Critical Care Commons^™

Case Of Undiagnosed Pneumocystis Pneumonia (Pcp, Verda Arshad, Nousheen Iqbal, Haider Ali Saleem, Muhammad Irfan

Section of Pulmonary & Critical Care

Pneumocystis pneumonia (PCP) is an opportunistic fungal infection that is usually seen in immunocompromised patients, especially those with HIV, malignancies, organ transplants and on drug therapies like chemotherapy and steroids. PCP has subacute presentation in patients with AIDS which if left untreated gets worse and is a significant cause of morbidity and mortality. Here we present a case of PCP went undiagnosed, partially due to the patient being unaware of his HIV positive status and partially because no organism could be found under the microscope.

Spectrum Of Interstitial Lung Disease From A Tertiary Care Hospital In Karachi, Ali Bin Sarwar Zubairi, Maryam Hassan, Talha Shahzad, Sajjad Sarwar, Aamir Abbas, Huzaifa Ahmad, Muhammad Irfan

Section of Pulmonary & Critical Care

Objective: To determine the clinical features and patterns of interstitial lung disease.
Methods: This retrospective study was conducted at the Aga Khan University Hospital, Karachi, and comprised record of patients diagnosed with interstitial lung disease from January 2005 to December 2015. All patients aged 16 years and above diagnosed with interstitial lung disease on the basis of clinical features, radiological features on high-resolution computed tomography of the chest, and lung biopsies were included. SPSS 19 was used for data analysis.
Results: Of the 537 patients, 324(60.3%) of the participants were females. The overall mean age was 60.5±14.9 years. The most …

Pharmacological Threat To Lungs: A Case Series And Literature Review, Omar Irfan, Jaleed A. Gilani, Abeel Irshad, Babar Irfan, Javaid A. Khan

Section of Pulmonary & Critical Care

Drug-induced organ damage stands as a prevalent yet much-neglected issue globally. Keeping in view it's rising frequency, health care providers stand obliged to be well versed with the de-merits of the agents they prescribe. Drug therapies causing damage present with a non-specific clinical presentation, histological findings or radiology, which further elaborates on the necessity of a conscientious diagnosis. Pulmonary architecture ranging from the airways, lung parenchyma, mediastinum, pleura, pulmonary vasculature or the neuromuscular system, all can fall victim to the dreaded outcomes of this menace. In order to establish successful diagnosis, the definite temporal relation between initiation of drug therapy …

Bilateral Moyamoya Disease In A 2-Year-Old Pakistani Male Treated With Bilateral Encephaloduroarteriosynangiosis: A Positive Outcome., Shahvaiz Magsi, Adeel Khoja, Mansoor Ali Merchant Rameez, Ariba Khan, Noman Ishaque

Department of Medicine

Background. We present a rare case of bilateral moyamoya disease presenting as multiple strokes and neurological deficits, treated with the neurosurgical procedure, encephaloduroarteriosynangiosis (EDAS), in a 2-year-old male Pakistani minor. A positive outcome was achieved and the patient recovered fully. Case Summary. Our patient presented with a history of seizures and multiple episodes of hemiparesis (on and off weakness) at the age of 2 years. He had a delayed speech development and could not speak more than a few words. He had a slight slurring of speech too. He was diagnosed with bilateral moyamoya disease on Computed Tomography Angiography (CTA). …

Pleural Effusion As A Manifestation Of Multiple Myeloma, Nousheen Iqbal, Muhammad Usman Tariq, Mohammad Usman Shaikh, Hashir Majid

Section of Pulmonary & Critical Care

Multiple myeloma is a clonal B-cell malignancy, characterised by proliferation of plasma cells and secretion of paraproteins. These plasma cells accumulate predominantly in the bone marrow; rarely, they invade other areas, especially the thorax. Myeloma presenting with a pleural effusion is rare and reported in only 6% of patients with myeloma. Such patients generally present late and have a poor prognosis. Here, we describe a patient presenting with a lung mass, renal failure and a massive unilateral pleural effusion due to multiple myeloma who was treated successfully.

