Background: Systemic sclerosis (SSc) is a rare connective tissue disorder of unknown aetiology. Pulmonary involvement contributes substantially to its morbidity and mortality. Treatment of pulmonary disease due to SSc remains unsatisfactory. We examined the effect of sequential six-month intravenous pulse therapy with cyclophosphamide (CYC) followed by azathioprine and low-dose corticosteroids on SSc associated interstitial lung disease (SSc-ILD). Methods: In a single-centre, prospective, observational, open-labelled study; nine patients (eight females, one male) with SSc-ILD were treated with intravenous pulse CYC (600mg/m2 body surface area) at monthly interval for six cycles with oral prednisolone 10mg daily. Subsequently, azathioprine (2-3mg/Kg) was administered while continuing with the same dose of prednisolone. Primary end-points were forced vital capacity (FVC) and high resolution computed tomography (HRCT) scan of thorax score. Secondary end-points were quality of life measured by health assessment questionnairedisability index (HAQ-DI) and six-minute walk distance (6WMD) test. Results: After one year of observation, the FVC showed significant improvement (p=0.003). The 6WMD also improved significantly (p=0.0028). However, change in HRCT scan scoring and HAQ-DI score was not significant. Conclusions: Intravenous, pulse CYC followed by azathioprine along with low-dose corticosteroids produces significant improvement in FVC and 6WMD at 12-month follow-up without significant change in radiological manifestations and health status.

Background: Human immunodeficiency virus (HIV) and tuberculosis (TB) epidemics continue to fuel each other and with dual infections with these two deadly diseases on the rise, it becomes imperative to devise effective HIV-TB collaborative strategies. The present study was designed to evaluate the existing HIV-TB cross-referral mechanism at an urban health centre; to determine HIV sero-prevalence among pulmonary TB patients referred from chest clinic to the integrated counselling and testing centre (ICTC); and to evaluate the TB suspects referred from ICTC to the chest clinic for a possible TB aetiology. Methods: The present study was a retrospective analysis of HIV-TB cross-referrals whereby a line list of all the patients referred under this strategy from January 2006 to December 2013 was retrieved and analysed. Results: A total of 3726 TB cases were referred to the ICTC and 641 TB suspects were identified by ICTC counsellors and referred to the chest clinic during this period. HIV sero-prevalence among TB patients was 2.8% (106 of 3726) and TB prevalence among HIV sero-positive and sero-negative TB suspects was 9.3% (10/108) and 4.3% (9/211), respectively (p=0.07). HIV prevalence was found to be significantly higher among male (n=2024) than among female (n=1702) TB patients (4.4% versus 0.9%; p<0.0001). Only 319 of 641 (49.8%) ICTC patients referred to the chest clinic reached there. Conclusion: Our study highlights the strong need to scale up the integration and partnership between HIV and TB programmes for better and integrated diagnosis and care of HIV-TB co-infected patients.

Background: Pleural fluid loculations due to complicated parapneumonic effusion (CPE), empyema, tubercular effusion and traumatic hemothorax can be managed either by video-assisted thoracoscopic surgery (VATS) or intrapleural fibrinolytic therapy (IPFT). The former is more invasive, not easily available and is also more expensive. On the other hand, IPFT is less invasive, cheaper, easily accessible and if used early, in loculated pleural collections, break loculations and early pleural peel, thereby facilitating pleural space drainage. Objective: To study the efficacy of IPFT in facilitating pleural space drainage in loculated pleural collections of diverse aetiologies. Methods: A five-year retrospective, observational study of 200 patients, with loculated pleural collections and failed tube drainage and managed with IPFT was carried out. Responders were defined as those with significant volume of fluid drained and significant radiological resolution. Results: There were 106 (53%) cases of CPE, 59 (29.5%) cases of tubercular effusion, 23 (11.5%) cases of empyema and 12 (6%) cases of hemothorax. Responders were 148 (74%) in number. The distribution of responders as per type of loculated pleural collection was as follows: CPE 88 (83%), tubercular 37 (62.7%), empyema 14 (60.8%) and traumatic hemothorax 11 (91.6%). The adverse effects were mild and included chest pain in six patients and low-grade transient fewer in three cases. Conclusions: Intrapleural fibrinolytic therapy is a safe and cost-effective option in the management of selected patients with loculated pleural effusions.

