1
|
Soundappan K, Sehgal IS, Prabhakar N, Rana S, Raju R, Dhooria S, Prasad KT, Muthu V, Rudramurthy SM, Chakrabarti A, Garg M, Agarwal R. Incidence and prevalence of chronic pulmonary aspergillosis in patients with post-tuberculosis lung abnormality: Results from a community survey in North India. Mycoses 2024; 67:e13711. [PMID: 38414309 DOI: 10.1111/myc.13711] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/08/2023] [Revised: 01/23/2024] [Accepted: 02/17/2024] [Indexed: 02/29/2024]
Abstract
BACKGROUND Post-tuberculosis lung abnormality (PTLA) is the most common risk factor for developing chronic pulmonary aspergillosis (CPA). However, the prevalence and incidence of CPA in PTLA patients in India remain unknown. OBJECTIVES We aimed to ascertain the incidence and prevalence of CPA in subjects with PTLA. METHODS We identified a cohort of pulmonary tuberculosis who completed anti-tuberculosis therapy (ATT) before November 2019 from the records of the 12 tuberculosis treatment centers attached to the national program. We recorded the clinical and demographic details. We performed computed tomography (CT) of the chest and estimated serum A. fumigatus-specific IgG. We categorised subjects as PTLA with or without CPA using a composite of clinical, radiological, and microbiological features. We resurveyed the subjects at 6 months (or earlier) for the presence of new symptoms. We calculated the prevalence and the incidence rate (per 100-person years) of CPA. RESULTS We included 117 subjects with PTLA, with a median of 3 years after ATT completion. Eleven subjects had CPA in the initial survey, and one additional case developed CPA during the second survey. The prevalence of CPA in PTLA subjects was 10.3% (12/117). The total observation period was 286.7 person-years. The median (interquartile range) time to develop CPA after ATT completion was 12.5 (5-36.7) months. We found the CPA incidence rate (95% confidence interval) of 4.2 (1.8-6.5) per 100-person years. CONCLUSION Chronic pulmonary aspergillosis complicates 10% of PTLA subjects after successful outcomes with ATT. Four new CPA cases may develop per 100-persons years of observation after ATT completion. We suggest screening patients with PTLA who develop new symptoms for CPA.
Collapse
Affiliation(s)
- Kathirvel Soundappan
- Department of Community Medicine and School of Public Health, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Nidhi Prabhakar
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Samriti Rana
- Department of Pulmonary Medicine, PGIMER, Chandigarh, India
| | | | | | | | | | - Shivaprakash M Rudramurthy
- Department of Medical Microbiology, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | | | - Mandeep Garg
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, PGIMER, Chandigarh, India
| |
Collapse
|
2
|
Dhooria S, Bal A, Sharma R, Prabhakar N, Arora S, Sehgal IS, Kashyap D, Garg M, Bhalla A, Aggarwal AN, Agarwal R. Association of MUC5B promoter polymorphism with interstitial lung changes after COVID-19: A preliminary observation. Indian J Med Res 2024; 159:109-113. [PMID: 38344913 PMCID: PMC10954098 DOI: 10.4103/ijmr.ijmr_137_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/25/2023] [Indexed: 03/06/2024] Open
Affiliation(s)
- Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Riya Sharma
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis & Imaging, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Siddhant Arora
- Department of Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Dharambir Kashyap
- Department of Histopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Mandeep Garg
- Department of Radiodiagnosis & Imaging, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| |
Collapse
|
3
|
Basavanagowda PA, Prabhakar N, Prabhakar A, Sethi J. Blunt Trauma Abdomen Leading to Bilateral Renal Segmental Infarction: Resolving the Enigma. Indian J Nephrol 2023; 33:476-477. [PMID: 38174294 PMCID: PMC10752407 DOI: 10.4103/ijn.ijn_274_23] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/27/2023] [Accepted: 07/14/2023] [Indexed: 01/05/2024] Open
Affiliation(s)
- Pooja A. Basavanagowda
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Anuj Prabhakar
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Jasmine Sethi
- Department of Nephrology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| |
Collapse
|
4
|
Dhooria S, Arora S, Chaudhary S, Sehgal IS, Prabhakar N, Mohammad N, Sharma R, Das P, Kumar Y, Garg M, Puri GD, Bhalla A, Muthu V, Prasad KT, Agarwal R, Aggarwal AN. Risk factors for clinically significant diffuse parenchymal lung abnormalities persisting after severe COVID-19 pneumonia. Indian J Med Res 2023; 157:427-437. [PMID: 37322633 PMCID: PMC10443720 DOI: 10.4103/ijmr.ijmr_2360_22] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/15/2022] [Indexed: 06/17/2023] Open
Abstract
Background & objectives The risk factors for clinically significant diffuse parenchymal lung abnormalities (CS-DPLA) persisting after severe coronavirus disease 2019 (COVID-19) pneumonia remain unclear. The present study was conducted to assess whether COVID-19 severity and other parameters are associated with CS-DPLA. Methods The study participants included patients who recovered after acute severe COVID-19 and presented with CS-DPLA at two or six month follow up and control group (without CS-DPLA). Adults volunteers without any acute illness, chronic respiratory illness and without a history of severe COVID-19 were included as healthy controls for the biomarker study. The CS-DPLA was identified as a multidimensional entity involving clinical, radiological and physiological pulmonary abnormalities. The primary exposure was the neutrophil-lymphocyte ratio (NLR). Recorded confounders included age, sex, peak lactate dehydrogenase (LDH), advanced respiratory support (ARS), length of hospital stay (LOS) and others; associations were analyzed using logistic regression. The baseline serum levels of surfactant protein D, cancer antigen 15-3 and transforming growth factor-β (TGF-β) were also compared among cases, controls and healthy volunteers. Results We identified 91/160 (56.9%) and 42/144 (29.2%) participants with CS-DPLA at two and six months, respectively. Univariate analyses revealed associations of NLR, peak LDH, ARS and LOS with CS-DPLA at two months and of NLR and LOS at six months. The NLR was not independently associated with CS-DPLA at either visit. Only LOS independently predicted CS-DPLA at two months [adjusted odds ratios (aOR) (95% confidence interval [CI]), 1.16 (1.07-1.25); P<0.001] and six months [aOR (95% CI) and 1.07 (1.01-1.12); P=0.01]. Participants with CS-DPLA at six months had higher baseline serum TGF-β levels than healthy volunteers. Interpretation and conclusions Longer hospital stay was observed to be the only independent predictor of CS-DPLA six months after severe COVID-19. Serum TGF-β should be evaluated further as a biomarker.
Collapse
Affiliation(s)
- Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Siddhant Arora
- Department of Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Shivani Chaudhary
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis & Imaging, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Nasim Mohammad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Riya Sharma
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Prabir Das
- Department of Immunopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Yashwant Kumar
- Department of Immunopathology, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Mandeep Garg
- Department of Radiodiagnosis & Imaging, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Goverdhan Dutt Puri
- Department of Anaesthesia & Intensive Care, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ashish Bhalla
- Department of Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| |
Collapse
|
5
|
Choudhary S, Prabhakar N, Muthu V, Bhujade H, Sekar A, Debi U, Garg M. 'T2 Hypointense Rim Sign' on Chest MRI in a Patient of Pulmonary Mucormycosis. Mycopathologia 2023:10.1007/s11046-023-00729-x. [PMID: 37185791 DOI: 10.1007/s11046-023-00729-x] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/08/2023] [Accepted: 03/20/2023] [Indexed: 05/17/2023]
Affiliation(s)
- Sonam Choudhary
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India.
