALA, Prof.Pradyuth Waghray, Dr.A.N.V.Koteswara Rao ,Dr. Venkateswara ReddyTummuru , Dr. Chetan, Dr.Sowmya, Dr. Harish, Dr.Aditya, DR. Rikin, DR. K.C , Dr.Ramakrishna reddy*

Dept. of Pulmonary Medicine, S.V.S. Medical college, Mahabubnagar, Telangana.

*Dept of Radiology

Introduction: Lung cancer is today the most common amongst the malignancies in the world. Several studies havedemonstrated that early detection, localisation, and aggressive treatment of lung cancer results in five yearsurvival rate of 70 to 80%.

objective: Study to know the value of various diagnostic methods like bronchial brushings , bronchial wash,TBNA(transbronchial needle aspiration) , bronchial biopsy , TBLB(transbronchial lung biopsy) under fluoroscopicguidance.

Type of study: observational study conducted in Pulmonary Medicine department at SVS Medical College ,Mahabubnagar during a period of 2 years.

Method: patients in whom lung cancer was suspected , bronchoscopy was done and the yeild of differentdiagnostic techniques was observed.

Observation: out of total 100 patients , 70 patients had central lesions and 30 patients had peripheral lesions. forpatients with central lesions bronchial brushings in 54 patients (77.14%) ,bronchial wash in 46 patients (65.71),bronchial biopsy in 62 patients (88.57 % ) , TBNA done in 32 patients 25 patients (78.12%) gave diagnosis.

In 30 patients who had peripheral lesions bronchial brushings in 12 patients ( 40%) , bronchial wash in 16 patients(53.3%), TBLB under fluoroscopic guidance in 21 patients( 70%) could give diagnosis.

CONCLUSION: Our study suggests that, in investigating suspected cases of lung malignancy we should adopt alldiagnostic techniques of biopsy, brushing, and washing ,TBNA to increase the yield of diagnosis. Cytologicalprocedures of washing and brushing yield acceptable optimum results in case of peripheral lesions but fluoroscopyguided biopsy is best.

P304

Primary pulmonary Lympho Epithelioma like Carcinoma;

Rare case Report in South India.

Abstract:

Primary pulmonary lymphoepithelioma-like carcinoma (LELC) is a rare tumor, with more favorable prognosiscompared with other type of non small cell lung cancer. This tumour is a variant of large cell carcinomacharacterised by abundant invasion of lymphocytes. Here in we describe an interesting case of primary pulmonaryLELC in 26 year old male, smoker confirmed post operatively.

305

Serum concentration of IFN-γ in patients with new, Under-treatment & MDR tuberculosis cases

Nazish Fatima*, M Shameem**, Nabeela*, Haris M Khan*, Afreen Hashmi

Department of Microbiology, Jawaharlal Nehru Medical College, A.M.U, Aligarh

Introduction: - Mycobacterium tuberculosis (Mtb) infects approximately one third of world population. Manycytokines are produced during tuberculosis (TB) with predominance of Th1 cytokines during the early stage and

Th2 cytokines in the later stages of the infection. INF-γ play a key role in control of Mtb infection is produced byboth CD4+ and CD8+ T cells, as well as by NK cell.

Objectives: To evaluate the levels of IFN-γ, in the serum of New, Under-treatment (UT) & Multi-drug resistant(MDR) TB patients.

Materials and Methods: The study was conducted at Department Of Microbiology, J.N.M.C, A.M.U, Aligarh.76patients of TB cases were enrolled in this study of whom 30 were new TB cases, 24 under-treatment, 22 wereMDR TB cases, 44 were pulmonary and 36 were extra-pulmonary TB cases by ELISA kit (Diaclone France) alongwith 20 healthy BCG vaccinated controls. A complete clinical, radiological & treatment data was collected.Statistical analysis was done by using sigma plot 10.1.

Results: The levels of INF-γ were significantly increased in new and MDR TB cases compared to healthy anduntreated cases (P<0.001). There were no significant variations in their level according to the site of infection(Pulmonary vs. extra-pulmonary).

Conclusions:- Measuring the serum levels of several cytokines may be useful for evaluating the activity of TBdisease and monitoring the clinical effects of ATT. INF-γ can serve as a potential biomarkers of anti-tuberculosistreatment response. The discovery of biomarkers for TB treatment response is therefore important for bothclinical practice and clinical trials of new anti TB drugs.

306

Comparative study of Indacaterol and Tiotropium in patients of COPD

Dr. Mohammad Sajid alam, Dr. Jameel Ahmad, Prof. Anil Kumar, Dr. Mohammad Shameem

: Department of Pharmacology and *Department of Tuberculosis & Respiratory diseases, J.N.M.C. & Hospital,A.M.U

Objective: Comparative study of safety and efficacy of Indacaterol and Tiotropium in patients of moderate &severe grade of COPD.

