Pakistan Journal of Chest Medicine

Beyond Diagnosis: Closing the Care Gap for Children with Tuberculosis in Pakistan

Afsar Khan — Tue, 02 Sep 2025 00:00:00 +0000

A familiar and sad story plays out in the busy outpatient departments of public hospitals in Pakistan: a child diagnosed with tuberculosis is started on treatment with optimism and disappears. The child does not return for follow-up. This disconnection between care is where the childhood battle against TB is too often lost. While the national dialogue rightly acknowledges key gaps in diagnostic service delivery, the silent epidemic of children lost in the treatment cascade is an important, yet overlooked, domain in our public health response.

A Complex Case of Relapsed Pre-XDR Tuberculosis Complicated by Pregnancy and Congenital Anomaly: Management and Lessons Learned

Shahab Yaquoob, Maria Akbar, Touqeer Anjum — Tue, 02 Sep 2025 00:00:00 +0000

Background: The emergence of drug-resistant tuberculosis, particularly the cases of multidrug-resistant (MDR-TB) and pre-extensively drug-resistant (pre-XDR-TB), proves to be a tremendous barrier to the world's control of TB programs. In addition, if these cases are manifested with the problems of pregnancy and comorbidities, they will be extremely hard to deal with.

Case Presentation: We report the case of a 28-year-old female with a chronic pulmonary tuberculosis infection. Initially, she experienced a partial response to a first-line Category-I regimen, which was later followed by a Category-II retreatment regimen that also did not work for her. She was diagnosed with Rifampicin-resistant TB (RR-TB) via GeneXpert and was then cured with a standard MDR-TB regimen. Nevertheless, relapses occurred six months after the treatment was deemed successful. An individualized MDR-TB regimen was started when she was found to be pregnant. Her pregnancy was complicated by poorly controlled diabetes mellitus that required treatment with insulin. A multidisciplinary team, including Pulmonology and Fetomaternal Medicine, managed her case. She delivered a girl baby with a cleft palate that was linked to uncontrolled diabetes. The patient continued her MDR-TB treatment without any signs of perinatal TB transmission.

Conclusion: The instance appears to demonstrate adequately the fundamental requirement for rapid drug susceptibility testing (DST), the extremely high relapse risk in drug-resistant TB, and the highly significant need for a multidisciplinary approach to manage MDR-TB in pregnant women. Additionally, it brings home the teratogenic risks tied to uncontrolled maternal diabetes and the necessity for very close monitoring and counseling in such complicated circumstances.

Assessment of Post-Vaccination Adverse Effects in Medical Students following COVID-19 Immunization in Peshawar

Safia Khanam, Aiman Hafeez, Areaba Shafiq — Tue, 02 Sep 2025 00:00:00 +0000

Background: As COVID-19 vaccinations became widely distributed, assessing their safety profile, especially among specific populations, has become crucial. Sinopharm, a prominent COVID-19 vaccine, has been administered extensively; however, data on its adverse effects in specific groups such as undergraduate Medical students remains limited.

Objective: To assess the adverse effects following COVID-19 vaccination with Sinopharm among undergraduate medica (MBBS) students at a tertiary care institution, providing insights into the vaccine’s safety within this demographic.

Methodology: A cross-sectional study was conducted among MBBS students at a tertiary care institution who received the Sinopharm vaccine at tertiary care institutions from January 2022 to June 2022. 200 MBBS students participanted in this study, and they were surveyed for adverse effects through a structured questionnaire administered immediately post-vaccination and during follow-up visits. Adverse effects were categorized into local and systemic reactions. Data analysis involved descriptive statistics to determine the frequency and severity of reported adverse effects.

Results: Among study cases, the most commonly reported adverse effects included pain at the injection site (68%), redness (25%), and swelling (15%). Systemic reactions included fever (45%), headache (40%), and fatigue (50%). Severe adverse effects were rare, with only 5% reporting significant reactions such as allergic reactions or persistent high fever. Most adverse effects were mild to moderate and resolved within a few days.

Conclusion: The study reveals that Sinopharm COVID-19 vaccination is generally well-tolerated among MBBS students, with the majority experiencing mild to moderate adverse effects. The findings align with existing literature on vaccine safety and provide reassurance regarding the vaccine's use in this population. Ongoing monitoring and reporting of adverse effects are essential to ensure continued safety and efficacy of COVID-19 vaccines. . Thus, it was concluded that vaccine have no serious side effects.

