Background: Chemical pleurodesis using tetracycline is an acceptable and commonly employed palliation for malignant pleural effusion. Rotation of patient during pleurodesis using the powder from tetracycline capsule is still practised in some centres and is undoubtedly associated with additional stress on the patients. The practice of rotation can only be eliminated after a properly designed study on the outcome of pleurodesis with rotation and non-rotation would fail to show benefit of rotation. Objective: To determine the association between patients positioning and the outcome of tetracycline pleurodesis in patients with malignant pleural effusion. Patients and methods: It is a prospective randomized study involving adults patients with cytologically proven malignant pleural effusion. Patients were randomized into 2 groups (rotation and supine) using alternate sampling technique. Tube thoracostomy was done and tetracycline pleurodesis using 2g of powder from tetracycline capsule via slurry instillation method was carried out. The outcome of the pleurodesis was assessed with a chest radiograph on the 30th day after removal of chest tube. Results: There were 51 patients studied with malignant pleural effusion. These consisted of 12 males (23.5%) and 39 females (76.5%). Twenty-five patients (49.0%) were rotated in the study while 26 patients (51.0%) were on supine position. A total of 30 patients (58.8%) achieved complete response, 16 patients (31.4%) achieved partial response while 5 patients (9.8%) had failed response. The study also showed that in the rotated group, 23 patients (92%) had successful response and 23 patients (88.5%) in the supine group also achieved successful response (P = 0.175); there was no significant difference between the two groups. Conclusion: This study showed that, though the powder from tetracycline capsule is only slightly soluble in water, it gives a good and similar successful outcome in both arms of the study. This implies that positioning of patient during pleurodesis plays no significant role in the outcome of tetracycline pleurodesis using the powder from tetracycline capsule.

Background: The presence of endometrial tissue in the tracheobronchial tree, pleural, and lung is normally referred to as thoracic endometriosis. The association of catamenial pneumothorax, catamenial haemothorax, catamenial haemoptysis and pulmonary nodules is referred to as thoracic endometriosis syndrome (TES). TES is rare but not as rare as it has always been thought of. Case summaries: Case 1: We present EA, a 26-year-old chef/baker who presented to our unit on account of recurrent cyclical right sided chest pain and difficulty in breathing, recurrent haemoptysis and cyclical abdominal pain and swelling with multiple tender umbilical nodules. On general physical examination she was found to be in respiratory distress but not cyanosed with peripheral arterial oxygen saturation 97% on room air. Examination of the chest revealed a right sided chest fullness and reduced movement with breathing. Percussion note was stony dull and absent of breath sound on right hemithorax. Abdominal examination revealed a moderately distended abdomen with positive fluid thrill. Both Pleurocentesis (thoracocentesis) and paracentesis abdominis yielded a haemorrhagic fluid acellular and pleural and lung biopsy demonstrated endometrial stroma and glands. Imaging examination by way of chest X-ray showed a homogenous opacity of the right hemithorax, and pulmonary nodule following drainage. A diagnosis of Thoracic Endometriosis Syndrome was made. She had VAT with lung and pleural biopsy, pleural abrasion and a thoracostomy tube drainage. Case 2: We present IAE, a 29year-old Po+0 who presented to our unit on account of recurrent cyclical right sided chest pain and difficulty in breathing, unproductive cough. On general physical examination she was found to be in moderate respiratory distress but not cyanosed with peripheral arterial oxygen saturation of 98% on room air. Chest examination revealed an apical flattering of anterior chest wall with left trachea deviation. Percussion note was stony dull on the right lower third and hyper resonance middle and upper zones of right hemithorax. Pleurocentesis (thoracocentesis) yielded air and haemorrhagic fluid acellular and pleural and lung biopsies demonstrated endometrial stroma and glands. Imaging examination by way of chest X-ray and chest CT-scan showed air fluid level of the right hemithorax. A diagnosis of TES was made. She had Laparoscopy and VAT at the same sitting with pleural and lung biopsies. She was managed medically after closed thoracostomy tube drainage. She had partial collapse of right lower lobe and thoracotomy with right lower lobectomy was planned but patient declined. She also had Stage IV endometriosis by (rASRM)/ENZIAN systems Case 3: We present JA a 29-year-old lady, a filling station attendant who presented to our unit with a history of gradual onset of right sided chest pain, progressive difficulty in breathing and non-productive cough, and abdominal pain and swelling. On general physical examination she was found to be in respiratory distress but not cyanosed with SPO2 of 98% on room air. Examination of the chest revealed a right apical flattening, reduced ipsilateral chest movement with breathing. Percussion notes were stony dull and absent air entry on the ipsilateral hemithorax. Abdominal examination showed a mildly distended abdomen with a positive shifting dullness. Both Pleurocentesis (thoracocentesis) and paracentesis abdominis yielded a haemorrhagic fluid acellular at cytology and pleural and lung biopsy demonstrated endometrial stroma and gland. Imaging examination by way of chest X-ray showed a homogenous opacity of the right hemithorax. A diagnosis of Familial Thoracic Endometriosis Syndrome (FTES). Had USS guided lung and pleural biopsy and a thoracostomy tube drainage. She had chemical pleurodesis with tetracycline Conclusion: Thoracic endometriosis syndrome is the diagnosis in a lady of reproductive age who present with cyclic or a cyclical recurrent right sided chest pain, cyclical or a cyclical dyspnoea, haemoptysis, cyclical or a cyclical abdominal swelling and peritonitis.