Method: This is a randomized, prospective, open labelled and parallel group study. Eligible patients were enrolledand randomized according to the table generated by random allocation software into two groups (20 patients ineach group).

Group I patients received Indacaterol in the dose of 150μg once daily and Group II patients received Tiotropium

18μg once daily for 10 weeks. The patients were evaluated by measuring FEV1 at zero, two weeks, four weeks, six

weeks, eight weeks and ten weeks.

Results: The gradual improvement is observed in both the groups. There is more improvement in Indacaterol as

compared to Tiotropium. Although the difference was not statistically significant.

P307

Association of body mass index with severity of obstructive sleep apnea

Nitin Goel, Mandeep Singh, Vikas Dogra, Kuldeep Patial, Raj Kumar, Rajendra Prasad

Sleep Disorder Centre, Vallabhbhai Patel Chest InstituteUniversity of Delhi, Delhi- 110007, India

Background: Obesity has reached epidemic proportions in India in the present century, with National Family

Health Survey 2007, showing 12% males and 16% females to be obese.Obesity is one of the most powerful

reversible risk factor for obstructive sleep apnea (OSA). The present study was planned to assess the association

between body mass index in adults on the severity of obstructive sleep apnea.

Materials and Methods: The present study is a retrospective analysis of the sleep studies done in Vallabhbhhai

Patel Chest Institute over a period of one year from 1 January to 31 December 2012. The patients were divided into

2 groups based on their body mass index (BMI) into non-obese (18.50 - 24.99 kg/m2) and obese (> 25kg/m2). The

patients from these groups were then assessed for apnea hypopnea index (AHI).

Results: There were 81 subjects who underwent sleep study in 2012 comprising of 52 males and 29 females with

the mean age of 52.62 ± 10.03 years. Most of the subjects belonged to obese group (n = 75) whereas non-obese

group comprised of only 6 subjects. 66.67% subjects in non-obese group and 78.66% subjects in obese group had

severe obstructive sleep apnea (AHI ≥ 30/ hour). The difference in occurrence of severe OSA in non -obese versus

obese subjects was not statistically significant (p>0.05).

Conclusions: OSA has high occurrence in obese individuals and severity of OSA may not be related to obesity

alone.

Table 1: Apnea hypopnea index in different groups of body mass index

Body massindex

(kg/m2)

Number ofPatients

Apnea hypopnea index Percent of cases having AHI ≥ 30

< 5 ≥5- <15 ≥ 15- <30 ≥ 30<25 6 1 0 1 4 66.67%≥ 25 75 0 9 7 59 78.66%

P308

Bronchial anthracosis and anthracofibrosis

RAJ KUMAR, MOHAMMED NOUFAL POONGADAN, MANDEEP SINGH, NITIN GOEL, NITESH GUPTA, SAURAB,RAJENDRA PRASAD

National Centre for Respiratory Allergy, Asthma and Immunology

Vallabhbhai Patel Chest Institute, Delhi-110009, India

Objective: Anthracosis is a term used to describe a condition in which there is deposition of black pigments on thebronchial mucosa. On the other hand, bronchial anthracofibrosis (BAF) has been used to describe bronchialstenosis associated with anthracosis without a relevant history of pneumoconiosis or smoking. The present studywas planned to assess the clinico-radiological, bronchoscopic and pathological features of anthracosis with orwithout BAF

Method: The present study is a retrospective review of bronchoscopic cases of anthracosis diagnosed in a unit ofVallabhbhai Patel Chest Institute from Jan-August 2014. The clinical presentation, radiological features,bronchoscopic findings and histopathogical specimens of patients having anthracosis were analysed.

Results: There were a total of nine patients who were diagnosed to have anthracosis, out of which two hadassociated BAF during the study period. All the subjects were female with an average age of 59.4 years (age range:38-70 years). Past history of tuberculosis was present in 2 cases. The most common clinical symptoms in patientswith anthracosis were cough in 9 (100%), breathlessness in 8 (88.9%) cases. All the subjects had history of biomassfuel exposure. Computed tomography chest showed consolidation, nodules, bronchiectasis. Evidence of bronchialstenosis or obstruction was seen in 2 cases. Bronchoscopy revealed black bronchial deposits in all cases, with 2 outof them showing bronchial stenosis. Histo-pathological evaluation showed chronic inflammation of the bronchialmucosa, submucosal anthracotic pigment deposition in all and fibrosis in 2 cases.

Conclusions: The diagnosis of anthracosis and BAF is based mainly on bronchoscopic evaluation. It may beassociated with biomass fuel exposure or tuberculosis.