Epidemiology And Outcomes Of Out-Of-Hospital Cardiac Arrest In A Developing Country-A Multicenter Cohort Study., Minaz Mawani, Muhammad Masood Kadir, Iqbal Azam Syed, Amber Mehmood, Bryan Mcnally, Kent Stevens,, R. Nuruddin, Mohammad Ishaq, J. Razzak

Section of Cardiology

Background

Out-of-hospital cardiac arrest (OHCA) is one of the leading causes of death and disability worldwide. Overall survival after an OHCA has been reported to be poor and limited studies have been conducted in developing countries. We aimed to investigate the rates of survival from OHCA and explore components of the chain of survival in a developing country.

Methods

We conducted a multicenter prospective cohort study in the emergency departments (ED) of five major public and private sector hospitals of Karachi, Pakistan from January 2013 to April 2013. Twenty-four hour data collection was performed by trained data collectors, using a …

Tobacco Control Laws In Pakistan And Their Implementation: A Pilot Study In Karachi, Javaid Ahmed Khan, Abdul Malik Amir Humza Sohail, Muhammad Arslan Arif Maan

Section of Pulmonary & Critical Care

Objective: In order to limit the high prevalence of tobacco use in Pakistan various tobacco control laws have been implemented. The objective of this study is to serve as a pilot study to assess the implementation of these laws in the largest city of Pakistan, Karachi.

Methods: A cross-sectional study was conducted in Karachi. The implementation of tobacco control laws in 'smoke-free' places, the adherence of tobacco companies to these laws, the regulation of cigarette sale, and the awareness and views of the general public regarding tobacco control laws were assessed via direct observation by visits and through self-administered …

The Pediatric Disease Spectrum In Emergency Departments Across Pakistan: Data From A Pilot Surveillance System, Huba Atiq, Emaduddin Siddiqui, Surraya Bano, Asher Feroze, Sayyeda Ghazala Kazi, Jabeen Fayyaz, Shivam Gupta, Junaid A. Razzak, Adnan A Hyder, Asad Mian

Department of Emergency Medicine

Background: There is an increasing number of urgently ill and injured children being seen in emergency departments (ED) of developing countries. The pediatric disease burden in EDs across Pakistan is generally unknown. Our main objective was to determine the spectrum of disease and injury among children seen in EDs in Pakistan through a nationwide ED-based surveillance system.
Methods: Through the Pakistan National Emergency Department Surveillance (Pak-NEDS), data were collected from November 2010 to March 2011 in seven major tertiary care centers representing all provinces of Pakistan. These included five public and two private hospitals, with a collective annual census of …

Sarcoidosis Presented As Retroperitoneal And Lung Mass, Nousheen Iqbal, Aamer Mahmood, Muhammad Irfan, Khurram Minhas

Section of Pulmonary & Critical Care

Sarcoidosis is a multisystem granulomatous disorder of unknown aetiology characterised pathologically by the presence of non-caseating granulomas in involved organs. Sarcoidosis most frequently involves the lungs followed by eye and skin. Presentation as retroperitoneal and lung mass is rare in sarcoidosis. We describe an unusual case of sarcoidosis where the patient presented with large retroperitoneal and lung masses, and was treated as tuberculosis

Prevalence Of Tobacco Use Among Women: A Cross Sectional Survey From A Squatter Settlement Of Karachi, Pakistan, Nousheen Iqbal, Muhammad Irfan, Nida Ashraf, Safia Awan, Javaid A. Khan

Section of Pulmonary & Critical Care

Background: While the prevalence of tobacco use has been slowly declining in the developed countries, rates have been steadily rising in the developing countries. This has led to a rapid rise in tobacco related lung diseases among women.

Objective: Determine the prevalence of tobacco use (both smoking and smokeless) among women in an urban squatter settlement (Orangi Town) in Karachi, Pakistan.

Methods: A cross-sectional survey was conducted on 19,325 females aged between 15 and 80 years in Orangi Town, an urban squatter settlement in Karachi, Pakistan. Modified questionnaire, developed by World Health Organization WHO and Global Adult …

Pulmonary Arteriovascular Malformation: A Rare Cause Of Unexplained Hypoxia And Acute Dyspnoea In Young Patients, Nousheen Iqbal, Karim Abdur Rehman, Javaid Ahmed Khan, Tanveer Ul Haq

Section of Pulmonary & Critical Care

2014 BMJ Publishing Group Ltd.Pulmonary arteriovenous malformations (PAVMs) are anomalous vascular connections between arteries and veins in the lung and comprise of two types, simple and complex. PAVMs are associated with congenital conditions such as hereditary haemorrhagic telengiectasia along with acquired causes. We present a case of a 26-year-old man who presented with dyspnoea, palpitations and decreased oxygen saturation as an initial presentation of PAVM, which was treated successively with embolisation.

