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Randomised controlled trials, including the National Lung Screening Trial (NLST) and the NELSON trial, have shown reduced mortality with lung cancer screening with low-dose CT compared with chest radiography or no screening. Although research has provided clarity on key issues of lung cancer screening, uncertainty remains about aspects that might be critical to optimise clinical effectiveness and cost-effectiveness. This Review brings together current evidence on lung cancer screening, including an overview of clinical trials, considerations regarding the identification of individuals who benefit from lung cancer screening, management of screen-detected findings, smoking cessation interventions, cost-effectiveness, the role of artificial intelligence and biomarkers, and current challenges, solutions, and opportunities surrounding the implementation of lung cancer screening programmes from an international perspective. Further research into risk models for patient selection, personalised screening intervals, novel biomarkers, integrated cardiovascular disease and chronic obstructive pulmonary disease assessments, smoking cessation interventions, and artificial intelligence for lung nodule detection and risk stratification are key opportunities to increase the efficiency of lung cancer screening and ensure equity of access.

Aerosol generating procedures are avoided for COVID-19 patients to lower the risk of transmission to healthcare providers. However, when bronchoscopy is indicated, it remains unclear if the procedure performed under general anesthesia leads to contamination of the surroundings and if standard endoscopy reprocessing methods are effective in eradicating SARS-CoV-2. We share our experience of bronchoscopic retrieval of airway foreign body under general anesthesia in a patient tested positive for novel 2019 coronavirus disease (COVID 19). We focus on anesthesia techniques to minimise aerosolization.

Supplementary Data from Color Fluorescence Ratio for Detection of Bronchial Dysplasia and Carcinoma In situ

Background: Autofluorescence bronchoscopy is more sensitive than conventional bronchoscopy for detecting early airway mucosal lesions. Decreased specificity can lead to excessive biopsy and increased procedural time. Onco-LIFE, a device that combines fluorescence and reflectance imaging, allows numeric representation by expressing red-to-green ratio (R/G ratio) within the region of interest. The aim of the study was to determine if color fluorescence ratio (R/G ratio) added to autofluorescence bronchoscopy could provide an objective means to guide biopsy.Methods: Subjects at risk for lung cancer were recruited at two centers: VU University Medical Centre (Amsterdam) and BC Cancer Agency (Canada). R/G ratio for each site appearing normal or abnormal was measured before biopsy. R/G ratios were correlated with pathology, and a receiver operating characteristic curve of R/G ratio for high-grade and moderate dysplasia was done. Following analysis of the training data set obtained from two centers, a prospective validation study was done.Results: Three thousand three hundred sixty-two adequate biopsies from 738 subjects with their corresponding R/G ratios were analyzed. R/G ratio 0.54 conferred 85% sensitivity and 80% specificity for the detection of high-grade and moderate dysplasia, area under the curve was 0.90, and 95% confidence interval was 0.88 to 0.92. In another 70 different sites that were assessed, κ measurements of agreement of R/G ratios with visual scores and pathology were 0.66 (P < 0.0001) and 0.61 (P < 0.0001), respectively. R/G ratio combined with visual score improved specificity to 88% (95% confidence interval, 0.73-0.96) for high-grade and moderate dysplasia.Conclusion: Color fluorescence ratio can objectively guide the bronchoscopist in selecting sites for biopsy with good pathologic correlation.

BACKGROUND AND OBJECTIVE Simulation enhances a physician's competency in procedural skills by accelerating ascent of the learning curve. Training programmes are moving away from the Halstedian model of 'see one, do one, teach one', also referred as medical apprenticeship. We aimed to determine if a 3-month structured bronchoscopy curriculum that incorporated simulator training could improve bronchoscopy competency among pulmonary medicine trainees. METHODS We prospectively recruited trainees from hospitals with accredited pulmonary medicine programmes. Trainees from hospitals (A, B and C) were assigned to control group (CG) where they received training by traditional apprenticeship while trainees from hospital D were assigned to intervention group (IG) where they underwent 3-month structured curriculum that incorporated training with the bronchoscopy simulator. Two patient bronchoscopy procedures per trainee were recorded on video and scored independently by two expert bronchoscopists using the modified Bronchoscopy Skills and Tasks Assessment Tool (BSTAT) forms. A 25 multiple choice questions (MCQ) test was administered to all participants at the end of 3 months. RESULTS Eighteen trainees participated; 10 in CG and eight in IG with equal female:male ratio. Competency assessed by modified BSTAT and MCQ tests was variable and not driven by volume as IG performed fewer patient bronchoscopies but demonstrated better BSTAT, airway anaesthesia and MCQ scores. Bronchoscopy simulator training was the only factor that correlated with better BSTAT (r = 0.80), MCQ (r = 0.85) and airway anaesthesia scores (r = 0.83), and accelerated the learning curve of IG trainees. CONCLUSION An intensive 3-month structured bronchoscopy curriculum that incorporated simulator training led to improved cognitive and technical skill performance as compared with apprenticeship training.