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Harish Bhujade
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Aravind Sekar
- Department of Histopathology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Uma Debi
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| | - Mandeep Garg
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, 160012, India
| |
Collapse
|
6
|
Shantagiri A, Prabhakar N, Bhatia A, Roy S, Sodhi KS, Mathew JL, Saxena AK. Congenital lung malformations-Spot one, hunt for others. Pediatr Pulmonol 2023; 58:1283-1285. [PMID: 36635982 DOI: 10.1002/ppul.26316] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/15/2022] [Revised: 12/25/2022] [Accepted: 01/12/2023] [Indexed: 01/14/2023]
Affiliation(s)
- Arpit Shantagiri
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Anmol Bhatia
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Satarupa Roy
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Kushaljit Singh Sodhi
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Joseph L Mathew
- Department of Pediatrics, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| | - Akshay Kumar Saxena
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education & Research, Chandigarh, India
| |
Collapse
|
7
|
Saxena AK, Naik N, Bhatia A, Prabhakar N, Sodhi KS. Transarterial Embolization of Pulmonary Sequestration. Radiographics 2023; 43:e220204. [PMID: 36701246 DOI: 10.1148/rg.220204] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/27/2023]
Affiliation(s)
- Akshay Kumar Saxena
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Niveditha Naik
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Anmol Bhatia
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Kushaljit Singh Sodhi
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| |
Collapse
|
8
|
Garg M, Devkota S, Prabhakar N, Debi U, Kaur M, Sehgal IS, Dhooria S, Bhalla A, Sandhu MS. Ultra-Low Dose CT Chest in Acute COVID-19 Pneumonia: A Pilot Study from India. Diagnostics (Basel) 2023; 13:diagnostics13030351. [PMID: 36766456 PMCID: PMC9914217 DOI: 10.3390/diagnostics13030351] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/03/2022] [Revised: 01/14/2023] [Accepted: 01/16/2023] [Indexed: 01/19/2023] Open
Abstract
The rapid increase in the number of CT acquisitions during the COVID-19 pandemic raised concerns about increased radiation exposure to patients and the resultant radiation-induced health risks. It prompted researchers to explore newer CT techniques like ultra-low dose CT (ULDCT), which could improve patient safety. Our aim was to study the utility of ultra-low dose CT (ULDCT) chest in the evaluation of acute COVID-19 pneumonia with standard-dose CT (SDCT) chest as a reference standard. This was a prospective study approved by the institutional review board. 60 RT-PCR positive COVID-19 patients with valid indication for CT chest underwent SDCT and ULDCT. ULDCT and SDCT were compared in terms of objective (noise and signal-to-noise ratio) and subjective (noise, sharpness, artifacts and diagnostic confidence) image quality, various imaging patterns of COVID-19, CT severity score and effective radiation dose. The sensitivity, specificity, positive and negative predictive value, and diagnostic accuracy of ULDCT for detecting lung lesions were calculated by taking SDCT as a reference standard. The mean age of subjects was 47.2 ± 10.7 years, with 66.67% being men. 90% of ULDCT scans showed no/minimal noise and sharp images, while 93.33% had image quality of high diagnostic confidence. The major imaging findings detected by SDCT were GGOs (90%), consolidation (76.67%), septal thickening (60%), linear opacities (33.33%), crazy-paving pattern (33.33%), nodules (30%), pleural thickening (30%), lymphadenopathy (30%) and pleural effusion (23.33%). Sensitivity, specificity and diagnostic accuracy of ULDCT for detecting most of the imaging patterns were 100% (p < 0.001); except for GGOs (sensitivity: 92.59%, specificity: 100%, diagnostic accuracy: 93.33%), consolidation (sensitivity: 100%, specificity: 71.43%, diagnostic accuracy: 93.33%) and linear opacity (sensitivity: 90.00%, specificity: 100%, diagnostic accuracy: 96.67%). CT severity score (range: 15-25) showed 100% concordance on SDCT and ULDCT, while effective radiation dose was 4.93 ± 1.11 mSv and 0.26 ± 0.024 mSv, respectively. A dose reduction of 94.38 ± 1.7% was achieved with ULDCT. Compared to SDCT, ULDCT chest yielded images of reasonable and comparable diagnostic quality with the advantage of significantly reduced radiation dose; thus, it can be a good alternative to SDCT in the evaluation of COVID-19 pneumonia.
Collapse
Affiliation(s)
- Mandeep Garg
- Department of Radiodiagnosis & Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
- Correspondence:
| | - Shritik Devkota
- Department of Radiodiagnosis & Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis & Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Uma Debi
- Department of Radiodiagnosis & Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Maninder Kaur
- Department of Radiodiagnosis & Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Inderpaul S. Sehgal
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Ashish Bhalla
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| | - Manavjit Singh Sandhu
- Department of Radiodiagnosis & Imaging, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh 160012, India
| |
Collapse
|
9
|
Garg M, Bhatia H, Chandra T, Debi U, Sehgal IS, Prabhakar N, Sandhu MS, Agarwal R. Imaging Spectrum in Chronic Pulmonary Aspergillosis. Am J Trop Med Hyg 2023; 108:15-21. [PMID: 36375457 PMCID: PMC9833062 DOI: 10.4269/ajtmh.22-0366] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/31/2022] [Accepted: 09/14/2022] [Indexed: 11/16/2022] Open
Abstract
Chronic pulmonary aspergillosis (CPA) is a life-threatening respiratory fungal infection that is almost exclusively seen in patients with preexisting structural lung disease with no or mild immunosuppression. The clinical presentation and imaging findings are varied and often pose a diagnostic challenge; and the disease is often present for a long time before being correctly diagnosed. High-resolution chest computed tomography is the imaging modality of choice because it helps identify various forms of CPA, which can range from a simple aspergilloma and chronic cavitary form, to the subacute invasive and end-stage fibrotic form. The knowledge of the imaging features of this disease cannot be overemphasized because it can assist the clinician in reaching at an early diagnosis and timely initiation of appropriate antifungal therapy, thereby improving patient management and treatment outcome. Moreover, imaging also plays a pivotal role during follow-up in patients of CPA to assess the treatment response. In the current review, we present an illustrative review of radiologic patterns seen in various forms of CPA.
Collapse
Affiliation(s)
- Mandeep Garg
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harsimran Bhatia
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Tany Chandra
- Department of Radiodiagnosis and Imaging, All India Institute of Medical Sciences, New Delhi, India
| | - Uma Debi
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Manavjit Singh Sandhu
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
10
|
Garg M, Lamicchane S, Maralakunte M, Debi U, Dhooria S, Sehgal I, Prabhakar N, Sandhu MS. Role of MRI in the Evaluation of Pulmonary Sequel Following COVID-19 Acute Respiratory Distress Syndrome (ARDS). Curr Probl Diagn Radiol 2023; 52:117-124. [PMID: 36253228 PMCID: PMC9508699 DOI: 10.1067/j.cpradiol.2022.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/10/2022] [Revised: 08/23/2022] [Accepted: 09/21/2022] [Indexed: 02/05/2023]
Abstract
To evaluate the role of magnetic resonance imaging (MRI) chest as an alternative modality to CT chest for follow-up of patients recovered from severe COVID-19 acute respiratory distress syndrome (ARDS). A total of 25 subjects (16 [64%] men; mean age 54.84 years ± 12.35) who survived COVID-19 ARDS and fulfilled the inclusion criteria were enrolled prospectively. All the patients underwent CT and MRI chest (on the same day) at 6-weeks after discharge. MRI chest was acquired on 1.5T MRI using HASTE, BLADE, VIBE, STIR, and TRUFI sequences and evaluated for recognition of GGOs, consolidation, reticulations/septal thickening, parenchymal bands, and bronchial dilatation with CT chest as the gold standard. The differences were assessed by independent-sample t-test and Mann-Whitney U test. P-value of less than 0.05 was taken significant. There was a strong agreement (k = 0.8-1, P<0.01) between CT and MRI chest. On CT, the common manifestations were: GGOs (n=24, 96%), septal thickening/reticulations (n=24, 96%), bronchial dilatation (n=16, 64%), parenchymal bands (n=14, 56%), pleural thickening (n=8, 32%), consolidation (n=4, 16%) and crazy-paving (n=4, 16%). T2W HASTE, T2W BLADE, and T1 VIBE sequences showed 100% (95% CI, 40-100) sensitivity and 100% (95% CI, 3-100) specificity for detecting GGOs, septal thickening/reticulations, pleural thickening, consolidation, and crazy-paving. The overall sensitivity of MRI for detection of bronchial dilatation and parenchymal bands were 88.9% (95% CI, 77-100) and 92.9% (95% CI, 66-100), respectively; and specificity was 100% (95% CI, 29-100) for both findings. MRI chest, being radiation-free imaging modality can act as an alternative to CT chest in the evaluation of lung changes in patients recovered from COVID-19 pneumonia.
