Friday, February 19, 2016

Changing scenario of Sarcoidosis in India


There has been a rapid change in recognition and spectrum of sarcoidosis in India in the last decade. This was considered a rare disease almost till the end of the last century even though the disease was recognized and reported from different places. The change is remarkable considering the fact that the number of publications on the subject has suddenly jumped in the last decade. Of 340 total papers which are listed in PubMed since 1980, about two-third (228) have appeared in the last 10 years. There were only rare publications before 1980. The increase can be attributed to several different causes:
  1. True increase in incidence
  2. Increased awareness of disease among physicians. Many cases of sarcoidosis were dismissed as tuberculosis in the past.
  3. Increased availability of diagnostic tests such as chest CT scanning, fiberoptic bronchoscopy and endo-bronchial ultrasound sound guided fine needle aspiration (EBUS-FNA)
  4. Insistence of physicians as well as patients in making a confirmed diagnosis than starting anempiric treatment

Clinical spectrum of sarcoidosis: There is also a change in the spectrum of disease and organ involvement described in the reports of the recent past. Previously, it was mostly the pulmonary involvement i.e. hilar and mediastinal lymphadenopathy which was commonly described. Now, there is a greater recognition of extra-pulmonary involvement including that of the liver, spleen, nervous system and other organs. Moreover, atypical pulmonary presentations such as miliary involvement of lung parenchyma and pleural effusions are frequently reported. It is again a moot question whether this finding is a true change in the spectrum or only an increased recognition because of the factors already listed above.

Sarcoidosis tuberculosis enigma continues to bother physicians in India not only because of similar presentations of both diseases but also since the treatments are different for the two diseases. Corticosteroids, which are used for sarcoidosis may in fact precipitate tuberculosis and are necessarily avoided except in a few specific situations. There is no place to start the treatments for both conditions simultaneously as had been a common practice in the past. It is therefore important to make a firm diagnosis before starting treatment for either condition.

The other major shift which has happened relates to the more frequent use of non-steroidal drugs. Drugs such as methotrexate, hydroxy chloroquin and other immunosuppressants are now available for use for relapse and in the presence of co-morbidities with or without corticosteroid therapy, depending upon the clinical condition.  


S.K. Jindal

Medical Director, Jindal Clinics, Chandigarh

Monday, January 11, 2016

Medical Encounters: True stories of patients – Memoirs of a Physician By Dr. S. K. Jindal




Jindal Clinics is proud to announce the release of the latest book by Dr. S. K. Jindal - the medical director of the institute and ex head, Department of Pulmonary Medicine, PGI Chandigarh.

The book, meant for general reading chronicles the stories of some of the patients seen by the author during a career of about half a century. It provides glimpses of the trials and tribulations faced by patients and their doctors in their heroic struggles against disease and death. It also tends to project the physician’s handling of the myths and dilemmas about disease management and treatment modalities faced by different patients. 

The pen portraits reflected in this fascinating book encompass the lives of Prime Ministers, Governors, Chief Ministers, Judges, highly placed officials, army-men, police officers, newly married couples, precocious teen agers, wealthy men and farm labourers. It is a captivating story of life and living process. Full with vignettes from history, classical civilization, epics and mythology, it is enjoyable to read and meaningful for the doctors, the patients and the care-givers into disease management. A brief synopsis of its contents follows:
 
Foreword

Prologue

1.      The Childhood Adventures: Life in a community riddled with superstitions about health in a haunted house during 1950s in small towns of Punjab. Medical practice was rather scarce and simple maladies were often handled in medieval fashions.  

2.      Dissection Hall: Vivid scenes from the ‘dissection hall’ of the medical college (Government Medical College, Patiala) during the author’s first year of MBBS in 1966-67. Does the virtual dissection now provide the same attachment with human body?

3.      Patient with Scalded Palms: Lessons during bed-side case demonstration in the Skin Out-patient department. Was the reason of scalded palms in an otherwise healthy young man?

4.      Labour Ward: Melodrama in the busy ‘labour-room’ of the hospital while witnessing the first delivery by the author during the final year MBBS. 

5.      Bhag Singh: A former army soldier who used to brag about fighting with enemy forces and cockroach sized mosquitoes was admitted with cancer. Both he and the doctor were quite afraid of catheterization at night for urinary obstruction. 