Clinical Course And Outcome Of Acute Severe Asthma (Status Asthmaticus) In Adults., Ali Khawaja, Hira Shahzad, Murtaza Kazmi, Ali Bin Sarwar Zubairi

Department of Medicine

Objective: To evaluate the clinical course and outcomes in patients with acute severe asthma in a tertiary care setting.
Methods: The retrospective cross-sectional study was conducted at the Aga Khan University Hospital, Karachi, and comprised data of patients of age 16 and above who were admitted with a diagnosis of acute severe asthma from January 2000 to December 2013.These patients had undergone clinical evaluation to assess the severity of illness as well as the complications and eventual outcomes. SPSS 16 was used for statistical analysis.
Results: Of the 50 patients in the study, 41 (82%) were females. The overall mean …

Effects Of Polypharmacy On Adverse Drug Reactions Among Geriatric Outpatients At A Tertiary Care Hospital In Karachi: A Prospective Cohort Study., Bilal Ahmed, Kashmira Nanji, Rakshinda Mujeeb, Muhammad Junaid Patel

Department of Medicine

Background: Adverse drug reactions (ADRs) present a challenging and expensive public health problem. Polypharmacy is defined according to the WHO criteria as the, ‘‘concurrent use of five or more different prescription medication’’. Elderly are more prone to adverse reactions due to comorbid conditions, longer lists of medications and sensitivity to drug effects. The aim of the study is to estimate the incidence and strength of association of ADRs due to polypharmacy among the geriatric cohort attending outpatient clinics at a tertiary care center.

Methods: A hospital based prospective cohort study was conducted at ambulatory care clinics of Aga Khan University …

Coronary Artery Dissection After Blunt Chest Trauma., Fahad Shamsi,, Javed Tai, Syedah Saira Bukhari

Department of Medicine

Blunt thoracic trauma may result in cardiac injuries ranging from simple arrhythmias to fatal cardiac rupture. Coronary artery dissection culminating in acute myocardial infarction (AMI) is rare after blunt chest trauma. Here we report a case of a 37-year-old man who had an AMI secondary to coronary dissection resulting from blunt chest trauma after involvement in a physical fight.

Association Of Airborne Aspergillus With Asthma Exacerbation In Southern Pakistan., Ali Bin Sarwar Zubairi, Iqbal Azam Syed, Safia Awan, Afia Zafar, Asifali Imam

Department of Medicine

Background: Exposure to airborne fungi has been related with exacerbation of asthma in adults and children leading to increased outpatient, emergency room visits, and hospitalizations. Hypersensitivity to these airborne fungi may be an important initial predisposing factor in the development and exacerbation of asthma.

Objective: This study was conducted to determine an association between fungal types and spore concentrations with the risk of asthma exacerbation in adults.

Methods: This cross-sectional study was conducted from May 2008 to August 2009 at the Aga Khan University Hospital Karachi, Pakistan. All adult (age≥16 years) patients presenting to the hospital with acute asthma exacerbation …

Compliance With Continuous Positive Airway Pressure (Cpap) Therapy For Obstructive Sleep Apnea Among Privately Paying Patients- A Cross Sectional Study, Syed Fayyaz Hussain, Muhammad Irfan, Zeeshan Waheed, Naveen Alam, Saba Mansoor, Muhammad Islam

Section of Pulmonary & Critical Care

Background: To evaluate the compliance, benefits and side effects associated with continuous positive airway pressure (CPAP) therapy among Pakistani patients treated for obstructive sleep apnea (OSA) in private sector.Methods: Patients diagnosed to have OSA based on overnight study who were recommended for CPAP therapy, between 1998 and 2003, were evaluated by telephonic survey and review of hospital notes. Compliance, benefits and side effects associated with CPAP therapy were assessed.Results: Out of 135 patients who were prescribed CPAP therapy, 75 could be contacted. Sixty (80%) started using CPAP within one month of diagnosis and 46 (61%) continued to use it long-term …