Background:The management of pleural effusion usually involves the drainage of the effusion, identification, and treatment of the underlying cause (s). Studies have shown that the initial diagnostic techniques do not give conclusive diagnosis in some cases of pleural effusion. This group of patients described as patients with indeterminate or undiagnosed pleural effusion constitutes a significant proportion of patients with pleural effusion in clinical practice. In this study, we examined the role of video-assisted thoracoscopy (VAT) in the diagnostic work-up of these patients. Aim:To determine the diagnostic outcome of VAT in the management of indeterminate pleural effusion in our center. Patients and Methods:Consecutive patients who presented with pleural effusions and who met the inclusion criteria had video-assisted thoracoscopy for diagnostic purposes. Outcome measures including the diagnostic yield, sensitivity, specificity, positive predictive value (PPV), and negative predictive value (NPV) of VAT in patients with indeterminate pleural effusion, duration of the procedure, duration of hospitalization after the procedure, and complications for all the patients were documented and analyzed. Results:Of the 22 patients with indeterminate pleural effusion, conclusive diagnosis was obtained in 18 (81.8%) with a sensitivity of 91.7% [95% confidence interval (CI); 61.5-99.8%], specificity of 100% (95% CI; 69.1-100%), PPV of 100% (95% CI; 0-100%), and NPV of 90.9% (95% CI; 60.5-98.5%) for malignancy and a sensitivity of 78% (95% CI; 40-97%), a specificity of 100% (95% CI; 75.3-100%), PPV of 100% (95% CI; 0-100%), and NPV of 86.7% (95% CI; 65.7-95.7%) for tuberculosis. Conclusion:Our results show that video-assisted thoracoscopy plays a useful role in our center in obtaining diagnosis in patients with indeterminate pleural effusion.

Background Although chest tube drainage is the primary management method for many pleural effusions, it has a failure rate of 9.4–48%. In this study, we examined the factors that predict the outcome of management of nonpurulent exudative effusions. The aim of this study was to determine the predictors of outcomes of chest tube drainage of pleural effusions. Methodology Consecutive patients who had a chest tube drainage of nonpurulent exudative pleural effusions were followed up in a prospective observational cohort study until extubation and discharge. Data on the management of the patients were recorded, analysed and compared between groups of patients with good and poor outcomes. Results Of the 52 patients studied, 38 had good outcomes, while 14 had poor outcomes. The mean±sd age was 39.7±15.9 years. Multivariate analysis demonstrated that empyema thoracis complicating drainage was an independent predictor of a poor outcome, while the duration of drainage ≤14 days and duration of illness before presentation <30 days were predictive of a good outcome. Conclusion Our results show that the development of empyema thoracis during drainage, a long duration of drainage and a prolonged period of illness before presentation are predictive of the outcome of chest tube drainage.

Background: Empyema thoracis portrays pleural effusion with demonstrable actively multiplying bacteria. It is a significant cause of morbidity, and commonly complicates parapneumonic effusions. It is important to identify those factors that can be used to prognosticate the outcome of its management in our locality so that those that are modifiable could be applied to improve management outcomes. Materials and Methods: A prospective cohort study of patients managed for empyema thoracis at the Ahmadu Bello University Teaching Hospital (ABUTH), Zaria, Nigeria from February 2017 to January 2018 was conducted. Eighty-three patients were enrolled for this study and recruitment into the study included all consecutive patients being managed for empyema thoracis in ABUTH, Zaria during the study period. Data collected included age, gender, aetiology, microbial isolates, BMI, initial and total empyema volumes, and duration before hospital presentation. The patients were subsequently managed and observed, and the outcome of management (duration of drainage and hospital stay, percentage of lung expansion, and need for decortication) was noted. Results: Patients in the paediatric age group correlated positively with an earlier presentation to the hospital. The duration before presentation correlated positively with the stage of the disease. The duration before presentation and the total empyema volume indexed to body surface area could prognosticate all four outcome parameters assessed. The age and stage of the disease prognosticated the lung expansion and the need for decortication. The initial empyema volume indexed to body surface area prognosticated the length of hospital stay. The presence of complications was a determinant of the need for decortication. Adolescents and adults had 2.1 times increased probability of requiring a decortication for successful management. Conclusion: The age, stage of the disease, duration before presentation, initial empyema volume indexed to body surface area, and total empyema volume indexed to body surface area can be used to prognosticate the outcome of empyema thoracis. With the onset of complication comes a higher chance of requiring decortication. Children are less likely to require decortication for satisfactory management of empyema thoracis.

