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 Ddimer 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 (WellвЂ™s score > 6) and undergone CTPA and/or VQS were screened. The Study includes data from 41 patients (mean age 54.7В±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 52.3В±15.00 vs. 57.2В±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 (3303В±2472 vs. 2337В±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. Physiological basis of Acid Base Disorders P2 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 вЂ�normalвЂ™ 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 structurefunction 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 yearвЂ™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 в‰Ґ 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 в‰Ґ 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 doesnвЂ™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 (вЂ�budsвЂ™) 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 DвЂ™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 ILDвЂ™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 UniversityвЂ™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 вЂ“ 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 вЂ“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 вЂ“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 pneumomediastinum 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 вЂ“ 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 вЂ“ 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 вЂ“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 вЂ“ 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 вЂ“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 TM pleural effusion by bedside pleurodesis due to use of Thopaz 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. TM Conclusion: Use of Thopaz 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 Department of Minimally Invasive and Robotic Thoracic Surgery Medanta The Medicity, Gurgaon Objective: We present our experience of facilitation of conservation management patients with secondary TM pneumothorax with air leaks by bedside pleurodesis due to use of Thopaz 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. TM Conclusion: Use of Thopaz 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 1 1 1 2 2 3 S Khandelwal , K Ali , N Agarwal , S Khanna , A Sharma , T Piplani , A Z Khan 1 1 Department of Minimally Invasive and Robotic Thoracic Surgery 2 Department of Anesthesiology 3 Department of Radiology Medanta The Medicity, Gurgaon Objective: We set out to present our experience of extracting unusual endobronchial foreign bodies. Methods: A total of 11 cases were diagnosed roentogenographically and bronchoscopically at our hospital. 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 1 1 1 2 2 3 S Khandelwal , Kamran Ali , N Agarwal , S Khanna , A Sharma , T Piplani , A Z Khan 1 1 Department of Minimally Invasive and Robotic Thoracic Surgery 2 Department of Anesthesiology 3 Department of Radiology Medanta The Medicity, Gurgaon 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 nonoperative bronchus with the patient in a lateral position with affected side down to prevent spillage. A FogartyвЂ™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 1 1 1 2 2 3 S Khandelwal , Kamran Ali , N Agarwal , S Khanna , A Sharma , T Piplani , A Z Khan 1 1 Department of Minimally Invasive and Robotic Thoracic Surgery 2 Department of Anesthesiology 3 Department of Radiology Medanta The Medicity, Gurgaon 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 вЂ“ 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 HodgkinвЂ™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-HodgkinвЂ™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 rd mass in the upper 1/3 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 вЂ“ 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 1 2 3 4 5 Dr P P JAIN , Dr A S PANDEY , Dr D A MODH , Dr H V DESAI , Dr S R Ghadiya 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 Nacetylcysteine 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 Nacetylcysteine 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 вЂ“ 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 вЂ“ 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, SpO 2 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 patientвЂ™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 п‚· Right sided chest pain for 2 month п‚· Low grade intermittent fever for 15 days п‚· progressive SOB for 1 year with increasing severity for last 15 days EXAMINATION: п‚· Features of right sided pleural effusion with tracheal displacement to right п‚· Sternal percussion - dull INVESTIGATION: вЂў Pleural fluid: hemorrhagic, exudative lymphocytic, low ADA, Malignant cells ~ negative вЂў Pleural biopsy ~ chronic inflammatory cells. вЂў Serum alfa fetoprotein and beta-HCG ~ normal FURTHER EVENTS: вЂў ICTD for severe SOB with drainage of 4.6 liters of fluid over 9 days. вЂў Right antero-lateral thoracotomy вЂњLarge mediastinal mass adherent to right lung, pericardium, chest wall, diaphragm with thickened pleuraвЂќ. HISTOPATHOLOGY: вЂў вЂњTumor with nests, cords, trabeculae of Polygonal cells with round oval nuclei, prominent nucleoli, Mitotic figures seenвЂќ. IMMUNOHISTOCHEMISTRY: вЂў 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 вЂў Exertional SOB for 1 year вЂў dull aching chest pain for 6 months вЂў Low grade intermittent fever for 1 month EXAMINATION: вЂў Dull percussion note left hemithorax with в†“ Vesicular breath sound & в†“ Vocal resonance CHEST RADIOLOGY: Large heterogenous SOL in whole left hemithorax TRU-CUT BIOPSY: вЂў Tumour cells are bland, monomorphic, hardly any mitotic activity, arranged in vague fascicles, stroma is markedly collagenous & contain hyalinized vesselsвЂќ. IMMUNOHISTOCHEMISTRY: вЂў 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: вЂў compatible with solitary fibrous tumour of pleura FINAL DIAGNOSIS: вЂў Solitary Fibrous Tumor of Pleura with intraparenchymal extension CONCLUSION: Sometimes common symptoms can be presentation of rare diseases вЂў 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:[email protected] 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. п‚— 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 вЂ“ Non HodgkinвЂ™s Lymphoma presenting as a chest wall mass Authors вЂ“ 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 BackgroundMalignant 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-HodgkinвЂ™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 reportA 47 year old Male, Farmer, addicted to Tobacco chewing ВЅ 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 вЂ“ prevascular compartment extending to superior mediastinum. USG guided biopsy revealed Non Hodgkins Lymphoma. Patient was referred to Onco surgery for further management. Conclusion вЂ“ 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 hemidiaphragm 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 parameters among smoker and non smoker lung cancer. of these Methods: Study was undertaken among admitted lung cancer patients in a medical college of Kolkata during the period Sept 2013 вЂ“ 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 В± 8.86) of smoker lung cancer is significantly high(p<.05) than that of non smoker(54.21 В± 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 вЂ“ A case report DR.B.NITHILAVALLI, DR.K.ANUPAMA MURTHY, DR.R.KARTHIKEYAN DEPT OF RESPIRATORY [email protected] MEDICINE, PSG IMS&R, COIMBATORE, TAMILNADU, INDIA; 97906-51384; 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 THREE CASES FEATURES OF 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 shouldnвЂ™t be put on ATT merely on CXR basis without microbiological/histological evidence. P48 P49 Abstract : TITLE : - вЂњ The Changing Face of TBNA вЂќ 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 вЂ“TBNA Percentage of Representative samples was 47 % (137/292) c-TBNA vs 68 % ( 183/269) EBUS вЂ“TBNA No of Diagnostic Punctures was 36% (106/292 ) c-TBNA vs 53% (144/269) EBUS вЂ“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. GramвЂ™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 5.9Г—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 вЂ“ 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 AbrahamвЂ™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 KochвЂ™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-О± 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 Department of Respiratory Medicine, Ruby Hall Clinic, Pune, Maharashtra, India OBJECTIVES : Pulmonary Embolism is the most common preventable cause of death in the world. Post-operative deep 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 Department of Respiratory Medicine, Ruby Hall Clinic, Pune, Maharashtra, India INTRODUCTION : Tracheo-esophageal fistula (TEF) are a rare entity which can either be congenital or acquired. Acquired TEF 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 вЂ“ 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 RyleвЂ™s tube in situ since 2 months. He was referred to us with complaints of regurgitation of RyleвЂ™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 вЂ“ surgical interventions like tracheal stenting A case report on pulmonary alveolar microlithiasis P62 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 Kartagener Syndrome treatment aspects of 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 [email protected] 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 вЂ“ 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 вЂ“ 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 A forty-six year old male patient presented with chest pain on left side and dyspepsia for the past two months, associated with few episodes of vomiting. Chest radiograph showed lesion mimicking a cavity in the left lower zone overlying cardiac shadow with a surrounding area of collapse(Figure 1). Initially, he had presented to a general practitioner, where he was misdiagnosed as a case of pulmonary tuberculosis and was prescribed anti-tubercular drug treatment The findings led to a provisional diagnosis of spontaneous acquired diaphragmatic hernia, which was later confirmed on contrast enhanced tomography scan. Patient was referred to the cardiothoracic surgery department. Conclusion The presentation of diaphragmatic rupture is often a result of herniation of abdominal contents into thorax. Spontaneous Diaphragmatic Rupture (SDR) describes the rupture of the diaphragm due to increasing pressure in the abdominal cavity and chest wall without any direct trauma. It is difficult to diagnose SDR in the absence of visceral organ injury or herniation. The diagnosis may be delayed by a few days or even several years as the symptoms are non-specific. Diagnostic procedures for traumatic diaphragmatic ruptures include: chest x-ray, CT scan, ultrasound, Magnetic Resonance Imaging (MRI), Upper GI contrast studies, laparoscopy and thoracoscopy. However chest x-ray has only a diagnostic accuracy for diaphragm injuries of just 25-50%. The management of SDR is surgical. P66 Early stages of scleroderma- A case report Dr.N.Snigdha,Dr.N.Gopi chand,Dr.D.sudeena,Dr. C. Suma latha Siddhartha medical college, Vijayawada, Andhra Pradesh, India. ABSTRACT Introduction: Scleroderma or systemic sclerosis (SSc) is a clinically heterogeneous, multi-system autoimmune disorder characterized by endothelial dysfunction, dysregulation of fibroblasts resulting in excessive production of collagen and autoantibody formation with profound abnormalities of the immune system.Incidence of scleroderma is about 9-19 per million populations. Pulmonary involvement like Interstitial Lung Disease(ILD) and Pulmonary arterial hypertension(PAH) are common and occurs in all SSc subsets. Progression of lung disease in SSc is variable and difficult to predict. Case Report: A 30 year old female home-maker presented with shortness of breath and dry cough since 3 months.On general examination she has pallor, skin showed shiny ,light hide bound skin over extensor aspect of forearm and front of legs. Salt and pepper pigmentation over both ears, microstomia, digital pitting scars are seen. Respiratory examination reveals bilateral normal vesicular breath sounds with basal fine end inspiratory crepitations. Chest X-ray PA view,2-D Echo are normal, Electrocardiography shows sinus tachycardia. High Resolution computed Tomography shows peripheral ground glass pattern in basal segments and bilateral lower zones which is consistent with nonspecific interstitial pneumonia(NSIP). Spirometry showed restrictive pattern. Complete hemogram shows microcytic hypochromic anemia. She is positive for serum antinuclear antibodies , anti scl70 antibody and negative for anticentromere antibody. Endoscopy shows erosive antral gastritis. Barium swallow shows delayed filling of barium in lower 1/3 of esophagus. Liver Function TestвЂ™s and Renal Function TestвЂ™s are within normal limits. She is diagnosed to have diffuse type of systemic sclerosis. Discussion: PAH and ILD are most common pulmonary manifestations in Systemic sclerosis, with ILD of NSIP more commonly associated with diffuse subset.PAH can occur in these patients secondary to ILD. Early diagnosis would enable us to prevent progression to severe forms of pulmonary fibrosis. However the outcome may vary. Steroids and antineoplastic drugs like cyclophosphamide , methotrexate, mycophenolate remain main stay of treatment. Anti-fibrotic drugs like D-penicillamine have a role.PAH is managed on drugs like sildenafil or bosentan. P67 Unusual presentation of Right sided Bochdalek Hernia in an adult Ravi Bhaskar, Alok Chandra, Tariq Mahmood, Rajneesh Shrivastav, Neha Agrawal Moti Lal Nehru Medical College and Swaroop Rani Nehru Hospital, Allahabad, India Introduction: Bochdalek hernia is a type of congenital diaphragmatic hernia resulting from failure of closure of th posterior pleuro- peritoneal membrane by 8 week of gestation. It primarily manifests in neonates and infants. It is rare in adults and accounts for about 0.17% to 6% of all diaphragmatic hernias. As 80%-90% occur on left side, right sided presentation is exceedingly rare in an adult with only about 20 cases reported in literature. Case presentation: A 24 year old male presented with gradual onset breathlessness on exertion for 3 months and pain over epigastrium for 1 day. Patient was non-smoker. General and systemic examinations were within normal limits. On auscultation, air entry was decreased on right side of chest. Chest X-Ray PA view(fig 1) revealed that right diaphragm was exceptionally high. USG abdomen showed epigastric location of right kidney with eventration of right hemidiaphragm. Barium follow-through showed that hepatic flexure of large bowel loops and ileal loops were higher up in position under the right dome of diaphragm. CECT Thorax and Abdomen(fig 2) confirmed the presence of small bowel, right colon, right kidney and right lobe of liver in thoracic cavity causing mass effect on right lung. Patient underwent short lateral thoracotomy and herniated organs were moved back to abdominal cavity and defect was closed. Postoperative course was uneventful and patient had no symptoms on follow up. Conclusion: Bochdalek hernia occurs in about 1 in 2,200 to 12,500 live births and is a rare finding in adults. Right sided hernias are rare because right pleuroperitoneal cavity closes earlier and liver buttresses the diaphragm. P68 INTRAPULMONARY SOLITARY FIBROUS TUMOR OF LUNG PRESENTING AS PANCOAST TUMOR. Dr VIPUL KUMAR, Dr K B GUPTA, Dr RITU AGGARWAL Pt BD Sharma Post Graduate Institute of Medical Sciences INTRODUCTION Intrathoracic solitary fibrous tumors (SFT) are the rare mesenchymal tumors, commonly arising from the pleura. Inward tumor growth into the lung parenchyma is infrequent while totally intra-pulmonary localized fibrous tumors without histological continuity with visceral pleura have been described rarely. These tumors are three times more likely to arise from visceral than parietal pleura with variable morphological presentation. CLINICAL DETAILS 45 year old female presented with right side chest pain since two months. CECT revealed hypo dense mass lesion of size 58mm x 66mm x 61mm in apical and posterior segment of right upper lobe showing heterogeneous enhancement with central non-enhancing or necrotic area. CT guided biopsy of the lesion revealed replacement of normal lung parenchyma by haphazardly distributed fibroblast like cells embedded in matrix of variable density with low mitotic activity. On immunohistochemistry, tumor cells were positive for CD34, vementin and negative for cytokeratin, smooth muscle antigen consistent with the diagnosis of SFT. DISCUSSION SFTs account for 8% of benign intrathoracic tumors and 10% of pleural tumors. Most of the patients are asymptomatic and lesion is detected incidentally on routine chest radiograph. The diagnosis is usually made histopathologically either by CT guided lung biopsy or surgical resection. As these lack distinctive histological features, immunohistochemical examination is very important for their diagnosis. Although CD34 is expressed by various cell types such as hematopoietic progenitor cells and mesenchymal tumor cells, its detection along with vimentin and absence of cytokeratin in cells from a pleural tumor excludes the diagnosis of mesothelioma and of most other pleural tumors such as carcinomas, fibrous histiocytomas, fibromatosis, fibrosarcomas, and synovial sarcomas. The treatment of choice is surgical resection either through VATS or open thoracotomy depending on the size. P69 CATAMENIAL HAEMOPTYSIS Dr.MOUNIKA.V*, Dr. H.V.PRASAD MALLA **, Dr.P.SUBBARAO***, DEPARTMENT OF PULMONARY MEDICINE, KONASEMA INSTITUTE OF MEDICAL SCIENCES &RESEARCH FOUNDATION, CHAITANYANAGAR, NH-214,AMALAPURAM, ANDHRA PRADESH-533201. BACKGROUND: The monthly periodicity of the symptoms led to the coining of вЂ�вЂ™CATAMENIALвЂќ( In Greekmonthly).Thoracic endometriosis can involve the lung parenchyma causing catamenial haemoptysis or it may involve the pleura causing pneumothorax. We present a case of catamenial haemoptysis associated with pelvic endometriosis. CASE REPORT: A 25 yr old multiparous women was presented with recurrent episodes of haemoptysis at the time of menstruation since 6 years. She had no fever, cough, weight loss, family H/O TB. Physical Examination was unremarkable. Her chest radiography was normal and microscopy for mycobacterium tuberculosis was negative. nd Mantoux test 20 mm induration with BCG scar present. CT scan of chest was carried out on the 2 day of menstruation with normal study. Fibre optic bronchoscopy showed normal endobronchial appearences. Considering the history of haemoptysis during menstrual periods, pulmonary endometriosis was diagnosed. DISCUSSION: Endometriosis is a common gynecologic disorder with peak prevalence between 30 to 45 years of age. Only 10 25% of women with endometriosis are presenting with gynecological symptoms. It is most commonly found in pelvis and only rarely in sites such as umbilicus or lungs. Pulmonary endometriosis gives rise to symptom of catamenial haemoptysis. The etiology of pulmonary endometriosis is unknown, but the theories of haematogenous spread and coelomic metaplasia are plausible. The diagnosis is often presumptive, based on clinical history of cyclical haemoptysis at the time of menstruation. Other diagnostic aids include endometriotic plaques on bronchial washings and endometrial tissue on lung biopsy. Imaging technique of choice is CT scan of chest during days of menstruation and in mid cycle. P70 Hereditary Hemorrhagic Telangiectasia presenting as recurrent Haemoptysis Dr.Rajesh Kumar B, Dr.S.V.Ghorpade, Dr.Vinit Niranjane, Dr.Gyan S Mishra. Dept. Of Pulmonary Medicine, Govt. Medical College, Nagpur, Maharashtra. Introduction: Osler-Weber-Rendu syndrome is a rare hereditary, autosomal dominant disease characterized by a local angiodysplasia. Patients usually have nasal and gastrointestinal bleeding and characteristic mucocutaneous telangiectasia associated with Arteriovenous malformations in the viscera commonly lungs, brain and liver. Case report: 48yrs old male patient presented with recurrent haemoptysis, had recurrent epistaxis in past and operated for brain abscess previously. He also had multiple cutaneous telangiectasias in face, chest and hands. During evaluation CT Thorax and CT Pulmonary Angiogram were done, which showed multiple pulmonary A-V Malformations bilaterally. Discussion: Epistaxis caused by spontaneous bleeding from nasal mucosal telangiectasia is the most common manifestation of this disease; about 80% of the patients have recurrent epistaxis. Cutaneous manifestations are macular telangiectasia, which affect the face, lips, nose, tongue, ears, hands, upper body and feet. Pulmonary A-V malformations caused by direct communication between the pulmonary vein and artery by means of a thin-walled aneurism. They are usually multiple and bilateral, common in lower lobes, the treatment of choice is embolization of vessels. Cerebral manifestations like Brain abscesses, Ischemic strokes, Bacterial encephalitis may occur due to pulmonary A-V malformations. Cerebral malformations occur in about 28% cases. Gastrointestinal tract bleeding is caused by mucosal telangiectasia in GIT. Liver involvement may cause congestive heart failure, hepatic encephalopathy, and portal hypertension with oesophageal varicose veins. Our patient fulfilled three criteria for the diagnosis of HHT. Pulmonary A-V Malformations were occluded by multiple Coil Embolization. After Coil Embolization, his Orthodeoxia improved dramatically. Conclusion: Hereditary hemorrhagic telangiectasia should be suspected in a case of recurrent haemoptysis. Awareness must be created about this disorder and its genetic nature to enhance early diagnosis and appropriate management. Diagnostic facilities for this disorder should be made available at specialised centres in India. Atypical presentation of achalasia cardia P71 B S Behera, P Dutta, R Manjhi, S Pothal Department of Pulmonary Medicine,V S S Medical College ,Burla ,Odisha, India Background:- Achalasia is defined as failure of organised peristalsis in esophagus and failure of relaxatiuon at the level of lower esophageal spincter. It is a disease of unknown etiology. Case report:- A 62 yr old male presented with history of low grade fever and cough for the past one year. No history of hemoptysis. He had history of dysphasia, regurgitation or vomiting. These symptoms were mild so he consulted either a local physicain and sometimes was on some home remedies, but his symptoms were not relived on medications. He is non diabetic and non hypertensive. His physical examination was normal. On examination of respiratory system tubular bronchial breath sound was found over left mammary, upper interscapular& lower interscapular areas. His laboratory parameters showed a raised TLC count with rest of the blood parameters were within normal limits. Chest X-ray showed widening of mediastinum with a patch of consolidation in the left upper zone. CT scan of chest revealed a dilated and tortous bowel loop with a dilated loop of esophagus in thorax with hiatus containing food particles with consolidation of the left upper zone. Barium swallow was performed which showed a dilated and tortous esophagus. On Upper GI endoscopy the diagnosis of achalasis cardia was confirmed. His respiratory symptoms subsided with antibiotics there was also radiological improvement of the consolidation. He was referred to cardiothoracic department for further management. Conclusion:- Achalasia remains an elusive diagnosis. The diagnosis is often delayed in asymptomatic patients as in the present case. AN UNUSUAL CASE OF MILIARY INFILTRATES P72 Dr.HAJI, Dr.KRISHNAMOORTHY,Dr.SANGAMITRA,Dr.MATHAN,Dr.RAHMAN,Dr.JEYAKUMAR DEPARTMENT OF THORACIC MEDICINE, TIRUNELVELI GOVT MEDICAL COLLEGE AND HOSPITAL,TIRUNELVELI(TAMILNADU) ABSTRACT: Carcinomatosis is described as a condition in which multiple carcinomas develop simultaneously, usually after dissemination from a primary source. They are forms of metastasis and whether they spread in a general manner or in a defined pattern, they will still be a form of disseminated cancer. Miliary carcinomatosis is similar to military tuberculosis in terms of their radiographic appearance. They are characterized by a pattern of metastases which are not only nodular but also small in sizes.Usually presents late .We have described a 59 year old Female a case of military carcinomatosis whose primary was papillary carcinoma of thyroid.Her thyroid had been removed and was started on palliative chemoradiation. P73 Ascending aortic aneurysm with left lung atelectasis P74 Dr.Dishan.Y, Dr.Yuvarajan S, Dr.Bency Koickal Thomas Sri Manakula Vinayagar Medical College and Hospital, Puducherry, India ABSTRACT Pulmonary atelectasis may be caused by endobronchiallesions or by extrinsic compression of the bronchus. However, lung collapse due to compression from a thoracic aneurysm is uncommon. We report a 52 yr old male patient who has pulmonary atelectasis due to an extrinsic compression from the ascending thoracic aortic aneurysm. He came with complaints of breathlessness for past 1 year. He was a non smoker and non alcoholic. On examination of chest ,breath sounds reduced on left side of chest. Chest xray showed enlarged cardiac shadow with left sided volume loss, following which 2D echo was done which showed right atrium and right ventricle enlargement with moderate pulmonary artery hypertension and aortic aneurysm with bicuspid aortic valve. CT thorax showed dilated ascending aorta and anomalous left brachiocephalic vein, joined with left atrium directly and compression of pulmonary trunk between ascending aneurysm and anomalies vein. Also narrowing of left main bronchus by left pulmonary artery and anomalous vein. Apical segment atelectasis with patchy hyperinflation was also noted in left lung. Bronchoscopy showed carina shifted to left side with narrowing of left main bronchus. No evidence of endobronchial obstruction at the level of left main bronchus. Patient was referred to CTVS for the opinion regarding definitive surgical management. P75 A rare anterior mediastinal paraganglioma-a case report. Anandeswari P, Ramesh.P.M, Chitrakumar.A. Gangadharan.V Govt. Kilpauk Medical College>HTM,Chennai, Tamil Nadu, India. Case report: 40 yrs. male, pest controller, presented with hoarseness of voice-5 years, weight loss, breathlessness3 months. He was chronic smoker and alcoholic-20 years. On examination there were dilated veins over left anterior chest wall. Examination of respiratory system revealed normal breath sounds with occasional wheeze with impaired to dull note over the left infraclavicular and left mammary region. His blood counts were normal. Chest X Ray PA view revealed a large well circumscribed homogenous opacity with left border abutting the lateral chest wall and right border extending up to right mid clavicular line. Left lateral view revealed obliteration of retrosternal space. Echo revealed moderate pericardial effusion. CT Chest revealed a well-defined hyper dense lesion in anterior mediastinum extending from lower neck to anterior pericardium abutting the anterior chest wall compressing and displacing trachea and vascular structures. CT guided biopsy revealed nests of small round to oval cells separated by richly vascular thin stromal cells separated by dysmorphic stroma with focal calcification. Neuron specific enolase was strongly positive suggestive of paraganglioma. Immunohistochemical markers showed weak to moderate activity of synaptophysin and chromagranin. Patient was discharged and referred to surgical oncology department for further management. Discussion: Paraganglioma are rare, highly vascular, extra adrenal neuroendocrine tumors. First described by Von Haller in 1743 involving various body sites(Abdomen-85%, Thorax-12%, Head&Neck-3%). <1% seen in mediastinum. Anterior mediastinal paraganglioma arise from paraganglias associated with parasympathetic system located in head and neck and extends into anterior mediastinum. They are asymptomatic, seen in older people, identified incidentally and serve chemoreceptor function. Diagnosis is usually made by biopsy and immunohistochemistry. So far only about 34 cases have been reported in the literature. Ours is another interesting case presented for its rare incidence. P76 ABSTRACT Early Detection Of The Rare Entity Pulmonary Alveolar Proteinosis M.M MODI,B.SIDDESH, R.K JALAN, K S K GOUD. Department of Medicine, Ruby Hall Clinic, Pune, Maharashtra, India 300 OBJECTIVES: 142 Pulmonary alveolar proteinosis (PAP) is a rare syndrome characterized by pulmonary surfactant accumulation with in the alveolar spaces with a reported prevalence of 0.1 per 100000. It occurs in an individual with distinct clinical forms of which primary (idiopathic) represents the vast majority of cases, secondary form due to underlying lung infections, haematological malignancies and inhalation of mineral dusts and insecticides, congenital form due to mutations in the genes encoding for the granulocyte- macrophage colony stimulating factor receptor and very few with surfactant gene mutations. Here we report a case of secondary PAP who was successfully treated with total lung lavage which is accepted as the most effective treatment for advanced cases. The main objective of presenting this is to increase awareness regarding this rare disease as early detection and prompt treatment increases the survival where if delayed leads to death. METHODS: 99 A 30 year old male patient, smoker, presented with complaints of productive cough with whitish expectoration along with breathlesness on exertion from 3 months and fever on and off from 8 days. Patient had history of working in blast mines and fertilizer Company. On ausculatation the patient had fine inspiratory crepitations all over lung fields. Chest X ray showed bilateral reticulo- nodular shadows. HRCT Thorax showed crazy paving pattern along with ground glass opacities and reticulo- nodular shadows. Bronchoscopy with transbronchial lung biopsy was done which was consistent with PAP. Patient had pneumothorax post biopsy for which intercostal drain was inserted. lavage patient was put on invasive ventilation. he developed ventilator associated pneumonia and died due to sepsis. CONCLUSION: 28 PAP is a rare entity which can be confused with many conditions. Early diagnosis and appropriate treatment improves the life expectancy and quality of life of such patients. P77 P78 A CASE OF TRACHEOESOPHAGEAL FISTULA PRESENTING WITH RECURRENT LRTIвЂ™S P.sireesha,G.P.vignan kumar Postgraduate,department of pulmonary medicine,narayana medical college,Nellore,Andhra Pradesh INTRODUCTION:Tracheoesophageal fistula (TOF) is a congenital or acquired communication between trachea and oesophagus.These can often lead to severe and fatal pulmonary complications.Among the acquired causes,malignancy is the most common cause of tracheoseophageal fistula.The second most common cause is the endotracheal cuff related trauma. CASE REPORT:Here we report a case of 45 yr old male who presented with increased cough on foodintake,breathlessness and recurrent LRTIвЂ™S.Past history of insecticide poisoning with prolonged intubation was present.Investigated with routine laboratory tests.CBP was normal.Chest xray showed a pneumonic patch.Furthur work out with bronchoscopy revealed a Tracheoseophageal fistula.case was planned for surgical repair of the fistula. P79 Title abstract for oster presentation: Skin associated lymphoid tumour Name of author: Saurabh P borgaonkar Dr vasantrao pawar medical college , nashik. india A 28/M ,case of pleural effusion on cat 1 since 1 month. Pleural fluid was exudative and also was on oral steroids. Presented to us with fever,cough with white frothy sputum ,dyspnea , oedema over hand ,arm . Pleural tapping was done , it was exudative with ADA 29.cytology negative for malignancy. TLC Venous doppler was done for right arm suggestive of thrombus in axillary vein and brachilal vein. USG suggestive of multiple LN with splenomegaly.CECT thorax shows mediastnal widening with right pleural effusion. Supraclavicular LN biopsy suggestive of monotonous population of lymphoid cells. Biopsy could not be done due to deranged PT INR. Meanwhile his oedema increased and neck vein engorged,odema on face and periorbital region.he developed reddish skin papule on face and chest ,biopsy was done suggestive of monotonous population of atypical lymphoid cell suggestive of SALT. Skin biopsy Block was sent for IHC but unfortunately patient succumbed. ADA are sensitive and specific for diagnosis TB pleurisy. Incidence of thrombosis is 6.5% with NHL and 4.5% for HL. Incidence of pleural effusion with NHL is between 6 to 50% and with HL is 7 to 21%. Result lymphoma presenting with pleural effusion then developing into thrombosis. Conclusion not every exudative pleural effusion is tubercular. P80 Kikuchi Fujimoto disease--a case report P81 Dhamodharan P, Chella Raja C, Chitrakumar.A. Gangadharan V Govt. Kilpauk Medical College>HTM, Chennai, TN , India Case report: 13 year old female from villupuram district in Tamil Nadu presented with swelling over the left side of neck -1 month, fever, headache and projectile vomiting - 1 week. On examination she was febrile and anemic. Examination of cardiovascular and respiratory system were normal. There were multiple, mobile, tender, firm lymph nodes over left side of neck each measuring 2 x1.5 cms. X ray and CT of chest-Normal. USG abdomen and CT abdomen-Normal. CT Neck revealed multiple enhancing bulky lymph nodes with central areas of necrosis over both submandibular, deep cervical, left posterior cervical, left supraclavicular and left retroclavicular areas. MRI Brain revealed features suggestive of raised ICT. CSF analysis suggested chronic inflammatory pathology. Excision biopsy of node reported as necrotizing lymphadenitis with immunohistochemistry positive for CD3+, CD43+, CD8+ and CD68+ suggesting Kikuchi. After 6 months she developed node on same side and it was also confirmed as KikuchiвЂ™s disease by biopsy and immunohistochemistry. Discussion: Kikuchi-FujimotoвЂ™s disease is a benign self limiting cervical lymphadenitis with fever and other constitutional symptoms. It should be differentiated from lymphoma, tuberculosis and SLE which presents with multisystem and multinodal involvement. It was first described in Japan by Dr Kikuchi in 1972 and independently by Y. Fujimoto. The mean age of was between 20-30 yrs and occurs predominantly in young female due to nonspecific, hyper immune reaction to a variety of infections, physical, chemical and neoplastic agents. Confirmation is done by histopathological examination of excision biopsy showing expansion of the paracortex with phagocytic histiocytes and immunohistochemistry showing positive for CD3, MAC 387, CD68, CD43, CD45RO, CD8, CD4,CD11b and CD11c. Treatment involves supportive, NSAIDS and corticosteroids. Since then only 23 cases have been reported and ours is a very rare and interesting case and hence we are presenting it. P82 IDIOPATHIC CD4 LYMPHOCYTOPENIA P.ANAND K.RAJARAJAN, S.P.VENGADAKRISHNARAJ, G.ALLWINVIJAY, R.SRIDHAR, O.R.KRISHNARAJASEKHAR, C.CHANDRASEKAR STANLEY MEDICAL COLLEGE Introduction Idiopathic CD4 lymphocytopenia(ICL) is defined by CDC as a clinical condition in patients with depressed numbers of circulating CD4 T lymphocytes (<300 cells/Ојl or <20% of total T cells) at a minimum of two separate time points at least 6 weeks apart, with no laboratory evidence of infection with human HIV-1 or HIV-2, and the absence of any defined immunodeficiency or therapy associated with depressed levels of CD4 T cells. Case Report A 28 Years male admitted with C/o Cough with sputum вЂ“ 3 months, Breathlessness - 15 days , left sided chest pain, No other significant positive history. On general examination, he is pallor. With no clubbing, no generalised lymphadenopathy, Vitals are stable. Respiratory system examination revealed normal vesicular breath sounds on both sides, with decreased breath sounds on both infrascapular regions. пЃЅ Investigations : CBC вЂ“ Hb - 7 .6 g,WBC- 8,700 / cu mm DC - Neutrophils вЂ“ 84.4% Lymphocytes вЂ“ 13.3 % Mixed - 2.3 % . HIV 1& 2 вЂ“ non reactive ,HBsAg - negative , HCV - negative,Mantoux вЂ“ 0 mm, Sputum AFB вЂ“ negative. X-ray revealed bilateral pleural effusion.Pleural Fluid Analysis showed AFB вЂ“ Positive .ATT was started. пЃЅ Since the patient condition did not improve despite ATT and Since lymphocyte count is very low, CD4 count was done and it came as 186 cells/cu.mm. Patient gradually showed improvement. His CD4 count after 6 weeks was 205 cells/cu.mm ICL in an immunocompetent adult is very rare. ICL patients are susceptible for various opportunistic infections. Cryptococcal infections were the most prevalent infections in ICL patients (26.6%), followed by mycobacterial infections (17%), candidal infections (16.2%), and VZV infections (13.1%). Because of sustained CD4 T lymphocyte depletion, the lack of serological evidence of HIV infection, and the absence of any immunodeficiency or immunosuppresive therapy associated with T cell depletion, our patient met the existing criteria for ICL. Conclusion In treating patients with tuberculosis who are slow to respond, complete hematological workup may be necessary to find out conditions like idiopathic lymphocytopenia. P83 TITLE: LONG TERM FOLLOW UP OF A CASE OF PULMONARY ALVEOALAR MICROLITHIASIS (PAM): A CASE REPORT Author 1: SHIVALINGASWAMY SALIMATH rd 3 year Post graduate Department of Pulmonary Medicine JSS Medical College Hospital, Mysore Author 2: DR. JAYARAJ B S Professor and Head Department of Pulmonary medicine JSS Medical College Hospital, Mysore Author 3: DR. MAHESH P A Professor Department of Pulmonary medicine JSS Medical College Hospital, Mysore INTRODUCTION: PAM is a rare disease of unknown pathogenesis, characterized by widespread laminated calcospherites in alveolar spaces. PAM is an autosomal recessive disease caused by mutations of SLC34A2 gene, encoding a sodium phosphate cotransporter. There is a need for long term progression and survival data in India. CASE REPORT: We present an 8 year follow-up of a 52 year old female with pulmonary alveoalar microlithiasis. Patient presented with exertional dyspnoea and cough in 2006. Chest radiograph had typical вЂњsandstorm appearanceвЂќ. HRCT showed diffuse infiltrates and вЂњBlack pleura signвЂќ. BAL showed microliths and BAL cytology showed multiple calcospherites. COURSE OF DISEASE OVER 8 YEARS: The progression of various clinical, radiological, spirometric and biochemical parameters are presented. She underwent BAL 6 times in initial 2 years and clinically improved for 6 years. Last two years showed progressive deterioration in clinical, spirometric and radiologic parameters with corpulmonale. FOLLOW UP: Patient 2006 2008 2010 2012 2014 characteristics: Dyspnoea 3 1 2 3 3 (MMRC grade) FVC in litres (%Pred) FEV1 in litres (%Pred) FEF25-75 in litres 1.93(66) 1.50(59.6) 1.43(62.4) 1.20(50.2) 1.05(46) 1.28(59.6) 0.97(45.3) 0.97(50.2) 0.77(38.2) 0.64(34) 1.03(36.4) 0.57(20.7) 0.58(22.0) 0.42(16) 0.29(12) (%Pred) +2 Serum Ca (mg/dl) Chest X-Ray (Zones) Pulmonary artery systolic pressure (mmHg) 9.8 9.0 8.8 9.0 9.5 4 4 5 6 6 15 18 30 48 55 Conclusion: Further studies are necessary to identify markers for progression and better treatment modalities to delay the progression of the disease. P84 Pulmonary Thromboembolism - A Rare Combo!!! 1 Dr.Javid Abdullah , Prof.Dr.Meenakshi, Dr.Subramanian, Dr.Vishwambhar, Chettinad Health Institute, Kelambakkam, Chennai. Background: Most cases of pulmonary embolism occur as a result of thrombus originating in the lower extremity. Many patients who develop venous thromboembolism are found to have an inherited risk factor due to abnormal levels of or functional abnormalities in coagulation factors. Case Report: 34 year old male presented with sudden onset chest pain and breathlessness, family history negative for PTE and DVT. Blood investigations revealed elevated D dimer and aPTT. CT Pulmonary angiography revealed a saddle shaped non enhancing, intraluminal filling defect noted in the bifurcation of main pulmonary artery, extending to superior and inferior pulmonary artery branches in both sides. Doppler study showed a thrombus in short saphenous vein. Further workup revealed Antithrombin III deficiency -49.1% (normal- 83-128%), lupus anticoagulant 1(screen) -93.2 s (normal- 28-48 s), lupus anticoagulant 2 (confirm)-64.6 s (normal 28-40 s). Ratio (LA1/LA2) - 1.44 (>2 - strong presence, 1.5-2 -moderate presence,1.3-1.5- weak presence, < 1.3 normal). Homocysteine-22Вµmol/L(normal-3.7-13.9Вµmol/L) Anticardiolipin Ab-negative, protein C & S - normal. Factor V leiden assay normal. Thereby establishing a diagnosis of pulmonary thromboembolism with multiple etiological factors DISCUSSION Hereditary antithrombin deficiency is estimated to occur in about 1 in 2,000 to 3,000 individuals with PTE. Several studies have shown a good relation between homocysteinemia and thrombovascular disease. Antiphospholipid antibodies (APLA) have been reported in 2-5% of the general population. Combination of these 3 etiological factors has not been commonly reported. CONCLUSION Co existence of hyperhomocystinemia, antithrombin deficiency and lupus antibody (APLA) in pulmonary thromboembolism is a rare entity. This case is reported for its rarity. P85 MEDIASTIASTINAL MASS PRESENTING AS THYMIC CARCINOID Dr.AVINASH R GANDHARE, Dr.S.V.GHORPADE Dr.S.H.MESHRAM, Dr.V.NIRANJANE, Dr.G.MISHRA, Dr.P.GHOLAP GOVERNMENT MEDICAL COLLEGE AND HOSPITAL, NAGPUR Introduction - Thymic carcinoids are unusual and rare tumors, and prognosis is difficult to predict. We hereby report a rare case of primary neuroendocrine carcinoma of the thymus which had an aggressive behavior and patient died within 6 months. Case Reports- A 45 yrs. old married female farmer was admitted with complaints of breathlessness for 3 months, multiple joints pain for 3 months, generalized weakness for 3 months and retrosternal chest pain for 1 month. Xray chest showed mass in left hemithorax. Computed tomography scan (CT scan) thorax revealed mass in left hemithorax which appeared to arise from superior mediastinum. CT scan guided fine needle aspiration cytology (FNAC) from the mediatinal mass revealed small cell neuroendocrine tumors. CT scan guided biopsy showed neuroendocrine carcinoma with possibility of thymic carcinoid. Patient was advised surgical excision for which patient was unwilling. Patient was then started on chemotherapy vincristine, doxorubicin and cyclophosphamide. Discussion- Neuroendocrine neoplasms of the mediastinum form part of a family of tumors characterized by genotypic, immunophenotypic and functional properties of neuroendocrine differentiation. Such tumors comprise lesions derived from; elements within the thymus, paraganglionic nests, misplaced embryonal structures within the mediastinum and rarely from aorticopulmonary or aorticosympathetic paraganglia or from ectopic or supernumerary parathyroid glands. Neuroendocrine Carcinomas of the thymus may be asymptomatic or have signs and symptoms of rapidly growing mediastinal mass. One third of patients may have endocrine symptoms, Multiple Endocrine Neoplasia (MEN) -type 1 syndrome, polyarthropathy, proximal myopathy, peripheral neuropathy, hyperparathyroidism, inappropriate antidiuretic hormone secretion, Eaton-Lambert syndrome, and hypertrophic osteoarthropathy. They are not associated with myasthenia gravis, hypogammaglobulinemia, or the carcinoid syndrome Conclusion- Primary neuroendocrine tumors of the thymus are rare aggressive tumors associated with poor survival. Surgical resection of the tumor remains the treatment of choice because the experience with adjuvant therapy has been unsatisfactory. P86 AETIOLOGY OF HEMOPTYSIS IN PATIENTS PRESENTING IN DEPARTMENT OF PULMONARY MEDICINE, MEDICAL COLLEGE HOSPITAL, THIRUVANANTHAPURAM. Dr Smitha P.S, Dr Anithakumari .K, Dr Ronald Win , Dr Sanjeev Nair INTRODUCTION Hemoptysis is defined as coughing up of blood originating from the lungs or tracheobronchial tree. The material and amount produced varies from mere blood streaking of expectorated sputum to massive volumes of pure blood .Massive hemoptysis has been variably defined according to the volume ,but Bronchiectasis, pneumonia and malignancy are the main causes of hemoptysis. The frequency of each disease as a cause of hemoptysis varies in different series, according to the geographical areas implies a life threatening process requiring immediate evaluation and treatment. AIM OF STUDY To determine the proportion of patients presenting with different aetiologies of hemoptysis in Department of Pulmonary Medicine in Medical College Hospital, Thiruvananthapuram for a period from February 2013 to august 2014. MATERIAL AND METHODOLOGY Study design-Descriptive study. Study Period-From February 2013 to August 2015. Assessment include sputum AFB, Sputum Cytology, Chest X-ray, CT chest, Bronchoscopy. All patients were advised to do sputum AFB and chest X ray, if diagnosis was uncertain CT chest and bronchoscopy with tissue diagnosis was done .All patients are assessed for one month after discharge from hospital. RESULTS AND DISCUSSION Total 265 cases of hemoptysis were analysed. Till now, analysis had shown Post TB bronchiectasis вЂ“ 26.79%, PneumoniaвЂ”20.37%, BronchiectasisвЂ”13.58% MalignancyвЂ”13.58%, Smearpositive pulmonary TBвЂ”9.43%, AspergillomaвЂ”3.39%, c/c bronchitis --3.37%, ABPAвЂ”4%, lung abcess 2% and other causes вЂ“3.57%. Massive hemoptysis was present in 11 patients and main etiology was post TB bronchiectasis. Bronchial artery embolisation done in 12 patients Lobectomy was done electively in one patient. There were death of 5 patients while in IP care due to massive hemoptysis. Is inhaled budesonide useful in bronchiectasis? 1 P87 2 S K Singaraju , E P Chelluri . 1. Resident, Post-graduate department of Pulmonary medicine, Shadan Institute of Medical Sciences & Research Centre, Hyderabad, Andhra Pradesh. Phone number: +918897565555 Email: [email protected] 2. Head, Post-graduate department of Pulmonary medicine, Shadan Institute of Medical Sciences & Research Centre, Hyderabad, Andhra Pradesh. Address for the correspondence:[email protected] Background. Role of inhaled steroids in bronchiectasis is controversial. None of the previous studies examined effect of inhaled corticosteroids on post bronchodilator reversibility in bronchiectatic patients. Effect of inhaled budesonide 400 mcg/day on ventilatory functions of 23 consecutive bronchiectatic patients was studied. Subjects and Methods: Bronchiectasis was diagnosed by clinical & imaging criteria. Randomized into two groups. Study group (n=12) inhaled budesonide 400 mcg/day through spacer while Controls (n=11) received placebo inhaler. Both groups received amoxicillin & physiotherapy. Spirometry was performed at 7-day intervals at the same hour of the day. FEV1, FVC, PEFR, FEF 25-75% and вЂњsalbutamol reversibilityвЂќ were tested as per ATS guidelines. Percent change in FEV1, FVC, PEFR, FEF 25-75% and FEV1 reversibility at 0,7,14, and 21 day were analyzed by Student вЂњtвЂќ test. Results: Study group Time FEV1 FVC FEV1 вЂњReversibilityвЂќ Day O 1.58+/- 0.67 1.94+/-0.97 8.18+/-7.3 Day 7 1.59+/-0.74 1.94+/-0.80 11.27+/-11.63 Day 14 1.61+/-0.8 2.07+/-0.93 11.79+/-15.48 Day 21 1.66+/-0.76 2.12+/-0.87 6.44+/-4.95 Control group Day 0 1.28+/-0.48 1.45+/-0.65 5.92+/-8.93 Day 7 1.35+/-0.45 1.63+/-0.65 4.75+/-3.79 Day 14 1.38+/-0.5 1.72+/-0.72 4.82+/-5.90 Day 21 1.48+/-0.46 1.79+/-0.78 3.33+/-5.46 No statistically significant change between study and control groups. Conclusion: The present small study, though the results are not statistically significant, shows a trend of improved вЂњreversibilityвЂќ of FEV1 in the budesonide treated bronchiectatic subjects. P88 Tracheal diverticulum : a rare cause of chronic cough 1 2 3 4 S D GABHALE , S JAIN , N JOSHI , S P AGNIHOTRI DEPT. OF RESPRATORY DISEASES AND TUBERCULOSIS, INSTITUTE OF RESPIRATORY DISEASES, S.M.S. MEDICAL COLLEGE, JAIPUR, RAJASTHAN Introduction : Tracheal diverticulum is a rarely encountered entity, It is an out pouching of tracheal wall progressing as an air filled paratracheal cyst. Most cases are asymptomatic, however they can act as a reservoir for secretions with secondary chronic infections of the tracheobrochial tree. We herein report a case of tracheal diverticula that presented with chronic cough. Case report : A 40 year old female nonsmoker presented with recurrent cough since 1 year. atient had no improvement on antituberculosis treatment. Chest x-ray revealed left lower lobe consolidation, CT chest revealed left lower lobe atelectasis. Fiber optic bronchoscopy showed an opening in left posterior wall of trachea, air bubbles and secretions were coming from opening. Barrium contrast study of the case showed no oesophageal communication. Diagnosis of tracheal diverticulum was made causing recurrent respiratory infection. Conclusion : This malformation is a rare anomaly with two types, the congenital and the acquired one. It must be included into the differential diagnosis of recurrent respiratory infection.computed tomography scans (with thin section and reconstructed images) seem the proper imaging. Bronchoscopy can also visualize the diverticulum although sometimes the connection with trachea can't be detected. Most cases are asymptomatic and need no special treatment. A possible danger of repeated respiratory infections and insufficient intubation and/or ventilation must be in mind. P89 A case of systemic sclerosis with atypical chest presentation Dr. K.NAGA CHAITANYA , Dr. S.V. PRASAD , Dr. T.V. RAJIV MNR MEDICAL COLLEGE AND HOSPITAL BACKGROUND вЂ“ Systemic sclerosis is a relatively uncommon condition with an average annual incidence of 6-12 patients per million population. The disease is most prevalent between 30 and 50 years of age with female preponderance(7:1). Systemic sclerosis is characterized by progressive fibrosis of skin and multiple organs. Parenchymal lung involvement is very common in these patients , lung fibrosis being the most common pattern of abnormality. This current case is unique in that a male patient with cavities in the lung is unusual in Systemic sclerosis. CASE REPORT - A 48-year-old man came to Pulmonary medicine OPD , with the complaints of breathlessness , cough , haemoptysis, generalised weakness since 6 months. He was diagnosed earlier as a case of Bronchial asthma and later as PTB and was started on ATT since 10 days. On examination, his skin was smooth, shiny, thick, hard and hidebound with pigmentary alteration of 'salt and pepper' appearance on limbs, and trunk . Hands and fingers appeared tight and digital ischaemia was present (atrophy, ulceration ) Examination of the respiratory system showed restriction of chest movement and reduced expansibility of chest wall on right side. Decreased Vesicular breath sounds and Crepitations are present on right side of chest . After corroborative investigations the positive findings were:TLC 18000cells/mm3. CUE вЂ“ albumin +. CXR - showed cavities in right lung . Bronchoscopy вЂ“ showed mucus plug in right intermediate bronchus. BAL вЂ“NAD.CT-CHEST showed cavities in right UL, consolidation with cavities in right LL . Serology was non-reactive (negative ANA, Antitopoisomerase antibody, Anticentromere antibody ). Upper GI endoscopy вЂ“ Sliding hernia, erosive gastritis.ECG вЂ“ sinus tachycardia. 