A Comparison of Combined Pulmonary Rehabilitation and Chest Physiotherapy versus Chest Physiotherapy alone in Bronchiectasis

Mujtaba Ahmad, Farhan Ahmad, Naseer Abbass — Tue, 02 Sep 2025 00:00:00 +0000

Background: Bronchiectasis is a chronic respiratory illness defined by irreversible dilation of airways, mucus trapping, and recurrent infections, and decreased quality of life. Although chest physiotherapy (CPT) assists in airway clearance, the synergistic effect of pulmonary rehabilitation (PR) combined with CPT on functional, clinical, and quality of life measures is not entirely established.

Objective: To compare the effectiveness of pulmonary rehabilitation in combination with chest physiotherapy to chest physiotherapy alone in patients with bronchiectasis.

Methodology: A total of 140 stable bronchiectasis patients were randomly allocated to a PR + CPT or a CPT-only group in this randomized controlled trial. The intervention was for a duration of eight weeks, during which PR involved supervised aerobic and resistance training, breathing retraining, and patient education. Outcomes measured were exercise tolerance (6-minute walk test), lung function (FEV1, FVC), dyspnea (mMRC and Borg scores), health-related quality of life (St. George's Respiratory Questionnaire), daily sputum volume, exacerbations, and healthcare utilization.

Results: The two groups were similar at baseline. At eight weeks, the PR + CPT group had significantly larger improvements in exercise tolerance (+60.3 m vs. +21.1 m, p < 0.001), lung function (FEV1 +5.5% vs. +1.9%, p = 0.01; FVC +3.3% vs. +1.6%, p = 0.02), dyspnea scores, quality of life (SGRQ total score ?12.7 vs. ?5.6, p = 0.004), and morning sputum volume (?17.1 mL vs. ?7.5 mL, p = 0.002) compared with CPT alone.

Conclusion: Pulmonary rehabilitation with chest physiotherapy yields greater advantages than chest physiotherapy alone in bronchiectasis. The combined intervention improves exercise capacity, lung function, symptom control, quality of life, and reduces exacerbations and health care use, warranting its addition to regular bronchiectasis care.

Glycemic Control and Pulmonary Function in Diabetes: A Comparative Study of Inflammatory Pathways

Maryam Shoaib, Hassan Hammed, Hifza Shah, Muhammad Abdullah — Tue, 02 Sep 2025 00:00:00 +0000

Background: Diabetes mellitus (DM) is a metabolic disorder of the whole system that is becoming more and more recognized to impact the lungs through inflammation and microangiopathic mechanisms. One of the reasons for this recognition is the chronic hyperglycemia and low-grade systemic inflammation that gradually induce changes in the lungs resembling other diabetic complications in both structure and function.

Objective: To compare pulmonary function between patients with controlled and uncontrolled type 2 diabetes and to investigate the association between glycemic control, systemic inflammatory markers, and lung function impairment.

Methodology: This study was cross-sectional and comparative in nature to include 180 type 2 DM patients categorized into two groups by glycated hemoglobin (HbA1c): the controlled group with HbA1c levels of 7% or less and the uncontrolled one with levels above 7%. Measurements taken included fasting plasma glucose, HbA1c, high-sensitivity C-reactive protein (hs-CRP), and fibrinogen. Pulmonary function tests (PFTs), forced vital capacity (FVC), forced expiratory volume in 1 second (FEV?), and peak expiratory flow (PEF) were conducted using a calibrated spirometer following ATS/ERS guidelines.

Results: Patients with uncontrolled diabetes had significantly higher hs-CRP and fibrinogen levels (p<0.01) and lower FVC, FEV?, and PEF (p<0.001) compared to the controlled group, while FEV?/FVC remained normal, indicating a restrictive pattern. HbA1c and inflammatory markers showed a strong negative correlation with FVC and PEF (r = ?0.33 to ?0.61, p<0.001).

Conclusion: Poor glycemic control and systemic inflammation are closely linked to restrictive lung impairment in type 2 diabetes. Routine spirometric evaluation should be integrated into diabetes management to detect early pulmonary involvement and prevent long-term complications.

Comparative Long-Term Outcomes of ICU and Non-ICU COVID-19 Patients: A Six-Month Follow-up study

Amna Haq, Sabir Shaheen, Khalid Rehman, Nadeem Shah — Tue, 02 Sep 2025 00:00:00 +0000

Background: COVID-19 survivors often deal with long-term issues related to their lungs, overall function, and quality of life. Patients who needed ICU care during their acute infection may have worse outcomes than those treated outside the ICU. Understanding these differences is crucial for directing care and rehabilitation after discharge.

