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   Table of Contents - Current issue
July-December 2019
Volume 8 | Issue 2
Page Nos. 69-136

Online since Monday, July 1, 2019

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Postintubation tracheal stenosis: Adevastating complication! p. 69
Laxmi Shenoy, Anitha Nileshwar
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Study of association between exposure to indoor air pollution and chronic obstructive pulmonary disease among nonsmokers in a North Indian population – A case–control study Highly accessed article p. 71
Madhurmay, Suryakant, Hemant Kumar, Santosh Kumar, Rajendra Prasad, Ajay Kumar Verma, Arvind Kumar Singh
Background: Chronic obstructive pulmonary disease(COPD) is one of the most killing diseases worldwide. Tobacco smoking is still the most common single cause of COPD, but in developing countries such as India, indoor air pollution is one of the common etiological factors for COPD. This study was done to find out the association of various indoor pollution and COPD, especially in women who are exposed most due to the burning of domestic fuel. Patients and Methods: This is a case–control study in which 164 spirometry-confirmed COPD patients and 328 matched controls were studied. Various types of indoor air pollution were compared between cases and controls. Results: Of 164cases, 72cases(43.9%) had regular exposure to indoor air pollution. Common types of indoor air pollution were biomass fuel, wood smoke, coal smoke, and stove smoke. The odds of having indoor pollution such as biomass fuel exposure, wood exposure, coal, and stove in COPD patients were 3.16, 2.70, 2.45, and 2.05, respectively, in comparison to the control group. Except stove exposure, other indoor air pollutions were statistically significant with P =0.001, 0.003, and 0.02, respectively. Longer time exposure in terms of number of years of biomass fuel exposure, wood exposure, and coal fuel exposure was statistically significant as compared to exposures in the control group with P =0.001, 0.0009, and 0.0006, respectively. Conclusion: Indoor air pollutants(biomass fuel, coal, and wood smoke) are associated with the development of COPD, especially in the female population.
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Efficacy of pleural brush cytology in the diagnosis of pleural diseases p. 76
Rakhee Sodhi Khanduri, Varuna Jethani, Sanjeev Kumar, Girish Sindhwani, Smita Chandra, Suchita Pant
Background: The accurate diagnosis of pleural effusion remains a challenging clinical problem. Medical thoracoscopy has an established role in achieving the etiology of pleural effusion. Pleural biopsies provide us with best results, but if cytological results can be shown to give concordant results, therapy can be instituted early. Aim: The aim was to study the efficacy of pleural brush in diagnosing pleural diseases. Study Design: This is a prospective study. Patients and Methods: The study was done between December 2015 and June 2017 in all patients of undiagnosed exudative effusions who were taken for thoracoscopy. Both pleural biopsy and pleural brushings were obtained in each patient. Results: We present the data of 45patients. The mean age was 59.68years. Nodule was the most common finding on thoracoscopic examination. Pleural brush cytology was positive in 26patients with malignancy, 13 for infection and 6 were inadequate. However, forceps biopsy was positive in 42cases out of 45(93.3%) in detecting malignancy and infectious diseases. Conclusion: Pleural brush cytology can help in increasing the diagnostic yield. It can also be used to commence early treatment of the patient.
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Clinicopathological profile of patients with bronchogenic carcinoma at a tertiary care center in Western India p. 80
Dharitri Thakkar, Pradipkumar Damor, Kamlesh Vithalani
Background: Bronchogenic carcinoma is the most common malignancy all over the globe in terms of incidence and mortality, especially in males. Its increasing incidence in nonsmokers and females is also an important concern. Objectives: The objective of this study was to study various demographic, clinical, radiological, and histopathological features of patients with confirmed diagnosis of lung cancer. Patients and Methods: Patients with confirmed histopathological diagnosis of bronchogenic carcinoma attending a tertiary care center in western India were included in the study. Results: A total of 50patients were studied. Of 50, 45 were male and 5 were female. Average age of the patient was 59.92years. Forty-six(92%) patients were current or ex-smokers, whereas only 4patients were never-smokers. Cough(90%) followed by chest pain(62%) was the presenting symptom. Soft-tissue density mass lesion was the most common radiographic finding. Adenocarcinoma(36%) followed closely by squamous cell carcinoma(32%) was the diagnosed histological subtype. Of 50, 9(18%) patients had evidence of distant metastasis at the time of diagnosis. Conclusions: This study concludes that adenocarcinoma was the most common subtype even in smokers. Ahigh index of suspicion and prompt investigations in a patient with respiratory symptoms should be employed to diagnose patients at an early stage.