Collapse
Affiliation(s)
- Mandeep Garg
- Deptt. of Radiodiagnosis & Imaging, PGIMER, Chandigarh, India.
| | | | | | - Uma Debi
- Deptt. of Radiodiagnosis & Imaging, PGIMER, Chandigarh, India
| | | | | | - Nidhi Prabhakar
- Deptt. of Radiodiagnosis & Imaging, PGIMER, Chandigarh, India
| | | |
Collapse
|
11
|
Subramanian PC, Chidanandaswamy N, Soundararajan R, Bhujade H, Prabhakar N. An Aberrant Right Subclavian Artery-Esophageal Fistula-A Fatal Complication of a Common Anomaly: A Case Report and Review of Literature. Indian J Radiol Imaging 2022; 33:117-120. [PMID: 36855716 PMCID: PMC9968551 DOI: 10.1055/s-0042-1758194] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/27/2022] Open
Abstract
An aberrant right subclavian artery (ARSA), also called as arteria lusoria, is one of the most common aortic arch anomalies. ARSA-esophageal fistula is a rare, life-threatening complication, with only 37 cases reported in literature. We describe a case of a young girl who developed acute episode of massive hematemesis after the recovery from novel coronavirus disease 2019 (COVID-19) pneumonia. Computed tomography (CT) angiography showed ARSA with retroesophageal course and active contrast leak in esophagus. Digital subtraction angiography confirmed the site of active contrast extravasation from the ARSA. However, the patient succumbed to hypovolemic shock even before the endovascular or surgical interventions could be done.
Collapse
Affiliation(s)
- Pavithra C. Subramanian
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Naveen Chidanandaswamy
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Raghuraman Soundararajan
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Harish Bhujade
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence Harish Bhujade, MD, FVIR Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and ResearchChandigarh 160012India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
12
|
Damaraju V, Agarwal R, Dhooria S, Sehgal IS, Prasad KT, Gupta K, Prabhakar N, Aggarwal AN, Muthu V. Isolated tracheobronchial mucormycosis: report of a case and systematic review of literature. Mycoses 2022; 66:5-12. [PMID: 35984683 DOI: 10.1111/myc.13519] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/13/2022] [Revised: 07/27/2022] [Accepted: 08/15/2022] [Indexed: 11/30/2022]
Abstract
BACKGROUND Isolated tracheobronchial mucormycosis (ITBM) is an uncommonly reported entity. Herein, we report a case of ITBM following coronavirus disease 2019 (COVID-19) and perform a systematic review of the literature. CASE DESCRIPTION AND SYSTEMATIC REVIEW A 45-year-old gentleman with poorly controlled diabetes mellitus presented with cough, streaky hemoptysis, and hoarseness of voice two weeks after mild COVID-19 illness. Computed tomography and flexible bronchoscopy suggested the presence of a tracheal mass, which was spontaneously expectorated. Histopathological examination of the mass confirmed invasive ITBM. The patient had complete clinical and radiological resolution with glycemic control, posaconazole, and inhaled amphotericin B (eight weeks). Our systematic review of the literature identified 25 additional cases of isolated airway invasive mucormycosis. The median age of the 26 subjects (58.3% men) was 46 years. Diabetes mellitus (79.2%) was the most common risk factor. Uncommon conditions such as anastomosis site mucormycosis (in 2 lung transplant recipients), post-viral illness (post-COVID-19 [n=3], and influenza [n=1]), and post-intubation mucormycosis (n=1) were noted in a few. Three patients died before treatment initiation. Systemic antifungals were used in most patients (commonly amphotericin B). Inhalation (5/26; 19.2%) or bronchoscopic instillation (1/26; 3.8%) of amphotericin B and surgery (6/26; 23.1%) were performed in some patients. The case-fatality rate was 50%, primarily attributed to massive hemoptysis. CONCLUSION Isolated tracheobronchial mucormycosis is a rare disease. Bronchoscopy helps in early diagnosis. Management with antifungals and control of risk factors is required since surgery may not be feasible.
Collapse
Affiliation(s)
- Vikram Damaraju
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kirti Gupta
- Department of Histopathology, * Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh N Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| |
Collapse
|
13
|
Prabhakar A, Prabhakar N, Garg M, Kumar A. The Integral Role of Radiology in the Diagnosis and Management of COVID-19-Associated Mucormycosis Infections. Am J Trop Med Hyg 2022; 106:1022-1025. [PMID: 35139486 PMCID: PMC8991342 DOI: 10.4269/ajtmh.21-1135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/28/2021] [Accepted: 01/18/2022] [Indexed: 11/19/2022] Open
Abstract
Recently, there has been a sudden surge in COVID-19-associated mucormycosis (CAM) infections. Rhino-oculo-cerebral and pulmonary mucormycosis are the two most common forms of CAM. Radiology plays an integral role in the management of CAM. Computed tomography (CT) determines gross bony and soft tissue involvement in COVID-19-associated rhino-oculo-cerebral mucormycosis, whereas magnetic resonance imaging helps in evaluation of the orbital and intracranial extension. Paranasal sinus soft tissue with extrasinus infiltration with or without bony destruction is suggestive of COVID-19-associated rhino-oculo-cerebral mucormycosis. High-resolution CT chest scan has shown to be helpful in the diagnosis of COVID-19-associated pulmonary mucormycosis. Consolidation and cavitation are the most common imaging features. Other CT abnormalities include the reverse-halo sign, pleural effusion, ground-glass opacities, pneumothorax, nodules, and pulmonary embolism. A high index of suspicion with appropriate imaging findings can lead to the early diagnosis of CAM and timely initiation of antifungal treatment and/or surgical debridement, which can be lifesaving.
Collapse
Affiliation(s)
| | | | - Mandeep Garg
- Department of Radiodiagnosis & Imaging, Post Graduate Institute of Medical Education, Chandigarh, India
| | - Ajay Kumar
- Department of Radiodiagnosis & Imaging, Post Graduate Institute of Medical Education, Chandigarh, India
| |
Collapse
|
14
|
Dhooria S, Chaudhary S, Sehgal IS, Agarwal R, Arora S, Garg M, Prabhakar N, Puri GD, Bhalla A, Suri V, Yaddanapudi LN, Muthu V, Prasad KT, Aggarwal AN. High-dose versus low-dose prednisolone in symptomatic patients with post-COVID-19 diffuse parenchymal lung abnormalities: an open-label, randomised trial (Acronym: COLDSTER). Eur Respir J 2021; 59:13993003.02930-2021. [PMID: 34887325 PMCID: PMC8850687 DOI: 10.1183/13993003.02930-2021] [Citation(s) in RCA: 28] [Impact Index Per Article: 9.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/21/2021] [Accepted: 11/22/2021] [Indexed: 11/16/2022]
Abstract
In some patients, respiratory symptoms and imaging abnormalities persist after acute coronavirus disease 2019 (COVID-19) pneumonia [1–3]. Chest computed tomography (CT) scans generally show diffuse parenchymal lung abnormalities consistent with organising pneumonia [4]. It has been proposed that the novel severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2) could act as a trigger to exalt the presence of pre-existing interstitial lung abnormalities encountered in the general population, especially in smokers. Previous observational studies reported improvement with glucocorticoids in symptomatic patients with post-COVID-19 diffuse parenchymal lung abnormalities (PC-DPLAS) [4–6]. A recent guideline recommended glucocorticoids for treating PC-DPLAS [3]. However, there are no randomised controlled trials on therapies for this condition. High-dose prednisolone may not be superior to a low-dose 6-week regimen in improving clinical, physiological and radiological outcomes, or health-related quality of life, in patients with symptomatic post-COVID-19 diffuse parenchymal lung abnormalitieshttps://bit.ly/32zqnXt
Collapse
Affiliation(s)
- Sahajal Dhooria
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India .,These authors contributed equally to the manuscript and may be considered as first authors
| | - Shivani Chaudhary
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India.,These authors contributed equally to the manuscript and may be considered as first authors
| | - Inderpaul Singh Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ritesh Agarwal
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Siddhant Arora
- Department of Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Mandeep Garg
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Goverdhan Dutt Puri
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashish Bhalla
- Department of Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Vikas Suri
- Department of Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Lakshmi Narayana Yaddanapudi
