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   Table of Contents - Current issue
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April-June 2017
Volume 11 | Issue 2
Page Nos. 74-171

Online since Tuesday, April 25, 2017

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INTERVENTIONAL PULMONOLOGY: ORIGINAL ARTICLES  

Electrocautery and cryotherapy in inoperable malignant lung lesions p. 74
Reham M Elkolaly, Emad El-Dine A Korraa, Ibrahim S-E Ibrahim
DOI:10.4103/ejb.ejb_23_16  
Background Malignant lung lesions have symptoms that differ according to the lesion site, rate of growth, and diagnosis time. Many palliative modalities have been tried to mange patients’ complaints and improve their quality of life. Bronchoscopic electrocautery and cryotherapy are two different techniques that are used in this field. Objective The aim of the paper was to assess the role of cryotherapy and electrocautery as a palliative treatment for inoperable malignant endobronchial lesions. Patients and methods A total of 30 patients with inoperable malignant lung lesions were randomized into two groups, 15 patients in each. Group A was subjected to bronchoscopic cryotherapy and group B was subjected to bronchoscopic electrocautery. Dyspnea, cough, hemoptysis, spirometric indices, chest radiography, fiberoptic bronchoscopy, and airway patency were recorded before, 1 week after, and 3 weeks after the last session of each procedure. Results In group A, symptoms and chest radiography showed improvement in 26–40% to a little extent after 1 week, but showed significant improvement after 3 weeks in 67–80%. In group B, symptoms and chest radiography showed improvement after 1 week in 46–73% and then improvement increased to a lesser degree after 3 weeks in 67–87%. In group A, after 3 weeks, airway reopening was complete in 53.33%, partial in 20%, and no success in 26.67%, whereas in group B, complete success was in 66.67%, partial success was in 20%, and failure was 13.33% (two cases). In group A, 10 (66.67%) patients required 1–4 sessions whereas in group B, only four (26.67%) patients required second session. Complications were few (hemoptysis, arrhythmia, hypoxemia, and bronchospasm), with a higher rate in group B. Conclusion Electrocautery and cryotherapy are two different maneuvers for palliative management of endobronchial lesions but with nearly equal outcome on long term. Cryotherapy is safe but requires prolonged time and more than one session are usually required to get satisfactory response, whereas electrocautery is rapid and effective but with few complications.
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Comparative study between bronchoalveolar lavage and induced sputum in the diagnosis of inflammatory lung diseases p. 81
Mohammad S Soliman Atta, Ayman I Baess, Mai H Mohammad Abdullah
DOI:10.4103/ejb.ejb_78_16  
Background Airway sampling is implicated in the workup of inflammatory lung diseases. Objective The aim of this study was to compare between induced sputum (IS) and bronchoalveolar lavage (BAL) in the diagnosis of inflammatory (including infectious) lung diseases regarding safety, cell composition (total and differential), microbiology workup, and cytology. Patients and methods This was a prospective comparative study that was carried out between February 2015 and February 2016. We enrolled 30 patients with inflammatory (including infiltrative and infectious) lung diseases whom presented to the Chest Department of Alexandria Main University Hospital. IS was performed in all included patients by inhalation of hypertonic saline (3%), using an ultrasonic nebulizer. In the same cohort, BAL was performed using flexible bronchoscopy within 1 week of IS. Samples from both techniques were sent for cytological (total and differential cell counts), microbiological, and cytopathological workup. Results The study sample included 26 (86.7%) female and 4 (13.3%) male patients. Their mean age was 43.57±16.30 years. BAL samples were more voluminous than IS samples (52.83±18.69 and 15.33±5.03 ml, respectively; P<0.001). Total cell counts were significantly higher in IS than in BAL (292.5 and 105.5 cell/cm2, respectively; P<0.001). No statistically significant differences were noted between both groups regarding the differential cell counts, culture results, or cytology. Complications in the form of hemorrhage occurred in two (6.67%) patients during BAL. No complications were recorded in the IS group. Conclusion IS is comparable to BAL. Although BAL is more voluminous, the total cell count in IS is higher. No differences were noted between both techniques regarding differential cell count, culture, and cytology results. IS is safe and can replace BAL in the workup of inflammatory, including infiltrative and infectious, lung diseases.
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PULMONARY INFECTIONS - ORIGINAL ARTICLE Top