In advanced esophageal carcinoma (EC), there is limited data on risk factors predicting tracheobronchoesophageal fistula (TEF) formation and survival among patients who required airway interventions.A retrospective analysis of consecutive patients with EC, who had airway involvement requiring intervention, was conducted from 1998 to 2018. Demographics, clinical progress, disease stage, treatment and survival outcomes were recorded. Patients were followed up till death or until completion of the study. Survival was estimated with the Kaplan-Meier method and curves compared by log-rank test. Multivariate analyses of risk factors were performed using Cox proportional hazard regression.A total of 122 patients were included. The median (IQR) survival from time of airway intervention was 3.30 (1.57-6.88) months, while the median (IQR) survival from time of histological diagnosis was 8.90 (4.91-14.45) months. Tumour location within 20 mm of the carina, prior radiotherapy and/or esophageal stenting were significantly associated with formation of TEF. Mid EC [adjusted hazard ratio (HR) 1.9; 95% confidence interval (CI): 1.1-3.2] or presence of TEF (adjusted HR 1.8; 95% CI: 1.0-3.2) were associated with lower survival. Patients receiving chemotherapy (adjusted HR 0.46; 95% CI: 0.25-0.84), or esophageal stenting whether before or after airway intervention (adjusted HR 0.32; 95% CI: 0.15-0.68 and adjusted HR 0.51; 95% CI: 0.29-0.90) were associated with increased survival.Factors associated with TEF formation include airway location, radiotherapy and prior esophageal stenting, and the development of TEF was associated with poorer survival. An algorithmic approach towards tracheobronchial involvement in EC is proposed based on these findings and a review of the literature.

Video-assisted thoracic surgery (VATS) is the treatment of choice for recurrence prevention in patients with spontaneous pneumothorax (SP). Although the optimal surgical technique is uncertain, bullous resection using staplers in combination with mechanical pleurodesis, chemical pleurodesis and/or staple line coverage is usually undertaken. Currently, patient satisfaction, postoperative pain and other perioperative parameters have significantly improved with advancements in thoracoscopic technology, which include uniportal, needlescopic and nonintubated VATS variants. Ipsilateral recurrences after VATS occur in less than 5% of patients, in which case a redo-VATS is a feasible therapeutical option. Randomized controlled trials are urgently needed to shed light on the best definitive management of SP.

Symptomatic pleural disease, specifically malignant pleural effusion, refractory benign pleural effusion, and pneumothoraces are common diseases that often require therapeutic interventions. The spectrum of management strategies often includes selection of a chemical pleurodesis agent administered in combination with an indwelling pleural catheter or chest tube.Additionally, there is a role for minimally invasive techniques which include medical thoracoscopy or more advanced video-assisted thoracoscopic approaches. Ongoing clinical trials continue to evolve best practices regarding the optimal sclerosant agents and procedural approaches in the management of these diseases.

Thoracoscopy is an increasingly common procedure that provides significant clinical information and therapeutic applications. The procedure allows the physician to biopsy the parietal pleura under direct visualization with high accuracy. In addition, one can drain pleural fluid, place a chest tube in a precise location, and perform poudrage pleurodesis. Medical thoracoscopy (MT) is carried out in the operating room or procedure suite under moderate sedation with spontaneous ventilation. In comparison, video-assisted thoracoscopic surgery (VATS) is performed under general anesthesia with single lung ventilation and through multiple ports in the operating room. MT is less invasive, has a comparable diagnostic yield, and may be better tolerated in high-risk patients. The indications, complications, and advances in thoracoscopy will be discussed in this article. In the era of rapidly evolving therapeutics for lung cancer, immune-modulation and ever-increasing risks of immunosuppression, MT will evolve and continue to play a pivotal role in the evaluation and research of pleuropulmonary diseases.

