Napcon 2014 presentation abstract

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) are
currently standard diagnostic methods for PTE and DVT respectively. Role of D-dimer as screening tool is not
objectively assessed for RICU patients with pulmonary and other co-morbidities where dyspnoea is common
presentation at admission and they are at high risk to develop PTE due to immobility prior to and after admission
in the RICU. Due to patients respiratory condition it may not be possible to do definitive tests on all patients and
many times due to waxing and waning nature of respiratory symptoms repeating them may not be feasible in
same 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 for
CTPA/VQS positive and negative patients were compared.
RESULTS: The Demographics of CTPA/VQS positive (n=21) and negative (n=20) groups are comparable (Mean age
52.3±15.00 vs. 57.2±14.95; p=0.305). Both group had similar prevalence of COPD (30%). Higher prevalence of other
respiratory 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 not
significantly different.
CONCLUSIONS: D-dimer or CUS are not useful guide for evaluation of PTE in RICU setting in patients with
respiratory co-morbidities. Therefore there is need for low threshold for definitive tests (CTPA/VQS) to reliably
diagnose PTE cases in RICU patients in differential diagnosis of dyspnoea.
P2
Physiological 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 and
balances which keep its chemical constituents within a narrow ‘normal’ range. Despite the enormous load of acid
due to catabolic activities the internal milieu is tightly controlled and the H+ ion concentration therefore the pH is
kept within normal limits. The body is able to do this with help of certain buffer systems which are able to nullify
the effect of the additional acid load. Various disease states or organ malfunctions due to extrinsic stresses like
poisoning tend to induce changes in the metabolic environment by making it more acidic or alkaline. These are
resisted by compensatory mechanisms which are primarily mediated through the lungs and the kidneys. Before we
understand the physiological basis of these acid base disorders it is necessary to define few basic terms.

P3
IMMEDIATE ECHOCARDIOGRAPHIC ASSESSMENT OF PAP IN PATIENTS ADMITTED WITH EXACERBATION OF COPD
IN 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 Indian
patients admitted with acute exacerbation of COPD with severity of COPD (spirometry) ,severity and duration of
current exacerbation of COPD
Methods: PAP (systolic & mean) assessed by immediate echocardiography in 64 patients admitted with COPD
with acute exacerbation as per GOLD 2013 Guidelines at Metro Centre for Respiratory diseases were
retrospectively analyzed for their clinical symptoms, assessment of severity in the last one year’s using SPSS
software.
Results: Mean age 64.90+10.12 yrs and 15 (23.5%) were females. sPAP correlated with Pred post bronchodilator
FEV1 % (r=-0.321** ,p=0.010), severity of COPD (commonly seen C & D) (r=0.339** ,p=0.006), duration and
severity 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 of
COPD in this study.
Clinical implications: As COPD is a progressive disease, investigations like PFT and serial Echocardiography should
be done to assess the progression and complications of associated PH. However repeat Echocardiography, once
exacerbation has resolved is likely to give valuable information regarding PAP.
P4
Diagnosing 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 is
usually based on manual examination of ascitic fluid (AF) having long reporting time. AF infection is diagnosed
when 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 in
patients who underwent abdominal paracentesis and to calculate the sensitivity, specificity, positive, and negative
predictive values.
Materials and Methods:

The study was carried out on 103 patients with ascites. Cell count of AF as determined by colorimetric scale of
Multistix 10 SG reagent strip was compared with counting chamber method (PMNL count ≥ 250 cells/mm3 was
considered positive).
Results and Observations:
Of the 103 patients SBP was diagnosed in 20 patients, 83 patients were negative for SBP by manual cell count. AF
culture was positive in 55% (11) of these cases. The sensitivity and specificity of the LE test for detecting neutrocytic
SBP taking grade 2 as cut off were 95% and 96.4% respectively, with a positive predictive value of 86.4% and a
negative 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 studies
have been published on the use of LE reagent strip in AF. It is a very sensitive and specific method for the prompt
detection of elevated PMNL count, and represents a convenient, inexpensive, simple, and bedside method for
diagnosis of SBP. A negative LE test result excludes SBP with a high degree of certainty.
P5
Comparison 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 status
assessment 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 PH
group was 73.12 and in non-PH group was 60.44 (P value 0.004). Patients with PH had Grade 3MMRC dyspnoea or
above (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 distance
correlates with presence of PH. Higher MMRC dyspnoea grade are seen in those with PH. HRCT fibrosis score
doesn’t show any significant association with PH

Clinical implication: PH is a significant worse prognostic factor in IPF. This study helps in identifying factors
associated with PH so that such patients can be identified early and given appropriate care
P6
Case 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 acute
respiratory failure. Cryptogenic organizing pneumonia is a clinical entity of unknown etiology. A prevalence of 6 to
7 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/o
bilateral patchy alveolar airspace consolidation. HRCT chest s/o: Patchy ground-glass opacities in a subpleural and
peribronchovascular distribution, bilateral basal airspace consolidation, small nodular opacities measuring 1-10 mm
in diameter,noted,which is suggestive of COP.Transbronchial lung biopsy was performed which showed features
consistent with COP. Patient improved with initial NIV support, intravenous steroids later maintained on oral
steroids,presently on a gradual tailoff.
RESULTS: Histopathological examination revealed anastomosing plugs (‘buds’) of granulation tissue, the Masson
bodies, 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 imaging
features should be evaluated for possibility of COP, simultaneously excluding various infective etiologies.
P7
Diagnostic 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 were
performed. 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; the
total positive diagnostic rate was 59.7%. Diseases included adenocarcinoma 8/57 (14%), Non-specific interstitial
pneumonia 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
P8
Interstitial Lung Disease (Ild) In Rheumatoid Arthritis (Ra)-A Study Of forty seven cases.