2decho вЂ“ mild PAH. DISCUSSION Systemic sclerosis is a systemic and complex collagen vascular disease of unknown etiology The AMERICAN COLLEGE OF RHEUMATOLOGY (ACR) criteria for the diagnosis of systemic sclerosis. One major criteria / two or more minor criteria for diagnosis. п‚— п‚— Major criterion : Proximal scleroderma Minor : 1.Sclerodactyly 2.Digital pitting scars/loss of substance from the finger pad 3.Bibasilar pulmonary fibrosis Serologic specificity of the disease is the presence of ANA ,directed against cellular nuclear enzymes, like DNA topoisomerase -1 (anti вЂ“Topo 1 ) and RNA polymerase, as well as centromeric proteins (anticentromere Ab) . Antitopoisomerase antibody is positive in 20-70% of cases. In this case though the serology was negative as he fulfilled one major and two minor criterias , we diagnosed him as a case of Systemic sclerosis. Pulmonary fibrosis is the most common radiographic finding, present in 20%вЂ“65% of patients.The histologic pattern is of usual interstitial pneumonia. CONCLUSION It is an unusual presentation because of its rare occurrence in male and presentation as cavities in lung. This case highlights the wide variety of presentations in connective tissue disorders and importance of thorough investigation in connective tissue diseases P90 A rare case of haemoptysis with Pulmonary artery thrombosis Dr Subash Immanuel G , , Dr Richa Gupta, Dr D J Christopher Christian Medical College, Vellore, Tamil Nadu, India Hughes Stovin syndrome (HSS) is a rare and life threatening disorder characterized by pulmonary artery aneurysm (PAA) and thrombosis. So far, less than 30 cases have been reported in literature. We report a case of Hughes Stovin syndrome presented with haemoptysis, pulmonary artery aneurysm and thrombosis. A 19 year old male presented with complaints of cough, dyspnoea with intermittent haemoptysis of 4 months duration. His general and systemic examination was unremarkable. His routine blood examination was normal. Connective tissue disease, vasculitis work up and sputum AFB smear were negative. Radiology revealed normal chest x-ray; however, CT pulmonary angiogram (CTPA) showed pulmonary artery aneurysm with intra mural thrombus in bilateral lobar and segmental pulmonary arteries. With above investigations, differential diagnosis of BehcetвЂ™s disease and Hughes Stovin syndrome were considered. Our patient had no complaints of oral or genital ulcers and Pathergy test was negative. His ophthalmology examination was normal and HLA B51 was negative which ruled out the possibility of Behcets disease. He was diagnosed to have Hughes Stovin syndrome and improved on treatment with Immunosuppressant and corticosteroids. Hughes Stovin syndrome was first described in 1959 as a combination of deep venous thrombosis, cerebral venous sinus thrombosis and PAA . It is considered to be a variant of Behcets disease. Diagnosis is made on the basis of clinical history and imaging studies for detection of PAA. Initial management of HSS involves corticosteroids and immunosuppressive drugs. Anti-coagulants are contraindicated due to risk of life threatening rupture of aneurysm. Surgical resections may be the option in patients with localised aneurysm. We conclude that in young patients with haemoptysis and normal initial work up, CTPA and Doppler studies should be considered to look for rarer causes like HSS which if left undiagnosed can be potentially life threatening due to aneurysmal rupture. Aortic aneurysm вЂ“ a rare cause of ortnerвЂ™s syndrome P91 DR. JYOTI PATNAIK, DR. H.K.SETHY, DR. T. MOHANTY, PRADHAN, DR. B.P.TRILOCHAN, Dr. BIJAYA KUMAR MEHER DR. G.PANDA, DR.M.R.DASH, DR. S. Department of pulmonary medicine, scb medical college & hospital,cuttack, Odisha,India OBJECTIVE: To study the cause of hoarseness of voice in a 60yr old male METHODS: detailed history, physical examination, routine blood test, chest x-ray, bronchoscopy, HRCT Thorax, echocardiography, CT-angiography RESULTS: A 60yr old man presented with hoarseness of voice and was found to have left vocal cord paralysis and a medistinal widening on chest X-ray. Fibre optic laryngoscopy & bronchoscopy showed absent movement of left vocal cord. A HRCT scan of thorax and CT Angio Aortogram revealed fusiform aneurysmal dilatation of the arch of aorta possibly compressing left recurrent laryngeal nerve. ortnerвЂ™s syndrome or cardio-vocal syndrome CONCLUSIONS: Hoarseness of voice is a very common condition and underlying causes vary from reversible benign causes to life-threatening malignancies. Unilateral recurrent laryngeal nerve injury is most commonly caused by surgical trauma or a malignant tumor. OrtnerвЂ™s syndrome is a rare disorder characterised by left recurrent laryngeal nerve palsy secondary to a cardiovascular cause. Cardiovocal syndrome was originally described in 1897 by Nobert Ortner in three patients with severe MS. He explained that hoarseness was caused by compression of the left recurrent laryngeal nerve by the enlarged left atrium. Later it has been encountered with other mediastinal structures causing mass effect and in many cardiac conditions for example, congenital heart diseases, mitral valve disorders, ventricular and aortic aneurysms, atrial enlargement and in iatrogenic conditions. Chest radiograph is usually ordered as the first imaging study which can give hints of the underlying condition and direct further studies. CT is useful for evaluating the mediastinum and especially the aortopulmonary region. P92 Title: Tracheobronchopathia osteochondroplastica (TO) вЂ“ only case series from India Dr. Jebin Roger S, Dr. Prince James, Dr. Richa Gupta, Dr. D.J Christopher Christian Medical College, Vellore Introduction: Tracheobronchopathia osteochondroplastica (TO) is a rare benign disease of unknown etiology characterized by cartilaginous or bony outgrowths in the tracheobronchial tree. We present first and largest case series of 8 cases of TO from India. Case Presentation: Out of 13,700 bronchoscopies done from year 2004 to 2014 at Christian Medical College , Vellore , India, we diagnosed 8 cases of TO. Male to Female ratio was 6:2 with a mean age of 48 years (range 2958 years) at the time of diagnosis. The most common symptoms were cough (100%), dyspnea (50%) and hemoptysis (43%). CT thorax showed multiple beaded calcified nodules in the tracheobronchial tree in 7 cases. Bronchoscopy showed diagnostic typical appearance of multiple irregular hard nodules in trachea, sparing the posterior membranous wall. In 6 cases, bilateral main bronchi were also studded with TO nodules. Bronchoscopic biopsy of these nodules gives hard gritty feeling of cutting hard structure. Bronchoscopic biopsies showed calcifications, cartilage and lamellar bone formation in respiratory mucosa. In one patient, TO presented as right upper lobe endobronchial growth, for which she underwent right upper lobectomy. Out of 8 cases, one patient also had active TB and received ATT. The rest of the patients were put on symptomatic treatment. Discussion: Bronchoscopy remains the gold standard for identifying TO with typical findings of multiple irregular nodules in tracheobronchial tree, sparing the posterior wall of trachea. Though the course of disease remains benign, some cases may present with airway obstruction, post-obstructive pneumonia, atelectasis, and difficult intubation. The treatment of TO varies from symptomatic management, endobronchial treatments to operative debulking surgeries depending on the severity of airway obstruction. Conclusion: TO is a rare benign disease and Bronchoscopy is the most important tool to detect TO. Awareness of the condition among physicians is important to identify this rare disorder of the tracheobronchial tree. P93 Bilateral Congenital Cystic Adenomatoid Malformation with Tuberculosis in an adolescent: a rare presentation DR. J. PATNAIK, DR. H.K. SETHY, DR. T. MOHANTY, DR. G. PANDA, DR. M.R. DASH, DR. S. PRADHAN, DR. BP TRILOCHAN, DR. DIBYA PRAKASH ACHARYA Dept. of Pulmonary Medicine, SCB Medical College, Cuttack, Odisha. Introduction Congenital cystic adenomatoid malformation (CCAM) of the lung is a rare developmental anomaly of tracheobronchial tree beyond terminal bronchioles. Incidence 1 in 25,000в€ј30,000 pregnancies. The lesion is usually unilateral. Most cases are diagnosed antenatally or in neonates/infants who present with severe respiratory distress or pulmonary infections. Occasionally, CCAM remains unrecognized until adolescence or adulthood. Recurrent bacterial infections are frequent feature of CCAM. Case Summary A 14 year old female presented with the complains of Fever for 4months low grade, intermittent, with evening rise of temperature, not a/w chills, rigor. Cough for 4months with scanty mucoid expectoration. Chest examination revealed diminished breath sounds at left anterior chest. Sputum for AFB- negative. Chest x ray showed nonhomogenous opacity over left hemithorax. Patient was started on Anti Tubercular Therapy CAT I DOTS. She improved with ATT. CXR PA View showed multiple cystic lesions; opacities in the previous radiograph had cleared. HRCT Thorax :Left Lung showed multiple large cystic lesions, largest of size 14.4 * 6.6 cm Type I CCAM .Right Lung showed multiple small cystic lesions largest size 1.2* 1 cm Type2 CCAM.A diagnosis of bilateral CCAM in adolescent secondarily infected with Tuberculosis was hence made. Discussion CCAM is an abnormality characterised by a hamartomatous multicystic mass of pulmonary tissue with an abnormal proliferation of bronchial structures.Type I CCAM most common includes multiple large cysts (>2 cm in diameter) Type II CCAM has multiple small cysts, less than 2 cm in diameter.Type III CCAMs are a solid mass consisting multiple adenomatoid microcysts, less than 0.5 cm in diameter. Radiograph: Multiple air filled cysts Diagnostic method of choice is the HRCT. Lobectomy is the treatment of choice. Unusual bilateral involvement Left Lung Type1 Right Lung type2 CCAM and Tubercular superadded infection in adolescent makes it a rare presentation. Spontaneous esophagopleural fistula:a rare case report P94 DR J.PATNAIK,DR HK SETHY,DR T.MOHANTY,DR G PANDA,DR MR DASH,DR S.PRADHAN,DR BP TRILOCHAN DR JYOTIRMAYA SAHOO. Dept of Pulmonary medicine,SCB Medical college and hospital ,cuttack,Odisha. INTRODUCTION:-Esophagorespiratory fistula (ERF) is an uncommon condition despite the anatomical proximity of these structures.Malignany of esophagus,lung and mediastinum is recognized as the most common cause.Benign ERF is very rare and may be due to trauma and infections.Here we report a rare case of spontaneous esophagopleural fistula. CASE REPORT:-A 34 year old male was admitted to scb medical college,cuttack,odisha complaining of right side chest discomfort and regurgitation of food particles during feeding.He has known psychiatric(bipolar ) disorder since last 7years on antipsychotic medications.He had no smoking history.No previous operative history.No medical history like diabetes mellitus,hypertension,tuberculosis or hepatitis.On physical examination diminished breath sound in right IAA,ISA and lower inter scapular area.Dull note on same area.Rest of the right hemithorax is normal resonant note and normal breath sound.All routine investigations are WNL.Chest x ray revealed a homogenous opacity with straight upper boarder in right lower zone.Diagnostic tap was dry.On usg thorax there was minimal collection in right pleural space.On CT Thorax there was a suspicious connection between esophagus and pleural space.On oral contrast administration the contrast moved to pleural space.On barium swallow study barium passed into pleural space.On upper GI endoscopy there was fistulous opening in esophagus that connects to right pleural space.So final diagnosis is Spontaneous esophagopleural fistula.Finally patient was operated (closure of EPF and reconstruction of esophagus ) and patient is doing well now. Tissue biopsy was taken and it was nontubercular. DISCUSSION:-Spontaneous esophagopleural fistula is a very rare condition.Spontaneous rupture of esophagus occurs due to sudden raise of itraesophageal pressure .usual complains of patients are retrosternal chest pain and vomiting.On chest x ray reveals as pleural effusion,hydropneumothorax or pneumothorax.CT thorax helps to find any mediastinal involvement.Conservative management with ICT drainage of pleural space and finally definite surgery required. P95 A RARE CASE OF LEFT UPPER LOBE LESION AUTHORS вЂ“ DR SANJEEV MEHTA, DR SWAPNIL THORVE, DR ANURATI MEHTA, DR KARISHMA BHATIA CASE: 28 YEAR ASYMPTOMATIC FEMALE REFERRED FOR LEFT ZONE OPACITY PERSISTENT SINCE 5 YEARS. INVESTIGATIONS: HRCT CHEST REVEALED LARGE, WELL ENCAPSULTED, LEFT UPPER LOBE MASS 7.1 x 4.5 CM WITH ECTOPIC CALCIFICATION, INDENTING THE TRACHEA AND SUPERIOR MEDIATINAL STRUCTURES WITHOUT INFILTRATING THEM. FNAC REVEALED LYMPHOID CELLLS. CT GUIDED BIOPSY REVELAED CASTELMANвЂ™S DISEASE. TREATMENT: COMPLETE SURGICAL EXCISION OF THE MASS. UNEVENTFUL RECOVERY. SURGICAL SPECIMEN CONFIRMED THE DIAGNOSIS. DISCUSSION: CASTLEMANвЂ™S DISEASE OR ANGIOFOLLICULAR LYMPH NODE HYPERPLASIA IS A RARE DISORDER CHARACTERISED BY BENIGN PROLIFERATION OF LYMPHOID TISSUE (CERTAIN B CELLS). WHILE NOT OFFICIALLY A CANCER, OVERGROWTH OF LYMPOID CELLS RESEMBLES A LYMPHOMA. TWO CLINICAL ENTITIES HAVE BEEN DESCRIBED, UNICENTRIC (CONFINED TO A SINGLE LYMPH NODE STATION) OR MULTICENTRIC (GENERALISED, WITH MORE AGGRESSIVE CLINICAL COURSE, USUALLY WITH HIV INFECTION). FOUR HISTOPATHOLOGICAL SUBTYPES HAVE BEEN DESCRIBED, HYALINE-VASCULAR, PLASMA CELL, PLAMABLASTIC AND MIXED. PREOP DIAGNOSIS IS DIFFICULT AND FINAL SUBTYING IS USUALY ON THE POST OP SPECIMEN. WHILE RADIATION, STEROIDS, ANTIVIRAL DRUGS, CHEMOTHERAPY AND IMMUNOTHERAPY ARE TREATMENT OPTIONS, THE BEST CURE, IN UNICENTIRIC DISEASE, IS COMPLETE SURGICAL EXCISION. OUR CASE IS IMPORTANT AS IT HIGHLIGHTS A RARE CONDITION THAT IS OFTEN MISSED OR CONFUSED WITH TB OR LYPHOMA. HIGH INDEX OF SUSPICION AND AGGRESSIVE APPROACH TO MANAGEMENT IS NEEDED. P96 Title: The oxidative stress determined through the levels of antioxidant enzymes and the effect of N-acetylcysteine in aluminium phosphide poisoning. MANISH GUTCH, AVINASH AGARWAL, ROTO ROBO, NIRDESH JAIN Department of Internal medicine, King GeorgeвЂ™s medical university, Lucknow, India ABSTRACT Objectives: The primary objective of this study to determine the serum level of antioxidant enzymes and to correlate them with outcome in patients of aluminium phosphide (ALP) poisoning and secondly, to evaluate the effect of N-acetylcysteine (NAC) given along with supportive treatment of ALP poisoning. Design: We conducted a cohort study in patients of ALP poisoning hospitalized at tertiary care center of NorthIndia. The treatment group and control group were enrolled during the study period of one year from May 2011 to April 2012. Interventions: The oxidative stress was evaluated in each subject by estimating the serum levels of the enzymes viz. Catalase, superoxide dismutase (SOD) and Glutathione reductase (GR). The treatment group comprised of the patients who were given NAC in addition to supportive treatment (magnesium sulphate and vasopressors, if required), while in control group only supportive treatment was instituted. Primary end point of the study was the survival of the patients. Measurements and Results: The baseline catalase and SOD were reduced, however GR level was not reduced rather was increasing with due time, and more so in treatment group. The baseline catalase (p =0.008) and SOD (p <0.01) levels were higher among survivors than to Non-survivors. But, no association of outcome with baseline GR levels (p =0.064), but the levels on day 1 was associated with outcome (p =0.017).Out of total, 31(67.4%) expired and 15(32.6%) survived. Survival rate was 45.8% (11/24) in treatment group and 18.2% (4/22) in controls (p =0.045). Among who expired, the mean duration of survival was 2.92В±0.40 days in test group and 1.82В±0.33 days in control (p=.043). Conclusions: This study suggests that the baseline level of catalase and SOD have reduced in ALP poisoning, but baseline GR level has not suppressed, rather is increasing with due time, and more so in treatment group. NAC along with supportive treatment has improved survival in ALP poisoning P97 Pulmonary arteriovenous malformations with recurrent stroke late diagnosed but well managed!!! N.D.Gondaliya, R.M.Kshatriya, N.V.Khara, R.P.Paliwal, S.N.Patel. Dept of Respiratory Medicine, Pramukhswami Medical College, Karamsad 388325,Gujarat. Introduction: PAVMs is an abnormal communication between the pulmonary artery and vein being congenital in origin; it may be acquired in several conditions. Approximately 70% cases of PAVMs are associated with Hereditary Hemorrhagic Telangiectasia(HHT). Presenting symptoms include dyspnea, easy fatiguability and rarely hemoptysis. Approximately 4% to 12% develop complications like paradoxical embolism and stroke. Contrast enhanced pulmonary angiography (CTPA) is the gold standard test. Treatment of choice is therapeutic embolization and lung surgery. We report a case here as was managed as chronic obstructive pulmonary disease (COPD) for 5 years and later diagnosed as PAVMs with stroke. Case report: A 62 year female patient presented with exertional dyspnea and easy fatiguability for 5 years which exacerbated since 10 days with inability to speak since 2 days. On examination cyanosis,clubbing and crepitations were present over right lung. Neurological examination revealed Opercular syndrome (Trigemino-lingio-faciobuccal apraxia). She was on treatment for COPD for 5 years and had cerebrovascular stroke(Left frontal lobe) 3 years back. On investigatigating blood report showed hypoxemia and polycythemia. Where as chest X-ray showed right lower zone opacity with CTPA showing complex pulmonary arterio-venous malformations in the right middle, lower and left upper lobe largest being 12.1 mm. CT scan of brain suggested acute infarct in right temporal lobe. Contrast echocardiography showed 'extracardiac right to left shunt'. Finally she was diagnosed as PAVMs with paradoxical brain embolism. Angioembolization was done and anticoagulant therapy started with supportive treatment and patient is better now. Conclusion: Uncommon disorder like PAVMs can be misdiagnosed and managed as chronic obstructive pulmoanary disease. So it is worth to investigate in detail in patients with unexplained hypoxia, cyanosis, clubbing and recuurent stroke. For earlier diagnosis of PAVMs and better outcome, emphasis should be placed on a multidisciplinary approach and inclusion in differential diagnosis. P98 Prospective Study around Etiology of Mediastinal Lymphadenopathy using TBNA in a tertiary care center A. Prabhu, R. Chawla Indraprastha Apollo Hospital, New Delhi, India Objectives:To find diagnostic yield in various etiology of mediastinal lymphadenopathy in a tertiary care center Method:Following a meticulous,clinical and radiological assessment, bronchoscopic TBNA was performed in all patients. Other procedures performed were Bronchial Biopsy and BAL. Result:The most common etiology found in our study was Tuberculosis in 43 patients (41%) followed by Granulomatous Inflammation, mostly Sarcoid, in 31 patients (29.5%). Lowest prevalence was for Lymphoma (found in 1 patients only) вЂ“ 1%. There were 7 (6.7%) cases of Malignancy and Fungal in 8 patients (7.6%). Our study could not find the final diagnosis in 15 patients (14.3%) due to lack of conclusive evidence. A sufficient specimen was obtained in 87 out of 105 patients and TBNA could establish a diagnosis in these cases. Overall yield of TBNA was 82.86% and the diagnostic yield of TBNA was 68.57%. Coming to specific yields, highest came from malignancy and lymphoma (100%) and lowest yield came from necrotizing/AFB (Tubercular etiology) [58.1%]. Granulomatous Inflammation (Sarcoid) diagnosed patients gave a yield of 64.5% while patients diagnosed with Fungal during TBNA gave a yield of 87.5%. Conclusion: We recommend that TBNA is a reliable, safe and relatively cheap investigational method with good diagnostic accuracy. Especially for endobronchial lesions, it may obviate the need for more invasive surgical procedures. We also learnt multiple sampling of nodes, rapid onsite cytology method and optimizing interactions at every step may prove to be most cost effective measures. EBUS TBNA is not very practical owing to high cost especially in developing country like India. So the novel approach to be recommended is to first perform conventional TBNA and refer only inconclusive cases for EBUS procedure. P99 Effect of oral Zileuton in acute asthma вЂ“ a prospective, randomized, double blinded study. Shahul Hameed ABOOBACKAR, Rahul MAGAZINE, Bharti CHOGTU Kasturba medical college, Manipal, Karnataka, India Objective: 5- Lipoxygenase inhibitors are well established in the management of chronic asthma. However, very little is known about their role in acute asthma. Our objective was to study the efficacy of oral Zileuton in acute asthma. Methods: We conducted a prospective, randomized, double blinded study whereby 80 patients aged 18 to 65 attending the outpatient department or emergency department under Pulmonary Medicine unit of Kasturba Medical College, Manipal with a primary diagnosis of acute asthma were admitted and randomly assigned to receive either 600 mg of oral Zileuton or placebo at enrolment and again after 12 hours, with twice daily administration thereafter in addition to the standard therapy for acute asthma. The peak expiratory flow (PEF) was measured at baseline, at 6 hours, 12 hours, 24 hours and 48 hours following administration of the study drug and then at discharge. Additionally, PEF was measured between 8 вЂ“ 10 am during the morning following admission. The primary endpoint was the difference in PEF between the Zileuton and placebo groups at the various time points following treatment. The secondary endpoint was the need for rescue medications by patients in each group. Results: Data of all 80 enrolled patients were analysed at the end of the study. It was found that patients receiving Zileuton had significantly higher PEF values than patients receiving placebo (p = 0.007). The higher PEF values were sustained over the entire hospital stay. Moreover, the need for rescue medications in the Zileuton group were significantly lesser (p = 0.049) in comparison with the placebo group. No adverse effects were reported during the study. Conclusion: Additional administration of Zileuton results in greater improvement in lung functions in acute asthma than that attained by current standard treatment. P100 Asymptomatic Achalasia cardia presenting with bilateral bronchiectasis Shahul Hameed ABOOBACKAR, Aswini Kumar MOHAPATRA, Manu Mohan K Kasturba medical college, Manipal, Karnataka, India Introduction: Achalasia is a disorder of oesophageal motility characterised by aperistalsis of oesophageal body, and impaired relaxation of lower oesophageal sphincter. Most cases of Achalasia are symptomatic and usually present with dysphagia, nasal regurgitations and heart burns. The oesophageal dysmotility can predispose to repeated aspirations, resulting in recurrent pneumonias and bronchiectasis. We present a case of asymptomatic achalasia cardia which presented initially as a pulmonary complication. Asymptomatic achalasia presenting with bilateral bronchiectasis is extremely rare. History and physical examination: A 25-year-old female, presented with chronic expectorative cough and exertional shortness of breath since 10 years with recent aggravation. She had undergone multiple hospital admissions for recurrent pneumonias in the past. There was no past history of pulmonary tuberculosis. General physical examination was normal. Respiratory system examination revealed bilateral diffuse coarse crepitations. Examination of other systems did not reveal any abnormality. Investigations: Routine blood investigations were normal. Chest radiograph showed bilateral bronchiectatic changes, predominantly over the right mid-zone and left lower zone. Sputum Ziehl-Neelsen staining for acid fast bacilli was negative. High resolution computerised tomography (HRCT) of thorax revealed cystic bronchiectasis involving right upper lobe and middle lobe segments, left lingular segments and anterior medial basal segment of left lower lobe, along with dilatation of the entire extent of esophagus and smooth narrowing at gastroesophageal junction. Upper gastrointestinal endoscopy showed inflammatory changes with minimal ulcerations along the lower esophagus. Barium swallow study showed dilated thoracic oesophagus with narrowed gastroesophageal junction. Oesophageal manometry showed high pressure at the level of lower oesophageal sphincter and confirmed aperistalsis along the lower esophagus. Management and outcome: She was offered surgical management (HellerвЂ™s myotomy), but she declined and her symptoms persisted on follow up. P102 Title : INSULINOMA PRESENTING AS ADULT-ONSET SEIZURE DISORDER Name: Dr VENKATESH MALALI , Dr SHIVKUMAR B.G , Dr SHASHIKANTH M Institution: JJM MEDICAL COLLEGE, DAVANGERE. INTRODUCTION: Once diagnosed with a refractory seizure disorder, patients often receive aggressive and escalating pharmacotherapy. Toxic and metabolic causes of seizures should always be considered as they are potentially curable, and may be fatal if untreated .We describe a case of insulinoma who presented with recurrent seizures. METHOD: A 62 year old female presented to ED with H/o of generalised tonic clonic seizures. She was a known epileptic since one year on multiple anticonvulsants. On enquiry she gave H/o dizziness and excessive sweating prior to each seizure episodes and was mainly in morning and before meals. Patient claims feeling better after meals. No significant past medical and family history and denied addiction. O/E -Patient was well built, drowsy, PR=80/min, BP=130/80 mm Hg, bilateral pupil 3-4 mm equally reactive to light. Systemic examination was normal except drowsiness with no focal neurodeficits. Brain imaging and EEG including routine hematological investigations were normal except RBS-38mg/dl. She was started on dextrose infusion and anticonvulsant. During hospital stay she developed repeated hypoglycemia and seizure episodes. So she was further investigated and evaluated for cause of hypoglycemia. Investigations revealed FBS-30 mg/dl, S.insulin-6.96 uU/ml (normal < 6 uU/mL). Serum C-peptide-2.2ng/ml(normal < 2 ng/mL),HbAlc-<4.CECT Abdomen was done suggestive of 1.5 cm enhancing mass at head-neck junction of pancreas. So working diagnosis of pancreatic insulinoma with hypoglycaemic seizures was made. She underwent enucleation of the nodule at higher centre and became asymptomatic. Histopathology revealed well differentiated neuroendocrine tumour. CONCLUSION: A high index of suspicion for a rare cause like insulinoma is warranted for non diabetic patients presenting with intractable seizures with hypoglycemia not responding to anticonvulsant treatment, which is amenable to complete cure. P103 Unilateral hyperlucent lung: Common and uncommon causes presenting in the department of pulmonary medicine at GMC, Patiala, from january 2014 till date . VIDHU MITTAL , URVINDERPAL SINGH, ADITI, SUNIL KUMAR, MURLI Department of Pulmonary Medicine, Govt. Medical College, Patiala,Punjab, India Abstract: Unilateral hyperlucency is described as darker appearance at one side due to increased X-ray transmission. This radiologic appearance may be due to technical impropriety, chest wall abnormalities and increased air volume and decreased pulmonary vascularization on that side. In diagnostic approach to unilateral hyperlucency, soft tissues, lung volumes, air trapping existence, pulmonary vessels sizes and lung hilum should be carefully evaluated. Objectives: 1. To recognize a unilateral hyperlucent lung on chest radiography and computed tomography (CT). 2. To describe the common causes of a unilateral hyperlucent lung on chest radiography and CT and to understand the pathophysiology of certain conditions. 3. To list an appropriate differential diagnosis in case of a unilateral hyperlucent lung and to provide a targeted diagnosis when certain associated radiological signs are seen. P104 DIAGNOSIS BY TRANSTHORACIC PERCUTANEOUS FNAC IN PERIPHERAL LUNG LESIONS. Dr.Keyur Patel, Dr.Nasim Mondal, Dr. Savita Jindal, Dr. Nalin T. Shah, Dr. Kusum V.Shah Department of Pulmonary Medicine, BJMC, Ahmedabad, Gujarat- India. INTRODUCTION: Lung cancer is most commonly diagnosed cancer world wide Transthoracic Percutaneous FNAC of lung is rapid and safe diagnostic tool. AIM: To Assess a role of Transthoracic Percutaneous FNAC and to determine the sensitivity and specificity of FNAC with USG and CT guided aids in peripheral lung mass. METHODS AND MATERIALS: A study of 50 patients, conducted in Aug 2013 вЂ“ Aug. 2014 in age group of 30-90 years in both the sex. The samples were taken by the pathologist with the radiologist. At first, ultrasound was used. If lesion well visualized, aspiration performed otherwise CT was chosen for image guidance. RESULTS: The FNAC were positive for malignancy in 27 (54%) cases, hemorrhagic aspiration 10(20%) cases, Suspicious of malignancy in 6 (12%) cases, inflammatory infiltrate in 3 (6%) cases, inadequate aspirate in 3 (6%) cases, granulomatous lesion in 1 (2%) cases. Most common malignancy was Adenocarcinoma (44.44%) followed by squamous cell carcinoma (15%), Non-small cell carcinoma (15%), carcinoma (4%), small cell carcinoma (4%) Non HodkinвЂ™s Lymphoma (4%) and poorly differentiated 15% . Prevalence, sensitivity, specificity, positive predicted value. Negative predicted value, and Accuracy observed 80%, 82.5%, 100%, 100%, 58.82% and 86% respectively. The details of results will be discussed in study. CONCLUSION: Transthoracic FNAC for peripheral lung lesions is a safe and efficient method for cytological diagnosis. It has high Sensitivity Specificity, Positive Predicted Value and Negative Predicted Value. P105 Erasmus syndrome associated with broncholithiasis, bronchoesophageal fistula and active pulmonary tuberculosis: A rare case report Paulo Varghese Akkara, George Albert DвЂ™souza, Priya Ramachandran, Uma Devraj, Department of Pulmonary Medicine, St Johns medical college Background: Erasmus syndrome describes the association of generalised progressive systemic sclerosis following exposure to silica with or without silicosis. Silicosis and progressive systemic sclerosis coexisting in the same patient were published from western and Indian literature. We are reporting a case of 38-year-old female quarry worker who developed silicosis and systemic sclerosis complicated by broncholithiasis, bronchoesophageal fistula and active pulmonary tuberculosis. To our best of knowledge, this is the first case report of coexistence of Erasmus syndrome with broncholithiasis, bronchoesophageal fistula and active pulmonary tuberculosis Case Report: A 38-years-old female, quarry worker presented with history of fever, cough, and breathlessness of 3 months duration. All her symptoms worsened in the last 2 weeks and developed cough on swallowing. Examination findings revealed thickening of skin and microstomia suggestive of scleroderma. Signs s/o right sided lung fibrosis was also present. Her sputum was positive for acid fast bacilli (AFB). RA factor was negative and ANA was positive. Skin biopsy consistent with scleroderma. CECT showed multiple calcific lymph nodes with fibrotic changes, centrilobular nodules with tree in bud pattern along with reticular opacities consistent with ILD. Bronchoscopy showed distorted bronchial anatomy and multiple broncholiths and fistulous opening. Barium study showed the presence of bronchoesophageal fistulas. The patient was started on anti-tubercular therapy along with management of scleroderma and oral feeds through nasogastric tube as patient refused any further invasive management. Conclusion: This is the first case report of coexistence of Erasmus syndrome with broncholithiasis, bronchoesophageal fistula and active pulmonary tuberculosis P106 TITLE- To Assess the Knowledge of RNTCP in Post Graduate Students AUTHOR(S) вЂ“Dr Aparna Iyer, Dr Bhumika Madhav , Dr Girija Nair, Dr Abhay Uppe, Dr Jayalakshmi T.K, Dr Lavina Mirchandani, Dr Mugdha Bhide INSTITUTION-Dr D.Y.Patil Hospital and Research Centre, Sector 5 , Nerul, Navi Mumbai - 400706. Maharashtra . Background-Causes of MDR/XDR Tuberculosis are improper regimen, inadequate treatment and Default. RNTCP has protocol on evidence based regimens which intend to cope with these difficulties and ensure proper management.Awareness regarding the need for doctor to imply the RNTCP protocol needs to be ensured for success of the programme. PG students are the future of a country's medical care system; hence awareness should be created at an early stage. Aim- Evaluation of sensitisation and awareness regarding RNTCP protocol among PG students. Method-PG students who attended the RNTCP sensitisation programme were subjected to a set of questionnaire to assess their knowledge. Result-Following were the most common answers. Awareness in Students Percentage Aware of RNTCP 100% Source- Study Course/Sensitisation /Television 60%/30%/10% advertisement RNTCP Categories 50% Category III was scraped off 36% Category IV/V existed 40% Category1 Regimen 70% Category2 Regimen 46% Definition of MDR Tuberculosis 66% Definition of XDR Tuberculosis 46% Diagnosis of MDR Tuberculosis 55% Diagnosis of XDR Tuberculosis 46% Persistent cough> 2 weeks for AFB examination 26% HIV- TB National Programme 16% Dots Principle:-Common Answer-Early Detection, Prevents Relapse, Free of Cost Rare Answer-Ensures compliance HIV-TB Co infection- Common Answer- Anti Koch Treatment should be started 2 weeks prior to antiretroviral Treatment Awareness Score Card вЂ“100% students said they benefited from the sensitization programme. Conclusion- Regular Intradepartmental RNTCP sensitisation programme will create better awareness among PG students about the RNTCP protocols, hence reducing the rate of MDR / XDR tuberculosis. P107 Clinical Audit of a Community Respiratory Centre in Bangladesh Kamrun Nahar, GM Monsur HABIB, President, Primary Care Respiratory Group, Khulna, Bangladesh A clear shifting of respiratory diseases from communicable to non-communicable (NCD) sector is observed during last decade in the developing countries of South East Asia. Asthma, COPD, Allergic Rhinitis, Bronchiectasis etc are imposing huge burden on primary care health service in Bangladesh where these respiratory NCDs are well managed. Aim of this study is to examine the power of primary care respiratory service by analyzing a clinical audit of a CRC in Bangladesh. Method: We have selected one of the 15 CRCs in the southern part of Bangladesh under the GARD-WHO recognized project вЂњBetter Breathing BangladeshвЂќ. We analyzed clinical audit report of CRC to examine the power of service for improvement of respiratory NCDs. Study period was from 19 September 2013 to 19 September 2014. Result: A total of 4366 patient was registered and all the medical records were saved in software вЂњDoctors GuideвЂќ in the CRC. The distribution of disease was: Asthma 2736, Allergic Rhinitis 263, High probability of Asthma 335 (symptom based diagnosis, not confirmed reversible airway obstruction due to age i.e. under-7 children), transient BHR 108, UACS 45, COPD 499, bronchiectasis 17, Chronic Bronchitis 13 and others 350. Co-morbidities are also recorded in the audit among them, GERD, AR, ACOS, Pregnancy, Rheumatoid Arthritis, visual, hearing and cognitive impairment are also recorded to set up the target of care for the coming year in the centre. Conclusion: Respiratory NCDs are common in South East Asia and its care need to invest all the efforts to primary care rather than secondary or tertiary care health service. Primary care respiratory services should be updated and empowered for the better service through continuous clinical audit and developing appropriate Clinical Practice Guidelines (CPG). P108 RARE CASE OF ALVEOLAR MICROLITHIASIS R A S KUSHWAHA, RAJIV GARG, SANTOSH KUMAR, S K VERMA, ASHWINI KUMAR MISHRA, NEHA KAPOOR. Pulmonary alveolar microlithiasis (PAM) is an uncommon chronic disease characterized by calcifications within the alveoli and a paucity of symptoms in contrast to the imaging findings. It occurs sporadically and it is regarded as an autosomal recessive lung disease. A 21 years old male, Non Smoker, presented to us with chief complaints of non progressive exertional breathlesness since childhood. He had no other significant history and no abnormality was detected on physical examination. Chest X Ray PA view showed bilateral diffuse nodular shadows more on lower lung fields. Spirometry was suggestive of restrictive lung disease. CT Thorax showed bilateral multiple fine nodular lesions with basal predominance, intra and interlobular septal thickening in both lung fields. Foci of calcification noted in both lung fields, pericardium and mediastinal pleura. There was clinicoradiological dissociation as the patient was quite asymptomatic despite significant radiological findings. A HRUSG of the scrotum was done which revealed calcification of the testes. Hence,a provisional diagnosis of pulmonary alveolar microlithiasis was made. Pulmonary alveolar microlithiasis (PAM) is a rare disease of unknown etiology characterized by the widespread intra-alveolar deposition of laminated calcispherites in the lung. Most patients are between the ages 30 to 50 years at the time of diagnosis. It is often diagnosed incidentally following a chest radiograph. The aetiology and pathogenesis are obscure. Technitium 99 scan is diagnostic. Most patients remain symptom-free for many years despite extensive radiological changes. There is a striking contrast between the paucity of signs and symptoms and the marked radiographic features. Patients eventually develop dyspnoea on exertion that limits their physical activity. Eventually respiratory failure and corpulmonale supervene. Survival of 10-20 years is characteristic. So far no reversible treatment of this disorder is known. We report this rare and interesting disorder in an asymptomatic young adult. P109 Acute onset rapidly progressive multisystem Granulomatosis with polyangiitis(WegenerвЂ™s Granulomatosis) requiring plasmaphersis JAIN R.S., MATHUR R.S., KADAM S.J. Abstract Granulomatosis with polyangiitis (WegenerвЂ™s Granulomatosis) is a rare idiopathic autoimmune multisystem vasculitis characterised by necrotising granulomatous inflammation and pauci-immune vasculitis involving small and medium size blood vessels. Here we present a case of a 21 year old male who had a 4 day history of cough, fever and haemoptysis followed by epistaxis. Granulomatosis with polyangiitis was diagnosed by CT guided lung biopsy and p-anca being positive. Patient had a rapid progressive involvement of renal system in spite of giving pulse cyclophosphamide and oral steroids. Renal biopsy showed focal necrotising glomerulonephritis with crescents. Patient required plasmaphersis to which he responded. P110 A CASE REPORT OF CONGENITAL PULMONARY AIRWAY MALFORMATION DR NALINI GHANATE, DR.A.SATHYA PRASAD, DR.PRASHANTHY, DR.VIJAY, DR.SUBBA RAO MAMATA MEDICAL COLLEGE AND HOSPITAL, KHAMMAM Introduction: Congenital pulmonary airway malformation (CPAM), previously known as congenital cystic adenomatoid malformation (CCAM), is a rare developmental anomaly of the lower respiratory tract with a reported incidence between 1:25,000 and 1:35,000.It is a multi-cystic mass of segmental lung tissue with abnormal bronchial proliferation and is considered part of the spectrum of bronchopulmonary foregut malformations. We report a case of CPAM in a 6year old child with recurrent infections. Case report: A 6-year-old boy born of secondary consanguineous marriage presented with high grade fever and cough with expectoration of 15 days duration. Past history revealed admission in NICU at birth for respiratory distress and similar complaints at the age of four. Physical examination revealed decreased breath sounds and end inspiratory crackles in right upper part of chest. Finger clubbing was absent. Laboratory investigations showed anemia and neutrophilic leukocytosis. Mantoux test was negative. A chest radiograph showed multiple cystic lesions in the right upper lobe. Computed tomography (CT) showed organized multiple cystic changes with surrounding consolidation in the right upper lobe. He was treated with antibiotics and referred to pediatric surgeon. Surgical resection was done and biopsy revealed congenital pulmonary airway malformation. Conclusion: Early recognition and surgical intervention of CPAM is essential in view of complications like recurrent infections and bronchogenic carcinoma. It is usually diagnosed in fetal or neonatal life. Serial ultrasonographic evaluation, fetal lung mass size, and fetal echocardiography are needed for management of antenatally detected cases .We report this case for its rarity. P112 Primary pulmonary hypoplasia masquerading as cystic bronchiectasis in an adult. K.V.V. Vijaya kumar, K. Preethi, Ch.R.N. Bhushan Rao, K.Venkataramana, Government Hospital for Chest & Communicable diseases (GHCCD) , Andhra Medical College, Visakhapatnam,AP,India. Introduction : Primary pulmonary hypoplasia is an intrinsic defect in the process of lung development with an incidence of 1-2 cases for 12000 live births. Congenital anomalies are increasingly diagnosed in the adulthood as they mimic other thoracic pathology or remain asymptomatic in the childhood. We report a case of right sided primary pulmonary hypoplasia masquerading as cystic bronchiectasis. Case report : A 30 year old nonsmoker male patient presented with complaints of cough , expectoration which is more on left lateral position , shortness of breath and right sided chest pain of 1 month duration. He had similar complaints since 16 years and was being treated under the provisional diagnosis of right total lung cystic bronchiectasis of congenital etiology. Chest examination revealed loss of lung volume with diminished breath sounds and coarse crepitations on right side. Chest radiograph showed cystic changes and ipsilateral mediastinal shift on right side with compensatory hyperinflation on left side. Spirometry showed severe obstructive and severe restrictive abnormality. HRCT chest showed multiple thin and thick walled intercommunicating cystic areas connected to lobar bronchi which had decreased calibre on the right side. 2D ECHO showed situs solitus with dextro position of heart. Bronchoscopy revealed multiple blind pouches at the distal end of right main bronchus with narrowing of lumen of right lobar bronchi. CTPA showed small calibre of right main pulmonary artery (16mm) , lobar and segmental arteries than left side. Conclusion : Prognosis depends on integrity of remaining lung and presence of associated congenital malformations. Pulmonary hypoplasia should be kept in mind as a differential diagnosis in cases of congenital cystic brochiectasis. P113 Myth and Truth of Patient Satisfaction Surveys in Teaching hospital AP KANSAL, Kiran N, Nancy GARG, Kamal Deep, Sudesh Kumari, Varinder SINGH Bamrah Department Of Chest & TB, GMC, Patiala, Punjab Introduction: The primary goal of hospital is to provide best possible health care to patients. Where it is the right of every patient to demand best possible care, it is the duty of every staff member of the hospital to deliver optimum efforts to the entire satisfaction of the patient and its assessment will give us an opportunity to find loopholes in our services and future ratification.Measuring and reporting of impartial patient satisfaction survey is major issue . Method & Materials:The patients admitted over year were randomly selected in three groups,one group was interviewed by health professional or hospital staff, one by volunteers, and third was by patient satisfaction questionnaire. Patient satisfaction is assessed regarding the outpatient department services, waiting time, facilities, and perception about the performance of staff, appointment system, behavior and knowledge of staff, cleanliness and any other suggestions of patients. Observations Out of 3342 patients admitted in year in department, 2978 agreed for survey and average scores in three groups are shown in graph. It is seen survey becomes partial when hospital staff interviews, while similar results are observed with questionnaire or when third person like independent body or volunteers are used to assess. Conclusion: Patient satisfaction survey in country like India with limited literacy is best done with help of volunteers or independent body which make it less partial and more realistic P114 Right lower zone opacity on chest Xray: Rule out eventration of diaphragm AP KANSAL, Don Gregory MASCARENHAS, Prabhleen KAUR, Shiyas MOHAMMED, Nancy GARG, Anand Kumar BANSAL Department of Chest & TB, GMC, Patiala, Punjab Introduction: Eventration of diaphragm is characterised by elevation of right or left leaf of diaphragm abnormally high into the chest. Usually its congenital, rarely can be acquired. Left side eventration is more common than right sided.Asymptomatic cases are managed conservatively. We report three cases of right lower zone opacities on chest Xray(CXR), which eventually proved to b cases of eventration of diaphragm. Case series: Case1: 80 year old non-smoker male presented to us with dry cough for two weeks, right sided chest pain for 3days.there was no h/o ATT or trauma in the past.GPE was unremarkable. On chest examination, trachea was central. Chest movements were reduced on right ISA, IAA,IMA. Breath sounds as well as Vocal Fremitus/Vocal Resonance were reduced in corresponding areas.CXR showed RLZ opacity. Right lateral Xray showed raised right hemidiaphragm. Lab investigations & ECG were normal. Fluoroscopy showed reduced movement of right hemidiaphragm .sniff test showed no paradoxical movement. CECT chest proved it to b a case of eventration. Case 2: 65 year old female presented to us with generalised weakness & exertional dyspnoea. GPE was unremarkable. On chest examination, trachea was central. Chest movements were reduced on right ISA, IAA,IMA. Breath sounds as well as Vocal Fremitus/Vocal Resonance were reduced in corresponding areas.CXR showed RLZ opacity. Right lateral Xray showed raised posterior end of right hemidiaphragm. Fluoroscopy, sniff test & CECT chest proved it to b a case of eventration P115 Title : Genetic Dissection of Birt Hogg Dube' syndrome in an Indian family 1 2 2 Authors: Anindita Ray , Suman Paul , Susmita Kundu , Bidyut Roy 1, * 1 Address: Human genetics Unit, Indian Statistical Institute, 203 B.T. Road, Kolkata 700108 2 R. G Kar Medical College & Hospital, Kolkata - 700004 *corresponding author, Bidyut Roy, email:[email protected] 1 Anindita Ray,[email protected] Introduction and Objectives: Birt Hogg Dube' syndrome (BHDS,MIM 135150) is a rare genetic disorder which follows autosomal dominant mode of inheritance with incomplete penetrance. BHDS may predispose to three type of manifestations - kidney neoplasms, cutaneous fibrofolliculomas and/or lung cysts or pneumothorax,. It is a monogenic disorder, mapped to a gene encoding a 579 amino acid protein вЂ“ Folliculin (FLCN) at chromosome 17p11.2. We encountered a family, in Kolkata, with spontaneous pneumothorax and lung cysts in two members of the family but absence of skin lesions and renal tumors. Genetic studies were performed in the 8 individuals of a 3 generation family from Kolkata, India. Methods: Genomic DNA was isolated from venous blood from all 8 individuals of the family. Bidirectional DNA sequencing of all 14 exons of FLCN gene was done to identify mutations. Also high-resolution CT scan was performed in 4 individuals (two of them with pneumothorax and two phenotypically normal individuals) of the family. Results: Genetic analysis revealed presence of a heterozygous вЂњC nucleotideвЂќ deletion in the hypermutable polycytosine (poly-C) tract in exon 11 leading to a possible truncated protein. This mutation was found in two affected members along with 4 other members with no lung or renal complications in the family. CT scan for the phenotypically normal member (age: 28yrs) of the family but having this mutation, revealed presence of paracardiac lung cysts without any symptoms of BHD. We also checked for this mutation in 14 healthy unrelated control individuals but none of these controls carried this mutation. Conclusion: Our results confirmed presence of deletion mutation in poly C8 tract at exon 11 which is a mutational hot-spot for patients with BHDS. This study gives the first genomic insight in an Indian family with BHDS, correlating the mutation hotspot with radiological findings. P116 Thymomic myasthenia gravis with solely bul bar invol vement- a rare case report. S.harikrishnan, A.sundararaj aperumal, A.mahilmaran, D.ranganathan., Institute of thoracic medicine, madras medical college, Chennai, Tamilnadu, Indi a. Introduction: Overall incidence of thymoma is approximately 0.15/10,0000/yr. Thymoma is usually a rare begin tumor from anteri or mediastinum. About 1/3rd of cases were di gnosed during myastheni a evaluation.1/3rd during asymptomatic mass evaluation,1/3rd as obstructi ve features.Myasthenia gravis is the common paraneoplastic syndrome associated with thymoma.Ocular weakness is most typical usual present ation with or without limb invol vement,while early or isolat edoropharnygeal or limb weakness is less common. Case report : 40 yr old male manual labour, evaluated in otol aryngol ogy for dysarthria for past 3 months,reffered to pulmonol ogy for abnormal chest X-ray fi ndi ng- medi astinal wideni ng.patient had nasal speech and gave history of recurrent nasal regurgitation,occasional dysphagia and dry cough with no ocular or limb weakness symptoms. Necessary investigations were done.CECT chest confi rmed anterior medi astinal mass.CT gui ded FNAC was done- reported as thymoma with metaplastic squamous cells.Neurophysician opi nion obtained reported as decremental response in repeated nerve stimulation test which confi rmed Myastheni a gravis.Patient referred to surgery with consent. Cardiothoracic surgeon staged the tumor as stage-I thymoma during surgery . Histopathol ogical examinati on of resected tumour shows type-B2 thymoma(WHO classification) without evi dence of malignancy. Conclusion: Thymoma is a rar e tumor but its association with myasthenia gravis is well reported. Main stay of treatment of thymoma is surgical removal.if it is associated with myasthenia gravis surgery should be elective with adequate preoperative assessment such as avoidance of immunosuppressive drugs, adequate respiratory function, in which FVC > 2 liter is mandatory or else plasmapheresis/IVIg shoul d be carried out. We report end this case because despite of being a manual laborer by occupation patient had a rare presentation of only bulbar involvement without ocular and limb muscular involvement. P117 P118 Pediatric mucoepidermoid carcinoma DR. MEHTA N, Dr. SHETH V, DR.RAMI K, DR.GHANCHI F, DR.CHATTERJEE I Shri M.P.Shah Government medical college, Jamnagar, India 8 year old male child was referred to chest medicine department for recurrent respiratory tract infections for 2 year needing frequent treatment with antibiotics and decongestives. He had also been given short course Anti TB treatment for the same complaints. On Examination: At time of consultation He was afebrile, had quite breathing, but was pale and underweight and had no chest symptoms .Auscultation revealed less aerated right lower chest. There was neither digital clubbing nor any chest deformity. Other systemic examination was unremarkable. Except 10 gm/dl Hb his hematological, microbiological and biochemical reports were normal. His Chest X ray(PA view) [Figure 1] showed well outlined homogenous right lower zone opacity obliterating right dome and right cardiac border with spared right costophrenic angle. Similar opacity with varying size was present in the previous Chest X rays. He was suspected to have right intermediate bronchus occluding pathology with collapse of middle lobe and lower lobe and recurrent post obstruction infection. FOB(fiberoptic broncho scopy) revealed intermediate bronchus occluding, smooth surfaced tumor, that on CT scan was found infiltrating adjoining lung parenchyma. FOB guided biopsy was negative for carcinoma and carcinoid. He was advised surgical treatment and underwent bilobectomy. The tumor turned out to be Mucoepidermoid Carcinoma. Post operatively he has been asymptomatic and doing well after 9 months. Conclusion: Recurrent RTIs with variable response to anti infective measures and iso-positioned chest opacity is an alarming state of bronchus occluding pathology and endoscopic examination clubbed with CT scan are irreplaceable definitive diagnostic tools, directing further timely management. Pneumonic Carcinoma P119 DR. SHETH V, DR.RAMI K, DR.UDACHANKER G, DR.GHANCHI F, DR CHATTERJEE I Shri M.P.Shah Government Medical College, Jamnagar, India 60 year old lady was referred to chest medicine department for recurrent intermittent cough, trivial hemoptysis and transient spells of fever for 7 years. On Examination: On evaluation she reported to have mucoid expectoration and feeling short of breath on brisk walk for last one year. At time examination her resting pulse, respiratory rate, body temperature and blood pressure were normal. She had audible crepitation on left lung field. She did not have digital clubbing or enlarged lymphnodes. Her sputum microbiology and cytology reports were inconclusive while hematological, biochemical and urine analysis were normal. HIV, ANA, CEA were negative. Her chest X-rays(PA view) (Figure 1) showed progressive multicentric pneumonic shadows left lung in right middle zone and left mid zone lower zone. Her breast examination and abdominal sonology were normal. She was suspected to have Broncho Alveolar Carcinoma (BAC) with remote possibility of immunogenic inflammatory pneumonia and was further evaluated by HRCT chest and FOB(fiberoptic bronchoscopy) At bronchoscopy frothy secretion was found oozing from left bronchi and right upper lobe bronchus. However BAL, and transbronchial biopsy from left lower lobe were non diagnostic. For further confirmation Trans thoracic lung biopsy from left upper lobe was carried out. Histopathological examination of biopsy sample confirmed BAC. Conclusion: Slowly progressive multicentric pneumonic shadows with recurrent chest symptoms and variable response to antiinfectives is a suspect scenario of BAC especially in non smokers. High index of suspicion and timely further evaluation with interventional investigations can lead to specific diagnosis. Figure 1: Chest X rays(PA view)showed progressive multicentric shadow P120 A rare case report on pulmonary langerhanвЂ™s cell histiocytosis or histiocytosis x DR.ADITYA REDDY. VANGALA, Prof. Pradyut waghray**, Dr.A.N.V.Koteswara rao**, Dr.v.veena**, Dr. Chetan**, Dr. Sowmya **, Dr. Harish **, Dr. Rikin**, Dr. Krishna chaitanya**. prof. k.p.a.chandrashekhar # prof. ramakrishna reddy gaddam^ п‚· п‚· п‚· ** dept of pulmonary medicine,s.v.s.medical college, mahabubnagar,a.p # dept of pathology, s.v.s.medical college, mahabubnagar,a.p ^ dept of radiology, s.v.s.medical college, mahabubnagar,a.p We report a case of pulmonary langerhans cell histiocytosis in a 57 yr old male chronic smoker presented with 1 month h/o productive cough,chest discomfort ,joint pains & dyspnea gr-3. And he reported coughing up a few mouthfuls of blood over the previous 10-15 days. Chest radiography revealed cystic changes and nodules in the mid and lower zones with infiltrations. BAL,Endobronchial biopsy unremarkable. Trucut lung biopsy proved. 18 F-FDG PET in Benign Pulmonary Diseases P121 KETAKI UTPAT, MAKARESH YADAV, VINAYA KARKHANIS, SANDIP BASU, JYOTSNA M JOSHI Department of Pulmonary Medicine, T.N.M.C.& B.Y.L. Nair Hospital, Mumbai Objective 18 F-Fluorodeoxyglucose (FDG)-positron emission tomography (PET) is emerging as an important non-invasive investigation in benign conditions. We studied its utility in the diagnosis and monitoring of various benign pulmonary diseases. Materials and methods An observational study was conducted on 47 consecutive patients with benign lung diseases.FDG PET scan was performed at baseline and repeated after therapy in necessary cases. The findings of FDG scan were correlated with clinical, histopathological and radiological findings. Results 47 patients of benign pulmonary diseases were included in the study. Pulmonary tuberculosis(16), tuberculous mediastinal lymphadenopathy (5),sarcoidosis (9)- type 1(1), type 2(3) and type 3(5), IIPs (9)-IPF (5) and NSIP (4), CTD related ILD (1), alveolar proteinosis (1), silicotuberculosis (2), tropical pulmonary eosinophilia (2), pleural hydatid disease (1), diffuse panbronchiolitis (DPB (1). All patients showed increased FDG uptake in areas showing lesion on HRCT. Additional uptake was noted in 2 patients. Repeat FDG scan after treatment showed improvement in all patients which was consistent with clinico radiologic and/or spirometry findings.Findings of FDG PET scan in patients of pulmonary tuberculosis matched well with microbiological findings in all but 2 patients. 