Assessment of directly observed therapy short-course (DOTs) of tuberculosis in Dakahlia governorate chest hospitals from 2006 to 2011 p. 88
Medhat F Negm, Amira H Allam, Fatehia S El Zeheiry
DOI:10.4103/ejb.ejb_55_16  
Aim The aim of the study was to assess directly observed therapy short-course administered to diagnosed cases of tuberculosis (TB) in the period from 2006 to 2011 in Dakahlia chest hospitals as a tool for the treatment and control of TB in the community. Materials and methods Comprehensive collection of data was carried out of all TB cases registered in the Dakahlia governorate (six hospitals) from 2006 to 2011. Results TB was most commonly prevalent in the age group 15–29 years (32.3%). TB was common in male (65.6%) than female (34.4%), and common in rural areas (90%); in urban areas, the prevalence was 10%. Pulmonary cases (66.9%) were more prevalent than extrapulmonary cases (33.1%). There was a significant reduction in pulmonary cases from 69.2% in 2006 to 56.5% in 2011 and there was a significant increase in extrapulmonary cases from 30.8% in 2006 to 43.5% in 2011. The most common site of TB was sputum smear-positive pulmonary TB (74.2%) and sputum smear-negative pulmonary TB (25.8%). The most common site of extrapulmonary TB was pleural TB (50.9%) and tuberculous lymphadenitis (19.6%). New cases (88.8%) represented the highest percentage of all cases attending for treatment. Sputum conversion was 53, 51.5, and 75.9% at 2, 5 months, and at the end of treatment, respectively. In all, 84.8% of cases were treated successfully (23.1% cured cases and 61.7% cases that completed treatment; almost achieving the WHO target of 85%). In all, 5.1% of cases failed treatment, 5.1% died, 2.4% were defaulters, and 2.6% of cases were transferred out. Conclusion The introduction of directly observed therapy short-course in Dakahlia governorate chest hospitals has led to a significant increase in treatment success (84.8%) and a decrease in default and failure rates.
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AIRWAY DISEASES - ORIGINAL ARTICLES Top

