Brittle asthma is a life-threatening phenotype of asthma and was considered relevant in clinical practice before the year 2000. After the introduction of GINA guidelines, this entity was not discussed much in literature and the phenotype was included in acute severe asthma. Even the GINA guideline-2022 update is silent about this phenotype. This article discusses brittle asthma phenotypes and examines the relevance of this entity in clinical practice.

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Background: Vitamin D deficiency has been declared a public health problem for both adults and children worldwide. Asthma and related allergic disorders are leading causes of morbidity in children. The objective of this study was to estimate Vitamin D levels in children suffering from asthma and allergic rhinitis in North Kerala. Objectives: (1) To evaluate Vitamin D levels among children between the age group 5 and 18 years suffering from asthma and/or allergic rhinitis. (2) To study the factors associated with low levels of Vitamin D and (3) to study the correlation between Vitamin D levels, immunoglobulin E (IgE), and absolute eosinophil count (AEC). Materials and Methods: This is a retrospective analysis of hospital data in which data of children between the age group 5 and 18 years attending the pulmonology outpatient department of a tertiary care hospital in North Kerala are captured. The study period was 6 months from March 01, 2021, to August 31, 2021. Detailed clinical history, physical examination, and laboratory investigations including complete blood cell count, IgE, and 25 dihydroxyvitamin D3 (Vitamin D) level were done. Diagnosis of allergic rhinitis and asthma is made on the clinical presentation by an experienced pulmonologist. Family history of asthma or allergic rhinitis was also recorded. Data were entered into Microsoft Excel, and analysis was done using Epi Info 7. Means and standard deviation were calculated, and correlation was assessed between Vitamin D levels, IgE, AEC, and age of the children. Results: Thirty percent of children in the study group had Vitamin D deficiency, 56% had insufficient values, and 14% had normal values. Most of the children with low Vitamin D levels had raised values for IgE and AEC, but the association was not statistically significant. Conclusion: Most of the children in this part of the state presenting with respiratory allergy have low or insufficient levels of Vitamin D. This may be one of the reasons for poor control of symptoms and such children may require Vitamin D supplementation along with optimal treatment of respiratory allergy.

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Positive airway pressure therapy is usually a well tolerated mode of treatment used for managing patients with various diseases where either oxygenation or ventilation is compromised. Air regurgitation through the naso lacrimal duct (NLD) is a rare complication of positive airway pressure therapy. There are multiple valves in the nasolacrimal duct to prevent the retrograde airflow from the nasal cavity to the lacrimal sac, under normal physiological conditions. Failure of this multi level valve system will lead to the retrograde air flow from the nasal cavity to reach the lacrimal puncta via the nasolacrimal duct. Valve insufficiency by birth or due to a prior procedure done at this region could be the underlying cause for this complication. In this case report, we discuss about the appearance of air regurgitation in a patient with chronic obstructive pulmonary disease on bi-level positive airway pressure (BiPAP) therapy and we also discuss on the causes for this complication and the various treatment modalities to manage this condition.

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Background: Pulmonary hypertension (PH) is a disorder of the pulmonary vasculature caused due to vasoconstriction, vaso-destruction, or vaso-obliteration as a complication of a varied spectrum of diseases referred to a pulmonologist. We conducted this study to contemplate the profile of PH in a tertiary care hospital in Mumbai. Methodology: This was an observational study undertaken in the department of pulmonary medicine at a tertiary care center after internal ethical committee approval. Patients with respiratory symptoms referred to us with PH as estimated pulmonary artery systolic pressure (PASP) of ≥40 mmHg by transthoracic two-dimensional echocardiography (corresponding to mean pulmonary artery pressure of ≥25 mmHg) were included in the study. The profile of these patients was studied on basis of parameters such as demography, etiology, symptomatology, radiological features, 6-min walk distance (6-MWD), and spirometry. Data were analyzed using Microsoft Excel software. Results: Among 347 patients, 54% were men. Majority of the patients (53.5%) were aged between 45 and 65 years. The most common symptom was dyspnea (86%). The most common examination finding was loud pulmonary component of second heart sound (62%). The common etiologies of PH were postinfectious obliterative bronchiolitis (OB) 30%, interstitial lung diseases 26%, chronic obstructive pulmonary disease 24%, and obstructive sleep apnea 14%. There was a negative correlation between 6-MWD, forced vital capacity % predicted, forced expiratory volume in 1^st s % predicted, and PASP. Conclusion: Airway disease is the most common etiology of PH in patients presenting to a pulmonologist in India, out of which postinfectious OB forms the major bulk.