Objective: To investigate how COVID-19 affects lung structure, lung function, exercise capacity, and quality of life in patients discharged from ICU and medical wards.

Methodology: This study followed 110 adult COVID-19 patients who were discharged from ICU and non-ICU wards at a tertiary care hospital. At a six-month follow-up, all patients underwent high-resolution chest CT scans, pulmonary function tests, six-minute walk tests, and SF-36 quality-of-life assessments. Clinical data were analyzed using SPSS version 26.0. We used appropriate statistical tests to compare groups, setting significance at p<0.05.

Results: At six months, ICU patients had a higher rate of ongoing CT abnormalities (67.3% vs. 27.6%) and impaired lung function, especially reduced FVC and PEF values. The median distance walked in six minutes was significantly lower in the ICU group (435 m vs. 472 m), with 50% walking less than 80% of what was predicted. ICU patients also had lower SF-36 scores across most areas, showing a poorer quality of life.

Conclusion: COVID-19 patients who needed ICU care face more severe and lasting long-term issues than those not in the ICU. These issues include abnormal lung structure, reduced lung function, limited physical capacity, and lower quality of life. Early identification and focused rehabilitation are crucial. Ongoing follow-up care should be prioritized to enhance recovery outcomes.

Association of Baseline Hematological Parameters with Thromboembolic Events in Hospitalized COVID-19 Patients

Noshaba Mohmand, Ahsan Bhatti, Nabil Ahmad, Raees Khan — Tue, 02 Sep 2025 00:00:00 +0000

Background: COVID-19 carries an increased risk of blood clot complications because of its effects on the body's inflammation and clotting processes. Identifying patients who are at risk as early as possible is crucial for healthcare providers. Regular blood tests can provide useful information to predict these risks.

Objective: To determine the frequency of in-hospital thromboembolic events among COVID-19 patients and assess the influence of blood parameters, measured at the time of admission, on the occurrence of these events.

Methodology: This retrospective study included 364 hospitalized COVID-19 patients. Demographic, clinical, and laboratory data at admission were collected from medical records. Thromboembolic events were documented and confirmed through clinical and imaging findings. Logistic regression analysis was used to identify independent predictors.

Results: Thromboembolic events occurred in 6.6% of hospitalized COVID-19 patients, with myocardial infarction being the most common. Patients with such events had significantly lower hemoglobin, higher MPV, and elevated D-dimer levels. Age, low hemoglobin, and high MPV were identified as independent predictors. No significant differences were observed in C-reactive protein, LDH, or total WBC count.

Conclusion: Age, low hemoglobin, and high MPV are independent predictors of thromboembolic events in hospitalized COVID-19 patients. These common blood parameters may help identify risk early. Including them in clinical assessments can improve prevention measures. More prospective studies are necessary to confirm these findings.

Clinical, Epidemiological, and Microbiological Profile of Community-Acquired Pneumonia: A Cross-Sectional Study

Khanzada Khan, Haidar Ali, Rafi Ullah, Tanveer Khalid — Tue, 02 Sep 2025 00:00:00 +0000

Background: Community-acquired pneumonia (CAP) is a significant cause of illness and death around the world, especially in low- and middle-income countries. Its clinical features and the pathogens that cause it can differ by region. These differences are affected by existing health conditions and local resistance patterns. Knowing these factors is crucial for developing effective diagnosis and treatment methods.

Objective: To assess the clinical presentation, epidemiological characteristics, and microbiological etiology of patients diagnosed with community-acquired pneumonia.

Methodology: This study took place at a tertiary care hospital and involved 160 adult patients diagnosed with community-acquired pneumonia. We recorded detailed clinical histories, comorbidities, and radiological findings. Sputum samples were collected for bacterial culture and sensitivity testing using standard microbiological methods. We interpreted antimicrobial susceptibility following Clinical and Laboratory Standards Institute (CLSI) guidelines to identify resistance patterns.

Results: Out of 160 patients, 76% were male. The most affected age groups were 31 to 40 years and 61 to 70 years. Common other health issues included hypertension at 23.8%, smoking at 21.8%, COPD at 20%, and diabetes at 18.7%. Sputum cultures tested positive in 45% of cases. The leading pathogens were Klebsiella pneumoniae at 44% and Pseudomonas spp. at 22%. There was high resistance to ceftriaxone at 83%.

Conclusion: The study showed a heavy impact of CAP in middle-aged and older men with common health issues like hypertension and COPD. Gram-negative bacteria, especially Klebsiella pneumoniae and Pseudomonas spp., were the main pathogens. High resistance to cephalosporins restricts their use.