Audiological assessment in patients with chronic obstructive pulmonary disease p. 98
Aya M Abdel Dayem, Iman H Galal, Fathy Naeem, Maha A Hassan
DOI:10.4103/ejb.ejb_1_17  
Background Chronic obstructive pulmonary disease (COPD), as a multisystemic disease, might have an impact on the auditory function. Thus, this study was designed for the audiological assessment of COPD patients to investigate the effect of smoking, and to further assess its possible correlation with the severity of COPD. Patients and methods This prospective case–control study was conducted on 100 male patients with COPD with a mean age of 52.66±6.84 years. In addition, 25 healthy nonsmoker male participants with a mean age of 45.5±6.75 years were enrolled as the control group. For all COPD patients and controls, tympanometry and pure-tone audiometry at frequencies 250–8000 Hz were performed by an experienced audiologist. Results Tympanometry type C was observed in the right ear of 30 COPD patients and in the left ear of 28 COPD patients. All low and high frequency tone audiometry differed significantly between COPD patients and controls (P<0.001), and the cutoff for changes in auditory function was 15 dB at both low and high frequency tones with 96% sensitivity and 100% specificity. Audiometry and tympanometry in COPD patients were not affected by either the smoking status or the type of smoking (P>0.05). Both low and high frequency tone audiometry correlated significantly and inversely with partial pressure of oxygen and forced expiratory volume in the first second, whereas the annual COPD exacerbations correlated significantly and directly. Conclusion Changes in auditory function but not hearing loss is common in COPD and such audiological changes were not affected by smoking but correlates with the degree of airway obstruction and hypoxia as well as the rate of annual COPD exacerbation.
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Updates in computed tomography assessment of emphysema using computed tomography lung analysis p. 104
Yasser M Mohamed, Nehad M Osman, Ahmed M Osman
DOI:10.4103/ejb.ejb_67_16  
Introduction Computed tomography (CT) lung analysis is a new CT technique that allows assessment of emphysema in a quantitative pattern to avoid subjective analysis. Objective The aim of this study was to assess the role of a new CT lung analysis in quantitative assessment of pulmonary emphysema. Patients and methods Totally, 30 patients with emphysema were included in this study who presented to the Chest Department of Ain Shams University for follow-up. All patients underwent full history taking, clinical examination, spirometry, and body plethysmography, and were then referred to the Radiology Department for noncontrast chest CT followed by lung volume analysis. Four patients among them were followed-up before and after medical volume reduction therapy. Results There was a direct relationship between the CT lung volume, the percentage of low-attenuation area, as well as the total lung capacity measured by body plethysmography. Totally, 12 cases were found to be grade I by the Goddard score, with nine of them found to be GOLD I and three of them found to be GOLD II. Fifteen cases were found to be grade II by the Goddard score, with 12 of them found to be GOLD II and three of them found to be GOLD III/IV. Three cases were found to be grade III by the Goddard score with all of them found to be GOLD III/IV. The main site for distribution of the clusters according to their number was in the left upper lobe, whereas according to the cluster volume the main site was the right upper lobe. CT lung analysis guided the site of injection in four patients who underwent volume reduction therapy. Conclusion CT lung analysis is a new technique that allows quantitative assessment of emphysema, which is important for categorization, follow-up, and treatment strategies. It must be added as a routine study accompanied by spirometric function.
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Assessment of reduced mineral bone density in COPD p. 111
Mona S El-Hoshy, Enas El-Sayed, Dalia A Moaty El-Neely
DOI:10.4103/1687-8426.203803  
Background Chronic obstructive pulmonary disease (COPD) is responsible for reduced bone mineral density (BMD). Aim The aim of this study was to explore and assess the association of low BMD with systemic inflammation in patients with COPD. Patients and methods A total of 10 healthy normal control individuals and 30 patients with clinically stable COPD (Global Initiative for Chronic Obstructive Lung Disease stages I–III) were included in the study and divided into four groups. All patients underwent chest radiography; computed tomographic scan of the chest; spirometry; dual-energy X-ray absorptiometry for measurement of BMD of the lumbar (L) spines, forearm, and femur; and blood sampling for measurement of C-reactive protein (CRP) and total and ionized serum calcium. Statistical analysis Descriptive data are expressed as mean±SD. Pearson’s correlation analysis was used for drawing correlations. Results Osteoporosis in the spine was detected in 20% of both mild and moderate COPD cases and 100% of severe COPD cases, with statistical significant difference between patients with severe COPD and control group (P=0.027). Osteoporosis in the femur bone was shown in 30, 50, and 90% of mild, moderate, and severe COPD cases, respectively, whereas 20% of moderate and 30% of severe COPD cases had osteoporosis in the forearm. T-scores of BMD were different among the four studied groups (P=0.0001). BMD correlated positively with BMI and forced expiratory volume at timed interval 1 s (%) predicted. CRP values differed significantly between the four studied groups (P=0.0001). CRP correlated negatively with forced expiratory volume at timed interval 1 s (%) predicted and BMD. Conclusion CRP is seen in high levels with low BMD in severe COPD, indicating the association of low BMD with systemic inflammation in COPD.
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PLEURAL DISEASES - ORIGINAL ARTICLE Top

Role of ultrasonography in the diagnosis of pleural effusion p. 120
Entsar S Ahmed, Samiha M Abou Bakr, Hoda A Eid, Ahmed T Shaarawy, Wafaa T Elsayed
DOI:10.4103/1687-8426.203797  
Background Transthoracic ultrasonography (TUS) represents a useful diagnostic tool in the management of pleural diseases. It is the best method for guiding interventional procedures in the pleural space. Objectives The aim of this study was to detect the role of ultrasonography (US) in the diagnosis and management of pleural effusion in comparison with computed tomography (CT). Patients and methods Patients with suspected clinical and radiological evidence of pleural effusion were included. Routine laboratory investigations, chest radiography, CT of the chest, TUS, and thoracentesis with biochemical, bacteriological, and cytological examination of pleural fluid were carried out for all patients, and medical thoracoscopy and US-assisted interventions were carried out whenever needed. Results Eighty-four patients were included in the study. Male patients represented 56% (47 cases), whereas female patients constituted 44% (37 cases); their mean age was 51.21±14.1 years (range: 14–80 years). Seventy-three (86.9%) cases had exudative effusions; inflammatory causes (n=33) and malignancy (n=31) were the most common. TUS was equal to CT in the detection of pleural effusion, pleural thickening, hydropneumothorax, pleural nodule, and consolidation. Moreover, US was better than chest radiography in the detection of pleural thickening, encysted pleural effusion, pleural mass, and consolidation. US was better than CT in the detection of septations (n=30 vs. 5). However, CT was better than US in the detection of loculation (n=28 vs. 17) and pulmonary mass (n=8 vs. 4). Thorcoscopy was performed for nine patients, and was better than US and CT in the detection of pleural nodules. Conclusion TUS is an efficient, quick, inexpensive, radiation-free method for the evaluation of pleural diseases.
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CRITICAL CARE: ORIGINAL ARTICLE Top