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Radiation-induced lung injury (RILI) encompasses any lung toxicity induced by radiation therapy (RT). It manifests acutely as radiation pneumonitis (RP) and chronically as radiation pulmonary fibrosis. It is usually seen in patients who have undergone thoracic irradiation for the treatment of lung, breast, or hematologic malignancies. The volume of lung irradiated and the mean lung dose are important risk factors. The diagnosis is usually based on a combination of typical symptoms (e.g., cough, dyspnea, and occasionally fever), timing, dose, and location of radiation therapy, compatible imaging findings, and exclusion of other causes. We report a case of a patient with breast cancer, who had received locoregional radiotherapy (RT) and then palliative RT for metastasis in the rib, following which she developed symptoms and radiological manifestations consistent with RILI. The patient recovered clinically and radiologically with conservative management. It was important to accurately diagnose the entity early since RP with moderate-to-severe symptoms and impaired respiratory function needs to be treated early to prevent irreversible lung damage.

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Pulmonary embolism (PE) is a relatively common cardiovascular event with high early mortality rates. Many risk factors play a role in the causation of PE including acquired as well as inherited. Methylenetetrahydrofolate reductase (MTHFR) gene mutation is one of the inherited etiologies for PE which cause hyperhomocysteinemia which can lead to PE. This in turn can result in secondary complications such as pneumothorax or hydropneumothorax, which are rare presentations of PE. Hereby, we present this unique case of a 17-year-old boy who presented with a hydropneumothorax which on further evaluation was found to be a complication of bilateral PE which was due to hyperhomocysteinemia with MTHFR A1298C mutation. Hence, we present this unique case with rare presentation as well as rare etiology for PE. This shows the significance for considering PE as one of the differentials in situations such as cavitations, pneumo or hydropneumothoraces, and hyperhomocysteinemias.

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Mechanotransduction is the phenomenon of conversion of mechanical forces to biochemical signals in fibrosis. Knowledge on how mechanotransduction influences the behavior of cells and tissues will help to identify novel therapeutic targets for mechanomodulatory approaches. Innovative therapies based on these advances will potentially transform fibrotic healing into tissue regeneration.

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Extrapulmonary tuberculosis (EPTB) remains often ignored by both medical community and authorities. This review attempts to summarize the pathogenesis, clinical presentation, investigations, diagnosis, treatment, and complication of lymph node TB (LNTB) in India. LNTB refers to Mycobacterium tuberculosis infection of the lymph nodes and is the most common form of EPTB in India. Classical symptoms include low-grade fever, weight loss, loss of appetite, night sweats, and painless enlarged lymph nodes in the neck or axilla or groin. Mediastinal lymphadenopathy presents with cough and chest discomfort and uncommonly even with shortness of breath; wherever possible, a pathological and microbiological diagnosis must be attempted by fine-needle aspiration for cytology, histopathology, acid-fast bacilli smear, and molecular tests such as cartridge-based nucleic acid amplification test and culture. For deep nodes, ultrasound/computed tomography/endobronchial ultrasound-guided aspiration can be done. LNTB is primarily requires medical management, and adjunct surgical excision is generally associated with worse outcomes. Six-month antitubercular therapy standard first-line regimen is recommended for peripheral LNTB and can be provided at the nearest local directly observed treatment short-course chemotherapy center in India.

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