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Psychiatric manifestations in the patients of obstructive sleep apnea at tertiary care center of Northern India p. 84
Surya Kant, Neha Kapoor, Ajay Kumar Verma, SK Verma, R A S Kushwaha, Santosh Kumar, Rajiv Garg, Ved Prakash, Anuj Kumar Pandey
Aim: The aim of the study is to understand the role of anxiety and depression in obstructive sleep apnea(OSA) patients. Patients and Methods: This prospective, observational study was conducted at King George's Medical University, Lucknow, Uttar Pradesh, India, from September 2011 to August 2012. Seventy-one patients were enrolled in the study after obtaining informed written consent. Polysomnography(PSG) was performed to confirm OSA, and the psychiatric features were determined using the Hospital Anxiety and Depression Scale score. Results: A total of 71 individuals were enrolled in the study, and after exclusion, 48 individuals had participated in PSG. Of the 48patients, 44(91.67%) had shown OSA with PSG. From 44 OSA-diagnosed patients, 10(22.73%) patients were diagnosed of having psychiatric manifestations(50% with depression, 30% with anxiety, and 20% having features of both depression and anxiety). No significant difference was found in between those with psychiatric features than that those without in body mass index(mean±standard deviation[SD]: 32.38±7.17 and 31.64±3.93, P =0.610), Epworth's sleepiness scale score(mean±SD: 13.20±4.71 and 11.88±5.63, P =0.505), apnea/hypopnea index(mean±SD: 48.01±31.71 and 37.81±22.84, P =0.263), average saturation(mean±SD: 92.19±4.37 and 91.74±4.38, P =0.774), and lowest saturation(mean±SD: 74.50±11.97 and 74.32±11.97, P =0.968), respectively. Conclusion: Although patients with OSA must be screened for psychiatric manifestations, the severity of OSA is not directly related to the severity of psychiatric features.
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Study of nocturnal oxygen desaturation in chronic obstructive pulmonary disease patients p. 87
Naveen Kuzhikkattil, Kamal Nayan Shringi, Babulal Bansiwal, Anil Saxena, Suman Khangarot, Shinu A Wahab
Background: Abnormal sleep architecture with decreased rapid eye movement sleep and arousals during the periods of nocturnal oxygen desaturation(NOD) are seen in patients with chronic obstructive pulmonary disease(COPD) with significant consequences. This study was done to evaluate the prevalence of NOD and other sleep-related disorders in COPD patients. Patients and Methods: This prospective cross-sectional study was conducted in the sleep laboratory of our tertiary center over1year. Fifty COPD patients were enrolled in this study. They were classified into mild COPD and moderate COPD, according to the Global Initiative for Obstructive Lung Disease (GOLD)classification. Complete history, physical examination, and relevant laboratory investigations were taken. All patients were subjected to overnight polysomnography. Results: Eight patients had mild COPD, whereas 42patients had moderate COPD. Mean sleep efficiency was decreased with an average of 71.08% with a significant difference between mild and moderate COPD cases. Minimal SpO2, average SpO2, SpO2<90%, and duration of SpO2<90% in the study group showed mean values of 80.77%, 94.33%, 3.93%, and 12.09min, respectively, with a mean respiratory disturbance index(RDI) of 2.45. NOD was seen in 18%(9patients) and overlap syndrome was seen in 12%(6patients) in our study. Forced expiratory volume in 1 s and SpO2 were found to have statistically significant difference(P<0.05) between patients with respect to NOD. It correlated well with body mass index(BMI) and neck circumference with RDI and also overlap syndrome. Conclusions: NOD is related to the degree of respiratory dysfunction and can coexist with overlap syndrome. Occurrence of overlap syndrome can be predicted with the help of BMI and RDI.