4 patients with mediastinal lymphadenopathy showed favourable response on FDG PET on antituberculous therapy. All ILD patients had bilateral low grade FDG uptake. Unusual intense FDG uptake was seen in 2 cases in areas of honeycombing. Comparison of FDGPET scans with clinic-radiological correlation in silicosis, DPB and hydatidosis showed consistent findings at baseline and after therapy. Conclusion FDG-PET scan can be used as an important adjunct non invasive investigation in diagnosing and monitoring of various non-malignant lung conditions by assessing metabolic disease activity along with microbiology and computed tomography. P122 Traumatic Diaphragmatic Hernia Dr.Rajeshwari, Dr.K.RameshKumar I/C Professor Department of Pulmonary Medicine Govt. General and Chest Hospital, Hyderabad OBJECTIVES: The estimated rate of occurrence of congenital diaphragmatic hernia varies from 1:2000 to 1:4000 live births. Though thousands of such cases are reported during infancy, few reports describe adult patients diagnosed with Bochdalek hernia. Usually, these hernias become evident during the neonatal period, through symptoms and signs of respiratory distress. However the most frequent symptoms found in adult patients are slight respiratory and digestive symptoms. It is also possible for these hernias to be asymptomatic. Here we report a case of mild dyspnea within a traumatic posterolateral diaphragmatic hernia. Evaluation of 50 years old male with one month history of shortness of breath without any previous respiratory complaints. METHODS: A 50-year-old male patient was admitted to our department with a one month history of slight dyspnea. The discomfort was greatly obvious after heavy physical work, but could be alleviated by taking a rest. he denied having other symptoms such as chest pain, abdominal pain, dysphagia, vomiting, and dyspepsia. There was history of penetrating trauma and surgery. Upon physical examination we inspected nothing characteristic except the remarkable decrease of breathing sounds and increased bowel sounds in the left hemithorax. Computed tomography(CT) Chest showed herniation of stomach, splenic flexure and peritoneal fat in left hemithorax. Defect of about 65 cm was seen in the left diaphragm RESULTS: Sputum for gram stain, culture and sensitivity and sputum for AFB: No growth found. Blood group: вЂњoвЂќ positive. Ultrasound Abdomen Nothing abnormality detected. HIV: Non reactive. Ultrasound chest radio opacity which seen in radiograph is not appreciated on ultra sound. PFT moderate restriction. No significant brochodilation. CONCLUSION: For Bochdalek hernias, correct diagnosis and early treatment is significant to avoid the occurrence of serious complications. P123 Familial Spontaneous pneumothorax and lung cysts in an Indian family associated with Folliculin gene mutation. AUTHORS: S. PAUL, A. RAY, B. ROY. INSTITUTION: R.G Kar Medical College, Kolkata- 700004, India; Indian Statistical Institute , 203 ,Barrackpore trunk road ,Kolkata вЂ“ 700108; Indian Statistical Institute , 203, Barrackpore trunk road, Kolkata вЂ“ 700108. Approximately 10% patients of spontaneous pneumothorax have positive family history. BirtвЂ“HoggвЂ“Dube syndrome (BHD) is one of the cause of familial pneumothorax. BHD syndrome is associated with hamartomas of skin, renal cancer and spontaneous pneumothorax. However there have been reports of isolated spontaneous pneumothorax and lung cysts in patients of BHD syndrome in the absence of other manifestations . Mutation in Folliculin gene (FLCN) on chromosome 17 has been reported to cause BHD syndrome. A 32 year old non-smoker female presented with left sided spontaneous pneumothorax . Her sister had previously suffered from recurrent pneumothorax (twice). High Resolution CT (HRCT) scan of chest of both the sisters revealed multiple lung cysts. We decided to evaluate these patients of familial pneumothorax and identify any genetic basis for their disease. After getting informed consent , genetic study of the FLCN gene was performed in 7 family members. We subsequently screened willing family members by HRCT scan of chest for any lung abnormality. One of the sibling of the index patient did not wish to participate in the study. Physical examination and abdominal CT scan was done to rule out any skin and renal involvement. Genetic sequencing revealed Cytosine - deletion mutation in hypermutable region of exon 11 of FLCN gene in the index case, her 3 siblings, her mother and her son. HRCT scan of the patientвЂ™s brother showed lung cysts whereas her son had normal lungs. For cystic lung disease with an undetermined etiology, or familial pneumothorax, it is necessary to consider the possibility of BHD syndrome. Pulmonologists should be aware that BHD syndrome can occur as an isolated phenotype with pulmonary involvement. P124 A rare case report of churg-strauss syndrome and loefflers syndrome in the same patient Dr.J.SOWMYA , Prof.Pradyut waghray, Dr.A.V.N.Koteswar Rao, Dr.K.Surender Reddy , Dr.Venkateswara reddy T, Dr.Veena, Dr.Harish, Dr.Chetan, Dr.Aditya, Dr.Krishna Chaitanya, Dr.Rikin Dept of Pulmonary Medicine, SVS medical college, Mahbubnagar,TS BACK GROUND Churg-strauss syndrome is a systemic disorder characterized by asthma, transient pulmonary infiltrates, hyper eosinophilia and small vessel vasulitis.It is also called вЂњallergic angitis and granulomatosis or eosinophilic granulomatosisвЂќ. It may involve multiple organ systems including lungs, heart, skin, GIT, nervous system Loefflers syndrome is characterized by migrating lung infiltrates and by eosinophilia.Diagnosis is based on the radiographic picture and eosinophilia.it is most likely an allergic reaction in the lung to foreign antigen mainly parasites. CASE SCENARIO A 40 yr old male patient came to the OPD with the complaints of cough with sputum, SOB ,fever since 3 months ,pain abdomen since 1 month, headache since 15 days. On general examination skin lesions were seen. Chest x ray PA view showed bilateral migratory pulmonary infiltrtates. CBP showed increased WBC count with eosinophilic predominance of 64%, AEC,IgE were elevated. Stool for ova and cyst showed large number of stongyloides , giardia lambia larvae. Sputum and BAL for cytology showed increased number of eosinophils .Skin biopsy showed eosinophilic predominant small vessel vasculitis with granulomas. P-ANCA is elevated. Patient responded well with corticosteroids, albendazole and Diethyl carbamazine. P124 LAM PRESENTING AS PNEUMOTHORAX COMPLICATED BY ACINETOBACTER SPECIES - A RARE CASE REPORT AUTHOR NAME-SWAPNIL CHAUDHARI GUIDED BY- BABAJI GHEWADE ABSTRACT- 18 year old female presented with complaints of Breathlessness & Cough with mucoid expectoration вЂ“ 3 months Patient was started on Cat I DOTS from PHC on September 2013 based on chest X- Ray (Sputum for AFB вЂ“ Negative) , but no symptomatic relief was present She got admitted under us on November 2011 with complaints of Fever & Breathlessness-15 days, Right sided chest pain вЂ“ 2 days Clinical examination and chest x-ray suggestive of RIGHT SIDED PNEUMOTHORAX & Consolidation in Left mid & th lower zone & ICD Tube was inserted in the 4 intercostal space in mid вЂ“ axillary line. п‚· Hb-10, TLC-14000(P-86%,L-10%,E-3%M-1%) п‚· LFT & KFT вЂ“ WNL п‚· Sputum Culture & Sensitivity- No growth of pathogenic organisms (2 mucopurulent samples)- Negative for AFB п‚· ELISA & HBsAgвЂ“ Non Reactive п‚· ABG was suggestive of Type I Respiratory Failure п‚· Pleural fluid ADA-32, Culture & sensitivity- No growth seen , occasional RBCs seen, Triglyceride-31 mg/dl, Cytology- suggestive of Acute Mixed Leucocytic Exudation п‚· HRCT thorax- Bilateral Ground Glass Opacities With Air Bronchogram & Reticular Thickening In Interstitium with right sided pneumothorax п‚· Serum LDH вЂ“ 1135 IU/L (200-400) п‚· ANA вЂ“ 10.2 (< 20 u/l) п‚· Serum calcium вЂ“ 7.9 mg/dL п‚· SerumACE-Negative п‚· 24 hour urinary protein вЂ“ 0.5 g п‚· BAL culture & sensitivity вЂ“ Growth of Acinetobacter species п‚· BAL Cytology вЂ“ Benign epithelial cells in inflammatory & hemorrhagic background п‚· TBLB was suggestive of Type II pneumocyte proliferation & hemorrhage, smooth muscle proliferation around airways most likely possibility is Resolving Adult Respiratory Distress Syndrome P125 Title: Dysphagia and dysarthria with cavitary lung lesions: A Case Report Satyajeet SAHOO, Subhra MITRA Calcutta national medical college & hospital, Kolkata, India th th CASE: Lesions affecting the posterior parapharyngeal space involving the 9 to 12 cranial nerves with Horner syndrome is called VillaretвЂ™s syndrome. Etiologies include parotid gland tumor, nasopharyngeal tumors, parapharyngeal abscess and aneurysms of internal carotid artery. We report this case of 42 year immunecompetent housewife presenting with high grade fever, headache and neck pain for 25 days with inability to take food and difficulty in speech for 10 days. She was admitted in a local hospital 20 days back, where she was diagnosed meningitis and put on intravenous antibiotics. During the previous hospitalization she developed cough and dyspnoea with CXR showing bilateral pleural effusions and patchy opacities in lower zones. There were no 2 complaints of haemoptysis or chest pain. On examination she had decreased appetite with BMI of 15 kg/m . She was dysarthric, dysphagic and febrile. Her respiratory rate was 26/min with scattered crepitations. HornerвЂ™s syndrome was noticed on right side. CNS examination showed right lateral rectus paralysis and lower motor th th th th neuron palsy of 9 , 10 , 11 and 12 cranial nerves bilaterally. Meningeal signs were absent. She was put on ryleвЂ™s tube feeding and intravenous antibiotics. MRI brain revealed prevertebral (upper cervical) abscess. Sputum for Gram stain and culture showed growth of Staphylococcus aureus. CECT thorax showed minimal bilateral pleural effusion and multiple bilateral nodules with cavitations in some of them. A week later she had become afebrile, her neck pain had subsided, she was taking soft diet and put off ryleвЂ™s tube. She is under follow-up with some improvement in speech, though her tongue remains atrophic and weak. DISCUSSION: We present this case of staphylococcal abscess of prevertebral space complicated with VillaretвЂ™s syndrome with hematogenous spread to lungs which presented to our department with unusual features of dysphagia and dysarthria with multiple cavitating lesions and bilateral pleural effusions. P126 Title: Invasive pulmonary aspergillosis (IPA) in liver transplant recipient(LTR) вЂ“ a case report. R CHOPRA, A TAKALE, V PANDHARKAR Grant Medical FoundationвЂ™s Ruby Hall Clinic, Pune, Maharashtra, India Objectives: IPA post liver transplant is a devasting complication with high mortality(40-90%) despite newer antifungal agents. Rapid and reliable diagnosis may improve the outcome. This is an interesting case, with late onset IPA in a LTR being presented. Methods(case report): A 45 years old, post HCV liver cirrhosis, underwent liver transplant in 2011 and now presented in 2014 with cough, fever and haemoptysis since 2 wks prior. He has been on steroids and cyclosporine based immunosuppressive drugs. CXR and CT scan showed macronodules, consolidation, cavity, halo and crescent signs. WBC count and renal functions were normal. BAL showed branching hyphae and culture grew green colonies of A. fumigates. Galactomanan index was high. IPA diagnosis was confirmed. Treated with incremental doses of liposomal Amphotericin B(total 2.5 gms) followed by oral Voriconazole. Clinical and CT scan resolution was satisfactory. Results(discussion): With changed epidemiology and better immunosuppressive drugs, late onset IPA in post liver transplant is reported frequently. Our patient developed IPA as late as 3 yrs after liver transplantation. Characteristics CT scan findings in IPA patients, cavity and patchy consolidation, halo and crescent signs, were present and this also described in retrospective analysis of 2150 liver transplant cases. Though mortality is high, some trials documented better survival with combination antifungal treatment with liposomal Amphotericin and Voriconazole. Our patient received liposomal Amphotericin followed by Voriconazole with good result. Conclusion: IPA is uncommon but severe complication in LTR and has high mortality. Quick diagnosis of IPA with typical CT scan findings and culture was made in our patient. Results with liposomal Amphotericin and Voriconazole were satisfactory. P127 P128 A Rare Encounter With Hemoptysis Dr. Natraj. M, Dr. N. Meenakshi, Dr. S. Subramanian, Dr. Thirunavukarasu, Chettinad Hospital And Research Institute, Rajiv Gandhi Salai, Kelambakkam, Chennai Introduction Rhinosporidiosis is a chronic granulomatous disorder caused by Rhinosporidium seebri. Molecular biological techniques have more recently demonstrated that this organism is an aquatic protistan parasite. It is grouped under the class Mesomycetozoea. This disease is endemic in Sri Lanka and India, predominantly South India. Case Report Here we present a case report of a 70 years old male patient who presented with multiple episodes of hemoptysis for one month duration (10 вЂ“ 15 ml per episode, frank blood), progressive dyspnea, cough with expectoration (mucoid, not foul smelling ) associated with loss of weight and appetite for the last one month. Patient is a known smoker for more than 40 years. Patient was a bus driver by occupation. Chest X ray PA view and CT thorax for the patient were normal. Routine blood investigations revealed no significant abnormality. Initial nasal examination revealed only congested turbinates and deviated nasal septum but Direct Nasal Endoscopy revealed reddish granular mass seen occupying right nasopharynx. The mass was surgically removed. Histopathology report was consistent with the diagnosis of rhinosporidiosis. Patient was asymptomatic after surgery. An Unsusal Cause of Fungal Pneumonia. S.dharmic, V.suryanarayana, M.harish Sree balaji medical college and hospital,Chennai,india P129 A 65 year old female, known asthmatic on steroids intermittently, with no other co-morbidity presented with fever, breathlessness and cough with mucoid expectoration of ten days duration. Bilateral crepts were heard in auscultation. She was maintaining saturating well in room air. Blood investigations revealed leucocytosis with neutrophilic predominance. CT chest showed multiple patchy consolidations of the right upper, middle and lower lobes with ground glass appearance and enlarged mediastinal lymph nodes. Work up for retrovirus and tuberculosis was negative. Sputum for KOH mount was negative. Sputum showed gram negative bacterial growth and she was started on antibiotics. Meanwhile patient went for Type II respiratory failure and was intubated followed by tracheostomy in view of prolonged ventilator support. In spite of high end antibiotics, weaning off the ventilator was not possible. Bronchoscopy showed pus along with flakes in the right lateral basal bronchus. Bronchial wash sample grew Curvularia species. Fluconazole 150mg OD was added. Serial imaging of the chest showed resolution of the consolidation. She was weaned off the ventilator and was comfortable on room air. Discussion: The genus Curvularia (filamentous fungi) contains some 35 species which are mostly subtropical and tropical plant parasites. Three ubiquitous species have been recovered from human infections, principally from cases of mycotic keratitis; C. lunata, C. pallescens and C. geniculata. Clinical manifestations of phaeohyphomycosis include sinusitis, endocarditis, peritonitis and disseminated infection. Pneumonia caused by Curvularia in an immune competent patient is very rare and if diagnosed and treated early, will respond well to first line drugs like azoles. This case report highlights a unilateral fungal pneumonia with dramatic clinical improvement post treatment once the rare causative organism was identified. P130 Progressive allergic fungal rhinosinusitis with stable lingular bronchiectasis 1 2 3 1 Sindhoora Rawul , Prasad E Chelluri , SK Sistla , Fahad Aleem , Sai Singaraju 1 Background: Allergic fungal rhinosinusitis with or without asthma has been mentioned in literature. Criteria for diagnosis have been proposed without a consensus. We report one such case in a 59 year old lady with recurrent rhinopulmonary allergy with progressive nasal and sinus disease since year 2006 and stable non-progressive lingular bronchiectasis. Methods:Clinical assessment, Imaging(X-ray,CT:PNS,Chest,Brain),Echocardiogram,Spirometry,EEG, Eosinophil count,Serum Chemistry (VitaminD,Calcium,Thyroid, Immunology), Specific IgE, Total IgE,Sputum examination, FESS in June2013,histopathology of nasal mucosa. Patient refused skin prick test and bronchoscopy. Results: On examination: postnasal drip, crackles in the left infraaxillary and paracardiac areas. CT PNS: left side turbinate hypertrophy,maxillary sinusitis with polyps, CT chest: left lingular segmental bronchiectasis with patch of consolidation, eosinophil count increased(24%), total IgE: 4574 IU (Lab Normal 400 IU), Specific IgE to aspergillus,candida markedly increased, Echocardiogram normal,Spirometry:mild airflow obstruction without any moderate or severe episodes since 4years,Histopathology:profuse eosinophilic infiltraton, no bony changes, no fungal elements,Sputum examination revealed fungal elements,CT brain normal,EEG: temporal lobe epilepsy. Conclusion: A case of fungal rhinosinusitis with turbinate hypertrophy, maxillary polyps, high eosinophil counts and total IgE with highly elevated specific IgE to aspergillus and candida, mild airflow obstruction with reversibility and lingular bronchiectasis is presented. The unusual feature being stable lung disease while rhinosinusitis was progressive. Treatment: Nasal, inhaled, oral steroids, bronchodilators and Itraconazole Clinical implications: Any patient of rhinosinusitis with or without asthma should be screened by tests of allergy and lung function for early diagnosis of allergic fungal disease. P131 An unusual case of invasive Aspergillus pseudomembranous and obstructive involvement of lung parenchyma in a immunocompetent patient. tracheobronchitis without Dr Ramesh S.Pal, Dr Sonam Spalgais, Dr Amit Kumar, Dr U C Ojha department of pulmonary medicine esi pgimsr basaidarapur new delhi india A 19 years aged young female presented with cough, mild expectoration since 3 month and life threatening hemoptysis since 1 week. She was non diabetic, not suffering from any chronic illness, not on any cytotoxic and immunosuppressive drugs.Immune status was evaluated in terms of HIV status, hepatitis B, IgA, IgG, C3,C4 complement components and were found normal. CECT thorax revealed segmental collapse of left lower lobe. Videobronchoscopy showed tiny nodules in trachea and left lower lobe bronchi. Dark brown intra luminal thready material was visualized and taken out in piecemeal. Direct smear KOH preparation shows fungal elements. Biopsy from nodules shows chronic non specific inflammation. Repeated sputum KOH preparation also showed fungal elements and culture revealed Aspergillus flavus. Serum Galactomannan was positive. Thus a conclusion is made of Invasive Apergillus Tracheobronchitis. Patient received intravenous Voriconazole for one month than switchover to oral Voriconazole for next two months. Her hemoptysis was stopped and improved clinically and radiologically. Repeat Serum Galactomannan become insignificant. Discussion The finding of Aspergillus spp. in respiratory tract samples in critically ill patients should not be routinely discarded as colonisation, even in presumably immunocompetent hosts like the case mentioned above. However risk factors for the development of invasive aspergillosis in critically ill patients include neutropenia, haematological malignancy and immunosuppressive treatment. But, invasive disease can occur in the absence of these risk factors. Figure1 Vediobronchoscopic view of left lower lobe showing luminal obstruction Figure 2 Vediobronchoscopic view of left lower lobe showing brown thready structure protruding through lumen Figure3 Bronchial wash from left lower lobe showing brownish sediment P132 SOUVENIER in the ICD BAG Dr Kumar Utsav, IInd Year Resident, BJMC, Ahmedabad Dr Savita Jindal, Asst. Professor, BJMC, Ahmedabad BACKGROUND: Pleural effusion is common in INDIA. The importance of this case study is how a clinician can be easily misled by Age of the patient, past AKT, when clinically symptoms are not prominent. CASE HISTORY: An 80 year old male patient presents to O.P.D. with chief complaints of Breathlessness slowly progressive over the period of 2 years. Cough with expectoration over a period of 2 years, Generalised weakness over 5 days. Pt has a past history of AKT and has been a smoker but left smoking since 10 years. CXR: Massive U/L pleural effusion, An ICD was placed in situ. Pleural fluid assessment was not leading anywhere, neither were Pleuroscopy and CECT Thorax RESULTS: Incidentally, one day patient mentioned something crawling in ICD BAG. It was a full grown worm of A.Lumbricoides. It was extracted from ICD BAG& sent for MICROBIOLOGICAL assessment. Pt was given Tab Albendazole 400mgSTAT. 2 days later stool R/M and parasitic examination was sent for, came negative for ova/cysts/eggs. Tab Prednisolone (5mg) 5-0-5 was started. Pt was regularly followed up, was healthy, lost to follow up at 6 months. CLINICAL IMPLICATIONS: Seeing the age and presentation of patient, correlating with Past history of the patient one can easily make a mistake of presuming above case to be tuberculosis induced pleural effusion or malignant effusion, but like every lock has a different key, every case is to be looked OBJECTIVELY. This is perhaps rare case with uncommon presentation of parasitic infestation where a fully grown worm is roaming freely in pleural cavity. P133 Isolated pulmonary cystic lesion? Always suspect hydatidosis. D.N.Prajapati, R.M.Kshatriya, N.V.Khara, R.P.Paliwal, S.N.Patel department of respiratory medicine, pramukhswami medical college, karamsad 388325, gujarat, india. Introduction: Hydatidosis is caused by echinococcus granulosus. Humans may be infected incidentally as intermediate host by accidental consumption of soil, water or food contaminated by fecal matter of an infected animal. Lung is the 2 most commonly affected organ following liver. The symptoms depend on the size and site of the lesion. There are very few reported cases of isolated lung hydatidosis. For hydatidosis, serology and imaging are diagnostic tools. Surgical removal and/or chemotherapy are the mainstay of treatment. Here we discuss a case of persistent left lower lobe lesion with history of operated left breast carcinoma. Case report: A 36 years old female presented with 1 month history of cough with yellow expectoration, dyspnea and left sided chest pain, with history of trace hemoptysis before 1 month. Patient was a known case of infiltrating ductal carcinoma of left breast operated before 3 years and had cystic lesion in left lower lobe of lung confirmed on CT scan. Physical examination revealed dullness to percussion and diminished breath sounds over left lower chest. Blood reports showed eosinophilia with normal leukocytes. Chest radiograph was interpreted to have a left lower zone round opacity (possibly metastatic) which was increased in size as compared to previous x-rays and on ultrasound it was found to be a cystic lesion with fluid collection. So diagnostic fluid aspiration was performed and surprisingly hooklets of ecchinococcus were found on microscopy. Abdominal ultrasound was nomal including liver. Patient was referred for surgical intervention and underwent left lower lobectomy. There were no complications in the postoperative period and no recurrence of the disease. Conclusion: Pulmonary hydatidosis should always be considered as a differential diagnosis when dealing with a cystic lesion on radiology in our country. P134 Co-existence of ABPA and aspergilloma in same individual: a rare entity. URVINDERPAL SINGH, VIDHU MITTAL, ADITI, SUNIL KUMAR. Government Medical College, Patiala,Punjab,India. ABSTRACT Coexistence of allergic bronchopulmonary aspergillosis (ABPA), a hypersensitivity disorder to Aspergillus antigen, and aspergilloma, in same individual is of rare occurrence. Aspergilloma is a fungus ball caused by saprophytic overgrowth of Aspergillus species in a cavitatory or cystic lung disease. However, tissue necrosis and invasion of blood vessels does not occur. We hereby present a case of a 42 years old male who was diagnosed as a case of ABPA with co-existing aspergilloma. P135 Clinicoradiological and laboratory profile of Allergic bronchopulmonary aspergillosis ( ABPA) patients presenting to a tertiary care centre AP KANSAL, Kiran.N, Shiyas MOHAMMED, Don Gregory MASCARENHAS, Nancy GARG, Hardik JAIN Department Of Chest & TB, GMC, Patiala , Punjab Introduction: ABPA is an idiopathic inflammatory lung disease characterized by an allergic inflammatory response to the colonization of Aspergillus or other fungi in the lung. Objective: To study the clinicoradiological and laboratory profile of ABPA patients presenting to our department from August 2013 to July 2014. Method & Materials : Patients diagnosed as ABPA based on Rosenberg Patterson criteria were retrospectively studied and analysed. Results: In our study of 61 patients, 35(57.3%) were males, 26(42.7%) were females. Median age was 32.8 years, youngest being 7 years & oldest 84 years. Cough was the commonest presenting complaint present in 57(94.4%) followed by breathlessness in 51(83.6%), haemoptysis in 8(13%) patients. History of asthma was present in 44(72.1%) patients. History of anti tuberculosis treatment was present in 11(18%) patients, all of them being prescribed ATT in the peripheral health centres merely on the basis of Chest X-ray(CXR). Fleeting opacities was present in chest X-rays in 14(22.9%) patients.On HRCT, 54(84.5%) patients has central bronchiectasis , consolidation/mucus plugs in 4(6.5%) and normal in 3(4.9%) patients. Total and specific IgE against aspergillus antigen was high in all 61 patients. Discussion : 70% of ABPA patients have a history of asthma.Keeping a high suspicion and evaluating on the lines of ABPA is necessary in bronchial asthma patients especially when they are poorly controlled on regular asthma treatment. CXR lesions are nonspecific when serial X-rays are unavailable. Patients shouldnвЂ™t be put on ATT merely on CXR basis without being properly evaluated for ABPA especially in asthma patients . п‚§ п‚§ п‚§ п‚§ п‚§ п‚§ P136 BILATERAL HYTADID CYST OF THE LUNG Dr. RJESWARI G, Dr.RAMESH KUMAR, Dr. SARTAJ HUSSAIN Department of Pulmonary Medicine, Osmania Medical College, Hyderadad A 17 years girl presented with the chief complaints of Cough with expectoration - 3 months Shortness of breath - 3 months L side chest pain - 3 months Past history - Relatively healthy without any co-morbidities Treatment history вЂ“ no history of worm infestations, no history of handling pets. Cough with expectoration, sputum moderate in quantity, mucoid,non foul smelling, aggravated on lying down to left side, no diurnal variation Shortness of breath, gradual in onset ,progressive, aggravated on lying down to left side, no history of orthopnea Left sided chest pain, dull aching in nature, no history of radiation of pain, increases on lying to left side No history of wheeze or hemoptysis History of sputum being salty 15 days ago п‚§ On examination Vitals вЂ“ stable; upper respiratory tract вЂ“ normal; examination of chest Inspection: deviation of trachea to the right side; Palpation : TVF decreased over the L hemi thorax. P137 A rare case report of disseminated cryptococcosis in immunocompetent host * Dr.G.AMBERNATH, Dr. Ajit Vigg, Dr.S.Gourishankar, Dr.S.V.N.Anuradha* Dept of Pulmonary Medicine, Apollo Hospitals, Hyderabad, TS *Dept of Pathology, Apollo Hospitals, Hyderabad, TS BACK GROUND Cryptococcosis is a defining opportunistic infecton for AIDS, and is the second most common AIDS defining illness. The distribution of Cryptococcus neoformans is worldwide and it is mostly seen in soil. Cryptococcosis is believed to be acquired by inhalation of the infectious propagule basidiospore from the environment. Pulmonary cryptococcosis with dissemination to brain in immunocompetent host is rare, which prompted us to report this case as a poster presentation. CASE SCENARIO A 59 year old gentleman,presented to ER in a state of altered sensorium, shortness of breath of grade II MMRC scale, low grade, intermittent fever associated with chills, cold and dry cough for the past 10 days and had a brief exposure to pigeon bird droppings over a period of 1month prior to development of these symptoms.Was a known 3 hypertensive,not a diabetic and also not on any immunosuppresants.TLC counts 26,000 cells/mm ,ESR 30mm at first hour. CXR PA view showed RLL consolidation. CT scan chest with contrast evidenced soft tissue density lesion in the antero-lateral segment of right middle lobe suggestive of segmental consolidation. BAL on PAS stain showed budding yeast cells of Cryptococcus in mucinous background. CT guided biopsy of lung tissue from RML on HPE showed necrotic tissue and encapsulated budding yeast cells with morphological features consistent with Cryptococcus.MRI of brain with contrast study showed evidence two descrete large irregular thick walled ring enhancing lesions in rt capsulo-ganglionoic area with significant peri-lesional edema causing midline shift. patient responded well to amphotericin-flucytosin combination therapy followed by oral fluconazole for six months. Patient on repeat MRI brain and CT chest showed significant resolution at four months. P138 Association of serum vitamin-D concentrations with pulmonary disorders: Tuberculosis, COPD and Bronchial Asthma. GAYATHRI B, SUJATHA R, NEHA GHALIB PSG Institute of Medical Sciences and Research, Coimbatore, India. Objectives: Vitamin-D is classically associated with bone and mineral metabolism, but the identification of vitamin-D receptor (VDR) in many human cells suggests a role for vitamin-D in extra-skeletal diseases. Several cross-sectional studies have associated lower vitamin-D status and decreased lung function. The present study was designed to find out the association of serum vitamin-D concentration with pulmonary disorders like Tuberculosis, COPD and Bronchial Asthma. Methods: A retrospective data collection of serum vitamin-D concentrations was performed between September 2013March 2014, for the patients attending the out-patient and in-patient clinics of PSG hospitals, out of which vitaminD levels of patients having the diagnosis of Tuberculosis, COPD and Bronchial Asthma were segregated and analysed. Serum 25-OH Vitamin-D levels were measured by electrochemiluminescence. Normal serum reference interval was 30-70ng/mL. The objective of the study was to determine the vitamin-D status in patients with these pulmonary diseases. Vitamin-D levels of 20 - <30ng/mL was classified as vitamin-D insufficiency and levels <20ng/mL were classified as vitamin-D deficiency(VDD). VDD was further classified based on Lips classification as mild (10-<20ng/mL), moderate (5-<10ng/mL) and severe (<5ng/mL). Results: The mean age of the study group was 62.85В±15.64 years. Of the total 28 pulmonary cases, 12 (43%) had severe vitamin-D deficiency, 2 (7%) had moderate deficiency, 5 (18%) had mild deficiency. Among the 14 tuberculosis patients, (36%) 5 patients had severe vitamin-D deficiency. There were also 5 severe vitamin-D deficiency cases among the 10 respiratory failure cases. Conclusion: Vitamin-D improves lung function by regulating inflammation, inducing anti-microbial peptides and its action on muscle. Vitamin-D deficiency has been associated with lowered lung function in COPD and Bronchial Asthma, and also in tuberculosis infections. The reduced levels of serum 25-OH Vitamin-D in pulmonary diseases suggest optimization of serum vitamin-D levels to improve the lung function among the general population. P139 Title: A study on bode index as a predictor of severity in patients with Chronic Obstructive Pulmonary Disease. Author: Dr. Manik Mahajan Co-authors: Dr. Stani Francis(Prof & Head), Dr. Arti Shah(Asso. Prof), Dr. Parth Shah (Asst. Prof). Designation: 2nd Year Resident, Respiratory Medicine Institute: Department Of Respiratory Medicine, SBKS Medical College & Research institute, Piparia, Vadodara. Introduction: Chronic Obstructive Pulmonary Disease (COPD) as defined by the Global initiative for chronic obstructive lung disease is a disease state characterized by airflow limitation that is not fully reversible. According to WHO, COPD was the 6th major cause of death in 1990 and is estimated to be the 3rd major cause by 2020. The present study has been undertaken to determine the factors other than the lung function that affect the outcome in COPD patients. The original BODE index ,body-mass index (B), degree of airflow obstruction (O) , dyspnea (D), exercise capacity (E), measured by the six-minuteвЂ“walk test, is a simple multidimensional grading system which is superior to FEV1 alone for prediction of mortality and hospitalization rates among COPD patients. Aims & Objectives: To study the outcome of COPD patients by using BODE Index. Method: It is prospective observational study. Total 50 adult patients with symptoms suggestive of COPD and who attended respiratory medicine department, SBKS & MIRC were included. The study was done to evaluate the BODE index as a predictor of hospitalization and severity in patients with COPD. Results: A total 50 COPD patients were enrolled in the study. 17 patients who had mild COPD with (BODE score between 0 вЂ“ 2). 16 patients had moderate (BODE score of 3 вЂ“ 5) and 17 patients had severe COPD (BODE score more than or equal to 6). The average age of participants in the study was 56.01yrs. Among the COPD patients, BODE index was found to increase with age. The average BMI of the patients in this study was 21.58kg/m2. The BMI was found to be significantly lower in patients with COPD. Conclusion: BODE index is reliable method to predict hospitalization and the severity in patients with COPD and which is relatively inexpensive. Keywords: COPD; BODE Index P140 Integrated Dose Counters: Technical Aspects and Functional Specifications 1 2 2 1 V NAIK , G MALHOTRA , K ROTE , DR J GOGTAY 1 Medical Services, Cipla Ltd., Mumbai, India 2 R&D Centre Introduction Currently there is no accurate test whereby the patient can estimate the number of doses remaining in a pressurized metered dose inhaler (pMDI). As a result patients may underuse or overuse the pMDIs thereby increasing the cost or the risk of not receiving the correct dose, respectively. CiplaвЂ™s dose counter is integrated into the pMDI and shows the number of puffs remaining in the inhaler with its use. It has been designed to satisfy the USFDAвЂ™s guidance on вЂњintegrated dose countersвЂќ, as well as meeting the needs of patients and physicians. Design Features The dose counter is integrated with the canister thus maintaining count integrity while minimizing interference with airflow and aerosol generation. No additional force is required to use a pMDI with a dose counter. The counter starts slightly above label claim doses in order to take care of doses lost in priming and re-priming. The last 40 doses are in red color, indicating the need to obtain a new pMDI, at position вЂњ0вЂќ the user knows that the device is empty. However the pMDI is functional even beyond this point thus confirming with US FDAs guidance that even partially therapeutic dose could be lifesaving. Accuracy Accuracy of count is a critical parameter and CiplaвЂ™s dose counter includes delivery of a dose without the possibility of jamming the valve and displacement-driven design which eliminates the possibility of under-counting. In vitro tests Robustness has been confirmed by various in vitro studies including temperature cycling (hot, cold), drop testing, transportation, contamination analysis, robustness testing, counting accuracy, and actuation force analysis. Conclusion CiplaвЂ™s dose indicator potentially provides reassurance and adds confidence on the usage of pMDIs, thus improving adherence to treatment and enhancing the effectiveness of aerosol drug delivery by pMDIs. P141 Profile of sensitivity to pollen allergens in the bronchial asthma patients attending a tertiary care hospital in Jaipur, India by skin prick testing 1 2 R SEHAJPAL , S KOOLWAL INSTITUTE OF RESPIRATORY DISEASES, SMS MEDICAL COLLEGE, JAIPUR Objective : To determine the profile of sensitivity to pollen allergens in the bronchial asthma patients attending a tertiary care hospital in Jaipur, India by skin prick testing . Methods: Skin test reactivity for 20 pollen allergens was studied by skin prick testing, using buffer saline as negative control and histamine phosphatase as positive control in 100 stable bronchial asthma patients .. Immediate cutaneous responses were recorded at 20 minute after allergen challenge. Pollen antigens were selected based on the local aerobiological calendar. Results :Fifty seven percent of the patients had a significant positive reaction( >+2). 57.7% of the males and 56.3 % of the females were found to be allergic to pollens.Pollen allergy was more common in urban population(64%)and in the occupational groups it was common in office job workers (66.6%), shopkeepers(66.6%)and students(60.7%) .Family history was positive in 40% of the patients. .Twenty three percent of the patients had positive reaction to single pollen , 17 % to two pollens and 24% to three or more pollen.Tree pollen were the most common allergen in the study population and among them Holoptelea integrifolia was the commonest pollen .Amaranthus spinosus was the commonest weed pollen and Pennisetum typhoides was the commonest grass pollen having significant positive reaction by SPT. Conclusion: Airborne pollens are important causal factor of allergic diseases such as asthma . Therefore identification of these pollens is important. Knowledge of profile of sensitivity may be useful to clinicians managing patients suffering from respiratory allergies and allergenвЂ‘specific immunotherapy could be a viable option for these patients. P142 Understanding perception of COPD among doctors at different specialty levels in India: a face-to-face survey Dr. ISHPREET KAUR, Dr. BHUMIKA AGGARWAL, Dr. JAIDEEP GOGTAY Cipla Ltd., Mumbai, India (for all three authors) Objective: COPD in India remains highly under-recognized and under-treated despite high prevalence and diagnosis usually does not occur until loss of significant lung function. This survey aimed to identify the existing barriers to an early and proper diagnosis and treatment of COPD in India by exploring the attitudes, beliefs, and knowledge of Indian doctors w.r.t. COPD. Methods: A cross-sectional study involving data collation through a questionnaire and face-to face interviews was conducted in 91 randomly selected physicians (primary care physicians & internal medicine specialists) and pulmonologists from 8 Indian cities. Results The response rate to the written questionnaire was 59.34% (54 out of 91). Majority of the doctors (57.4%) reported that COPD patients usually visit them at severe stages. Lung function testing is not routinely performed and diagnosis is largely symptom and history based - 44% physicians denied performing spirometry to make a diagnosis of COPD. About 35% of physicians believed that COPD occurs only in smokers. The most commonly reported challenges to diagnosis of COPD were a) spirometry related- access (22.22%), interpretation (27.77%), patientsвЂ™ unwillingness (44.44%), affordability issues (29.62%); b) doctor relatedinadequate training on COPD diagnosis (11.11% ) and c) patient related-lack of awareness about the disease. DoctorsвЂ™ perceived barriers to the treatment of COPD included difficulty in explaining COPD to patients (38.88%) and poor compliance to treatment (42.59%). Conclusion: Lack of awareness about COPD, its symptoms and its implications contribute significantly in preventing people at risk from reaching out to doctors. Inadequate use of or access to spirometry and the belief that COPD is a smokerвЂ™s disease are important barriers to diagnosis. A large scale study will help to further understand the physician and patient perceptions. Educational and awareness programs are needed both for doctors and patients to help address the awareness-gap, under-diagnosis and under-treatment associated with COPD. P143 Inspiratory flow rates using In-check Oral in patients of obstructive airway diseases in Indian population DR. ISHPREET KAUR, DR. JAIDEEP GOGTAY, DR. BARDAPURKAR SUHAS, DR. BARNALI BHATTACHARYA, DR. S. RAJU, DR. SHAILESH JAIN Introduction: The patientвЂ™s inspiratory flow has to be adeqaute to activate the dry powder inhaler or breath-actuated inhaler and to guarantee optimal pulmonary drug deposition. Peak inspiratory flows (PIFs) are dependent on the patient's inhalation effort and device resistance. Optimal inspiratory flow rates may not be achieved in few patients, -1 especially in children or elderly COPD patients. PIFs >60 l.min are generally accepted to be the optimal flows for -1 most of the devices, while PIFs < 30 l.min are believed to be insufficient. Methods: The present study measured PIF rates in patients (n=178) with asthma including children and with COPD including elderly. PIF was measured using the In-Check Oral (Clement Clarke International Ltd, Harlow, UK). The highest value of the three attempts was recorded. Results: -1 -1 The mean (В± SD) PIF was 201.89 (В±82.74) l.min and 134.78 (В±61.85) l.min in patients with asthma (n=132; mean age=35.88 years) and COPD (n=46; mean age=64.54 years), respectively. Paediatric (в‰¤12 years) asthma (n=22, mean age=7.98) and severe COPD patients (n=34, mean age=64.41) demonstrated a mean (В± SD) PIF of 124.54 -1 -1 (В±50.68) l.min and 124.70 (В±60.46) l.min , respectively; these subgroups representing two ends of the spectrum -1 with the lowest PIF values. The lowest PIF recorded was 40 l.min in 3 patients (2 elderly severe COPD patients and 1 paediatric asthma patient). PIF correlated positively with FEV1% (r=0.53). PIF showed a strong positive correlation with age till 12 years (r=0.60) while for 13 to 84 years it showed a moderate negative correlation (r= -0.50). PIF correlated positively with height (r=0.51) and negatively with severity of asthma and COPD. Conclusion: The present study demonstrates the ability across all age groups, including children and elderly patients, to generate sufficient inspiratory flow, irrespective of the severity of asthma or COPD. P144 Abstract Title вЂ“ECG and ECHO correlation in COPD patients in Tertiary health care centre. Authors-Dr Nikhilesh Pasari, Dr Ashok Bajpai, Dr Bhupendra Jain. Sri Aurobindo Institute Of Medical Sciences & PG Institute Indore,India Objective-To observe correlation in ECG and ECHO findings with COPD severity. Methods- A prospective study of 80 patients( pts) over a period of 7 months Jan 2014 to July 2014 are recruited at Sri Aurobindo Institute Of Medical Sciences Indore in Dept of Pulmonary Medicine and detailed history, clinical evaluation,spirometry,2D Echo & ECG obtained. COPD severity is categorized based on GOLD Guidelines and data were analysed by FisherвЂ™s Exact Test and p<0.05 considered significant. Results-We found that maximum number of pts was of grade 2 (42.50%) among which significant association between presence of P pulmonale and COPD grading was observed. ECG changes (P pulmonale) were observed. Grade 1 COPD 0% pt. was having P pulmonale while in Grade 4 91.66% ,pts were having the same. (P<0.001) Signifiacant association with echo findings was observed that maximum Grade 4 COPD pts were having moderate PAH. (P<0.007) while Cor pulmonale was present in 50% of cases in grade 4 COPD ( p<0.005) Conclusion-Stages of COPD is significantly proportional to ECG changes consider as a non invasive and easily available screening tool. P145 & Echo findings in COPD pts.& A rare cause for Hypercapnic respiratory failure Dr Janso KOLLANUR, Dr Vishnu SHARMA M., Dr.Alka BHAT, Dr Harsha D. S. Department of Respiratory Medicine, A. J. Institute of Medical Sciences, Kuntikana, Mangalore, 575004. INTRODUCTION Hypercapnic respiratory failure can be a manifestation of neuromuscular weakness due to various causes. CASE REPORT A 55 year old female presented with breathlessness of 8 months duration increased since 1 week. There was no history suggestive of asthma or COPD neither did she give any occupational exposure. Thyroidectomy was done 12 years back and she was on thyroxine 100mcg daily. On examination she was conscious, oriented, had pulse rate of 96/min, respiratory rate of 32/min and oxygen saturation of 82% with room air. Chest examination revealed normal vesicular breath sounds with bilateral basal crepitations and few scattered rhonchi. Thyroid function tests were within normal limits. Chest x-ray showed bilateral basal infiltrates. ABG showed metabolic alkalosis with hypercapnic respiratory failure. Despite adequate bronchodilators, antibiotics and NIV, patient did not improve. She developed focal seizures one day after admission. On further enquiry patient gave history of 3 episodes of seizures 3 months back. CT head was normal. Nerve conduction study showed mild asymmetrical sensory motor axonal peripheral neuropathy. Serum calcium level was 4.4mg/dl. Vitamin D3 level was 13.65ng/ml, parathormone level was 139.7pg/ml and urine calcium was 4.1mg/dl. A diagnosis of Post thyroidectomy hypothyroidism, hypocalcaemia with pseudohypoparathyoidism with hypercapnic respiratory failure secondary to hypocalcaemia was made. She made uneventful recovery with calcium supplementation and other supportive treatment. CONCLUSION This case report aims to highlight the fact that neuromuscular weakness secondary to electrolyte imbalance can lead to Hypercapnic respiratory failure and should be considered in differential diagnosis of causes for Hypercapnic respiratory failure. Effect of oral montelukast in acute asthma 1 B CHOGTU*, S HAMEED , R MAGAZINE P146 1 1 Department of Pharmacology, Department of Pulmonary Medicine , Kasturba Medical College, Manipal University, Manipal, Karnataka-576104, India Objectives: Montelukast is used in prophylaxis of asthma. Studies have shown that it has a beneficial effect in asthma exacerbations. Hence, the study was done to evaluate the effect of oral montelukast as an add on therapy in patient with acute severe asthma Methodology: It was a randomised, prospective study conducted in department of Pulmonary Medicine. After obtaining Institutional Ethics Committee clearance, the patients presenting to emergency triage from September 2012 to March 2014 with a primary diagnosis of acute exacerbation of asthma requiring hospitalisation, were included in the study. Informed consent was taken from the patients prior to inclusion. History, physical examination and laboratory investigations were recorded as per the proforma. Baseline peak expiratory flow rate (PEFR) was measured. All patients received standard treatment for asthma exacerbation and were randomised into 2 groups. Patients in group1 and group 2 received a placebo tablet and oral montelukast 10mg respectively at baseline. The investigational medications were continued once daily till the patient was discharged from the hospital. Nebulised salbutamol 2.5 mg was given as rescue medication. PEFR values, details of rescue medication and vital signs were recorded at 6 hours, 12 hours, 24 hours and 48 hours of drug or placebo administration and at discharge. The data was analyzed using SPSS software v20.0. Results: Of the total enrolled patients, 50 were randomized to placebo group and 40 patients to the montelukast group. Repeated measures ANOVA was used to compare the mean change in PEFR. The values at the various time points between the two groups were not statistically significant (p=0.189). However, the patients in the montelukast group required significantly lesser number of rescue medications than the placebo group (p=0.049). Conclusion: Montelukast decreases the need for rescue medication in acute severe asthma. P147 Title: Co-relation between risk factors of asthma and severity of the disease. Author: Dr. Rahul PANDYA. Co-authors: Dr. Stani FRANCIS, Dr. Arti SHAH, Dr. Parth SHAH. Introduction: Asthma is a major cause of chronic morbidity and mortality throughout the world and asthmaвЂ™s prevalence has increased considerably over past 20 years, mostly young adults. Globally asthma affected 235 to 330 million people in 2011, out of which 70-80% patients belong to developing countries. India has an estimated 15-20 million asthmatics, with prevalence rising more in recent decades. Worldwide, the economic costs associated with asthma exceed those of TB and HIV/AIDS combined. Aims & Objectives: To analyse the pattern of asthmatics in terms of environmental factors, indoor environment, ETS (Environmental Tobacco Smoke), occupational exposure, obesity, socio-economical status and correlate them with severity of their asthma. Methods: It is a prospective, observational type of study. 50 diagnosed patients of asthma were included in the study and their detailed clinical history was taken. Severity of the asthma was calculated based on frequency of asthma attacks, PFT values and FEV reversibility. Result: Out of 50 patients, the severity of asthma was as below: Co-existing allergic conditions were found in 30 asthmatics, while 40 had exposure to indoor or outdoor triggers. Conclusion: Severity of asthma was more with sedentary life-style, lower socio-economical status, occupational triggers, and indoor environmental triggers. Asthma was severe in smokers and ever-smokers. Presence of coexisting other allergic conditions resulted in poor prognosis of asthma. P148 Effect of Inhaled Anticholinergic Drugs on Intraocular pressure In Chronic Obstructive pulmonary disease patients YADAV PRASHANT, CHAUDHRI SUDHIR, KUMAR ANAND, VERMA SANJAY, KUMAR AVDHESH GSVM Medical College, Kanpur, Uttar Pradesh, India Objective: The objective of this study is to know the effect of inhaled anticholinergics (Tiotropium/ Ipratropium bromide) on intraocular pressure in COPD patients and to evaluate their safety in potential glaucoma patients. Glaucoma is frequently seen in patients with chronic bronchitis who require treatment with nebulized Beta2 agonists and ipratropium due to accidental instillation in eyes. Significance of anti cholinergic drugs used as inhalers by Chronic Obstructive Pulmonary Disease (COPD) causing raised intraocular pressure is unknown. Methods: Initially 132 patients were included. 14 patients were excluded because on initial examination they had hyper mature senile cataract. 10 patients were excluded because they were not co-operative with the study protocol. Included patients were divided into 70 patients (study group) who received Ipratropium or Tiotropium with formetrol and fluticasone as Metered dose Inhaler (pMDI) and 38 patients(control group) took formetrol with fluticasone without ipratropium / tiotropium. General ophthalmic examination, and Gonioscopy was done as pretreatment. Intra-ocular pressure measurement done in all patients before starting treatment, 2 hours after first dose and thereafter weekly for four weeks. Results: Out of 108 patients, 73 were males and 35 were females. Mean age of patients was 64 years. Out of 70 patients (study group) 13 showed increase in intraocular pressure (IOP), 57 did not show any change. The maximum increment was 4mmHg. In Control group 33 out of 38 did not show any change in IOP, only 05 showed increment of IOP. The maximum increment was 2 mmHg. Conclusion: The inhaled anticholinergics all by Metered Dose Inhalers did not lead to any significant change in st nd rd th intraocular pressure (IOP) after 2 hours, 1 , 2 , 3 and at 4 week of starting treatment. All values of intraocular pressure are within normal clinical range. P149 Correlation of spirometry with impulse oscillometry, body plethysmography and DLCO VANJARE N, KODGULE R, RASAM S, BHOSALE S, SALVI S Chest Research Foundation, Pune, India Background: Spirometry, Impulse Oscillometry (IOS), Body Plethysmography (BP) and DLCO are tools that measure different aspects of lung function. However, there is inadequate knowledge about the correlation between the parameters measured by these tests. Aim: To study the correlation of spirometry indices with values measured by IOS, BP and DLCO. Methods: In this ongoing study 4 healthy, 9 asthma and 10 COPD patients underwent IOS, BP, spirometry and DLCO according to the international guidelines. Correlations between values obtained by IOS (R5, R20, and R5-20), BP (sGawtot, sGaweff, RV, TLC), spirometry (FEV1, FVC, FEF25-75%) and DLCO were analyzed using PearsonsвЂ™s correlation. Results: R5, R5-20 and DLCO correlated with FEV1 (r=-0.55, -0.61 and 0.87, all p<0.05) suggesting that small airway resistance increased and DLCO decreased linearly with reduction in FEV1. The correlation of FEV1 was highest with sGawtot and sGaweff (r=0.96, p<0.01 for both). FVC correlated with all the measured parameters suggesting that FVC is reflective of overall lung function (all p<0.05). Small airway parameter FEF25-75% correlated best with sGawtot and sGaweff (r=0.911 and 0.914, both p<0.01) and also correlated with R5 and R5-20 (r=-0.5 and p<0.05 for both). Neither FEV1 nor FEF25-75 correlated with R20 (p>0.05). sGawtot and sGaweff correlated best with FEF25% (r=0.95, p<0.01 for both). Conclusion: sGaw reflects more distal airways than R5 and R5-20. FEV1 majorly reflects small airway obstruction and FVC is a measure of overall lung function. DLCO decreases linearly as FEV1 decreases. P150 Can Impulse Oscillometry and Body Plethysmography differentiate response to two salbutamol doses? VANJARE N, KODGULE R, RASAM S, BHOSALE S, SALVI S Chest Research Foundation, Pune, India Background: Impulse Oscillometry (IOS) and Body Plethysmography (BP) are more sensitive in differentiating between mean percentage responses to sequentially increasing bronchodilator doses. However, whether IOS and BP can differentiate bronchodilator response between single doses of different strengths of bronchodilator is not known. Aim: To study the effect of 100 and 400 mcg of salbutamol on Impulse Oscillometry and Body Plethysmography parameters? Methods: In this ongoing study, 9 asthma and 10 COPD patients were randomized to receive either 100 mcg or 400 mcg of inhaled salbutamol in a cross-over manner. Impulse Oscillometry to study resistances at 5 Hz, 20 Hz and 520 Hz (R5, R20 and R5-20), body plethysmography to study specific airway conductances -sGawtot and sGaweff and spirometry to study FEV1 and FEF25-75 was done before and 30 min after drug administration. Within group changes were analyzed by paired t-test and the within-group changes were analyzed using independent t-test and ANCOVA. Results &Conclusion: R5, R20, R5-20 and FEF25-75% showed maximum differentiation between two doses. All parameters showed significant change after bronchodilation with 100 and 400 mcg of salbutamol (Table 1) Table 1: Mean percent change (MPC) in asthma &COPD Mean percent change (MPC) in asthma MPC Parameters 100 mcg FEV1 26.8 FEF25-75% 39.69 sGawtot 52.03 sGaweff 59.81 R5 -18.28 R20 -7.6 R5-20 -23.72 Mean percent change (MPC) in COPD MPC Parameters 100 mcg FEV1 16.31 FEF25-75% 7.9 sGawtot 43.25 sGaweff 46.82 R5 -9.2 R20 -16.31 R5-20 -19.41 P151 Std dev 17.35 48.71 26.6 23.86 34.06 19.29 59.61 MPC 400 mcg 30.63 71.18 40.36 50.7 -26.86 -18.44 -30.96 Std. dev 19.83 38.94 90.65 6.25 36.84 17.09 74.98 Std dev 13.5 16.27 21.48 30.18 21.33 15.73 23.76 MPC 400 mcg 14.07 18.92 50.4 49.65 -14.78 -10.37 -22.67 Std. dev 15.82 33.48 51.08 51.26 17.03 16.55 23.94 В® Confidence, usability, preference, satisfaction and errors with use of Revolizer : A single dose dry powder inhaler (SDDPI) for patients with obstructive airway disease (OAD). 1 1 1 2 2 SK RAJAN , S SHRIVASTAVA , I BUBNA , SP JADHAV , PV LONDHE , JA GOGTAY 1 2 2 Bhatia General Hospital, Mumbai, India, Cipla Ltd. Mumbai, India Objective: Optimal management of obstructive airway disease depends on adequate drug delivery to the airways. The choice of device therefore becomes pertinent. Ease of use should be given careful consideration when prescribing a device to patients. The objective of this study was to assess the confidence, usability, preference, satisfaction and В® errors associated with the use of Revolizer , a single dose dry powder inhaler (SDDPI) in India. Methods: 100 participants [50 healthy and 50 with obstructive airway disease (OAD)] of 18 years and above were enrolled in the study. At visit 1, the technique of using the device was explained and demonstrated twice by the investigator. Participants then repeated the procedure until they achieved three consecutive correct attempts. At visit 2 (two days later), participants made a single attempt before receiving demonstration from the investigator. They then repeated the steps until three consecutive correct attempts were made. At both visits, time taken to achieve three consecutive correct attempts was noted. The number and type of errors were recorded. The participants were asked to answer a questionnaire at both visits. Results: 100 participants (54 women, 46 men) with a mean (SD) age of 42 (+14) years were enrolled in the study. The mean time taken for three consecutive correct attempts at visit 1 was 3.75 (2.10) minutes and at visit 2 was 3.07 (1.32) minutes (p<0.001). Patients who made critical errors were 38 and 28, while non critical errors were 49 and 38 at two visits respectively. Most of these were device independent. Out of 48 patients who were using an inhaler device, 78% В® preferred Revolizer over their current device. В® Conclusion: Revolizer , a SDDPI is easy to use and scores high on confidence, preference and satisfaction in patients with OAD. P152 Usability, confidence, preference, satisfaction and errors with the use of spacers: a combined analysis of results from three studies 1 2 3 3 S SALVI , S RAJAN , SP JADHAV , PV LONDHE J GOGTAY 1 2 3 3 Chest Research Foundation, Pune India, Bhatia General Hospital Mumbai, India, Cipla Ltd., Mumbai, India Objectives: Errors with the use of pressurized metered-dose inhalers (pMDIs) reduces lung deposition and increases the local and systemic side effects. The use of a spacer reduces these errors. The objectives of these studies were to assess the usability, confidence, preference and satisfaction with the use of three spacers (Zerostat, Zerostat V and Zerostat VT) in three different but identically designed studies. Methods: The three studies were open-labelled, prospective and single center conducted in healthy volunteer and patients with mild asthma and COPD. The study consisted two visits. In these two study visits , the patients were trained to use the device at visit 1 and again at visit 2, and the average time taken for three consecutive correct attempts was reported (primary endpoint). The secondary endpoints included number and type of errors (critical and non-critical), and scores on usability, confidence, preference, and satisfaction questionnaires. Results: A total of 90 participants (30 participants per study, 1:1 healthy volunteers: patients with asthma/COPD) completed these studies. The average time taken for three consecutive correct attempts in patients with asthma/COPD in the three studies decreased at visit 2 (2.99, 4.65 and 1.91 minutes) from visit 1 (3.58, 4.99 and 2.23 minutes), respectively. The critical and non-critical errors also decreased at visit 2 from visit 1. Overall reduction in the scores at visit 2 was also observed on the usability, confidence, preference and satisfaction questionnaires. Conclusion: Zerostat, Zerostat V and Zerostat VT spacers are easy to learn, understand and operate. This highlights the fact that the spacer devices can be recommended for all patients finding difficulty in using a pMDI. P153 Evaluation of efficacy and safety profile of Fluticasone/ Formoterol (FF) combination versus Budesonide/Formoterol (BF) combination administered through a pressurized Metered Dose Inhaler (pMDI) in patients with moderate to severe persistent asthma- : A randomized controlled trial. A BALKI1; S DALAL2; A SINGH3; S BARDAPURKAR4; S BALAMURUGAN5; B SINGH6; R MEHTA7; SURYAKANT8; S BHARGAVA9; B TRIVEDI10; A ARYA11; S PAPINWAR12; S CHANDRATRE 13; B MUTHA14; K PODDAR15; P. PHOPALE16; A VAIDYA 16; J GOGTAY16. 