- Department of Anaesthesia and Intensive Care, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Kuruswamy Thurai Prasad
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ashutosh Nath Aggarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| |
Collapse
|
15
|
Affiliation(s)
- Mandeep Garg
- Department of Radiodiagnosis & Imaging, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis & Imaging, Postgraduate Institute of Medical Education & Research, Chandigarh 160 012, India
| | - Ashu Seith Bhalla
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi 110 029, India
| |
Collapse
|
16
|
Affiliation(s)
- Mandeep Garg
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Saurav Lamichhane
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
17
|
Garg M, Prabhakar N, Muthu V, Farookh S, Kaur H, Suri V, Agarwal R. CT Findings of COVID-19-associated Pulmonary Mucormycosis: A Case Series and Literature Review. Radiology 2021; 302:214-217. [PMID: 34463553 PMCID: PMC8717687 DOI: 10.1148/radiol.2021211583] [Citation(s) in RCA: 23] [Impact Index Per Article: 7.7] [Reference Citation Analysis] [What about the content of this article? (0)] [MESH Headings] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/03/2023]
|
18
|
Sharma R, Singh C, Khadwal A, Prakash G, Malhotra P, Jain A, Jandial A, Suri V, Muthu V, Prabhakar N, Gorsi U, Chakrabarti A, Varma S, Lad DP. Role of pre-transplant chest high-resolution computed tomography and serum galactomannan index in predicting post-transplant invasive pulmonary aspergillosis in allogeneic hematopoietic cell transplant recipients. Transpl Infect Dis 2021; 23:e13632. [PMID: 33973316 DOI: 10.1111/tid.13632] [Citation(s) in RCA: 3] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 01/17/2021] [Revised: 03/26/2021] [Accepted: 04/29/2021] [Indexed: 11/29/2022]
Abstract
INTRODUCTION The role of pre-HCT chest high-resolution computed tomography (HRCT) and serum galactomannan index (GMI) in predicting the post-allogeneic hematopoietic cell transplant (HCT) invasive pulmonary aspergillosis (IPA) is debatable. METHODS This was a single-center, prospective study from 2014 to 2019. The primary objective was to study if pre-HCT chest HRCT and serum GMI predicted IPA post-HCT. The secondary objective was day +100 mortality. All consecutive, consenting patients of ≥12 years of age undergoing allo-HCT were included and had pre-HCT chest HRCT and serum GMI. All patients received mold active antifungal prophylaxis. The EORTC/MSG criteria were used for the diagnosis of IPA. RESULTS A total of 82 patients with median age 27 years (12-59 years) were included. The underlying diagnoses included hematological malignancies (79%) and aplastic anemia (21%). Fifteen percent of patients was treated for prior history of probable IPA (>6 weeks before HCT). Pre-HCT chest HRCT satisfied EORTC clinical criteria in 24% patients. Serum GMI ≥0.5 was seen in 27% of patients. Post-HCT probable IPA was seen in 24% of patients. There were more patients with pre-HCT chest HRCT findings satisfying EORTC clinical criteria (45% vs. 18%, P = .014) and GMI ≥0.5 (45% vs. 21%, P = .03) in the group with post-HCT IPA compared to those without IPA. There was higher day+100 mortality in patients with post-HCT IPA (55% vs. 18%, P = .001). CONCLUSIONS The presence of EORTC clinical criteria on pre-HCT chest HRCT, serum GMI ≥0.5, and prior history of IPA predicted post-HCT IPA.
Collapse
Affiliation(s)
- Rintu Sharma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Charanpreet Singh
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Alka Khadwal
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gaurav Prakash
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Pankaj Malhotra
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arihant Jain
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Aditya Jandial
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikas Suri
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Valliappan Muthu
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arunaloke Chakrabarti
- Department of Microbiology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Subhash Varma
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Deepesh P Lad
- Department of Internal Medicine, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
19
|
Garg M, Prabhakar N, Bhalla AS, Irodi A, Sehgal I, Debi U, Suri V, Agarwal R, Yaddanapudi LN, Puri GD, Sandhu MS. Computed tomography chest in COVID-19: When & why? Indian J Med Res 2021; 153:86-92. [PMID: 33402610 PMCID: PMC8184074 DOI: 10.4103/ijmr.ijmr_3669_20] [Citation(s) in RCA: 11] [Impact Index Per Article: 3.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/19/2022] Open
Abstract
Computed tomography (CT) of the chest plays an important role in the diagnosis and management of coronavirus disease 2019 (COVID-19), but it should not be used indiscriminately. This review provides indications of CT chest in COVID-19 suspect, positive and recovered patients based on the current scientific evidence and our personal experience. CT chest is not indicated as a routine screening modality due to its poor sensitivity and specificity. However, it is useful in a small subset of COVID-19 suspects who test negative on reverse transcription-polymerase chain reaction (RT-PCR) with normal/indeterminate chest X-ray (CXR) but have moderate-to-severe respiratory symptoms and high index of clinical suspicion. CT chest is not indicated in every RT-PCR-positive patient and should be done only in specific clinical scenarios, where it is expected to significantly contribute in the clinical management such as COVID-19 patients showing unexplained clinical deterioration and/or where other concurrent lung pathology or pulmonary thromboembolism needs exclusion. Serial CXR and point-of-care ultrasound are usually sufficient to evaluate the progression of COVID-19 pneumonia. CT chest is also indicated in COVID-19-positive patients with associated co-morbidities (age >65 yr, diabetes, hypertension, obesity, cardiovascular disease, chronic respiratory disease, immune-compromise, etc.) who, despite having mild symptoms and normal/indeterminate CXR, record oxygen saturation of <93 per cent at rest while breathing room air or de-saturate on six-minute walk test. Finally, CT chest plays a crucial role to rule out lung fibrosis in patients recovered from COVID-19 infection who present with hypoxia/impaired lung function on follow up. In conclusion, though CT chest is an indispensable diagnostic tool in COVID-19, it should be used judiciously and only when specifically indicated.
Collapse
Affiliation(s)
- Mandeep Garg
- Department of Radiodiagnosis & Imaging, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis & Imaging, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ashu Seith Bhalla
- Department of Radiodiagnosis, All India Institute of Medical Sciences, New Delhi, India
| | - Aparna Irodi
- Department of Radiology, Christian Medical College & Hospital, Vellore, Tamil Nadu, India
| | - Inderpaul Sehgal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Uma Debi
- Department of Radiodiagnosis & Imaging, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Vikas Suri
- Department of Internal Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Ritesh Agarwal
- Department of Pulmonary Medicine, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Laxmi Narayana Yaddanapudi
- Department of Anaesthesia & Intensive Care, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Govardhan Dutt Puri
- Department of Anaesthesia & Intensive Care, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| | - Manavjit Singh Sandhu
- Department of Radiodiagnosis & Imaging, Postgraduate Institute of Medical Education & Research, Chandigarh, India
| |
Collapse
|
20
|
Naik BN, Singh N, Aditya AS, Gupta A, Prabhakar N, Grover S. Pulmonary embolism confounded with COVID-19 suspicion in a catatonic patient presenting to anesthesia for ECT: a case report. Braz J Anesthesiol 2021; 71:292-294. [PMID: 33766683 PMCID: PMC7983458 DOI: 10.1016/j.bjane.2021.02.031] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/10/2020] [Revised: 01/24/2021] [Accepted: 02/06/2021] [Indexed: 11/10/2022] Open
Abstract
Catatonic patients may develop deep vein thrombosis (DVT) and pulmonary embolism (PE) due to prolonged periods of immobility. These life-threatening conditions demand prompt recognition and management. We describe the case of a patient with catatonia who presented to anesthesia for electroconvulsive therapy (ECT) at the outset of the current coronavirus disease 2019 pandemic. She complained of breathing difficulty and was suspected to have COVID-19 infection. On further evaluation, she was found to have DVT and PE and required oxygen therapy and intensive care management. The diagnostic delay in our patient would have probably not occurred, had it not been for the existing pandemic situation.