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Acute exacerbation of chronic obstructive pulmonary disease in rural area: Why, how, and what next? p. 92
Ravish M Kshatriya, Rajiv P Paliwal, Nimit V Khara, Satish N Patel
Background: Acute exacerbation of chronic obstructive pulmonary disease(AECOPD) leads to fall in lung function, quality of life, and ultimately disease progression. The present study is an effort to study in detail about COPD exacerbation in a rural tertiary hospital. Aim: To study demographic, clinical, and laboratory profile of hospitalized patients of AECOPD. Methodology: Retrospective data of 170 consecutive patients of AECOPD were collected from records, were divided into two groups based on severity, and were analyzed: Group1 for admission in the wards and Group2 for intensive care unit(ICU) admissions. Results: A total of 141(82.9%) patients were hospitalized in the wards, whereas 29(17.1%) were admitted in the ICU. The mean age was 62.36years in the wards and 64.89years in the ICU. Nearly 89.4% of patients were smokers. Dyspnea(100%) was the most common symptom followed by cough(99%) and expectoration(98%). The mean respiratory rate at the time of presentation was 26/min in the wards and 31.56/min in the ICU. The mean oxygen saturation was 93% in the wards and 88.62% in the ICU. The mean post forced expiratory volume in 1 s(FEV1) was 43.98% in ward patients and 29.28% among ICU patients. Arterial blood gas revealed mean PaCO2 of 44.25mmHg in the wards and 63.24 mmHg in the ICU. The mean pH in the ward was 7.48 compared to 7.34 in the ICU. The mean pulmonary arterial pressure(PAP) was higher in the ICU(53.74mmHg) than in the ward(38.87mmHg). Conclusion: The ratio of hospitalization in ICU to ward was 1:5. The site of treatment depends on respiratory rate, oxygen saturation, post-FEV1%, PAP, pH, and PaCO2.
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Perioperative factors influencing the incidence of postoperative pulmonary complications in patients undergoing head-and-neck versus abdominal surgeries and their outcome p. 96
Bindu K Vasu, Sunil Rajan, Arathy M Raj, Jerry Paul, Lakshmi Kumar
Background: Postoperative pulmonary complications(PPCs) are frequent causes for adverse outcomes after major surgeries. Aim: The aim of this study was to compare the perioperative factors influencing the incidence of PPCs in two groups of patients undergoing prolonged major surgeries, namely head-and-neck versus abdominal surgeries, receiving postoperative ventilation. Patients and Methods: This prospective observational study was designed, and the necessary data were collected from consecutive patients fulfilling all criteria in a single center between August 2017 and March 2018. Correlation of PPCs with duration of surgery, perioperative mechanical ventilation(PMV), and volume of crystalloids used in both the groups was analyzed by multiple binary logistic regression. The inhospital mortality and number of days of intensive care unit(ICU) and hospital stay were analyzed with Student's t-test. Results: A total of 155patients were studied in which 77patients who underwent head-and-neck surgeries(Group1) and 78 who underwent abdominal surgeries(Group2). Both the groups had a comparable demographic profile. Group2patients had a higher incidence of PPCs. Duration of PMV but not of surgery influenced the occurrence of PPCs independently, showing 8.2%(1.2%–15.7%) increase in PPCs with every hour increase in PMV(odds ratio: 1.08[95% confidence interval, 1.01–1.16] with P =0.002). PPCs prolonged the ICU and hospital stays and mortality. Conclusion: Duration of PMV is an independent risk factor for the development of PPCs. Abdominal surgeries proved to be an independent risk factor for PPCs. Early identification and risk modifications are required to reduce PPCs in high-risk category of patients who receive general anesthesia with prolonged mechanical ventilation.