Long-Term Cardiopulmonary Sequelae in Severe COVID-19 Survivors

Fakhar Islam, Masooma Shah, Ijaz Ahmad, Muhammad Daud, Noor Islam — Tue, 02 Sep 2025 00:00:00 +0000

Background: Severe coronavirus disease 2019 (COVID-19) caused by SARS-CoV-2 has resulted in high morbidity and mortality worldwide. In addition to the acute disease, an increasing number of patients, particularly those who had severe disease, present with ongoing symptoms and dysfunction of organs, a syndrome known as long COVID. The cardiopulmonary system appears to be highly susceptible to long-term consequences.

Objective: To assess the chronic cardiopulmonary complications in survivors of severe COVID-19.

Methodology: This was a cross-sectional observational study of 235 adult patients hospitalized with severe COVID-19 and followed up at least three months after discharge. Baseline demographics, clinical information, residual symptoms, pulmonary function tests (PFTs), high-resolution computed tomography (HRCT) chest abnormalities, and cardiovascular evaluations were collected.

Results: The mean age of participants was 58.4 ± 12.6 years, with 62.1% being male. At follow-up, 58.7% reported dyspnea, 51.9% fatigue, and 47.2% exercise intolerance. PFTs revealed reduced DLCO in 51.5% and obstructive or restrictive defects in a significant subset. HRCT abnormalities persisted in over 80% of patients, with ground-glass opacities (45.1%) and fibrotic changes (34.9%) being the most common. Cardiovascular abnormalities were found in 28.9% as abnormal ECGs, 13.6% as left ventricular dysfunction, and 50% as myocardial fibrosis on cardiac MRI. 23.8% and 8.1% had elevated NT-proBNP and hs-Troponin I, respectively.

Conclusion: A high percentage of patients recovering from serious COVID-19 are left with persistent cardiopulmonary abnormalities, such as compromised lung function, residual radiological alterations, and cardiac impairment. These results highlight the importance of thorough long-term follow-up and multidisciplinary management for COVID-19 survivors, with a particular emphasis on cardiopulmonary health.

Diagnostic Performance of Bronchoscopic Sampling Techniques in Suspected Bronchial Carcinoma

Iftikhar Ahmad, Sohail Musa, Najeeb Ahmad, Aurangzed Khan — Tue, 02 Sep 2025 00:00:00 +0000

Background: Lung cancer is the top cause of cancer deaths worldwide. Delayed diagnosis worsens outcomes. Flexible bronchoscopy is a key tool with several sampling techniques. Assessing their effectiveness helps improve early, accurate detection.

Objective: To study the yield of malignant or suspicious cells from bronchoalveolar lavage (BAL), endobronchial biopsy (BX), and endobronchial brushing (BR) specimens obtained at bronchoscopy.

Methodology: A prospective cross-sectional study was conducted on 142 patients suspected of having bronchial carcinoma. All patients underwent flexible bronchoscopy (a procedure using a thin, flexible tube to inspect the airways) with bronchoalveolar lavage (BAL: washing fluid through the airways). When feasible, endobronchial biopsy (BX: sampling of tissue from inside the bronchial tubes) and brushing (BR: collecting cells with a small brush) were also performed. Samples were examined for cytology (the study of cells) and histopathology (the study of tissue structure and disease). The diagnostic yield was then calculated for each method and compared across tumor types, locations, and stages.

Results: Among 142 patients, the overall diagnostic yield using combined bronchoscopic techniques was 85.9%. BAL had the highest individual yield (70.4%), followed by BX (57.7%) and BR (25.4%). Combining sampling methods significantly enhanced diagnostic accuracy compared to individual methods. Diagnostic yield was not significantly affected by tumor location or TNM stage. The highest yield was observed in adenocarcinoma and centrally located tumors.

Conclusion: The combined use of BAL, BX, and BR significantly increases diagnostic yield in suspected bronchial carcinoma. Endobronchial biopsy and BAL are still the most effective individual techniques. A multimodal bronchoscopic approach should be employed for optimal diagnostic accuracy.

Comprehensive Evaluation of Endobronchial Lesions: Correlating Clinical, Radiological, Bronchoscopic, and Histopathological Findings in Patients Undergoing Fibreoptic Bronchoscopy

Ashraf Kamal, Momina Haq, Najam Ahmad, Tariq Durrani — Tue, 02 Sep 2025 00:00:00 +0000

Background: Endobronchial lesions are abnormal tumors or alterations of the bronchial tree with varied etiologies, including malignant, infectious, inflammatory, and benign conditions. Fibreoptic bronchoscopy continues to be a critical diagnostic modality for the direct visualization and tissue sampling.

