"Mushroom cloud": a giant left ventricular pseudoaneurysm after a myocardial infarction due to myocardial bridging – a case report

Left ventricular pseudoaneurysm is an uncommon complication after transmural myocardial infarction, occurring when a free wall rupture is contained by adhesions of the overlying pericardium preventing acute tamponade. In this report, an unusual case of a 61 year-old male with a giant apical left ventricular pseudoaneurysm after an unnoticed myocardial infarction is presented. On coronary angiogram myocardial bridging of the distal left anterior descending artery was judged to be the infarct related lesion. The echocardiographic diagnosis allowed for a timely surgical intervention which resulted in the patient's full recovery

Paradoxical tuberculosis immune reconstitution inflammatory syndrome (TB-IRIS) in HIV patients with culture confirmed pulmonary tuberculosis in India and the potential role of IL-6 in prediction

Background: The incidence, manifestations, outcome and clinical predictors of paradoxical TB-IRIS in patients with HIV and culture confirmed pulmonary tuberculosis (PTB) in India have not been studied prospectively. Methods: HIV+ patients with culture confirmed PTB started on anti-tuberculosis therapy (ATT) were followed prospectively after anti-retroviral therapy (ART) initiation. Established criteria for IRIS diagnosis were used including decline in plasma HIV RNA at IRIS event. Pre-ART plasma levels of interleukin (IL)-6 and C-reactive protein (CRP) were measured. Univariate and multivariate logistic regression models were used to evaluate associations between baseline variables and IRIS. Results: Of 57 patients enrolled, 48 had complete follow up data. Median ATT-ART interval was 28 days (interquartile range, IQR 14–47). IRIS events occurred in 26 patients (54.2%) at a median of 11 days (IQR: 7–16) after ART initiation. Corticosteroids were required for treatment of most IRIS events that resolved within a median of 13 days (IQR: 9–23). Two patients died due to CNS TB-IRIS. Lower CD4+ T-cell counts, higher plasma HIV RNA levels, lower CD4/CD8 ratio, lower hemoglobin, shorter ATT to ART interval, extra-pulmonary or miliary TB and higher plasma IL-6 and CRP levels at baseline were associated with paradoxical TB-IRIS in the univariate analysis. Shorter ATT to ART interval, lower hemoglobin and higher IL-6 and CRP levels remained significant in the multivariate analysis. Conclusion: Paradoxical TB–IRIS frequently complicates HIV-TB therapy in India. IL-6 and CRP may assist in predicting IRIS events and serve as potential targets for immune interventions

Oral abstracts of the 21st International AIDS Conference 18-22 July 2016, Durban, South Africa

The rate at which HIV-1 infected individuals progress to AIDS is highly variable and impacted by T cell immunity. CD8 T cell inhibitory molecules are up-regulated in HIV-1 infection and associate with immune dysfunction. We evaluated participants (n=122) recruited to the SPARTAC randomised clinical trial to determine whether CD8 T cell exhaustion markers PD-1, Lag-3 and Tim-3 were associated with immune activation and disease progression.Expression of PD-1, Tim-3, Lag-3 and CD38 on CD8 T cells from the closest pre-therapy time-point to seroconversion was measured by flow cytometry, and correlated with surrogate markers of HIV-1 disease (HIV-1 plasma viral load (pVL) and CD4 T cell count) and the trial endpoint (time to CD4 count <350 cells/μl or initiation of antiretroviral therapy). To explore the functional significance of these markers, co-expression of Eomes, T-bet and CD39 was assessed.Expression of PD-1 on CD8 and CD38 CD8 T cells correlated with pVL and CD4 count at baseline, and predicted time to the trial endpoint. Lag-3 expression was associated with pVL but not CD4 count. For all exhaustion markers, expression of CD38 on CD8 T cells increased the strength of associations. In Cox models, progression to the trial endpoint was most marked for PD-1/CD38 co-expressing cells, with evidence for a stronger effect within 12 weeks from confirmed diagnosis of PHI. The effect of PD-1 and Lag-3 expression on CD8 T cells retained statistical significance in Cox proportional hazards models including antiretroviral therapy and CD4 count, but not pVL as co-variants.Expression of ‘exhaustion’ or ‘immune checkpoint’ markers in early HIV-1 infection is associated with clinical progression and is impacted by immune activation and the duration of infection. New markers to identify exhausted T cells and novel interventions to reverse exhaustion may inform the development of novel immunotherapeutic approaches