We report a label-free Surface Enhanced Raman Spectroscopy (SERS) for pleural fluid analysis to distinguish Lung cancer from controls patients. Herein, we have used a novel silver coated silicon Nanopillar (SCSNP) as SERS substrate to acquire multiple SERS spectra for each pleural fluid sample and advanced chemometrics methods. We report a classification accuracy of 85% along with sensitivity and specificity of 87% and 83% respectively for the detection of Lung cancer over control pleural fluid samples with a receiver operating characteristics (ROC) area under curve value of 0.92 using PLS-DA binary classifier to distinguish between lung cancer over control subjects.

Thoracoscopy or pleuroscopy provides the physician a window into the pleural space. The procedure allows biopsy of the parietal pleura under direct visualization with good accuracy. In addition, it achieves therapeutic goals of fluid drainage, guided chest tube placement, and pleurodesis. Thoracoscopy fell into oblivion with the development of antituberculous drugs; however, the procedure enjoyed resurgence when thoracic surgeons introduced the technique for minimally invasive surgery, also known as video-assisted thoracic surgery (VATS). VATS is performed under general anesthesia with single-lung ventilation, while pleuroscopy is performed by the pulmonologist in an endoscopy suite using non-disposable rigid or flex-rigid instruments, local anesthesia, and conscious sedation. Despite more sensitive tools to image the pleura such as contrast-enhanced CT, MRI, ultrasonography, and positron emission tomography, increased yield with image guided biopsy, as well as advances in cytopathology, pleuroscopy will evolve with time, complement novel techniques, and continue to play a pivotal role in the evaluation of pleuropulmonary diseases.

A 32-year-old female never smoker presented with dyspnoea and stridor. CT thorax showed a polypoidal mass obstructing the trachea. Bronchoscopy revealed a circumferential nodular tumour 4 cm from the vocal cords, removed using electrosurgical snare and thereby re-establishing trachea patency (figure 1A,B). Histology showed adenoid cystic carcinoma (ACC). She underwent tracheal resection; as the resection margins showed ACC with perineural and fascia invasion, she received adjuvant radiation therapy 72 Gy. Yearly CT chest was performed for surveillance and CT 8 years after surgery showed enlarged subcarinal lymphadenopathy, bilateral pulmonary nodules and a left thyroid nodule (figure 1C,D). Thyroid ultrasound fine-needle aspiration confirmed 1 cm hypoechoic nodule due to ACC. Endobronchial ultrasound-guided transbronchial needle aspiration of subcarinal lymph node revealed metastatic ACC (figure 2), but no recurrence in the trachea. Figure 1 (A) Malignant polypoidal tracheal tumour with 80% obstruction (B) CT coronal view showed polypoidal …

Airway involvement, such as airway invasion, compression, and tracheobronchoesophageal fistula (TEF), in esophageal cancer is associated with significant morbidity. However, the risk factors and outcomes of airway complications remain unclear, with limited evidence to guide management.This retrospective analysis included 804 patients with a diagnosis of esophageal cancer from 1998 to 2018 at a tertiary care medical center (Singapore General Hospital, Singapore). Patients' demographics, treatment details, and airway involvement, as determined by bronchoscopic evaluation or computed tomographic imaging, were recorded and analyzed to determine risk factors and outcomes of airway involvement.The incidence of airway involvement and TEF was 36.6% and 13.1%, respectively. Airway involvement was associated with reduced survival from the time of diagnosis (hazard ratio, 1.52; 95% confidence interval [CI], 1.30 to 1.79) and increased hospitalizations per year (4.53 ± 4.80 vs 2.75 ± 3.68; P.001). On multivariate analysis, midesophageal tumors (odds ratio [OR], 11.0; 95% CI, 6.3 to 19.0) and upper esophageal tumors (OR, 8.5; 95% CI, 4.7 to 15.6), previous treatment with esophageal stenting (OR, 17.8; 95% CI, 4.1 to 77.6), and chemotherapy or radiotherapy were associated with development of airway involvement. In patients with TEF, treatment with chemotherapy (OR, 0.34; 95% CI, 0.20 to 0.60) and combined airway and esophageal stenting (OR, 0.48; 95% CI, 0.25 to 0.91) were independently associated with improved survival.Airway involvement and TEF are common and are associated with increased morbidity and poorer survival. Clinicians should remain vigilant for airway complications after treatment with esophageal stenting, chemotherapy, or radiotherapy, especially in patients with midesophageal and upper esophageal cancers. In patients with TEFs, survival is improved when they are treated with airway stenting, esophageal stenting, or chemotherapy.