Collapse
Affiliation(s)
- B Naveen Naik
- Postgraduate Institute of Medical Education and Research (PGIMER), Department of Anaesthesia and Intensive Care, Chandigarh, India
| | - Nidhi Singh
- Postgraduate Institute of Medical Education and Research (PGIMER), Department of Anaesthesia and Intensive Care, Chandigarh, India
| | - Ashish S Aditya
- Postgraduate Institute of Medical Education and Research (PGIMER), Department of Anaesthesia and Intensive Care, Chandigarh, India
| | - Aakriti Gupta
- Postgraduate Institute of Medical Education and Research (PGIMER), Department of Anaesthesia and Intensive Care, Chandigarh, India.
| | - Nidhi Prabhakar
- Postgraduate Institute of Medical Education and Research (PGIMER), Department of Radiodiagnosis and Imaging, Chandigarh, India
| | - Sandeep Grover
- Postgraduate Institute of Medical Education and Research (PGIMER), Department of Psychiatry, Chandigarh, India
| |
Collapse
|
21
|
Affiliation(s)
- Nidhi Prabhakar
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
| | - Anuj Prabhakar
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
| | - Mandeep Garg
- Department of Radiodiagnosis and Imaging, Post Graduate Institute of Medical Education and Research, Sector 12, Chandigarh 160012, India
| |
Collapse
|
22
|
Koshi S, Singla V, Singh T, Prabhakar N, Bal A, Singh G. Mammographic breast density and breast cancer risk: Evaluation using volumetric breast density software. J Cancer Res Ther 2021; 16:1258-1264. [PMID: 33342781 DOI: 10.4103/jcrt.jcrt_568_18] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/04/2022]
Abstract
Purpose The study aimed to assess breast density as a risk factor for breast malignancy using automated volumetric breast density software and to study the relationship of breast density with tumor histopathological characteristics. Materials and Methods One hundred and thirty-four women with unilateral core biopsy-proven breast cancer were taken in the "case group." Two hundred and one women with normal bilateral screening mammograms were enrolled in the "control group." The cases and controls were further divided into pre- and post-menopausal subgroups. The mammograms of the contralateral breast of the cases and bilateral breasts of the controls were evaluated by automated volumetric breast density software and classified into four density grades. The tumor histopathological characteristics in the various density grades were also evaluated. Results In premenopausal women, the odds of having breast cancer was significantly higher for Grade 3 breasts (odds ratio [OR] 3.03; 95% confidence interval [CI]: [1.19-7.71]) versus Grade 1 and 2 breasts. Grade 4 premenopausal breasts also had greater odds (OR 3.09; 95% CI [0.89-10.78]) of developing breast cancer. No such relationship was established for postmenopausal women. No significant difference was seen in the histopathology of breast cancer among various breast density groups. Conclusion Increased breast density can be considered as an inherent, independent risk factor for breast cancer in premenopausal women.
Collapse
Affiliation(s)
- Suzanne Koshi
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education Research, Chandigarh, India
| | - Veenu Singla
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education Research, Chandigarh, India
| | - Tulika Singh
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education Research, Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education Research, Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Postgraduate Institute of Medical Education Research, Chandigarh, India
| | - Gurpreet Singh
- General Surgery, Postgraduate Institute of Medical Education Research, Chandigarh, India
| |
Collapse
|
23
|
Garg M, Prabhakar N, Bhatia H, Dhooria S, Debi U, Muthu V, Maralkunte M, Sehgal I, Agarwal R, Sandhu MS. CT findings in sequel of COVID-19 pneumonia and its complications. BJR Open 2021; 3:20210055. [PMID: 36570781 PMCID: PMC9754056 DOI: 10.1259/bjro.20210055] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/01/2021] [Accepted: 09/19/2021] [Indexed: 12/27/2022] Open
Abstract
A significant number of patients after initial recovery from COVID-19 continue to experience lingering symptoms of the disease that may last for weeks or even months. Lungs being the most commonly affected organ by COVID-19, bear the major brunt of the disease and thus it is imperative to be aware of the evolution of the pulmonary parenchymal changes over time. CT chest is the imaging modality of choice to evaluate post-COVID lungs. Persistent ground-glass opacities, septal thickening, parenchymal bands, crazy-paving, traction bronchiectasis and consolidation constitute the commonly encountered imaging patterns seen on CT in post-COVID-19 lungs. Few vulnerable patients can develop lung fibrosis and show honeycombing on CT. Additionally, many complications like superadded infections (bacterial and fungal), pulmonary thromboembolism and pseudoaneurysm formation are also being reported. In the present pictorial review, we have tried to show the entire CT spectrum of sequelae of COVID-19 pneumonia and commonly associated infections and vascular complications.
Collapse
Affiliation(s)
- Mandeep Garg
- Department
of Radiodiagnosis and Imaging, PGIMER,
Chandigarh, India
| | - Nidhi Prabhakar
- Department
of Radiodiagnosis and Imaging, PGIMER,
Chandigarh, India
| | - Harsimran Bhatia
- Department
of Radiodiagnosis and Imaging, PGIMER,
Chandigarh, India
| | | | - Uma Debi
- Department
of Radiodiagnosis and Imaging, PGIMER,
Chandigarh, India
| | | | | | | | - Ritesh Agarwal
- Department
of Pulmonary Medicine, PGIMER,
Chandigarh, India
| | - MS Sandhu
- Department
of Radiodiagnosis and Imaging, PGIMER,
Chandigarh, India
| |
Collapse
|
24
|
Daniel P, Shukla S, Prabhakar N, Kulkarni A, Sharma R, Gupta R, Rana SS. Infected Pancreatic Hydatid Cyst with Cysto-Pancreatic Fistula Presenting as Acute Pancreatitis. Journal of Digestive Endoscopy 2020. [DOI: 10.1055/s-0040-1708069] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 10/24/2022] Open
Abstract
AbstractHydatid cysts can be found in almost any organ of the body with the most common sites being liver, lung, spleen, and kidney. A pancreatic hydatid cyst is rare but an isolated pancreatic hydatid cyst is even rarer. Cysts in the head of pancreas usually present with jaundice, whereas cysts located in the body and tail are usually asymptomatic. We present a rare case of isolated pancreatic hydatid cyst that presented with acute pancreatitis and mimicked a pancreatic fluid collection.
Collapse
Affiliation(s)
- Phillip Daniel
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Siddharth Shukla
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Aditya Kulkarni
- Department of Surgery, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Ravi Sharma
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Rajesh Gupta
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| | - Surinder Singh Rana
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research (PGIMER), Chandigarh, India
| |
Collapse
|
25
|
Singla V, Murugesan K, Singh AK, Prabhakar N, Sinha SK, Singh T, Dey P. Isolated breast cysticercosis. Breast J 2020; 26:1257-1258. [PMID: 32172539 DOI: 10.1111/tbj.13811] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/16/2020] [Revised: 02/24/2020] [Accepted: 02/26/2020] [Indexed: 11/29/2022]
Affiliation(s)
- Veenu Singla
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kannan Murugesan
- Department of Internal Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Anupam Kumar Singh
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Saroj Kant Sinha
- Department of Gastroenterology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Tulika Singh
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Pranab Dey
- Department of Cytology and Gynaec Pathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
26
|
Garg S, Garg M, Prabhakar N, Malhotra P, Agarwal R. Unraveling the mystery of Covid-19 cytokine storm: From skin to organ systems. Dermatol Ther 2020; 33:e13859. [PMID: 32559324 PMCID: PMC7323083 DOI: 10.1111/dth.13859] [Citation(s) in RCA: 34] [Impact Index Per Article: 8.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/02/2020] [Revised: 06/14/2020] [Accepted: 06/15/2020] [Indexed: 01/07/2023]
Abstract
COVID-19 is a global pandemic that emerged from Wuhan, China. Besides pneumonia and acute respiratory distress syndrome, the disease leads to multisystem involvement in the form of myocarditis, arrhythmias, cardiac arrest, gastrointestinal symptoms, hypoxemic brain injury, acute liver, and renal function impairment. There are also reports of cutaneous lesions in form of urticarial and maculopapular rashes, chilblain like fingers and toes (covid feet), livedoid vasculopathy, and chicken-pox like or varicelliform vesicles. Clinically, many of these skin lesions are likely secondary to occlusion of small to medium blood vessels due to microthrombi formation or due to viral laden antigen-antibody immune complexes; and same explanation may hold true for possible hypoxemic injury simultaneously occurring in other vital organs like lungs, heart, brain, and kidneys. The histopathology, immunoflorescence and RT-PCR analysis of skin biopsies can provide useful insights for ascertaining the pathogenesis of this complex viral syndrome. Apparently, it is interplay of disarmed cellular immunity and over-activated humoral immunity that culminates in end-organ changes. The morbidity and mortality can be significantly reduced by upgrading the cellular immunity and downgrading the humoral response; along with prevention of hypoxemic and reperfusion injuries by using antivirals, immunomodulators, antioxidants, anti-platelets, and anticoagulants in judicious and phased manner.