6.      Emergency Ward: Facing the first death in the over-crowded Emergency of the Postgraduate Institute of Medical Education & Research, Chandigarh in 1972. 

7.      JP – The quintessential Leader or 1975: Story of Jai Prakash Narain during the period of Emergency in India when he was interned in the hospital at Chandigarh. His care was a real challenge for which the author along with senior doctors faced political reverberations.

8.      Sherlock Holmes: A senior police officer who suffered from a relatively uncommon respiratory disease, was quite reluctant. It was Sherlock Holmes who helped in treatment.

9.      The two oustees: Struggles and superstitions of two village folks who suffered from chronic respiratory disease, both were displaced from the land where Chandigarh was built as the state capital of Punjab after Indian partition.

10.   Culture Shock: A young man from Denmark developed illness while visiting as a tourist. Both he and his friend had a tough time in the hospital in the beginning; both got adjusted very soon. On the other hand, Griffth who suffered from chronic obstructive pulmonary disease was evading law because of drug abuse and trafficking.

11.   ‘Morrie’ of Punjab: A senior Professor had a chronic muscle disease; his life was almost a replica of the Morrie immortalized by Mitch Albom (see ‘Tuesdays with Morrie’).

12.  The American Dream: Handling of a friend with asthma in Seattle during Fellowship in USA in 1982-83. He was a tough nut to crack - willfully avoiding treatment for his problem.

13.  Pickwick Papers: Obese patients with respiratory sleep disorders. The main character like the fat Joe of Pickwick Papers was blissfully unaware of his illness.

14.  God’s own People: Patients with respiratory problems belonging to ‘below poverty-line’ category faced multiple hardships. Their innocence was often overwhelming and over-bearing.

15.  Perseverance: A resolute youth was determined to cure disabling emphysema of his grand-father. His misdirected treatment proved disastrous.

16.  Mr Prime Minister: Visit to Nepal for a medical consultation. The Prime Minister had an exceptional medical knowledge.

17.  Mountain out of a mole hill: Pleasure of curing small problems which looked threatening to others. But one needs to know the problem!

18.  Corporate Honchos: Treatment of the rich and the mighty. One of them who suffered from a respiratory sleep disorder was quite secretive about his visit to the doctor.

19.  ‘If a man’s lungs pant with his work’: Problems of handling two senior judges who suffered from brittle asthma! The severe and almost near-fatal attacks used to develop with an electrifying speed. 

20.  Erythrocyte Sedimentation Rate: Misconceptions about and misinterpretations of non-specific medical tests! The test report was a good excuse for the two patients to repeatedly visit the hospital.

21.  Teenage Hiccups: Abrupt and angry outbursts of sick teenagers who needed tender care.

22.   Weakness of the Powerful: The powerful politicians including Chief-ministers and Governors who suffered from asthma or other respiratory diseases were as weak as the ordinary folks. Inhalation therapy was particularly difficult to teach and gullibility was the greatest weakness.

23.   Marital Woes: Sickness as a stigma for ‘soon to marry’ girls and boys. One young lady who suffered from asthma defied medical advice with serious consequences.

24.   The Stigma of Inderjeet: Isolation of young Inderjeet for her tuberculosis. She conquered her illness with courage and bravery.

25.  University Dons: Teachers at the University were generally difficult to convince. Professor Ahuja used to underplay his illness, while several others were over concerned, sometimes about hypothetical illnesses.

26.  Swami Anand: A pious and spiritual man who imbibed the greatest human values! 

27.  The Devilish Test: Misinterpretation of a simple medical test brought an engagement almost to a break-point. It was the medical counselling which helped.

28.  Yasin Mohammad: A bear performer who suffered from asthma was quite magnanimous. Petty favours by unrecognizable patients proved to be pleasant, sometimes even embarrassing.

29.  Barriers: It was difficult to communicate with an old man with hearing impairment. Yet the old man was quite satisfied!

30.  The Big League: The VIP attitudes of a few senior officers often interfered with good medical management. It was always better to shed the mask of bigness while seeking treatment.