Blood lactate level as a predictor of patients’ outcome at the Respiratory Intensive Care Unit of Zagazig University Hospitals p. 128
Rabie Mohamed Hussein, Hanan Mohamed El-Shahat, Waleed Mansour, Moamen Nabil Nada
DOI:10.4103/ejb.ejb_64_16  
Background Many variables measured in critically ill patients have been used to predict patient outcomes; however, it is unlikely that one measurement can replace all, but lactate levels may come close. Aim This study aims to evaluate the role of blood lactate level as a predictor of patients’ outcome at Respiratory Intensive Care Unit at Zagazig University Hospitals (RICU-ZUH). Patients and methods A prospective cohort study was conducted on 52 patients recruited from RICU-ZUH. All patients’ functional conditions were assessed on admission by the Simplified Acute Physiology Score II scoring system, Glasgow Coma Scale (GCS), and Sequential Organ Failure Assessment scores as well as assessment of sepsis. The blood lactic acid level was measured at H0 (initial blood lactate level), H6, H12, H24, and H48 (in mmol/l). Patients were classified into two groups: (i) normal blood lactate level group, and (ii) hyperlactatemia group. Lactate clearance and lactime were also measured. Results Out of the 52 cases studied, hyperlactatemia was present in 30 (57.6%) patients, whereas a normal blood lactate level was found in 22 (42.4%) patients. H0 was significantly high (P<0.01) in the hyperlactatemia group (4.41±1.69 mmol/l), with lactime 42.4±10.5 h; also, lactate clearance at H6 was nonsignificantly high (P>0.05). The Simplified Acute Physiology Score II and Sequential Organ Failure Assessment scores were significantly positively correlated with H0 and lactime, but significantly negatively correlated with lactate clearance, whereas GCS was negatively correlated in a significant way with H0 and lactime and positively correlated with lactate clearance. The significant highest mortality risk of 2.86 was reported with lactime more than 48 h, followed by a 2.28 risk of mortality with H0 blood lactate level more than 3.9 mmol/l, and the least risk was reported with GCS less than 10.5. Conclusion Hyperlactatemia at admission and a prolonged lactime are valuable independent predictors of mortality of RICU patients.
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INTERSTITIAL LUNG DISEASES - ORIGINAL ARTICLES Top