A Rare Aetiology Of Respiratory Failure In A 10-Year-Old Boy: Inflammatory Myofibroblastic Tumour., Ali Khawaja, Prem Kumar Maheshwar, Anwarul Haque, Ali Bin Sarwar Zubairi

Department of Medicine

Primary neoplasms of the respiratory tract are rarely encountered in the paediatric population. Inflammatory myofibroblastic tumour (IMT) is a rare soft tissue mesenchymal tumour but a distinct disease entity accounting for less than 1% of all primary lung tumours. We report a case of a 10-year-old boy who presented with respiratory failure and left lung collapse. On flexible fiberoptic bronchoscopy, a pedunculated mass in the lower part of the trachea originating from the left main stem bronchus was identified. The patient subsequently underwent a left-sided pneumonectomy with complete resection of the mass. The histopathological analysis was consistent with IMT. Two …

Six-Minute Walk Test Performance In Healthy Adult Pakistani Volunteers, Nisar Ahmed Rao, Muhammad Irfan, Ahmed Suleman Haque, Ali Bin Sarwar Zubairi, Safia Awan

Section of Pulmonary & Critical Care

Objective: To determine the six-minute walking distance (6MWD) for healthy Pakistanis, identify factors affecting 6MWD, compare published equations with the local data and derive an equation. Study Design: Cross-sectional study. Place and Duration of Study: Two medical institutes of Karachi, from January to May 2011. Methodology: Subjects between 15 and 65 years were prospectively enrolled after screening. A standardized 6MWT was administered. SpO2, HR, BP and dyspnoea scores were determined pre- and post-test. Results: Two hundred and eleven (71%) men and 85 (29%) women participated. Mean 6MWD was 469.88 ± 101.24 m: men walked 502.35 ± 92.21 m and women …

Bronchial Carcinoid Presenting As Multiple Lung Abscesses, Zeeshan Waheed, Muhammad Irfan, Saulat H. Fatimi, Ruqaiya Shahid

Department of Medicine

Bronchial carcinoid tumours is a rare group of pulmonary malignant neoplasm that is derived from neuroendocrine system. Bronchialcarcinoid usually present with hilar masses, atelactasis, bronchiectasis, or post-obstructive pneumonia. This case describes a very unusual presentation of bronchial carcinoid tumour with multiple lung abscesses involving the whole lung. This report is of an adult lady who presented with multiple lung abscesses involving her whole of the right lung. She was found to have an endo-bronchial lesion in her right main bronchus which eventually turned out to be carcinoid tumour. She responded to resection and antibiotic therapy.

Acute Respiratory Distress Syndrome-A Concise Clinical Review, Erfan Hussain, Fahad Hamid

Department of Medicine

Acute Respiratory Distress Syndrome (ARDS) is a challenging and deadly disease faced by critical care specialists. The literature concerning ARDS has been increasing for the last 12 years and there are now many options available to treat this disease. However, not all of these options work and some may even be harmful to patients. The purpose of this paper is to provide the reader with a review of the new criteria for ARDS definition and to discuss the pros and cons of the various treatment options now available.

Factors Associated Within 28 Days In-Hospital Mortality Of Patients With Acute Respiratory Distress Syndrome, Nadia Sharif, Muhammad Irfan, Javaid Hussain, Javaid Khan

Section of Pulmonary & Critical Care

Objective. To determine the factors leading to in-hospital mortality within 28 days in hospitalized patients with ARDS. It was a prospective observational cohort study conducted in Intensive Care Unit of Aga Khan University Hospital Karachi from March to August 2011. Methodology. Data was collected from patients admitted in the intensive care unit on the basis of inclusion and exclusion criteria. The patients were followed daily for 28 days to record any in-hospital complications and the outcome of patients. Results. Total of 46 patients were included during this period out of which 56% (26) were males and 43% (20) were females. …

Bronchial Carcinoid Presenting As Multiple Lung Abscesses, Zeeshan Waheed, Muhammad Irfan, Saulat Fatimi, Ruqaiya Shahid