31.   Holy Water – The Last Wish: A holy priest was afraid of admission in the hospital for the fear that his last wish may not be fulfilled. The medical personnel and the facilities need to respect the wishes of patients with terminal illnesses.

32.   One More world to go: ‘Not to be defeated’ attitude of a terminally sick patient.

33.  Dilemma of Critical Care:  The real question is ‘When to opt for assisted respiratory support?’ 

34.  Knowledge – Explosion: 21st century – the era of lung transplantation, advanced life-prolonging treatments and internet with a quagmire of information.





The book is available for purchase at: 

 Partridge India    000 008 10062 62



www.nobleandbarne.com



Monday, November 30, 2015

Air in the Pleural Cavity - Pneumothorax


Air is normally present in the lungs. On the other hand, the pleural cavities on the two sides (Right and left) formed by the two pleural membranes on the surface of the lungs are empty. The negative pressure in the pleural cavities keeps the lungs expanded with air. In some diseases of the lungs or due to injury to the pleural membrane, the air can enter the pleural cavity on either side. This condition is called ‘pneumothorax’ i.e. air the thorax – pleural cavity. (Pneumothorax is defined as presence of air in the pleural cavity, i.e. between the lung and the chest wall). Presence of air within the pleural space causes collapse of the lung.

 
TYPES OF PNEUMOTHORAX

 Pneumothorax is traditionally divided into primary and secondary varieties.  

  1. Spontaneous pneumothorax which occurs in the absence of external trauma.
i)                    Primary spontaneous where the underlying lung is healthy.
ii)            Secondary spontaneous where the pneumothorax occurs as a complication of some underlying disease.

  1. Traumatic:  It can result from injury from outside.

CAUSES OF PNEUMOTHORAX

1.      Primary spontaneous pneumothorax: It is caused by the rupture of sub pleural emphysematous blebs which may be congenital or acquired.  Recent studies have demonstrated such small emphysematous changes in up to 80% patients of spontaneous pneumothorax on CT scan.  Some risk factors identified for primary pneumothorax are:

  • Tall and thin body habitus
  • Smoking.  Risk may be as high as 100 times in heavy smokers (>20 cigarettes/day).
  • Genetic and inherited factors like presence of HLA A2, B40 haplotype.
  • Marfan’s syndrome
  • Mitral valve prolapse
  • Broad swings in atmospheric pressure, e.g., going on high altitude etc.
  • Bronchial abnormalities like disproportionate bronchial anatomy.

2.      Secondary spontaneous pneumothorax: The incidence of secondary spontaneous pneumothorax is almost the same as that of primary spontaneous.  Tuberculosis and Chronic Obstructive Pulmonary Disease (COPD) are the common causes.  Almost every lung disease is known to be associated with pneumothorax.



Other known causes are:

  • Infections.  Necrotizing pneumonias, lung abscess
  • Interstitial lung disease.  Rheumatoid arthritis, Wegener’s granulomatosis, idiopathic pulmonary fibrosis etc.
  • Occupational disease.  Silicosis, coal workers’ pneumoconiosis
  • Neoplastic disorders.  Bronchogenic carcinoma, lymphangioleiomyomatosis
  • Rare causes.  Pulmonary infarction, Bronchial asthma, Cystic fibrosis, Eosinophilic granuloma, Post-irradiation, etc.

3.      Traumatic Pneumothorax:  Trauma can result in pneumothorax in the following three ways viz.,

  • Blunt injury to chest and abdomen
  • Penetrating injuries to chest
  • Iatrogenic, following procedures like pleural tap, pleural biopsy, needle aspirations from intrathoracic lesions, bronchoscopy and lung biopsies, endoscopy and sclerotherapy.


CLINICAL FEATURES

Symptoms:  Primary spontaneous pneumothorax usually develops suddenly.  It has no relation to heavy exertion as is usually believed.  Symptoms depend on the amount of air present in the pleural cavity.  If pneumothorax is small there may be no symptom and it may be detected by chance on routine chest x-ray.  Main symptoms are chest pain and dyspnea.  Chest pain is sharp, pleuritic, acute in onset and localized to the side of the pneumothorax.  Dyspnea is proportional to the amount of pneumothorax.  Secondary pneumothorax is usually more symptomatic because of the pre-existing compromised lung functions.