Ever since the invention of the flexible bronchoscope, perhaps no other innovation in the field of interventional pulmonology has caused so much excitement the world over, as the convex probe endobronchial ultrasound (EBUS)-guided transbronchial needle aspiration (TBNA). While it took over a decade from 1992 to 2004 for the radial EBUS to evolve into the commercial convex probe EBUS scope, another exciting decade has gone by with the technology being thoroughly researched and appraised. The current evidence suggests that EBUS-TBNA can replace mediastinoscopy as the first investigation in the mediastinal staging of lung cancer. The use of EBUS-TBNA has been extended to several other areas including the diagnosis of undefined mediastinal lymphadenopathy, evaluation of intra-parenchymal lesions and others. In fact, EBUS-TBNA is the preferred modality for accessing mediastinal lesions in contact with the airways. The procedure not only has a high diagnostic efficiency (80%-90% for most indications) but is also safe compared to alternative options, such as image-guided fine needle aspiration and mediastinoscopy in the diagnosis of mediastinal lymphadenopathy. Apart from the traditional use of EBUS to perform TBNA, the last decade has seen the evolution of its transoesophageal use, development of novel EBUS-TBNA needles to obtain better histological specimens and a smaller EBUS scope. This review summarises the developments made in this field over the years since its inception.

We describe five cases of pulmonary alveolar microlithiasis (PAM) from North India with characteristic radiological and histopathological features. All patients were symptomatic with variable severity and duration of the symptoms and one patient developed cor-pulmonale during the course of follow-up. Diagnosis of PAM was suspected on the basis of classical sand-storm appearance on radiological examination and confirmed by transbronchial lung biopsy in four of the five cases. Apart from other features, presence of pleural and pericardial calcification in one case makes this discussion valuable. Awareness of this specific entity among the clinicians is essential to avoid unnecessary investigations.

Maintaining the high oxygen demands and bronchial hygiene of critically ill patients with advanced respiratory failure is often difficult. We describe three such cases with advanced respiratory failure where a modification of conventional transtracheal oxygenation was used successfully. This method provided the added advantage of being more cost-effective and helping in easy bronchial toileting.

Burkitt's lymphoma is a sub-group of non-Hodgkin's lymphoma of high-grade with an aggressive clinical course and is composed of diffuse, small and non-cleaved, undifferentiated malignant cells of lymphoid origin. Dennis Burkitt first described this entity in 1956 in equatorial Africa. It is one of the fastest growing cancers in humans with a growth fraction close to 100%. It commonly occurs in children and young adults, with frequent involvement of bone marrow and central nervous system. These are considered to be medical emergencies and require immediate diagnostic and therapeutic intervention. In this report, we present a case of Burkitt's lymphoma with unusual presentation with the involvement of both thorax and the whole of the abdomen.

Congenital cystic adenomatoid malformation (CCAM) occurs secondary to the cystic adenomatous over-growth of terminal bronchioles, which results in the secondary inhibition of alveolar growth. In most of the cases, respiratory distress is the presenting feature during the neonatal period. In about 90% of patients, recurrent respiratory infections necessitating chest imaging reveal CCAM before the age of two years. We describe here the occurrence of congenital cystic adenomatoid malformation of right lung in a 12-year-old girl presenting with haemoptysis and hypovolaemic shock. She underwent right middle lobectomy; and histopathological examination confirmed the diagnosis. She has been doing well on follow-up.

A 60-year-old female who was known to have rheumatoid arthritis for the preceding two-and-half years presented with difficulty in breathing associated with chest pain over the right hemithorax of two months duration. She was found to have a right-sided mild to moderate pleural effusion; there was no evidence of pleural thickening. The pleural fluid was pale yellow in appearance and diagnostic work-up confirmed it to be a pseudochylous pleural effusion. The present case highlights the rare occurrence of pseudochylothorax without pleural thickening as a complication of rheumatoid arthritis.

Primary tuberculosis of components of the chest wall is a rare entity. Involvement of skeletal muscle by tuberculosis without any primary focus is also rare. Here, we report a case of tuberculosis of chest wall without pulmonary or bone involvement, that invaded into the pleural space leading to a massive pleural effusion.