AimThe efficiency of various investigations and diagnostic criteria used in diagnosis of allergic bronchopulmonary aspergillosis (ABPA) remain unknown, primarily because of the lack of a gold standard. Latent class analysis (LCA) can provide estimates of sensitivity and specificity in absence of gold standard. Herein, we report the performance of various investigations and criteria employed in diagnosis of ABPA.MethodsConsecutive subjects with asthma underwent all the following investigations Aspergillus skin test, IgE levels (total and A.fumigatus specific), Aspergillus precipitins, eosinophil count, chest radiograph, and high-resolution computed tomography (HRCT) of the chest. We used LCA to estimate the performance of various diagnostic tests and criteria in identification of ABPA.ResultsThere were 372 asthmatics with a mean age of 35.9 years. The prevalence of Aspergillus sensitization was 53.2%. The sensitivity and specificity of various tests were Aspergillus skin test positivity (94.7%, 79.7%); IgE levels>1000 IU/mL (97.1%, 37.7%); A.fumigatus specific IgE levels>0.35 kUA/L (100%, 69.3%); Aspergillus precipitins (42.7%, 97.1%); eosinophil count>1000 cells/µL (29.5%, 93.1%); chest radiographic opacities (36.1%, 92.5%); bronchiectasis (91.9%, 80.9%); and, high-attenuation mucus (39.7%, 100%). The most accurate criteria was the Patterson criteria using six components followed by the Agarwal criteria. However, there was substantial decline in accuracy of the Patterson criteria if components of the criteria were either increased or decreased from six.Conclusions A.fumigatus specific IgE levels and high-attenuation mucus were found to be the most sensitive and specific test respectively in diagnosis of ABPA. The Patterson criteria remain the best diagnostic criteria however they have good veridicality only if six criteria are used.

BackgroundPenicillium marneffei is a dimorphic fungus, endemic in South-east Asia. The fungus causes severe disease in immunocompromised patients such as AIDS. However, no case of immune restoration disease of Penicillium marneffei is reported in literature from a non-endemic area.Case PresentationWe report the first case of Penicillium marneffei and Cytomegalovirus infection manifesting as a result of immune restoration one month after initiating HAART. This severely immunocompromised patient had presented with multiple lymphadenopathy, massive hepatosplenomegaly, visual impairment and mild icterus, but no skin lesions. Penicillium marneffei was isolated from lymph node fine-needle aspirates and blood cultures.ConclusionIn order to diagnose such rare cases, the clinicians, histopathologists and microbiologists alike need to maintain a strong index of suspicion for making initial diagnosis as well as for suspecting immune reconstitution syndrome (IRS) with Penicillium marneffei.

The evaluation of pleural diseases has been well established. If pleurocentensis is non-diagnostic, the second investigation depending upon availability could be either closed pleural biopsy or image guided pleural biopsy or thoracoscopic pleural biopsy (medical or surgical). Pleural disease presenting as thickness/mass/nodule in the mediastinum is difficult to access through ultrasound or computed tomography and will need thoracoscopy. Thoracoscopy is an invasive procedure which can be difficult to perform in localized mediastinal pleural disease without effusion or poor health condition not suitable for general anesthesia. An alternative method that can be utilized is sampling of pleural lesion through convex probe endobronchial ultrasound (CEBUS) either through the central large airways or from esophagus if the lesions are in proximity. We present our center’s experience in diagnosing pleural lesion using C-EBUS in 4 patients along with review of the literature.

Sheehan’s syndrome is a well-known cause of panhypopituitarism secondary to pituitary apoplexy, that generally occurs after an intra- or postpartum bleeding episode characterized by massive hemorrhage and hypovolemic shock. The diagnosis can be difficult and is often formulated after some years from the syndrome occurrence. We report the case of a woman with a relatively early diagnosed Sheehan’s syndrome associated with amenorrhoea and secondary hypothyriodism complicated by postpartum hemorrhage. DOI: http://dx.doi.org/10.3126/jcmc.v3i2.8444 Journal of Chitwan Medical College Vol.3(2) 2013 49-50

Fat embolism syndrome (FES) is a constellation of clinical symptoms characterized by a triad of respiratory insufficiency, altered sensorium and petechiae occurring after orthopaedic trauma or following surgical manipulation of long bones and spine. The diagnosis is based on clinical presentation and excluding other possible conditions. Beside histopathology, none of the investigations such as fat macroglobinuria in urine or lipid laden macrophages in bronchoalveolar lavage (BAL) is 100% specific. At times FES can present with atypical presentation such as intra alveolar haemorrhage and only high index of suspicion can help in making diagnosis.