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The utility of spirometry in assessment of presumptive diagnosis of bronchial asthma in a Nigerian tertiary hospital p. 102
Nnamdi I Nwosu, Chinwe J Chukwuka, Cajetan C Onyedum, Hilary C Odilinye, Paul I Nlewedim, Adaeze C Ayuk
Context: Spirometry with reversibility testing is the gold standard for definitive diagnosis of bronchial asthma. However, even in those with established bronchial asthma reversibility test result may subsequently become negative. Spirometry results may also be normal during exacerbation-free intervals. Aims: This study assessed the role of spirometry in diagnostic evaluation of bronchial asthma and determined the ventilatory patterns of patients with presumptive diagnosis of bronchial asthma using spirometry and the proportion of those who showed positive reversibility test. Patients and Methods: This was a retrospective study carried out at a teaching hospital in Nigeria. This was an audit of consecutive patients with presumptive diagnosis of asthma referred for spirometry between January 2013 and June 2015. Spirometer with disposable mouthpieces, stadiometer, and salbutamol inhalers were used. The statistical analysis was done with Statistical Package for the Social Sciences version20. Results: Eighty-nine participants did spirometry of whom 28(31.5%) had additional postbronchodilator testing. Fifty(56.3%) participants were females(mean age of 42.17±15.48years). Normal, obstructive, restrictive, and mixed ventilatory patterns were found in 39(43.8%), 31(34.8%), 10(11.2%), and 9(10.1%) participants, respectively. Positive reversibility test result occurred in 15(53.6%) participants, 9/19 obstructive(47.4%), and 6/9 mixed patterns(66.7%). Conclusion: Only a few patients with presumptive diagnosis of asthma were confirmed by spirometry. Spirometry is useful in asthma diagnosis, but clinicians should be aware of its limitations in diagnostic assessment. Although asthma is typically associated with obstructive spirometry, other spirometry patterns can occur.
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A study of outcome of noninvasive ventilatory support in acute respiratory failure p. 107
Ravish M Kshatriya, Nimit V Khara, Nisarg Oza, Rajiv P Paliwal, Satish N Patel
Introduction: Noninvasive ventilation(NIV) is often used in acute respiratory failure to prevent endotracheal intubation and its complications. Various factors influence favorable outcome for NIV. Aim: To assess the outcome of NIV in acute respiratory failure and to determine predictors of positive outcome. Patients and Methods: This was an observational study of 4years where 110patients with acute respiratory failure requiring NIV were included. Data of history, examination, investigations, and clinical outcome of all patients were recorded. The outcome was divided in two categories depending upon whether patients improved or required invasive ventilation. Results: Of 110patients, there were 78 men with a mean age of 64.24years and 32 women with a mean age of 56.59years. The causes of acute respiratory failure were acute exacerbation of chronic obstructive pulmonary disease(COPD)(61.81%), bronchial asthma(9.09), pneumonia(22.72%), tuberculosis(2.72%), interstitial lung disease(1.81%), and pulmonary artery hypertension(0.9%). Among them, 81(74%) patients improved. Patients who had acute respiratory failure due to COPD(P<0.00001) had favorable outcome compared to others. Improvement in PO2(48patients[43.63%]), PCO2(72patients[65%]), and pH(55patients[50%]) within/or at 24h of NIV correlated with successful outcome. Unfavorable outcome was seen when patients required invasive ventilation after failing NIV(P<0.00001) and when NIV was required for>3days(P=0.001). Conclusions: COPD patients with acute respiratory failure respond well to NIV. Improvement in pH, PCO2, and PO2 within or at 24h of NIV predicts successful outcome. Requirement of prolonged NIV leads to poor outcome.