S Bansal, D Talwar, S Joshi, R Gupta
Metro Hospital and Institution, MCRD, L-94 sec 11, Noida
OBJECTIVES
To evaluate Interstitial Lung Disease (ILD) in the patients with Rheumatoid Arthritis (RA) and to assess pulmonary
function tests and High Resolution Computed Tomography (HRCT) findings.
Methods
An unselected cohort of patients with a confirmed diagnosis of RA (satisfying the American College of
Rheumatology (ACR) criteria ) and known lung disease were identified (n =47 ) and evaluated for RA lung disease
activity and severity. Outcomes included abnormalities determined by the HRCT findings of the lung, forced vital
capacity (FVC) and diffusion capacity for carbon monoxide (DLco).
Results
Four 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 pattern
observed 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 in
FVC. DLco was normal in 12 (25.5%) cases where as 16 (34%) had mild, 18 (38.2%) had moderate and 1 (2%) had
severe reduction in diffusion capacity.
Conclusion
Pulmonary nodules are the most common pattern observed in our patients followed by ground glass haze. Pleural
effusion is seen in one forth of our patients with RA-ILD. UIP, OP, and NSIP interstitial pattern is observed in
decreasing frequency but mixed pattern is more commonly seen. Mild to moderate reduced FVC and DLco was
observed in more than 80% of our pts. Pulmonary complications in RA are directly related to the severity of
pleural, parenchymal and airway involvement. Our study emphasizes that all patients with RA should undergo
HRCT and PFT even with minimal respiratory symptoms so that more aggressive treatment can be justified in
otherwise stable patients.
P9
Title: 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 is
known hypertensive. she had history of amputation of distal phalynges due to gangrene. Patient is not a known
case of tuberculosis. On clinical examination she was found to have hypopigmented macules on scalp with bilateral
Velcro crackles on auscultation. On thorough investigations it was confirmed she was suffering from ILD with
dermatological involvement and aneurismal dilatation of descending thoracic aorta. Though ILD’S are
common,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 and
hypertensive. He underwent cholecysectomy and biopsy from liver was obtained. It was confirmed
histopathologically as non caseating granuloma. Chest Xray and CT revealed features of sarcoidosis. Such kind of
asymptomatic 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 Medical
College, Belgaum, Karnataka
Desquamative interstitial pneumonia (DIP) is a rare disease which was reported by Liebow et al. in 1965. We
hereby 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 fingers
involving both upper and lower limbs. Past history revealed, he was working in iron factory for last 25 years. Chest
radiography showed the presence of non-homogenous opacity with air bronchogram in the left upper and mid
zone. Patient was treated with appropriate antibiotic coverage and other supportive treatment. Repeat chest
radiography after 5 days showed no improvement and peripheral cyanosis persisted inspite of normal arterial
blood 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. CT
guided biopsy of lung was done, which showed alveoli filled with proteinaceous contents with plenty of
macrophages containing brown pigment and fibrosis of interstitial tissue which was suggestive of DIP. He was
treated with steroids and supportive medication. Repeat chest radiograph showed radiological improvement with
good resolution. However peripheral cyanosis progressed to developed gangrene of fingers of both lower and
upper limbs. The color Doppler study of arteries and venous system showed thrombus in the left cephalic and
subclavian vein, while other arteries and vessels had no evidence of thrombus. Patient was discharged and
continued 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-605014
Introduction
Nitrofurantoin is a commonly used drug in the treatment and prevention of urinary tract infections. Many adverse
effects of nitrofurantoin have been documented, including aplastic anemia, polyneuritis, and liver and pulmonary
toxicity.
Case presentation
We describe the clinical history and the autopsy findings in a 60-year-old man with Interstitial Lung Disease of
unknown etiology. He had a history of recurrent urinary tract infections, treated with nitrofurantoin for four
months. He came to our hospital with progressively worsening breathlessness for 1 month. He was in respiratory
failure and oxygen dependent and progressively worsened in spite of treatment with steroids and perfenidone. He
finally died of respiratory insufficiency.

At autopsy there were features of organizing pneumonia. With the microscopic pattern bronchiolitis obliterans
organizing pneumonia and the history of long-term nitrofurantoin use, we concluded that this was a drug induced
pulmonary toxicity.
Conclusion
This case shows that the use of nitrofurantoin may cause severe pulmonary disease. Patients with long-term use of
nitrofurantoin 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 in
which a failure of self-tolerance leads to autoimmunity and subsequent tissue injury. Involvement of the
respiratory system, particularly interstitial lung disease (ILD), is common and is an important contributor to
morbidity and mortality. The radiographic findings and histopathologic appearances of ILD among the CTDs closely
resembles idiopathic interstitial pneumonias. However, close examination of radiographs, pathologic tissue and
collagen profile may offer clues to a diagnosis of underlying CTD. Corticosteroids and immunosuppressive agents
are often used.
Case Reports: Here, we present 3 cases of CTD –ILDs in which two were females and 1 male. Two were aged more
than 70 years. Collagen profile of these patients confirmed the diagnosis of dermatomyositis in one case (Ro- 52
recombinant positive, increased CPK) , mixed connective tissue disorder in one case ( sRNP positive) , and
rheumatoid arthritis in one case ( raised RF , anti CCP and CRP ). 2D ECHO in two patients showed moderate PAH
and 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. Subclinical
disease 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 a
careful 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 patients
with 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 of
clinico-radiology and lung biopsy wherever required. Clinical characteristics, comorbidities, GAP score and GAP
stage 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 pulmonary
hypertension died at 3 year follow-up. At one, two, three years follow-up 17(46%), 22(60%), 23(62%) patients died
respectively. Patients classified into stages of GAP I, II, III consisted of 5, 17, 15 respectively. Of the GAP I patients
20% 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 thoracoscopy
during March 2014 – august 2014. Technique: Semirigid thoracoscopy under conscious sedation and local
anaesthesia. 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 were
empyema(22%), undiagnosed pleural effusion(31%) , non expanding lung(33%), hemorrhagic effusion(11%) and lung
biopsy(2%). 18 % of cases were diagnosed as malignancy and rest were due to benign causes. 4 out of 5 cases of
hemorrhagic effusion was malignancy.6 out of 10 cases of empyema were successfully drained.4 required
decortications. 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 peel
were main reasons for non expanding lung group.
Conclusion:Semi rigid thoracoscopy is relatively easy to use and efficient in management of pleural diseases .It is
safe 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. KRISHNA
RAJASEKHAR, C. CHANDRA SEKAR
BACK GROUND: Diagnosis of sputum smear –negative retreatment pulmonary tuberculosis patients can be
challenging 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 confirmative
and early diagnosis in such patients.
AIMS: To assess the role of fibreoptic bronchoscopy in the sputum smear – negative Retreatment pulmonary
tuberculosis 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 logically
suspected sputum smear –negative Retreatment Pulmonary Tuberculosis patients attending Government Hospital
of Thoracic Medicine, Tambaram, Sanatorium. Fibreoptic bronchoscopy was performed. Bronchial wash and brush
sent for AFB smear and malignant cytology. Bronchial wash for AFB culture by LJ medium, post FOB sputum for
AFB 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 a
definitive 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, yield
of thoracoscopic pleural biopsy for achieving a diagnosis in undiagnosed pleural effusions, defined as pleural
effusions with adenosine deaminase (ADA) levels less than 40 IU/L and negative pleural fluid cytology for
malignancy on three occasions was evaluated.
RESULTS:
A total of 34 patients (25 males and 9 females; mean age years) underwent thoracoscopy. Overall diagnostic yield
of thoracoscopic pleural biopsy was 97.05% in patients with undiagnosed pleural effusions. Malignancy was
diagnosed in 21 patients, tuberculosis was found in 09 patients, 03 patients had non-specific inflammation, and
was non-diagnostic in 01 patient. There were no major complications, only four patients had minor complication
like subcutaneous emphysema (three patients) and prolonged air leak (one patient).
Histologic diagnosis Prevalence
Malignant 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 with
minimal complication rates. In a tertiary care centre, thoracoscopy has shown more malignant pleural effusions
than 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 malignant
pleural effusion by bedside pleurodesis due to use of Thopaz
TM
digital suction suction device thus avoiding surgery
and general anesthesia for very sick patients.
Methods: 52 patients unfit for general anaesthesia underwent bedside Talc pleurodesis for prolonged air leak or
malignant pleural effusion. Talc slurry with lignocaine was introduced via the drain and digital suction was applied
at 2 Kpas for 48 to 72 hours
Results: 48/ 52 patients underwent successful talc pleurodesis due to complete lung expansion. 8/48 patients
needed 2 doses of talc over 4 days. Early mobilisation was facilitated by portable digital suction device. 2/ 52
patients had small localised apical pneumothorax with no clinical significance. 4 patients with tuberculosis were
put 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 specifically
seeking medela digital suction device.
Conclusion: Use of Thopaz
TM
digital suction device facilitates early expansion of lung and thus aiding in successful
bedside 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
Objective: We present our experience of facilitation of conservation management patients with secondary
pneumothorax with air leaks by bedside pleurodesis due to use of Thopaz
TM
digital suction device thus avoiding
surgery and general anesthesia for very sick patients
Methods: 18 patients with secondary pneumothorax with ICD with prolonged air leak, who were unfit for general
anaesthesia, underwent bedside Talc pleurodesis. Talc slurry with lignocaine was introduced via the drain and
digital 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 patients
needed 2 doses of talc over 4 days. Early mobilisation was facilitated by portable digital suction device. 2/ 18
patients had small localised apical pneumothorax with no clinical significance. 1 patient with tuberculosis was put
on a flutter bag and discharged home. Drain was removed at follow up. All patients had successful conservative
management of clinical problem.
Conclusion: Use of Thopaz
TM
digital suction device facilitates early expansion of lung and thus aiding in successful
bedside talc pleurodesis in very sick patients who are unfit for general anaesthesia
P21