P309

Effect of household air pollution from biomass combustion on respiratory related illness in rural area of NCR-Delhi

Raj Kumar, Mandeep Singh, Kamal Singh, Mohammed Noufal Poongadan, Nitin Goel, Nitesh Gupta, Saurab, UdayKumar Mehto, Anil Mavi, Deepak Kumar, Rajendra Prasad

National Centre of Respiratory Allergy, Asthma and Immunology (NCRAAI), Vallabhbhai Patel Chest Institute, DelhiUniversity, Delhi-110007

Introduction: Indoor air pollution is the third leading cause of disease burden in South East Asia as per Global

burden of disease study 2010. Indoor air pollution as assessed by particulate matters (PM10, PM2.5, and PM1) and

volatile organic compounds (VOCs) includes combustion of solid fuels and tobacco smoking. The present study was

thus planned to assess the effect of indoor air pollution on the health of adults.

Methodology: The present study is a cross sectional study to assess the difference in household air quality in

houses having adults (>18 years age) with or without asthma in a rural area (Village Khanpurjupti, Loni, Ghaziabad)

of Delhi NCR region. 83 households (Group-A: controls) were selected in which none of the adult had any

respiratory symptoms (breathlessness, cough and/or sputum) while the other 83 households (Group-B: cases) had

at least one adult with one of the above respiratory symptoms. A standard questionnaire was filled and levels of

various indoor air pollutants were measured using standard instruments.

Result: Out of total 430 adults, 94 (21.86%) adults in Group-B had respiratory illness related symptoms. The PM

and VOCs levels of homes of Group-B, were higher than homes of Group-A. Average 24 hours and 6 hours PM2.5

levels were significant high in homes of Group-B compared with homes of Group-A. 6-hours PM10 mean level of

homes of group-B were also significantly high than Group-A. PM1 and VOC levels were also higher in Group B as

compared to Group A but could not reach stastically significant value.

Conclusion: Indoor air pollution from smoking, chemicals and biomass fuel combustion results in increased levels

of particulate matters and volatile organic compounds in indoor air, which may be responsible for increased level

of respiratory illness in adults.

P310

Effect of household air pollution from biomass combustion on respiratory related illness in womenRaj Kumar, Mandeep Singh, Kamal Singh, Mohammed Noufal Poongadan, Nitin Goel, Nitesh Gupta, Saurab, Uday

Kumar Mehto, Anil Mavi, Deepak Kumar, Rajendra Prasad

National Centre for Respiratory Allergy, Asthma and ImmunologyVallabhbhai Patel Chest Institute, Delhi-09

Background: Indoor air pollution is third leading cause of disease burden in South East Asia as per Global burden ofdisease study 2010 published in lancet. The most significant sources of indoor air pollution in developing countriesare combustion of solid fuels, including biomass or coal and active and passive smoking. Females are much moresusceptible to household air pollutants as they spend most of their time indoors. The present study was planned toassess the correlation between respiratory symptoms in women and levels of indoor air pollution as assessed byparticulate matter 2.5 (PM 2.5) and volatile organic compounds (VOCs).

Methods: The present study is a cross sectional study of adult women from 77 households in a rural setting (VillageKhanpurjupti, Loni, Ghaziabad) of Delhi NCR region. A questionnaire based assessment for respiratory illnessrelated symptoms (cough, sputum, breathlessness) was done in women of these houses. In these housesassessment of PM 2.5 and VOCs levels were done by standard instruments.

Results: A total of 190 adult women from 77 households were included in the study. A total of 56 women from 44households had history of respiratory illness related symptoms. The PM 2.5 and VOC levels were measured from all77 households. The average PM 2.5 concentration was found to be significantly higher in houses with respiratoryillness as compared to controls (10.13mg/m3 versus 4.36mg/m3). The average level of VOCs was also higher inthese households as compared to controls but could not reach statically significant value.

Conclusion: Household air pollution from biomass fuel use and smoking resulted in increased levels of PM2.5 andVOCs in household air, which may be responsible for increased level of respiratory illness in women.

P311

A 54 year old man presented with dry cough, breathlessness on exertion, itching all over the body and heaviness inthe chest from last 2-3 months. He noticed progressive bulging of his anterior chest wall also. On examination his

anterior chest wall was bulged, anterio-posterior diameter was 90 cm and transverse diameter was 75 cm. Therewere multiple enlarged lymph nodes in both the axillas. His X-ray chest PA view showed mediastinal widening andleft lateral view showed mediastinal mass extending into anterior chest wall. CT scan showed a large homogenousminimally enhancing soft tissue density mass lesion diffusely involving anterior and middle mediastinum extendingfrom thoracic inlet superiorly, up to the level of diaphragm inferiorly, anteriorly causing destruction of upper partof sternum with infiltration into overlying pectoralis muscles, subcutaneous tissue and skin. CT abdomen showedmultiple hypodense lesions in spleen. Biopsy of chest wall lesion and axillary lymph node showed featuressuggestive of lymphoma. He was diagnosed as having stage 4 Hodgikns lymphoma and was treated with combinedchemotherapy and radiotherapy. Size of the tumour reduced and patient discharged in satisfactory condition withadvice of regular follow up. We report this case because of its unusual presentation.