Outcome of patients with interstitial lung diseases admitted to the Respiratory Intensive Care Unit p. 134
Nehad M Osman, Samar H Sharkawy, Ashraf A Gomaa
DOI:10.4103/ejb.ejb_92_16  
Introduction Clinicians may face unique challenges while managing critically ill patients with interstitial lung diseases (ILD) admitted to respiratory intensive care units (RICUs). Objectives The aim of the present study was to determine the outcome of ILD patients admitted to RICU as regards mortality rate and risk factors associated with mortality. Patients and methods Ninety-one patients with ILD admitted to RICU were prospectively recruited. We analyzed demographic data, pulmonary function test results, arterial blood gas values, therapeutic strategies, mechanical ventilation (MV) use, RICU and hospital duration, and mortality rates. Results The RICU morality rate was 9.9%. Presence of hemophilia, renal impairment, low-diffusion lung capacity for carbon monoxide, and low arterial oxygen saturation were significantly more frequent among nonsurvivor compared with survivor patients. All nonsurvivor patients had pulmonary hypertension compared with 69% of the survivors, but without a significant difference. Fifteen percent of our patients received invasive MV. There were no significant differences between nonsurvivors and survivors as regards need for MV and duration of MV. Whereas patients with a positive history of previous MV had a significant survival time that was less than those with a negative history of previous MV. The duration of hospital and RICU stay were significantly longer in the survivors group compared with the nonsurvivors group (12.65±9.06 vs. 5.55±4.12 and 10.51±7.51 vs. 4.88±2.31, respectively). Conclusion Our study population showed very low RICU morality rate when compared with previous studies. Nonsurvivors had a shorter hospital and RICU stay, positive history of previous MV, lower diffusion lung capacity for carbon monoxide, and lower arterial oxygen saturation.
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Evaluation of the questionnaires’ validity in assessing the severity of idiopathic pulmonary fibrosis in correlation with high-resolution computed tomography, lung diffusion, and cardiopulmonary exercise tests p. 141
Taher El Naggar, Adel M Said, Samar H Sharkawy, Riham H Raafat
DOI:10.4103/1687-8426.203798  
Introduction Health-related quality-of-life questionnaires need to be incorporated into the evaluations of idiopathic pulmonary fibrosis (IPF) patients to assess their influence. Aim The aim of the study was to evaluate the validity of generic and specific questionnaires in assessing the severity of IPF in correlation with high-resolution computed tomography (HRCT), diffusion lung capacity for carbon monoxide (DLCO), and cardiopulmonary exercise testing (CPET). Patients and methods Forty stable IPF patients were prospectively recruited and categorized on the basis of spirometry, DLCO, HRCT, and CPET. The results were correlated with a generic International Physical Activity Questionnaire (IPAQ) and a Specific Saint George Respiratory Questionnaire (SGRQ). Results IPF patients showed restrictive pattern with impairment of diffusion capacity (forced vital capacity (FVC)=56±14.8% and DLCO=48.5±20% of predicted value) with a total semiquantitative scoring of HRCT 16.6±8. The mean total score of the SGRQ questionnaire for all studied cases was 56.5+21 and categorical scoring of IPAQ showed that 45, 42.5, and 12.5% of patients were in moderate, severe, and mild categories, respectively. There was a negative correlation between the total score of SGRQ and VO2max (ml/kg/min) (maximum oxygen consumption) (r=−0.35) and VE’ (l/min) (minute ventilation) (r=−0.39) on CPET, as well as with DLCO (r=−0.53), and a positive correlation with HRCT score (r=0.63). There was a highly significant correlation between IPAQ and VO2max (χ2=28), VE’ (χ2=14.8) and desaturation percentage variables of CPET, DLCO (r=0.61), and HRCT score (r=−0.68). Conclusion Correlations between physiological parameters including DLCO and CPET, radiological parameters in the form of HRCT, and health-related quality-of-life assessment using SGRQ and IPAQ were strong and it was possible to distinguish IPF patients with severely impaired lung functions.
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LUNG CANCER: ORIGINAL ARTICLE Top

Immunohistochemical staining and computed tomography in early detection of lung cancer among heavy smokers: A pilot study p. 149
Nesrien M Shalabi, Mohammad K El-Badrawy, Ahmad S El-Morsy, Khalied R Zalata, Amina Soltan, Abdel-Hady EL-Gilany
DOI:10.4103/1687-8426.203800  
Objectives Early diagnosis of lung cancer carries a good prognosis. The aim of the present study was early detection of lung cancer among heavy smokers using immunohistochemical staining and chest computed tomography (CT). Patients and methods This descriptive cross-sectional study comprised 80 heavy smokers with smoking index more than 40 pack-years. They were recruited from the Smoking Cessation Clinic, Mansoura University Hospital. All participants were subjected to (a) chest radiography followed by high-resolution chest CT, (b) sputum sample collection, and (c) fiberoptic bronchoscopy evaluation of bronchoalveolar lavage (BAL) and bronchial mucosal biopsies from suspicious areas. All pathological samples were stained with hematoxylin and eosin followed by immunostaining using antibodies for p53 and thyroid transcription factor-1 (TTF-1). Data were analyzed using statistical package for social sciences, version 16. Results The majority of heavy smokers were male, with a mean age of 53.42±11.30 years. A solitary pulmonary nodule was detected in 1.3% of cases with chest radiography and in 5% with high-resolution CT. Hematoxylin and eosin staining of sputum, BAL, and mucosal biopsies was positive for premalignant changes in 35, 27, and 17.56% of cases, respectively. Sputum, BAL, and mucosal biopsies showed expression of p53 in 30, 37.8, and 35.1% of cases, respectively. Sputum, BAL, and mucosal biopsy showed expression of TTF-1 in 12.5, 10.8, and 14.9% of cases, respectively. Conclusion The immunohistochemical technique using p53 and TTF-1 is useful in the early detection of bronchial mucosal changes in heavy smokers. There is still need for a large-scale study to highlight its validity and acceptability. Meanwhile, chest CT is beneficial for the detection of peripheral small lesions.
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SLEEP DISORDERS: ORIGINAL ARTICLE Top