Unusual Endobronchial Foreign Bodies
S Khandelwal
1
, K Ali
1
, N Agarwal
1
, S Khanna
2
, A Sharma
2
, T Piplani
3
, A Z Khan
1
1
2
Department of Anesthesiology
3
Department of Radiology
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. These
patients consisted of 10 men and 1 woman with a mean age of 48.5 years (range 10 to 77 years). Symptoms on
presenting were usually cough, sputum, or chest pain. Three patients were not aware that they had aspirated a
foreign 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, pen
spring. 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 foreign
bodies.
P22
Robotic & VATS Lobectomy for post tuberculosis Aspergilloma
S Khandelwal
1
, Kamran Ali
1
, N Agarwal
1
, S Khanna
2
, A Sharma
2
, T Piplani
3
, A Z Khan
1
1
2
3
Objective: We present a video of our experience of Robotic & VATS Resection of Aspergilloma using a DaVinci 4
Arm robot. We also demonstrate a novel intraoperative technique to prevent spillage of aspergilloma into the
normal lung.
Methods: Between January 2012 to September 2014, 18 patients underwent surgical resection of Aspergilloma CT
scan 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’s
catheter was also introduced into the affected side (operative side). Fissure and hilum were exposed and
structures were stapled with endostaplers.
Results: Age group was 35 to 78 years (mean 48 years). 12 males and 6 females. Patients received antituberculous
drugs 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. Chest
X-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. Robotics
allows 3D visualization and 360 degree movement of endowrist. It gives good and accurate mobilization of
adhesions. Addition of anesthetic techniques like lateral double lumen intubation, Fogarty catheter prevent
spillage of aspergilloma into normal lung. In the background of tuberculosis, where the general feeling across the
country is that VATS is not possible we have not only done these very complex cases by VATS but shown clinical
efficacy of resection by robotic thoracic surgery.
P23
VATS Decortication: The Indian experience
S Khandelwal
1
, Kamran Ali
1
, N Agarwal
1
, S Khanna
2
, A Sharma
2
, T Piplani
3
, A Z Khan
1
1
2
3
Objective: A retrospective case matched analysis of clinical outcomes of VATS drainage of empyema and
decortication of patients with tuberculous and non-tuberculous empyema.
Methods: 180 patients with empyema presented for surgical treatment over a four year period. The diagnosis
confirmed on CT scan included simple and loculated early and late stage empyema with or without cortices. All
patients underwent VATS drainage of empyema and decortication to enable full expansion of trapped lung. Group
A consisted of 90 patients with tuberculous empyema and group B had 90 patients with non tuberculous
empyema. 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 radiological
data was collected to show clinical outcomes at discharge and subsequent follow-ups. Data was analyzed using
SPSS 16.0 software.
Results: Group A & group B had similar demographics with relation to age, gender, duration of illness, clinical
comorbidities. 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). One
patient in group A with Giant Bullous disease underwent lung volume reduction surgery. He subsequently had
prolonged 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. Besides
slightly longer operative time, the clinical outcomes are just as good as patients with pyogenic empyema. Presence
of suspected tuberculosis is not a contraindication for VATS decortication.
P26

