Han Loong Tan

Background: Delaying onset and early recognition of CLAD are clinically relevant strategic targets in lung transplantation. Flow volume (FV) curves provide a simple easy visual indicator of early/persistent allograft injury and scalloping on FV loop in particular is a marker of small airway obstruction which is characteristic of CLAD-BOS. Aims and objectives: To study if early scalloping on FV loop at 3 months post-transplant can predict onset of CLAD-BOS at 1 year post transplant and influence frequency of acute cellular rejection (ACR) or survival. Methodology: This is a non-interventional retrospective study involving all patients who underwent bilateral lung transplantation from 2012-2015 at Freeman Hospital, Newcastle Upon Tyne, UK. Serial post-transplant monitoring data were reviewed. Spirometry at 3 months post lung transplant, FV loop, incidence of ACR, BOS and long term survival post transplant were recorded and analyzed. Results: 156 subjects-93 males (59.6%) who underwent bilateral lung transplantation were included. 42 (27%) subjects demonstrated scalloping of FV loop at 3 months. Subjects with scalloping of FV loop have significant higher incidence of BOS at 1 & 2 year (16.7% & 26.2%) compared to those without scalloping (5.3% & 8%), p=0.023 & 0.002 respectively. Kaplan-Meier survival analysis estimates shorter median survival in subjects with scalloping (7.56 years versus 8.9 years), p=0.222. There is no significant correlation between scalloping of FV loop and number of ACR’s at 1 year. Conclusions: Early detection of scalloping on FV loop is clinically relevant and increases incidence of CLAD-BOS.

Hunter Syndrome is a genetic disease characterized by deficiency of Iduronate-2-Sulfatase enzyme activity, resulting in accumulation of glycoaminoglycans in various organs including the central airways. We report a case of severe tracheomalacia and airway stenosis at Hospital Sultanah Aminah, Johor Bahru, Malaysia requiring mechanical ventilation in a middle aged gentleman who was previously undiagnosed of mucopolysaccharidosis. The patient underwent emergency tracheostomy for failed intubation, when he presented with shortness of breath and acute respiratory failure. A contrast-enhanced computed tomography of the neck and thorax revealed that the trachea distal to the tracheostomy tube had collapsed with narrowed right and left main bronchus. These findings were confirmed via direct visualization of the airway through a flexible bronchoscopy. Eventually, a tracheal stenting were performed to maintain the airway patency and assist in weaning off from mechanical ventilation. Further investigations to identify the aetiology of the central airway stenosis revealed elevated urinary glycoaminoglycans and the absence of iduronate-2-Sulfatase activity tested on dried blood spots, thus confirming the diagnosis of Hunter Syndrome. Managing mucopolysacharidosis with central airway obstruction requires multidisciplinary team effort in handling the difficult airway, anaesthesiology risk, potential comorbidities and providing genetic counselling.

Introduction: The burden of MDR-TB leads to increment in healthcare cost and long treatment duration. Studying the disease characteristics and treatment outcome would assist the clinician in managing it. Objectives: To determine the MDR-TB treatment outcome in our centre and treatment side effects. We hypothesize that certain clinical characteristics are associated with poorer treatment outcome. Methods: A retrospective study was conducted to review the medical records of all MDR-TB patients registered in Institute of Respiratory Medicine, Kuala Lumpur from 2015-2016. Demographic data, disease characteristics, treatment outcome and adverse drug reactions were recorded and analyzed. Results: 63 patients were diagnosed to have MDR-TB, comprised of 42 males and 21 females, with mean age of 39.6±12.6 year. Primary and acquired MDR-TB were 33.3% and 66.7% respectively. Majority of the cases were pulmonary tuberculosis (88.9%) and 63.5% were smear positive. 71.4% were treated with conventional MDR-TB regimen; mean treatment duration are 13±8.1 months. MDR-TB treatment success rate in our centre was 49.2%(31/63). 41.3% of MDR-TB patients have poor outcome, including 20 treatment defaults, 2 relapse MDR-TB and 4 mortalities. 6 patients were transferred to other centres. Male gender(p=0.006) and smoker(p=0.018) were associated with poor treatment outcome. 66.7% patients developed adverse drug reactions such as vomiting (15.8%), hypothyroidism (15.8%), psychotic symptoms (14%) and ototoxicity (10.5%). Conclusions: About half of the MDR-TB cases in our centre achieved successful treatment outcome. Poor treatment outcome was seen in male and smoker.

Dental laboratory technicians are at risk of developing occupational respiratory diseases due to exposure to various potentially toxic substances in their working environment. Since 1939, few cases of silicosis among dental technician have been reported. We illustrate a 38 year-old female, who worked in a dental laboratory for 20 years, initially treated as pulmonary tuberculosis and chronic necrotising aspergillosis without much improvement. Computed tomography guided lung biopsy and bronchoscopic transbronchial lung biopsy were performed. Lung tissue biopsies showed presence of refractile dental materials within the areas of histiocyte proliferation. The diagnosis of dental technician pneumoconiosis was obtained and our patient underwent pulmonary rehabilitation. This case highlights the importance of obtaining a detailed occupational history in tuberculosis endemic area, as pulmonary tuberculosis is a great mimicker of other respiratory diseases.