Sleep-disordered breathing in ischemic cardiomyopathy and hypertensive heart failure patients p. 154
Suzan Salama, Amany Omar, Yasser Ahmed, Mahmoud Abd El Sabour, Mohamed Ismail Seddik, Doaa Magdy
DOI:10.4103/ejb.ejb_42_16  
Aims The aims of this study are to (a) detect the effect of different types of heart diseases [ischemic, cardiomyopathy, hypertensive heart failure (HF)] on the association with sleep disorders, and to (b) identify the relationship between Cheyne–Stokes respiration (CSR) and left ventricular dysfunction. Materials and methods In a cross-sectional study involving 100 HF patients, we performed echocardiography and a full-night attended polysomnography for all patients. Results In all, 47.9% of patients with ischemic heart disease had obstructive sleep apnea (OSA), whereas 37.5% had central sleep apnea (CSA). OSA was highly prevalent in patients with hypertensive heart disease (79.2%). On the other hand, 50.0% patients with dilated cardiomyopathy (DCM) had CSA, whereas 39.3% had OSA. Patients with DCM had a significant increase in the central apnea index (11.05±9.19 events/h), as well cycle length of CSR (68.14±13.26 s), as compared with other groups. There was an inverse increase of cycle length with reduction in left ventricular ejection fraction (LVEF) (LVEF≥50% had a cycle length of 41.55±10.84 s, whereas those with LVEF≤30% had a longer mean cycle length of 69.23±18.09 s). Conclusion Sleep-disordered breathing is a common disorder in different groups of HF. OSA was prevalent in ischemic and hypertensive heart disease, whereas CSA was prevalent in DCM. There was a significant increase in cycle length of CSR with a reduction in LVEF.
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SLEEP DISORDERS: CASE REPORTS Top

Primary pulmonary extraskeletal Ewing sarcoma/Primitive neuroectodermal tumor: Two case reports p. 161
Eman Sobh, Wael H El-Sheshtawy, Shady E Anis
DOI:10.4103/ejb.ejb_48_16  
Primary pulmonary extraskeletal Ewing sarcoma (EES)/primitive neuroectodermal tumor is an extremely rare tumor with only few cases reported in the literature. In this study, we present two cases of primary pulmonary EES diagnosed and treated at our institution. The median age was 20 years (range: 19–21). Cough, dyspnea, and hemoptysis were the predominant features at presentation, associated with a large lung mass on imaging. Image-guided core needle biopsies were the diagnostic modalities for both patients. Initial histopathology showed malignant small round cell tumor, which has been confirmed by immunohistochemistry as EES. Both patients received neoadjuvant chemotherapy followed by surgery; postoperative pathology for the first patient showed 98% tumor necrosis, whereas the second patient’s pathology showed no evidence of residual tumor after complete surgical excision.
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Enormous thymolipoma: A case report p. 165
Hoda A Eid, Ahmed E Ali, Mohmed A Elsabry
DOI:10.4103/1687-8426.203799  
Thymolipoma is unusual benign mediastinal, slow-growing, encapsulated tumor of the anterior mediastinum with no tendency to recur after a complete surgical excision. Here, we report the case of an adult female who presented with progressive dyspnea of 2 months’ duration especially on lying down. Chest radiograph showed opacity occupying the entire left side. Computed tomography of the chest revealed a large mass on the left side with fat attenuation. Computed tomography-guided biopsy obtained was diagnosed as hyperplasic thymic tissue. The tumor was successfully removed surgically, and histopathological examination confirmed thymolipoma.
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Respiratory failure in a patient with treated thymoma: A blast from the past p. 168
Animesh Ray, Vivek Nangia, Rajat Chatterji, Nikhil Bante
DOI:10.4103/ejb.ejb_71_16  
Thymomas are among the most common anterior mediastinal tumors that can uncommonly present with respiratory failure. This case discusses the development of type II respiratory failure in a patient with a history of treated and cured thymoma. The problem posed and the workup leading to the diagnosis is discussed in detail. Further, the possible and reported causes of respiratory failure in such a case has also been highlighted.
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ERRATUM Top

Erratum: Study of ventilator-associated tracheobronchitis in respiratory ICU patients and the impact of aerosolized antibiotics on their outcome p. 171

DOI:10.4103/1687-8426.203804  
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