Unusual presentation of anterior mediastinal mass - a case report
Srilata P. Naik, Jayaraj B S, Mahesh P A, Chaya S K.
JSS Medical College, Mysore, Karnataka, India
Introduction
Approximately half of all mediastinal lesions are asymptomatic and are detected on chest radiographs taken for
unrelated reasons. The absence of symptoms suggests that a lesion is benign, whereas the presence of symptoms
suggests malignancy. In adults, 48 to 62 percent of lesions are symptomatic, whereas the percentage of
symptomatic lesions is higher in children (58 to 78%). The most common symptoms are cardiorespiratory – in
particular, 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 a
common complaint.
Case Report
A 28 year old female presented with multiple pigmented papules and macules over the extremities and
inflammatory 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 an
anterior mediastinal mass enclosing the superior vena cava and right main bronchus. Mini thoracotomy and biopsy
confirmed Hodgkin’s lymphoma (nodular sclerosing type). Patient showed good response to standard
chemotherapy.
Conclusion
High degree of clinical suspicion is required as anterior mediastinal mass may have paucity of clinical symptoms at
presentation. Early diagnosis may help in improving the prognosis.
P27
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. We
describe a case of a 73 year old male who presented with exertional dyspnea and foreign body sensation in throat
with a normal chest radiograph. Until date very few cases of BALT lymphoma involving the trachea have been
described.
CASE REPORT
A 73 year old Indian male, non smoker, diabetic and hypertensive presented with exertional dyspnea and foreign
body sensation in throat since 4 months to the outpatient department. Auscultation revealed bilateral inspiratory
rhonchi. He was found to have a subglottic growth on Indirect Laryngoscopy. Chest Radiograph was essentially
normal. Computed Tomograph (CT) scan neck and thorax revealed a circumferential mural thickening with
intraluminal mass and narrowing involving the left lateral, anterior and posterior wall of the trachea with multiple
nodules extending up to the primary bronchus on either side. Bronchoscopy revealed a polypoidal endotracheal
mass in the upper 1/3
rd
of the trachea. Multiple endobrochial biopsies were taken from the mass and tissue sent
for histopathology. Histopathology of the bronchial tissue showed dense aggregates of the lymphoid cells with
fibrinous material within the pseudostrattified respiratory epithelium suggestive of Lymphoma. Further
Immunohistochemistry 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 and
clinical improvement.
CONCLUSION:
Tracheal BALT lymphomas have an indolent behavior. The lesions are commonly missed on chest radiographs
unless we have a high index of suspicion
P28
High Dose Rate Endobronchial Brachytherapy for Palliative Treatment of Lung Cancer – A Case Report
Muhammed Aslam N K , Rajeev Ram , Achuthan V , Manoj D K ,Rajani M
Pariyaram medical colleg , kannur , india
Introduction
High-dose-rate endobronchial brachytherapy (HDREB) is used in the treatment of endobronchial lung cancer for
the main purpose of symptom relief.
Case Report
76 year old male ex-smoker presented with 1 month history of exertional dyspnea .His chest X-ray revealed left
perihilar homogenous opacity. CECT Thorax showed infiltrating mass (7cm) in left hilum with mediastinal invasion
reaching up to 1.5 cm from carinal angle. Flexible video bronchoscopy showed proliferative growth partially
occluding the distal end of left main bronchus. Histopathology of bronchial biopsy showed squamous cell
carcinoma. Radiation oncology consultation done and posted for HDREB. An afterloading polyethylene catheter
passed through the bronchoscope. With Iridium -192 , a dose of 10 Gray was delivered using remote after loading
device. Repeat bronchoscopy done after 6 week showed significant reduction in size of mass. Patient got
symptomatic relief and now he is on 6 cycles of chemotherapy.
Conclusion
HDREB 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
P29
Utility of fibreoptic bronchoscopy in a case of left lung collapse with Guillain Barre Syndrome and 5 months of
amennorhea
Dr P P JAIN
1
, Dr A S PANDEY
2
, Dr D A MODH
3
, Dr H V DESAI
4
, Dr S R Ghadiya
5
Introduction
Lung collapse due to thick mucus plug impaction in a mechanically ventilated patient with GBS is a difficult clinical
sequel to manage. Involvement of respiratory muscles in GBS hampers cough reflex and muco-ciliary clearance
causing formation and accumulation of mucous plugs, which may result in life threatening complications.
Case Report
This 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 invasive
ventilator referred to us for left lung collapse. The Bronchoscopy findings were suggestive of impacted thick mucus
plug 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 maintained
above 90%. Post bronchoscopy, the left lung expanded and arterial blood gas analysis showed marked
improvement.

Conclusion
Prompt and timely intervention for lung collapse is required to manage patients of GBS with respiratory
complications with pregnancy. Risk versus benefit ratio must be evaluated and hypoxia should be avoided to
improve maternal and foetal outcome. Use of Mesna and N-acetylcysteine enhances mucus plug breakdown and
helps in reverting collapse thereby, improving the prognosis of the patient.
P30
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 in
development of lung cancer. In patients who develop lung cancer without a smoking history, potential
environmental or inherited causes of lung cancer are unclear. In Punjab, majority of the population is nonsmoking
due to religious prohibitions and also smoking is banned by law in public places and institutions. Inspite of this we
are getting quite a lot of lung cancer cases.METHODSThis study included 50 patients with proven diagnosis of lung
cancer. They were divided into 2 groups-smokers and nonsmokers. They were compared according to their
demographic characters like age, sex, occupation, smoking history, clinicoradiological findings and
histopathology.RESULTSIn our study of 50 patients, 48% were smokers whereas 52% were non-smokers. Mean age
of smokers was 62.25 years and that of nonsmokers was 56.15 years. All smokers were males. Amongst
nonsmokers 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 labourers
by occupation (50%) whereas 61% of the nonsmokers were unemployed. Most common symptom in smokers was
cough (41%) whereas nonsmokers presented with cough and breathlessness (42%). Most common examination
and radiological finding in both smokers and nonsmokers was mass lesion. Most predominant histological type in
smokers was squamous cell carcinoma(75%) and in nonsmokers was adenocarcinoma(69%).CONCLUSIONSFrom
this study we have concluded that lung cancer is equally prevalent in both smokers and nonsmokers. Most
smokers were males presented with squamous cell carcinoma whereas majority of the nonsmokers were females
and presented at an earlier age than smokers with adenocarcinoma as the predominant histological type. Factors
leading 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 – A
RARE 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 – A
RARE 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 and
breathlessness.
CASE REPORT: We report a case of 59 year male patient, teacher by occupation, presenting with gradually
progressive dyspnoea over two years and occasional cough with scanty mucoid expectoration. He was a smoker
since last 30 years, smoking 4-5 cigarettes per day. He was clinically diagnosed to have COPD and was put on
inhalational formoterol and budesonide (800 microgram/day) along with inhalational tiotropium. On clinical
examination, there was tachycardia, tachypnoea, SpO2 93% at room air. Auscultation of chest revealed diminished
vesicular breath sound and wheeze on left hemithorax. Spirometry demonstrated a restrictive pattern. ECG
revealed right axis deviation with first degree heart block. On chest X-Ray, left lung was found to be more
radiolucent in comparison to right. CT scan of thorax revealed a near complete cut off of left main bronchus due to
intraluminal soft tissue mass with parenchymal infiltrate in the left upper and lower lobe without evidence of
lymphadenopathy. Flexible bronchoscopy showed a tumour in the left main bronchus and biopsy was taken.
Histology revealed uniform polygonal cells suggestive of bronchial carcinoid. Immunohistochemistry indicated
neuroendocrine differentiation of tumour cells with cytoplasmic positivity for Cytokeratin, Chromogranin A and
Synaptophysin. Hence, a diagnosis of typical carcinoid tumour was established. Subsequently the patient was
referred to thoracic surgeon and left pneumonectomy was performed.
CONCLUSION: Though carcinoid is an uncommon tumour of respiratory system, its possibility should be kept in
mind in cases of refractory asthma or COPD.
P32

