Background: Lower lung field tuberculosis (LLF TB) is an atypical presentation of tuberculosis (TB). LLF TB is common, and a proportionate number of non-resolving pneumonia cases are diagnosed to have pulmonary TB. Materials and Methods: The prospective observational study was conducted during June 2013 to December 2015 in the Department of Pulmonary Medicine, MIMSR Medical College, Latur, India; the objective of the study is clinical, microbiological, and radiological presentation of LLF TB and the comparison of yield of conventional diagnostic techniques and bronchoscopy guided modalities in LLF TB. Additional important objective of the study is to find LLF TB in patients with nonresolving pneumonia (NRP). A total of 2,600 patients with pulmonary TB were included in the study after inclusion and exclusion criteria. Ethical clearance was taken from the ethical committee of the institutional review board. Consent was taken from the patients before inclusion in the study. Statistical analysis was done using chisquare test. Results: In the present study, 300 (11.53%) cases of LLF TB of total 2600 pulmonary tuberculosis were included, females constitutes 66.66% (200/300) with mean age of 58.4 ± 11.8 years and males constitutes 33.34% (100/300) with mean age of 56.8 ± 10.6 years. Constitutional symptoms were observed as cough in 93% cases, fever in 83% cases, shortness of breath in 72% cases, anorexia in 91% cases, and weight loss in 84% cases. Radiological assessment of study cases documented the involvement of right lower zone in 84% cases and left lower zone in only 16% cases. In the studied LLF TB cases, 57 cases (20.66%) were diagnosed by routine sputum microscopic examination for acid fast bacilli (AFB) and 80 cases (28%) were diagnosed by induced sputum microscopic examination for AFB. In the study of 170 LLF TB cases, headto-head comparison between conventional diagnostic techniques (sputum microscopy and Induced sputum microscopy for AFB) made diagnosis in 60 cases, while bronchoscopy-guided sampling techniques (BAL for AFB and BAL for Gene Xpert MTB/RIF) made diagnosis in 155 cases (91.17%) (P < 0.00001). Comorbid conditions such as human immunodeficiency virus (HIV) coinfection in 36 cases (12.00%), Diabetes mellitus in 64 cases (21.33%), and chronic kidney disease (CKD) in 22 cases (7.33%) were observed. Comorbidities were observed in 41.67% of the studied cases and found very significant assessment to have successful treatment outcome (P < 0.00001). In the study of 300 LLF TB cases, 60 cases were having NRP pattern. In LLF TB cases with NRP pattern, bronchoscopy-guided bronchial wash microscopy for AFB made diagnosis in 18 cases (42%), while bronchoscopy-guided BAL for Gene Xpert MTB/RIF made diagnosis in 58 cases (96.66%) (P < 0.00001). Conclusion: LLF TB is usually underdiagnosed because of diverse clinical and radiological presentation, less diagnostic yield of conventional diagnostic modalities, and these modalities used routinely and universally. Bronchoscopy-guided diagnostic techniques ar...

No abstract

Right middle lobe syndrome (RMLS) is a rare but important clinical entity that is characterized by recurrent or chronic collapse of the middle lobe of the right lung, but which may also involve the lingula of the left lung. In this case report, a 52-year-old female presented with typical constitutional symptoms of tropical disease like cough, fever, and shortness of breath. Chest radiology documented RMLS and bronchoscopy was key to the evaluation of this case, as a sputum examination was inconclusive. Transbronchial needle aspiration (TBNA) of the lymph node and bronchoalveolar lavage (BAL) specimens were tested and Mycobacterium tuberculosis (MTB) of the hilar lymph nodes on the right side was confirmed using the GeneXpert MTB/RIF assay. Four antituberculosis treatment drugs were initiated and maintained for a total of 8 months with steroids as an adjunct in tapering dosages for 4 weeks. Complete clinical and radiological recovery was documented and confirmed bronchoscopically. A high index of suspicion is important when managing RMLS cases and all possible measures should be taken to confirm diagnosis.

Lower lung field tuberculosis (LLF TB) is atypical presentation of tuberculosis. LLF TB is missed routinely because of confusing clinical and radiological presentation and usually these cases initially treated as pneumonia. In this case report, we observed 25 year pregnant female with dysphonia and cough as presenting feature of LLF TB. Chest radiograph was showing 'typical' LLF TB pattern with Cavity in lower zone on right side. Sputum examination for acid fast bacilli was positive in higher grades with 'laryngeal ulcerative lesions' in direct laryngoscopy examination. She was treated with recommended four drug regimen and documented 'cure' at the end of six months. High index of suspicion is must while evaluating these cases and all possible measures to diagnose underlying tuberculosis to have successful treatment outcome.

No abstract

No abstract

Pulmonary Tuberculosis has diverse radiological presentations such as consolidation, cavitation, airway disease, pleural effusion and lymphadenopathy. Pneumonia-like presentation in tuberculosis is very commonly reported in Pulmonary Tuberculosis. Fissural effusion is common in cardiac failure and isolated fissural effusion is rarely described in literature with etiology as tuberculosis. Round pneumonia is commonly described in pediatric cases with community acquired pneumonia and also frequently reported in childhood pulmonary tuberculosis. Round pneumonia is very infrequently reported in adults with pneumonia and to very few published data as due to tuberculosis. In this case report, a 21-year female, presented with constitutional symptoms for 3 months duration with partial response to medical treatment received in line with pneumonia, bronchial asthma and bronchitis. Radiological investigations documented round opacity in right mid-zone with no adventitious breath sound on clinical examination. Recurrent, progressive and partially responding constitutional symptoms was the reason for referral to our center. We have further evaluated with HRCT thorax and documented loculated right horizontal fissural effusion with subpleural parenchymal opacity in right upper lobe posterior segment and right middle lobe lateral basal segment with peri-consolidation satellite nodules in right posterior segment. We have done bronchoscopy due to negative induced sputum microbiological workup. Bronchoscopy guided BAL microbiological workup documented MTB genome with rifampicin sensitivity in cartridge based nucleic acid amplification test and negative BAL smear for AFB. Treatment initiated with anti-tuberculosis (ATT) and recorded near complete radiological resolution, bacteriological cure after six months with good compliance. High index of suspicion is required while managing these cases with constitutional symptoms and typical radiological features such as ‘round pneumonia or fissural effusion’ in absence of other causes for the same. Fissural effusion or round pneumonia due to tuberculosis is rare in adults but not uncommon. Bronchoscopy is a gold standard test to confirm etiological diagnosis due inadequate or poor quality of induced sputum sample in cases with round pneumonia and fissural effusion. Isolated Fissural effusion secondary to pulmonary tuberculosis is extremely rare in medical literature and this will be first case reported till date.