Section of Pulmonary & Critical Care

Bronchial carcinoid tumours is a rare group of pulmonary malignant neoplasm that is derived from neuroendocrine system. Bronchial carcinoid usually present with hilar masses, atelactasis, bronchiectasis, or post-obstructive pneumonia. This case describes a very unusual presentation of bronchial carcinoid tumour with multiple lung abscesses involving the whole lung. This report is of an adult lady who presented with multiple lung abscesses involving her whole of the right lung. She was found to have an endo-bronchial lesion in her right main bronchus which eventually turned out to be carcinoid tumour. She responded to resection and antibiotic therapy.

Expression Of M. Tuberculosis-Induced Suppressor Of Cytokine Signaling (Socs) 1, Socs3, Foxp3 And Secretion Of Il-6 Associates With Differing Clinical Severity Of Tuberculosis, Kiran I. Masood, Martin E. Rottenberg, Naseem Salahuddin, Muhammad Irfan, Nisar Rao, Berit Carow, Muniba Islam, Rabia Hussain, Zahra Hasan

Section of Pulmonary & Critical Care

Background

Appropriate immune activation of T cells and macrophages is central for the control of Mycobacterium tuberculosis infections. IFN-γ stimulated responses are lowered in tuberculosis (TB), while expression of Suppressor of Cytokine Signaling (SOCS) molecules – 1 and 3 and CD4⁺CD25⁺FoxP3⁺T regulatory cells is increased. Here we investigated the association of these molecules in regard to clinical severity of TB.

Methods

Peripheral blood mononuclear cells (PBMCs) were isolated from patients with pulmonary TB (PTB, n = 33), extra-pulmonary TB (ETB, n = 33) and healthy endemic controls (EC, n = 15). Cases were classified …

Cross-Sectional Study Identifying Forms Of Tobacco Used By Shisha Smokers In Pakistan, Sameer-Ur-Rehman, Mohammed Ali Sadiq, Maria Adnan Parekh, Ali Bin Sarwar Zubairi, Philippe. Frossard, Javaid Khan

Section of Otolaryngology, Head & Neck Surgery

Objectives: To estimate the frequency of different forms of tobacco intake such as smoker's tobacco, chewable tobacco and snuff tobacco among shisha smoker's and to study the patterns and predictors of shisha smoking affecting youth from different cities of Pakistan.
Methods: A cross-sectional study was conducted including youth from four cities. Participants were asked to fill out a data collection tool at shisha cafes, shopping malls and restaurants. Data was analyzed using SPSSv.18.
Results: A total of 406 participants, 296 (73%) males and 110 (27%) females were included in the study. There were 163 (40%) cigarette smokers; 65 (16%) chewed …

Population Attributable Risk Of Unintentional Childhood Poisoning In Karachi Pakistan, Bilal Ahmed, Zafar Fatmi, Amna R Siddiqui

Department of Medicine

Background: The percentage of unintentional childhood poisoning cases in a given population attributable to specific risk factors (i.e., the population attributable risk) which can be calculated, determination of such risk factors associated with potentially modifiable risk factors, are necessary to focus on the prevention strategies.

Methods: We calculated PARs, using 120 cases with unintentional poisoning and 360 controls in a hospital based matched case- control study. The risk factors were accessibility to hazardous chemicals and medicines due to unsafe storage, child behavior reported as hyperactive, storage of kerosene and petroleum in soft drink bottles, low socioeconomic class, less education of …

Treatment Outcome Of Multi-Drug Resistant Tuberculosis Treated As Outpatient In A Tertiary Care Center, Zeeshan Waheed, Muhammad Irfan, Ahmed Suleman Haque, Muhammad Owais Khan, Atif Zubairi, Noor Ul Ain, Javaid A. Khan

Section of Pulmonary & Critical Care

INTRODUCTION: Community-based out-patient treatment for multidrug-resistant tuberculosis (MDR TB) is relatively new concept with reported successful outcomes.

OBJECTIVE: To assess the treatment outcomes of HIV negative multidrug-resistant tuberculosis (MDR TB) patients treated as outpatient at a tertiary care center in Karachi, Pakistan.