Collapse
Affiliation(s)
- Suruchi Garg
- Department of DermatologyAura Skin InstituteChandigarhIndia
| | - Mandeep Garg
- Department of Radiodiagnosis and ImagingPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Nidhi Prabhakar
- Department of Radiodiagnosis and ImagingPost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Pankaj Malhotra
- Department of Internal MedicinePost Graduate Institute of Medical Education and ResearchChandigarhIndia
| | - Ritesh Agarwal
- Department of Pulmonary MedicinePost Graduate Institute of Medical Education and ResearchChandigarhIndia
| |
Collapse
|
27
|
Singh T, Prabhakar N, Singla V, Singh G, Nada R. Imaging of idiopathic nonsuppurative nodular panniculitis of breast. Breast J 2019; 26:536-538. [PMID: 31538369 DOI: 10.1111/tbj.13567] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/10/2019] [Revised: 05/15/2019] [Accepted: 05/16/2019] [Indexed: 11/28/2022]
Affiliation(s)
- Tulika Singh
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Veenu Singla
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Gurpreet Singh
- Department of General surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ritambhra Nada
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
28
|
Abstract
Primary pleural liposarcoma (PPL) is a rare malignant tumor of the pleura. The diagnosis of PPL may be suspected on chest imaging based on radiologic features such as large pleural mass showing areas of fat with or without calcification. Herein, we present the case of a 32-year-old male whose contrast-enhanced computed tomography scan of the chest revealed a large, heterogeneous, hypodense, right pleural-based mass with small areas of fat and calcification within it. An ultrasound-guided biopsy was performed, which confirmed the diagnosis of a myxoid variant of pleural liposarcoma.
Collapse
Affiliation(s)
- Nidhi Prabhakar
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Kim Vaiphei
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Vikarn Vishwajeet
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Eniyavel Ramamoorthy
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Ujjwal Gorsi
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Sahajal Dhooria
- Department of Pulmonary Medicine, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Rakesh Kapoor
- Department of Radiotherapy, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - M S Sandhu
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
29
|
Singla V, Dawadi K, Singh T, Prabhakar N, Srinivasan R, Suri V, Khandelwal N. Multiparametric MRI Evaluation of Complex Ovarian Masses. Curr Probl Diagn Radiol 2019; 50:34-40. [PMID: 31399230 DOI: 10.1067/j.cpradiol.2019.07.008] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 03/09/2019] [Revised: 07/04/2019] [Accepted: 07/08/2019] [Indexed: 11/22/2022]
Abstract
OBJECTIVE To assess the role of diffusion-weighted imaging and dynamic contrast-enhanced magnetic resonance imaging in the categorization of complex ovarian masses into benign and malignant. MATERIALS AND METHODS This prospective study was done on 33 complex ovarian masses. T1 and T2-weighted sequences, diffusion-weighted imaging, apparent diffusion coefficient, and dynamic contrast-enhanced magnetic resonance imaging were performed on 1.5 T MRI. Time-intensity curves, tissue signal intensity on unenhanced T1 images (SI0), maximum absolute contrast enhancement (SImax), time to reach SImax (Tmax), maximum relative SI (SIrel = [SImax - SI0]/SI0 ×100), maximum Slope (Slopemax = SIrel/Tmax ×100), and wash in rate (WIR = [SImax - SI0]/Tmax) were calculated. Histopathological diagnosis was taken as gold standard. RESULTS A total of 20/33 masses were benign, 2/33 were borderline tumors, and 11/33 were malignant. Diffusion restriction was seen in all malignant masses and 13/20 benign masses. The mean apparent diffusion coefficient values showed a significant difference between malignant and benign, with 81.8% sensitivity and 63.6% specificity. Type III curve showed 100% specificity for malignant lesions. Tmax and Slopemax were useful in differentiating benign and malignant masses; with Tmax cut-off at 73.5 seconds having a high specificity (81.8%) and Slopemax cut-off at 0.83%/s having high sensitivity (91%) and negative predictive value (94.4%). CONCLUSION Multiparametric MRI confers high diagnostic accuracy in stratifying complex ovarian masses.
Collapse
Affiliation(s)
- Veenu Singla
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education Research (PGIMER), Chandigarh, India.
| | - Kapil Dawadi
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education Research (PGIMER), Chandigarh, India
| | - Tulika Singh
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education Research (PGIMER), Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education Research (PGIMER), Chandigarh, India
| | - Radhika Srinivasan
- Department of Cytology and Gynaecological Pathology, Postgraduate Institute of Medical Education Research (PGIMER), Chandigarh, India
| | - Vanita Suri
- Department of Obstetrics and Gynaecology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Niranjan Khandelwal
- Department of Radiodiagnosis and Imaging, Postgraduate Institute of Medical Education Research (PGIMER), Chandigarh, India
| |
Collapse
|
30
|
Singla V, Prakash A, Prabhakar N, Singh T, Bal A, Singh G, Khandelwal N. Does Shear Wave Elastography Score Over Strain Elastography in Breast Masses or Vice Versa? Curr Probl Diagn Radiol 2019; 49:96-101. [PMID: 30981528 DOI: 10.1067/j.cpradiol.2019.02.013] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/06/2018] [Revised: 02/26/2019] [Accepted: 02/28/2019] [Indexed: 12/21/2022]
Abstract
OBJECTIVE This study was done to compare parameters of strain elastography (SE) and shear-wave elastography (SWE) for differentiation of benign and malignant breast masses and determine their best cut-offs. MATERIAL AND METHODS B mode ultrasound (USG), SE, and SWE were performed in 199 breast masses. During SE, 5-point visual elastography score (SEvisual score) and strain ratio (SEstrain ratio) were obtained. During SWE, mean and maximum elasticity values in kilopascals, and shear wave ratio were obtained in two orthogonal planes. The shear wave mean average (SWEmean avg), shear wave maximum average (SWEmax avg) and shear wave ratio average (SWEratio avg) were calculated by averaging the respective values in the two planes. The SE and SWE parameters of every mass were correlated with its histopathology. RESULTS The areas under the receiver operating characteristic curve of SEvisual score, SEstrain ratio, SWEmean avg, SWEmax avg, and SWEratio avg were 0.815, 0.814, 0.846, 0.846, and 0.799, respectively. CONCLUSIONS The best cut-off values that achieved the highest sensitivity and specificity for SEstrain ratio, SWEmean avg, SWEmax avg, and SWEratio avg were 3.91, 113 kPa, 123.5 kPa, and 7.32, respectively. Quantitative parameter of SE showed comparable diagnostic performance with quantitative parameters of SWE.
Collapse
Affiliation(s)
- Veenu Singla
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India.
| | - Aparna Prakash
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Tulika Singh
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amanjit Bal
- Department of Histopathology, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gurpreet Singh
- Department of General Surgery, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Niranjan Khandelwal
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
31
|
Abstract
The objective of this study was to evaluate the role of perfusion computed tomography (PCT) in differentiating benign from malignant adnexal masses. Twenty patients, each of pathologically proven malignant and benign adnexal masses who had undergone PCT on 64-slice CT scanner, were included in the study. The PCT parameters, viz. blood volume (BV), blood flow (BF), permeability surface index area (PS) and time to maximum of the tissue residue function (Tmax) of the adnexal masses were calculated. Statistical analysis to study the association between PCT parameters and histopathological diagnosis was done. In the malignant group, the mean PS, BV and BF values were elevated. The mean Tmax of the benign lesions was higher compared to that of the malignant lesions. There was a significant statistical difference in the PCT parameters between the malignant and benign groups (p value = .001). PCT can be a useful tool for differentiating benign and malignant adnexal masses. Impact statement What is already known on this subject? It is not always possible to distinguish benign from malignant adnexal lesions despite the application of various imaging techniques. Perfusion CT (PCT) is an imaging technique with which we can obtain both the morphological and functional information of tumours. Perfusion-based imaging enables us to objectively evaluate the neovascularity in a lesion. This helps in differentiating the benign lesions from aggressive malignant lesions. What do the results of this study add? The PCT parameters, viz. blood volume (BV), blood flow (BF), permeability surface index area (PS) and time to maximum of the tissue residue function (Tmax) were calculated from adnexal masses on a 64-multi-slice CT scanner and correlated with their histopathological diagnoses. The values of the mean PS, BV and BF values were significantly higher in the malignant adnexal masses. The mean Tmax in the benign masses was more compared to that of the malignant lesions. Significant statistical difference was seen in PCT parameters between malignant and benign groups. What are the implications of these findings for clinical practice and/or further research? PCT can be a useful tool for differentiating benign from malignant adnexal masses. However, more collaborative research and robust validation are imperative to further evaluate this innovative evolving technique.