Background: Up to 50% of Chronic obstructive pulmonary disease (COPD) exacerbations are due to viral infections. Influenza vaccinations have been shown to reduce exacerbations in countries with seasonal peaks. In tropical countries with year-round influenza infections, this is less clear. Methods: All COPD patients attending outpatient clinics at a Singapore tertiary hospital from 2013-2014 were recruited and followed-up for 2 years or death. They were participants of a quality improvement project aimed at improving vaccination rates. Primary outcomes were prevalence of COPD exacerbation requiring hospitalization and mortality. Secondary outcomes included pneumonia prevalence, intensive care unit (ICU) admission rates and prevalence of mechanical ventilation or non-invasive ventilation. Results: There were 370 COPD patients in the pre-intervention and 418 patients in the post-intervention periods, with vaccination rates of 47.5% and 83.7% respectively. Despite increasing vaccination rates, more COPD exacerbations [OR 1.53 (CI 1.08-2.15), p. 0.016] and increased mortality [OR 2.3 (CI 1.40-3.80), p=0.002] were still observed in the post-intervention period without attenuation of exacerbation severity. Vaccine efficacy varied in both years (51% in 2013-2014, 15% in 2014-2015). When comparing vaccinated versus non-vaccinated patients in individual years, there were fewer ICU admissions [OR 0.08 (0.01-0.45), p=0.006] among vaccinated patients in 2013-2014. In 2014-2015, there was no difference in outcomes between the vaccinated and non-vaccinated patients. Vaccination timing did not influence any of the outcomes. Conclusions: Annual influenza vaccination, regardless of administration timing, did not reduce exacerbation rates or mortality among COPD patients who live in Singapore, a tropical country experiencing year-round influenza infection. Funding Statement: None. Declaration of Interests: The authors declare no conflicts of interest. Ethics Approval Statement: The National Healthcare Group Domain-Specific Review Board approved the study with a waiver of informed consent (Reference 2016/01311).

We present a polymer-coated silicon microring resonator to detect volatile organic compounds (VOC) gases. Absorption of VOC gases into the polymer alters the refractive index around the microring, which enables quantification of absorbed gases as a resonance wavelength shift in the resonator. Two different polymers, hyperbranched polyesteramid and poly(2-vinyl pyridine), are tested as the absorption layers on the highly sensitive (80 nm/RIU and 10,000 Q-factor) silicon microring resonator. The sensing responses to VOC gases are characterized by flowing four different gases: styrene, acetone, toluene, and isoprene, in a wide range of concentration (sub-ppm to 100 ppm range). The hyperbranched polyesteramid coated sensor shows the highest sensitivity to styrene. Similarly, Poly(2-vinyl pyridine) coated device exhibits sensitive responses to styrene and acetone. From experiments with a wide range of gas concentrations, we observe that the sensors have two distinguished characteristics; linear and non-linear response with respect to gas concentration. To account for it, a dual mode sensing mechanism is proposed; Langmuir mode (doping effect) in the low concentration (

Endobronchial tuberculosis (EBTB) is defined as tuberculous infection of the tracheobronchial tree. The exact pathogenesis is unclear, and it has a heterogenous clinical course. Its diagnosis requires the clinician to have a high index of suspicion based on clinical symptoms and radiological features. Computed tomography and bronchoscopy are useful tools in its evaluation. The goal of treatment is in the eradication of tuberculous bacilli with appropriate anti-tuberculous therapy. Use of corticosteroids is controversial for the prevention of tracheobronchial stenosis. Interventional bronchoscopy or surgical intervention is employed to restore airway patency once significant stenosis occurs.