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Use of high-flow nasal oxygen in critically Ill adults with respiratory failure: Asingle-center, retrospective, descriptive study p. 111
John Paul, Varsha Mathews, Akhil Babu, Anuradha Thekkeyil, Cherish Paul
Background: High-flow nasal oxygen(HFNO) therapy is an upcoming modality used among patients with respiratory failure. The utility of this equipment in intensive care units(ICUs) is undergoing global scrutiny through trials. This article provides descriptive detail about its usage and factors affecting its outcome in an Indian ICU setting. Aims: The aim is to assess the use of HFNO therapy in managing respiratory failure in an ICU setting. Settings and Design: This is a single-center, retrospective, descriptive study in a tertiary care teaching hospital. Patients and Methods: All data of patients who received HFNO therapy between August 2015 and April 2017 were extracted from hospital medical records. Association of HFNO therapy failure rates with age, sequential organ failure assessment(SOFA) score, diagnosis, PaO2/FiO2, PaCO2, and duration of HFNO therapy was analyzed. Data were also analyzed for association of HFNO therapy duration with ICU length of stay and ICU mortality. Results: No significant relation was found between HFNO failure and age, diagnosis, SOFA score, PaO2/FiO2, or PaCO2 levels at initiation of HFNO therapy. Increased HFNO therapy failure rate was found in the first 2days of HFNO therapy(40.4%) when compared to HFNO therapy use>2days(8.7%)(P=0.006). No significant association was found between duration of HFNO therapy use and length of stay or mortality in the ICU. Conclusions: HFNO is an effective technique to manage respiratory failure in the ICU setting. Severe hypoxia and hypercapnia may effectively be managed using HFNO therapy. Most HFNO therapy failures occur as early as 48h after initiation of therapy. Prolonged HFNO therapy use does not prolong ICU stay or affect patient mortality.
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Role of oral valganciclovir in sick preterm with cytomegalovirus virus infection and ventilation dependence p. 116
Anumodan Gupta, Aditi Saini, Anukul Gowda, Sandeep Kadam
Cytomegalovirus(CMV) is the most common congenital viral infection in neonates. Postnatal infection regarding infants rarely has significant clinical consequences. However, preterm may be at higher risk of developing symptomatic postnatal CMV disease. Amultipara woman delivered vaginally a male preterm infant at 30weeks' gestation who was suspected of early-onset sepsis in view of chronic leaking. The baby developed severe hypoxemia, and persistent pulmonary hypertension after delivery, with progressive deterioration and minimal effect of advanced ventilation, antibiotics, and pulmonary vasodilators. Sepsis screen and cultures for bacteria and fungi were negative. The baby was having enlarged liver and spleen which was noticed on day 15 of life. TORCH titer of the baby revealed CMV IgM and subsequently, CMV was isolated in the urine and in the blood plasma by polymerase chain reaction. Oral valganciclovir improved hematological parameters of the baby and respiratory support could be weaned. CMV being the most common intrauterine infection should be considered in differential diagnosis in unusual presentation of suspected sepsis and oral valganciclovir can be considered as good option for treatment.
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Allergic bronchopulmonary aspergillosis in a patient with kartagener's disease: An unusual association p. 118
Govindaraj Vishnukanth, Dharm Prakash Dwivedi, Aneesa Shahul, Ravindra Chary Mulkoju, Jyotirmaya Sahoo
Primary ciliary dyskinesia(PCD) is a congenital disorder characterized by abnormal ciliary motility with associated impaired mucociliary clearance. When PCD has associated situs inversus, it is known as Kartagener's disease. Due to recurrent sinopulmonary infections, patients of Kartagener's disease develop bronchiectasis. Allergic bronchopulmonary aspergillosis(ABPA) is an allergic disorder characterized by exaggerated immune response to the fungus Aspergillus. Patients with ABPA also develop bronchiectasis in advanced stages. Here, we report a patient of Kartagener's disease who also had coexisting ABPA. We believe such an association has been reported in just a handful of cases. As Kartagener's disease can be easily diagnosed radiologically and bronchiectasis is a feature of Kartagener's disease, many of these patients do not undergo further evaluation. In reporting this rare occurrence, we believe many such associations will be revealed in future.