1Chest Care Hospital, Nagpur, India; 2Ashray Chest Center, Vadodara, India; 3Asthma Bhavan, Jaipur, India; 4Shree Nursing Home, Aurangabad, India; 5Dr.Balamurugan's Chest Clinic, Chennai, India; 6Surya Chest Foundation, Lucknow, India; 7Dr. Mehta's Allergy, Asthma Care And Research Center, Indore, India; 8Research Department, India; 9Gyanpushp Research Center For Chest And Allergy Diseases, Indore, India; 10Nashik Health Care And Research Centre, Nashik, India; 11Center For Chest Diseases, Delhi, India; 12 Dr. Papinwar Hospital, Aurangabad, India; 13Shatabdi Super Speciality Hospital, Nashik, India; 14Mutha Hospital, Nashik, India; 15Chest, Asthma And Allergy Clinic, Kolkatta, India; 16Cipla Ltd India. Objective: Combination of an inhaled corticosteroid (ICS) and long-acting beta agonist has become the mainstay of treatment of asthma when not controlled by ICS alone. A number of combination inhalers are already available, but there is scarce data on the combination of FF in a single inhaler. Hence, this study was conducted to evaluate efficacy and safety of FF 125/6 mcg pMDI combination versus BF 200/6 mcg pMDI combination in patients with moderate to severe persistent asthma. Method: This was a double blind, prospective, active controlled, parallel group, multicenter study, with a 2-4 weeks runin period during which patients received budesonide 100 mcg, 2 puffs twice daily. 232 patients, symptomatic with ICS alone, were randomized to receive either of the active treatments at a dose of 2 puffs twice daily for 12 weeks.. Levosalbutamol was provided as rescue medication. Spirometry and subject diary assessments were performed at 2, 4, 8, and 12 weeks. Adverse events (AE) were assessed at all visits. Results: 232 patients (117 - FF and 115 - BF group) were enrolled, out of which 59% were males and average age was 41 years. Both FF and BF produced a statistically significant improvement within group in mPEFR from baseline to 12 weeks (48.07L/min and 49.03 L/min respectively (p<0.005) and the difference between the two groups was not significant (p>0.005) (difference of -0.96 L/min, 95% CI: -2.38L to 0.46L). Improvement was observed from baseline in FEV1, evening PEFR, nighttime symptoms and rescue medication within both group at all treatment visits. BF reduced day time symptom scores over FF (p=0.0326). There was no difference observed in frequency of AE. Conclusion: This study showed comparable efficacy and safety data of FF to BF in terms of primary & secondary endpoints. P154 Comparison of a novel fixed dose combination (FDC) of nebulized formoterol/budesonide with pMDI formoterol/budesonide FDC in patients with severe to very severe COPD S SALVI1; H PANDYA2; A GHOSAL3; R DHAR4; S WALANJ5; N BOYILLA6; V DESHMUKH7; B TAYADE8; V NANGIA9; S JADHAV10; P PHOPALE10; A VAIDYA10; J GOGTAY10 1Chest Research Foundation Pune, India; 2Sheth LG Hospital and AMC Met Medical College, Ahmedabad, India; 3National Allergy Asthma Bronchitis Institute Kolkata, India; 4Fortis Hospital Kolkata India; 5Ethika Clinical Research Center Kalwa India; 6Axon Hospitals Hyderabad India; 7Nagpur Chest Centre Nagpur India; 8NKP Salve Institute Of Medical Sciences & Lata Mangeshkar Hospital, Nagpur India; 9Fortis Flt. Lt. Rajan Dhall Hospital New Delhi India; 10Cipla Ltd., India. Objective: To evaluate efficacy, safety and tolerability of 20 mcg/1mg of FB neb with 6/200 mcg of FB pMDI in patients with severe to very severe COPD Method: In this open-label, prospective, active-controlled, parallel group, 6 weeks, multicentre study, patients were randomised (2:1) after 2 weeks of run-in period to receive either FB neb or FB pMDI, with a non-static spacer, twice daily for 6 weeks. Combination of ipratropium 40 Вµg & levosalbutamol 50 Вµg, 2 puffs, thrice daily was provided in run in period. Levosalbutamol 50 Вµg pMDI was provided as rescue medication.Primary efficacy parameter was difference in mean change in trough FEV1 at the end of 6 weeks. Others included FVC, FEF25-75 and subject diary assessment at the end 2, 4 and 6 weeks. Results: 113 patients (96.43% males) were randomized, with a mean age 62 В± 9.11 years. Data of 94 patients with a mean baseline post bronchodilator (PB) FEV1% predicted 35.91% with reversibility 10.44% was analyzed. At the end of 6 weeks, the difference in the change in trough FEV1 between FB neb and FB pMDI was not significant (30 ml, 95% CI (-0.05L, 0.11L) (p=0.42)). Similar results were seen for PB FEV1, FVC and FEF25-75. There was a trend towards significance in the PB FEF25-75 at week 6 vs baseline in FB neb group (p=0.05) but not in the FB pMDI group. Use of rescue medication and adverse events were similar in both groups.. Conclusion: FB neb is as efficacious, safe and well tolerated as FB pMDI and can serve as an alternative treatment option in patients with severe to very severe COPD who are unable to use handled inhalers. P155 TITLE: D-dimer level in acute exacerbation of COPD. AUTHOR: P.PERIWAL, A.K SINHA, K. SAINI, D.TALWAR INSTITUTION: Pulmonary Medicine and critical care, Metro centre for respiratory diseases, Noida, Uttar Pradesh, India. INTRODUCTION: Acute exacerbations of COPD are associated with increased airway inflammation, causing imbalance in the endothelial- coagulation system, resulting in a potential prothrombotic stimulus. D-dimer is a marker of fibrin turnover but is also used as a predictor of pulmonary thromboembolism (PTE) in the absence of sepsis and trauma. It is elevated in a number of inflammatory conditions including acute exacerbations of COPD. METHODS: D-dimer levels of 27 consecutive known cases of COPD with acute exacerbations admitted in Respiratory ICU were evaluated, their values were adjusted for age (defined as age * 10 in patients 50 years or older) and statistical analysis of the data was done. RESULTS: Of the 27 patients admitted with acute exacerbation of COPD, 66.66% were male and 33.33% were female. The mean age of the admitted patients was 66.81+/-9.8 years. The mean D-dimer level in these patients was 3107.9 +/2882.7 ng/ml. 26 patients were >= 50 yrs of age. The mean age-adjusted D-dimer cutoff was 675.7+/-91.8 ng/ml. All these patients underwent MDCT thorax and that revealed no evidence of PTE or pneumonia. CONCLUSION: D-dimer level is elevated upto 4.6 times in acute excacerbations of COPD and is not a useful screening test for PTE. CLINICAL IMPLICATION: D-dimer cannot be used as a screening tool for pulmonary embolism in COPD with acute exacerbation. Futher studies are required to evaluate the D-dimer cutoff value that can be used to screen PTE in the patients of COPD exacerbation. P156 TITLE: - Adequacy of inhaler technique in COPD & asthma patients attending a tertiary care hospital in Navi Mumbai. AUTHORS: - Dr. Akanksha Das, Dr. Jayalakshmi T.K., Dr. Girija Nair, Dr. Lavina Michandani, Dr. Mugdha Bhide. OBJECTIVES: - Chronic obstructive pulmonary disease (COPD) & asthma are major concerns to health care system. Improper inhaler device used (Metered dose inhaler/ Dry powder inhaler) is one of the major causes associated with inadequate control of the disease. This study was performed to evaluate the inhaler technique among patients and to investigate factors associated with improper use and whether age or gender was associated with poor inhaler technique. Methods:- A cross-sectional study of all patients who visited chest out- patient department with asthma or COPD over a 6 months period in a tertiary care hospital in Navi Mumbai. Information was collected about demographic data and inhaler technique was assessed using a standard checklist. Results: - There were 107 patients, 71 with asthma and 36 with COPD. Inhaler techniques of 95% of patients were found to be inadequate in some form or the other as per check- list Of all the patients interviewed, only about 60% of patients recalled, that demonstration was done by doctors or other health care professionals. Twelve percent were instructed by pharmacists and remaining followed their friendвЂ™s or relativeвЂ™s suggestions along with insert literature. Conclusion: - The inhaler technique is inadequate among most patients. On every visit patientвЂ™s inhaler technique should be observed and adequate suggestions should be given to correct any deficiencies. P157 An Observational Study Of Risk Factors For Hospitalization Of Chronic Obstructive Pulmonary Disease Exacerbation And Their Outcome DR. S. BARMAN, DR. S. K. SAMANTA, DR. A. DATTA, DR. P. BISWAS Department of Pulmonary Medicine, Fortis Hospitals Kolkata Objectives By 2020 chronic obstructive pulmonary disease will be fifth leading cause of disability and third leading cause of death worldwide. By 2030, fourth leading cause of death. If risk factors of hospital admission can be identified preventive measures can be taken to affect outcome and reduce the economic burden. This study aimed to study risk factors associated with acute exacerbation, study the quality of life and evaluate the ultimate outcome of these patients. Method Using a preformed structured questionnaire; relevant blood parameters including C-reactive potein, Pulse oxymeter, Spirometry, Echocardiography, arterial blood gas analysis to assess risk of exacerbations and outcomein last one year. Results Of 60 patients included in study, majority are above 60 years (56.6%) with male predominance (80%) and 17 patients (28.3%) died during hospitalization. Advancing age (p value < 0.001), smoking status (p value < 0.001), duration of symptoms (p value < 0.004), FEV1 (GOLD grade p value < 0.001), past hospitalization (value < 0.018), Body mass index(p value < 0.005), Dyspnea scale (p value < 0.001) were statistically significant relating to exacerbations whereas sex is found to be statistically insignificant (p value 0.857). Conclusion Identification of risk factors of exacerbation helps respiratory specialists to extend their expertise to broader diagnostic and treatment. But the study has limitation of hospital based Barkesonian bias. P158 Number of pack year smoked increases frequency of COPD exacerbation per year Mohit Bhatia, J.K.Samaria, Ganeshee Lal Sharma Department of TB chest and respiratory diseases S.S. hospital IMS BHU Varanasi. Objective: Smoking is the most important risk factor involved in pathogenesis of COPD. Quantification of the risk due to smoking has done in form of pack per year (1). We investigate effect of increase quantity of risk factor (pack years) on the frequency of COPD exacerbation per year. Method: We evaluated 50 patients of COPD and classify them in 4 groups according to number of pack year smoked. Group- 1(o pack years, the non-smokers), group-2 (1-10 pack years), group-3(11-20 pack years), and group-4 (>20 pack years). We excluded group-1 from our study as some of non-smokers had other risk factors like exposure to biomass fuel etc. which are difficult to quantify. We obtain record of total number of exacerbation of COPD in last one year for all the patients included in study. Obtained data was analysed statistically. Results: In our study we found that mean value for group-2 was 0.12 (with standard deviation of + 0.35), for group-3 it was 1.25(with standard deviation of + 1.0) and in case of group-4 it was 1.55(with standard deviation of + 1.5). Number of pack per year has significant positive correlation with frequency of COPD exacerbation per year (f-value= 4.203, p-value= 0.024). Conclusion: As the numbers of pack year smoked increases risk of exacerbation of COPD increases. References: 1.Cigarette Calculator - American Cancer Society www.cancer.org вЂє Stay Healthy вЂє Tools and Calculators вЂє Calculators P159 Agreement between the spirometry criteria and peak expiratory flow rate criteria in diagnosing bronchial asthma вЂ“ a prospective observational study Rishabh Priyadarshi, Seshadri Varadarajan, Suganya, A Suresh Sundaram Medical Foundation, Chennai Objective: To compare the spirometry criteria (post bronchodilator reversibility of 200 ml plus 12% in FEV1 and/or FVC вЂ“ GINA & ATA/ERS) and peak expiratory flow rate criteria (post bronchodilator reversibility of 60 L/mt or 20% - GINA 2013) in diagnosing bronchial asthma. Study period: October 2013 to July 2014 Materials and Methods: The spirometry (Ganshorn spirometer) reports of all patients during the above period were collected. Peak flow recording (pre and post bronchodilator) using WrightвЂ™s peak flow meter, was done additionally during the spirometry tests and was mentioned in the reports. The reports of those patients who showed positive bronchodilator response in PEFR (GINA) and those with significant FEV1 (GINA &ATS/ERS) and/or FVC (GINA &ATS/ERS) reversibility were isolated. The sensitivity and specificity of PEFR method in diagnosing asthma was calculated in comparison with the spirometry method. Results: There were 258 spirometry reports during the above period and all the reports had the documentation of pre and post peak expiratory flow rates (PEFR) measured simultaneously. Sixty six out of 258 reports showed positive bronchodilator response in FEV1 and/or FVC, which means 66 (25.6%) patientsвЂ™ reports were consistent with the diagnosis of asthma. PEFR reversibility was seen in 33 (12.8%) patientsвЂ™ reports. Twenty one out of 33 PEFR positive patients were also positive for spirometry criteria (FEV1 and/or FVC reversibility) and the remaining twelve patients were positive for PEFR criteria alone. FEV1 and/or FVC positive (DISEASE) FEV1 and/or FVC negative (DISEASE) PEFR positive (TEST) 21 12 PEFR negative (TEST) 45 180 PEFR in comparison with spirometry as a gold standard showed, Sensitivity: 31.8% Specificity: 93.75% Positive predictive value: 63.6% Negative predictive value: 80% Though the PEFR reversibility has a good specificity, it seems to have a poor sensitivity in diagnosing asthma. Hence further testing with spirometry would still be required for the confirmation of asthma in patients with absence of PEFR reversibility. Conclusion: Peak expiratory flow rate (PEFR) measurement, though a simple method in a resource limited setting, is a doubtful parameter in asthma diagnosis. P160 FeNO and serum IgE do not correlate with asthma assessment tests in Indian untreated severe asthma patients Authors: Mayuri Johari, Deepak Talwar Metro Centre for Respiratory Diseases, Noida, India Objectives: Severe asthma patients demonstrate chronic inflammatory changes in the airway , severity being ascertained by assessment scores. FeNO and Serum IgE are well-establisehd markers of atopic inflammation. This study correlates FeNO and total serum IgE with asthma assessment scores in 50 adult untreated Indian patients with severe asthma. Smokers and ex-smokers were excluded from the study. Methods: 50 untreated patents of asthma satisfying the latest WHO criteria for adult severe asthma, attending outpatient clinic of Metro Centre for Respiratory diseases were retrospectively analyzed for their clinical symptoms, assessment scores and atopic biomarkers in the last two years using SPSS software. Results: Severity assessment of asthma was done with asthma control test (ACT) in 34 patients and asthma control questionnaire (ACQ) in 16 patients, and FeNO and Serum total IgE done in all patients included in the study. The mean ACT score was 13.44 + 3.71and mean ACQ score of 3.07 + 1.59. The mean FeNO was 62.09 + 52.96 parts per billion(ppb) and the mean IgE value was 540.54 + 705.12 IU/ml. The cut-off value for FeNO to be considered as raised was 50ppb and 168 IU/ml for serum total IgE. There was inverse relationship of FeNO and Serum total IgE with Asthma control test(ACT) and Asthma Control Questionnaire(ACQ)(p>0.05) Conclusions: FeNO and serum total IgE do not correlate with ACT and ACQ scores in adult severe asthma patients. Clinical implications: Severe asthma, caused by varied etiologies, may be atopic or non-atopic phenotype. Western studies show improvement in the assessment scores and atopic biomarkers corticosteroid treatment. However, in view of lack of data in severe untreated asthma, studies are required to correlate these variables in this subset of population. P161 FeNO and serum IgE do not inter-correlate in untreated severe asthma in adult Indian patients. Authors: Mayuri Johari, Deepak Talwar Metro Centre for Respiratory Diseases, Noida, India Objectives: Both serum IgE and FeNO are biomarkers of atopic inflammation, which is a hallmark of asthmatic airways. This study inter-correlates FeNO and total serum IgE in 50 adult untreated Indian patients with severe asthma. Patients with a history of smoking were excluded from the study. Methods: 50 untreated patents of asthma satisfying the latest WHO criteria for adult severe asthma, attending outpatient clinic of Metro Centre for Respiratory diseases were retrospectively analyzed for their clinical symptoms, assessment scores and atopic biomarkers in the last two years using SPSS software. Results: FeNO and Serum total IgE were done in all patients included in the study. The mean FEV1 was1.85 + 0.67 liters and FeNO was 62.09 + 52.96 parts per billion(ppb) with a mean IgE value was 540.54 + 705.12 IU/ml. According to the standard cut-off values, FeNO was raised in 23 patients (more than 50ppb), 13 patients had borderline raised values (between 25 to 50 ppb) and 12 patients showed normal values (less than 25 ppb). Total serum IgE was raised in 36 patients (more than 168 IU/ml) and normal in remaining 14 patients with a mean of 79.57 IU/ml. FeNO and total serum IgE showed negligible inter-correlation (r= 0.02, p>0.05). Conclusions: FeNO and serum total IgE do not inter-correlate in adult untreated severe asthma patients. Clinical implications: While both serum IgE and FeNO are markers of atopic inflammation, studies show conflicting data between the two variables. This could be due to varied etiologies of severe asthma including atopic or nonatopic phenotypes. However, in view of limited data in severe untreated asthma, studies are required to correlate these variables in this subset of population. P162 To determine the prevalence pattern of aeroallergens in patients of Bronchial Asthma and Allergic Rhinitis reporting to a tertiary care centre in western UP. A Jain, M Saluja, S Singh, S Kumar, S R Yadav Subharti Medical College, Meerut, India Allergens have been associated with diseases such as BA (Bronchial Asthma) and AR (Allergic Rhinitis) which are of most concern, among the patients visiting the chest physicians. Exposure to various aeroallergens has direct impact on pathogenesis as well as outcome of BA and AR. Allergens responsible for respiratory allergies (BA & AR) are found to be different from place to place as echoed in various Indian and international studies. This study is being done in Meerut district of western province of Uttar Pradesh to find out the major prevailing aeroallergens leading to respiratory distress. Objective: To determine the prevalence pattern of aeroallergens in patients of BA and AR reporting to tertiary care centreSubharti Medical College inwestern UP. Methods: It is a prospective study in which a cohort of 20 patients were assessed who were diagnosed as a case of BA or AR clinically or by pulmonary function test. These patients were subjected to skin prick test after taking written and informed consent. Results: Among the total cohort 13(65%) were females, 7(35%) males. In relation to age wise distribution maximum patients were in age group 20-29 yrs(7 pts, 35%) and minimum in 60 yrs and above with 1 pt(5%). In relation to disease status 11 had BA followed by 5 AR and 4 had mixed disease. Distribution of aeroallergens in maximum positivity in age groups were observed as; pollens 46 (97%significant) in age group 30-39, fungi 17 (94.4 sig) in 0-19yrs, insects 15 (100% sig)in 20-29yrs & 30-39yrs, dusts 11 (100%sig) in 20-29yrs, dander 6 (100% sig) in 20-29 yrs, feathers and fabric 5 (83.3% sig) in 20-29yrs. House dust mite was found to be positive in 70%(sig) of the total cohort group with maximum in 20-29yrs. Conclusion: The study concludes that most of the patients allergic belong to female gender. High allergenicity was observed in BA. Most of the patients had polysensitisation and the age group most vulnerable was 20-29yrs. Education of patient regarding avoidance of allergens help in reduction of symptoms and morbidity and increasing the overall health status. P163 RevolizerВ®: The Next Generation Novel Single Dose Dry Powder Inhaler 1 2 2 2 1 V Naik , G Malhotra , P Rege , V Mhapsekar , B Aggarwal , J Gogtay 1 1 Medical Services and 2 R & D Centre, Cipla Ltd, Mumbai, India Introduction Dry powder inhalers (DPIs) are breath-actuated devices which do not require propellants and eliminate the need for co-ordination and cold-freon effect associated with the use of metered dose inhalers. The RevolizerВ® - a novel, single dose DPI, is the result of a development program to address the critical requirements of an ideal inhalation device. It was developed using computational fluid dynamics simulation and enables visual, gustatory and acoustic feedback mechanism to assure patients of having taken their medication correctly. It is designed to be used with dry-powder capsule formulations and is currently available in India, Sri Lanka, Nepal, UAE, Dominican Republic, Lebanon, and South Africa. Performance of the Revolizer Revolizer shows a high drug deposition at flow rates of 30, 45 and 60 L/min. The Revolizer has medium airflow resistance and uses an optimized dispersion system to ensure effective de-agglomeration of the inhalation powder. Revolizer gets activated at inspiratory flow rates of approximately 44 L/min. Design features of the Revolizer The long and narrow mouthpiece of the Revolizer leads to a straight air path and a laminar exiting airflow while creating turbulence in the tubular capsule chamber, thus facilitating easier evacuation of the drug particles at all angles of holding the device. The design of the capsule chamber and the baffles inside ensure maximum drug delivery to the lungs. The transparent medication chamber provides visual confirmation, the vibration sound of the capsule whirring in the chamber gives an audio feedback, and the taste of the lactose (excipient) confirms dose inhalation. Conclusion The Revolizer has been designed to achieve optimal efficacy and to deliver doses consistently with minimal instruction. It can be used for delivering a variety of inhaled medications including bronchodilators, corticosteroids and their combinations. P164 Severity, risk factors and comorbid conditions in newly diagnosed smoking and non-smoking COPD patients:the SCOPEstudy Dr R. Kacker1,Dr A. Dalal2, Dr R. Palaniappan3 1.Dr Rajeev Kacker - Sr Consultant Pulmonary, Critical Care & Sleep Medicine, Regency Hospital,India 2.Dr AlpaDalal - HOD Pulmonology, Jupiter Hospital, India 3.Dr Ramanathan Palaniappan -Prof & HOD, Department of Pulmonary Medicine, Peelamedu SamanaiduGovindarajulu Hospitals,India Objective: Survey of newly diagnosed COPD PatiEnts (SCOPE)in India,to gain insights on theirhealth status. Method: This survey conductedin7 cities of Indiainvolved 47 pulmonologists, who recordedsymptoms, risk factors, lung function, previous respiratory ailments, inhaler use, history of exacerbations, hospitalizations, comorbid conditions and COPD assessment test (CAT) score for consecutive newly diagnosed COPD patients. Results: Data was obtained on 247 newly diagnosed COPD subjects, mean age (В± SD) 59.91 (В± 11.53) years, majority 209 (84.6%) males with 75.7%reportingcurrent or past history of smoking. Of the non-smokers, 24.29% reported biomass exposure. Average FEV1% predicted was 50.30 (В± 18.96) and average FEV1/FVC% was 60.38 (В± 20.30), indicating a higher degree of airflow limitation. Cough (97.57%), dyspnea (95.45%), sputum (92.41%) were the most common symptoms followed by wheezing (82.51%) and chest tightness (85.59%). Average CAT score (В± SD) was 21.26 (В± 7.68). Approximately 31%, 28% and 22% of all patients reported biomass exposure, living close to highway/ industrial areas and occupational exposure (cotton mills/ chemicals industry etc.), respectively. History of respiratory ailments included asthma (29.96%), tuberculosis (15.38%) and allergic rhinitis (5.73%). 45.9% patients were using inhalers, of whom 67.44% did not have a good inhaler technique and 59.77% reported poor compliance with therapy. On an average, there were 1.96 exacerbations and 0.79 hospitalizations in the last 1 year. Hypertension, diabetes mellitus, osteoporosis, depression was reported in 33.2%, 17.81%, 7.69% and 6.88% of the COPD patients. There was no significant difference between symptoms, clinical presentation, co-morbidities, number of exacerbations and CAT assessment in smokers and non-smokers. Conclusion: The SCOPE survey highlightsthat newly diagnosed COPD patients attending a chest physicianвЂ™s clinic in India, are at an advanced stage of COPD with comorbid conditions. Many of themare non-smokers showing symptoms, comorbidities and exacerbation frequencysimilar tosmokers. P165 Clinical effectiveness of anticholinergic tiotropium bromide as an add on therapy in patient with severe bronchial asthma: A randomized control trial. Dr. Santhosh V G, Dr. G.S. Gaude, Dr. Jyothi Hattiholi, Postgraduate in Department of Pulmonary Medicine, KLE UniversityвЂ™s Jawaharlal Nehru Medical College, Belgaum, Karnataka Introduction: Some patients with severe asthma remain symptomatic despite maximum recommended treatment. Tiotropium bromide, a long acting inhaled anticholinergic agent might be used as an effective bronchodilator in such patients. Aim: To evaluate clinical effectiveness of anticholinergic tiotropium bromide as an add on therapy to the usual standard therapy in severe Asthma patients. Methodology: In a randomized single blinded study involving 60 patients, aged more than 18 years with severe Asthma, the patients were randomized into two groups. The study group received addition of 18mcg of Tiotropium once daily, while both the groups were continued on standard therapy as per GINA guidelines. Improvement in lung function test, clinical symptom and quality of life by mini asthma quality of life questionnaire (AQLQ) were monitored at 4, 8 and 12 weeks. Results: A total of 30 patients were included in each group. Baseline characteristics were identical in both the groups with a mean age of 41.5В±11.87 years. At 12 weeks, the mean (В±SD) change in FEV1, FVC and PEFR from baseline was greater in Tiotropium group as compared to the control group, with a difference of 0.71В±0.36 L (pЛ‚ 0.001), 0.75В±0.40 L (p AQLQ was statically better in the Tiotropium group (pЛ‚ 0.001). There was no diп¬Ђerence in the number of exacerbations during the study period between the two groups. No serious adverse events were noted with the use of Tiotropium. Conclusion: The addition of once-daily Tiotropium to severe asthma treatment, including a high-dose inhaled corticosteroid plus a long-acting ОІ2-agonist, significantly improves lung function and quality of life in patients with inadequately controlled, severe asthma. Pulmonary Function test in patients of Allergic Rhinitis P166 Jinesh Shah, Ajay Akkara, Stani Akkara Smt. B. K. Shah Medical Institute and Research Centre Introduction: It is a known fact that there is a close relationship between allergic rhinitis (AR) and bronchial asthma (BA). However very rarely do pulmonologists and ENT surgeons cross refer patients or look for signs of concomitant disease, especially in the absence of symptoms or complaints in a given patient. Aim: To find the status of pulmonary function in patients of allergic rhinitis. Materials and methods: All patients of allergic rhinitis presenting to our institute were investigated for pulmonary functions tests (PFT) over and above their routine work up and treatment. The findings of PFT were collected, tabulated and analysed. Results and Discussion: A total of 20 cases were included in the study during the three month period of the study. Majority of the cases were female and the commonest age group of presentation was in the fourth decade of life. Only 6 of the cases had normal PFT. 2 of the cases had a history consummate with BA and manifested as severe obstructive and restrictive disease. Rest of the cases had varying degrees of obstruction and restriction on PFT. These results were as per contemporary literature. Conclusion: All cases of allergic rhinitis should also undergo work up for BA to detect sub clinical and pre clinical stages of the disease. P167 Clinical profile of diseases causing chronic airflow obstruction in a tertiary care centre in India AUTHORS: SS GUPTA, A SRIVASTAVA, S TRIPATHI Department of Pulmonary Medicine, EraвЂ™s Lucknow Medical College & Hospital, Lucknow, India OBJECTIVES: To evaluate the profile of patients with chronic airflow obstruction with an aim to establish a causeeffect relationship between various disorders vis-a-vis chronic airflow obstruction. MATERIALS AND METHODS: A total of 100 OPD and in-patients from the Department of Pulmonary Medicine with chronic airway obstructive disorders were included. Demographic profiles and environmental and occupational exposures were noted. Clinical features and spirometry results were used to confirm the diagnosis. RESULTS: Majority of patients had COPD (68%) followed by bronchial asthma (19%) and bronchiectasis (13%). Major etiology of COPD and bronchiectasis was smoking (70.6% and 53.8% respectively). Age of bronchial asthma patients was lowest (29.74В±4.78 years), followed by those suffering from COPD (non-smokers) (55.00В±10.67 years), bronchiectasis (58.46В±9.02 years) and COPD (60.67В±6.64 years). Majority of patients of COPD due to smoking (100%) were males. COPD owing to non-smoking reasons was more common in females who were exposed to biomass fuel smoke. A total of 11 (55%) COPD (non-smokers) patients had a history of ATT intake. No significant association between occupation and different types of chronic airflow obstruction (CAO) was observed. Pulmonary functions were significantly more impaired in bronchial asthma patients as compared to other groups. CONCLUSION: In this study, COPD was the most common chronic airway obstructive disorder. Risk of CAO was higher in smokers or those having exposure to biomass fuel smoke. Pulmonary functions of patients with different types of CAO showed a different trend P168 A study of pulmonary function assessment in patients with allergic rhinitis. Authors -ANUSHANALAMOTHU, B.VIDYASAGAR, B.P.RAJESH, B.J.ARUN DEPARTMENT OF PULMONARY MEDICINE, Institute :J.J.M.M.C, DAVANGERE, KARNATAKA, INDIA ABSTRACT: Objectives: a)To assess the pulmonary functions of patients with allergic rhinitis. b) To demonstrate the presence of airflow obstruction and post-bronchodilator reversibility and to correlate with severity of allergic rhinitis in these patients. Material and methods: 50 patients presenting with allergic rhinitis over a duration of 1year (from Dec 2012- Dec 2013) were enrolled in our study .All the patients were evaluated with complete history, clinical examination, blood investigations, spirometry (FVC,FEV1,FEV1/FVC,FEV25-75%) pre and post bronchodilator inhalation. The degree of airflow obstruction and reversibility were assessed and correlated with severity of allergic rhinitis. Results: : In our study of 50 patients with AR- obstructive flow pattern was observed in most of the patients27(54%) with reversibility in 17(63%). Among the patients with obstruction(n=27) - small airway obstruction with reversibility was demonstrated in 10(37%) patients and large air way obstruction with reversibility in 7(26%) patients. Majority of the patients presented with moderate-severe AR-34(68%)vs mild AR-16(32%).). Lower airway obstruction was more frequent 19(56%) in patients with moderate- severe AR(n=34) compared to patients with mild AR(n=16) - 8(50%).The mean baseline FEV1(% predicted)was 74.14В±20.42% and it tend to decrease with severity of AR(P<0.004).The mean baseline FEF25-75%(%predicted)-54.76В±24.64 and the flow rates tends to decrease with severity of AR(P<0.01). Conclusions: According to our study the prevalence of asthma in patients with allergic rhinitis was high. Small airway obstruction was found to be predominant and there was significant post-bronchodilator reversibility.The flow rates tend to decrease with severity of AR. Asthma and allergic rhinitis should not be treated as two seperate clinical entities. Patients with allergic rhinitis should be evaluated for lower airway obstruction to initiate a safe and effective combined treatment strategy for both upper and lower airway. P169 ISOLATED PULMONARY MUCORMYCOSIS PRESENTING AS FATAL SEVERE ASTHMA SANTOSHAM R, ANANTHA R KISKU KH, MADHUSMITA M Department of Pulmonary Medicine, Pondicherry Institute of Medical Sciences, Puducherry-605014 Pulmonary mucormycosis is an uncommon disease caused by zygomycetes. It occurs predominantly in immunocompromised host. Isolated pulmonary mucormycosis is extremely rare. We report a case of pulmonary mucormycosis presenting as acute severe asthma and consolidation with no other site of involvement and underlying risk factors We report a 30 year old female who presented with altered sensorium вЂ“ 1 day, wheeze, breathlessness and fever for 10 days. Her chest xray showed non homogenous opacity in the right lower zone. She was a known asthmatic not on regular treatment. She had no other comorbidities. She was found to have CO2 narcosis and was treated as acute severe asthma with ventillatory support. She died of respiratory insufficiency and her post mortem lung biopsy showed mucormycosis P170 IS COPD THE BREEDING GROUND FOR PULMONARY TUBERCULOSIS ? AP KANSAL, Kamal Deep, Prabhleen KAUR, Shiyas MOHAMMED, Anand Kumar BANSAL, Varinder SINGH Bamrah Department Of Chest & TB, GMC, Patiala, Punjab INTRODUCTION : Both chronic obstructive pulmonary disease (COPD) and tuberculosis (TB) primarily affect the lungs and are major causes of morbidity and mortality worldwide. COPD and TB have common risk factors such as smoking, low socioeconomic status and dysregulation of host defence functions. COPD is a prevalent co-morbid condition, especially in elderly with TB but in contrast to other diseases known to increase the risk of TB AIM AND OBJECTIVES: To study Profile of Geriatric Patients having Pulmonary tuberculosis and COPD and their co relation . METHOD AND MATERIALS: This study was conducted on 500 geriatric patients with different respiratory problems presenting in Department of Tuberculosis and Respiratory Diseases, Govt. Medical College, Patiala. This was a performa based study. A proforma was used to seek biodata, clinical history and relevant investigations. All the cases were subjected to detailed physical examination and specific investigations and final diagnosis was made. Newly diagnosed Pulmonary tuberculosis were checked for history of COPD, smoking and corticosteroid use . RESULTS : This study shows 372 (74.4%) males and 128 (25.6%) with different respiratory problem.243 were smokers or have smoked in past.116 were having COPD. 147 cases were diagnosed to have pulmonary tuberculosis , 124 males and 23 females. Out of 147 cases of pulmonary tuberculosis 79 had history of smoking, 15 had history of biomass fuel exposure, 58 had history of inhaled ICS use with mean duration of use 4В±3.2 and 54 were previously diagnosed as COPD. CONCLUSION: Keeping a high suspicion and regularly monitoring for the development of pulmonary TB in COPD patients are necessary,as majority are receiving oral corticosteroids and have history of smoking. P171 Intranasal Fluticasone vs Oral Montelukast in the management of NasoBronchial Allergy Dr Apar JINDAL, Dr Meenakshi N., Dr Subramanian S. Department of Respiratory Medicine, Chettinad Hospital and Research Institute, Kelambakkam, Chennai, India Introduction: Both asthma and rhinitis are considered to be inflammatory disorders of the airway as per the вЂњone airway hypothesisвЂќ. Thus it follows that a therapeutic approach targeting one site may significantly improve the other. Aim: To compare intranasal fluticasone and oral montelukast for - symptom control of asthma and allergic rhinitis (nasal and non nasal), reduction in acute exacerbations and adverse effect profile. Methodology: 120 Patients of Bronchial Asthma (GINA) and concomitant Allergic Rhinitis (ARIA) in the age group of 15 to 65 years were randomized into 2 groups receiving intranasal fluticasone propionate 200mcg and oral montelukast 10mg respectively, for a period of 60 days, and neither of the drugs for the following 30 days. During study period Asthma was treated with fluticasone/salmeterol 125/50 mcg via Metered Dose Inhaler for all patients. At each visit (Day 0, 30, 60 and 90) asthma and allergic rhinitis control was evaluated by symptom score questionnaire. Results: The baseline characteristics were comparable in both the groups. There was better asthma control in the fluticasone group at Day 60(p = 0.001) and 90 (p = 0.041). At day 60 the control of nasal and non-nasal symptoms of allergic rhinitis was better in fluticasone group (difference of mean -2.324, p = 0.000 & -1.369, p = 0.028 respectively). There were more adverse effects noted with Montelukast, most common being headache and GI disturbances (18.9% and 13.2% respectively). Adverse effects with fluticasone were nasal irritation (9.3%) and throat irritation (7.1%). At day 60 the Odds Ratio for Acute Exacerbation of Asthma for fluticasone versus montelukast was found to be 0.325(p = 0.098). Conclusion: The present study demonstrates the superior efficacy and better safety profile of intranasal fluticasone Propionate over oral montelukast, in control of Asthma and Allergic Rhinitis symptoms in patients with Nasobronchial Allergy. P172 Title- BODE index as a prognostic tool in COPD patients. Authors- Dr Kapil Jangid,Dr Ravi Dosi ,Dr Ravindra Chordia ,Dr Ashok Bajpai , Dr Satish Motiwale. Sri Aurobindo Institute of Medical science & PG Institute Indore, India Objective: - We hypothesize that BODE index is good prognostic tool in COPD patients. Methods: 100 pt over 2 year period at Sri Aurobindo Institute of Medical science indore in department of pulmonary medicine recruited in study and demographics, clinical evaluation, spirometry, peripheral oxygen saturation, body composition, 6-minute walking distance, dyspnea, and quality of life measurements were obtained and BODE score is calculated at 0 month (baseline) and after 1 yr of follow up of 51 patients. 3 groups as per BODE score severity were made & patient were followed accordingly. P <0.05 considerd significant & paired t test applied. ResultsBaseline of BODE 1 - 19 pts (patients) were in BODE 1 2 pts worsen to BODE 2 0 pt was in BODE 3 Baseline of BODE 2 - 7 pts were in BODE1 10 pts worsen to BODE 2 1 pt was in BODE 3 (p <0.001) Baseline of BODE 3 - 0 pt was in BODE 1 5 pts improved to BODE 2 7 pts remain in BODE 3 We obtain that 6 min walk distance significantly improved in BODE 2 & BODE 3 (p < 0.003 & p<0.012) FEV1 was not significant with either of BODE index. Patients addicted to both smoking and alcohol were more decrease in 6MWD (P 0.136) also decline in FEV1 (P 0.866). Conclusion- BODE index strongly determine prognosis of COPD patients and be should consider as a surrogate marker in assessment of COPD patients as compared to FEV1. P174 AIRWAY HYPERRESPONSIVENESS IN CHRONIC ASTHMATICS Dr. Jenam Mehta, Dr. J M Phadtare, Dr. N N Ramraje Department of Pulmonary Medicine, Grant Government Medical College, Mumbai-8 ABSTRACT 50 mild to moderate asthmatic patients were assessed for airway hyper responsiveness by direct method using graded concentrations of histamine.The youngest was 18 years, the oldest 51 years ,the mean age being 34 years.44% were males and 56% females. Bronchial challenge tests were positive in 90% of mild to moderate asthmatic patients. 62% of the asthmatics had an associated nasobronchial allergy as documented by X ray PNS. There was significant linear correlation of PC20 levels with FEV1, .There was no significant correlation of PC 20 levels with serum Ig E levels. P175 CONSOLIDATED REPORT OF THE PULMONARY FUNCTION TEST CHECK UP CAMPS FOR MUMBAI TRAFFIC POLICE JAIN S., MOHANTY K.C., BENDRE S.S., SAI H., BALAKRISHNAN R. K. J. SOMAIYA MEDICAL COLLEGE & RESEARCH CENTRE, MUMBAI INTRODUCTION-URBANISATION IS ASSOCIATED WITH AN ENORMOUS INCREASE IN VEHICULAR TRAFFIC EMITTING EXHAUST AND POLLUTION OF THE ATMOSPHERE.SO2,NO2,CO,SUSPENDED PARTICLE PLAYS A KEY ROLE IN OVERALL ATMOSPHERIC POLLUTION AND MOTOR VEHICLE EMISSION CONSTITUE THE MOST SIGNIFICANT SOURCE OF ULTRAPARTICLE IN AN URBAN ENVIRONMENT.TRAFFIC POLICE ALL EXPOSED TO POLLUTANT MORE THEN 8 HRS AS OCCUPATIONAL HAZARDAIM- DETERMINE THE PULMONARY FUNCTION TEST OF TRAFFIC POLICE PERSONALMETHOD-MEDICAL CHECK UP WAS DONE ON 1455 TRAFFIC POLICE PERSONNEL AT 12 MULTI SPECIALITY MEDICAL CHECK UP WITH CO-OPERATION OF ADDITIONAL COMMISSIONER OF POLICE DRAWING THE POLICEMEN FROM EASTERN,WESTERN SUBURB,CENTRALMUMBAI, .PFT WAS CARRIED OUT AS A PART OF COMPLETE MEDICAL CHECK-UP RESULTS ARE AS FOLLOWSRESULT-OF 1455 POLICEMEN ALL PERFORMED THE PFT. 210 (15%) WERE FEMALES AND 145(10%) WERE SMOKERS. 250(17%) HAD AIRWAY OBSTRUCTION, OF WHICH 204(14%) HAD MILD OBSTRUCTION,45(3%)HAD MODERATE OBSTRUCTION AND ONE POLICEMAN HAD SEVERE AIRWAY OBSTRUCTION . MACHING INDIAN STANDARDS OF SPIROMETRY. NO POLICEMAN DEMONSTRATED RESTRICTIVE PATTERN. AVERAGE DURATION OF WORKING HOURS WAS 8 HOURS PER DAY.CONCLUSION-OUR RESULT SUGGEST THAT EVEN AFTER EXPOSURE TO ENVIROMENTAL POLLUTION PFT CHANGES WERE NOT MUCH AS EXPECTED .MOST OF THEM HAD MILD AIRWAY OBSTRUCTION WHICH CAN BE CONTROLLED BY BREATHING EXCERCISE AND USING FACIAL MASK. INTRODUCTION OF UNLEADED PETROL, LOW SULPHUR DIOXIDE CONTENT DIESEL AND IMPLEMENTATION OF BHARAT III EMISION NORMS HAS PROBABLY PLAYED A MAJOR ROLE IN PREVENTING DEVELOPMENT OF ABNORMAL LUNG FUNCTION. P176 ROLE OF SPUTUM EOSINOPHILS CORRELATION WITH SPIROMETRY DURING ACUTE EXACERBATION AND REMISSION IN BRONCHIAL ASTHMA AND COPD P.RAVI KMC OBJECTIVES:-The presence of eosinophilia has been considered typical asthmatic inflammation where as neutrophils,macrophages and lymphocytes are the most significant inflammatory cells found in the airways of patients with COPD.The aim of the present study is to compare the eosinophils in sputum of pts with asthma and COPD. MATERIALS AND METHODS:-30 pts presenting with airway disorders were prospectively studied in the year 20122014 they were evaluated with spirometry and sputum for eosinophil count during exacerbation and remission. RESULT:-Out of 30 pts, 20 were COPD and 10 were bronchial asthma.In the bronchial asthma group 9 out of 10 had sputum eosinophilia(90%) and 1 pt didnвЂ™t. (Mean level during exacerbation- 13.2).In remission 8 pts had sputum eosinophilia 2 pts didnвЂ™t.(Mean level - 3.8). In the COPD group out of 20, 18 had sputum eosinophilia and 2 pts didnвЂ™t.(Mean level in COPD exacerbation-9.8),during remission 3 patients had sputum eosinophilia,17 pts didnвЂ™t.(Mean level during remission -1.5). CONCLUSION:-There was no difference in the occurrence of sputum eosinophilia during exacerbation in bronchial asthma and COPD.But mean level of eosinophilia is more in asthma than COPD.During remission sputum eosinophilia was more common in asthma than COPD P177 CONSOLIDATED REPORT OF THE PULMONARY FUNCTION TEST CHECK UP CAMPS FOR MUMBAI TRAFFIC POLICE JAIN S., MOHANTY K.C., BENDRE S.S., SAI H., BALAKRISHNAN R. K. J. SOMAIYA MEDICAL COLLEGE & RESEARCH CENTRE, MUMBAI INTRODUCTION-URBANISATION IS ASSOCIATED WITH AN ENORMOUS INCREASE IN VEHICULAR TRAFFIC EMITTING EXHAUST AND POLLUTION OF THE ATMOSPHERE.SO2,NO2,CO,SUSPENDED PARTICLE PLAYS A KEY ROLE IN OVERALL ATMOSPHERIC POLLUTION AND MOTOR VEHICLE EMISSION CONSTITUE THE MOST SIGNIFICANT SOURCE OF ULTRAPARTICLE IN AN URBAN ENVIRONMENT.TRAFFIC POLICE ALL EXPOSED TO POLLUTANT MORE THEN 8 HRS AS OCCUPATIONAL HAZARDAIM- DETERMINE THE PULMONARY FUNCTION TEST OF TRAFFIC POLICE PERSONALMETHOD-MEDICAL CHECK UP WAS DONE ON 1455 TRAFFIC POLICE PERSONNEL AT 12 MULTI SPECIALITY MEDICAL CHECK UP WITH CO-OPERATION OF ADDITIONAL COMMISSIONER OF POLICE DRAWING THE POLICEMEN FROM EASTERN,WESTERN SUBURB,CENTRALMUMBAI, .PFT WAS CARRIED OUT AS A PART OF COMPLETE MEDICAL CHECK-UP RESULTS ARE AS FOLLOWSRESULT-OF 1455 POLICEMEN ALL PERFORMED THE PFT. 210 (15%) WERE FEMALES AND 145 (10%) WERE SMOKERS. 250 (17%) HAD AIRWAY OBSTRUCTION, OF WHICH 204(14%) HAD MILD OBSTRUCTION, 45 (3%) HAD MODERATE OBSTRUCTION AND ONE POLICEMAN HAD SEVERE AIRWAY OBSTRUCTION. MACHING INDIAN STANDARDS OF SPIROMETRY. NO POLICEMAN DEMONSTRATED RESTRICTIVE PATTERN. AVERAGE DURATION OF WORKING HOURS WAS 8 HOURS PER DAY.CONCLUSION-OUR RESULT SUGGEST THAT EVEN AFTER EXPOSURE TO ENVIROMENTAL POLLUTION PFT CHANGES WERE NOT MUCH AS EXPECTED .MOST OF THEM HAD MILD AIRWAY OBSTRUCTION WHICH CAN BE CONTROLLED BY BREATHING EXCERCISE AND USING FACIAL MASK. INTRODUCTION OF UNLEADED PETROL, LOW SULPHUR DIOXIDE CONTENT DIESEL AND IMPLEMENTATION OF BHARAT III EMISION NORMS HAS PROBABLY PLAYED A MAJOR ROLE IN PREVENTING DEVELOPMENT OF ABNORMAL LUNG FUNCTION. P178 Triple drug therapy in patients with COPD: a survey of prescription practices in India DR A HASAN1, DR P PRABHUDESAI2 1Deccan College of Medical Sciences and Care Institute of Medical Sciences, Hyderabad, India 2Lilavati Hospital & Research Center, Mumbai, India Objective: Recent guidelines recommend the use of triple therapy (Long acting ОІ2 agonists [LABA] + long acting muscarinic antagonists [LAMA] + inhaled corticosteroids [ICS]) in patients with advanced chronic obstructive pulmonary disease (COPD). Triple drug therapy finds a place in the prescribing practices of physicians in India, especially in the moderate and severe stages of COPD. This survey was designed to understand the ground realities of COPD practice in India in terms of triple drug therapy. Methods: The data for this survey was obtained through a questionnaire from those respiratory physicians across India who routinely manage COPD patients. Results: Two hundred respiratory physicians participating in the survey reported that on an average COPD patients comprised 26.1% of all their patients. According to the survey, 35% [95% CI: 31.3 - 39.8] of patients with COPD were receiving the three drugs in combination. A concurrent administration of [ICS+LABA] fixed dose combination and LAMA was the most preferred line of treatment by respiratory physicians for prescribing triple drug therapy in patients with COPD. Eighty percent of the physicians agreed that using triple drug combination in a single inhaler could simplify therapy (especially for patients with comorbidities), improve compliance, reduce overall cost of therapy and improve efficacy. 48.7% of those physicians who did not prescribe the three drugs in a single inhaler admitted to lack of data about the combination as the primary factor for reluctance to prescribe the combination. Patients with severe (51%) or moderate to severe (39%) COPD were more likely to be prescribed triple drug therapy. Conclusion: This survey provides insight into the fact that respiratory physicians in India frequently employ triple therapy comprising LABA, LAMA and ICS in patients with COPD. They also acknowledged that using triple therapy in a single inhaler helps improve efficacy, compliance and simplifies treatment regimen. P179 Title COPD-6 a screening device to detect obstructive airways disease in patients with respiratory symptoms from a primary care centre in India. AUTHORS 1. 2. 3. 4. Dr Shobhit Bansal MBBS (Presenting Author); Metro Hospitals & Heart Institute; L-94, Sector-11, Noida, Delhi NCR, India-201301. Dr. Vidya Nair, MD; Metro hospital & heart Institute; L-94, Sector-11, Noida, Delhi NCR, India-201301. Mr. Abhijit Vaidya, MSc, [email protected]; MSc; Medical Service (Clinical Research Division), CIPLA Ltd., Mumbai Central, Mumbai, Maharashtra, India-400008. Dr. Deepak Talwar , [email protected], MD; Metro Hospitals & Heart Institute; L-94, Sector-11, Noida, Delhi NCR, India-201301. INTRODUCTION AND BACKGROUND Despite rising mortality and health care costs COPD and asthma remains the most undiagnosed diseases due to lack of required infrastructure in primary care hospitals. AIMS AND OBJECTIVES To evaluate clinical equivalence in terms of sensitivity, specificity and reliability of COPD-6 device in comparison with pneumotach spirometer in detecting patients with obstructive airway disease with respiratory symptoms. Methods This was a descriptive, cross-over, prospective study which included 60 participants. Screening was done sequentially with COPD-6 device and pneumotach spirometer. The validity and specificity of the COPD-6 device in detecting obstruction was determined using standard formulas, and the sensitivity, specificity, positive predictive value (PPV) and negative predictive value (NPV), were calculated. We also estimated the area under the ROC (Receiver-Operating Characteristic) curve of the FEV 1/FEV6 ratio (measured with the COPD-6) in the discrimination of the obstruction, using the FEV1/FVC <0.7 quotient obtained with spirometry as the gold standard. Results There were 29 participants detected to have obstructive airway disease. The kappa index was 0.66 when an FEV1/FEV6 cut-off point of <0.7 was used as gold standard. The ROC AUC was 0.88. To detect obstruction, if the cutoff point of FEV1/FEV6 for COPD-6 was <0.70, the sensitivity, specificity, PPV and NPV were, 65.5%, 93.5%, 90.5% and 74.4% respectively. For a cut-off point of <0.76, they were 76.9%, 95.2%, 96.8% and 69%, respectively. Conclusion COPD-6 is a moderately accurate device to detect airway obstruction in patient with respiratory symptoms. Greater accuracy is observed when cut-off point is 0.76. P180 Bird FancierвЂ™s Lung - usefulness of ImmunoCAP technology to measure IgG precipitating antibodies against avian antigens Authors and affiliations: S KHAN, S R CHOWDHURY, S GHOSH, A SENGUPTA, B GHOSH and S RAMASUBBAN Department of Allergy & Immunology, Apollo Gleneagles Hospital, Kolkata, India Department of Pulmonary Medicine, Apollo Gleneagles Hospital, Kolkata, India Department of Intensive Care Unit, Apollo Gleneagles Hospital, Kolkata, India OBJECTIVES: Bird fancier's lung is a hypersensitivity pneumonitis (HSP) involving the pulmonary interstitia in response to avian droppings or antigens on bird feathers. There is little data on the usefulness of serum specific IgG antibodies and whether a cut-off value can be determined at different stages of the disease. METHODS: A retrospective analysis was done on suspected HSP patients with data collected from radiologic analyses, absolute eosinophil count, total IgE levels and avian specific IgG antibodies using ImmunoCAP (Thermo Fisher Scientific) with Ge91 (pigeon serum, feathers and droppings). Six-point calibration was done using ImmunoCAP IgG calibrators and serum analyzed at 1 in 100 dilution. Different cut-off levels of Avian Precipitins IgG were analyzed including negative and positive predictive values. The current cut-off for significant exposure determined from previous studies is 10 mgA/L. RESULTS: 23 patients (10 males, 13 females) with a mean age of 49.9 years (range 20-66 years) between June 2013 to May 2014 were studied. Dyspnea and cough were present in 100% of patients. Mean absolute eosinophil count was 277 (n=11) and mean total IgE was 877 kU/L (range 40-2810, n=7). Specific IgE to Aspergillus fumigatus done in 6 patients were negative (range 0.03-0.28 kUA/L, manufacturer recommended cut-off 0.35). Eleven patients (47.8%) had high values of avian precipitins from 30.3 to >200 mgA/L, of which 6 patients in the acute phase with extensive honey combing on HRCT had very high levels at >200 mgA/L. Five patients had levels in the intermediate range 30.3-68.1 mgA/L, of which only one patient did not have significant changes on HRCT. 12 patients without significant lung involvement had mean (В± SD) value at 16.74(В± 8.34) mgA/L. Cut-off value at 10mgA/L would yield sensitivity (Se) at 100% but very low specificity (Sp) at 16.67%; cut-off value 20mgA/L, Se 100% Sp 58.33; and at 30mgA/L Se 100% Sp 91.67% PPV 91.67 NPV 100%. CONCLUSIONS: Use of the ImmunoCAP Ge91 avian precipitin technology proved helpful to clinicians and we recommend a higher cut-off at 30mgA/L with concomitant HRCT findings to determine significant antigen exposure. Patients with acute HSP had levels >200 mgA/L. The actual cut-off of avian precipitins for subacute and chronic stages of the disease remains to be determined. P181 Use of ImmunoCAP technology to measure Aspergillus fumigatus specific IgE and IgG precipitating antibodies (precipitins) in the management of ABPA Authors and affiliations: S KHAN, S R CHOWDHURY, S GHOSH, A SENGUPTA, B GHOSH, S RAMASUBBAN, D Department of Allergy & Immunology, Apollo Gleneagles Hospital, Kolkata, India Department of Pulmonary Medicine, Apollo Gleneagles Hospital, Kolkata, India Department of Intensive Care Unit, Apollo Gleneagles Hospital, Kolkata, India Department of Medicine, Apollo Gleneagles Hospital, Kolkata, India SEN Objectives: Allergic bronchopulmonary aspergillosis (ABPA) is a hypersensitivity pneumonitis in the lung interstitium and terminal bronchioles induced by chronic exposure to moulds. We present our experience in using the quantitative estimates of specific IgE and precipitating IgG antibodies against Aspergillus fumigatus using the automated ImmunoCAP method (Thermo Fisher Scientific) in the management of ABPA. Methods: A retrospective analyses was done on suspected ABPA patients who had total IgE (kU/L), specific IgE and IgG against Aspergillus fumigatus (m3 IgE and m3 IgG) blood tests done using ImmunoCAP (fluoroenzyme immunoassay), including skin prick tests on some patients. Criteria for ABPA were assessed using the Patterson or Agarwal criteria. Normative data on specific IgE level for sensitization to Aspergillus fumigatus were calculated on patients with asthma without ABPA. Descriptive statistics and unpaired t-test was done using GraphPad Prism software. Results: 71 patients (39 males, 32 females) with average age 53.4 years (age range 9-94 years) between June 2013 to May 2014 were evaluated for ABPA. 19 patients (26.7%) fulfilled criteria for ABPA of which 11 had m3 IgG between 40-90 mgA/L, 5 between 90-200 mgA/L, 2 had >200 mgA/L and one patient with skin test positive to 3 Aspergillus species but low m3 IgG (18 mgA/L). The mean (SD) m3IgG value of the ABPA patients was 98.1 (56.38) as compared with mean value of 58 patients with bronchiectasis but without ABPA 17.33 (SD 9.68) (p<0.0001, 95%CI 64.85 to 96.66). Mean m3 IgE in the 8 patients was 13.32 kUA/L (SD 22.77). Unpaired t-test to compare means between gender and m3 IgG (98.08 mgA/L vs 90.15 mgA/L) and m3 IgE were non-significant (p=0.77 and 0.47 respectively). Of 65 consecutive patients with asthma (without ABPA) as controls checked for sensitization to Aspergillus fumigatus, 5 were sensitized (0.35-1.19 kUA/L) with mean total IgE 840.58 kU/L (SD 1129.39). Conclusions: Around 8% of asthmatics were sensitized to Aspergillus fumigatus in our study. The cut-off value of specific IgG against Aspergillus fumigatus at 40mgA/L for diagnosis of ABPA had 100% sensitivity but specificity is much higher when the cut-off is 90mgA/L. The diagnosis of chronic pulmonary aspergillosis appears more plausible at levels between 40-90mgA/L. Title- Life Threatening Occupational Hazards P182 Author- Dr Nikhilesh pasari Dr Ashok Bajpai Dr B.Jain Sri Aurobindo Institute Of Medical Sciences & PG Institute Indore, India Toluene Inhalation is an important occupational health hazard in persons working in factories manufacturing paint, pharmaceuticals& rubber .The present report describes an unusual case of toluene induced ALI threatening life. Key words:-Health, Lung injury, Toulene REFERENCES 1) U.S Depart of labor occupational safety &Health Administration. Safety & Health topics; Toulene available from:http://www.osha.gov/dts/chemicals/data/CH_272200.html. 2) Byrme A,Kirby, ZibinT,EnsmingerS.Psychiatric &Neurological effects of chronic solvent abuse. Can J Psychiatry 1991;36:735 P183 Effects of cotton dust exposure on the respiratory system in spinning mill workers Santhosh C, nageswari A D, srinath D, rajalakshmi R, aishwarya R SRM medical college hospital and research centre, chennai, india Objective To estimate the prevalence of respiratory symptoms and to evaluate the pulmonary function changes in spinning mill and textile workers Method The study was conducted in the spinning mills in and around Tirupur district in Tamilnadu, at their workplace itself. The workers were asked to fill the modified ATS respiratory questionnaire along with necessary demographic data followed by spirometry. Chest symptoms and spirometric variables for all workers were analyzed. Results вЂ“ The study was conducted among 251 spinning mill workers. The median age group of the population was 21years (minimum вЂ“ 17, maximum вЂ“ 63). The gender distribution of the population was 142 males and 109 females. Among them 136 were local people and 115 were migrants from other states. Out of 251 workers, 18(7%) were in carding department, 106(42%) in spinning, 64(26%) in cone winding, 20(8%) in simplex and 43(17%) were from other departments such as machine cleaning, technical support, drawing, and supervising. Out of 251, 73(29%) were having respiratory symptoms, among the symptomatic 40(55%) were having chest tightness. Among 251, 36(14%) were having obstruction in PFT (FEV1/FVC < 0.70), in which 20(19%) were working in spinning department. Out of 251, 114(45%) were having FEV1 <80%, among them 49(43%) were in spinning department. Out of 251, 106(42%) were having FVC < 80%, in that 43(41%) were in spinning department. Among 251, 208(83%) had PEF% < 80%, in that 116(56%) were in spinning department ConclusionIn this study, chest tightness was the most prominent symptom which accounts for 55% of chest symptomatics. Workers in spinning department were having more obstruction (19%), reduced FEV1% (43%), FVC (41%) and reduced PEF% (56%) in spirometry. Workers in the spinning department of textile mills require personal protective measures than those in other departments to prevent respiratory ailments. P184 PROFILE OF PATIENTS PUT ON INTERCOSTAL DRAINAGE TUBE(ICD) IN A TERTIARY CARE HOSPITAL AP KANSAL , Prabhleen KAUR , Don Gregory MASCARENHAS, Shiyas MOHAMMED , Nancy GARG Department Of Chest & TB,GMC, Patiala , Punjab Introduction : Chest tubes are used in pneumothorax, hemothorax, empyema and malignant pleural effusion(MPE) Method and materials : A retrospective study was done of patients put on ICD in our department between November 2013 to july 2014 Results: Out of the 34 patients who were inserted a ICD, 27 were males and 7 were females .Youngest was a 17 yr old and oldest being 84 yrs with a median age of 42.9yrs. Most common(M/C) indication was hydropneumothorax(38%) followed by pneumothorax(26.4%), empyema(17.6%) MPE(8.8%).most common underlying condition was pulmonary tuberculosis , both for hydropneumothorax and pneumothorax(56%) accounting for 64.7% of cases, followed by COPD(14.7%), trauma(5.9%) and malignancy(5.9%). Majority of patients were manual labourers(50%) .2 pts were smokers . 