Nirish Vaidya

Introduction and importance: Williams–Campbell syndrome (WCS) is a rare congenital syndrome that can lead to bronchiectasis. Although commonly found in pediatric age groups, it can also be seen in adults due to delayed diagnosis with respiratory symptoms of cough, sputum, and wheezing. Presentation of case: A 31-year-old male presented with an incidental finding of bilateral cystic lesions in the lung field for which high-resolution computed tomography of the chest was done, which showed bilateral multiple cystic lesions without any clinical findings except mild inspiratory wheeze. Clinical discussion: Diagnosis: Any suspected case of bronchiectasis must undergo imaging: chest radiograph or computed tomography scan, along with blood investigations, sputum tests, and, if needed, a biopsy to help establish a diagnosis. Diagnosis of WCS is made after exclusion of common causes, which can be cystic fibrosis, foreign body aspiration, tuberculosis, COPD, and congenital causes like bronchomalacia, Mounier–Kuhn syndrome, tracheoesophageal fistula, etc. Therapeutic intervention: Chest physiotherapy, antibiotic therapy, vaccination, and pulmonary rehabilitation are primary modes of treatment. En bloc lung transplantation can be done in some cases. Conclusion: Diagnosis is made by ruling out all other causes of bronchiectasis, but a dynamic CT scan confirms the diagnosis. Chest physiotherapy and antibiotics are the treatment of choice.

Introduction: The mainstay treatment according to the Global Initiative for Chronic Obstructive Lung Disease 2023 guidelines for Chronic Obstructive Pulmonary Disease is combination of long acting bronchodilators with addition of inhaled corticosteroids only in patients with increased exacerbations and an eosinophil count of ≥ 300 cells/μL. Despite the recommendations, inhaled corticosteroids are most commonly overprescribed. So, this study aims to follow patients with mild to moderate cases of this disease who are currently on inhaled corticosteroids combination therapy for clinical efficacy after its withdrawal. Methods: The study was a prospective interventional study conducted at Dhulikhel Hospital that followed individuals with mild to moderate COPD for eight weeks after a sudden ICS withdrawal. Forced Expiratory Volume in first second, modified Medical Research Council grading, COPD Assessment Tool score and number of exacerbations were assessed with follow-up either by telephone or face to face. Results: Total of 33 patients were enrolled in the study with mean age 68.9 years and standard deviation 9.3 years. Paired t-test analysis showed no significant mean difference in Forced Expiratory Volume in first second and COPD Assessment Tool values before and eight weeks after the withdrawal of Inhaled Corticosteroids. Conclusions: Our study supported the conclusion of previous larger studies that withdrawing ICS in stable mild to moderate COPD patients makes no difference in clinical symptoms and spirometry.

Introduction and importance: Pachydermoperiostosis is a syndrome characterised by the triad of pachydermia, digital clubbing and periostosis of long bones and its scarce incidence and similarity in clinical features with acromegaly makes the diagnosis challenging. The elevated PGE2 levels have been hypothesised as one of its mechanisms and therapies have been targeted to inhibit this prostaglandin. Case presentation: A 25-year-old man with no comorbidities presented to OPD with 10-year history of bilateral pain and swelling of hands and feets associated with hyperhidrosis, grade IV clubbing and marked skin thickening on his forehead. X-ray revealed hyperostosis of metacarpals, proximal and middle phalanges and periosteal bone formation with cortical thickening of ankle joint. Tests done to rule out differentials such as thyroid acropachy, acromegaly, psoriatic arthritis were normal and clinical diagnosis of pachydermoperiostosis, a rare genetic disease characterised by pachyderma, digital clubbing, and periostosis was made. Clinical discussion: The patient was managed conservatively with Etoricoxib for six months on a follow-up basis. The symptoms were improving and a repeat X-ray showed partial improvement of soft tissue thickening and periostosis. Conclusion: Pachydermoperiostosis is a rare diagnosis with no clear consensus on management approach. Its management with selective COX-2 inhibitors such as Etoricoxib should be considered but its long term effects should be studied further.