Collapse
Affiliation(s)
- Veenu Singla
- a Department of Radiodiagnosis , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Nidhi Prabhakar
- a Department of Radiodiagnosis , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Niranjan Khandelwal
- a Department of Radiodiagnosis , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Gaurav Sharma
- a Department of Radiodiagnosis , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Tulika Singh
- a Department of Radiodiagnosis , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Neelam Aggarwal
- b Department of Obstetrics and Gynecology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| | - Srinivasan Radhika
- c Department of Cytology and Gynecological Pathology , Post Graduate Institute of Medical Education and Research , Chandigarh , India
| |
Collapse
|
32
|
Garg M, Prabhakar N, Singla V, Singh T, Singh G, Bal A, Khandelwal N. Breast cancer in a patient with neurofibromatosis type 1. Breast J 2017; 24:666-668. [PMID: 29286196 DOI: 10.1111/tbj.12987] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/02/2016] [Revised: 12/08/2016] [Accepted: 12/13/2016] [Indexed: 11/27/2022]
Affiliation(s)
- Mandeep Garg
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Veenu Singla
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Tulika Singh
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Gurpreet Singh
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Amanjit Bal
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Niranjan Khandelwal
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
33
|
Prabhakar N, Kalra N, Behera A, Das A, Lal A, Dhiman RK, Khandelwal N. Large Heterogeneous Calcified Masses in Liver: A Diagnostic Dilemma. J Clin Exp Hepatol 2017; 7:385-386. [PMID: 29234206 PMCID: PMC5719463 DOI: 10.1016/j.jceh.2017.09.001] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/07/2017] [Accepted: 09/24/2017] [Indexed: 12/12/2022] Open
Affiliation(s)
- Nidhi Prabhakar
- Department of Radio Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Naveen Kalra
- Department of Radio Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence: Naveen Kalra, Professor, Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh 160012, India. Tel.: +91 7087009388.Department of Radiodiagnosis, Post Graduate Institute of Medical Education and ResearchChandigarh160012India
| | - Arunanshu Behera
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Ashim Das
- Department of Histopathology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Anupam Lal
- Department of Radio Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Radha Krishan Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Niranjan Khandelwal
- Department of Radio Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
34
|
Prabhakar N, Ahuja CK, Khandelwal N. B/L Basal Ganglia Lesions in a Child Leading to a Diagnosis of Glucose-6-Phosphate Dehydrogenase Deficiency. Ann Neurosci 2017; 25:50-52. [PMID: 29887684 DOI: 10.1159/000481907] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/27/2017] [Accepted: 06/29/2017] [Indexed: 11/19/2022] Open
Abstract
Bilateral basal ganglia lesions are a common non-specific finding seen in many diseases. One of the differential diagnoses for it, in a child, is kernicterus occurring due to hyperbilirubinemia. Glucose-6-phosphate dehydrogenase (G6PD) deficiency is a common cause of severe hyperbilirubinemia. A 1-year old child presented to the hospital with history of generalized dystonia in the previous 3 days. MRI showed evidence of symmetrical lesions in bilateral globus pallidus, which were hyperintense on T2/FLAIR and isointense on T1. Patient's blood test revealed G6PD deficiency. Hence, a diagnosis of G6PD deficiency leading to kernicterus was made. In a child, the diseases that may affect the basal ganglia symmetrically and bilaterally include kernicterus, hypoxia, carbon monoxide poisoning, hypoglycemia, inherited metabolic and dysmyelinating disorders like Leigh disorder, Canavan and Krabbe, Neurofibromatosis, Herpes encephalitis, congenital HIV infection, manganese poisoning and extrapontine myelinolysis. Important causes of kernicterus are Rh incompatibility, ABO incompatibility, sepsis, hemolytic anaemia and G6PD deficiency. G6PD deficiency leading to kernicterus should be considered a differential diagnosis of bilateral basal ganglia lesions in children. Proper elicitation of history with appropriate blood biochemical tests will help in arriving at a proper diagnosis.
Collapse
Affiliation(s)
- Nidhi Prabhakar
- Department of Radiodiagnosis and Imaging, PGIMER, Chandigarh, India
| | - Chirag K Ahuja
- Department of Radiodiagnosis and Imaging, PGIMER, Chandigarh, India
| | | |
Collapse
|
35
|
Moudgil S, Kalra N, Prabhakar N, Dhiman RK, Behera A, Chawla YK, Khandelwal N. Comparison of Contrast Enhanced Ultrasound With Contrast Enhanced Computed Tomography for the Diagnosis of Hepatocellular Carcinoma. J Clin Exp Hepatol 2017; 7:222-229. [PMID: 28970709 PMCID: PMC5620356 DOI: 10.1016/j.jceh.2017.03.003] [Citation(s) in RCA: 9] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 08/19/2016] [Accepted: 03/01/2017] [Indexed: 12/12/2022] Open
Abstract
BACKGROUND/AIMS The most common primary malignant tumor of liver is hepatocellular carcinoma (HCC). The highest risk of developing HCC is seen in patients of cirrhosis. Ultrasound is used for surveillance in these patients. This study evaluates the role of contrast enhanced ultrasound (CEUS) in the diagnosis of HCC and compares CEUS to contrast enhanced computed tomography (CECT). MATERIALS AND METHODS This prospective study included 22 patients with cirrhosis and suspected to have HCC on the basis of gray scale ultrasound or elevated Alpha-fetoprotein. Multiphasic CECT and CEUS were done. On both CECT and CEUS, arterial phase enhancement patterns of the lesions were classified as heterogeneously hyperenhancing, homogeneously hyperenhancing, isoenhancing or nonenhancing. The enhancement patterns of the lesions in portal venous phase were classified as hyperenhancing, isoenhancing, washout or nonenhancing. Presence or absence of neovascularity and peripheral capsule were also noted. The diagnosis of HCC was made as per American Association for the Study of Liver Diseases (AASLD) guidelines. RESULTS There was moderate degree of agreement between the two modalities in characterizing the enhancement pattern in arterial phase, as calculated by using kappa test (k = 0.59, P < 0.05). Substantial agreement between them, for demonstrating the neovascularity, was also seen (k = 0.772, P < 0.05). CEUS was found to be superior to CECT in demonstrating portal venous phase wash out and peripheral capsule. Only fair agreement was seen between them, with kappa value for portal venous washout being k = 0.38 (P < 0.05) and for peripheral capsule being k = 0.328 (P < 0.05). CONCLUSION CEUS is comparable to CECT in demonstrating the arterial phase enhancement pattern of HCC and the neovascularity. CEUS was found to be better than CECT in demonstrating the portal venous phase washout and peripheral capsule.
Collapse
Key Words
- AASLD, American Association for the Study of Liver Diseases
- CECT, contrast enhanced computed tomography
- CEMR, contrast enhanced magnetic resonance
- CEUS, contrast enhanced ultrasound
- CT, computed tomography
- HCC, hepatocellular carcinoma
- MI, mechanical index
- MRI, magnetic resonance imaging
- OPD, outpatient department
- RFA, radiofrequency ablation
- UCA, ultrasound contrast agents
- US, ultrasound
- k, kappa value
Collapse
Affiliation(s)
- Sandeep Moudgil
- Department of Radio Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Naveen Kalra
- Department of Radio Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India,Address for correspondence: Naveen Kalra, Department of Radiodiagnosis, PGIMER, Chandigarh, India. Tel.: +91 7087009388.Department of Radiodiagnosis, PGIMERChandigarhIndia
| | - Nidhi Prabhakar
- Department of Radio Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Radha Krishan Dhiman
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Arunanshu Behera
- Department of General Surgery, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Yogesh Kumar Chawla
- Department of Hepatology, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Niranjan Khandelwal
- Department of Radio Diagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
36
|
|
37
|
Garg M, Prabhakar N. Incidental detection of a curved radiopacity on the chest X-ray. Lung India 2017; 34:97-98. [PMID: 28144073 PMCID: PMC5234212 DOI: 10.4103/0970-2113.197105] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/02/2022] Open
Affiliation(s)
- Mandeep Garg
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| | - Nidhi Prabhakar
- Department of Radiodiagnosis, Post Graduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
38
|
Singla V, Prabhakar N, Singh T, Khandelwal N, Singh G, Vasishta R. Primary Mucormycosis of the Breast: A Rare Entity. Breast J 2016; 23:231-233. [PMID: 27886415 DOI: 10.1111/tbj.12716] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022]
Affiliation(s)
- Veenu Singla
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | | | - Tulika Singh
- Department of Radiodiagnosis, PGIMER, Chandigarh, India
| | | | - Gurpreet Singh
- Department of General Surgery, PGIMER, Chandigarh, India
| | | |
Collapse
|
39
|
Reddy KL, Rai M, Prabhakar N, Arppe R, Rai SB, Singh SK, Rosenholm JM, Krishnan V. Controlled synthesis, bioimaging and toxicity assessments in strong red emitting Mn2+ doped NaYF4:Yb3+/Ho3+ nanophosphors. RSC Adv 2016. [DOI: 10.1039/c6ra07106f] [Citation(s) in RCA: 28] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022] Open
Abstract
Rare earth, Yb3+/Ho3+ doped NaYF4 nanophosphors co-doped with Mn2+ showed enhanced red emission under NIR irradiation and were successfully used for cancer cell imaging.