P33
A Rare Case Of Tracheal Tumour
A.M KHOJA, K S K GOUD, R.K JALAN, D L JAIN
Department of Respiratory Medicine, Ruby Hall Clinic, Pune, Maharashtra, India
BACKGROUND:
Primary tracheal tumours either benign or malignant account upto less than 0.1% of all tumours. Benign tumours
are usually misdiagnosed as asthma or COPD and are usually diagnosed late. On contrary because of the rapid
growth and hemoptysis malignant tumours are usually diagnosed a little early. Here we report a case of squamous
cell carcinoma of trachea which was being treated as bronchial asthma for 6 months. The main objective of
reporting this case is to always keep a suspicion of tracheal tumour when an elderly male being treated for chronic
airway 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 6
months. Physical examination revealed severe stridor and wheeze. He was being treated as bronchial asthma with
no improvement in symptoms. HRCT showed an enhancing mid-tracheal mass lesion with collapse consolidation of
right 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 for
HPE.

Histopathological examination showed moderately differentiated Squamous cell carcinoma. Post-resection PET-CT
was 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. Mostly
they are treated either as asthma or COPD. The most common tracheal tumour being squamous cell carcinoma
followed by adenoid cystic carcinoma.The initial management in acute setting includes relieving the symptoms by
resection of mass. Modern techniques for tracheal surgery include laryngotracheal, tracheal, or carinal resection
combined with radiotherapy and have shown good outcome.
P34

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 of
tobacco use. This case concerns a 32 year old male with no history of tobacco use who complaints of hoarseness of
voice, chest pain, dry cough, breathlessness grade II and loss of weight and appetite for two weeks. Chest x ray
showed left sided massive pleural effusion. Computerized tomography showed massive left sided pleural effusion
with complete collapse of left lung with numerous enhancing lobulated nodules in the left pleura. Patient
underwent 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, despite
aggressive therapy, the patient’s disease progressed and he died within one week following chemotherapy. In this
paper 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 diagnosis
S K SAMANTA, S BARMAN, J JOSEPH
FORTIS HOSPITAL, KOLKATA, INDIA
CASE 1
A 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 thickened
pleura”.
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 a
pedicle with part of lung tissue adherent to it.
HISTOPATHOLOGY:

• compatible with solitary fibrous tumour of pleura
FINAL DIAGNOSIS:
• Solitary Fibrous Tumor of Pleura with intraparenchymal extension
CONCLUSION: Sometimes common symptoms can be presentation of rare diseases
P37
CASE OF TRACT CARCINOMA
Dr.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.she
presented 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 drained
via icd 4 months back, 1 month h/o swellings in lateral chest wall & back.2) examination revealed dull note on
percussion on left side, icd scar, swellings in chest wall.3) cxr & CT scan thorax to visualize mass.4) usg abdomen to
r/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 with
convoluted nuclei s/o metastasis from Ca breast.
Conclusion: case of tract carcinoma at intercostal tube drainage & pleural fluid aspiration site due to metastasis
from old operated Ca breast..
P38
Multiple small nodule and medistinal lymph node with minimal pleural effussion cause tubercular misdiagnose as
Ca 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 thorasic
surgeon 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 the
world, accounting for one fifth of the global incidence-an estimated 1.9 million cases annually. Tuberculosis has a
lots of presentation. It can present like pleural effusion, mediastinal lymph node, pulmonary nodule, sputum
positive 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 40
years of age.
Case description- A 40 year old female came to our department with the chief complaint of low grade fever from 7
days and left side chest pain from 5 days. Chest x-ray was done outside and it showed left sided costophragnic
angle blunting. USG guided pleural fluid was aspirated and sent for biochemistry and cytology. It was lymphocytic
predominant 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 that
PET scan was done and it revealed multiple small nodules in left upper lobe with mediastinal lymph node. Open
lung biopsy was done and sent for histopathology. It showed multiple necrotizing granulomas. Patient is not having
previous 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 common
among children and women. Pulmonary tuberculosis is common adults and elderly. Multiple small nodule is a rare
presentation of pulmonary tuberculosis. It is missed on chest x-ray. It is diagnosed on HRCT scan. For
histopathology 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 of
multiple pulmonary nodule is lung metastasis.
Conclusion-HRCT scan of thorax is the basic investigation for diagnosis of multiple pulmonary nodule. For
histopathology VATS guided biopsy or open lung biopsy can be done.
Key words- Pulmonary TB, Adenocarcinoma, Multiple nodule
P39
TOPIC NAME:- Posterior mediastinal mass presenting as paraparesis
DR IBRAHIM SIDDIQUE,DR.LAVINA MIRCHANDANI,DR JAYALAKSHMI T.K,DR GIRIJA NAIR,DR ABHAY UPPE,DR
APARNA 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 usually
detected on routine radiographic imaging
Ten percent schwannomas grow across the adjacent intervertebral foramen and extend across the spinal clumn in
an 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 to
paraplegia over a period of one month .A chest X-ray done as routine evaluation revealed a posterior
mediastinal mass confirmed by taking lateral chest x-ray. Hence MRI of spine was done which revealed
hour glass or dumbbell shaped tumour.FNAC done showed spindle cell neoplasm confirming
schwannoma. Complete surgical resection of tumour was done within 3 days of diagnosis Thus
radiography is a vital diagnostic tool in the detection of these silent tumours and early diagnosis and
complete 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 MUGDHA
BHIDE, 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-morbidities
came in OPD with complains of tender swelling over chest wall, breathlessness, chest pain, cough & low grade
fever 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 revealed
reduced breath sounds, left infrascapularly. Chest X-ray showed left sided CP angle blunting with homogenous
opacity in the left lower lobe, silhouetting with left heart border & diaphragm. High Resolution Computed
Tomography showed a large lobulated heterogeneously enhancing lesion in the anterior mediastinum –
prevascular compartment extending to superior mediastinum. USG guided biopsy revealed Non Hodgkins
Lymphoma. 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:
1
Annuls 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 quite
favorable if diagnosed early.
Case report: A 32 year old male, manual labourer by occupation presented with recurrent episodes of cough, right
sided 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 right
infrascapular 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 enhanced
computed 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 well
defined 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%) and
appendix (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 of
bronchial 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 pulmonary
carcinoid 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.
P42
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 these
parameters 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 Sept
2013 – Aug 2014. 160 lung cancer patients with smoking habits and 14 lung cancer patients without h/o smoking
were admitted during the study period. To facilitate comparison between profile of smoker and non smokers 30
patients with lung cancer were selected randomly from the smoker group .Thus the sample size is 44; smokers -30
and 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%).commonest
occupation 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 lung
cancer whereas cough(93%), dyspnoea(43%), hemoptysis(43%) were common in non smokers .Smokers with lung
cancer radiologically presented with pleural effusion(46.7%), collapse(30%), mass lesion(30%)and Mediastinal
lymph 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 among
smokers 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 patients
2) 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 nonsmall
cell 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 streaky
hemoptysis of one month duration.
On examination he was hemodynamically stable. General examination revealed a right supraclavicular
lymph node of 2.0 x 1.0 cm. CXR showed right lower zone non- homogeneous opacity. Sputum for acid-fast bacilli
was 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 heterogenous
enhancing irregular lesion of 3.0 x 1.0 cm in right lower lobe with minimal effusion. A possibility of malignant lesion
with an ipsilateral cervical node metastasis was considered. Since the patient was not willing for invasive
procedures, excision biopsy of the lymph node was done. Biopsy revealed granulomatous inflammation s/o
tuberculosis and was negative for malignancy. Patient was initiated on anti-tuberculous treatment. During review
CXR 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 into
pleura-stage IV lung malignancy.
Patient was initiated on chemotherapy and ATT continued. This case has been reported for the
concurrent existence of tuberculosis and malignancy in the same patient.
Discussion:
Clinical diagnosis of co-existing tuberculosis and malignancy is often challenging. Lymphadenitis of various
etiologies 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 proven
lymphadenitis.
Conclusion:
The clinicians need to be aware of the protean manifestations of tuberculosis and malignancy and
maintain a high index of suspicion for simultaneous and / or misleading presentations.
P44
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 typical
presentation of bronchoalveolar carcinoma is asymptomatic (solitary nodule) and remains without symptoms even
as disease disseminates. We report a case of bronchoalveolar carcinoma presenting as non-resolving consolidation
in 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 biopsy
revealed bronchoalveolar carcinoma. Patient had a good performance score and was managed conservatively
P45
SPINDLE CELL SARCOMA OF THE LUNG: CLINICAL, RADIOLOGICAL AND HISTOPATHOLOGICAL FEATURES OF
THREE 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 retrospectively
reviewed the records of 45 patients with lung cancer over 3 years and re-examined the clinical, radiological and
histopathological features of three patients of Spindle Cell Sarcoma. Thus the incidence of SpCC was 6.6% of all
lung malignancies in our hospital. All three patients were females and non-smokers. The age of the patients was
34, 43 and 56 years. The SpCC was initially detected by routine chest X-ray examination in all cases. Two were
peripheral tumors and one was a central tumour with total lung collapse. One patient had a surgical resection
other two cases were treated by chemotherapy. The survival period was 7 and 16 months for two patients. One
patient for whom surgical resection was done is still under our follow up 15 months after surgery. Histologically, all
the 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 the
frequency (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 of
mortality in both males and females.Recently there is a change in histopathological presentation of lung carcinoma
among 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 in
Adult male and female.
Methods-Prospective study of lung carcinoma was conducted by using histopathological diagnosis.Weanalysed
patients 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 were
analysed using chisquare test and logistic regression analysis.
RESULTS-During this period of 2 years 40 lung cancer patients were diagnosed in the department of pulmonary
medicine (vydehi institute of medical sciences and research centre, Bangalore). Out of 40 patients small cell
carcinoma 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.all
female 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 among
males.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 our
department over one year period.
Method & Materials : 67 patients suspected of lung cancer on symptomatology & Chest Xray(CXR) were subjected
to sputum examination, CT Scan of chest, followed by interventions like FNAC of the lesions and bronchoscopy to
prove the diagnosis .
Results : In our study of 67 patients, 53 were males, 14 were females. Median age was 59. 9 years, youngest being
26 years & oldest 95 years. All 14 females were non-smokers but had exposure to biomass fuel. Among males, 20
were 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 homogenous
opacity(21%),and hilar enlargement(12%). Most common findings in CT chest were peripheral mass(34.3%), central
mass(20.9%), consolidation(15%), pleural effusion(11.95%),bilateral nodules(5.97%), Cannonball secondaries in 2
cases, SOL , Pancoast tumour & Lymphangitis carcinomatosis in 1 case each. Histological patterns included poorly
differentiated NSCLC in 29 cases(45.3%).,squamous cell carcinoma(SCC) in 28 cases(43.8%), adenocarcinoma in 5
cases(7.8%), large cell carcinoma & mesothelioma in one case each. Most of the patients were in stage 3 or stage 4
lung cancer.
Conclusion: Lung cancer has equally high incidence among non-smokers , SCC still being most common histological
variant. 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 of
conventional 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 or
hilar lymphadeopathy who underwent TBNA were included of which the first 75 cases were done by conventional
TBNA 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 punctures
per 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 and
Hilar 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, increasing
dyspnoea for 4 months and weight loss of four kgs. in last two months. The clinical findings & CXR was suggestive
of right-sided massive pleural effusion. Computed tomography (CT) scan of the thorax showed a large patchily
enhancing mixed density lesion having both solid & cystic component involving Rt. Lung, with minimal pleural
effusion. CT-guided tru-cut biopsy from the mass revealed Spindle cell neoplasm. However, on
immunohistochemistry tumour cells
P51
Comparison of Diagnostic yield of fiberoptic bronchoscopic procedures in the evaluation of bronchogenic
carcinoma
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 in
bronchogenic carcinoma.
Design: Retrospective analysis.
Method:-Present study was carried out in 100 cases of bronchogenic carcinoma, proved either by Bronchial
washing, brushing, biopsy or TBNA. Bronchoscopy was done by flexible fiber-optic video bronchoscope at 280
bedded 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 highest
i.e. 92.5% , followed by brushing (75%) and washings (65%) respectively.In peripheral lesion (20 cases) , yield of
bronchial brushing was higher than washings. TBNA (Trans-bronchial needle aspiration) was done in 18 patients
and were found positive in 77.77%.
Conclusion: The overall diagnostic yield of flexible bronchoscopy procedures can be increased if conventional
TBNA 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 of
bronchial obstruction. Broncholiths originate from calcified material in peribronchial lymph nodes eroding into the
tracheobronchial tree. Flexible bronchoscopy plays an important role in the diagnosis of broncholithiasis, but its
therapeutic application is still controversial. We report a case of broncholith removal with the help of flexible video
bronchoscope without any complications.
Case report: A 45 year old male, farmer, chronic smoker was admitted with the complaint of cough with
hemoptysis and low grade fever, off and on since 8 months. He had similar episodes in past and was diagnosed
previously as a case of recurrent left upper lobe pneumonia. He never received antitubercular treatment. Clubbing
was the only finding in the general physical examination. Chest auscultation revealed diminished breath sound
over left infraclavicular region. AFB smear and malignant cytology of sputum were negative. Gram’s and KOH
stain revealed no pathogenic organism. Mantoux test was 4 mm. Chest x-ray showed left upper and mid zone
homogenous opacity with calcified lesions with bilateral hilaradenopathy. CT thorax showed calcified density in
lingular bronchus. Flexible video bronchoscopy revealed a loosely attached greyish white broncholith in the
lingular segment. We successfully removed broncholith with a toothed forceps. Patient was stable and had no
episodes of hemoptysis after the procedure.
Discussion: Usually rigid bronchoscopy with Nd-YAG laser photocoagulation or cryotherapy is used for safe
removal of broncholiths. Flexible bronchoscopy can be a promising tool in removal of broncholiths that are not
incarcerated 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, Sanjay
GEHLOT
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 grade
fever for last six months with occasional streaky haemoptysis. He was having dull aching pain on back of chest in
right side. Physical examination revealed pallor and clubbing. Tenderness was present over right interscapular
region. Diminished breath sound was present over same region on auscultation. Other system examinations
revealed 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 posterior
pleural based cavitating mass lesion of size 5.9×4.9 cm with posterior rib erosion. USG guided FNAC was suggestive
of adenocarcinoma. Bronchoscopic study was inconclusive. Transthoracic tru-cut biopsy was performed.
Histopathological examination and immunohistochemistry for EGFR & TTF-1 confirmed the diagnosis. Patient was
then referred to the oncology department.
Discussion: Overexpression of epidermal growth factor present in neoplastic cells cause rapid tumor growth that
exceeds blood supply, favoring central necrosis and cavity formation. This case is interesting because cavitating
primary 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 Reddy
Tummuru ; 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 of
pulmonary apex. They account for less than 5% of all bronchogenic carcinomas. It is a type of lung cancer defined
primarily by its location situated at the top end of either the right or left lung . Clinically patient presents with the
characteristic symptoms of severe pain in the shoulder radiating toward the axilla and/or scapula and along the
ulnar distribution of the upper arm, atrophy of hand and arm muscles and obstruction of the subclavian vein
resulting 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 chest
pain from 2 months ,radiating to left hand , absence of sweating on left side of face. General examination showed
clubbing and wasting of hypothenar muscles. Opththalmological examination showed horners syndrome with
reverse ptosis. X ray chest showed a mass with 1st and 2nd rib erosions. CECT chest showed a contrast enhancing
mass with first 2 rib erosions.pt was diagnosed as having pancoast tumour. CT guided biopsy showed
adenocarcinoma 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. Cardiac
angiosarcoma, originates from mesenchymal tissue and endothelial subepicardium. Although angiosarcmoa
constitutes 31% of all malignant cardiac tumors, it is rare and prompted us to report this case.The diagnosis of
angiosarcoma 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 to
tamponade and pleural effusion which occur late in the progression of angiosarcoma. Right atrial presentation is
the 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 radiograph
showed marked cardiomegaly with right atrium (RA) & right ventricle (RV) enlargement. Echocardiography
showed large hollow cystic mass attached to RA & RV. MRI chest with contrast showed irregular mass in the right
lateral wall with pedunculated & nodular areas in the RA anterior wall .PET-CT showed metabolically active
skeletal & bilateral lung lesions suggestive of metastases and non-avid RA lesion possibly angiosarcoma arising
from RA with pulmonary, skeletal & hemorrhagic brain metastases. Pulmonary metastasectomy by video assisted
thoracoscopic 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.The
patient 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.AMBERNATH
Dept of Pulmonary Medicine, Apollo Hospitals, Hyderabad, TS
Dept of CTVS, Apollo Hospitals, Hyderabad, TS
* Dept of Pathology, Apollo Hospitals, Hyderabad, TS
BACK GROUND
Low Grade Fibro Mixoid Sarcoma (LGFMS) is a rare neoplasm commonly affecting young adults and typically
arising in the somatic soft tissue of the proximal extremities. Its occurrence with in the thorasic cavity in the
anterior mediastinum is exceedingly rare.
CASE DETAILS
A 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 cardiac
border in the anterior mediastinum in the hilar and supra hilar region. CECT chest showed well defined round mass
lesion 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 did
not reveal any distant metastasis. Wide local excision of the mass lesion was done through median sternotomy and
sent for histology for definitive diagnosis and on HPE showed hyalinised tumor cells arranged in loosely cellular
mixoid 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 was
asymptomatic and leading a good quality of life for the last two months.
P57
A 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 and
young adults. It usually arises from the soft tissues of the trunk or the extremities,the most frequent sites of
occurrence are the chestwall, the para vertebral region and the lower extremities. EES is associated with reciprocal
translocation between chromosomes 11 and 22.