Medical thoracoscopy provides the physician a window into the pleural space. The procedure allows biopsy of the parietal pleura under direct visualization with good accuracy. In addition, it achieves therapeutic goals of fluid drainage, guided chest tube placement, and pleurodesis.Comparable diagnostic yield is achieved with the flexi-rigid pleuroscope even though pleural biopsies are smaller using the flexible forceps as compared to rigid thoracoscopy. Flexi-rigid pleuroscopy is extremely well tolerated and can be performed safely as an outpatient procedure. Biopsy quality can be further enhanced with accessories that are compatible with the flex-rigid pleuroscope such as the insulated tip knife and cryoprobe.With more sensitive tools to image the pleura such as contrast-enhanced computed tomography, MRI, ultrasonography, PET, increased yield with image-guided biopsy as well as advances in cytopathology, what lies in the future for medical thoracoscopy remains to be seen. However, it is the authors' opinion that medical thoracoscopy will evolve with time, complement novel techniques, and continue to play a pivotal role in the evaluation of pleuropulmonary diseases.

Background and aim COVID-19 pandemic has resulted in an unprecedented increased usage of Personal protective equipment (PPE) by healthcare-workers. PPE usage causes headache in majority of users. We evaluated changes in cerebral hemodynamics among healthcare-workers using PPE. Methods Frontline healthcare-workers donning PPE at our tertiary center were included. Demographics, co-morbidities and blood-pressure were recorded. Transcranial Doppler (TCD) monitoring of middle cerebral artery was performed with 2-MHz probe. Mean flow velocity (MFV) and pulsatility index (PI) were recorded at baseline, after donning N95 respirator-mask, and after donning powered air-purifying respirator (PAPR), when indicated. End-tidal carbon-dioxide (ET-CO2) pressure was recorded for participants donning PAPR in addition to the N95 respirator-mask. Results A total of 154 healthcare-workers (mean age 29 ± 12 years, 67% women) were included. Migraine was the commonest co-morbidity in 38 (25%) individuals while 123 (80%) developed de-novo headache due to N95 mask. Donning of N95 respirator-mask resulted in significant increase in MFV (4.4 ± 10.4 cm/s, p, Highlights • Most N95 mask users develop de novo headache or worsening of pre-existing headache. • End-tidal carbon dioxide levels increase while donning N95 respirator mask. • Significant cerebral hemodynamic changes occur during donning of N95 mask. • Powered air-purifying respirator restores N95 mask induced cerebral hemodynamic changes.

Purpose LUME-Meso is a phase II/III randomized, double-blind trial designed to assess efficacy and safety of nintedanib plus chemotherapy as first-line treatment of malignant pleural mesothelioma (MPM). Phase II results are reported here. Patients and Methods Chemotherapy-naïve patients with unresectable, nonsarcomatoid MPM (Eastern Cooperative Oncology Group performance status 0 to 1), stratified by histology (epithelioid or biphasic), were randomly assigned in a 1:1 ratio to up to six cycles of pemetrexed and cisplatin plus nintedanib (200 mg twice daily) or placebo followed by nintedanib plus placebo monotherapy until progression. The primary end point was progression-free survival (PFS). Results Eighty-seven patients were randomly assigned. The median number of pemetrexed and cisplatin cycles was six; the median treatment duration for nintedanib was 7.8 months and 5.3 months for placebo. Primary PFS favored nintedanib (hazard ratio [HR], 0.56; 95% CI, 0.34 to 0.91; P = .017), which was confirmed in updated PFS analyses (HR, 0.54; 95% CI, 0.33 to 0.87; P = .010). A trend toward improved overall survival also favored nintedanib (HR, 0.77; 95% CI, 0.46 to 1.29; P = .319). Benefit was evident in epithelioid histology, with a median overall survival gain of 5.4 months (HR, 0.70; 95% CI, 0.40 to 1.21; P = .197; median [nintedanib v placebo], 20.6 months v 15.2 months) and median PFS gain of 4.0 months (HR, 0.49; 95% CI, 0.30 to 0.82; P = .006; median [nintedanib v placebo], 9.7 v 5.7 months). Neutropenia was the most frequent grade ≥ 3 adverse event (AE; nintedanib 43.2% v placebo 12.2%); rates of febrile neutropenia were low (4.5% in nintedanib group v 0% in placebo group). AEs leading to discontinuation were reported in 6.8% of those receiving nintedanib versus 17.1% of those in the placebo group. Conclusion Addition of nintedanib to pemetrexed plus cisplatin resulted in PFS improvement. AEs were manageable. The clinical benefit was evident in patients with epithelioid histology. The confirmatory phase III part of the study is ongoing.