Early Onset Chyliform Pleural Effusion-A Rare Case

Chyliform pleural effusion is turbid or milky from high lipid content without cholesterol crystals. Chyliform pleural effusion is a rare presentation than chylous or pseudochylous pleural effusion. The mean duration of the effusion to turn chyliform is 5 years. A 20 year old male presented with dry cough, left side chest pain and dyspnea on exertion and gives history of bilateral pleural effusion for which he had taken empirical antituberculous treatment. Chest radiograph showed bilateral pleural effusion more on left side. Thoracentesis done on left side revealed milky white coloured fluid with elevated cholesterol levels and Mycobacterium tuberculosis was detected and was not resistant to Rifampicin in cartridge based nucleic acid amplification test[CBNAAT] for pleural fluid. Contrast enhanced CT chest showed healed fibrotic lesion in bilateral upper lobe with bilateral pleural effusion with thickened pleura on left side. Patient diagnosed as chyliform effusion and treated with Intercostal drainage and antituberculous treatment. Less than 200 cases of chyliform have been reported in the medical literature of which microbiologically confirmed tuberculous chyliform effusion is rarely reported. Chyliform effusion rarely develops within one year and Tuberculosis presenting as Chyliform pleural effusion is a rare phenomenon

A Rare Case of Dapsone Induced Eosinophilic Pneumonia without Peripheral Eosinophilia

Eosinophilic lung diseases are a diverse group of pulmonary disorders which may result from different etiologies, including drug treatment. Dapsone, a sulfone drug useful for treating wide variety of infectious and inflammatory dermatological conditions including leprosy, has been described as a possible cause of eosinophilic lung diseases. We report a 40 year old female patient with leprosy who presented with respiratory symptoms and pulmonary infiltrates and was diagnosed as suffering from eosinophilic pneumonia which was managed successfully

Recurrent tuberculosis due to subtherapeutic levels of antitubercular treatment

Most patients with tuberculosis respond well to treatment. Even in patients with good compliance to DOTS and sensitive to first-line drugs, treatment failure or relapse still occurs, the phenomenon of cryptic adherence needs careful evaluation. We present a case of frequent recurrence due to possible subtherapeutic levels of isoniazid (INH) and rifampicin. A 32-year-old male with no other comorbidities came with complaints of cough with expectoration with constitutional symptoms. He was treated for the primary complex at the age of 12 years and declared as cured. In 2006, he was diagnosed as right axillary TB lymphadenitis which was confirmed by histopathological examination and treated with Anti tubercular treatment (ATT) for 9 months. After 2 years (2008), he had developed left axillary lymphadenitis for which he was treated again with Anti tubercular treatment empirically. In 2016, he was diagnosed as smear-negative pulmonary tuberculosis (PTB) whose chest X-ray suggestive of PTB. Hence, he was treated with Anti tubercular treatment for 6 months, declared as cured. Now (2018), he was diagnosed as sputum-positive PTB with INH and rifampicin sensitive. Hence, we did a pharmacokinetics study, which revealed subtherapeutic levels of rifampicin and isoniazid. The patient responded well after increasing the dosage of drugs. Slow responders and patients with complications warrant the need of therapeutic drug monitoring (TDM). Drug concentrations which may be help resolve the problem of slow response to Anti Tuberculosis Therapy. TDM however is not routinely indicated in each case

Single Coronary Artery from the Left Sinus with Atherosclerosis

We report a rare case of a single coronary artery originating from the left sinus of Valsalva with extensive atherosclerosis in a patient presenting with unstable angina. The distal circumflex artery continued the course of the right coronary artery. </jats:p

Price of Passion - Pigeon Breeder’s Disease in a Young Male

Hypersensitivity pneumonitis (HP), also called extrinsic allergic alveolitis, is a complex syndrome of varying intensity, clinical presentation, and natural history rather than a single, uniform disease. It represents an immunologic reaction to an inhaled agent, particularly an organic antigen, occurring within the pulmonary parenchyma. Prompt diagnosis of HP is important, as the disease is reversible when diagnosed early in its course. Here we present a case of a 26 year old male, whose hobby/passion was the reason of his lung condition. He was breeding pigeons for racing and had won many titles in it. He presented to us with symptoms of breathlessness, dry cough for 4 months and Velcro crackles on auscultation. Computed tomography of his chest showed ground glass nodules. Bronchoalveolar lavage recovered lymphocytes. When removed from his home environment he had improvement in his symptoms. He was diagnosed with bird breeder’s disease and treated. We have reviewed the diagnosis, management, outcome and prevention of bird breeder’s disease