METHODS: A retrospective observational study of 53 consecutive, culture proven HIV negative MDR TB patients (resistant at least to both Isoniazid (H) and Rifampin(R) treated at Aga Khan University Hospital, Karachi between August 1999 and March 2007. Data were collected on predesigned performa regarding patient’s demography, clinical features, radiological findings, drug sensitivity, treatment and outcome.

RESULTS: A total …

Drug Resistance Pattern In Multidrug Resistance Pulmonary Tuberculosis Patients, Nisar Ahmed Rao, Muhammad Irfan, Mir Mir Soomro, Zeeshan Mehfooz

Section of Pulmonary & Critical Care

Objective: To evaluate accuracy of modified Kenneth Jones scoring criteria (MKJSC) as a screening tool to diagnose tuberculous meningitis in children. Study Design: Cross-sectional study. Place and Duration of Study: Paediatric Medicine, Unit-I, Bahawal Victoria Hospital, Bahawalpur, from May 2006 to March 2007. Methodology: A total of 100 children admitted through emergency in Paediatric Medicine, Unit-I, were included who were having fever and features suggestive of central nervous system (CNS) infection. Lumbar puncture was done in all patients after written consent. Findings of lumbar puncture were taken as gold standard for the diagnosis of TBM. MKJSC was applied on each …

Ccl2 Responses To Mycobacterium Tuberculosis Are Associated With Disease Severity In Tuberculosis, Zahra Hasan, Jacqueline M. Cliff, Hazel M. Dockrell, Bushra Jamil, Muhammad Irfan, Mussarat Ashraf, Rabia Hussain

Section of Pulmonary & Critical Care

Background

Leucocyte activating chemokines such as CCL2, CCL3, and CXCL8 together with proinflammatory IFNγ, TNFα and downmodulatory IL10 play a central role in the restriction of M. tuberculosis infections, but is unclear whether these markers are indicative of tuberculosis disease severity.

Methodology

We investigated live M. tuberculosis- and M. bovis BCG- induced peripheral blood mononuclear cell responses in patients with tuberculosis (TB) and healthy endemic controls (ECs, n = 36). TB patients comprised pulmonary (PTB, n = 34) and extrapulmonary groups, subdivided into those with less severe localized extrapulmonary TB (L-ETB, n = 16) or severe disseminated ETB (D-ETB, …

Treatment Outcome Of Multi-Drug Resistant Tuberculosis In A Tertiary Care Hospital In Karachi, Nisar Ahmed Rao, Zeeshan Mahfooz, Muhammad Irfan

Section of Pulmonary & Critical Care

Objective: To assess the outcomes of pulmonary multidrug-resistant tuberculosis (MDR-TB) patients treated at Ojha Institute of Chest Diseases (OICD), a reference hospital for TB in Karachi, Pakistan. Methods: Clinical study for the period 1996-2006, with follow-up until June 2007 was performed. All the culture and sensitivity proven cases of MDR pulmonary TB were initially admitted for 3-6 months till the sputum converted negative. Treatment regimen was decided on individual basis, and included 4-6 drugs. Supervised treatment was given to all patients during the hospitalization. After discharge from the hospital, patients were followed at monthly interval at the outpatient department of …

Differential Live Mycobacterium Tuberculosis- , M. Bovis Bcg-, Recombinant Esat6-, And Culture Filtrate Protein 10-Induced Immunity In Tuberculosis, Zahra Hasan, Bushra Jamil, Mussarat Ashraf, Muniba Islam, Maqboola Dojki, Muhammad Irfan, Rabia Hussain

Section of Pulmonary & Critical Care

The high prevalence of Mycobacterium tuberculosis makes it imperative that immune responses to evaluate could be predictive of infection. We investigated live Mycobacterium- and recombinant antigen-induced cytokine and chemokine responses in patients with active tuberculosis (TB) compared with those of healthy controls from an area where TB is endemic (ECs). M. tuberculosis-, M. bovis BCG-, ESAT6-, and culture filtrate protein 10 (CFP10)-induced responses were determined in peripheral blood mononuclear cells from patients with pulmonary TB (n = 38) and ECs (n = 39). The levels of the cytokines gamma interferon (IFN-γ) and interleukin-10 (IL-10) and the …