Tension Pneumothorax

This clinical syndrome associated with any sort of pneumothorax is a medical emergency and needs urgent recognition and attention.  It develops due to persistent air leak into the pleural cavity by a communication which opens up only during inspiration when pleural pressures rises, thus acting as a check valve.   Air accumulates with each successive breath and causes rising pressure in the pleural cavity thereby causing shift of mediastinum to the opposite side and pressure on great vessels.  There is decreased venous return to the heart and cardiac output falls leading to hypotension and cyanosis.

It commonly presents with sudden onset of shortness of breath or sudden increase in symptoms in a patient of pneumothorax. In addition, tachypnea, tachycardia, hypotension, cyanosis and pulsus paradoxus are usually present.



DIAGNOSIS

A high index of suspicion is required to diagnose pneumothorax in a given clinical setting.  Chest x-ray usually confirms the suspected pneumothorax.  It is also helpful in quantitating the pneumothorax. 

Chest CT scan is required to confirm a small pneumothorax and to see the condition of the underlying lung. Differentiation from a large bulla is at times very difficult on a plain chest x-ray.


TREATMENT

The treatment of pneumothorax is aimed at:
A.  Removal of air from pleural space, and
B.  Prevention of recurrence.


  1. Removing air from pleural space

Pneumothorax needs aspiration if it is symptomatic, more than 20%, and if the underlying lung is diseased. Secondary spontaneous pneumothorax is better managed with intercostal tube drainage.

Intercostal tube drainage (ICTD) is required for all cases of:
       i)          Tension pneumothorax
ii)                  Secondary pneumothorax
iii)                Failed aspiration in primary pneumothorax

The tube should be kept under water seal or one way valve if available, should be used.  Once the lung expands, the tube should be clamped for 12-24 hours and a check x-ray should be done to exclude the recurrence before removing the tube.  Chest tube should be kept in situ for at least 24 hours after the lung has expanded and the air leak has ceased.  This is known to be associated with lesser recurrence rates than when ICTD is removed earlier.

Tension Pneumothorax needs immediate relief of tension.  It can be achieved by simply inserting a small needle (16G) into the pleural space even without any under water seal to relieve the tension till an ICTD can be put in place.


  1. Preventing Recurrence

About 20-25% patients with primary spontaneous pneumothorax have recurrence in the first year.  Risk for second and third recurrence is even higher reaching up to 80% after the third episode.  The recurrence rates for secondary spontaneous pneumothorax are a little higher.


Pleurodesis:  Pleurodesis involves instillation of talc or other adhesive material into the pleural cavity before removal of ICTD. The resultant fusion of pleural membranes prevents recurrence of pneumothorax in future. Some people advocate instillation of sclerosing agent after the first episode of primary spontaneous pneumothorax while others believe it to be necessary only after the second episode on the same side. 


Role of Thoracoscopy: Thoracoscopy is a useful method to examine the pleural cavity from within, remove the air/fluid and produce pleurodesis. One can also look for the cause of recurrent of persistent air leaks, if any. Indications for thoracoscopy in a case of pneumothorax are:
 a) Poor expansion of lung after 5 days of ICTD.
 b) Persistent air leak after 5 days of ICTD.
 c) Failed chemical pleurodesis.


RE-EXPANSION PULMONARY EDEMA can rarely occur following drain of a massive pneumothorax in a short span of time. It occurs more frequently if the lung has remained collapsed for longer period and if negative pressure is applied.  Preventive steps include slow removal of fluid/air, avoidance of negative pressures in draining pneumothorax and careful monitoring.



 SUMMARY

  • Pneumothorax is a medical emergency which needs to be recognized with a high index of suspicion and should be treated promptly.
  • It can occur in previously healthy lungs or in a patient with a pre-existing lung disease.
  • Symptoms will depend on the amount of air present in the pleural cavity and if under tension, it can be life threatening.
  • Treatment lies in the drainage of air from the pleural space which can be achieved with the help of inter-costal tube insertion.
  • Chances of recurrence are prevented by pleurodesis done through instillation of sclerosing agents within the pleural cavity.
  • Thoracoscopy is important to do especially in cases of persistent and/or recurrent pneumothorax both to examine the source of air leak and to produce pleurodesis.