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Isoniazid-induced thrombocytopenia in a patient with ocular tuberculosis p. 121
Preeti Gupta, Hemant Kumar, Arpita Singh, Utkarsh Kumar Srivastava, Ajay Kumar Verma, Rishabh Chaudhary
Antitubercular therapy(ATT)-induced thrombocytopenia is a rare and serious adverse drug reaction which may be fatal if not identified timely. Although rifampicin is the common culprit ATT causing thrombocytopenia, other ATTs such as isoniazid have also been reported to cause thrombocytopenia. Here, we report a case of isoniazid-induced thrombocytopenia in a 56-year-old female with ocular tuberculosis who developed multiple purpura on both upper limbs, face, and oral cavity. Her condition improved with the withdrawal of isoniazid.
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Cryptogenic organizing pneumonia mimicking a mass lesion: An unusual case p. 124
Shubhra Jain, Yogendra Singh Rathore, Anshika Jindal, Vinod Joshi
Cryptogenic organizing pneumonia(COP) is less common interstitial lung disease with varying clinical picture. It can be misdiagnosed as lung cancer as COP usually presents with malaise, fever, weight loss, and myalgia, which overlap with clinical features of lung cancer. Here, we present a rare case of a 68-year-old male smoker admitted with cough, hemoptysis, arthralgia, fever, and chest pain. On chest X-ray, unilateral homogenous opacity was seen. Blood culture and sputum for Ziehl–Neelsen stain were negative. High-resolution computed tomography chest revealed consolidation in middle and lower zone of the left lung with ground-glass opacity with centrilobular nodules. Bronchoalveolar lavage specimen was negative for bacteria, Mycobacterium tuberculosis, and atypical cells. Transbronchial lung biopsy showed evidence of OP. The patient responded well to steroids.
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Postintubation tracheal stenosis: Report of two cases and literature review p. 127
Eti Ajit, Anup Banur, Kushal Bondade, Priyadarshini Raykar
Tracheal stenosis(TS) is a well-recognized yet underdiagnosed complication of prolonged intubation. Mechanisms include tracheal injury during intubation and ischemia of tracheal mucosa at the site of the endotracheal tube cuff and resultant fibrotic stenosis. TS usually develops 3–6weeks following extubation and is often misdiagnosed as bronchial asthma. We report two such cases who developed TS following prolonged intubation.
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Acute onset of refractory hypoxemia: Arare hemodynamic cause of dyspnea p. 130
Tommaso Valobra, Umberto Ceratti, Alessandra Cernuschi
Platypnea-orthodeoxia syndrome(POS) is a rare condition of positional dyspnea with hypoxemia that can pose a diagnostic challenge to clinicians. We report two cases of POS with different pathophysiologic triggers and similar clinical features. In our report, both patients manifested a severe hypoxemia with low response to increase of fractional inspired oxygen, unremarkable physical examination of the lungs, and no radiological findings of the pulmonary embolism. In both cases, an interatrial communication was found in association with a right-to-left interatrial shunting. Recognition of POS is crucial because symptoms can be quickly relieved by recumbency, unlike other types of hypoxemia. This simple solution may prevent the use of sedative therapy, invasive ventilatory support, and vasopressor agents, which could even exacerbate the right-to-left extrapulmonary shunt and worsen clinical conditions.
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Pleural mesothelioma with peritoneal involvement: Diagnosed on 18F-FDG positron emission tomography/computed tomography p. 134
Anuja Anand, Farhan Siddique, Jaspriya Bal, Madhavi Chawla, Pankaj Dougall
Pleural mesothelioma with metastatic peritoneal involvement is an extremely rare finding. Very few cases are reported in the literature. We present a case of pleural mesothelioma referred for F-18-fluorodeoxyglucose positron emission tomography/computed tomography (PET/CT). There was extension of pleural thickening into the omentum and peritoneum. This case demonstrates the role of F-18-fluorodeoxyglucose PET/CT in detecting other sites of involvement in case of malignant mesothelioma.
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Pleuropulmonary aspergillosis presenting as hydropneumothorax in second trimester pregnancy p. 136
Mahmood Dhahir Al-Mendalawi
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