A male lifelong nonsmoker aged 58 years with no prior asbestos exposure complained of gradual worsening breathlessness over 3 months. This was associated with abdominal and leg swelling and a 2-kg weight loss. He had no fever, night sweats, hemoptysis, joint pain, rash, abdominal pain, chest pain, or orthopnea. The patient had no recent travel or contact with pulmonary TB. He had stage I left-side testicular seminoma treated with left-sided radical orchidectomy 10 years previous and recently received a diagnosis of Child's B alcoholic liver cirrhosis. His hepatitis B and C screen result was normal.

For a long time lung cancer was associated with a fatalistic approach by healthcare professionals. In recent years, advances in imaging, improved diagnostic techniques and more effective treatment modalities are reasons for optimism. Accurate lung cancer staging is vitally important because treatment options and prognosis differ significantly by stage. The staging algorithm should include a contrast computed tomography (CT) of the chest and the upper abdomen including adrenals, positron emission tomography/CT for staging the mediastinum and to rule out extrathoracic metastasis in patients considered for surgical resection, endosonography-guided needle sampling procedure replacing mediastinoscopy for near complete mediastinal staging, and brain imaging as clinically indicated. Applicability of evidence-based guidelines for staging of lung cancer depends on the available expertise and level of resources and is directly impacted by financial issues. Considering the diversity of healthcare infrastructure and economic performance of Asian countries, optimal and cost-effective use of staging methods appropriate to the available resources is prudent. The pulmonologist plays a central role in the multidisciplinary approach to lung cancer diagnosis, staging and management. Regional respiratory societies such as the Asian Pacific Society of Respirology should work with national respiratory societies to strive for uniform standards of care. For developing countries, a minimum set of care standards should be formulated. Cost-effective delivery of optimal care for lung cancer patients, including staging within the various healthcare systems, should be encouraged and most importantly, tobacco control implementation should receive an absolute priority status in all countries in Asia.

This Year in Review examines the most relevant articles published on lung cancer, respiratory infections, tuberculosis (TB), cystic fibrosis (CF), pleural diseases, and interventional pulmonology and imaging in Respirology and other respiratory medicine journals during 2013. Important findings are highlighted with comments in the following sections, each of which was contributed by an author as named in the beginning of each section.

Background and objective Pleural procedures such as tube thoracostomy and chest aspirations are commonly performed and carry potential risks of visceral organ injury, pneumothorax and bleeding. In this context limited information exists on the complication rates when non-pulmonologists perform ultrasound-guided bedside pleural procedures. Bedside pleural procedures in our university hospital were audited to compare complication rates between pulmonologists and non-pulmonologists. Methods A combined safety approach using standardized training, pleural safety checklists and ultrasound-guidance was initially implemented in a ∼1000-bed academic medical centre. A prospective audit, over approximately 3.5 years, of all bedside pleural procedures excluding procedures done in operating theatres and radiological suites was then performed. Results Overall, 529 procedures (295 by pulmonologists; 234 by non-pulmonologists) for 443 patients were assessed. There were 16 (3.0%) procedure-related complications, all in separate patients. These included five iatrogenic pneumothoraces, four dry taps, four malpositioned chest tubes, two significant chest wall bleeds and one iatrogenic hemothorax. There were no differences in complication rates between pulmonologists and non-pulmonologists. Presence of chronic obstructive pulmonary disease (COPD) independently increased the risk of complications by nearly sevenfold. Conclusions Results from this study support pleural procedural practice by both pulmonologists and non-pulmonologists in an academic medical centre setting. This is possible with a standard training program, pleural safety checklists and relatively high utilization rates of ultrasound guidance for pleural effusions. Nonetheless, additional vigilance is needed when patients with COPD undergo pleural procedures.