Collapse
Affiliation(s)
- K. L. Reddy
- School of Basic Sciences and Advanced Materials Research Center
- Indian Institute of Technology Mandi
- Mandi
- India
| | - M. Rai
- Department of Physics
- Banaras Hindu University
- Varanasi
- India
| | - N. Prabhakar
- Pharmaceutical Sciences Laboratory
- Faculty of Sciences and Engineering
- Åbo Akademi University
- Turku
- Finland
| | - R. Arppe
- Department of Biotechnology
- University of Turku
- Turku
- Finland
| | - S. B. Rai
- Department of Physics
- Banaras Hindu University
- Varanasi
- India
| | - S. K. Singh
- Department of Physics
- Indian Institute of Technology (Banaras Hindu University)
- Varanasi
- India
| | - J. M. Rosenholm
- Pharmaceutical Sciences Laboratory
- Faculty of Sciences and Engineering
- Åbo Akademi University
- Turku
- Finland
| | - V. Krishnan
- School of Basic Sciences and Advanced Materials Research Center
- Indian Institute of Technology Mandi
- Mandi
- India
| |
Collapse
|
40
|
Prabhakar N, Vyas S, Taneja S, Khandelwal N. Intrahepatic aneurysmal portohepatic venous shunt: what should be done? Ann Hepatol 2015; 14:118-20. [PMID: 25536649] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Affiliation(s)
- Nidhi Prabhakar
- Departments of Radiodiagnosis Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sameer Vyas
- Departments of Radiodiagnosis Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Sunil Taneja
- Departments of Hepatology. Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | - Niranjan Khandelwal
- Departments of Radiodiagnosis Postgraduate Institute of Medical Education and Research, Chandigarh, India
| |
Collapse
|
41
|
Peng Y, Makarenko V, Nanduri J, Vasavda C, Raghuraman G, Yuan G, Gadalla M, Kumar G, Snyder S, Prabhakar N. Strain‐Dependent Variations in Carotid Body O
2
Sensing: Role of CO‐H
2
S Signaling. FASEB J 2015. [DOI: 10.1096/fasebj.29.1_supplement.682.7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/11/2022]
Affiliation(s)
- Y.‐J. Peng
- Institute for Integrative Physiology University of ChicagoChicagoILUnited States
| | - V. Makarenko
- Institute for Integrative Physiology University of ChicagoChicagoILUnited States
| | - J. Nanduri
- Institute for Integrative Physiology University of ChicagoChicagoILUnited States
| | - C Vasavda
- Institute for Integrative Physiology University of ChicagoChicagoILUnited States
- Department of Neuroscience Johns Hopkins UniversityStillwaterOKUnited States
| | - G. Raghuraman
- Institute for Integrative Physiology University of ChicagoChicagoILUnited States
| | - G. Yuan
- Institute for Integrative Physiology University of ChicagoChicagoILUnited States
| | - M. Gadalla
- Department of Neuroscience Johns Hopkins UniversityStillwaterOKUnited States
| | - G. Kumar
- Institute for Integrative Physiology University of ChicagoChicagoILUnited States
| | - S. Snyder
- Department of Neuroscience Johns Hopkins UniversityStillwaterOKUnited States
| | - N. Prabhakar
- Institute for Integrative Physiology University of ChicagoChicagoILUnited States
| |
Collapse
|
42
|
Prabhakar N, Kalra N, Bhasin DK, Rana SS, Gupta V, Singh R, Khandelwal N. Comparison of CT colonography with conventional colonoscopy in patients with ulcerative colitis. Acad Radiol 2015; 22:296-302. [PMID: 25435187 DOI: 10.1016/j.acra.2014.09.016] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [What about the content of this article? (0)] [Affiliation(s)] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/06/2014] [Revised: 09/21/2014] [Accepted: 09/26/2014] [Indexed: 02/01/2023]
Abstract
RATIONALE AND OBJECTIVE Patients with ulcerative colitis require recurrent conventional colonoscopy (CC) to define the extent of the disease. Computed tomography (CT) colonography (CTC) can be used as an alternative technique for studying the colon in these patients. The purpose of the study was to compare the findings of CTC to CC in patients with ulcerative colitis. MATERIALS AND METHODS Twenty patients proven to have ulcerative colitis on biopsy and in clinical remission state were enrolled in the study. They underwent CTC and CC within 1 week of each test. The investigators performing CTC and CC were blinded to the findings of each other. The chi-square test, kappa test, sensitivity, and specificity were used to compare the findings on CTC and CC. In addition, patient acceptance for both the procedures was compared. RESULTS Sensitivity and specificity on CTC for detecting granular appearance were 81.0% and 73.8%, respectively, and for pseudopolyps were 82.1% and 84.5%, respectively. Good correlation was seen between CTC and CC for detection of granular appearance and pseudopolyps. Loss of haustral folds, wall thickening, pericolonic vascularity, and pericolonic lymph nodes seen on CTC were found to correlate with intraluminal findings seen on CC. Patient acceptance for CTC was better than that for CC. CONCLUSIONS CTC can be used for evaluating patients with ulcerative colitis who are in remission.
Collapse
Affiliation(s)
- Nidhi Prabhakar
- Department of Radiodiagnosis, PGIMER, Chandigarh 160012, India
| | - Naveen Kalra
- Department of Radiodiagnosis, PGIMER, Chandigarh 160012, India.
| | | | | | - Vikas Gupta
- Department of General Surgery, PGIMER, Chandigarh, India
| | - Rajinder Singh
- Department of General Surgery, PGIMER, Chandigarh, India
| | | |
Collapse
|
43
|
Abstract
Hypothalamic glioma account for 10-15% of supratentorial tumors in children. They usually present earlier (first 5 years of age) than craniopharyngioma. Hypothalamic glioma poses a diagnostic dilemma with craniopharyngioma and other hypothalamic region tumors, when they present with atypical clinical or imaging patterns. Neuroimaging modalities especially MRI plays a very important role in scrutinizing the lesions in the hypothalamic region. We report a case of a hypothalamic glioma masquerading as a craniopharyngioma on imaging along with brief review of both the tumors.
Collapse
Affiliation(s)
- Sameer Vyas
- Department of Radiodiagnosis, Postgraduate Institute of Medical Education and Research, Chandigarh, India
| | | | | | | | | |
Collapse
|
44
|
|
45
|
Gidwani G, Pallan P, Saker M, Prabhakar N. Abstract No. 328: Age factors and indications for congential portosystemic shunt embolization. J Vasc Interv Radiol 2012. [DOI: 10.1016/j.jvir.2011.12.385] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022] Open
|
46
|
|
47
|
Marek W, Prabhakar N, Mückenhoff K. Atemarbeit bei externen Stenosen und Bronchialmuskelkontraktion. Pneumologie 2008. [DOI: 10.1055/s-2008-1074394] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
48
|
Marek W, Prabhakar N, Mückenhoff K. Atemarbeit und Atemmuskelaktivität während Stimulation chemosensibler Afferenzen mit und ohne vagale Rückkopplung. Pneumologie 2008. [DOI: 10.1055/s-2008-1076130] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|
49
|
Kakarla R, Vaghani A, Prabhakar N, Saker M. Abstract No. 246 EE: Persistent Sciatic Artery: Radiologic Features and Role of Angiography in Patient Management. J Vasc Interv Radiol 2008. [DOI: 10.1016/j.jvir.2007.12.274] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/30/2022] Open
|
50
|
Marek W, Prabhakar N, Mückenhoff K. Zur Interaktion von Lungendehnungsrezeptoren und Chemoafferenzen während extrathorakaler Stenosen. Pneumologie 2007. [DOI: 10.1055/s-2007-973297] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [What about the content of this article? (0)] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 10/21/2022]
|