13 pts had taken att prior to ICD insertion .only 3 patients came out to be sputum positive for AFB .3 patients had AFB detected in their pleural fluid, all three being cases of empyema .16 had right sided involvement and 18 had left sided involvement . Duration for lung expansion on an average was 5days for pneumothorax, & 7 days each for Hydropneumothorax(HPT) and empyema with the latter two requiring streptokinase injection in some cases(33%) for complete lung expansion. Pleurodesis was successfully done in 11 out of 12 cases using 1.5gm single dose tetracycline intrapleurally(92%) Discussion: Tuberculosis is still the major cause of pneumothorax(SSP), HPT & empyema in our part of country. ICD insertion causes quick resolution of fluid/air & decreases morbidity. Tetracycline is a very effective agent for pleurodesis. Silicotuberculosis : A case report P185 AP KANSAL, Prabhleen KAUR , Don Gregory MASCARENHAS, Kamal Deep, Nancy GARG, Varinder SINGH Bamrah Department Of Chest & TB, GMC, Patiala , Punjab Introduction: Silicosis, the most prevalent disease of all the pneumoconioses is caused by inhalation of crystalline silica particles. Tuberculosis is notorious to alter its course and outcome. Case Report: A 55 year old chronic smoker male presented to us with progressive breathlessness and productive cough for 3 months with loss of appetite for 1 month. There was no history of fever , chest pain or hemoptysis.He was a chronic bidi smoker for 30 years(pack year=30). He was a marble grinder for the past 30 years. On chest examination, patient had bilateral rhonchi. Chest xray revealed multiple dense nodular shadows in both the lung fields. patient came sputum positive for acid fast bacilli. Pulmonary function tests showed obstructive pattern. HRCT showed multiple centrilobular nodules along with pleural thickening and multiple calcified lymph nodes along with cavitatory lesion and consolidation in the bilateral upper lobes .Based on the clinicoradiological features and occupatinal exposure to silica , diagnosis of silicotuberculosis was made. Patient was put on anti tubercular drugs for which he responded well clinically and radiologically. Discussion: Silicosis is caused by prolonged exposure to silica dust. Silica particles absorb body iron and act as a reservoir of iron. Mycobacteria are dependent on iron for growth and produce the iron chelators mucobactin. Hence silica-exposed workers are at increased risk for tuberculosis and other mycobacterium-related diseases. TB complicates silicosis and viceversa. Silicotuberculosis affects the parenchyma ,arteries and the veins. Synergistic effect of silicosis and TB leads to proliferative fibrous reaction leading to end stage lung disease. Conclusion: Active surveillance of the workers in industries causing silica exposure is required both preemployment and post-employment periods to reduce the morbidity and mortality of silicotuberculosis. P186 Chronic hypersensitivity pneumonitis: a case series of 18 biopsy proven cases SANTOSH JHA,ANKUR AGRAWAL,PRAHLAD PRABHUDESAI Lilavati hospital and research centre,Mumbai,india. Objectives: 1)To retrospectively analyse the clinical features, radiological findings, spirometry and biopsy results of 18 patients of chronic hypersensitivity pneumonitis(HP) 2)to compare pre and post treatment spirometry findings in these patients. Methods and materials: 18 cases of biopsy proven HP was retrospectively studied. history, spirometry and radiological findings were analysed. therapy was instituted and post therapy spirometry was compared to pre treatment finding. Results : Mean age was 46.2yrs. Exposure to pigeons was there in 15 patients. Most common symptom on presentation was dyspnea on exertion and dry cough. Most common radiological findin was reticulonodular shadow on CXR and centrilobular nodules, interstitial thickening, ground glass opacity in chronic HP cases. Most common spirometric finding was restriction and reduced DLCO. and most common histopathological findings were multinucleated giant cells, ill defined granulomas. Post treatment spirometry was done after 1 years, which showed no significant improvement or deterioration in lung functions. Conclusion: Exposure to pigeons was most common etiological agent in our study, in 3 patients we couldnot find any cause.there was no significant improvent in spirometric values despite treatment with steroids, although there was symptomatic improvement. More studies are required for elusive disease. P187 Bird Fancier Lung: Clinico-radiological presentation in 15 patients MANDEEP SINGH, RAJ KUMAR, RAJENDRA PRASAD National Centre for Respiratory Allergy, Asthma and Immunology Vallabhbhai Patel Chest Institute, Delhi-110009, India Category: for ICS - Dr. J. C. Kothari Young Scientist Award (3 Awards) Objective: Bird fancier's lung (BFL) is a type of hypersensitivity pneumonitis occurring in response to avian antigens. The diagnosis is based on a combination of clinical, radiological and biopsy characteristics. The present study was planned to highlight the clinico-radiological presentation in cases of bird fancier's lung. Methods: The present study is a retrospective analysis of cases of BFL diagnosed in a unit of Vallabhbhai Patel Chest Institute from 2013-14. The diagnosis of BFL was made as per criteria laid down by Mark Schuyler and Yvon Cormier. The clinico-radiological features of the subjects were analysed. Results: There were a total of fifteen cases diagnosed with BFL during the study period comprising of twelve females and three males with a mean age of 54.93 В± 14.21 years. All studied subjects gave significant history of exposure to pigeons and were non smokers. The period of symptoms prior to presentation varied from 1-8 years. The main symptoms on presentation were exertional breathlessness in 100% (15/15), cough in 93.3% (14/15). On examination, crepitations were heard in all patients and 73.33% (11/15) patients desaturated on 6MWT. Radiologically, diffuse centrilobular nodules, ground glassing- predominant in upper lobes, was each seen in 40% (6/15) cases, fibrosis with or without traction bronchiectasis in 40% (6/15) cases, honeycombing in 13.3% (2/15) cases. Pulmonary function testing showed mild obstruction in one, was completely normal in another case while in the rest there was evidence of restrictive lung disease with reduced diffusion capacity in all except one case in which it was normal. Bronchoscopy showed ill defined granulomas in 60% (9/15) cases and chronic interstitial inflammation in all cases. Conclusions: BFL can exhibit a wide range of radiological patterns and high index of suspicion must be maintained and particular attention paid to detailed exposure history in every case of ILD. P188 Role of Adenosine Deaminase in the Diagnosis of Tubercular Pleural Effusion Mehta A, Rohatgi A Prashant Mehta, PG, Deptt. of Medicine LHMC & SSKH Delhi Introduction: TB is common in India. ADA has recently become a valuable tool in diagnosing Extrapulmonary TB as definitive diagnosis of TB pleural effusion is difficult due to the low sensitivity and specificity of non invasive tests. Objectives: This Study was undertaken to evaluate the role of ADA in the diagnosis of TB Pleural effusion where diagnosis based on conventional Non- Invasive tests is difficult. Methods: Patients with exudative Pleural effusions were taken for this study after relevant investigations. ADA levels were estimated in Pleural fluid by GiustiвЂ™s method. ADA>40 U/L was considered diagnostic of TB. In addition L/N ratio > 0.75 in fluid was considered an additional supportive evidence . Results: 50 cases were analysed of which 36 had TB effusion(group I) and 14 due to other causes(Group II :Malignant- 5; CTD- 6; Hypothyroidism- 1; SynPneumonic- 1). Mean ADA was 134 U/L in Group I compared to 15.17 U/L in Group II. Sensitivity, Specificity, Positive Predictive Value and Negative Predictive Value of ADA in effusion was 100%, 86%, 95% & 100% respectively. L/N ratio was >0.75 in Group I as against None in Group II. Of 36 cases of TB effusion( Group I), 28 responded to ATT however the remaining were lost to follow up. Conclusion: The performance of ADA in TB effusion is reasonably accurate and is hence a good diagnostic method as it is simple, rapid, easily available with high sensitivity and specificity. However larger multicentric studies would be advisable to further look into this. P189 Massive right sided haemorrhagic pancreatic pleural effusions :Case Series Dr. N. Snigdha , Dr.N.Gopichand ,Dr.D.Sudeena,Dr.C.Suma lata Siddhartha Medical College, Vijayawada, Andhra Pradesh,India. INTRODUCTION: Pleural effusion occurs as a complication of pancreatic disorders like Acute pancreatitis, Pancreatic Abscess, Pseudocyst, Pancreatic malignancy,Chronic pancreatitis.It is usually bilateral but 22% account for left ,10% right sided. Diagnosis is established by demonstrating high levels of pleural fluid amylase. Here we present four different cases of right sided pancreatic pleural effusions. CASE REPORTS Case1: A 36 year old alcoholic male came with shortness of breath (SOB), cough and chest pain on right side. Absent breath sounds present over right side. Chest X-Ray (CXR) PA views showed right massive pleural effusion. Thoracocentesis revealed hemorrhagic fluid which showed elevated amylase-59740 U/l. Contrast CT chest and abdomen showed pancreatic pseudocyst. Case2:A 45 year male, alcoholic and smoker came with complaints of severe SOB.CXR PA view showed massive right sided pleural effusion. On evaluation his serum amylase was 457 U/l, pleural fluid amylase was 14,830 U/l. Pleural fluid was haemorrhagic and showed malignant cells on cytology. Contrast CT chest and abdomen along with ultrasound abdomen confirmed malignancy involving head and neck of pancreas. Case3:A 33 year male, alcoholic came with complaints of SOB.CXR PA view revealed massive right sided pleural effusion. On evaluation pleural fluid is haemorrhagic pleural fluid amylase was 14,486 U/l. Ultrasound abdomen and CT abdomen showed features of chronic pancreatitis. Case4:A 38 year male presented with SOB. On evaluation he is found to be having massive right sided pleural effusion that is haemorrhagic. Pleural fluid amylase was 38,365U/l. Ultrasound abdomen revealed pancreatic pseudocyst. Discussion: Pleuro-pulmonary complications secondary to pancreatic etiology are well known but rare. These effusions are usually left sided but all the above 4 cases are right sided, heamorrhagic, showed elevated amylase levels. Often the underlying pancreatic disease is missed due to lack of abdominal symptoms. The best modality for diagnosis in these cases remains pleural fluid amylase. They often tend to recur after thoracocentesis. P190 Rare cause for pneumothorax in a young male Manjunath M, Vishnu SHARMA M, Alka BHAT, Harsha D S Department of Respiratory Medicine, A. J. Institute of Medical Sciences & Research Centre, Kuntikana, Mangalore, Karnataka. INTRODUCTION When a patient develops pneumothorax proper evaluation should be done to find the cause. Identifying the cause will help to prevent recurrences and is essential to treat the underlying disease. CASE REPORT A 20 year male presented with complaints of sudden onset of dyspnea, left sided chest pain and cough with scanty expectoration since 3 days. No other significant history. He had started smoking at the age of 15 years, daily smoked two packs of cigarettes. Clinical examination revealed features suggestive of left sided pneumothorax. Chest X ray showed Left sided pneumothorax with bilateral reticulonodular and occasional cystic lesions in both lower zones. Intercostal tube drain was inserted. Routine blood investigations were normal. Sputum AFB smear was negative. In view of radiological findings patient was empirically started on anti tuberculosis treatment. On further work up with HRCT showed features suggestive of Pulmonary Langerhans cells Histiocytosis with left sided pneumothorax. He had an uneventful recovery. He was discharged with advice of smoking cessation and oral prednisolone 40mg/day. He was asymptomatic on 6 month follow up and steroid was tapered and stopped after 6 months. CONCLUSION Pulmonary Langerhans Cell Histiocytosis should be considered as a cause for pneumothorax in young smokers when chest radiography shows bilateral reticulo nodular or cystic changes. Complete work up with HRCT should be done when cause of pneumothorax is uncertain. CASE REPORT P191 Massive right sided hemorrhagic pleural effusion in a patient of Acute Necrotizing Pancreatitis - A rare case of Pancreatico-Pleural Fistula BUDHRAJA AKSHAY, SHARMA KAPIL, TANDON SANJAY, MAQSOOD SHEEMA, JOSHI PRIYANKA, DAUSAGE CHIRAG Peoples College of Medical Sciences & RC, Bhopal (M.P), India ABSTRACT Hemorrhagic pleural effusion in patients of acute pancreatitis is very rare and warrants the consideration for diagnosis of pancreatico-pleural fistula. We report a case of 30 year old chronic alcoholic male with alcohol dependance with acute presentation of severe epigastric pain and respiratory distress for last 2 days. He was being managed conservatively from past 3 months for acute necrotizing pancreatitis. On examination he had tachypnea, tachycardia and hypotension. Breath sounds were absent over the entire right hemithorax. Massive right sided effusion was confirmed radiologically. Pleural fluid examination revealed blood clots, protein of 4.9gm%, TLC=18000/mm3 with extensively hemorrhagic background. Pleural fluid AFB was negative and pleural fluid cultures were sterile and cytology was unremarkable. Serum Amylase and lipase were 101/1592 U/L respectively. Liver function test (LFT) were normal except Total protein of 4.9gm% and Albumin of 2.2 gm%. Serum Calcium was 6.7mg%. Pleural fluid amylase was 1500U/L. PT/INR was within normal limits. Patient was managed prophylactically by pancreatic duct stenting even though ERCP failed to detect fistulous tract. After 30 days of admission, patient made complete recovery and was discharged in good health. He was followed later for upper GI endoscopy for removal of pancreatic duct stent. Pancreatico-pleural fistula is a clinico pathologico radiological diagnosis requiring high index of suspicion and early MRCP(sensitivity-80%) to detect fistulous tract. ERCP may be helpful in detecting fistulous tract but a failure rate of 32% is reported. Duct stenting facilitates early drainage of pancreatic fluids and promote healing. Surgical closure of tract is reserved for resistant cases. A misdiagnosed case of malignant pleural effusion P192 Paresh Chandra Mohanta, Pravati Dutta, Rekha Manjhi, Sudarsan Pothal, Madhumita Nayak,Sasmita Meher Department of pulmonary medicine, VSS Medical College, Burla, Odisha, India Background: Malignant pleural effusion was on of the leading cause of exudative pleural effusion.Carcinoma of lung and breast and lymphoma accounts for 75% of malignant pleural effusion.In tuberculosis prevalent country like India it is sometimes misdiagnosed as tubercular pleural effusion. Case Report: A 70 year old smoker presented with chest pain for 1 month and breathlessness for 20 days.He was managed as a case of tubercular pleural effusion and was put on ATT for past 3 months.He was not relieved of his symptoms despite of 3 months of treatment.On clinical examination features of massive pleural effusion with pallor and not associated with clubbing and lymphadenopathy.Routine blood investigations revealed a raised blood urea and creatinine.Chest X-ray suggestive of massive left pleural effusion.Pleural fluid analysis showed a low ADA,exudative fluid and its cytology report showed TLC-4300 cells,DC-N-1%,L-86%,mesothelial cells 12%,macrophages 1% and enlarged cells with binucleate,trinucleate reactive/hyperplastic changes.CT thorax shows solitary nodule left lower lobe.On flexible thoracoscopy showed pleural adhesions and multiple pleural growth and biopsy from suspicious lesion revealed invasive squamous cell carcinoma. Conclusion: This case illustrates that in an elderly smoker presenting with pleural effusion, our first suspicion should be to rule out malignancy. P193 An incidental finding of Pleural Lipomas:Case series P.Ajoy kumar, C.Sumalata, N Gopichand, D.Sudeena Department Of Pulmonology, Siddhartha Medical College, Vijayawada,A.P Abstract Introduction: Lipoma is a benign mesenchymatous tumour seen in subcutaneous parts of the body, its presence in pleura is a rare entity.They are incidentally found on chest x-rays or Computed tomographies.Here we present two case reports of pleural lipoma, which are of intrapleural variety. Case reports: Case 1:A 65 year old female patient came to chest OP with complaints of cough and shortness of breath.On examination she had decreased breath sounds and was dull on percussion on right infrascapular and infra axillary region.She was then subjected to radiological investigations where a large intrapleural lipoma of 9.8 cm x11.2 size tumour was observed.Case2:A 80 year old man was referred to chest OP for a lesion on the right lower zone.When he was subjected to a CT chest plain,it was found to be a intrapleural tumour of 6x7cm. Discussion:Pleural lipoma are extremely rare. They are of two types(1)hour glass or dumb bell lipomas (2)intrathoracic lipomas. According to their origin,they are calssified into various types endobronchial lipoma, diaphragmatic lipoma. Most patients are asymptomatic.The occurrence of symptoms depend on the size of the lipoma. Although the tumours were detected incidentally in a chest X-ray, CT scan has replaced conventional x-ray and ultrasound scan for accurate detection of thoracic lipomas. CT allows a definitive diagnosis when it demonstrates a homogeneous fat attenuation mass (-50 to -150 Hounsfield units, or HU) which formed obtuse angles with the chest wall and displaced adjacent pulmonary parenchyma and vessels .Management includes clinical and radiological follow up.Follow up is done to see for malignant changes so that surgical intervention can be planned accordingly. CT scan of case no 1 Chest x-ray of case 2 P194 RARE PRESENTATION OF PLEURAL MALIGNANT MESOTHELIOMA IN A PATIENT WITHOUT PRIOR EXPOSURE TO ASBESTOS DR.K.VIJAY KUMAR, Dr.A.Sathya Prasad, Dr.Ganesh Chandra,Subba rao, Prashanti, Nalini MAMATA MEDICAL COLLEGE & HOSPITAL ,KHAMMAM Background: th th Most common primary tumor of pleura is malignant mesothelioma occurring commonly in age group of 5 -7 decade with male: female - 2.6:1 with exposure to asbestos constituting about >70% cause. spontaneous (non asbestos exposure related) incidence 1/million/year. Here we present you one such rare case. Case report: A 60 year old female Sandamma Kanakapudi came to OPD with c/o left sided pleuritic chest pain with SOB on moderate exertion with occasional dry cough with decreased appetite and sleep of 40 days duration and a non-smoker, non-alcoholic and agriculture labour by occupation without any exposure to any environmental risk factor. Husband is also an agricultural labour who is non-smoker, non-alcoholic . Chest X-Ray PA view - Left U/L lesion confined to pleura with shagging borders & blunting of Costophrenic angle .USG guided TTNA in Left ant th Axillary line 4 ICS - Revealed large epithelial cells with increased N/C ratio strongly suggestive of epithelial malignancy. correlate accordingly . CTguided pleural biopsy done at MNJ cancer institute suggestive of epithelial variant of Mesothelioma Conclusion: Our case high lightens the fact that we should widen our horizon in decision making with such patient in a country like India that can lead to early diagnosis resulting in better survival rate by effective treatment and follow-up P195 CASE REPORT P196 Spontaneous Pneumothorax and Myocardial Infarction in Marfan Syndrome without Valvular Heart disease SHEEMA MAQSOOD,KAPIL SHARMA,PRIYANKA JOSHI,ST NAGDEOTE,AKSHAY BUDHRAJA Dept. of Pulmonary Medicine, Peoples College of Medical Sciences,Bhopal ABSTRACT : Marfan Syndrome is a heritable disorder of connective tissue mainly affecting skeletal, cardiovascular and ocular systems. Lungs are rarely involved.We report a case of a 19 year old young adult with history of progressive dyspnea along with cough with expectoration with features of Marfan Syndrome. He also had past history of ATT for pulmonary tuberculosis with same features of Marfan Syndrome in other siblings also. On general examination he was tall with long slender limbs (Dolicostenomilia), long fingers and toes (Arachinodactyly) and protruded sternum with scoliosis. On respiratory examination bilateral breath sounds were decreased with bilateral occasional crepts with tapping apex beat. Sputum for AFB was negative with HIV non reactive. During the hospital stay he developed MI confirmed by raised troponin levels and spontaneous pneumothorax. Chest X-Ray followed by CECT Thorax showed right upper lobe fibrosis with right lower lobe bronchiectetic changes along with left sided hydropneumothorax. Pus was sent for AFB and DST was planned. Pus for AFB was positive. No valvular involvement on 2D-ECHO Heart. Patient was planned for ICDT insertion but he expired. Case opens our eyes in view that MI as such can be rare entity in Marfan syndrome but precipitating factors like chronic hypoxia in post tubercular pleuroparenchymal fibrosis with acute development of spontaneous pneumothorax (Amjadi K, Alvarez GG, Vanderhelst E,Velkeniers B, Lam M, et al: Chest 2007;132: 1140вЂ“1145.) can cause MI in marfan syndrome which spares heart valves. P197 A study of pleural fluid adenosine deaminase levels in tubercular and other exudative pleural effusions at a tertiary care center in U.P. A AGARWAL, A JAIN , L SINGH, R TANDON, A CHAWLA, A SINHA Shri Ram Murti Smarak Institute of medical sciences, Bareilly, U.P., India Objective вЂ“ To study pleural fluid adenosine deaminase (ADA) levels in tubercular and other exudative pleural effusions. Methods вЂ“ A prospective study was designed at SRMS Institute of Medical Sciences, Bareilly, U.P. to evaluate the importance of pleural fluid ADA level in the diagnosis of tubercular pleural effusion and differentiating it from other causes of exudative pleural effusion. Results вЂ“ A total of 232 cases of pleural effusion were evaluated, of which 169 (72.85%) were observed to be exudative pleural effusion. Tuberculosis was diagnosed in 76 (45%) cases, malignancy in 32 (19%) cases and parapneumonic effusion in 50 (29.6%) cases. 11 (6.5%) cases were found to be due to miscellaneous causes or remained undiagnosed. Median В± SD values of ADA for tubercular pleural effusion, malignant pleural effusion and parapneumonic effusion were 62.37 В± 22.63, 24.12 В± 10.88, and 34.55 В± 20.45 U/L respectively. Our study showed that 68 (89.5%) out of 76 cases of tubercular pleural effusion had ADA в‰Ґ 40 U/L and only 3 (9.3%) out of 32 cases of malignant pleural effusion had ADA в‰Ґ 40 U/L. For the diagnosis of tuberculosis the pleural fluid ADA в‰Ґ 40 U/L yielded 89.47% sensitivity and 72.04% specificity; the positive predictive value was found to be 72.34% and the negative predictive value 89.33%. Conclusion Pleural fluid ADA level can be used for differentiating tubercular effusions from other causes of non-tubercular exudative effusion. Moreover, it can reduce the diagnostic need of pleural biopsy for the diagnosis of malignancy. P198 A case of complicated parapneumonic effusion presenting as empyema necessitans Dr. K.NAGA CHAITANYA , Dr. S.V. PRASAD , Dr. T.V. RAJIV MNR MEDICAL COLLEGE AND HOSPITAL , Sangareddy , Telangana BACKGROUND : Empyema necessitans is an extremely rare condition developing secondary to infection by mycobacterium tuberculosis , staphylococcus , fusobacterium , actinomycosis . The following case report is of a wrongly diagnosed and neglected parapneumonic effusion which went on to develop empyema necessitans CASE REPORT : A 40 year old male presented with complaints of right sided chest pain , non productive cough and dyspnea on exertion for 1 month and a swelling in the axilla and back over the right chest for 10 days. Patient had no history of haemoptysis or fever. He was treated 2 months back with injectables for 10 days for productive cough and fever. He had no history of contact with TB patient. There was grade 3 clubbing bilaterally and no cervical lymphadenopathy. Chest examination showed 7 * 8 cm swelling over the right chest extending from the back to the axilla. It was firm in consistency and mobile with warmth and no tenderness. Skin over the swelling was smooth and had no discharging sinuses. There was no palpable crepitus. Apart from the swelling ,the right hemithorax shows bulging with reduced respiratory movements. Intercostal tenderness was present on palpation along with dull note on percussion in right mammary, inter and infrascapular , infraaxillary areas. Absent breath sounds were present in the same areas. Rest of the chest was normal Blood investigations revealed TLC = 13200 cells/mm3 , negative for HIV and ESR was 70 mm/1st hr. Chest xrays PA and lateral views revealed right sided moderate pleural effusion and adjacent soft tissue swelling. USG revealed right loculated pleural collection which was aspirated. The aspirate was thick pus with ADA of 80 IU/dl , LDH вЂ“ 1200 IU/dl , proteins 5.6 gm/dl , glucose 60 mg/dl. CT scan chest confirmed encapsulated pus in the right hemithorax and soft tissue swelling and no rib erosions. Soft tissue swelling was treated by incision and drainage. Pus for culture was negative for any bacterial growth and for AFB stain patient was posted for thoracoscopy and ICD was placed. Histopathology of pleural biopsy specimen revealed granulomatous inflammation and epitheloid histocytes, lymphocytes and multinucleate giant cells. Culture was positive for AFB. DISCUSSION: Empyema necessitans is an extremely unusual complication of empyema seen only in immunocompromised patients and in neglected TB empyemas. Although accounting only for 10 % of empyemas, Mycobacterium tuberculosis is responsible for 75 % cases of empyema necessitans causing an overall mortality of 60 % CONCLUSION: This case is being presented to highlight a rare condition and to emphasize on the fact that wrong and delayed diagnosis of TB is still a major problem in our country leading to increased morbidity and mortality. GOVT. MEDICAL COLLEGE, NAGPUR P199 DEPARTMENT OF PULMONARY MEDICINE Dr. Anuroop Shankar S., Dr.P.Gholap , Dr. S.H.Meshram, Dr.S.V.Ghorpade A RARE PRESENTATION OF TENSION PNEUMATOCELE ABSTRACT INTRODUCTION Pneumatocele are air filled lung cyst that occurs when bronchial injury or inflammation creates check valve mechanism for air entry in to the lung parenchyma. Underlying causes include severe pneumonia, blunt thoracic trauma, COPD, hydrocarbon ingestion with aspiration CASE PRESENTATION 48 yrs old married farmer ,known case of type 2 DM ,presented with left side chest pain ,continous and gradually progressing its severity ,shortness of breath , fever for 15 days and sudden onset of swelling over left side of chest.chest Xray and CT scan revealed tensed pneumatocele herniated in to the subcutaneous plane of chest wall .sputum revealed staph. Aureus. Condition was treated with CT Guided percutaneous catheter placement using a pigtail catheter for decompression with good antibiotic cover. DISCUSSION Pulmonary pneumatocele are thin walled, air-filled cysts that develop within the lung parenchyma. They can be single emphysematous lesion but can be multiple, thin walled cyst like cavities. Most often they occur as a sequelae to acute pneumonia, commonly caused by staph.aureus. Complicated tension pneumatocele which is herniating to subcutaneous plane of chest wall is rare. It may cause cardio respiratory compromise. So decompression with pigtail insertion is necessary but it is difficult for this patient due to herniation. Patient expired postoperatively due to cardio respiratory compromise. CONCLUSION A rare presentation of complicated tension pneumatocele herniating in to subcutaneous plane P200 Diagnostic efficacy of biochemical parameters in differentiating transudative and exudative pleural effusion Bhavya S, Department of Respiratory Medicine Regional institute of Medical sciences, Imphal Abstract : Objectives: To study the diagnostic efficacy of absolute level of pleural fluid cholesterol,pleural fluid and serum ratio of triglycerides and bilirubin in differentiating transudative and exudative pleural effusion Methods: A cross sectional study conducted in the Department of Respiratory Medicine, RIMS ,Imphal included fifty six cases of pleural effusion with definite clinical diagnosis were classified as transudates and exudates . The pleural fluid cholesterol (pf CHOL), Pleural fluid/serum triglycerides ratio (pfTRIG/s TRIG), pleural fluid /serum bilirubin ratio (p BIL/s BIL ) were compared with clinical diagnosis with regard to their usefulness for distinguishing between pleural exudates and transudates Results:A total of 56 patients withb effusion who were definitively diagnosed were included in the trial and analyzed. Out of which 36 and 20 cases are exudative and transudative respectively. The Pchol levels demonstrated a sensitivity of 89%, a specificity of 100%, The p/s TRIG ratio showed a sensitivity of 89, a specificity of 100%, p/s BIL ratio had a sensitivity of 100% and specificity of 80%. Combination of any two criteria had a sensitivity and specificity of 100% Conclusion:The pleural cholesterol level ,the pleural/serum triglycerides and bilirubin ratio can be utilized as unique and cost effective biomarkers in differentiating transudative and exudative pleural effusions. P201 CLINICO-LABORATORY PROFILE OF NON-MALIGNANT EXUDATIVE PLEURAL EFFUSION IN A TERTIARY CARE HOSPITAL DR.M.D.VARUNN, DR.K.SURENDRA MENON, DR.R.PAJANIVEL DEPARTMENT OF PULMONARY MEDICINE, MAHATMA GANDHI MEDICAL COLLEGE AND RESEARCH INSTITUTE BACKGROUND: Pleural effusion remains the commonest pleural disease making a significant contribution to the pulmonologists. It is always a systematic approach which helps in arriving at an etiological diagnosis. OBJECTIVE: The study was designed to investigate the clinical and laboratory profile of non-malignant exudative pleural effusions. METHODS: Patients who were diagnosed to have pleural effusion over a period of 6 months (Jan-Jun, 2014) were subjected to diagnostic pleurocentesis. Patients with pleural fluid protein of >3gms% were taken into study and were analyzed retrospectively for symptoms, side of effusion and pleural fluid analysis of cell count, ADA, glucose and culture. Cytology showing malignancies were excluded. RESULTS: Out of the study population of 65 patients, cough (99%) and breathlessness (97%) were the commonest presentation, followed by chest pain (80%) and constitutional symptoms (46%). Based on the clinical features and radiology, 72% of patients had right-sided effusion. Tuberculosis was diagnosed in 44 patients, parapneumonic effusion in 21 patients. 79% of patients diagnosed as tuberculosis had lymphocyte count of >80%. The mean ADA in tuberculous pleural effusion was 68.83. Parapneumonic effusions had cell count of predominant polymorphs. 83% of the pleural fluids pyogenic cultures were sterile and the commonest organism in culture positive samples (17%) were staphylococcus aureus, streptococcus pneumonia. Majority of the isolated organisms were sensitive to piperacillin, ciprofloxacin, vancomycin, gentamycin and amikacin. CONCLUSION: Pleural fluid differential cell counts are helpful in narrowing the differential diagnosis but none are disease specific. High lymphocyte proportions (>80%) with high ADA occur most frequently in TB, neutrophilpredominant pleural effusions are associated with acute processes like parapneumonic effusions. The sensitivity pattern from this study helped us with the empirical choice of antibiotics in cases of parapneumonic effusions. Despite the high incidence of indeterminate diagnoses, the measurement of protein and cytological examination must be ordered routinely which plays an important role in arriving at the diagnosis. P202 Osteosarcoma presenting as multiple calcified metastases to lung and pleura: A rare case report Dr. K. Rajendra Kumar, Dr. S. Raghu, Dr. CH. Hanumantha Rao. Dept. Of pulmonary medicine, Govt. Fever Hospital / Guntur Medical College, Guntur, Andhra Pradesh, India. Abstract: Osteosarcoma is a most common primary bone tumor in children and adolescents, arising from primitive bone forming mesenchymal cells. The lung is the most common site of metastasis of osteosarcoma. Here we report a case of an 18years old male patient presenting with progressive breathlessness for last the 2months. Chest X-ray suggestive of extensive pleural calcifications and bilateral parenchymal lesions with right sided moderate pleural effusion. CT scan chest revealed multiple calcified metastatic nodules in both lungs and pleural calcification with right side pleural effusion. On examinantion, we found bony mass of left humerus which is of 3 months duration, punch biopsy of which revealed osteosarcoma. FNAC of pleural lesion is diagnostic of metastatic deposits. Osteosarcoma presenting as multiple calcified metastasis to lung and pleura is very rare that too within very short duration. P203 Empyema secondary to submandibular gland abscess : a rare case report K.BHARATH P.SWETHA K.SAILAJA H.N.SREEDHA RAO U.KIRAN KUMAR Department of Pulmonary Medicine, Kurnool Medical College, Kurnool ,Andhra Pradesh,India INTRODUCTION:Although empyema is frequently seen in general population,but this condition secondary to neck space infection [submandibular gland abscess] and mediastinitis is rarely seen .Mortality in such conditions reported to be 15 to 40% despite high antibiotic therapy and in some cases surgical intervention is required We would like to report a case of empyema secondary to submandibular gland abcess here. CASE REPORT: A 38yr male presented to us with dyspnea,fever,purulent discharge from mouth,difficulty in swallowing both to solids and liquids since 15 days. History of large swelling in the left submandibular area with severe pain,that gradually reduced after taking medication .On examination,a swelling of 2x2cm below the angle of mandible noted, which was tender, freely mobile. A small fistula [1x1 cm] noted in left retromolar area with purulent discharge draining from it CXR revealed homogenous opacity left side with mediastinal shift to opposite side s/o pleural collection and CECT neck showed enlarged left submandibular gland with air and fluid collections and abcess is extending into right side of neck through pretracheal space causing erosion & thrombosis of right IJV and retropharangeal space. CECT chest showed abcess is extending into anterior,posterior and middle mediastinum causing left empyema and lung fields were normal. With this imaging findings we suspect empyema secondary to submandibular infection. Pus was drained from left pleural cavity and patient is kept on broad spectrum higher antibiotics.The patient responded well with complete expansion of lung and reduction of submandibular swelling CONCLUSIONS : The term descending necrotising mediastinitis implies the infection started from a head and neck source, here from submandibular gland and extending into mediastinum. Infection from cervical region can spread to pleural spaces and anterior mediastinum through pretracheal space, middle mediastinum through carotid space, posterior mediastinum through retropharangeal or prevertebral spaces P204 Carcinoma Breast related Metastatic Pleural Effusion вЂ“ A Thoracoscopic Evaluation. CHETAN B PATIL, RAKESH C GUPTA, RAMAKANT DIXIT, NEERAJ GUPTA, A GUPTA, P. PACHAR Department of Respiratory Medicine, J.L.N Medical College, Ajmer. Objective: Carcinoma Breast is one of the common malignancies that metastasize to lungs and pleura, here we evaluated four cases of Carcinoma breast that presented with recurrent massive pleural effusion, which showed metastasis to the pleura, diagnosed by thoracoscopy. Method: Carcinoma breast cases that presented to our centre with recurrent pleural effusion within a year of diagnosis, treated by surgery alone or with multimodal therapy. Pleural effusion in these cases remained undiagnosed even after routine initial workup & pleural fluid cytology negative for malignant cells on three occasions. We performed thoracoscopy after informed consent, Thoracoscopic appearances of the pleura were recorded and pleural biopsy was sent for histopathological analysis. Results: All the four cases of Carcinoma Breast that presented with massive pleural effusion had hemorrhagic pleural fluid with hematocrit less than 50% of peripheral blood. Thoracoscopic view revealed edematous pleurae, grossly studded with multiple nodules of varying sizes forming grape like pattern which were hyperaemic and bleeds on touch, nodularity was seen even on the diaphragmatic pleura which is rarely involved in metastatic adenocarcinoma lung. Thin fibrinous adhesions were also noted. Pleural biopsy revealed metastatic deposits from the primary carcinoma breast. Conclusion: Thoracoscopy should be considered in all cases of undiagnosed pleural effusion with background history of Ca Breast without any evidence of local recurrence or pulmonary metastasis. A RARE CASE OF DRUG INDUCED CHYLOTHORAX P205 BACK ROUND:DASATINIB IS USED AS A THERAPY FOR IMATINIB RESISTANT CHRONIC MYELOID LUEKEMIA. INITIALLY APPROVED STANDARD DOSE OF DASATINIB 70MG TWICE DAILY PRODUCES VARIOUS SIDE EFFECTS LIKE ANAEMIA,HYPERTENSION,PERIPHERAL EDEMA ,DRY COUGH ,DYSPNEA, PLEURAL AND PERICARDIAL EFFUSIONS . METHODS: I REPORT MY EXPERIENCE IN MANAGING A CHRONIC MYELOID LEUKEMIA PATIENT - FOLLOWING IMATINIB FAILURE ,WAS TREATED WITH DASATINIB AT 140 MG DAILY FOR 3 MONTHS,DEVELOPED CHYLOTHORAX AS A COMPICATION. RESULTS: MY PATIENT IS TREATED FOR CHRONIC MYLOID LEUKEMIA WITH DASATINIB 140 MG DAILY WHO DEVELOPED CHYLOUS PLEURAL EFFUSION. THE PATIENT WAS MANAGED BY THERAPEUTIC PLEURAL TAPPING, REDUCED DOSE OF DASATINIB AND DIURECTICS. CHYLOTHORAX RESOLVED. CONCLUSION:IN CONCLUSION ,CHYLOUS PLEURAL EFFUSION IS A RARE COMPLICATION OF DASATINIB . MANAGEMENT SHOULD BE DISCONTINUING DASATINIB / DOSE REDUCTION OF DASATINIB/ ALTERNATIVE CHEMOTHERAPEUTIC DRUGS WITH DIURETICS OR STEROIDS. HENCE, PATIENTS ON DASATINIB SHOULD BE MADE CLOSE FOLLOW UP TO MONITER THEIR SIDE EFFECTS AND FOR INITIATION OF PROMPT TREATMENT. Giant solitary fibrous tumour of the pleura P206 GAURAV GUPTA, RISHABH RAJ, SUSHEEL BINDROO Dept. of respiratory medicine, jaslok hospital and research centre, mumbai, India Solitary fibrous tumour of the pleura is a rare primary pleural neoplasm. They usually arise from visceral pleura but may also arise from parietal pleural. These tumours are usually asymptomatic and are incidentally detected. Sometimes they may be associated with chest pain, shortness of breath and cough. Majority of these neoplasms are benign and surgical excision provides excellent results. Here we are discussing a rare case who presented to us with complaints of breathlessness on exertion and loss of weight since one year. Also he was having frequent episodes of hypoglycemia since one month though he was a known case of diabetes mellitus. Chest Xray showed a homogenous mass occupying left hemithorax. Usg guided biopsy was done and a diagnosis of solitary fibrous tumor was made. Associated multiple episodes of hypoglycemia were present (Doegge potter syndrome) which is seen in 5% of patients with solitary fibrous tumor. P207 TitleMetastatic alveolar rabdomyosarcoma presented as massive pleural effusion. Authors- M N BHAKARE, G P GODBOLE, A DIWAN, N H BHAKARE, M KULKARNI. Smt. Kashibai Navale medical college & general hospital, Pune Maharashtra, India. IntroductionRabdomyosarcoma is the commonest soft tissue sarcoma of adolescence. The tumor commonly occurs in the soft tissues of the head & neck, genitourinary & extremities. Alveolar rabdomyosarcoma presenting as massive pleural effusion is extremely rare and presents diagnostic challenges, especialy in resource limited centers. Rabdomyosarcoma is an aggressive tumor with poor prognosis especially when diagnosed late. Case presentation We present a case of 14 years female who was presented to us with left side massive pleural effusion, which was primarily diagnosed as tuberculosis & started with antituberculous treatment at another center. But after CT thorax & left axillary lymph node biopsy diagnosis was revised as metastatic rabdomyosarcoma with unknown primary. Ascites developed within 2 weeks of admission.The bone scan showed no evidence of any skeletal metastases. Due to unavailability, PET scan could not be done. Metastatic malignant cells were seen in both pleural fluid & ascitic fluid. The patient failed to respond to chemotherapy & succumbed to the disease. ConclusionThough very rare, alveolar rabdomyosarcoma may be present as massive pleural effusion. Usually bone metastases are common, which were absent in our patient. So massive pleural effusion in teen aged patient should be investigated properly. We think this case will add knowledge for diagnosing alveolar rabdomyosarcoma. P208 Title: Profile of patients underwent inter-costal drainage in a medical college hospital R Bansal, PK Sharma Dr. Rajendra Prasad Government Medical College, Kangra at Tanda (HP) 176001 Objective: To study the profile of patients underwent Inter Costal Drainage (ICD) procedure by the author Methods: Information of all the patients underwent ICD was recorded on an approved proforma. The data was analysed keeping objectives in mind. Result: A total of 101 patients were treated with ICD over the study period of 18 months by the author. Only 2 were females, 60 and 76 years old. Average age of male patients was 48.11В± 15.86 years. Maximum 29% patients were within 50-59 years of age. Duration of ICD in place: Mean duration В± 1SD of ICD in place was 23.84В±38.33 days; Mode duration = 6 days; Median duration = 14 days with a range of 2-251 days Presenting complaints: Only Chest pain 19% and only shortness of breath (SOB) 15%. Chest pain with or without other complaints 43%, SOB with or without other complaints 36%, fever with or without other complaints 13%, cough with or without other complaints 6%, incidental 3%, leakage from previous tube site 2% and 1 case was iatrogenic. Provisional diagnosis: Pneumothorax 48% (Primary spontaneous 24%, Secondary spontaneous 23% and iatrogenic 1%), Pleural Effusion 23%, Empyema 18%, Hydropneumothorax 9% and Hemothorax 1% Co-morbidity: On ATT 19%, Old Treated Case of TB 13%, Malignancy 9%, COPD 7%, Bullous lung disease 4%, Lung abscess 1% Final outcome: Expanded fully 60%, Expanded partially 15%, Pleural thickening 14%, Collapse lung 9% and Cortex formation 3%. Associated events: Readjustment 12%, Repeated flushing 4%, Surgical emphysema 4%, Pleurodesis 2%, Tissue growth 2%. Conclusion: ICD procedure is done almost exclusively in male patients of productive age groups with pneumothorax, they mostly present with chest pain with SOB and is mostly associated with tuberculosis. P209 PLEURAL FLUID BILIRUBIN- A NEW DIAGNOSTIC AID IN DIFFERENTIATION OF TRANSUDATES AND EXUDATES ANANTHA R, KISKU KH, MADHUSMITA M DEPARTMENT OF PULMONARY MEDICINE, PONDICHERRY INSTITUTE OF MEDICAL SCIENCES, PUDUCHERRY605014 The primary aim when investigating a pleural effusion is to establish the correct diagnosis with minimal investigation. The conventional method for classifying the pleural fluid as trtansudates and exudates is based on the diagnostic criteria established by Light et al. The most frequently used LightвЂ™s criteria, though still considered as a gold standard; often misclassify a transudate as an exudate which has been proven by many studies To evaluate the diagnostic accuracy of pleural fluid bilirubin and its ratio to serum levels in differentiating the pleural fluid into transudates and exudates This study was conducted on 30 patients above 18 years of age who had symptomatic pleural effusions on whom a diagnostic thoracocentesis was performed after meeting the inclusion and exclusion criteria. The initial pleural fluid analysis were gross appearance, biochemical parameters like LDH, protein, cholesterol, albumin, bilirubin and their serum values. The etiology of effusions were determined and the diagnostic accuracy of the bilirubin criteria was compared with that of lightвЂ™s criteria In our study of 30 pleural effusions there were 7 transudative and 23 exudative effusions. There were 13 tuberculous, 3 malignant and 7 parapneumonic effusions. The mean bilirubin concentration ratio in exudative effusions was 0.6 and in transudative effusions was 0.5. We found that the pleural fluid to serum total serum bilirubin ratio is a useful marker in differentiating transudates and exudates. The correlation of a bilirubin concentration ratio of 0.6 or more with the presence of an exudate as determined by established criteria is highly significant and also helps in identifying false positives with that of the lightвЂ™s criteria P210 Syringo-Pleural Shunt after fifteen years- A rare cause of Recurrent Pleural Effusion. MANDILWAR SAURABH, PRAKASH K ASHISH, PRABHUDESAI PRALHAD, SHASHTRI B S Lilavati hospital and research centre, Mumbai, India. This is a case report of one of the rarest cause of recurrent pleural effusion because of syringe-pleural shunt which after fifteen years has led to the said complication. The patient reported is case of post spinal tuberculosis who developed syringomyelia which itself is a rare sequelae of tuberculosis, has underwent syringopleural (SP) shunting. After fifteen years of normal working of shunt, the patient developed recurrent pleural effusion. Thoracentesis both diagnostic and therapeutic has been done. The fluid repeatedly examined was transudative and every effort to find out the cause was non-yielding. Computed Tomography (CT) done focusing the shunt showed that it was in exact place. Pleural fluid was positive for Beta-2 transferrin. Video-assisted thoracoscopic (VATS) exploration done and it was found that distal tip of shunt was adhered with the lung parenchyma. The pleural biopsy was negative for any malignancy or tuberculosis. The effusion did not progress further after the dislodgement of distal tip from lung parenchyma. Key words: Syringopleural shunt; Ventriculoperitoneal shunt; Pleural effusion; Thoracentesis; VATS; Beta-2 Transferrin; Transcytosis; LDH-lactate-dehydrogenase; CSF-Cerebrospinal fluid; syrinx cavities. P211 VATS in management of Tuberculosis Sequelae 1 1 1 2 2 3 S Khandelwal , Kamran Ali , N Agarwal , A Sharma , S Khanna , T Piplani , A Z Khan 1 1 Department of Minimally Invasive and Robotic Thoracic Surgery 2 Department of Anesthesiology 3 Department of Radiology Medanta The Medicity, Gurgaon Objective: To present our experience of VATS for management of Tuberculosis and its sequelae in the chest Methods: 130 patients with suspected tuberculosis presented for surgical treatment. The diagnosis included simple and loculated pleural effusions, early and late stage empyema with thick cortices, residual pulmonary cavity with fungal ball, and pneumothorax with air leak. Procedures performed were; adhesiolysis, decortication, lobectomy, resection of giant bullae, lung volume reduction surgery, bullectomy/ pleurectomy/ pleurodesis. Results: Pleural effusions were treated with VATS (Uniportal and three ports) drainage. Empyema with thick cortices underwent VATS drainage followed by decortication of both visceral and parietal cortices. Two patients with cavitatory lung lesions presented with haemoptysis underwent VATS lobectomy. Two patients presented with pneumothorax underwent VATS bullectomy and pleurectomy. All patients had good post operative outcomes. Microbiological culture was negative before removal of drain. Radiological improvement with good lung expansion was seen. All patients continued antituberculous treatment. One patient with MDR TB needed treatment for 2 years. One patient with Giant Bullous disease underwent lung volume reduction surgery. He subsequently had prolonged air leak requiring indwelling drain. All patients with decortication were given post-operative intrapleural antibiotic washout till drain fluid is culture negative. One patient who was 80 years old, presented with pneumothorax was treated with bullectomy/pleurectomy/pleurodesis had prolonged air leak and died due to secondary sepsis. One case required conversion to open surgery. Conclusion: VATS does have a role in the surgical management of patients with tuberculosis. We can achieve good surgical results with minimal morbidity and mortality. P212 Use of Urobag in place of a conventional underwater chest drainage system in patients with air leaks after VATS Kamran Ali, S Khandelwal, N Agarwal, A Z Khan Department of Minimally Invasive and Robotic Thoracic Surgery Medanta The Medicity, Gurgaon Objective: Prolonged air leak from the parenchyma is a frequent complication of lung surgery leading to an increased hospital stay. We wish to share our experience with the use of a Urobag with a non-return valve connected to a chest drain, which works on the same principle as a Heimlich valve, as an alternative to underwater chest drainage system in facilitating early discharge in patients undergoing VATS. Methods: Between August 2013 to August 2014, 58 patients with persistent air leak after VATS done for varying etiologies, were managed with application of a Urobag to the intercostal chest drain and discharged home early. Results: The period of chest drainage varied from 3-11 days post operatively. There were no major complications except for clot obstruction of valve of the Urobag in 2 patients. Conclusion: Urobag with its inbuilt one-way valve offers many advantages over the underwater seal system. It helps maintain a more negative intrapleural pressure and by being physiologically more effective than the underwater drain which may occasionally increase the intrapleural pressure and diminish drainage. It is light weight and easy to manage, thereby allowing early ambulation and discharge, apart from being cost effective and easily available at all centres. In a country like India where cost of treatment is an issue use of urobag is a cheaper option than urobag. P213 A study on pleural fluid eosinophilia in patients presenting with pleural effusion in RIMS, Imphal Dr. Moirangthem Seilaja, Prof. W. Asoka Singh Department of Respiratory Medicine, Regional Institute of Medical Sciences, Imphal Objectives: пѓ� To determine the prevalence rate, пѓ� To determine the causes of pleural fluid eosinophilia, пѓ� To explore its clinical importance, пѓ� To evaluate the outcome of treatment. Methods: A cross sectional study of 53 patients who presented in Respiratory Department of Regional Institute of Medical Sciences with pleural fluid eosinophilia was analysed from October 2012 to August 2014. Results: The prevalence rate found was 7.89. Out of 53 patients, 35 were males and 18 were females with age ranging from 16 to 86 years. The causes were paragonimiasis: 15 (28.30%); tuberculosis: 10(18.87%); carcinoma: 8(15.09); parapneumonic effusions: 6(11.32%); pneumothorax: 5(9.43%); blood or air in the pleural cavity due to chest injury: 4(7.55%); MeigвЂ™s Syndrome and amoebiasis: 1 each (1.89%) and others: 3(5.66%). It affected all adult age groups. Males are more affected. It affects more people from rural areas. Forty-seven(88.68%) cases showed exudative effusion. Absolute eosinophil count was raised in 36 patients. Conclusions Pleural fluid eosinophilia is mostly seen in males from rural areas affecting all age groups mainly caused by parasitic infestation, Paragonimus westermanii. Raised absolute eosinophilic count is seen in maximum cases. The treatable cases responded well to the treatment given specific for the disease. Eleven patients are being followed up in OPD with improvement. A case series of pancreatic pleural effusions. P214 K.V.V.Vijaya kumar, K. Preethi, CH.R.N.Bhushan rao, K.Venkata Ramana Government Hospital for Chest & Communicable diseases (GHCCD), Andhra Medical College, Visakhapatnam, AP, India. Introduction: Chronic pancreatic pleural effusions are uncommon and often unrecognized clinical syndrome which results from internal pancreatic fistulas and usually presents as exudative pleural effusion of unknown cause. The effusion frequently occurs without clinical evidence of pancreatitis but occasionally it may be associated with pseudocyst of pancreas. Case reports: Here, we present three cases of chronic recurrent hemorrhagic pleural effusions of pancreatic etiology. All three cases were males among whom two were alcoholics and one was non alcoholic. Two cases presented as bilateral pleural effusions and one case presented as left pleural effusion of exudative etiology. Pleural and serum amylase levels were elevated in all three cases. One subject had associated erythema nodosum and another subject had coincidental finding of horse shoe kidney. Therapeutic ERCP was done in all three cases and there was complete resolution. Discussion: Chronic pancreatic pleural effusion is usually recurrent and characterized by very high levels of amylase in pleural fluid. Of several possible mechanisms involved, transdiaphragmmatic lymphatic transfer of pancreatic enzymes, intrapleural rupture of mediastinal extension of pseudocyst and diaphragmatic perforations are the most important. Enzyme rich effusions are more commonly left sided and often hemorrhagic and frequently associated with pancreatic pseudocysts and if long standing may be complicated by broncho pleural fistula. P215 Right sided massive pleural effusion secondary to Pancreatic pseudocysts and Pancreatico pleural fistula - An Unusual Presentation Dr.Anusha. M, Dr.Yugandhar.K , Dr.Bhanurekha.B , Dr.V.V.S.D.S.R.Sagar Dr.Pinnamaneni Siddhartha Institute Of Medical Sciences &Research Foundation Background: Pleural effusion on the right side, due to acute on chronic pancreatitis, is a rare manifestation. We are here with reporting an unusual case of Necrotizing pancreatitis with Pseudo pancreatic cyst presenting as Right sided massive Pleural effusion secondary to Pancreatico pleural fistula. Case Presentation: A 35 year old alcoholic male patient presented with grade вЂ“ IV breathlessness with right sided chest pain, with a history of non-productive cough and pain abdomen on and off for six months. Chest x-ray PA view showed right sided massive pleural effusion, tube thoracotomy was done and 2 Lts of exudative pleural fluid with markedly elevated amylase in pleural fluid (22450 IU/Lt) was obtained. Ultrasound abdomen, CT Chest and Abdomen, and MRCP showed acute on chronic pancreatitis with parenchymal fluid collections/pseudo cysts and fluid collection from tail of pancreas communicating with fluid in abdominal lesser sac and tracking upwards medially towards midline in right sub diaphragmatic region, fluid seen in right pleural cavity. Therapeutic Thoracoscopy was done and the locules ruptured and fluid drained. Pseudo cysts were managed conservatively. Conclusion: Massive right sided pleural effusion with high amylase levels and right sided Pancreatico pleural fistula is a very rare condition and managed with tube thoracostomy and therapeutic thoracoscopy . P216 TOPIC NAME: PANCREATICO PLEURA FISTULA PRESENTING AS RECURRENT PLEURAL EFFUSION. Authours: Dr.R.Nedunchezhian, Prof.Dr.D.Ranganathan, Pror.Dr.A.Mahilmaran, Dr.V.Sundar Institution: Institute of Thoracic Medicine, Madras Medical College, Chennai-31. Introduction: Pancreatic pleural effusion is due to accumulation of fluid in pleural space with high amylase content resulting from disruption of pancreatic duct.When pancreatic duct disrupts anteriorly results ascites and disrupts posteriorly results Pseudocyst and gives rise to retroperitoneal fistula which tracts through Esophagus or Aortic hiatus gives rise to pleural effusion.Pleural effusion also occurs with fistula from Pseudocyst extending through dome of diaphragm.Spontaneous resolution unlikely.Endoscopic Retrograde Cholangio Pancreatography is essential in both diagnosis and management.Partial disruption of main pancreatic duct is treated with panreatic stent placement.Complete disruption of Main pancreatic duct needs surgical correction Case History: 43 yr old male,chronic alcoholic ,completed cat 1 ATT for 6month 10 yr back for sputum AFB negative Pulmonary TB,admitted in Rajiv Gandhi Govt General Hospital Madras Medical College,as Left pleural effusion.History of Intrcostal tube drainage of pleural effusion done two times previously in private hospital present. On examinatin left pleural effusion was present.USG&MRI abdomen done and reported as chronic calcific pancreatitis with pseudocyst in tail of pancreas.Plueral fluid amylase reported as 34600 somaygi units,serum amylse reported as 3640 somaygi units.Endoscopic retrograde cholangio pancreatography done:Fistulous communication from pseudocyst to left side dome of diaphragm confirmed and pancreatic stent placement done.patient uneventful during the hospital Conclusion: Pancreatico pleural fistula a rare cause of recurrent pleural effusion has good prognosis with surgical treatement or pancreatic stent placement Key words:pleural effusion,pancreatico pleural fisula,stent placement. presentation P217 Comparison Of Clinical diagnosis And Light's Criteria in Distinguishing Transudative and Exudative pleural effusions G.Ramya, V.V.Ramana Reddy, Ganeswar behra, J.V.praveen, D.S.S.sowjanya, B.K.Prithvi Department of pulmonary medicine, MaharajahвЂ™s Institute of Medical Sciences, NTR University of health Sciences , Andhra Pradesh, India OBJECTIVE: The delineation of pleural effusions as being either exudate or transudate is the initial and crucial step in the diagnosis of pleural effusions. The aim of this study is to ascertain the role of clinical diagnosis in segregating the exudative and transudative pleural effusions and to compare with the LightвЂ™s criteria and serum-pleural fluid albumin gradient (SAPA). MATERIALS AND METHODS: Forty patients with pleural effusion admitted from August 2013 to August 2014 in our institute were studied. Clinical examination, chest x-ray, LightвЂ™s criteria and serum-pleural fluid albumin gradient were used to distinguish transudates and exudates.Further investigations like 2D echo ,pleural fluid culture,sputum for AFB ,thoracoscpoic and bronchoscopic biopsies were done to confirm the diagnosis. RESULTS: A total of 40 patients having pleural effusion were divided into 2 groups. Group I Transudates (n=10, 25%), Group II Exudates(n=30, 75% ) based on SAPA, which is taken as gold standard. According to the LightвЂ™s criteria, there were 37( 92.5%) exudates and 3(7.5%) transudates. Out of the 37 exudates, 7 exudates on diuretic therapy were found to be transudates by clinical diagnosis and SAPA which were misdiagnosed as exudates by Lights. With clinical diagnosis 29(72.5%) cases were classified as exudates and 11(27.5%) cases were classified as transudates. LightвЂ™s criteria misclassified 17.5% of cases whereas Clinical diagnosis misclassified only 2.5% of cases while differentiating transudates from exudates. CONCLUSION: The discriminative value of clinical diagnosis appears to be superior to lightвЂ™s criteria in the diagnostic separation of transudates and exudates. In conclusion, though lightвЂ™s criteria is mostly recommended, coalesced use of clinical diagnosis improves the diagnostic confidence in distinguishing exudates and transudates.In primary care where biochemical analysis were not available clinical diagnosis alone can be considered for treating the patients. P218 CLINICO MICROBIOLOGICAL PROFILE OF EMPYEMA THORACIS DR.S.SOWMYA KAKATIYA MEDICAL COLLEGE OBJECTIVES-comparing the clinical & microbiological profiles of patients with tuberculous and nontuberculous empyema. MATERIALS AND METHODS-A prospective study of adult cases of nonsurgical thoracic empyema was performed over a period of 18 months. A comparative analysis of clinical characteristics, treatment modalities, and outcomes of patients with tb and nontb empyema was carried out. RESULTS-40 cases of empyema were seen during the study period, of which 18 (,45%) were of nontb etiology while tb constituted 22(, 55%) cases. Among the nontuberculous empyema patients, pseudomonas 6( 15%) was the most frequent pathogen isolated. tb empyema was more frequent in younger population compared to nontb empyema (mean age of 32.7 years vs. 46.5 years). Duration of illness and mean duration of chest tube drainage were longer (48.7 vs. 23.2 days) in pts with tb empyema. Also the presence of parenchymal lesions and bronchopleural fistula often requiring surgical drainage procedures was more in tb empyema pts CONCLUSION-TB empyema remains a common cause of empyema thoracis in India. TB empyema differs from nonTB empyema in the age profile, clinical presentation, management issues, and has a significantly poorer outcome P219 Role of pleural fluid adenosine deaminase in etiological diagnosis of pleural effusion Lokeswara Reddy .A, Yugandhar .P, Satya sri .S ASRAM Medical college, Eluru, A.P Abstract: Objectives: To estimate ADA levels in pleural effusions and to find out diagnostic utility of ADA in etiological diagnosis of pleural effusion. Methods: This prospective study has been approved by our ethical committe.The study was carried out in 75 patients in age group of 10-75years both Out and In patients in ASRAM hospital,Eluru with intial diagnosis of PLEF during September 2013 вЂ“February 2014.After taking consent ,detailed clinical history,physical examination,routine investigations of all patients including ADA estimation by Galanti and Giusti colorimetric method was done. Results:Total no. of Tuberculosis patients were 55 and in all of them pleural fluid ADA was more than 40 IU(mean 66.4+29.3).In 10 cases proved to be Malignant the ADA was less than 40(mean17.3+2.64) where as patients with Transudative effusion were 7 and their pleural fluid ADA was less than 40(mean11+3.12).The mean ADA activity in tuberculous pleural effusion is significantly high when compared to malignant and transudate effusions(p<0.001).Based on this data we have taken 40 IU/L as cut off point in differentiating tuberculous and non-tuberculous effusions with a sensitivity of 98.8% ,specificity 100% and positive predictive value of 100% each for tuberculous effusion. Conclusion: Pleural fluid ADA is a very good parameter to differentiate tubercular from non tubercular pleural effusion. It is a simple,low cost investigation and should be considered routinely in all cases of pleural effusion. P220 A case of asymptomatic atraumatic rupture of spleen with pleural effusion in a diabetic patient. A.B. SRIVASTAVA, B. WAANBAH Department of Respiratory Medicine, RNT Medical College, Udaipur Background: Atraumatic rupture of spleen is a condition associated with many disorders and it mainly presents with abdominal pain in the left upper quadrant, hypovolemic shock and peritonitis. We report a case of left sided pleural effusion due to atraumatic rupture of spleen without abdominal symptoms. Case Report: A 68 yrs old male presented with progressive shortness of breath for 10 days. No history of trauma or syncope or any unusual effort. He is a known case of Diabetes Mellitus on oral hypoglycaemics for the last 20 yrs. On examination the patient was afebrile and vitals were normal. Respiratory system examination showed findings of pleural effusion on the left side. Pleural fluid was aspirated in four different sittings. It was about 2500ml in amount, hemorrhagic, exudative and showed PCV = 1.2%, ADA = 25.62U/L with cell count of 80 cells/cumm which mainly included RBC, lymphocytes and few mesothelial cells. No malignant cells were found. CECT scan showed free fluid collection in left pleural space and multiple hypodense lesion in spleen with peripheral enhancing low attenuation fluid density collection in subcapsular region suggestive of splenic rupture. Discussion: Atraumatic rupture of the spleen has been described in the medical literature as a clinical oddity with grave consequences, if unrecognised and untreated. The true incidence of this condition is difficult to state as a Medline literature search revealed only 44 such case reports over the last 34 years. Symptoms can be subtle and the condition may be mistaken for angina pectoris, myocardial infarction, pulmonary embolism, peptic ulceration or pneumonia. In our case, conservative management was given, though we did not rule out the possibility of a splenectomy during the period. Patient was discharged after 2 weeks. P221 To study the therapeutic use of streptokinase in loculated empyema Dr. VIKASH KUMAR, Dr. G.V.SINGH, Dr. SANTOSH KUMAR, Dr. R.K.GUPTA, Dr. SANJEEV ANAND, Dr. ANKIT DESHWAL, Dr. BHARTESH, Dr. SANTOSH S. N. Medical College, Agra OBJECTIVE- to study the therapeutic effect of streptokinase in loculated empyema. MATERIAL AND METHODS- Patients complaining of fever and dry cough, having clinical and CXR findings suggestive of empyema will be evaluated by USG, and patients having loculated empyema will be considered for intrapeural instillation of streptokinase. In total, 30 lac IU of streptokinase will be instilled intrapleurally via transthoracic route in three divided doses daily (diluted in normal saline) in duration of three days. Patients will be evaluated clinically and radiologically using CXR, before and after treatment. Pt. will be kept in follow-up, along with drugs according to the etiology of empyema, and monthly CXRs will be done to find out any recuurent empyema. RESULTS- Atotal of 7 patients established to have loculated empyema were considered for intrapleural instillation of streptokinase, and all the 7 patients were cured as evident on serial CXRs done. In follow-up, none of the cases was found to have recurrence of loculated empyema. CLINICAL IMPLICATION- Patients having loculated empyema are difficult to treat, as there are loculations in pleural cavity along with pus. Once intercostal drain is placed, it takes months to extubate such patients because of loculations. In such patients, instead of putting ICD, intrapleural instillation of streptokinase via transthoracic route by injection can prove to be a better treatment option as it will lead to early cure and lesser duration of hospital admission. P222 A rare case of left lower lobe pulmonary sequestration presenting as empyema DR. CHETAN RAO.VADDEPALLY , Prof. Pradyut Waghray, Dr.A.N.V.Koteshwara rao, Dr. Venkateswara reddy.T, Dr.Rama Krishna reddy.G*,Dr. Veena , Dr. Harish, Dr. sowmya, Dr. Rikin, Dr. Aditya, Dr. Krishna Chaitanya. Dept. of Pulmonary Medicine, S.V.S medical college, mahboobnagar, Telangana. *Dept. of Radiology Introduction : with an overall incidence of 0.15 to 6.4% of all congenital pulmonary malformations, pulmonary sequestration forms a rare disorder. The condition is characterized by aberrant formation of segmental lung tissue that has no connection with the bronchial tree. It preferentially affects the lower lobes, predominantly the left lower lobe. We hereby present a case of the rarer variety presenting as empyema. The case report: A 35 yr old male was admitted with complaints of high grade , intermittent fever with chills and cough with expectoration and haemoptysis since the last 10 days. The patient gave history of recurrent episodes of fever and cough since childhood. Physical examination revealed a healthy appearing, well nourished man. On auscultation, there were decreased breath sounds on the left lower zones. Total leucocyte count was raised and all other routine investigations were within normal limits. Chest X-ray showed an ill-defined, homogenous opacity, occupying the left lower zone with obliteration of the CP angle. Ultrasound of the thorax revealed moderate pleural effusion. Diagnostic tap showed frank pus which was drained with ICD. After removal of ICD patient had an episode of massive haemoptysis. Subsequent contrast enhanced CT showed heterogenous enhancing cystic mass lesion in the left lower lobe. A small arterial branch from the abdominal aorta supplying the mass lesion was visualized. Given the history and imaging features characteristic of intra lobar sequestration, the patient was reffered to thoracic surgeon. Conclusion : The diagnosis of sequestration can be easily missed in adults as many of the symptoms overlap with other pulmonary processes. The constellation of recurrent pneumonia and cystic lower lobe mass fed by an anamalous systemic arterial vessel are hallmarks of an intralobar bronchopulmonary sequestration. A rare case of Thoracic Empyema вЂ“ Double Trouble P223 Authors вЂ“ Avik GHOSHAL, Koushik MUTHU RAJA.M, B.RAJAGOPALAN Institution - Sri Ramachandra Medical College and Research Institute Introduction: - Pleural space is always a riddle.Tuberculous empyema is rare compared to tuberculous pleural effusion and the pleural fluid is smear positive for acid вЂ“ fast bacilli(AFB) unlike that in pleural effusion. Presence of other systemic disease makes the etiological diagnosis more challenging. Here we present a case of empyema, AFB positivity and suspected Adult Onset StillвЂ™s disease (AOSD) вЂ“ all together. Case Report:A 21 years female presented with complaints of breathlessness, chest pain and high grade fever. On detailed history patient revealed fever for 20 days-initially low grade intermittent, later high grade continuous. She had pain with tenderness left lower chest, was febrile, toxic and breathless-MMRC grade III . She also gave history of intermittent polyarthralgia and pink coloured rash over extremities, predominantly lower limbs, for nearly a year. Clinical examination revealed Right cervical lymphadenopathy. Chest X-ray revealed bilateral pleural effusion left more than right. Nearly 170ml of pus was aspirated from left pleural cavity. Pleural fluid analysis revealed Sugar-2, Protein-6, LDH-6066, ADA-221, with smear positive for AFB. Patient was started on Anti-tubercular therapy (ATT). Fever was not subsiding. Laboratory investigations revealed TLC-10200, S.Bilirubin-4.13(Direct-3.65), SGOT-1567, SGPT-942. Based on history of polyarthralgia and skin rash for a year and raised S.Ferritin concentration of 2047.7 mcg/L (normal range 30 вЂ“ 300mcg/L), patient was diagnosed with Adult Onset StillвЂ™s Disease. Patient was put on oral Steroids, Hydroxychloroquine and Hepatic safe ATT regimen. Her fever subsided and liver function normalised. Conclusion:Adult Onset StillвЂ™s Disease is uncommon (incidence < 1/1,00,000 ) and characterised by polyarthritis, rash, fever and leucocytosis. The diagnosis is primarily a diagnosis of exclusion suggested by coexistent elevated level of Ferritin. Pleural effusion and even pleuro-pericardial effusion are less recognised components of AOSD. We present this case as it may be a combination of tuberculosis with AOSD. P224 Spectrum of sleep disturbances in patients undergoing haemodialysis KRISHNOJI RAO S, KRISHNASWAMY U, CHENNABASAPPA GK, MANTHA SP, ANEJA A Departments of Respiratory Medicine and Nephrology MS Ramaiah Medical College, Bangalore, Karnataka, India Objectives: To study the spectrum of sleep disturbances in patients with End Stage Renal Disease (ESRD) undergoing haemodialysis. Method: This cross-sectional study was conducted on 121 ESRD patients undergoing haemodialysis in M.S. Ramaiah Hospitals. After obtaining informed consent, patients were screened using a clinical proforma, Epworth Sleepiness Scale (ESS) and Pittsburgh Sleep Quality Index (PSQI). Results: Out of 121 patients with ESRD included in the study, there were 34 (28.1%) females and 87 (71.9%) males, with age ranging from 20-81 years. Ninety seven (80.2%) patients were undergoing dialysis for more than 6 months while 24 (19.8%) patients were undergoing dialysis for less than 6 months. Ninety three (76.8%) patients reported sleep disturbances. These included excessive daytime sleepiness in 32(34.4%), insomnia in 35(37.6%), restless legs in 17(18.3%) and various combinations of the above in 9(9.7%) patients. Among patients with excessive sleepiness, symptoms suggestive of obstructive sleep apnea (snoring, witnessed apneas) were reported in 10 (31.2%) patients. However, when the ESS and PSQI were administered, it was found that ESS was >10 in 61(50.4%) patients qualifying them as excessively sleepy and PSQI score was >5 in 111(91.7%) which was indicative of poor quality sleep. Conclusion: This study shows that there is a high frequency of self-reported sleep disturbances among patients undergoing hemodialysis, and the frequency further increases if validated questionnaires are administered. Thus, there is a need to routinely screen these patients for sleep disturbances and perform polysomnography to diagnose wherever indicated. P225 Sleep quality in patients with Hypercapnic Chronic Obstructive Pulmonary Disease by Polysomnography K.Rajarajan, S.P.VengadaKrishnaraj, G.AllwynVijay, R.Sridhar, O.R.Krishnarajasekhar, C.Chandrasekar StanleyMedicalCollege, Chennai Background: COPD is fast emerging as global health problem and is the fourth leading cause of death among developed countries. There are few studies on COPD establishing differences between functional parameters of the disease and sleep variables. Objective: To describe the sleep pattern in COPD patients with Chronic Hypercapnic Respiratory Failure and to describe the influence of hypercapnia on the quality of sleep . Methods: Patients enrolled in the COPD registry at Government Hospital Of Thoracic Medicine, Tambaram , with severe stable COPD evidenced by FEV1< 40% by spirometry are included, Arterial Blood Gas analysis is done. Those with Chronic Hypercapnic Respiratory Failure (Group A) are included in the study. Patients with similar degree of obstruction without Respiratory Failure are used as comparision group (Group B). Overnight Polysomnography was performed in those patients and Pittsburg sleep quality index scoring is done. Data is analysed by standard statistical methods. P226 BILATERAL TUBERCULOSIS OF AREOLA & NIPPLEвЂ“A RARE CASE 1) Dr Srikanth Ravoori, 2) Dr V.A.N.Raju, 3) Dr P.Subbarao Department of Pulmonary Medicine, Konaseema Institute of Medical Sciences & Research Foundation, NH-214, Amalapuram, E.G. Dist, Andhra Pradesh-533201. BACKGROUND: Though TB is common in India, Tuberculosis of Breast is an uncommon finding or may be overlooked and treated commonly as Pyogenic Abscess. This is a case of TB of areola and nipple. CASE REPORT: A 25 yr unmarried woman presented with pain, fever, and discharge from nipples for last 7 yrs. There was no history of pulmonary tuberculosis, but her brother was treated adequately for sputum positive pulmonary tuberculosis 5 years back. Sputum AFB of the patient was negative but mantoux with 36mm induration with a BCG scar was noted. On physical examination, there were multiple healed scars present on both the breasts around the retracted nipples. Grayish white thick, cheesy discharge was expressed from both the nipples and examined for AFB by ZN staining which was found to be POSITIVE. Chest x-ray was normal. Patient is kept under DOTS and responding well to treatment. DISCUSSION: In India the incidence of TB breast has been reported to be 0.63%to 4.5%. Bilateral breast tuberculosis is rare, TB of areola and nipple being rarest. Bilateral involvement holds for only 3% of patients with breast tuberculosis. In most of cases histology contributes to diagnosis by identifying a granulomatous lesion with typical caseous necrosis. The Gold standard for diagnosis of TB is Zeil Neelsen staining/culture, which is positive in our case. The differential diagnosis to be considered is carcinoma, although other diseases of the breast such as fatty necrosis, plasma cell mastitis, periareolar abscess, actinomycosis & blastomycosis should also be considered. P227 Pulmonary Mucormycosis Masquerading As Endobronchial Growth with Non Resolving Pneumonia 1) Dr Srikanth Ravoori , 2) Dr Mootha Vamsi Krishna Department of Pulmonary Medicine, Konaseema Institute of Medical Sciences & Research Foundation, NH-214, Amalapuram, E.G. Dist, Andhra Pradesh-533201 BACKGROUND: Non resolving pneumonia has a wide range of etiology which needs extensive investigations including bronchoscopy, radiological and microbiological tests. We present an unusual case of Non resolving pneumonia CASE SUMMARY: Patient is a 40 year old diabetic male, presented to us with complaints of chronic cough and fever of 4 weeks duration. He was evaluated elsewhere with chest X rays, CT SCAN which showed left lower lobe consolidation. Sputum was sent for bacterial culture. He received antibiotics for K.pneumonia infection as per sensitivity pattern. Despite 2 weeks injectable antibiotics he had persistant symptoms. Repeated sputum examination for AFB was negative. Repeat CT scan showed persistent consolidation. At this juncture patient was referred to us. He was subjected to BRONCHOSCOPY. It revealed an endobronchial growth in left lower lobe main bronchus, causing partial obstruction of lumen. Endobronchial biopsy has shown features of INVASIVE MUCORMYCOSIS. He received liposomal Amphotericin B 100 mg/day for 10 days with which clinical improvement was noted and was followed by Posaconazole syrup. Patient had complete clinical, radiological improvement and confirmed by resolution of endobronchial growth and normalization of airways. Posaconzole was continued till complete radiological resolution. CONCLUSION: We report a case of pulmonary mucormycosis presenting as endobronchial growth. We successfully treated the patient with liposomal Amphotericin B and Posaconazole, avoiding surgery. CLINICAL IMPLICATION: Diabetic patients with uncontrolled blood sugars presenting with non resolving pneumonia should be investigated for fungal etiologies TITLE: Endobronchial tuberculosis: case report. P228 AUTHORS: Dr.Bharat Bhushan, Dr.Ramesh Chander, Dr. N.C.Kajal, Dr. Rosy Aggarwal, Dr. Sandeep Gupta, Dr. Satish Duggal. Department of Chest and TB, Government Medical College, Amritsar (Punjab), India ABSTRACT BACKGROUND : Tuberculosis remains major threat to mankind worldwide with India accounting for one-fifth of global incidence. Endobronchial tuberculosis is disease of tracheobronchial tree with microbial and histopathological evidence. It remains difficult to be diagnosed because of nonspecific clinical presentations with normal chest skiagram and absence of acid fast bacilli in direct sputum smear oftenly. Accordingly patient remains undiagnosed and source of infection to the family and community. Procedural investigations like fiberoptic bronchoscopy are sometimes of great help in patients with strong suspicion of disease in country like India with high disease incidence. Case Report : A 27yr married female presented with three months complaint of having fever, dry cough , right side chest pain along with hemoptysis of fifteen days duration. There was no history of ATT previously. GPE and Chest examination were normal. Hb7 g/dl, TLC7800, DLC N60,L40, ESR110mm, HIV non-reactive, Mantoux negative, CXR showed no abnormality. Direct sputum smear microscopy was negative for AFB. FOB showed inflammation, hyperemia and ulceration with caseous material on bronchial mucosa of intermediate bronchus and adjoining lower lobe bronchus on right side. Brush-smear, broncho-alveolar lavage and post bronchoscopic sputum specimen were taken. BAL centrifuge revealed AFB on direct smear. Cytology revealed lymphocytic predominance. Post-bronchoscopic sputum and brush-smear were negative for AFB. Accordingly diagnosis of EBTB was established. The patient was put on anti-tubercular chemotherapy (DOTS) along with oral prednisolone (1 mg/kg). The patient improved markedly and the prednisolone dose being tapered during follow up. Conclusion : EBTB is less frequently diagnosed because of non-specific clinical presentations, misleading normal radiological findings and low incidence of AFB positivity in routine sputum-smear. A high index of suspicion is required for its diagnosis, especially in high endemic regions like Indian subcontinent. Added procedural investigations including FOB will help for early diagnostic yield. Key words: Atelectasis, Endobronchial, cancer, complication, pneumonia, tuberculosis P229 ALTERNARIA ALTERNATA PNEUMONIA A RARE CASE REPORT Dr. V.Mounika, Prof. Dr.P.Subbarao, Dr.H.V.Prasad Konaseema Institute of Medical Sciences & Research Foundation Amalapuram, Eastgodavari, Andhrapradesh BACKGROUND CASEREPORT Alternaria alternata is a rare fungal organism, that usually Seen on dead and dying plant parts , house dust. CASE REPORT In this case report a 50 year-old female with a 10 year history of asthma and 4 year history of diabetes mellitus, presented with two months duration of right chest pain, cough with purulent sputum and streaky haemoptysis. Chest x-ray and CT chest showed non homogenous opacity in right mid zone. Ultrasound guided Fine needle aspiration of right lung lesion revelead pus.The cytology of pus showed branched septate hyphae, and few hyphae are brown in colour and culture on sabouraud's dextrose agar showed colonies of Alternaria alternata. The patient was treated with Amphotericin B and fluconazole. Patient was discharged after resolution of symptoms. DISCUSSION ALTERNARIA fungus is a large universally occurring genus. Several form-species are found as saprophytes on dead and dying plant parts. Commonly found in house dust, carpets, textiles, and on horizontal surfaces in building interiors and is one of the main fungal causes of allergy. Outdoors, it may be isolated from samples of soil, seeds and plants, and is frequently reported in air. Conidia of this fungus are easily carried by the wind. The large spore size suggests that the spores from this fungus will deposit in the nose, mouth and upper respiratory tract causing nasal septum infections. It has also been associated with hypersensitivity pneumonitis It is a common cause of extrinsic asthma includes, BakerвЂ™s asthma and FarmerвЂ™s lung . Acute symptoms include edema and bronchospasms; chronic cases may develop pulmonary emphysema. Other diseases caused by Alternaria include mycotic keratitis, skin infections, and osteomyelitis P230 P231 Validity of empiric anti-tubercular treatment in suspected extra-pulmonary TB patients in tertiary health careRetrospective study Dr. Avinash Chauhan(Presenting Author), Prof. Dr. Meena Hingorani, Prof. Dr. Tushar Sahasrabudhe Department of Pulmonary Medicine Padmashree Dr. D. Y. Patil Medical College Hospital and Research Centre, Pimpri, Pune, Maharashtra, India. OBJECTIVES: To study the validity of empiric anti-tubercular treatment in suspected extra-pulmonary TB patients METHOD: A retrospective case series study was conducted at Dr D.Y Patil medical college, Pune, Maharasthra. All cases diagnosed and treated as EPTB from September 2013 to February 2014 were included. Data was retrieved from the RNTCP register. Details of clinical, laboratory and radiological records of the patients were retrived from respective departments. Extra-pulmonary TB was defined as patients with TB of any organ other than the lungs according to WHO definition such as gastrointestinal (G.I), musculoskeletal and genitourinary systems. Lymphadenopathy and pleural effusion were excluded as their diagnosis is based on histopathological and ADA findings respectively. All cases were registered on DOTS-CAT-1 and followed up after 3 months to evaluate the response to therapy. RESULTS: Out of the 36 patients treated for EPTB, 19 patients were males and 17 were females and mean age was 30 yrs (range 15-40). Most of the patients were unskilled workers and farmers. 60% patients were alcoholics. G.I and musculoskeletal(joints) were the most common sites involved (80.5%).Common complaints were abdominal pain and fever when G.I system was involved, and joint pain in case of musculoskeletal system. Among G.I patients, 63.8% (12 patients out of 19) symptoms resolved at the end of 3 months and 36.2% (7 patients out of 19) patients there was no change in symptoms- 3 defaulted within 2 months due to no improvement in symptoms and 4 are continuing treatment inspite of no change in symptoms . Among musculoskeletal, 60%(6 patients out of 10) symptoms resolved and 40%(4 patients out of 10) patients there was no change in symptoms-2 defaulted within 2 months due to no change in symptoms and 2 are continuing inspite of no change in symptoms. No additional treatment was taken either as alternative therapy or treatment for co-morbidity by the patients during 3 months period. CONCLUSION: Our study shows that suspected extra-pulmonary patients must be investigated thoroughly for tuberculosis and all other differential diagnosis must be excluded before starting anti-tubercular treatment. P232 TITLE: Diagnostic value of PCR in sputum of patients with pulmonary tuberculosis AUTHORS: SS GUPTA, A MEHROTRA, R SHARMA Department of Pulmonary Medicine, EraвЂ™s Lucknow Medical College & Hospital, Lucknow, India OBJECTIVES: To find out diagnostic utility of PCR in sputum of patients with pulmonary tuberculosis, to determine sensitivity and specificity of PCR in diagnosis of pulmonary tuberculosis, and to compare the results of PCR with sputum smear reports of Mycobacterium tuberculosis (MTB) by Ziehl-Neelsen (ZN) staining. METHODS: The study group consisted of 65 out-patients with strong suspicion of active pulmonary tuberculosis on basis of clinico-radiological evidence. 40 out-patients having non-tubercular respiratory disease during the same period formed the control group. Sputum of all the patients was subjected to smear microscopy by ZN staining and PCR for MTB in MJ mini thermal cycler (BIO RAD UK) using IS6110 (123bp) primer for amplification. All patients were subsequently followed clinico-radiologically. RESULTS: Of the 65 cases, 40 were smear positive and 25 were smear negative for MTB. All smear positive cases were PCR positive. Out of 25 smear negative cases, 14 were PCR positive. All 40 controls were PCR negative. All 54 PCR positive cases responded to anti-tuberculosis therapy. The sensitivity and specificity of smear microscopy was found to be 61.5% and 100%, while that of PCR was found to be 83% and 100% respectively. CONCLUSION: This study suggests that detection of MTB by a PCR based test could lead to rapid detection, early treatment, application of isolation procedures and also, investigation of contacts. P233 Deep Vein Thrombosis in a patient with Pulmonary Tuberculosis - A Case Report KB GUPTA, VIPUL KUMAR, MOHIT AGGARWAL Pt B.D. Sharma Post Graduate Institute of Medical Sciences INTRODUCTION: Deep vein thrombosis (DVT) is clinically observed and can be confirmed with laboratory methods in 3-4% of patients with pulmonary tuberculosis (PTB). But the real incidence may be closer to 10%, because most of the patients are thought to be clinically inapparent. The lack of awareness regarding the association is possibly responsible for the condition not being recognized and hence screening and treatment strategies have not been standardized. CASE RECORD: A 25 year old male TB patient was admitted with painful swelling of left lower limb for last 5 days. On examination the leg was tender &signs of DVT were present. Color Doppler Ultrasonography of left limb showed echogenic thrombus in lumen of left external iliac, common femoral, superficial femoral, popliteal, posterior tibial and anterior tibial veins. CT Angiogram chest showed no evidence of pulmonary embolism. Patient was treated with subcutaneous low molecular weight heparin with an overlap of warfarin for 10 days. Repeat Color Doppler ultrasonography done after 2 weeks of treatment of antithrombotics showed resolution of thrombus. DISCUSSION : The thrombogenic potential of TB is not well known but can have serious consequences. Activation of endothelial cells occurs in response to numerous physiological stimuli and results in the expression of endothelial proteins that change the normally non-thrombogenic internal surface of the vessel into a thrombogenic surface with subsequent development of local thrombosis. Priming of vascular endothelium occurs as a result of interaction between mycobacterial products and the host monocyteвЂ“macrophage system. It is also postulated that these changes result in hypercoagulable state predisposing to DVT. Prognosis of the DVT in PTB was found to be good if ATT and LMWH were started simultaneously and earlier. We emphasize on early detection of deep vein thrombosis, early start of prophylactic low molecular weight heparin in severe pulmonary tuberculosis A RARE CASE OF PAROTID TUBERCULOSIS P234 P Dani, P Dutta, R Manjhi, S Pothal Department of Pulmonary Medicine,V S S Medical College ,Burla ,Odisha, India Background:- parotid tuberculosis is a rare form of extrapulmonary tuberculosis which usually presents as a unilateral parotid swelling or abscess. Only about 100 cases of parotid tuberculosis have been reported is the literature. . Case report:- The present case reports a 33yrs old male patient presented with swelling of left parotid area of 2 yrs duration which gradually is increasing in size. On excamination swelling was firm in consistency non tender with ill defined borders, which was not fixed to masseter or any underlying structure. Skin over the swelling was normal. Facial nerve was intact.Chest X-ray and other routine blood investigations were normal.USG guided FNAC and biopsy of the swelling were suggestive of tubercular sialoadenitis. Z-N stain for AFB was negative. Patient improved with a course of ATT. Conclusion:- In a case of parotid swelling the possibility of tuberculosis should be kept in mind even though it is rare. The early diagnosis and suspicion is required to avert the need for surgery which may be a hazardous procedure in a medically treatable condition. P235 Calcified subcutaneous cysticercosis in a treated pulmonary TB patient--a case report Saravanan.M, Ramanujam.P., Chitrakumar.A., Gangadharan.V Govt.Kilpauk Medical College/ GTHTM, Chennai, Tamil Nadu, India Introduction: WHO designated cysticercosis as one of the 17 "neglected tropical diseases" worldwide. Encystment of larval form of tapeworm in various tissues of body is called cysticercosis.Eventhough CNS is the most commonly involved organ, subcutaneous cysticercosis is also reported in literatures. Objectives: To highlight that calcified subcutaneous cysticercosis has to be considered in differential diagnosis of calcified lesions in chest xray Case report: 70yrs non-diabetic male,agriculturist,pork eater,presented with complaints of cough and expectoration for 2-3 weeks.10 yrs back,he was treated for pulmonary TB.On examination,there were multiple subcutaneous small,multiple swellings all over the body.chest xray showed typical millet seed calcifications in soft tissue areas and lung zones.xrays of abdomen and both lower limbs showed similar calcified lesions in soft tissue areas.Excision biopsy of subcutaneous swelling revealed fibrocollagenous wall with foci of calcification.no cysticercosis demonstratable in specimen.sputum for AFB was negative.respiratory symptoms improved with antibiotics. Discussion : Subcutaneous cysticercosis is a less common presentation of tapeworm infestation. Man is the definitive host. Pigs are the intermediate host.Humans get the infection when they ingest undercooked infected pork meat which is harbouring the cysticerci. Biopsy and HPE demonstrating the cysticerci is the definitive diagnostic method. In FNAC, the presence of eosinophils, neutrophils, palisading histiocytes, giant cells in a typical granular dirty background should alert the cytopathologist of a parasitic infection . When characteristic morphology is absent in histopathology specimen, mitochondrial DNA diagnosis is a powerful tool for a definitive diagnosis of cysticercosis. .Asymptomatic calcified subcutaneous cysticercosis can be left alone without treatment P236 Association between DVT and pulmonary TB-- a case series report Saravanan.M, Ramesh.P.M, Chitrakumar.A, Gangadharan.V Govt. Kilpauk Medical College /GTHTM, Chennai, Tamil Nadu, India Introduction: India accounts for 1/3rd of global burden of Tuberculosis. Pulmonary TB is a risk factor for DVT. Thromboembolic complications associated with pulmonary TB had been reported in literatures with incidence varying between 1.5 to 3.4%. Objective: To analyze the epidemiological factors associated with DVT in pulmonary TB patients. Methods: We did a case series study of 4 cases of smear positive pulmonary TB patients who developed DVT while on treatment for pulmonary TB. All 4 cases reported to our hospital within a period of 2 months. All cases were subjected to routine blood investigations, sputum for AFB, x-ray chest Results: All the 4 patients were male smokers. Age of the patients ranged from 35 -- 53 yrs. Sputum positivity grading was 2+ in 3 patients and 1+ in one patient. All the 4 patients had bilateral extensive lesions in chest x-ray. All the patients developed DVT within 4 weeks of diagnosing PTB. All were poorly nourished with low BMI. Venous Doppler USG confirmed the diagnosis of DVT in all 4 cases. All were treated with ATT, heparin and oral warfarin. All 4 patients responded well to the treatment and no one developed pulmonary embolism in our study Discussion: Pulmonary TB infection causes elaboration of IL-1,6 and TNF-О± and release of pro-inflammatory cytokines resulting in a hypercoagulable state. Further rifampicin used in the ATT regimen alters the coagulant and anticoagulant protein balance resulting in hypercoagulable state. In our study, in all 4 cases, smoking, extensive lung disease leading to release of pro-inflammatory cytokines and patientвЂ™s poor nutritional and bed-ridden status contributed to the development of DVT.. Conclusion: In all severely ill pulmonary TB patients,we should be aware of development of DVT and early screening for DVT and encouraging early ambulation in such patients will prevent life threatening pulmonary embolism. P237 A case of paradoxical TB IRIS in NON-HIV TB cervical adenitis patient on ATT--a case report Saravanan.M, Karthikeyan J.J., Chitrakumar. A. , Gangadharan .V Govt. Kilpauk Medical College/GTHTM, Chennai, Tamil Nadu, India Introduction: Paradoxical TB IRIS is an immunological reaction seen in HIV patients on ART while on treatment for tuberculosis, seen within 2 months of initiating ATT. It is characterized by enlargement of existing lymph nodes, appearance of new nodes, tuberculoma in brain, new lesions in lung and serositis. It poses a challenge to clinician because it is difficult to distinguish between paradoxical reaction and treatment failure or drug resistance. We report a case of paradoxical TB IRIS in non-HIV female patient with TB cervical adenitis Case report: A 33yrs female, non-HIV, non-diabetic, who presented with left cervical lymphadenopathy was diagnosed as TB cervical adenitis based on symptoms, mantoux positivity and excision biopsy. After 3-4 weeks of starting ATT, patient developed fever, chest pain,myopathy,arthritis and enlargement of existing node with abscess formation. CT chest revealed mediastinal adenopathy, pleuro-pericardial effusion and parenchymal involvement and presternal abscess collection. Aspirate from abscess was sent for AFB culture. Sputum for AFB was negative. LFT was normal. Meanwhile, patient was continued ATT and treated with NSAID and steroid as clinical features were suggestive of IRIS. Fever subsided. Pleuro-pericardial effusion resolved. AFB culture report came as negative for Mycobacterium tuberculosis. Patient improved clinically and ATT was continued whereas steroid was stopped after gradually tapering the dose. Patient completed full course of ATT with resolution of nodes. Discussion: Paradoxical reaction during ATT treatment must be considered after careful exclusion of medication non-adherence, development of resistance and other similar conditions. The addition of short course of steroid may be necessary to control severe form of reaction with or without drainage or surgical excision of lymph node to avoid fistula. . P238 Awareness of Tuberculosis among patients attending RNTCP at Siddhartha Medical College, Vijayawada S.N. Mani devi. K , N.Gopichand , D.Sudeena Department of Pulmonology , Siddhartha Medical College , Vijayawada , A.P. Introduction: Tuberculosis is one of India's major public health problems. According to WHO estimates, India has the world's largest tuberculosis epidemic. Public awareness about its causative organism, modes of spread, diagnosis, treatment, and prevention plays an important role in TB control. The present study was carried out to assess awareness of Tuberculosis among patients attending tertiary care hospital(Siddhartha Medical College) Methodology: A cross sectional observational study was conducted among 100 patients taking treatment at Siddhartha Medical College, Vijayawada using a preformed questionnaire. The questionnaire contains socio-demographic variables such as age, sex, religion, literacy status, and knowledge about symptoms, mode of transmission, aetiology, Investigations, prevention and treatment of tuberculosis Results: Out of these 100 Patients 97% were aware that Tuberculosis is an infectious disease. Regarding symptoms only 69% identified cough more than 2 weeks as an important warning sign for Tuberculosis. Regarding investigations only 69% were aware that sputum test was done for diagnosis of Tuberculosis. Only 60% knew DOTS as treatment for Tuberculosis. Only 56% were aware that Tuberculosis is most common in HIV individuals. Conclusion: The current study revealed that although awareness regarding certain basic aspect of tuberculosis was adequate; however there is a great need to improve awareness about the symptoms and treatment of tuberculosis. P239 Prevalence of extra pulmonary multi drug resistant tuberculosis among retreatment tuberculosis patient admitted in tertiary care hospital by using gene x pert assay Dr. K. Maheswaran, S. P. Vengada krishnaraj, G. Allwyn vijay, J. Arivozhi, R. Sridhar, O.R Krishnarajasekhar, C. Chandrasekar Institution.stanley.medical.college.chennai Background: In 2012, out of the estimated global annual incidence of 8.6 Million TB cases, 2.3 million occurred in India, of which 15% falls under extra pulmonary tuberculosis. India accounts for one fourth of global burden of tuberculosis. Because of human immunodeficiency virus infection incidence of extra pulmonary tuberculosis is raising, occupying 50% of tuberculosis in retro viral positive patients. Multi drug resistance among retreatment case is 1217%; primary drug resistant is 2-3%. The X pert MTB/Rif test is a cartridge-based fully automated NAAT (nucleic acid amplification test) for TB case detection and rifampicin resistance testing, suitable for use in disease-endemic countries. It provides results from unprocessed sputum samples in less than 2 hours, with minimal hands-on technical time. This Study where done to identify Multi Drug Resistance tuberculosis among extra pulmonary tuberculosis patient admitted in our hospital (Government Hospital of Thoracic Medicine tambaram), as similar previous data unavailable in Tamil Nadu. Study place: Government Hospital of Thoracic Medicine, Tambaram, Tamil Nadu. Study period: Between March 2014 to August 2014. Study design: prospective study Methods and material: Patient with extra pulmonary tuberculosis came for retreatments were chosen for my study to analyze drug resistance among them. Samples from extra pulmonary sites like lymph node, pleural fluid and abscesses were send for gene x pert analysis in IRL Chennai Results: 71 extra pulmonary tuberculosis specimen were subjected to gene x pert of which 10 where retroviral positive, among which pleural effusion occupies 43.6 %, lymph node tuberculosis 52.1 %, abscess 4.6%. Multi drug resistant was diagnosed in 7 patients (9.8%), MTB detected in 50.7%, MTB not detected in 33.8%, 3 of the 71 samples (4.2%) was repeated because of indeterminate report. sensitivity of gene x pert in diagnosing MTB complex from various specimen includes 64.8% for lymph node aspiration, for pleural fluid it is 32.2% and for abscess is 50%. Conclusion: 1. Compare to conventional culture methods for diagnosis of extra pulmonary MDR TB used previously; gene x pert method is quicker hence we are able to diagnose extra pulmonary MDR TB more easily accounting for its higher incidence in recent years in our institute. TB presenting as right paratracheal mass. P240 Dr. Praveen.R, Dr. Yuvarajan.S, Dr. Kavitha devi. M Sri Manakula Vinayagar Medical College and Hospital,Puducherry, India Introduction: Mediastinal tuberculous lymphadenitis is a rare disease in adults. Dysphagia as a presenting symptom is even rarer. Dysphagia due to mechanical obstruction is usually related to malignant disease. Case report: Our case is a 56 year old lady who came with complaints of difficulty in swallowing for 2 months, cough with scanty mucoid sputum and loss of appetite for six months. Patient was initially evaluated at an outside hospital with chest x-ray, upper gastrointestinal scopy( Impression вЂ“ mild oesophagitis) and treated with antacids. As the patient did not have symptomatic improvement, came to our hospital, was evaluated with Chest x-ray which showed well defined homogenous opacity in right paratracheal region. Bronchoscopy was done and trans tracheal needle aspiration was taken which was suggestive of granulomatous lesion. C.T Thorax (plain and contrast ) was done which showed conglomerated mediastinal lymph nodes present. C.T guided needle aspiration of nodes done which was suggestive of non caseating granulomatous lesion. With a working diagnosis of sarcodosis / TB lymphadenitis, Mantoux was done, showed 15mm induration. Patient was started on Anti-tuberculous treatment CAT -1, improved symptomatically. Follow up chest x rays were taken which showed regression in size of the homogenous opacity and complete resolution of it after six months of Anti-tuberculous treatment. P241 EVALUATION OF MYCOBACTERICIDAL ACTIVITY OF SUPEROXIDIZED WATER ON CLINICAL ISOLATES OF MYCOBACTERIUM Dr Ritu Aggarwal, Dr Uma Chaudhary, Dr Vipul Kumar, Dr K B Gupta, Dr Nidhi Goel Pt BD Sharma Post Graduate Institute of Medical Sciences, Rohtak (Haryana) INDIA Objectives- In 2012, 8.6 million people fell ill with TB and 1.3 million died from TB. The main cause for concern is the spread of MDR TB strains and HIV-TB co infection. Resistance to medication does not mean that at the same time there is also a resistance to disinfectants. Careful disinfection in the everyday clinical environment is of great importance today and is a particularly effective measure for the prevention and breaking down of infection chains. In this context the methods of asepsis and active chemical antisepsis are currently becoming increasingly important in terms of the prevention of transmission of infection. So, this study was conducted to investigate the activity of superoxidized water on mycobacteria. Methods- For clinical isolates of Mycobacteria and Mycobacterium tuberculosis H37Rv (NCTC 7416) were included in the study. Suspension of the five mycobacterial strains was prepared in distilled water in six sets for each strain. Three set of tubes were used as test and were treated with SOW for a period of 05, 10 and 15 minutes. Remaining three acted as control and was treated with D.W. Results- Colony counts of all strains were reduced to zero within five minutes of treatment with SOW. Control tubes for all the organisms showed growth. Superoxidized water gave >5 log 10 reduction of Mycobacterium spp with five minutes of exposure in the absence of organic load. Conclusion- Our study shows, significant reduction in mycobacterial load i.e >5 log 10 in the absence of organic load within 05 minutes of exposure with SOW. Such high level of disinfection has also been demonstrated by other authors. So, SOW can be a good alternative high level disinfectant for various health care purposes. P242 Comparative study of clinical and radiological features of pulmonary tuberculosis patients with or without diabetes mellitus AUTHORS: J SIRCAR, SS GUPTA, AS SINHA, A VERMA Department of Pulmonary Medicine, EraвЂ™s Lucknow Medical College & Hospital, Lucknow, India OBJECTIVES: To compare the clinical and radiological similarities/dissimilarities between diabetic and non-diabetic pulmonary tuberculosis patients. METHODS: The study group consisted of 65 new patients of pulmonary tuberculosis who were sputum smear for acid-fast bacilli (AFB) positive and were either known cases of diabetes mellitus (DM) or were recently diagnosed as having DM. The control group consisted of 65 new pulmonary tuberculosis patients who were sputum smear for AFB positive and did not have diabetes. RESULTS: Of the 65 patients in the study group, 40 (61.5%) were newly diagnosed cases of DM and 25 (38.5%) were old known cases of DM. Of these 25 patients, the duration of diabetes was в‰¤5 years in 5 (20%) and в‰Ґ5 years in 20 (80%) cases. 2 (8%) of these 25 patients were on insulin therapy, 21 (84%) were on oral hypoglycemic therapy, while 2 (8%) were not taking any treatment for DM. Fifty-two (80%) out of the 65 diabetic patients were males. Grade and duration of fever, and lower zone lung involvement was significantly higher in diabetic patients. Incidence of cough and cavitary lesions was significantly higher in non-diabetic patients. CONCLUSION: Male sex, old age and lower zone lung involvement are strong predictors of DM among pulmonary tuberculosis patients. As a significant number of patients were diagnosed to have DM on screening, routine screening for DM should be made essential for pulmonary tuberculosis patients to help improve the treatment outcome and to prevent the emergence of multi-drug resistant tuberculosis. P243 ABPA - A MASQUERADER OF PULMONARY TUBERCULOSIS DR.VARIKUTI SUBBARAO, DR.A.SATHYAPRASAD, DR.Ganesh Mohapatra, Dr Vijay, Dr Nalini, Dr Prashanthy MAMATA MEDICAL COLLEGE & HOSPITAL, KHAMMAM Background: Allergic Bronchopulmonary aspergillosis is an idiopathic inflammatory lung disease characterized by allergic inflammatory response to the colonization of aspergillus. High degree of suspicion is required in order to make its diagnosis since the presenting complaints are often non specific and overlap with other clinical situations like pneumonias, bronchiectasis, pulmonary tuberculosis.The delay in diagnosis of ABPA often leads to significant morbidity. The wide spectrum of this disease can be severe requiring lung transplantation. However, if diagnosed early, it can be treated effectively to reduce future remission and progressive lung damage. We report one such case, who was treated with anti tuberculous drugs without any significant improvement. Case Report: A 35 years old female with clinical history suggestive of bronchial asthma since childhood, presented to us with unremitting symptoms of breathlessness, cough, expectoration, wheeze, fever, chest pain since 2 years. She was being treated outside with ATT, based on chest radiograph finding inspite of her sputum and bronchial washings were being negative for AFB. Upon further evaluation she was found to have elevated total serum IgE levels, immediate skin hypersensitivity reaction was positive to aspergillus fumigatus antigen, with elevated peripheral eosinophil count. All these findings, in addition to central bronchiectasis as seen on HRCT Thorax were fulfilling the Greenburger and Patterson criteria for the diagnosis of ABPA. She was treated with oral steroids, antifungal agents and followed upto 6 months with good clinical and radiological improvement. Conclusion : Suspicion for ABPA should be maintained while managing any patient with bronchial asthma with any severity or any level of control and should not be misdiagnosed and wrongly treated for other pulmonary diseases. Here this case was diagnosed as per Greenberger and Patterson criteria. P244 Pulmonary tuberculosis presenting as organizing pneumonia-a case report Karthiga.G, Chellaraja.C, Chitrakumar A, Gangadharan .V, Govt. Kilpauk Medical College/GTHTM, Chennai, Tamil Nadu, India Case Report: 18 years old unmarried female, housemaid by occupation presented with severe hypoxia (SpO2-82%) even with high flow oxygen, high grade fever with chills, dry cough and dyspnea at rest for 10 days duration. There was no past h/o tuberculosis /ATT intake. Clinically patient was febrile (102 F), dyspnoeic, tachypnoeic and tachycardia. Auscultation of chest revealed bilateral crepitation. Investigations done-Sputum AFB, widal, ANA, RA, HIV, blood urine C/S were negative; CRP positive; ESR 25/50mm. Chest X ray showed bilateral peripheral air space opacities. CT chest revealed extensive lobar consolidation with GGO pattern predominantly involving lower lobe. Patient was treated with supportive care, antibiotics and steroids. After stabilizing patient general condition, FOB and DLCO were done. BAL revealed mixed cellularity with increased lymphocytes. Microbiological tests showed positive for AFB and negative for fungal and NT culture. PFT showed severe restriction with reduced DLCO. Patient was started on ATT category I with continuous O2 flow for 2 weeks. Hypoxia improved after 2-3 weeks of O2 therapy. After 6 weeks of hospitalization with tapering steroids, patient improved clinically with minimal radiological improvement and discharged with an advice to continue ATT. Discussion: Organising pneumonia is a type of pneumonia in which usual process of resolution has failed and organization of inflammatory exudates occur in alveoli by fibrous tissue. Etiology of organizing pneumonia includes bacterial, viral, parasitic infections, connective tissue disorders, drugs, ionizing radiation and toxic fumes. It affects people of ages 40-60 years. It has no sex predilection. Patients usually present with flu like symptoms which include dry cough, dyspnea, fever, weight loss and fatigue. Pathophysiology-delay in clearance of fibrinous exudates and granulation tissue which leads to intra alveolar accumulation of fibromyxoid connective tissue leading to organising pneumonia. Our case presented like organizing pneumonia due to tuberculosis, a very rare presentation. P245 Case of Non-Tuberculosis infection mimicking Aspergiloma. Dr. Abhinandan B. Mutha, Co-author- Dr. B. K. Mutha, Dr. S. Dugad, Dr. G. Kulkarni. Case history- 50 years old female, came with C/O cough with expectoration, low grade fever & breathlessness on exertion since 6 months. Also C/O loss of weight and appetite. Past history of Pulmonary KochвЂ™s 25 years back, for which treatment was taken of which details were not available. No H/O DM, HTN, B.A. No significant family and personal history. O/E вЂ“ patient was averagely built and nourished, vitally stable, no e/o pallor, cyanosis, clubbing, lymphadenopathy, oedema. On Respiratory system examination- trachea central, B/L chest movements equal, B/L BS present, crepitations present in left infrascapular area. CVS, CNS, PA вЂ“ WNL. CxR & HRCT Thorax вЂ“ bilateral fibrocavitatory lesions with aspergiloma in left lower lobe. Bronchoscopy done and BAL taken which was sent for AFB, Fungal & Pyogenic culture. BAL AFB culture- Mycobacterium other than tuberculosis grown, which on identification revealed Mycobacterium Abscessus, which was sensitive to trimethoprim sulfamethoxazole, moxifloxacin, amikacin, clarithromycin, linezolid. Treatment was given as per sensitivity report and patient responded well to treatment. Fig 1 &2 are pre treatment, fig 3 is post treatment. P246 Clinical and Bacteriological profile of Comminity Acquired Pneumonia among adult patients Aji Mathew Joseph, R N toshniwal Department of Pulmonary Medicine, Navodaya Medical College Hospital and Research Centre, Raichur, Karnataka, India. Objectives: 1. To assess the types of clinical presentation of Comminity acquired pneumonia (CAP) 2. To study the associated risk factors and their outcome on the disease. 