Hemoptysis is a crucial entity taking into account its morbidity and mortality. Pulmonary tuberculosis is the leading cause for massive hemoptysis in our part of the world, which if left untreated may be life threatening. We present a case of a 37-year-old male patient with pulmonary tuberculosis with concurrent pulmonary thromboembolism presenting with massive hemoptysis, which was successfully managed with Bronchial Artery Embolization. This case represents that this measure can be a viable therapeutic choice for a patient with a severe life-threatening hemoptysis, particularly when other treatment options are unavailable or ineffective.

Introduction: and importance: Acute massive pulmonary thromboembolism is a potentially life-threatening condition requiring urgent management to decrease mortality. Although the standard dose of systemic throm-bolysis with alteplase is 100 mg, half the dose of alteplase can be used to break up clots successfully, especially if bleeding is a concern.Case presentation: We report a case of massive pulmonary thromboembolism presenting with cardiopulmonary arrest, successfully managed with advanced cardiac life support, anticoagulants, and low-dose thrombolytics.Clinical discussion: Management of massive pulmonary thromboembolism includes medical thrombolysis along with maintenance of hemodynamic stability. Our patient was successfully managed with low-dose thrombolytics and was continued with standard oral anticoagulants for 6 months.Conclusion: In patients of acute massive pulmonary thromboembolism, a low dose of the thrombolytic agent can achieve complete resolution of the thrombus with less bleeding risk.

Background: It is universally recommended that blood pressure should be measured on bare arm for accurate reading. However, this is seldom done in busy clinical schedules. This study aims to see if clothing adjustments should be a concern while measuring blood pressure under suboptimal conditions. Materials and Methods: This was a cross sectional study conducted at medicine department of Kathmandu University Hospital, Dhulikhel Hospital among conveniently selected 100 patients. After getting informed consent, consecutive blood pressure measurements were done over rolled-up sleeve arm, sleeve arm and bare arm in seated position. Socio-demographic information were obtained through an interview using a semi-structured questionnaire. Data were entered in Microsoft Excel and analyzed using descriptive and inferential statistics in Statistical Software for Social Sciences version 20. Results: The median of differences between sleeved arm and bare arm was 0 for both systolic and diastolic blood pressure and the median value for differences between rolled up arm and bare arm was 2 units for both systolic and diastolic blood pressure. Although the differences looked statistically significant, the size of the differences was not clinically significant. Conclusion: Meticulous clothing adjustment has clinically insignificant differences in measurement of blood pressure if patient is wearing thin sleeves. Therefore, in suboptimal conditions, blood pressure can be measured on rolled-up sleeve arm and sleeve arm if patient is wearing thin sleeve clothes.

Background Diagnostic evaluation of pleural fluid according to Light’s criteria to differentiate between exudative and transudative fluid takes 1 or 2 working days. For rapid clinical management, especially in critically ill patients, a simpler bedside diagnostic test can be done which has similar diagnostic accuracy as that of Light’s Criteria. Objective To determine the diagnostic accuracy of Drop Hydrogen Peroxide test to differentiate exudative and transudative pleural effusion in comparison to Light’s criteria. Method A concurrent validity test was performed using a convenient sampling technique including patients presenting to the Department of Internal Medicine from January to September 2021, who had pleural effusion. Two milliliters of tapped pleural fluid of patients who underwent aseptic thoracocentesis was collected in a test tube to which one to two drops of 20% hydrogen peroxide was added. Presence of bubbles suggested an exudative type of fluid. Rest of the tapped pleural fluid was sent to the laboratory for further evaluation by Light’s criteria, which was compared with the results by Drop Hydrogen Peroxide Test. Result There were 83 patients who had pleural effusion, of them a total of 43 patients had transudative pleural effusion while 40 patients had exudative pleural effusion based on Light’s criteria and 37 patients had transudative pleural effusion while 46 patients had exudative pleural effusion based on drop hydrogen peroxide test. Conclusion The drop hydrogen peroxide test allows cost effective and prompt evaluation of the type of pleural effusion is exudative or transudative, thereby making it a convenient diagnostic bedside test.