The case report:A 16years old male patient who presented to the ER with complaints of fever,right sided
hypochondriac pain,shortness of breath since 10days
Physical examination revealed tenderness at right hypochondriac region on palpation,dull note felt on percussion
on 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 right
costophrenic and cardiophrenic angle
Ultrasound suggestive of irregular heterogenously hyperechoic lesion measuring 4*5 cms noted in the right pleural
space 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 pleura
obscuring the daiphragm in its superior aspect and causing erosion of adjacent rib with moderate collection of
pleural 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 differential
Diagnosis of any patients but especially in adolescents or young adults, with a soft tissue mass of the trunk or the
extremities, 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 be
idiopathic (primary form) or associated with various inflammatory, hereditary, or neoplastic diseases (secondary
form). Pulmonary amyloidosis may be part of a widespread process that involves many organs, or it may be
localized to the airways and lung parenchyma.
Case scenario:
A 40 year old female presented with a two months history of progressive dyspnoea, productive cough, and
weight loss. She suffered from several episodes of respiratory infection in preceding months that improved after
antibiotic therapy. She had a past history of military tuberculosis treated well ten years ago. She was not a
hypertensive and diabetic.
Upon admission, physical examination showed an ill looking patient who was thin and pale. Her blood
pressure was 100/70 mmHg, her pulse 100 beats/min, respiratory rate was 26 breaths/min and pulse oxymetry
saturation was 94%.There was cervical lymphadenopathy. Chest auscultation revealed diffusely scattered crackles
and polyphonic rhonchi bilaterally. A physical examination of the heart and abdomen revealed no abnormal
findings. Routine blood investigation showed moderate anaemia and elvated serum creatinine (1.8mg%). She was
non-reactive for HIV, HBV and HBC. Her sputum for acid-fast bacilli and fungi was negative. A chest radiograph and
computed tomography (CT) on the thorax showed multiple calcified nodular opacities of varying sizes with
irregular 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 no
myocardial or valvular abnormalities. Bronchoscopy showed no abnormalities and bronchial washings disclosed
only chronic inflammatory changes. CT guided transthoracic core needle biopsy and excisional biopsy of cervical
lymph 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 stained
sections viewed under polarized light. This was further fortified by immunohistochemistry positive for serum
amyloid A protein.
Conclusion:
Secondary amyloidosis is a rare systemic complication of pulmonary Koch’s. Tuberculosis is still the most
common cause of secondary amyloidosis (AA form) followed by chronic suppurative lung diseases in developing
countries. Several cytokine like IL-1, IL-6 and TNF-α stimulate hepatic synthesis of serum amyloid A precursor
during tuberculosis inflammation. It should be considered in the differential diagnosis of calcified pulmonary
nodules due to malignancy, baritosis, alveolar lithiasis and granulomatous diseases.
P60
An Atypical Presentation of Pulmonary Embolism
M.M. MODI, R.K. JALAN
OBJECTIVES :
Pulmonary Embolism is the most common preventable cause of death in the world. Post-operative deep vein
thrombosis from the pelvic veins is the most common cause. Cardiac Atrial myxomas are an extremely rare cause
for pulmonary embolism. 75% of myxomas are located in left atrium. Right atrial myxomas are extremely rare. We
report a rare case of pulmonary embolism due to fragmentation of an atrial myxoma in an usual location in right
atrium. The main objective of reporting this case is to consider such diagnosis when all other common causes of
pulmonary embolism are ruled out as timely surgical resection is the treatment of choice to prevent fatal
consequences 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 - Exudative
pleural effusion. Patient was diagnosed as having syn-pneumonic effusion and started on antibiotics . After 21 days
of treatment repeat chest x- ray showed no reduction in pleural effusion and consolidation. Patient was referred to
us for further management. HRCT- Thorax with Pulmonary Angiography - Dense calcific plaque in right descending
artery. 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 a
freely floating mass in the right atrium with 2 attachments , one near anterior lip of coronary sinus and other just
above the opening of IVC into RA.
Mass was completely excised and sent for HPE - Stellate cells surrounded by abundant loose myxoid stroma with
areas 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 pulmonary
embolism.
P61
ABSTRACT
Successful Non- Surgical Management Of Acquired Benign Tracheo- Esophageal Fistula
A.M. KHOJA , R.K. JALAN, D.L. JAIN, K.A. PATIL, KSK GOUD, B. SIDDESH