3. To study the spectrum of organisms causing CAP 4. To study the drug sensitivity pattern of the organisms isolated. Methods: Etiology and clinical profile of 50 patients with CAP above 18 years were studied retrospectively from October 2012 to November 2013. Data regarding clinical features, physical examination, chest xray, sputum samples for smear microscopy and cultures were collected in a preformed proforma and analysed. Results: The commonest mode of presentation was cough (96%), followed by fever (94%) and expectoration(86%).All patients had bronchial breathing and 70% had crepitations.The commonest risk factor was copd (20%) with a mortality of 2%.,. Streptococcus pneumonia was the commonest pathogen(38%) followed by pseudomonas aeruginosa (18%) , staphylococcus aureus (12%), klebsiella pneumonia (8%).organisms were most sensitive to ciprofloxacin (44%) followed by amikacin (32%), piperacillin tazobactum (28%),and amoxicillin clavulanic acid (26%) Conclusions: CAP was common in elderly (>50 years) .Incidence was more common in men .Commonest predisposing factor was copd. Majority of the patients had cough with expectoration and fever followed by chest pain and dyspnea.Most patients had leukocytosis and sputum examination showed predominance of gram positive organisms. Streptococcus pneumonia was the commonest organism isolated which was most sensitive to fluoroquinolones followed by aminoglycosides and broad spectrum pencillins with beta lactum inhhibitor.The mortality was high in copd patients. P247 Unusual presentation of tuberculosis N.G.KUNJIR, R. NARASIMHAN Department of Respiratory Medicine, Apollo hospital, Chennai. Hereby we report a case of 27 year old female, who presented with persisting moderate to severe left sided chest pain since last 3 weeks. Pain was localised to left infraaxillary and interscapular region and was not responding to analgesics. She denied any other co-existing respiratory complaints or any constitutional symptoms. Breast examination was normal. ECG showed sinus rhythm. Chest X ray and Plain CT scan chest revealed pleuroparenchymal nodule in the left lower lobe region. She was referred to our hospital for further evaluation. Contrast CT chest was done which showed that nodule was localized to costal pleura and was associated with pleural thickening. CT guided biopsy of the nodule showed perivascular round cell infiltrates. PET CT showed hypermetabolic soft tissue mass in left chest wall and FDG avid pleural nodules in left hemithorax region, with imaging differentials of Lymphoma or Askins tumour/PNET or Metastasis. Since suspicion of malignancy was high, she was subjected to open pleural biopsy. Left pleural nodule biopsy showed necrotizing granulomatous inflammation with few acid fast bacilli. We report this case to emphasis the fact that false positivity of PET CT in high prevalent countries like India should be always kept in mind while interpreting the results. CONCLUSION All that glitters on PET, is not cancer. P248 Spirometric analysis in post-tuberculois sequelae BHATIA H, GUPTA P, MITTAL R, DASH DJ, CHHABRA SK Department of Pulmonary Medicine, Vallabhbhai Patel Chest Institute, Delhi Background. In a substantial proportion of cases, treatment of tuberculosis does not ensure a complete anatomical and functional recovery and the patient is left with posttubercular sequelae. These sequelae lead to significant impairment of lung function that is responsible for significant morbidity and mortality. The present study was carried out to explore the spectrum of spirometric abnormalities in patients presenting with Posttuberculosis sequlae. Methods: A retrospective analysis of spirometric patterns of cases diagnosed with posttubercular sequelae over a period of two years was carried out. Active tunerculosis was ruled out. The patients underwent spirometry for their functional assessment. Results: There were 37 subjects (22 male and 15 females) with mean age of 44.78 В± 12.67 years. All the studied subjects confirmed pulmonary or pleural tuberculosis in the past with 4 (11%) patients having received treatment twice or more frequently. Majority had completed treatment or were declared cured (33/37) while 4 had defaulted at different stages. The main symptoms on presentation were cough with expectoration and breathlessness on exertion. Thirteen subjects (13/37,35%) had clinical history suggestive of bronchial asthma. Active tuberculosis was ruled out by sputum examination for acid fast bacilli by direct smear and culture. Spirometry revealed abnormality in 27/37 (73%) subjects. It showed obstructive pattern in 7 (19%) subjects (6male/1female) restrictive pattern 11 (30%) subjects (4male/7female) & mixed pattern 9 (24%) subjects (7Male/2Female) while it was normal in Normal 10 (27%) subjects (4Male/6Female). Significant response to bronchodilator was observed in 14 (38%). Eight subjects (8/37,22%) were smokers, out of whom 43% (3/7) had mixed abnormality, 43% (3/7) had airflow limitation & 14% ( 1/7) had restrictive pattern. Conclusions: Functional abnormalities are common in tuberculosis after completion of treatment and result in continued morbidity. The majority of patients had restrictive pattern followed by mixed patterns of abnormalities. P249 An Interesting Case of Tuberculosis with Intraoral Involvement Dr Karl DM, Dr Ajit H, Dr Sivaraj AL, Dr Alamelu H, Dr Rajashekar MB, Dept of Pulmonary Medicine and Dr Rachna K, Dept of Oral Medicine & Radiology Vydehi Institute of Medical Sciences & Research Centre and Vydehi Institute of Dental Sciences & Research Centre Tuberculosis is still endemic to India. Mycobacterium tuberculosisвЂ™ ability to infect any part of the human body is a fact. Tuberculosis of oral cavity is an uncommon entity because of the bacilliвЂ™s inability to penetrate the intact squamous epithelium. This case report is of a 63 year old farmer, a smoker for more than 35 years. He presented with complaints for the last 3 months, which were: pain in the left side of the mouth, which was aggravated on opening his mouth, while talking and chewing food. Pain arose from an ulcerative lesion in the left buccal mucosa, which gradually increased in size to involve the left angle of the mouth. For the last 1 month he also complained of progressive trismus. He also gave history of productive cough with scanty, white, mucoid sputum, non-blood stained and intermittent, lowgrade fever. He denied losing weight and claimed to have a normal appetite. On clinical examination, he had fever of 101oF. Local examination showed an irregularly shaped solitary ulcer, about 2.5 cm x 3 cm, involving the left buccal mucosa, extending anteriorly to involve left commissure, left mucocutaneous junction of lower lip and upper lip. Auscultation of his lung fields revealed bilateral scattered crepitations. A punch biopsy of the ulcer was reported as caseating granulomatous inflammation while Ziehl-Neelson stain confirmed the presence of acid-fast bacilli. Incidentally, his sputum was positive for acid-fast bacilli. A diagnosis of pulmonary tuberculosis with intraoral involvement was made. He was started on RNTCP Category 1 antitubercular treatment. This case illustrates an atypical presentation of tuberculosis and the diagnostic challenge clinicianвЂ™s face. India being a high burden country for TB, our clinicians must continue to remain aware of this disease and keep it as a differential diagnosis in any atypical medical scenario. P250 SPUTUM POSITIVE PULMONARY TUBERCULOSIS WITH HANSENвЂ™S DISEASE(PURE NEUROTIC TYPE) - An Unusual Presentation Dr.Kiran, Dr.Krishnamurthy , Dr.Vijay kumar,Dr.Pramod kumar OSMANIA MEDICAL COLLEGE ,GGCH Background: Pulmonary kochвЂ™s with hansenвЂ™s, is a rare manifestation. We are here with reporting an unusual case of sputum positive pulmonary tuberculosis with pure neurotic type of leprosy Case Presentation: A 34 year old male patient presented with grade вЂ“ I breathlessness , cough with expectoration since 2 months and inability to use left upper limb and tingling sensation of left upper limb for one month.Chest x-ray PA view showed left upper zone infiltrates, sputum for AFB 3+ and 1+ Skin chip for AFB taken from right ear and left hand dorsum suggestive of pure neurotic type leprosy Patient treated with anti tubercular treatment under RNTCP DOTS cat-1 and and hansenвЂ™s treatment under NLEP P251 Role of geneXpert in lymph node aspirates via EBUS in diagnosis of TB in evaluation of isolated mediastinal lymphadenopathy A.BHANOT, S.JOSHI, R.GUPTA, D.TALWAR Pulmonary Medicine and Critical Care, Metro centre for respiratory diseases, Noida, Uttar Pradesh, India. OBJECTIVE: To investigate the role of geneXpert in diagnosis of tubercular mediastinal lymphadenopathy from real-time endobronchial ultrasound and transbronchial needle aspiration (EBUSTBNA) material. EBUS-TBNA of the mediastinal and hilar lymph nodes is now becoming a standard care that is safe and has a good diagnostic yield. GeneXpert assay has high sensitivity and specificity for identification of MTB in expectorated samples of lower airways secretions. However, few performance data have been published to date on non-respiratory specimen in TBNA samples from mediastinal lymphnodes where the diagnosis of tuberculosis depends upon the cytology findings. METHODS: We collected clinical, cytological, and microbiological data from 30 patients admitted to our centre from January-August 2014 with mediastinal lymphadenopathy. All patients underwent EBUSTBNA. Performance of a single Xpert-MTB assay as compared to the cytology was evaluated against microbiologically confirmed TB lymphadenitis. вЂњDefinite-TBвЂќ was defined as positive microscopy and/or culture with consistent clinical features. RESULTS: A total of 30 patients with a mean age of 46.3 В± 17.3 years underwent EBUS-TBNA in whom mediastinal TB was clinically suspected. Xpert-MTB demonstrated an overall sensitivity for stain and/or culture positive TB of 33% and specificity of 94.4%, PPV of 80% and NPV of 60%. Positive TBNA Cytology showed an overall diagnostic sensitivity of 75% for stain and/or culture positive TB patients but with a specificity of 27.8% , PPV of 41% and NPV of 62.5%. CONCLUSION: Our study showed that although sensitivity of geneXpert in EBUS-TBNA material from mediastinal lymphnodes (believed to be paucibacillary) is low but high specificity and high positive predictive values would support the use of positive result to start empirical treatment in patients with pending microbiological data or justify in its absence. Therefore we conclude that Xpert-MTB in EBUSTBNA aspirate provides a rapid, useful, and accurate test to diagnose mediastinal nodal TB. P252 A STUDY OF 70 CASES OF PULMONARY TUBERCULOSIS IN HIV INFECTED PATIENTS DR.HEMANT NAYI, DR.PRAGNESH PATEL, DR.SAVITA JINDAL, DR.NALIN T.SHAH, DR.KUSUM V.SHAH Department of pulmonary medicine, BJ Medical college, Ahmedabad, INTRODUCTION: The emergence & pandemic spread of AIDS and HIV have posed the greatest challenge to public health in modern times. The rate of TB infection has been steadily mounting. AIM 1. 2. 3. To study the relation b/w HIV infection & Pulmonary TB. To assess the clinical profile and outcome of pulmonary TB in HIV seropositive patient. To study the presentation of pulmonary TB in relation to CD4+ T Cell lymphocyte count among HIV seropositive case. MATERIAL AND METHODS A study was carried out on 70 patients, from April 2013 to April 2014 in pulmonary medicine department, BJMC, Ahmedabad Gujarat. RESULTS 1. 2. 3. 57 cases (82%) were males and 13 (18%) cases were females with Male : Female ratio 4:1. This suggests that males are commonly affected in HIV with TB than females. 3 As far as pulmonary TB is concerned, 43 cases (61.43%) had CD4+ T Cell count < 200/mm and 27 cases (38.57%) had CD4+ Cell в‰Ґ 200. In pulmonary TB Sputum smear for AFB was positive in 14 cases (19.99%) and Negative in 56 cases (80%) 3 10 cases (14.28%) with CD4+ T Cell count в‰Ґ 200.mm had positive sputum smear for AFB as compared to 3 4 cases (5.71%) with CD4+ T cell count <200 /mm . Majority of these patients with positive sputum smear 3 had CD4+ T Cell count в‰Ґ 200/mm .Detail results will be discussed in case study. CONCLUSION: HIV and pulmonary TB co-infection may aggravate both conditions as both are intracellular organism and TB coinfection increase replication of HIV virus. P253 A survey of knowledge and attitude of general population about tuberculosis Sivakumar Reddy P, Nageswari AD, Srinath D, Rajalakshmi R,Kavita Vani K SRM Medical college and hospital, Kattankulathur Background: Tuberculosis is a major public health problem. Tuberculosis the most common opportunistic infection in diabetes, hiv and aids, it has gained even greater importance. RNTCP depends on the passive reporting of the chest symptomatic patients to the health institutions. Therefore, it is important that the basic knowledge about the disease and the availability of treatment is clear among the individuals in the community. Equally important is to assess the practices of the people to find out unhealthy practices. Objectives: To assess the knowledge about symptoms, mode of transmission, causation, prevention and treatment relating to tuberculosis in a general population. Study design: Cross-sectional. Setting: Kanchipuram dist. Participants: Individuals above 18 years and who are willing for answering tuberculosis questionnaire were selected. A total of 350 patients were selected Results: A total of 350 individuals with mean age of 43.02 years (Range: 20-70 years) were interviewed, out of which 202(57.7%) were males and 148(43.3%) were females. One-fourth (24.6) of the individuals were illiterate. 94.6% were aware about tuberculosis disease. cough with sputum (31.5%) was common symptom associated with tuberculosis. 27.7% of responders said TB is not contagious.51% responders thought TB is spread through coughing. 59% responders believed TB is curable. When questioned about the social acceptance of tuberculosis, 16.3% said they will hide the disease. Only 13.9% responders had heard about TB through media. 22.5% responders had said that TB is associated with DM followed by HIV (19.9%) and both DM & HIV (20.5%). Conclusion: Although knowledge regarding symptoms, mode of transmission and causation was fairly good, misconception like non contagious nature of disease still exist among the general population. despite advances in medicine the stigma attached to tuberculosis is still prevalent. P254 PYRAZINAMIDE INDUCED CUTANEOUS LEUKOCYTOCLASTIC VASCULITIS SINGH A, MISHRA M, JAIN V K, SHARMA A, NAYYAR P , KUMAR A DEPARTMENT OF RESPIRATORY MEDICINE, MAHATMA GANDHI MEDICAL COLLEGE & HOSPITAL, JAIPUR, INDIA Cutaneous leukocytoclastic vasculitis is a small vessel Vasculitis localized to skin. There are any possible causes for this pathological condition like infections, collagen vascular disorder, use of medications and malignancies. A 30 year old male was diagnosed as left sided tubercular pleural effusion. He was put on daily anti-tubercular therapy, regimen comprising of isoniazid, ethambutol, rifampicin and pyrazinamide. After 1.5 months of initiation of treatment patient presented to us with complaint of purpuric lesions that developed on bilateral lower legs. The lesion first appeared over the both ankles and spread upwards upto the knees. Histopathically the lesion was leukocytoclastic vasculitis. The lesions improved after the discontinuation of ATT. ATT was re-challenged one by one over next few days. The lesions reoccurred with Pyrazinamide. Thereafter pyrazinamide was withdrawn and remaining drugs were continued. Diagnosis of pyrazinamide induced leukocytoclastic vasculitis was made. P255 A Rare Case of Disseminated Tuberculosis - Laryngeal Tuberculosis with Lupus Vulgaris and Pulmonary Tuberculosis B.SriTeja, V.V.Ramana Reddy, Ganeswar behera, J.V.Praveen, D.S.Sowjanya, G.Ramya, B.K.Prithvi, P.V.V.Bharadwaj Department of Pulmonary Medicine, MaharajahвЂ™s Institute of Medical Sciences, NTR University of health sciences, India. Laryngeal tuberculosis is a rare disease. It is almost always associated with pulmonary tuberculosis. Lupus vulgaris is a common morphologic form of cutaneous tuberculosis, but this type of association with laryngeal and pulmonary tuberculosis is rare. CASE REPORT: A 46 yr old female patient presented to the department of Pulmonary Medicine with complaints of dry cough, skin lesions over nose and lip, hoarseness of voice, dysphagia since 1year. On examination large skin lesions with crusting over plaques were present all over the nose extending onto the upper lip and filtrum. INVESTIGATIONS: Chest X ray - a large nodular opacity of approximately 1x 1cm size in the left upper zone. Sputum for AFB negative. Mantoux test - 25 mm of induration at the end of 72 hrs. ESR - 45 mm. CECT chest - a well defined nodular lesion with central calcification and air lucencies in posterior segment of left upper lobe suggestive of pulmonary tuberculosis. Bronchoscopy showed yellow coloured crusts in the base of the both nostrils. Normal architecture of Epiglottis, ariepiglottic folds, arytenoids, false cords and Vocal cords was lost, which were replaced by the thick proliferative granulomatous lesion. We proceeded with biopsy from the skin and epiglottic lesions. Histopathological examination revealed typical granulomatous tubercle with epitheloid cells, langhanвЂ™s giant cells and a mononuclear infiltrate with minimal caseation suggestive of tuberculosis. Diagnosis of lupus vulgaris with laryngeal and pulmonary involvement was made. The patient responded very well and the lesions in the lip, larynx and lung regressed with ATT. DISCUSSION: A high index of suspicion and a thorough clinical examination of the pharynx and larynx is mandatory for not missing this diagnosis of laryngeal lupus. Therefore, efforts should be made to locate an active or inactive lesion elsewhere in the body. P256 MDR TB-Cold Abscess in Chest WallвЂ”Secondary To Mediastinal And Pulmonary Tuberculosis In a HIV Patient RAHAMAN TANZIL*, HARI PRASAD**, BHARGAV PRASAD **, VAMSI KRISHNA** SUBBA RAO*** DEPARTMENT OF PULMONARY MEDICINE, KONASEEMA INSTITUTE OF MEDICAL SCIENCES, CHAITANYA NAGAR ,AMALAPURAM,EAST GODAVARI, ANDHRA PRADESH-533201. INTRODUCTION: Tuberculosis is a major public health problem in India. Further itвЂ™s complicated by the spread of HIV and increased drug resistance. There are very few reports of MDR-TB at extra-pulmonary sites from India. We report here about a rare occurrence of MDR-TB involving chest wall abscess. CASE REPORT: A 35 year old, HIV positive male patient, initially presented with symptoms suggestive of PTB . Sputum for AFB was positive. We started him on ATT with CAT-1. After completion of ATT there was no relief in symptoms and developed left suprascapular lymphadenopathy, firm with matting. Chest x ray showed mediastinal widening in addition to persistent pulmonary infiltrates. CECT chest showed multiple enlarged mediastinal lymphnodes with peripheral rim enhancement suggestive of tuberculous lymphnodes. FNAC of cervical lymphnodes showed granuloma due to tubercular etiology. CAT 2 ATT was started. While patient was in 5th month of CAT II ATT, he presented with complaints of large swelling over sternum. On examination, swelling of 8 X 8 cm in size, skin is shiny and fluctuation test was positive. Aspirated pus was sent for ZN staining and DST. Z N staining positive 2+ for AFB. As patient had already received CAT I and was on CAT II treatment, MDR TB was suspected. On L J medium, culture growth was seen after 3 weeks. DST done from the growth showed Mycobacterium tuberculosis which is resistant to INH and rifampicin. MDR вЂ“TB was confirmed&CAT IV regimen started. Patient responded very well to the treatment with complete reduction in size of chest wall DISCUSSION: MDR-TB is an emerging and alarming health problem. The actual treatment regimens for MDR-TB are complex, expensive, long term, associated with high rates of side effects and poor outcome, and high morbidity and mortality.pulmonary TB is the common mode of presentation of MDR-TB. P257 ATYPICAL PRESENTATION OF GENITO URINARY TUBERCULOSIS KRISHNA KARTHIK *, HARI PRASAD**, BHARGAV PRASAD **, VAMSI KRISHNA** SUBBA RAO*** DEPARTMENT OF PULMONARY MEDICINE, KONASEEMA INSTITUTE OF MEDICAL SCIENCES, CHAITANYA NAGAR ,AMALAPURAM,EAST GODAVARI, ANDHRA PRADESH-533201. INTRODUCTION: Lymph nodes, pleura, and osteoarticular areas are common sites of extra pulmonary tubercular nd involvement but any organ can be involved. Genitourinary TB is the 2 most common cause of extra pulmonary TB with kidney being the most common site. CASE REPORT: A 26 year old married woman presented with a 6 months history of recurrent episodes of increased frequency of micturation and dysuria. She has anorexia, weight loss, fatigue ,evening rise of temperature and irregular periods since 1 yr.On examination chest was clear, per abdomen a suprapubic mass of 7 Г— 8cm was found, which diminished in size on micturition.Urine AFB was negative.CT abdomen showed B/L enlarged kidneys with hydroureteronephrosis, bladder wall thickening with patulous vesicoureteric junctions. Multiple calcifications in peritoneal cavity, hydrosalpinx and retroperitoneal lymphadenopathy. Bladder biopsy revealed caseous necrosis sugessestive of tuberculosis cystitis. DISCUSSION: Genitourinary TB complicates 3-4% of pulmonary TB cases & constitutes 30 % of extra pulmonary disease. Involvement of the bladder is usually secondary to renal infection and is found in nearly one-third of the patients Chronic inflammation causes reduced compliance and capacity manifesting as frequency of micturition .The common presentation is irritative voiding symptoms, renal mass, hematuria,sterile pyuria,etc. In our case the women had a suprapubic swelling which is a rare presentation of genitourinary tuberculosis. P258 P259 Initial sputum smear grading as a factor to predict treatment outcome in new sputum smear positive pulmonary tuberculosis Don Gregory MASCARENHAS, Vishal CHOPRA, Prabhleen KAUR, AP KANSAL Department of Chest & TB, GMC, Patiala, Punjab Introduction: Sputum positivity is used as a basis for initiating antitubercular treatment(ATT) under RNTCP. Though sputum smear grading is done, its not used to modify ATT regimen Objective: To assess the association between the initial sputum smear grading and treatment outcomes in new sputum smear positive pulmonary tuberculosis patients. Method & Materials : 500 patients who were started on RNTCP Category 1 ATT on sputum positive basis in our department were analysed for sputum conversion and cure in relation to their initial sputum grading. In our study, we considered scanty and 1+ as low grade sputum smear specimen and 2+ as well as 3+ as high grade sputum smear specimen. Observations: Majority of the patients belonged to the age group of 21-40 years. The mean age was 36.6 years, 68.6% being males and 31.4% being females. The initial sputum smear grading was scanty in 29(5.8%) cases, 1+ in 158 (31.6%) cases, 2+ in 143( 28.6%) cases and 3+ in 170(34%) cases. Sputum conversion rate at 2 months was inversely related to initial sputum grading(p=0.0005) and age. At the end of treatment, a cure rate of 85.8% was accomplished. cure rate was high in patients with initial low sputum grading(p=0.045),age 60 years or less (p=0.0255) and in patients who had sputum conversion at 2 months(p<0.001). There was a high default rate in high initial sputum grading group(7.66%) and in patients who had persistent sputum positivity at 2 months of ATT(12.72%).Death rate was high in initial high grade group(p=0.08) and patients >60years (p=0.0004).Failure rate was high in initial high grade group and in those with low SCR at 2 months of ATT (p=0.0004) Conclusion: Initial sputum grading, sputum conversion rate and advancing age appear to be strong predictors of treatment outcome in new sputum positive patients put on category 1 ATT. In patients with initial high bacterial load(2+ and 3+), advanced age (>60 years ), a modification of current RNTCP regimen (which as of now, has a unified chemotherapy regimen irrespective of initial bacteriological load ) and greater vigilance is called for. P260 The Sternoclavicular Joint Involvement: A Rare Presentation Of Tuberculosis Vishal CHOPRA, Don Gregory MASCARENHAS, Prabhleen KAUR, Parul MRIGPURI Department of Chest & Tuberculosis(TB), Govt Medical College, Patiala , Punjab Introduction: The involvement of the sternoclavicular joint in TB is rare and have been reported in 1-2% of all cases of peripheral TB. Case report: A 43 year-old woman presented with the left sternoclavicular joint swelling which was gradually increasing in size since 4 months. The swelling was associated with pain that radiated to the left side of neck and aggravated with bending and turning. She gave a history of low grade fever especially in the evening. There was no history of cough, expectoration, weight loss or dyspnea. Local examination of the sternoclavicular joint revealed a rounded swelling about 7cm in diameter. The overlying skin was shiny and red. The swelling was immobile, non tender and fixed to underlying tissue. The local temperature was normal. Patient gave past history of uveitis, since 6 years for which patient was on oral and local steroids off and on. There was no evidence of any cervical or axillary lymphadenopathy. There was no history suggestive of involvement of any other organ system. The haematological investigations were within normal limits. Mantoux test was strongly positive (18*18mm). CT scan revealed cortical erosions at medial end of left clavicle and along left lateral margin of sternum with associated soft tissue component. FNAC of the swelling revealed a chronic granulomatous pathology and also showed the presence of AFB which is very rare. Patient was put on antitubercular treatment and responded well. Discussion: Extrapulmonary tuberculosis presenting with involvement of the skeletal system accounts for approximately 1 to 4% of cases. Tuberculosis of sternoclavicular joint has been reported in 1-2% of all cases of peripheral tuberculosis and 1- 9% of septic arthritis. Differential diagnosis for swelling at the sternoclavicular joint can be due to sternoclavicular hyperostosis, condensing osteitis, septic arthritis, tumor, rheumatoid arthritis, ankylosing spondylitis, osteoarthrosis or Tietze syndrome The diagnosis of tuberculosis should be considered in every patient with involvement of sternoclavicular joint. The features of any monoarticular arthritis, cold abscess, positive tuberculin skin test, epidemiological risk factors or chest Xray abnormalities consistent with healed or active pulmonary tuberculosis. Conclusion: A high index of suspicion of TB is to be maintained in swellings at unusual sites even if they lack systemic features of tuberculosis as in this case. P261 Non resolving pneumonia: A clinicopathologic dilemma DR P.SHARMA, DR S. MOTIWALE Department of Respiratory Medicine, Shri Aurobindo Institute of Medical Sciences, Indore, India. Background: Pneumonia showing a slow resolution of radiologic infiltrates and/or clinical symptoms inspite of giving adequate antibiotic therapy ,has been defined as non-resolving pneumonia .The term вЂњunresolved organizing or protracted pneumoniaвЂќ was first coined by Amberson in 1943. Approximately 10% - 15% of nosocomial pneumonias ultimately converts into non resolving or slowly resolving pneumonia and delayed treatment may lead to rise in its mortality by 3-5%. The common causes of non-resolving pneumonia are incorrect diagnosis, inadequate and irrational antibiotic therapy, impaired host defence, atypical organisms, resistant pathogens, non-infectious causes, and tuberculosis and endobronchial lesions. Case report: We report a case of 53 yr old female admitted in SAIMS with the presenting complaints of fever with chills and rigors since four months and cough with minimal expectoration since fifteen days. She reported shortness of breath, pain in chest and generalized bodyache since ten days. Patient was febrile( temperature was 0 102 F) with remarkable pallor. Fibreoptic bronchoscopy showed right lower lobe inflammed mucosa with retained purulent secretions. Bronchoalveolar lavage/ culture sensitivity showed growth of Pseudomonas aeruginosa which was sensitive to- Amikacin , Imipenem , Tobramycin and Colistin. During hospital stay course, patient was treated initially with antibiotics like Piperacillin - Tazobactum combination along with Levofloxacin for 7 days then started on injection Gentamicin and Imipenem for 10 days.Significant clinical improvement was noticed by 7 days and then the patient was discharged on tablet Faropenem for 2 weeks, and on follow-up, she became alright. Conclusions: Non-resolving pneumonia has always been referred as an area of clinical dilemma by pulmonologists. Its early diagnosis by fibreoptic bronchoscopy and rational treatment is mandatory for its treatment. Study of Tuberculosis with Diabetes Mellitus P262 DR. POOJA SHARMA, DR. RAVI DOSI Department of Pulmonary Medicine, SAIMS, Indore, India OBJECTIVES: To analyze presentation of Pulmonary Tuberculosis with Diabetes mellitus in terms of clinical and radiological pattern. METHODS: The study includes 100 cases, among these, 50 are diabetic patients with sputum positive tuberculosis and 50 are non-diabetic patients with sputum positive tuberculosis visiting SAIMS Hospital ,Indore during the study period (July 2012 to June 2014). RESULTS: There was male preponderance, 76% males in diabetic group and 80% in non diabetic group with majority of the patients in the age groups more than 40 years in diabetic and less than 40 years in non-diabetic group. Weakness and cough were predominant symptoms with 94% and 90% in diabetic group, and 70% and 90% in non- diabetic group respectively. Mean FBS was 201.55 В± 67.34 mg/dl and mean PPBS was 268.94 В± 93.93 mg/dl. Cavitary lesion was more common in diabetic group. There was a linear relation between the duration of diabetes mellitus and the development of tuberculosis. Poorly controlled hyperglycemia is associated with development of tuberculosis. Lower lung field tuberculosis was more common in diabetics. CONCLUSIONS: All the diabetics with abnormal weight loss, unexplained cough or sudden increase of insulin requirement should have sputum examination and chest x-ray done thus helping in early diagnosis and treatment. P263 Comparison of rate of sputum conversion in smokers and non-smokers on DOTS Category I under RNTCP Kandala Venu, Srikar Darisetty, Raghudeep Palla, Mateenuddin Saleem, Laxman Babu Department of Pulmonary Medicine, Kamineni Institute of Medical Sciences, Narketpally, Telangana, India. AIM AND OBJECTIVES: 1. To assess and compare the rates of sputum conversion in smokers and non smokers on DOTS category I (RNTCP) after 2 months of therapy. MATERIALS AND METHODS: A prospective study was conducted in our institute between the periods of August 2012 to January 2014 among patients who were newly diagnosed as sputum smear positive for AFB using LED microscopy (Auramine staining) after fulfilling the inclusion and exclusion criteria. A total of 100 subjects were studied. (55 smokers, 45 non smokers). Amongst these, 5 subjects were lost to follow up, 5 subjects died during the study period. The remaining 90 subjects (48 smokers, 42 non smokers) were followed up. The data was tabulated and analyzed after 2 months of therapy. RESULTS: SMOKERS (N = 48) NON SMOKERS (N = 42) SPUTUM SMEAR POSITIVITY INITIATION OF THERAPY AFTER 2 MONTHS OF THERAPY 48 (100%) 22/48 (45.8%) 42(100%) 3/42 (7.14%) The Chi Square test was used to analyze the data. Chi square value = 8.47, P value < 0.05 CONCLUSION: The response of subjects to ATT was better in non smokers when compared to smokers. Hence, it is advisable for patients with pulmonary tuberculosis to quit smoking to enhance the efficacy of therapy and hence, to control the spread of tuberculosis in the community. P264 Outcome of chemotherapy in lung cancer : Effect on quality of life & reasons of default among patients AUTHOR(S) - DR TARUSHI SHARMA, DR BABAJI GHEWADE INSTITUTION- Jawaharlal Nehru medical college, Sawangi(meghe),Maharashtra,India ABSTRACT OBJECTIVES-The objective is to study the outcome of chemotherapy in lung cancer patients in form of Survival & Quality of life and investigate the factors that contribute to low rate of acceptance and adherence to chemotherapy. METHODS- A prospective study of lung cancer patients admitted in AVBRH,SAWANGI who had taken atleast one cycle of chemotherapy was performed from Sept 2013 to Sept 2014. FACT-L questionnaire was used to measure Qol(Quality of life) in patients who completed the course of chemotherapy. RESULTS- A total of 20 patients were included in the study. The ages ranged from 20 to 70 years.Only 3(15%) patients completed the course of chemotherapy.An increase in Qol score was seen in these patient. 17 patients(85%) dropped out of chemotherapy during the treatment. 9(53%) of these defaulted due to inadequate funds to procure chemotherapy.5 (30%)patients switched to alternate form of medication and the rest 3 (17%)discontinued due to non tolerance of the side effects of treatment. CONCLUSION- Lack of funds to procure chemotherapy was the major factor responsible for default among patients. In patients completing the chemotherapy, significant improvements were seen in Qol. In past few years , little progress has been made in treatment of lung cancer patients in form of increased survival. As a result, the effect of chemotherapy on Qol becomes important while discussing the benefits of treatment with patients. P265 Disseminated tuberculosis in an immunocompetent host: A rare entity AUTHOR(S)- DR TARUSHI SHARMA, DR BABAJI GHEWADE INSTITUTION- Jawaharlal Nehru medical college, Sawangi(meghe),Maharashtra,India ABSTRACT OBJECTIVES- Disseminated tuberculosis with liver and spleen involvement in an immunocompetent host is a rare entity today, not frequently diagnosed and reported. We report a case of 22 year old female which was diagnosed as a case of Disseminated tuberculosis and started on antitubercular therapy & responding well. METHODS-Patient was referred to our hospital as a suspected case of malignancy from PHI. A detailed history of patient was taken and physical examination done. Routine blood investigations such as CBC and serum biochemistry were ordered .Radiological investigations included chest Xray, HRCT Thorax and USG abdomen. Sputum smear for AFB and USG guided FNAC was done along with bone marrow examination before arriving on final diagnosis. RESULTS-A final diagnosis of disseminated tuberculosis was made based on investigations & clinical findings. The patient was started on category-I antitubercular drugs.Gradually patient improved symptomatically and repeat radiograph after 1 month showed good radiological improvement. CONCLUSION- Disseminated tuberculosis is a potentially lethal form of tuberculosis arising from hematogenous dissemination of Mycobacterium tuberculosis bacilli. Disseminated tuberculosis is rare, particularly in immunocompetent people. Diagnosis is often difficult due to variable clinical presentations,poorly sensitive smears and diverse radiologic findings. Although positive chest radiographic findings or a positive tuberculin skin test may support the diagnosis, negative results however do not exclude extrapulmonary tuberculosis. A high index of clinical suspicion is needed and antimycobacterial therapy should be administered urgently to prevent an otherwise fatal outcome. 1-2 % of all cases of tuberculosis in immunocompetent patients FIGURE- On Admission, Chest X-Ray PA view showing diffuse nodular opacities of variable sizes P266 Outcome of Cat IV ATT from DOTS-plus site: Govt Fever Hospital, Guntur, Andhra Pradesh, India. Dr. K. Rajendra Kumar, Dr. S. Raghu, Dr. M. Venkata Rao, Dr. N. Bhaskara Rao, Dr. S. Lakshmi Kumari, Dr. CH. Hanumantha Rao. Dept. of Pulmonary Medicine, Guntur Medical College/Govt Fever Hospital, Guntur, Andhrapradesh, India. Abstract: Introduction: India is one of the high burden countries for tuberculosis as well as drug-resistant tuberculosis. Standardized treatment regimen (STR) for management of multi-drug resistant tuberculosis (MDRTB) has been approved by RNTCP national DOTS-plus committee. Objective: Study was done at Government fever hospital / Guntur medical college, Guntur, to know the effectiveness, adherence and the outcome of DOTS-plus. Methodology: A total of 106 patients who were confirmed to have MDRTB and came for pre-treatment evaluation were enrolled in to this prospective study conducted from October 2009 to March 2012. Patients were treated rd with DOTS-plus and were followed up mainly on out-patient basis. Results: At the end of 3 month 61 (57.5%) th patients were culture converted and at the end of 6 month 68 (64%) patients were culture converted. At the end of treatment, 57 were cured, 25 defaulted, 13 failed, 11 died. 5 failure cases were converted to extensively drug resistant (XDR) TB during the treatment. 92 patients were complained of adverse drug reactions (ADR) and change of medication needed in 13 (12%) patients with severe ADR. Conclusion: The treatment outcome results of patients treated with DOTS-plus was not up to the mark. Defaulters are main obstacle to the success of DOTS-plus. Patient as well as family counselling, close attention to the timely recognition and treatment of ADRs will improve the adherence to the treatment and thus the cure rate. P267 Childhood tuberculosis presenting as multiple rib osteomyelitis: A rare case report Dr. K. Rajendra Kumar, Dr. S. Raghu, Dr. CH. Hanumantha Rao. Although tuberculous infection of bone is fairly common i.e., 15% of all tuberculosis, tuberculous osteomyelitis of the rib shaft is rare. Rib involvement occurs in approximately 5% of all bony tuberculosis and in 0.1% of all tuberculosis cases. And tubercular parietal chest wall abscess is also a rare form of extrapulmonary TB. Though bony tuberculosis is common between 2 to 10 years of age, rib involvement is common between 20 to 30 years of age. We report a case of 3 year male child presented with chest pain, fever and posterior chest wall swellings. Chest X ray revealed osteolytic lesions of multiple ribs and homogenous opacity in right mid and lower zones. Computed tomographic findings suggestive of multiple rib osteomyelitis with extension into the both chest wall and right hemithorax. FNAC of chest wall lesion suggestive of cold abscess formation. The pathogenesis, differential diagnoses and management for rib osteomyelitis were reviewed and briefly discussed. Key words: childhood tuberculosis, rib osteomyelitis, chest wall abscess P269 Tuberculous Dactylitis (Spina Ventosa) In A 17 Year Old Girl - A Rare Entity SR YADAV, M SALUJA, S TANEJA, K CHOUDHARY, K LOCHAB Subharti Medical College, Meerut , India Vertebral tuberculosis is the most common form of skeletal tuberculosis and it constitutes 50% of all cases of skeletal tuberculosis. The less common sites of skeletal tuberculosis are mandible, tempromandibular joint, scull and metacarpals and phalanges. Tuberculous infection of metacarpals, metatarsal and phalanges of hands and feet is known as tubercular dactylitis. Tuberculosis of the short tubular bones quite uncommon after the age of 5 years. Here we present a case of 17yrs. girl who presented with swelling of left middle finger since one month which was tender, non-mobile with slight increase in local temperature. Patient was previously treated by private doctors and antibiotics were given to her which gave no relief to her. Her detailed history was took which was insignificant except of family history of extra pulmonary TB in her sister. She was admitted and entire work up was done including general blood tests, urine, montoux test, sputum examination, USG abdomen, and X-ray of chest and left hand. All the test reports were with in normal limits, montoux test was strongly positive and X-ray of left hand was suggestive of spondylarthropathy- juvenile RA. Patient RA factor was tested and was found to be negative. Patient was subjected to FNAC from her swelling which was suggestive of tuberculosis and Z-N staining of smear revealed acid fast bacilli (grade1+), hence a diagnosis of Tuberculous Dactylitis was made. Patient was put on ATT according to her weight; dramatic improvement was seen as all her symptoms subsided. Size of swelling also decreased to normalcy. P270 Pulmonary Tuberculosis presenting as Pneumomediastinum with Subcutaneous emphysema: A Rare Presentation K.BHARATH , P. SWETHA, K.SAILAJA, H.NAGASREEDHAR RAO, U. KIRAN KUMAR Department Of Pulmonary Medicine, Kurnool medical college Back ground: Pneumomediastinum may develop due to (i) mediastinal sepsis from gas forming organism or traumatic disruption of large gas containing organs or damage to alveoli and to bronchioles, allowing gas to leak towards the mediastinum. Chest pain, tachypnea, cyanosis and respiratory failure are seen. Pulmonary tuberculosis presenting as Pneumomediastinum with subcutaneous emphysema without Pneumothorax is rare. Patient and methods: A 65 year old male patient presented with Acute onset of dyspnea with cough and swelling of chest wall, neck and face. Patient also complained of chest pain and change in voice two days duration. History of intermittent fever, shortness of breath, cough, Loss of weight and appetite for 2 months duration. Examination of respiratory system reveals palpable crepitus all over the front and back of neck, chest wall and both upper limbs upto to the tip of fingers. Emergency chest X ray showed features suggestive of air in subcutaneous planes. HRCT revealed Fibrobronchiectactic changes in left upper lobe, pleural thickening, Pneumomediastinum and no evidence of Pneumothorax. Sputum for AFB was positive. Patient was started on ATT and high flow Oxygen. Complete resolution of the subcutaneous emphysema was noted at the end of one week. There was no recurrence of pneumomediastinum thereafter. Conclusions: It is said that in both tuberculosis and bronchiectasis, local airway obstruction with distal air trapping can cause alveolar rupture and subsequent Pneumomediastinum. Conservative treatment is indicated in majority. The present report describes a self limiting case of Pneumomediastinum with subcutaneous emphysema a rare complication of pulmonary tuberculosis. P271 ATYPICAL PRESENTATION OF DISSEMINATED TUBERCULOSIS IN AN IMMUNOCOMPETENT PATIENT DR.PRASANTHY REDDY CH,dr.A Sathya prasad,dr.M ganesh,dr nalini G,dr vijay kumar K,dr subba rao V Mamata medical college and general hospital Introduction: Disseminated tuberculosis refers to involvement of 2 or more non contiguous sites. it is rare in immunocompetent host Case report: A 30 year old female presented to out patient department with bleeding per vagina and lower abdominal pain since 3 months with no past history of tuberculosis. on further evaluation chest x ray pa view showed ill defined opacities in right lower zone. Sputum for AFB was negative. Fibre optic bronchoscopy was done and bronchial washings and brushings for AFB were positive. Dilatation and curettage was done and menstrual blood for AFB stain was positive. Ultrasound abdomen revealed bilateral hydronephrosis. urine for AFB negative. Patient was started on anti tubercular therapy. Patient improved symptomatically after intensive phase of therapy. Conclusion: This is an atypical presentation of disseminated tuberculosis in an immunocompetent host where diagnosis was achieved and confirmed P272 Association of tuberculosis with deep venous thrombosis DR.TARUN SHARMA, DR.K.N.MOHAN RAO rajarajeswari medical college and hospital, bangalore, india Introduction: Tuberculosis (TB) is one of the most devastating curable infectious diseases and persists as a major cause of morbidity and mortality in India. India accounts for almost one-third of the global burden of TB. Respiratory infections have been documented to increase the risk of venous thromboembolism. There is also evidence that there is a hypercoagulability state in TB, which may be attributed to the increase in plasma fibrinogen and factor VIII, and reactive thrombocytosis. There can also be stasis due to local compression of veins by lymph nodes or immobility due to respiratory compromise. There is also evidence regarding endothelial dysfunction in tuberculosis, which may be a result of bodily reactions to Koch's Bacillus, or the use of Rifampin. Being able to affect all the three components of the Virchow's triad, TB could be a significant risk factor for venous thromboembolism. Objective: To highlight occurrence of DVT in severe pulmonary and extrapulmonary TB. Method: We report 5 cases of pulmonary and extrapulmonary TB associated with venous thromboembolism who presented to our department. A 45 year-old male who had DVT, a 60 year-old male that developed deep venous thrombosis later in the course of the disease, a 20 year old male who presented with effusion and later developed DVT and massive pulmonary embolism, a 25 year old woman with disseminated TB and DVT with pulmonary embolism, and a 32 year old male with pulmonary TB and DVT. Conclusion: There is a strong association between inflammation induced by TB and a hypercoagulable state. Therefore, the occurrence of DVT or pulmonary embolic episodes should be considered in patients with TB particularly those with poor response to treatment. The treating doctorвЂ™s awareness of this phenomenon while treating severe forms of TB is important for early diagnosis and starting anticoagulation to prevent fatal outcomes. P273 An Interesting Case of Tuberculosis of the Left Breast Dr Ajit H, Dr Karl DM, Dr Sivaraj AL, Dr Alamelu H, Dr Rajashekar MB, Dept of Pulmonary Medicine and Dr Sabaretnam M, Dept of Endocrine & Breast surgery Vydehi institute of medical sciences and research centre Bangalore Karnataka Tuberculous breast abscess continues to be an uncommon presentation in developing countries where tuberculosis is an endemic disease. It still poses a clinical challenge with its presentation being similar to breast carcinoma and pyogenic breast abscess. Its incidence in developing countries is: less than 4% of mammary diseases. This is a case report of a 28 year old housewife who presented to our hospital with complaints of: left breast lump for the last 8 months that gradually progressed from 1.5 cm x 1.5 cm to 8 cm x 6 cm on presentation associated with intermittent pain to touch and lifting heavy weights. It was not associated with menstrual cycles, which were regular. She gave no history of respiratory symptoms, constitutional symptoms, comorbidities or past surgeries. Her general physical and systemic examination was unremarkable. Breast examination revealed diffuse firm swelling palpable in the upper-inner quadrant of the left breast extending into the upper part of the lower left quadrant which was 8 cm x 6 cm, immobile and adherent to the chest wall with an area of cystic consistency. There were no signs of breast tenderness and nipple discharge. There were no palpable axillary and supraclavicular lymph nodes. Routine investigations and CXR-PA were unremarkable. Purulent fluid aspirated showed: occasional acid-fast bacilli (AFB) on Zeihl-Neelson stain. Multiplex DNA TB-PCR was positive for Mycobacterium tuberculosis. However, AFB culture report is awaited. She was started on RNCTP Category-I ATT for Tuberculous breast abscess. P274 Quantitative assessment of MDR positives among MDR suspects during the period of six months K.V.V. Vijaya kumar, S. Vinay kumar, G.Sambasiva rao, A.Prem kumar Government Hospital for Chest & Communicable diseases (GHCCD), Andhra Medical College, Visakhapatnam,AP,India. Background: Multi Drug Resistant tuberculosis (MDR-TB) is an increasing global problem with most cases arising from a mixture of physician error and patient noncompliance during treatment of susceptible tuberculosis. There should be strong suspicion of drug resistance in persons with a history of prior treatment or treatment failure cases. We have tried to ascertain the number of MDR-TB cases in MDR suspect patients Objectives: To identify the number of MDR positives among MDR suspects who are subjected to culture and drug susceptibility testing ( C-DST) laboratory at GHCCD, a teaching hospital of Andhra Medical College, from 3 north Andhra Pradesh Districts(Srikakulam, Vizianagarm and Visakhapatnam)from January 2014 to June 2014 as per PMDT suspect criteria 2012. Methods: Two sputum samples ( early morning and spot ) are taken from the cases with the above criteria and sent to C/DST laboratory at GHCCD , Visakhapatnam. Line probe assay (LPA) is used for the rapid DST. Results: The results of first 3 months are as follows- Out of total 932 MDR suspects, 58 were MDR positive. Among 932 suspects ,3 were failures(none of them were found to be MDR), 1 was a contact of MDR-TB(found to be MDR), 396 suspects were smear positive at time of diagnosis, retreatment(40 were found to be MDR), 129 suspects were any smear positive follow up results(9 were found to be MDR), 159 suspects were smear negative at diagnosis of retreatment case(3 were found to be MDR), 244 suspects were HIV-TB coinfected group(5 were found to be MDR).The entire data will be projected during platform presentation. P275 Correlation of CD4 count with respect to opportunistic infections (OIs) K.V.V. Vijaya kumar, L.Haritha kumari, G. Sambasiva Rao, A.Prem Kumar Government Hospital for Chest & Communicable diseases, Andhra Medical College, Visakhapatnam, AP, India. Background: human immunodeficiency virus pandemic is among the greatest health crisis ever faced by humanity. Morbidity and mortality in HIV disease is due to immunosuppression leading to life threatening opportunistic infections during the natural course of the disease. The most common OI among them being the pulmonary or extra pulmonary tuberculosis. This study was aimed to asses prevalence and CD4 correlates of OIs among adult HIV infected patients attending Government Hospital for Chest & Communicable diseases, a teaching hospital of Andhra medical college, Visakhapatnam. Objective: To correlate CD4 count with respect to OIs in HIV infected patients. Methodology: Cross sectional study was conducted on 200 adult HIV infected patients attending GHCCD, ART centre from September 2013 to july 2014. Patients OIs status determined through clinical diagnosis, laboratory investigations and clinical data obtained from medical records. CD4 count was assessed by using flow cytometry. Results: Preliminary results of the study of 200 HIV infected patients included 64.5% males, 35.5% females. Out of 200 seropositives 82.5% were between 15-45 years and 17.5% were greater than 45. Tuberculosis carrying the major burden of OIs i.e 89% of which 42.5% pulmonary tuberculosis, 44.5% extra pulmonary tuberculosis and 2% disseminated tuberculosis. The entire study data would be projected at the time of presentation. P276 Massive hemoptysis in a pulmonary KochвЂ™s patient: A case report of RasmussenвЂ™s aneurysm AP KANSAL, Don Gregory MASCARENHAS, Kamal Deep, Prabhleen KAUR, Hardik JAIN Dept. of Chest and TB, GMC, Patiala. Introduction: Massive hemoptysis is a serious complication of Pulmonary KochвЂ™s. We present a case report of a patient of massive hemoptysis which was later proven to be a case of RasmussenвЂ™s aneurysm. Case report: A 52 year old male patient, manual labourer by occupation, presented to us with persistent cough and progressive breathlessness since 7 months, fever since 1 month and massive hemoptysis since 2 days. He had completed RNTCP Cat I anti-tubercular treatment one month ago. He was a chronic smoker and type 2 diabetes mellitus patient on irregular treatment. On chest examination, rhonchi were present over all lung fields along with crepitations in right infraclavicular and mammary areas. Chest X ray showed bilateral diseased lung with heterogenous opacity in right upper zone. Hb was 9.5 gm%, TLC 10,600/mm3, platelet count 2.2 lakh/mm3, RFT, LFT and BT/CT/PT-INR were normal. Patient came sputum positive for AFB and LPA showed resistance to Rifampicin and Isoniazid. He was treated with DOTS PLUS regimen and symptomatically for hemoptysis. But hemoptysis was persistent. CECT chest showed bilateral emphysematous changes and consolidation with cavity formation in right upper lobe. Multidetector computerised tomography angiography revealed a pseudoaneurysm in one of the segmental branches of pulmonary artery in right upper lobe cavity, suggestive of RasmussenвЂ™s aneurysm. Patient was referred for embolisation. P277 HEPATOTOXICITY AS AN ADVERSE EFFECT WITH FIRST LINE ANTI-TUBERCULAR AGENTS: A PROSPECTIVE STUDY AP KANSAL, Shiyas MOHAMMED, Kiran N, Kamal Deep, Hardik JAIN, Komal BHATTI, Department Of Chest & TB,GMC, Patiala , Punjab Introduction: The incidence of Anti-tuberculosis drug induced liver injury( ATLI) during standard multi-drug TB treatment has been reported varying from 2.0% to 28.0% according to different populations and definitions. Material and methods: Present study was conducted on 200 patients (100 in cat I and cat II) presenting to Department of TB and Chest Diseases and Department of biochemistry, Government Medical College, Patiala. Liver function tests were performed before initiating the treatment and thereafter every month till the regimen continued (6 months in Cat-I and 8 months Cat-II). Results: In the present study, out of total 114 patients with ADRs, 33 developed raised liver enzymes (Serum Bilirubin, SGOT, SGPT) due to ATT and it was second most common ADR after gastrointestinal side effects. It was observed that it was found more in females (n=18) as compared to males (n=15), in patients on cat I (n=18) as compared to patients on cat II (n=15). Most common age group affected was in range of 40-60 years. Weight band which was affected the most was of less than 40 kg. Patients with moderately advanced lesion on CXR were most commonly affected. Discussion: Out of total 10 patients who required their regimen to be changed due to various adverse effects, hepatotoxicity accounted for 5. Predicting who will be at an increased risk for ADRs to first-line TB therapy can assist in identifying the patients who require closer monitoring to prevent potential morbidity, hospitalization and mortality .Therefore, close monitoring of patients is crucial to ensure that the adverse effects of drugs are recognized as soon as possible by health care personnel P279 TUBERCULOSIS AND LEPROSY CO-INFECTION: A RARE CASE IN THE MODERN ERA. Dr. Priti Meshram, Dr. Rohit Hegde, Dr. N N Ramraje (Professor & Head) Department of Pulmonary Medicine. Grant Govt. Medical College & sir J J Group of Hospitals, Mumbai. Introduction: The concommitant