Objective: To evaluate the clinical, radiological, bronchoscopic, and histopathological features of endobronchial lesions identified via fibreoptic bronchoscopy.

Methodology: A cross-sectional descriptive study was carried out at a tertiary care center (LRH) from January to December 2024. Sixty-four patients with endobronchial lesions visible on bronchoscopy were enrolled. Clinical evaluations, imaging, bronchoscopic findings, and biopsies were examined and categorized.

Results: The majority of the patients were older males (mean age group: 56–65 years; 73.4% male). Dyspnea (64%) was the most frequent symptom, and mass lesions (54.6%) were the most frequent radiologic finding. Exophytic growths were noted in 46.8% on bronchoscopy. Squamous cell carcinoma (23.4%) was the most frequent diagnosis by histopathology, followed by small cell carcinoma (17.1%) and chronic inflammation (20.3%). The right upper lobe was the most frequently involved site (29.6%).

Conclusion: Endobronchial lesions primarily occur in elderly men and often present as malignant masses. Fibreoptic bronchoscopy with histopathological analysis remains crucial for early and accurate diagnosis, particularly in areas endemic for both infectious and malignant conditions.

Bacteriological Profile and Antibiotic Susceptibility Patterns in Acute Exacerbations of COPD Among Hospitalized Patients

Muhammad Ramazan, Junaid Shah, Amjad Nawaz, Muddasir Shehzad — Tue, 02 Sep 2025 00:00:00 +0000

Background
Acute Exacerbations of Chronic Obstructive Pulmonary Disease (AECOPD) are critical events, often triggered by bacterial infections. The bacteriological profile and antibiotic susceptibility patterns are highly region-specific and evolve over time, necessitating local surveillance to guide effective empirical therapy.

Objective: To determine the sputum bacteriological profile in hospitalized patients with acute exacerbation of COPD.

Methodology
A prospective cross-sectional study was conducted on 240 hospitalized patients who met the GOLD criteria for AECOPD and were enrolled. Demographic and clinical data were collected. Sputum samples were obtained for culture and antibiotic susceptibility testing, which was performed using the Kirby-Bauer disk diffusion method.

Results
Results showed that the mean age of participants was 61.4 ± 10.2 years, with a male predominance (76.7%). Sputum culture was positive in 118 patients (49.2%). Streptococcus pneumoniae (28.8%) was the most common single isolate, but Gram-negative bacteria collectively predominated, led by Escherichia coli (16.9%) and Klebsiella pneumoniae (12.7%). Culture positivity showed a strong, significant association with purulent sputum (94.5%), severe GOLD grade (76.7%), and hypoxemia at presentation (SpO?<80%; 80.0%). Antibiotic susceptibility revealed high resistance in Gram-negative isolates to ceftriaxone (15-30%) and fluoroquinolones (20-45%), while carbapenems and polymyxins remained highly effective.

Conclusion
The bacteriology of AECOPD in our region is characterized by a high prevalence of multidrug-resistant Gram-negative bacilli. Clinical markers, such as sputum purulence and hypoxemia, can help identify patients with a high probability of bacterial infection. The documented resistance patterns necessitate an urgent revision of empirical antibiotic guidelines, favoring carbapenems over cephalosporins and fluoroquinolones in cases of severe infection.

Risk factors and clinical outcome in XDR TB patients in public sector Karachi

Farzana Batool, Sana Siddiqui, Muzaiyyena Fayaz Qureshi, Iftekhar Ahmed — Tue, 02 Sep 2025 00:00:00 +0000

Background: Tuberculosis is one of a growing concern in Pakistan when it comes to Public Health. The growing burden of drug-resistant TB is a major threat to the entire nation. Lack of awareness, demographic factors, illiteracy as well as inadequate healthcare facilities are the major causes of spread to this communicable disease across the country.

Objective: To monitor and evaluate the outcome of treated XDR-TB patient registered at OICD a tertiary care hospital.

Methods: This is a retrospective case-series study conducted on patients registered for XDR-TB treatment from January 2017-January 2021. All data was extracted on Excel sheets. Appropriate statistical methods were used with SPSS to evaluate the frequencies and percentages.

Results: 5 patients were included in this study according to the criteria for XDR-TB patients, 3 male and 2 female. Treatment lasted for 24 months, 4 were declared completed upon showing sputum conversion while 1 was declared dead. No adverse effects were observed.