Eine indische Frau mittleren Alters mit Schmerzen im Kniegelenk hatte seit 6 Monaten täglich ayurvedische Medikamente (Ostolief®- und Arthrella®-Tabletten) eingenommen. Sie stellte sich mit einer sich verschlechternden Dyspnoe, mit Husten und einem seit 2 Monaten fortschreitenden Gewichtsverlust in der pneumologischen Klinik vor. Sie war Hausfrau, hatte nie geraucht und hielt keine Vögel. Die körperliche Untersuchung ergab feine Rasselgeräusche beim Einatmen. Trommelschlägelfinger, Gelenkdeformitäten oder -schwellungen, Hautläsionen oder eine Lymphadenopathie mit vergrößerten zervikalen Lymphknoten lagen nicht vor. In der hochauflösenden Computertomographie waren diffuse zentrilobuläre Knoten mit Milchglastrübung zu erkennen. In der Spirometrie wurde eine restriktive Ventilationsstörung festgestellt (FVC 44% des Sollwerts, FEV1/FVC-Quotient 93%), und das Autoimmun-Screening war negativ. In der bronchoalveolären Lavage wurde eine Lymphozytose mit erhöhtem CD4/CD8-Verhältnis (T-Helfer-/T-Suppressorzellen) entdeckt. Kulturen für Bakterien, Mykobakterien, Pilze, Viren und Pneumocystis carinii waren negativ. In der bronchoskopischen Lungenbiopsie wurden eine Alveolitis mit lymphozytärer Infiltration des Interstitiums sowie peribronchioläre, nichtverkäsende Granulome festgestellt. Die Diagnose «Hypersensitivitätspneumonitis infolge ayurvedischer Medikation» wurde gestellt. Der Patientin wurde geraten, die auslösenden Medikamente abzusetzen; eine Behandlung mit hochdosierten Steroiden und prophylaktisch verabreichtem Bactrim® wurde eingeleitet und über 3 Monate wieder ausgeschlichen; sie schlug gut an, und die radiologische Bildgebung zeigte eine vollständige Abheilung. Die Patientin wurde 1 Jahr nachbeobachtet; ein Rückfall trat nicht auf.

A middle-aged Indian woman with knee pain had consumed ayurvedic medicine (Ostolief and Arthrella tablets) daily for 6 months. She presented to the respiratory clinic with worsening dyspnea, cough and weight loss of 2 months' duration. She was a homemaker, never-smoker and did not keep birds. Physical examination detected fine end-inspiratory crackles. There was no clubbing of the fingers, joint deformity or swelling, skin lesion or enlarged cervical lymphadenopathy. High-resolution computed tomography showed diffuse centrilobular nodules with ground-glass attenuation. Restrictive ventilatory defect (FVC 44% predicted, FEV1/FVC ratio 93%) was observed on spirometry, and the autoimmune screen was negative. Bronchoalveolar lavage fluid revealed lymphocytosis with an increased CD4/CD8 (T helper:T suppressor) ratio. Cultures for bacteria, mycobacteria, fungi, viruses and Pneumocystis carinii were negative. Alveolitis with infiltration of interstitium by lymphocytes and peribronchiolar noncaseating granulomas were observed on bronchoscopic lung biopsy. A diagnosis of hypersensitivity pneumonitis as a result of ayurvedic medicine was made. She was advised to stop the offending medicine; high-dose steroids and bactrim prophylaxis were commenced and tapered over 3 months with good response and radiological resolution. She was followed for 1 year without relapse.

A 42-year-old Malay man presented with cough productive of yellowish sputum, hoarseness and intermittent daily fever associated with chills and rigours for 3 weeks. Apart from previous pulmonary TB in 1994 for which treatment was complete, there were no other comorbidities. The patient was an active cigarette smoker of 20 pack-years, and worked as an outdoor project coordinator frequently in contact with soil during field surveys in gardens. Chest radiograph showed right perihilar consolidation (figure 1A). CT thorax showed mass-like consolidation of the right upper lobe with extensive mediastinal lymphadenopathy (figure 1B). White cell count was 8.8 (range 3.4–11.0×109/L) with neutrophilia 72.2%; blood, sputum and urine for bacterial cultures, as well as sputum for acid fast bacilli smears and TB PCR assay, were negative. Random blood sugar level was 23.0 mmol/L (range 4.0–7.8 mmol/L) and glycated haemoglobin level was 12.1%. Bronchoscopy showed mobile …