occurrence of both tuberculosis and leprosy in a singal individual,the oldest reported mycobacterial diseases, is not rare. Tuberculosis and Leprosy have been diagnosed together since antiquity. However, since the Industrial revolution of the 16 th century, there has been a steady decline in Leprosy though Tuberculosis has now reached epidemic proportions. The decline has been partly explained due to some studies showing that Tuberculosis provides protective immunity against Leprosy. Hence, there is very infrequent reporting of the occurrence of these infections together in modern medicine. Case Report: We report one such case a 18 yr old male diagnosed as borderline lepromatous leprosy with type 2 reaction, who later developed pulmonary tuberculosis. The patient had received steroids for his Lepra reaction for 9 mths prior to becoming symptomatic with respiratory complaints. On investigating, patient had bilateral infilates with Rt sided hydropneumothroax which was respiratory complaints. On investigating, patient had bilateral infiltates with Rt sided hydropneumothorax which was treated with Intercostal drain insertion. His sputum was also screened for MDR TB. He was sensitive to both INH and Rifampicin. The patient was treated with both AKT and MBMDT and steroids for his Type 2 Lepra reaction. Conclusions: The use of steroids in leprosy (for treating Lepra reactions and neuropathy) warrants screening of individual for tuberculosis including Multi drug resistant TB. Multi-drug therapy for leprosy may lead to acquired drug resistance for Rifampicin, which is mainstream of anti-tubercular therapy. Hence awareness is necessary for screening and diagnosing tuberculosis, especially MDR TB in patients who infected Leprosy and are on steroids. P280 Persistent upper lobe pneumonia- a case report A YADAV, D BHATTACHARYYA, CDS KATOCH, T AJAI KUMAR, SAFIA AHMED Dept of Respiratory Medicine, Military Hospital CTC, AFMC, Pune Non resolving pneumonia is a challenging, interesting and intriguing puzzle for the clinician to unravel. We treated one such unusual case in our hospital recently. The patient was a 31 year old soldier who presented with complaints of cough with mucoid expectoration, breathlessness (mMRC grade II), intermittent fever, new onset wheeze and 10 kg weight loss of one year duration. The complaints were associated with episodic exacerbations on exposoure to dust and cold. He gave history of treatment for tuberculosis a year back. Examination revealed bilateral polyphonic expiratory wheeze. At this point a differential diagnosis of collagen vascular diseases, cryptogenic organising pneumonia, sarcoidosis, hypersensitivity pneumonitis and chronic eosinophilic pneumonia was entertained. Investigations revealed an eosinophilia of 58% and AEC of 4,350/cumm. Chest x-ray showed bilateral upper zone peripheral non homogenous opacities with air bronchograms. HRCT chest showed multifocal peripheral airspace opacities in bilateral upper lobes. Pulmonary function testing revealed obstruction with significant reversibility and mild diffusion defect. Bone marrow biopsy showed increase in eosinophilic precursors with no atypical/blast cells. The diagnosis of chronic eosinophilic pneumonia was confirmed by fibre optic bronchoscopy which showed 10% eosinophils in broncho alveolar lavage and eosinophilic infiltration on transbronchial lung biopsy. The patient was managed with oral corticosteroids (tab prednisolone 1mg/kg), inhaled corticosteroids and long acting ОІ2-agonists, which led to prompt clinical improvement and resolution of upper lobe opacities, which is a hallmark of the disease. Considering his clinico-radiological presentation in conjunction with histopathological examination reports, the final diagnosis of Chronic eosinophilic pneumonia with adult onset asthma was made. At follow up after 3 months, patient was asymptomatic with normal chest x ray on a tapering steroid regime. P281 PREVALENCE OF CARDIAC COMORBIDITIES AND ITS RELATION TO SEVERITY STAGING OF CHRONIC OBSTRUCTIVE PULMONARY DISEASE Dr.VINEETH ALEXANDER, DR.R.PAJANIVEL ,DR.K.SURENDRA MENON, DR.ARUN PRASATH DEPARTMENT OF PULMONARY MEDICINE, MAHATMA GANDHI MEDICAL COLLEGE AND RESEARCH INSTITUTE INTRODUCTION: Complexity of COPD and mortality from the disease is increased by co morbidities and exacerbations OBJECTIVE: This study was conducted with aim to find the prevalence of cardiac co morbidity in COPD and its relation to severity staging of COPD. METHODS: The study was done in the Department of Pulmonary medicine for 1 year. The study subjects were all the patients which were previously diagnosed and newly diagnosed of COPD. The selected patients were subjected to Pulmonary Function Test, assessment of blood pressure, electrocardiography and echocardiography. The statistical analysis was done to assess the cardiovascular status and its relation to severity staging of COPD. RESULTS: On the basis of GOLD guidelines there were 5(11.4%), 13(29.5%), 16(36.4%) and 10(22.7%) mild, moderate, severe, and very severe COPD respectively. Right axis deviation, p-pulmonale, T-wave inversions, dominant R-wave, persistent S-wave in electrocardiography were present in 45.5%,52.6%,40.0%,33.3%,36.4% of severe and 54.5%, 36.8%, 60.0%, 58.3%, 63.6% in very severe cases of COPD. In echocardiography, right atrium and ventricle dilatation, left ventricular dysfunction, tricuspid regurgitation, and regional wall motion abnormalities were present in 55.6%, 46.15%, 50.0%, 37.5% of severe and 38.9%, 53.85%, 33.3%, 62.5% of very severe cases of COPD. All the cases of mild and moderate COPD had mild (30-50mmHg) Pulmonary artery systolic pressure (PASP). In severe COPD, 5(19.2%), 10(76.9%) and 1(20.0%) had mild (30-50mmHg), moderate (50-70mmHg) and severe (>70mmHg) PASP respectively. In very severe COPD, 3(11.5%), 3(23.1%) and 4 (80.0%) had mild (30-50mmHg), moderate (50-70mmHg) and severe (>70mmHg) PASP respectively. In severe COPD 7(29.2%), 5(62.5%), 3(30.0%) and 1(50.0%) had normal, pre hypertension, stage 1 hypertension, stage 2 hypertension respectively. In severe COPD 3(12.5%), 6(60.0%), 1(50.0%) had normal, prehypertension, stage 2 hypertension respectively. CONCLUSION: Prevalence of cardiac co morbidities has a linear relationship with severity of COPD with severe and very severe COPD associated with cardiovascular diseases. Early detection of cardiac complications in COPD cases give time for early interventions P282 OCCURRENCE OF ATOPIC MANIFESTATIONS IN PULMONARY TUBERCULOSIS SEQUELAE T. VIVEK KAKATIYA-MEDICAL-COLLEGE OBJECTIVES-Mycobacterium tuberculosis has been shown to suppress allergic airway disease driven by type 2 helper T cells in animal models.In this study we investigated development of allergic airway disease in pulmonary tuberculosis (PTB) sequelae pts presenting with airway obstruction. MATERIALS AND METHODS-Twenty one pts with a past history of PTB without any past history of airway disorder presenting with SOB and/or wheeze were prospectively studied from july 2013 to july 2014.They were evaluated by spirometry, total serum IgE levels, sputum for eosinophil count and absolute eosinophil count (AEC).Other systemic manifestations of atopy were also taken into account. RESULTS-Out of the 21 pts,12 pts had reversible and 9 had irreversible airway obstruction.Out of the 12 reversible pts,10 had elevated serum IgE(mean IgE-1150.3IU/L),8 had sputum eosinophilia and 8 high AEC(mean AEC431.6).Out of the 9 irreversible pts,4 had elevated IgE(mean-450 IU/L),no pt had sputum eosinophilia and 2 had elevated AEC(mean-314).4 pts among the reversible group presented with other systemic manifestations of allergy like rhinitis(3) and dermatitis(1). CONCLUSION-Our study does not support the hypothesis that PTB supresses atopy (manifestations).On the contrary atopic manifestations occur with an increasing incidence after PTB,but larger prospective experimental studies are needed before excluding possibility of relationship. P283 Bronchoscopic diagnosis of Tuberculosis: A stitch in time saves nine PASHA MD, MANTHA SP, ANEJA A, PRASHANTH D, HALAPPA S, KRISHNASWAMY U M.S.Ramaiah Medical College, Bangalore, India Objective: To report a case of actively caseating type of endobronchial tuberculosis presenting as community acquired pneumonia. (CAP) Case report: A 31 year old immune competent patient with no co-morbidities had presented to another hospital with history of persistent productive cough, high grade fever, wheezing and dull left sided chest pain since one month. She had been treated with multiple courses of broad spectrum antibiotics including cephalosporins and PiperacillinTazobactum. She was referred to us after 1 month of the above treatment in view of persistent high fever and opacities on serial chest radiograms. On evaluation in our hospital, sputum analysis was negative for Acid Fast Bacilli (AFB) and did not grow any organism on culture. Respiratory system examination revealed reduced breath sounds, rhonchi and coarse crepitations all over the left hemi-thorax. A diagnosis of non-resolving pneumonia was made and bronchoscopy was performed. It revealed tenacious cheesy material lining the entire left bronchial tree. Endobronchial biopsy was taken and BAL fluid was sent for Gram stain, culture and AFB smear. BAL and post-bronchoscopy sputum were positive for AFB (+++) and no other organism was grown on culture. Endobronchial biopsy report was also consistent with tubercular pathology. Patient was started on anti-tubercular therapy (ATT).Oral steroids were also given in view of the extensive endobronchial component to prevent fibrostenotic sequelae. Patient came for follow up after 1 month of ATT and had improved clinically and radiologically. It is planned to repeat the bronchoscopy after completion of intensive phase. Conclusion: This case highlights importance of timely performance of bronchoscopy in patients with pneumonia who have persistent unilateral wheeze and exhibit sub-optimal response to treatment for CAP. P284 P285 MDR-PottвЂ™s Spine: The hidden danger P286 DR.SAURABH SINGH, DR.MEDHA BARGAJE, DR.ANITA ANOKAR, DR.RAM DEOSKAR. Department of Pulmonary Medicine, Bharati Vidyapeeth Deemed University Medical College and Hospital, Pune-43, India. Background: Tuberculosis (TB) of the spine (PottвЂ™s disease) is the most common and dangerous form of skeletal TB infection. The exact incidence and prevalence of spinal tuberculosis in most parts of the world are not known. Case report: We report MDR Potts spine in two previously treated TB cases. 1. A 34 years man was diagnosed for lumbar spine tuberculosis based on MRI and biopsy with initial isolation of Mycobacterium TB monoresistant to streptomycin. Despite 1 year of treatment with first line drugs, clinical and radiological progression warranted repeat spinal abscess drainage and was found to have MDR M. tuberculosis nd complex. Patient is being treated with 2 line drugs and followed up. He had sputum positive pulmonary, lymph node and shoulder joint tuberculosis 13 years back and was treated. (2 HRZE, 12HRE). 2. A 20 years woman, with lymph node TB (biopsy proven) and Potts spine (radiology based) received (2HRZE+6HRE+9HR) was on regular treatment with symptomatic and radiological improvement in spinal TB and lymph node regression. She showed clinical and radiological deterioration while on treatment (18 months). Hence, tissue biopsy obtained and MDR M.tuberculosis complex was grown on culture. The patient was put on DOTS category 4 under RNTCP. Both the patients showed symptomatic improvement after 6 months with satisfactory radiological response of properly supervised treatment with adverse effects prominently due to aminoglycosides. Both the patients are following up with our department regularly. Conclusion: In India, with increasing incidence of MDR TB, stress should be given on obtaining tissue sample for mycobacterial culture and sensitivity. This is important in order to diagnose MDR cases early and promptly treat the otherwise disabling spinal tuberculosis with correct regimen. H-Isoniazid, R-Rifampicin, Z-Pyrazinamide, E-Ethambutol, MDR- Multidrug Resistant, RNTCP- Revised National TB Control Programme. P287 Additional yield of cases of tuberculosis from household contact screening of newly diagnosed sputum smear positive tuberculosis patients. M. GUPTA, A.A. SAIBANNAVAR RCSM Government Medical College, Kolhapur, India Objectives: Aim of present study was to assess prevalence of tuberculosis among household contacts of newly diagnosed sputum positive tuberculosis index cases. Secondary objective was evaluation of risk factors in household contacts for acquiring tuberculosis disease; and also evaluation of various characteristics of index cases which influence transmission of disease to household contacts. Methods: 521 household contacts of 133 newly diagnosed sputum smear positive tuberculosis patients which were registered for RNTCP at the DOTS centres of DTC, Kolhapur from July 1, 2013 to February 28, 2013 (8 months) were included in the study. Household contacts with symptoms suggestive to TB subjected to sputum AFB examination and X ray Chest PA view. Presence of risk factors in suspected contacts was also recorded Results: 18 contacts out of 521 (3.45%) had symptoms suggestive of TB. Out of them 8 (44.44%) were female and 10 (55.55%) mere male. Mean age of symptomatic contacts was 43 years. In 5 contacts, sputum AFB came out positive. In one of the contact, sputum AFB was negative, but chest X ray was suggestive of TB. This resulted in 4.51% (6 cases) secondary yield of tuberculosis cases. Conclusions: Although additional yield (4.51%) is very modest, but the effort put in to detect these cases is very minimal. Also, lead time is obtained in these cases by means of early diagnosis. Household contact screening for tuberculosis cases is a very promising tool for case detection. Therefore, it can prove to be an important method to boost case detection rate for tuberculosis. P288 Tuberculosis of the thyroid gland. a rare case report DR. KRISHNACHAITANYA PANYAM**,, Prof. Pradyut Waghray**, Dr.A.N.V.Koteswara rao**,Dr. Venkateswara Reddy T**, Dr.v.veena**, Dr. Chetan**, Dr.Harish**, Dr. Sowmya**, Dr. Aditya**, Dr. Rikin**. Prof. k.p.a.chandrashekhar # Dr.suresh kumar reddy.g ^ п‚· п‚· п‚· * DEPT OF PULMONARY MEDICINE,S.V.S.MEDICAL COLLEGE, MAHABUBNAGAR,A.P # DEPT OF PATHOLOGY, S.V.S.MEDICAL COLLEGE, MAHABUBNAGAR,A.P ^ DEPT OF GENERAL SURGERY, S.V.S.MEDICAL COLLEGE, MAHABUBNAGAR,A.P Abstract. We report the case of a 54-year old female patient with tuberculosis of the thyroid gland. She presented to the pulmonology o.p with h/o swelling at the neck region since 2months,evening rise of temp,cough with mild sputum,loss off appetite&weight since 30 days in jan 2014.All routine investigations were unremarkable. Sputum&BAL are negative for AFB. FNAC of thyroid-Features suggestive of nodular goiter. Specimen- caseating granulomatous lesion. On ATT for 6 months. Doing well. P289 SIDS WITH PULMONARY TUBERCULOSIS WITH BILATERAL PNEUMOTHORACIES Introduction : A case of SIDS on ART and Cat-1 ATT for Pulmonary Tuberculosis presenting with Pneumothorax. During treatment developing contraletaral Pneumothorax. Discussion : Cases of SIDS ,quite commonly present with PCP. Quite a few of such cases develop Pneumothorax,even biletaral ones, which have been known to enhance mortality in such cases. A YOUNG patient with SIDS on ART , presented with features suggestive of PULMONARY TUBERCULOSIS. He was investigated and was found to be SPUTUM POSITIVE.There were no other co-morbidities. CAT 1 was started and the patient was discharged. Within the next 2 months the patient presented again with history of chest pain and dyspnoea since last 5 days. Xray chest PA view suggested a Left Pneumothorax.Vitals were normal and , again , on other comorbidities were noticed. ICD under water seal was done and the patient was continued on CAT 1 and Sulfa-Methoxazole вЂ“Trimithoprim, Ceftriaxone and other supportive treatment. Within a span of 5 days , the patient , developed , Pneumothorax on Right Side. ICD under water seal was done on and the medical treatment continued as required. PatientвЂ™s respiratory parameters kept on deteriorating and he expired within 10 days despite adequate treatment. P290 Title: IL-1ОІ & IL-12p70 cytokine secretion in Tuberculosis patients Author: Nazish Fatima, Mohammad Shameem, Nabeela, Haris M Khan, Asma Roohani Institute: Department of Microbiology, Jawaharlal Nehru Medical College, A.M.U, Aligarh. Introduction: Tuberculosis (TB) remains a significant public health problem with an estimated one-third of the worldвЂ™s population being infected. If TB control is not improved, 1 billion people will be infected by 2020. Cytokines play a major role in protection against Mycobacterium tuberculosis infection and regulate the immune responses at a cellular level. The discovery of biomarkers for TB treatment response is therefore important for both clinical practice and clinical trials of new anti TB drugs. Objectives: To determine the levels of IL-1ОІ & IL-12p70 in the serum of TB patients. Materials and Methods: The study was conducted in the Deptt. Of Microbiology, J.N.M.C., A.M.U, Aligarh. Cytokines levels were measured in 76 serum samples from tuberculosis patients of whom 30 were new TB cases, 24 under-treatment, 22 were MDR TB cases, 44 were pulmonary and 36 were extra-pulmonary TB cases by ELISA kit (Diaclone France) along with 20 healthy BCG vaccinated controls. A complete clinical, radiological & treatment data was collected. Statistical analysis was done by using sigma plot 10.1. Results: The serum levels of IL-1ОІ & IL-12p70 were significantly higher in new & MDR TB cases (P<0.001). During treatment IL-1ОІ & IL-12p70 remained low or unchanged. IL-1ОІ & IL-12p70 showed no significant variations according to the site of involvement in Pulmonary vs. Extra-pulmonary TB cases. Conclusions: The above findings are encouraging as they support the concept of host biomarkers IL-1ОІ & IL-12p70 for the prediction of differential TB treatment responses. This concept, if validated, could lead to the development of clinical interventions and accelerate the conduction of TB clinical trials. P291 DIAGNOSTIC ACCURACY OF COMBINED PLEURAL FLUID ADENOSINE DEAMINASE AND LYMPHOCYTE/ NEUTROPHIL RATIO IN TUBERCULAR PLEURAL EFFUSION Dr. ANIRUDDHA UDUPA K , Dr S Vinod Kumar, Dr Manju R and Dr. H.Nandeesha Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India Increased pleural fluid adenosine deaminase (ADA) activity is classically associated with tuberculous pleural effusion. However, increased activity can also occur in a number of other diseases and this may negatively affect the diagnostic utility of ADA measurements and decrease its specificity for the diagnosis of tuberculosis (TB). The presence of ADA in pleural fluids reflects the cellular immune response in the pleural cavity and in particularly, the activation of T lymphocytes. Different disease entities are typically associated with the presence of particular types of leukocytes. OBJECTIVE: To evaluate efficacy of combined use of ADA activity and lymphocyte/neutrophil ratio for diagnosing tuberculous pleural effusion. METHODS: Biochemistry, cytology, and microbiology studies were performed on 164 consecutive pleural fluids. ADA and differential cell counts were determined on all exudative effusions. RESULTS: Pleural fluid ADA activity at a level of в‰Ґ40 U/L, the sensitivity=95.5%, specificity=93.4%, positive prediction value=94.4%, negative prediction value=94.7% and efficacy= 94.5 %. It was statistically significant (p value<0.001). When the additional requirement of a lymphocyte/neutrophil ratio of в‰Ґ0.75 was included, had sensitivity=95.45, specificity=100%, positive prediction value=100%, negative prediction value=97.45 and efficacy=97.5. CONCLUSION: 1. ADA is a highly sensitive diagnostic marker of tubercular pleural effusion, 2. Combined pleural fluid ADA and Lymphocyte /neutrophil ratio increases diagnostic accuracy in tubercular pleural effusion patients compared to pleural fluid ADA alone. P292 Role of Non invasive Ventilation in the Management of Acute Respiratory Failure Dr. Srinivas Banoth, Dr S Vinod Kumar and Dr Manoj Kumar Panigrahi Jawaharlal Institute of Postgraduate Medical Education & Research, Puducherry, India Objective: To assess the effect of Noninvasive ventilation (NIV) and to identify the factors associated with the outcome in NIV among patients with acute respiratory failure. Study Design: Descriptive study Methods: All the patients with acute respiratory failure requiring NIV were enrolled in the study. We had collected serial clinical and arterial blood gas parameters at baseline, one hour and four hours. These parameters include respiratory rate, heart rate, mean blood pressure, PH, PaO2, PaCO2 and PaO2/FiO2 ratio. Results: A total of 122 patients presented with acute respiratory failure during the study period and 82 patients fulfilled the inclusion criteria were enrolled in the study. The study included 54(65.9%) male and 28 (34.1%) female. It showed significant decrease (p < 0.05) in respiratory rate, heart rate and PaCO2 at one and four hour and significant increase (p < 0.05) in PH at one and four hour compared to baseline values after NIV application. The overall NIV success and failure rates in our study were 82.92% and 17.07% respectively. NIV was most successful in patients with COPD (92.1%) and bronchiectasis (90.9%) with failure rates of 7.89% and 9.1% respectively. All patients of pneumonia with COPD failed the NIV trial. In our study, it was observed that the duration of the hospital stay was significantly higher in patients with bronchiectasis with corpulmonale (9.41В±4.47 days) than COPD with corpulmonale (5.26В±2.25 days)(P <0.05). Conclusion: Noninvasive ventilation is an effective modality in preventing endotracheal intubation in acute (hypercapneic) respiratory failure with possible exception of pneumonia. The duration of the hospital stay was significantly higher in patients with bronchiectasis with corpulmonale than COPD with corpulmonale. P293 Aortic Aneurysm presenting as a Posterior Mediastinal Mass- a case report Dr Bhumika Madhav, Dr Aparna Iyer, Dr Girija Nair, Dr Abhay Uppe, Dr Jayalakshmi T.K, Dr Lavina Mirchandani, Dr Mugdha Bhide Dr D.Y.Patil Hospital and Research Centre, Sector 5, Nerul, Navi Mumbai - 400706. Maharashtra India. Background- Descending Aortic Aneurysm is one of the rare causes of Posterior Mediastinal masses.The sources of posterior mediastinal masses are usually neurogenic tumors, cysts, malignancy, paraspinal abscess or lymphadenopathy .Prompt recognition and earlier identification of thoracic aortic aneurysm upon routine screening is necessary since it can be catastrophic. Descending aortic aneurysm mimicking a posterior mediastinal mass is a rare presentation. Case Report- A 65 yr old male was referred in view of chest xray findings patient was posted for cataract Surgery. Patient was asymptomatic. Patient denied of any respiratory complains. He was non diabetic, non hypertensive. Respiratory system examination was suggestive of breath sounds reduced in the infrascapular area with a few crepts. On cardiovascular examination a mid systolic murmur was heard. Chest X Ray showed a well defined rounded opacity seen in the Left Lower Zone with rounded regular margin not obscuring the cardiac border or diaphragm. A rim of calcification seen in lower part of the opacity. Thoracic lesion has its caudal end visible below the dome of diaphragm. Thoraco abdominal sign was positive. High Resolution Computer Tomography was suggestive of fusiform thoracic descending aortic aneurysm with eccentric mural thrombosis with impending rupture with a small abdominal aortic aneurysm with mural thrombosis within with bilateral renal artery ostial stenosis. Conclusion-Aortic Aneurysm can present as Posterior Mediastinal opacity or an Anterior Mediastinal Opacity depending on the site of aneurysm- ascending or descending aorta. P294 A CASE REPORT OF RARE PLEURAL TUMOUR MIMICKING MALIGNANT MESOTHELIOMA M.L.VED, MAHENDRA KUMAR, MINI GARG RNT MEDICAL COLLEGE, UDAIPUR Background: Solitary fibrous tumour of pleura(SFTP) represent 5% of all pleural tumours.It resemble malignant mesothelioma in clinicoradiological presentation.It is mostly benign and localised,tumour though rare but still present in community.So need to be kept in differential diagnosis as its treatment is completely different from malignant tumours. Case Report:A 65 years old ,non smoker female presented with right side chest pain,cough,exertional dyspnoea for one month.On examination,clubbing was present.Respiratory system examination reveals decreased intensity of breath sound in right suprascapular region.Other system examination were normal.Xray showed multiple soft shadows in right upper and mid zone.`CT reveals multiple nodular pleural masses and thickening in right upper and mid zone with mild pleural effusion suggestive of malignant mesothelioma more likely than benign.Pleural fluid examination and percutaneous fine needle aspiration cytology reports were inconclusive.The diagnostic dilemma was overcome by histopathology examinationof tissue taken by video thoracoscopy and confirmed to be SFTP from immunohistochemistry staining. Discussion:SFTP originates from submesothelial mesenchymal layer of pleura.These are most common pleural tumours after malignant mesothelioma.Unlike malignant mesothelioma,SFTP is not associated with tobacco smoke or asbestos exposure.SFTP is associated with two paraneoplastic syndromes:1)Pierre Marrie Bamberger Syndrome 2)Doege Potter Syndrome.Radiolologically,diffuse pleural involvement without loss of volume is unlikely for malignant mesothelioma and other malignant pleural effusion.The treatment of malignant pleural tumour and benign sftp is entirely differentand it is treated by en bloc resection.Its survival is excellent(96%).One should have high suspicion of SFTP in such presentation for early diagnosis and treatment to improve quality of life of patient. P295 CASE OF POST HEMOPTYSIS LUNG COLLAPSE IN A PATIENT OF PULMONARY TUBERCULOSIS A.B. SRIVASTAVA, DINESH KUMAR SHARMA, PRIYANK JAIN RNT MEDICAL COLLEGE, UDAIPUR Background: Endobronchial obstruction by blood clot following massive hemoptysis is an unusual cause of lung collapse. It is seen in variety of clinical conditions but very few cases are reported in pulmonary tuberculosis patient. We are presenting such a case of smear positive pulmonary tuberculosis female. Case Report: A 20 yrs old female admitted with productive cough and fever for one month and one episode of hemoptysis 2 days back. On examination the patient was anaemic and respiratory system examination revealed coarse crepitations in left interscapular region. Chest x ray was normal and sputum examination for AFB was positive. During hospitalization, 2 days later patient had another episode of massive hemoptysis in night with sudden onset of dyspnoea. By next morning dyspnoea relieved to some extent and on examination vitals were normal. Respiratory system examination and chest x ray were suggestive of complete collapse of left lung. Routine blood investigations were normal including BT & CT except low blood hemoglobin level. Patient was stable and SpO2 was 95%, so managed conservatively. Subsequent chest x ray after 3 days showed partial expansion of left lung. On fiberoptic bronchoscopy there were few patches of blood clots adherent to wall of left main bronchus and CECT Thorax showed a cavity in left upper zone posteriorly. There was no hemoptysis thereafter and patient was referred for category I under DOTS. Discussion: Pulmonary collapse due to an endobronchial obstruction by blood clot following hemoptysis is seen in bronchiectasis, tuberculosis, mitral stenosis, pulmonary infraction, sarcoidosis, bronchial carcinoma and post operative patients. Lung collapse is diagnosed by clinical examination and radiology. Blood clot is confirmed by direct endoscopic visualisation. Stable patient are managed conservatively until clot resorbs, and in haemodynamically unstable patients clot is removed urgently by way of lavage, suctioning, or bronchoscopy. P296 A CASE REPORT OF DEEP VEIN THROMBOSIS IN SMEAR POSITIVE PULMONARY TUBERCULOSIS PATIENT A.B. SRIVASTAVA, PRIYANK JAIN, DINESH KUMAR SHARMA RNT MEDICAL COLLEGE, UDAIPUR Background: An association between tuberculosis induced inflammation and hypercoagulable state is well known. Venous thromboembolism (VTE) is a rare complication of extensive pulmonary and disseminated tuberculosis which can cause a potentially life threatening event. Undiagnosed pulmonary thromboembolism may be one of the cause of sudden unexplained death in patient of tuberculosis with clinically asymptomatic DVT. Here we report a case of extensive pulmonary tuberculosis with DVT without any other risk factor Case Report: A 15 years old girl with constitutional symptoms of pulmonary tuberculosis for 2 months, also having left leg pain and edema since 12 days was admitted. Her chest x ray showed bilateral extensive pulmonary tuberculosis and sputum examination for AFB was also positive. On routine blood investigation hemoglobin was 9.8 gm% and platelet count was 4.93 lakh/cumm, ESR was 35mm/hr. DVT was suspected on clinical grounds and color Doppler confirmed thrombosis of left lower limb veins. Anti-tubercular therapy was started and anti coagulation therapy and related blood investigations were planned meanwhile patient absconded. Discussion: VTE may occur at presentation or later in the course of pulmonary tuberculosis. Elevated plasma fibrinogen coupled with decreased Antithrombin III , reactive thrombocytosis, platelet hyperaggregation and protein S deficiency favor the development DVT in pulmonary tuberculosis as inflammatory cytokines produced by inflammatory cells in tuberculosis such as IL-6, TNF-О± which are responsible for reactive thrombocytosis and down regulation of protein S. These hematological parameters worsen during the first 2 weeks of therapy in most of the cases, but normalize after a month of anti tuberculer therapy. Association between DVT and rifampicin is also present. Our report emphasise the need of clinical suspicion of DVT in cases of extensive pulmonary tuberculosis. 297 THE UTILITY OF SINGLE SITE CONVENTIONAL TRANSBRONCHIAL NEEDLE ASPIRATION (C-TBNA) IN PATIENTS WITH DIAGNOSIS OF BRONCHOGENIC CARCINOMAS AND MEDIASTINAL LYMPHADENOPATHIES WITHOUT ROSE DR. MAHENDRA KUMAR, DR.MAHESH MAHICH ,DR.BANAME WAANBAH, DR.RAVI PANWAR RNT MEDICAL COLLEGE, UDAIPUR Introduction : Transbronchial needle aspiration of mediastinal structures was described by Schiepatti in 1949, but its use with flexible bronchoscopy was described and systematized by Wang in 1978. Currently the usefulness of CTBNA lies mainly in its effectiveness as a diagnostic tool and in the mediastinal staging of bronchial carcinoma. It is a simple technique to learn, with a short learning curve, and has proven to be cost effective, despite which it has always been underused. Objective : To analyze the utility of C-TBNA for diagnosis. Patients and methods : Retrospective observational study. All the TBNA was performed in suspected cases of bronchogenic carcinoma having mass presentation with or without mediastinal or hilar adenopathies on CT Thorax. We did C-TBNA by single site puncture technique with a 19G needle without the facility of ROSE. Result : We performed C-TBNA in 21 patients (19 male, 2 female). 16 cases were true TBNA, 4 were EBNA and 1 ETNA was done. The overall diagnostic yield was 90.47% in our cases. Out of that, 15 cases (71.42%) were confirmed as malignancy, 2 cases (9.52%) were Tuberculosis, 2 were non diagnostic, 1 case (4.76%) Non Hodgkins Lymphoma and 1 case was non specific inflammation. We did the single site puncture in these cases at 4R (13), 7(5), 10R (2), 11R (2), and 4L (1) for confirmation of diagnosis. Peri-procedural complications included 2 cases of chest pain on puncture by needle, 1 minimal pneumothorax and 1 was needle stuck at lower end of scope. Conclusion : C-TBNA is a clinically useful, cost effective technique with minimal complications. It could therefore be performed on a regular basis during diagnostic bronchoscopy of such patients. P298 Chyluria and Recurrent Chylothorax cause - Idiopathic Lymphatic dysplasia syndrome AuthorsPRAKASH K ASHISH , MAMNOON FATIMA, PRABHUDESAI PRALHAD, SHASTRI B S. Institute вЂ“ Lilavati Hospital and Research Centre, Mumbai, India. AbstractThis is a case report of one of the rarest cause of recurrent left sided pleural effusion which was basically recurrent chylothorax. The patient reported is case of lymphatic duct dysplasia which has led to said problem. He also had history of chyluria in 2005 for which he was operated. He had post operative complication of shrunken kidney. Patient after being asymptomatic for such long period has presented to us with recurrent chylothorax. We investigated with computed tomography, PET-CT, magnetic resonance imaging and finally with lymphoscintigraphy and came to the conclusion that it was the lymphatic duct abnormality which has initially presented with chyluria and after being operated for that has presented with chylothorax. We ultimately did pleurodesis and thoracic duct ligation through VATS (videoscopic assisted thoracic surgery). Key words: chylothorax; idiopathic lymphatic dyslpasia; Pleural effusion; Thoracentesis; positron emission tomography-CT; computed tomography; lymphoscintigraphy; LDH-lactate-dehydrogenase; chyle. VATSvideoscopic assisted thoracic surgery P299 No scope without bronchoscope in abnormal chest x- ray Dr.J.SOWMYA , Prof.Pradyut waghray, Dr.A.V.N.Koteshwar Rao, Dr.Venkateswar reddy T, Dr.Veena, Dr.Harish, Dr.Chetan, Dr.Aditya, DrKrishna Chaitanya, Dr.Rikin Dept of Pulmonary Medicine, SVS medical college, Mahabubnagar,TS INTRODUCTION: Flexible bronchoscopy has evolved in recent years to be the first choice of investigation in radiologically abnormal cases for both diagnostic and therapeutic purposes. AIM: To evaluate the yield of fibreoptic bronchoscopy in our institute over a period of 18 months. TYPE OF STUDY: Observational study MATERIALS AND METHODS: The study was conducted in 200 patients with abnormal chest x rays in whom it was indicated and were subjected to bronchoscopy. All the findings and complications were noted , materials taken were sent for pathological and microbiological examination. RESULTS AND DISCUSSIONS: Out of 200 patients 130 patients were males with in the range of 14-75 yrs. Following findings were observed. Plenty of thick secretions in 85 pts(42.5%), Extraluminal compression in 15 pts(7.5%), Intraluminal growth in 3 pts(1.5%), Anatomical variations in 4 pts(2%) Post intubatioin tracheal stenosis in 1 pt(0.5%), Visible fungal ball in 3 pts(1.5%) , Blood clot in1 pt(0.5%), Endobronchial TB in 2pts(1%), Nodules in the airways in 4(2%), Paralysis of vocal cords in 3pts(1.5%), Air leak in 2 pts(1%), Icd in the bronchus visible through bronchoscope in 1 pt(0.5%), Fibrotic changes in airway walls in 9pts(4.5%), Black coloured patches in 6 pts(3%), Foreignbodies in 14 pts(7.5%), Active bleeding in 10 pts(5%), Inconclusive in 30 pts (15%). CONCLUSION: Disease was found in 89.1% cases in bronchoscopy .Thus flexible bronchoscopy should be the investigation of choice in abnormal chest x rays P300 PULMONARY MUCORMYCOSIS MASQUERADING AS ENDOBRONCHIAL GROWTH WITH NON RESOLVING PNEUMONIA MOUNIKA.V*, VAMSIKRISHNA.M* , J ** , DR.P.SUBBARAO *** . DEPARTMENT OF PULMONARY MEDICINE, KONASEEMA INSTITUTE OF MEDICAL SCIENCES NH-214, CHAITANYA HEALTH CITY, AMALAPURAM, ANDHRA PRADESH-533201 BACKGROUND: Non resolving pneumonia has a wide range of etiology which needs extensive investigations including bronchoscopy, radiological and microbiological tests. We present an unusual case of Non resolving pneumonia CASE REPORT: Patient is a 40 year old diabetic male, presented to us with complaints of chronic cough and fever of 4 weeks duration. He was evaluated elsewhere with chest X rays, CT SCAN which showed left lower lobe consolidation. Sputum was sent for bacterial culture. He received antibiotics for K.pneumonia infection as per sensitivity pattern. Despite 2 weeks injectable antibiotics he had persistent symptoms. Repeated sputum examination for AFB was negative. Repeat CT scan showed persistent consolidation. At this juncture patient was referred to us. He was subjected to BRONCHOSCOPY. It revealed an endobronchial growth in left lower lobe main bronchus, causing partial obstruction of lumen. Endobronchial biopsy has shown features of INVASIVE MUCORMYCOSIS. He received liposomal amphotericin B 100 mg/day for 10 days with which clinical improvement was noted and was followed by posaconazole syrup. Patient had complete clinical, radiological improvement and confirmed by resolution of endobronchial growth and normalization of airways. Posaconzole was continued till complete radiological resolution CONCLUSION: we report a case of pulmonary mucormycosis presenting as endobronchial growth. We successfully treated the patient with liposomal amphotericin B and posaconazole, avoiding surgery. CLINICAL IMPLICATION: Diabetic patients with uncontrolled blood sugars presenting with non resolving pneumonia should be investigated for fungal etiologies P301 A COMPARITIVE STUDY OF SPIROMETRIC PATTERNS IN OBESE AND NON-OBESE ASTHMATICS Dr.VARGHESE LOUIS, DR.K.SURENDRA MENON, DR.R.PAJANIVEL DEPARTMENT OF PULMONARY MEDICINE, MAHATMA GANDHI MEDICAL COLLEGE AND RESEARCH INSTITUTE BACKGROUND: The incidence of obesity and asthma has increased by 75% in recent decades and this has led clinicians to investigate potential links between the two medical conditions. There is an increased annual risk of asthma if associated with antecedent obesity. OBJECTIVES: The aim of this study was to estimate pulmonary function parameters in obese and non-obese asthmatics, and to observe the relation between obesity and spirometric patterns in asthma. METHODS: The study was carried out in the Out-Patient Department of Pulmonary Medicine in our institute. The participants (n=90) included all patients above sixteen years of age of both sexes with signs and symptoms of Asthma,. BMI was measured in all subjects using height/weight2 and waist circumference measured in centimetres. Spirometric parameters studied were FEV1 and FVC and derived parameters based on pulmonary function tests, before and after bronchodilator therapy. Data was then analysed using statistical tests. RESULTS: Of the total 90 patients studied, 77 (85.5%) had post-bronchodilator therapy reversibility of obstructive pattern on spirometry. Of these 27(37.1%), were classified as obese based on BMI measurements (p=0.05), and 32(42.6%) were classified as obese based on waist circumference (p=0.018). These values were statistically significant. These patients were also found to have a restrictive pattern on spirometry assessment, as shown by a FVC less than 80% recording (p=0.05). CONCLUSION: Based on the present descriptive study, the following factors were determined: There is a significant correlation between asthma and obesity. Waist Circumference helped us identify more Obese asthmatics than Body Mass Index. Obese Asthmatics had a more Restrictive pattern on spirometry compared to Non- Obese Asthmatics. P302 Aortic Aneurysm presenting as a Posterior Mediastinal Mass- a case report Author(s)вЂ“Dr Bhumika Madhav, Dr Aparna Iyer, Dr Girija Nair, Dr Abhay Uppe, Dr Jayalakshmi T.K, Dr Lavina Mirchandani, Dr Mugdha Bhide Institution-Dr D.Y.Patil Hospital and Research Centre, Sector 5 , Nerul, Navi Mumbai - 400706. Maharashtra India. Address- 43/1, RCF Row Houses. Sector-6, Vashi, Navimumbai, Maharashtra 400703 BackgroundDescending Aortic Aneurysm is one of the rare causes of Posterior Mediastinal masses.The sources of posterior mediastinal masses are usually neurogenic tumors, cysts, malignancy, paraspinal abscess or lymphadenopathy .Prompt recognition and earlier identification of thoracic aortic aneurysm upon routine screening is necessary since it can be catastrophic. Descending aortic aneurysm mimicking a posterior mediastinal mass is a rare presentation. Case ReportA 65 yr old male was referred in view of chest xray findings patient was posted for cataract Surgery. Patient was asymptomatic. Patient denied of any respiratory complains. He was non diabetic, non hypertensive. Respiratory system examination was suggestive of breath sounds reduced in the infrascapular area with a few crepts. On cardiovascular examination a mid systolic murmur was heard. Chest X Ray showed a well defined rounded opacity seen in the Left Lower Zone with rounded regular margin not obscuring the cardiac border or diaphragm. A rim of calcification seen in lower part of the opacity. Thoracic lesion has its caudal end visible below the dome of diaphragm. Thoraco abdominal sign was positive. High Resolution Computer Tomography was suggestive of Fusiform thoracic descending aortic aneurysm with eccentric mural thrombosis with impending rupture with a small abdominal aortic aneurysm with mural thrombosis within with bilateral renal artery ostial stenosis. ConclusionAortic Aneurysm can present as Posterior Mediastinal opacity or an Anterior Mediastinal Opacity depending on the site of aneurysm- ascending or descending aorta. P303 Diagnostic yield of various techniques 0f Fibreoptic video bronchoscopy in diagnosing lung cancer Dr.VEENA REDDY VANKAYALA, Prof.Pradyuth Waghray, Dr.A.N.V.Koteswara Rao ,Dr. Venkateswara Reddy Tummuru , Dr. Chetan, Dr.Sowmya, Dr. Harish, Dr.Aditya, DR. Rikin, DR. K.C , Dr.Ramakrishna reddy* Dept. of Pulmonary Medicine, S.V.S. Medical college, Mahabubnagar, Telangana. *Dept of Radiology Introduction: Lung cancer is today the most common amongst the malignancies in the world. Several studies have demonstrated that early detection, localisation, and aggressive treatment of lung cancer results in five year survival rate of 70 to 80%. objective: Study to know the value of various diagnostic methods like bronchial brushings , bronchial wash, TBNA(transbronchial needle aspiration) , bronchial biopsy , TBLB(transbronchial lung biopsy) under fluoroscopic guidance. Type of study: observational study conducted in Pulmonary Medicine department at SVS Medical College , Mahabubnagar during a period of 2 years. Method: patients in whom lung cancer was suspected , bronchoscopy was done and the yeild of different diagnostic techniques was observed. Observation: out of total 100 patients , 70 patients had central lesions and 30 patients had peripheral lesions. for patients with central lesions bronchial brushings in 54 patients (77.14%) ,bronchial wash in 46 patients (65.71) ,bronchial biopsy in 62 patients (88.57 % ) , TBNA done in 32 patients 25 patients (78.12%) gave diagnosis. In 30 patients who had peripheral lesions bronchial brushings in 12 patients ( 40%) , bronchial wash in 16 patients (53.3%), TBLB under fluoroscopic guidance in 21 patients( 70%) could give diagnosis. CONCLUSION: Our study suggests that, in investigating suspected cases of lung malignancy we should adopt all diagnostic techniques of biopsy, brushing, and washing ,TBNA to increase the yield of diagnosis. Cytological procedures of washing and brushing yield acceptable optimum results in case of peripheral lesions but fluoroscopy guided biopsy is best. P304 Primary pulmonary Lympho Epithelioma like Carcinoma; Rare case Report in South India. Abstract: Primary pulmonary lymphoepithelioma-like carcinoma (LELC) is a rare tumor, with more favorable prognosis compared with other type of non small cell lung cancer. This tumour is a variant of large cell carcinoma characterised by abundant invasion of lymphocytes. Here in we describe an interesting case of primary pulmonary LELC in 26 year old male, smoker confirmed post operatively. 305 Serum concentration of IFN-Оі in patients with new, Under-treatment & MDR tuberculosis cases Nazish Fatima*, M Shameem**, Nabeela*, Haris M Khan*, Afreen Hashmi Department of Microbiology, Jawaharlal Nehru Medical College, A.M.U, Aligarh Introduction: - Mycobacterium tuberculosis (Mtb) infects approximately one third of world population. Many cytokines are produced during tuberculosis (TB) with predominance of Th1 cytokines during the early stage and Th2 cytokines in the later stages of the infection. INF-Оі play a key role in control of Mtb infection is produced by both CD4+ and CD8+ T cells, as well as by NK cell. Objectives: To evaluate the levels of IFN-Оі, in the serum of New, Under-treatment (UT) & Multi-drug resistant (MDR) TB patients. Materials and Methods: The study was conducted at Department Of Microbiology, J.N.M.C, A.M.U, Aligarh.76 patients of TB cases were enrolled in this study of whom 30 were new TB cases, 24 under-treatment, 22 were MDR TB cases, 44 were pulmonary and 36 were extra-pulmonary TB cases by ELISA kit (Diaclone France) along with 20 healthy BCG vaccinated controls. A complete clinical, radiological & treatment data was collected. Statistical analysis was done by using sigma plot 10.1. Results: The levels of INF-Оі were significantly increased in new and MDR TB cases compared to healthy and untreated cases (P<0.001). There were no significant variations in their level according to the site of infection (Pulmonary vs. extra-pulmonary). Conclusions:- Measuring the serum levels of several cytokines may be useful for evaluating the activity of TB disease and monitoring the clinical effects of ATT. INF-Оі can serve as a potential biomarkers of anti-tuberculosis treatment response. The discovery of biomarkers for TB treatment response is therefore important for both clinical practice and clinical trials of new anti TB drugs. 306 Comparative study of Indacaterol and Tiotropium in patients of COPD Dr. Mohammad Sajid alam, Dr. Jameel Ahmad, Prof. Anil Kumar, Dr. Mohammad Shameem * : Department of Pharmacology and Department of Tuberculosis & Respiratory diseases, J.N.M.C. & Hospital, A.M.U Objective: Comparative study of safety and efficacy of Indacaterol and Tiotropium in patients of moderate & severe grade of COPD. Method: This is a randomized, prospective, open labelled and parallel group study. Eligible patients were enrolled and randomized according to the table generated by random allocation software into two groups (20 patients in each group). Group I patients received Indacaterol in the dose of 150Ојg once daily and Group II patients received Tiotropium 18Ојg once daily for 10 weeks. The patients were evaluated by measuring FEV1 at zero, two weeks, four weeks, six weeks, eight weeks and ten weeks. Results: The gradual improvement is observed in both the groups. There is more improvement in Indacaterol as compared to Tiotropium. Although the difference was not statistically significant. P307 Association of body mass index with severity of obstructive sleep apnea Nitin Goel, Mandeep Singh, Vikas Dogra, Kuldeep Patial, Raj Kumar, Rajendra Prasad Sleep Disorder Centre, Vallabhbhai Patel Chest Institute University of Delhi, Delhi- 110007, India Background: Obesity has reached epidemic proportions in India in the present century, with National Family Health Survey 2007, showing 12% males and 16% females to be obese.Obesity is one of the most powerful reversible risk factor for obstructive sleep apnea (OSA). The present study was planned to assess the association between body mass index in adults on the severity of obstructive sleep apnea. Materials and Methods: The present study is a retrospective analysis of the sleep studies done in Vallabhbhhai Patel Chest Institute over a period of one year from 1 January to 31 December 2012. The patients were divided into 2 2 2 groups based on their body mass index (BMI) into non-obese (18.50 - 24.99 kg/m ) and obese (> 25kg/m ). The patients from these groups were then assessed for apnea hypopnea index (AHI). Results: There were 81 subjects who underwent sleep study in 2012 comprising of 52 males and 29 females with the mean age of 52.62 В± 10.03 years. Most of the subjects belonged to obese group (n = 75) whereas non-obese group comprised of only 6 subjects. 66.67% subjects in non-obese group and 78.66% subjects in obese group had severe obstructive sleep apnea (AHI в‰Ґ 30/ hour). The difference in occurrence of severe OSA in non-obese versus obese subjects was not statistically significant (p>0.05). Conclusions: OSA has high occurrence in obese individuals and severity of OSA may not be related to obesity alone. Table 1: Apnea hypopnea index in different groups of body mass index Body mass index 2 (kg/m ) Number of Patients <25 в‰Ґ 25 6 75 Percent of cases having AHI в‰Ґ 30 Apnea hypopnea index <5 1 0 в‰Ґ5- <15 0 9 в‰Ґ 15- <30 1 7 в‰Ґ 30 4 59 66.67% 78.66% P308 Bronchial anthracosis and anthracofibrosis RAJ KUMAR, MOHAMMED NOUFAL POONGADAN, MANDEEP SINGH, NITIN GOEL, NITESH GUPTA, SAURAB, RAJENDRA PRASAD National Centre for Respiratory Allergy, Asthma and Immunology Vallabhbhai Patel Chest Institute, Delhi-110009, India Objective: Anthracosis is a term used to describe a condition in which there is deposition of black pigments on the bronchial mucosa. On the other hand, bronchial anthracofibrosis (BAF) has been used to describe bronchial stenosis associated with anthracosis without a relevant history of pneumoconiosis or smoking. The present study was planned to assess the clinico-radiological, bronchoscopic and pathological features of anthracosis with or without BAF Method: The present study is a retrospective review of bronchoscopic cases of anthracosis diagnosed in a unit of Vallabhbhai Patel Chest Institute from Jan-August 2014. The clinical presentation, radiological features, bronchoscopic findings and histopathogical specimens of patients having anthracosis were analysed. Results: There were a total of nine patients who were diagnosed to have anthracosis, out of which two had associated BAF during the study period. All the subjects were female with an average age of 59.4 years (age range: 38-70 years). Past history of tuberculosis was present in 2 cases. The most common clinical symptoms in patients with anthracosis were cough in 9 (100%), breathlessness in 8 (88.9%) cases. All the subjects had history of biomass fuel exposure. Computed tomography chest showed consolidation, nodules, bronchiectasis. Evidence of bronchial stenosis or obstruction was seen in 2 cases. Bronchoscopy revealed black bronchial deposits in all cases, with 2 out of them showing bronchial stenosis. Histo-pathological evaluation showed chronic inflammation of the bronchial mucosa, submucosal anthracotic pigment deposition in all and fibrosis in 2 cases. Conclusions: The diagnosis of anthracosis and BAF is based mainly on bronchoscopic evaluation. It may be associated with biomass fuel exposure or tuberculosis. P309 Effect of household air pollution from biomass combustion on respiratory related illness in rural area of NCRDelhi Raj Kumar, Mandeep Singh, Kamal Singh, Mohammed Noufal Poongadan, Nitin Goel, Nitesh Gupta, Saurab, Uday Kumar Mehto, Anil Mavi, Deepak Kumar, Rajendra Prasad National Centre of Respiratory Allergy, Asthma and Immunology (NCRAAI), Vallabhbhai Patel Chest Institute, Delhi University, Delhi-110007 Introduction: Indoor air pollution is the third leading cause of disease burden in South East Asia as per Global burden of disease study 2010. Indoor air pollution as assessed by particulate matters (PM10, PM2.5, and PM1) and volatile organic compounds (VOCs) includes combustion of solid fuels and tobacco smoking. The present study was thus planned to assess the effect of indoor air pollution on the health of adults. Methodology: The present study is a cross sectional study to assess the difference in household air quality in houses having adults (>18 years age) with or without asthma in a rural area (Village Khanpurjupti, Loni, Ghaziabad) of Delhi NCR region. 83 households (Group-A: controls) were selected in which none of the adult had any respiratory symptoms (breathlessness, cough and/or sputum) while the other 83 households (Group-B: cases) had at least one adult with one of the above respiratory symptoms. A standard questionnaire was filled and levels of various indoor air pollutants were measured using standard instruments. Result: Out of total 430 adults, 94 (21.86%) adults in Group-B had respiratory illness related symptoms. The PM and VOCs levels of homes of Group-B, were higher than homes of Group-A. Average 24 hours and 6 hours PM2.5 levels were significant high in homes of Group-B compared with homes of Group-A. 6-hours PM10 mean level of homes of group-B were also significantly high than Group-A. PM1 and VOC levels were also higher in Group B as compared to Group A but could not reach stastically significant value. Conclusion: Indoor air pollution from smoking, chemicals and biomass fuel combustion results in increased levels of particulate matters and volatile organic compounds in indoor air, which may be responsible for increased level of respiratory illness in adults. P310 Effect of household air pollution from biomass combustion on respiratory related illness in women Raj Kumar, Mandeep Singh, Kamal Singh, Mohammed Noufal Poongadan, Nitin Goel, Nitesh Gupta, Saurab, Uday Kumar Mehto, Anil Mavi, Deepak Kumar, Rajendra Prasad National Centre for Respiratory Allergy, Asthma and Immunology Vallabhbhai Patel Chest Institute, Delhi-09 Background: Indoor air pollution is third leading cause of disease burden in South East Asia as per Global burden of disease study 2010 published in lancet. The most significant sources of indoor air pollution in developing countries are combustion of solid fuels, including biomass or coal and active and passive smoking. Females are much more susceptible to household air pollutants as they spend most of their time indoors. The present study was planned to assess the correlation between respiratory symptoms in women and levels of indoor air pollution as assessed by particulate matter 2.5 (PM 2.5) and volatile organic compounds (VOCs). Methods: The present study is a cross sectional study of adult women from 77 households in a rural setting (Village Khanpurjupti, Loni, Ghaziabad) of Delhi NCR region. A questionnaire based assessment for respiratory illness related symptoms (cough, sputum, breathlessness) was done in women of these houses. In these houses assessment of PM 2.5 and VOCs levels were done by standard instruments. Results: A total of 190 adult women from 77 households were included in the study. A total of 56 women from 44 households had history of respiratory illness related symptoms. The PM 2.5 and VOC levels were measured from all 77 households. The average PM 2.5 concentration was found to be significantly higher in houses with respiratory illness as compared to controls (10.13mg/m3 versus 4.36mg/m3). The average level of VOCs was also higher in these households as compared to controls but could not reach statically significant value. Conclusion: Household air pollution from biomass fuel use and smoking resulted in increased levels of PM2.5 and VOCs in household air, which may be responsible for increased level of respiratory illness in women. P311 A 54 year old man presented with dry cough, breathlessness on exertion, itching all over the body and heaviness in the chest from last 2-3 months. He noticed progressive bulging of his anterior chest wall also. On examination his anterior chest wall was bulged, anterio-posterior diameter was 90 cm and transverse diameter was 75 cm. There were multiple enlarged lymph nodes in both the axillas. His X-ray chest PA view showed mediastinal widening and left lateral view showed mediastinal mass extending into anterior chest wall. CT scan showed a large homogenous minimally enhancing soft tissue density mass lesion diffusely involving anterior and middle mediastinum extending from thoracic inlet superiorly, up to the level of diaphragm inferiorly, anteriorly causing destruction of upper part of sternum with infiltration into overlying pectoralis muscles, subcutaneous tissue and skin. CT abdomen showed multiple hypodense lesions in spleen. Biopsy of chest wall lesion and axillary lymph node showed features suggestive of lymphoma. He was diagnosed as having stage 4 Hodgikns lymphoma and was treated with combined chemotherapy and radiotherapy. Size of the tumour reduced and patient discharged in satisfactory condition with advice of regular follow up. We report this case because of its unusual presentation.