INTRODUCTION :
Tracheo-esophageal fistula (TEF) are a rare entity which can either be congenital or acquired. Acquired TEF are
seen in adults and are most commonly due to malignancy. Benign TEF are rare and are most commonly attributed
to post intubation injuries. Till date,surgical correction for management of benign TEF has been most commonly
employed. Tracheal stenting with self expanding metallic stent (SEMS) has been mostly reserved for palliative
management of malignant TEF. Here, we report a case of benign TEF caused due to high tracheostomy cuff
pressure 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 in
the 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 the
tracheostomy site since 10 days. Examination and X- ray findings were suggestive of aspiration pneumonitis. He
was posted for bronchoscopy which showed a large trachea-esophageal fistula in the upper part of the trachea. As
the patient was unfit for surgical closure of the fistula due to poor neurologic status, he underwent tracheal
stenting 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
P62
A 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 unknown
etiology and familial association in which concretions composed of calcium and phosphorus collect in alveolar
spaces.
Case Report: A 42 year old male non smoker weaver presenting with 6 months history of fever,cough with mild
expectoration and dyspnea on exertion was diagnosed as miliary tuberculosis by a local physician for which he
was taking antitubercular treatment.His general physical examination was unremarkable with vitals being
normal.Respiratory system examination revealed bilateral fine inspiratory crackles in axillary area.His laboratory
parameters and Pulmonary function test were normal and sputum was negative for acid fast bacilli.Chest X-ray
shows bilateral diffuse micronodular shadows (sand-storm pattern) predominant in middle and lower
zones.Presence of diffuse calcified micronodular opacities with lower lobe and subpleural predominance and
septal thickening on high resolution computed tomography of chest confirmed the diagnosis of Pulmonary
alveolar microlithiasis.
Conclusion: Pulmonary alveolar microlithiasis being a rare disease with unknown etiology has burdened the
patient with unnecessary doses of anti-tubercular treatment because of its resemblance to miliary tuberculosis
on chest X-ray.Patients due to delayed diagnosis ultimately progress to end stage lung disease necessitating lung
transplantation. 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 of
Kartagener Syndrome
Methods: A 20 year old female came to the Pulmonology O.P. with a complaint of cough with mucoid
expectoration , breathlessness and common cold like symptoms since 3 months. Patient claimed to have had a
history 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 randomly
in half the patients with primary ciliary dyskinesia; therefore, for every patient with Kartagener syndrome, another
patient 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.
P64
A rare cause for stridor in an elderly male
Dr.Madhusudhan.Y, Dr Vishnu Sharma.M, Basavaraj.S.
A.J.Institute of Medical Science, NH-66 , Kuntikana, Mangalore ,Karnataka- India 575004 madhu4788@gmail.com
INTRODUCTION:
Stridor is most often due to upper airway obstruction. Any intra thoracic lesion leading to tracheal obstruction can be a
rare cause for stridor.
CASE REPORT
An 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. Respiratory
system 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 from
posterior aspect narrowing the tracheal lumen. Upper GI scopy showed a fleshy growth in the upper end of esophagus
and 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 almost
completely which lead to stridor.
CONCLUSION:
Consider and evaluate for intra thoracic causes for stridor when ENT evaluation is normal. Carcinoma in the upper end
of esophagus can invade the trachea and can lead to stridor.
P65
A rare presentation of spontaneous acquired diaphragmatic hernia – case report.
B.Bhushan, N.C.Kajal, A.Gupta, S.Gupta
TB and Chest Department, Government Medical College, Amritsar
Background
Diaphragmatic hernias represent a weakness that can evolve into a localized defect, allowing abdominal structures
to protrude. Spontaneous diaphragmatic rupture is one of the rarest thoracoabdominal emergencies, and is harder
to detect in patients without visceral damage. A sceptical approach is key to the diagnosis of this condition.
Case Report

Napcon 2014 presentation abstract

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Napcon 2014 presentation abstract