Indigestible intra-gastric foreign bodies are encountered in the mentally deranged, transporters of illicit drugs or those desiring weight control. They are often complicated by obstruction, migration, or perforation. Pseudobezoars are indigestible objects introduced intentionally into the digestive system. They may be indicated in bariatric practice for control of obesity. We present an 87-year-old man managed for a 2-year history of burning epigastric pain, aggravated by lying down and relieved by antacids. He had associated reflux symptoms for which he adopted lifestyle modifications. He had an upper gastrointestinal endoscopy which showed a stone attached to the anterior wall of the body of the stomach with associated pseudo-pouch formation. Mucosal overgrowth on the stone could be noted. Attempts at endoscopic retrieval failed as the stone could not be dis-impacted from its lodgement in a mucosal pouch. He had a laparotomy and gastrotomy for retrieval. A piece of stone, identified as granite, which measured 2 × 2 × 2.5 cm was retrieved from the stomach with accompanying formation of the mucosal pouch. Mucosal response, which may include overgrowth, could be an initial step in the migration of intra-gastric foreign bodies.

Cryptococcosis, a global disease problem, seen frequently in the immuno-suppressed, also affects patients without apparent immuno-suppression. Pulmonary cryptococcosis patients often present as cryptococcal pneumonia, whereas intracranial cryptococcosis presents with meningitis. We present a 33-year-old immunocompetent man, diagnosed with invasive pulmonary cryptococcal disease with spread to the brain. This case is unique because the patient was previously treated for tuberculosis and presented with typical bronchopulmonary thoracic, extra-thoracic as well as computed tomography (CT) scan features suggestive of lung cancer. Cryptococcosis was diagnosed by identification of oval thick-walled yeast on histology of lung biopsy specimen. The patient was treated with flucytosine and fluconazole initially and subsequently with Amphotericin B and fluconazole. He made clinical improvement with the resolution of symptoms but had residual radiological features. Invasive cryptococcosis affecting the lung and brain may present with a clinical picture similar to metastatic lung cancer. We recommend routine fungal stains and fungal culture in suspected cases.

Targeted empirical antibiotic therapy based on local microbiology and antibiotic resistance patterns is essential for the treatment of empyema thoracis. Our retrospective review of 105 pleural empyema culture and sensitivity reports aimed at determining the causative microorganisms and their antimicrobial resistance pattern. Of 105 pleural aspirate samples, 46 (43.8%) were positive on culture. Gram-negative organisms (n = 43) were the predominant isolates, the commonest of which was Klebsiella pneumoniae. It was concluded that empyema thoracis is predominantly caused by Gram-negative organisms in our locality. This should guide protocols on the initiation of empirical therapy.

Background: Current management of empyema thoracis requires that patients receive appropriate empiric antibiotics targeted to treat the bacterial profile of modern pleural infection and based on local antibiotic policies and resistance patterns until results of cultures are available. There are few studies on the local microbial patterns of empyema in most regions of Africa. Objectives: To determine the common aetiologic organisms and antimicrobial resistance pattern of pleural empyema Methods: We conducted a retrospective review of 105 pleural empyema culture and sensitivity reports. Results: Out of the 105 pleural aspirate samples, 46(43.81%) were positive on culture. Of the 46, Gram-negative bacilli (n=43) were the predominant isolates, the commonest of which were Klebsiella pneumoniae (32.56%, 14/43), Pseudomonas aeruginosa (25.58%, 11/43) and E. coli (20.93%, 9/43). The Gram positive isolates (n=17) were Staphylococcus aureus (47.06%, 8/17), Coagulase Negative Staphylococcus (29.41%, 5/17), and Streptococcus pneumoniae (23.53%, 4/17). The other isolates were Mycobacterium tuberculosis (n=13) and non albicans Candida (n=2). Klebsiella pneumoniae (n=14, 32.56%) was the most common isolate and showed high sensitivity to levofloxacin (71.43%), Ciprofloxacin (69.23%), Imipenem (57.14%) and Cefepime (57.14%) but was resistant to Cefuroxime (92.86%), Amoxicillin/ Clavulanic acid (66.67%), Ceftriaxone (64.29%) and Ceftazidime (57.14%). Conclusion: Our finding differ from most studies locally and globally. Local protocols on initiation of empirical therapy should be based on the resistance profile of aetiological agents prevalent in a locality and should be reviewed from time to time.

Bronchogenic cancer can metastasize to several organs of the body. Metastases to skin and subcutaneous tissue are uncommon. We present our experience with the management of a patient with an unusual presentation of bronchogenic carcinoma with multiple skin nodules. In patients with bronchogenic cancer, metastasis to the skin and subcutaneous tissues could heighten the index of suspicion of advanced disease. The nodules should be histologically assessed and if confirmed metastatic, only palliative therapies are indicated.

Aim: To evaluate the effect of analgesia for chest pain control in multiple rib fractures in adult blunt chest trauma patients in terms of improvement in ventilatory function, reversal of abnormal lung function test parameters at different periods of analgesia. Methodology: Prospective study of 64 adult patients with blunt chest injury. Results: There were 64 adult patients with blunt chest trauma studied with male-female ratio 8.4:1.5; dominated by young adults and middle age (92.2%). Commercial motorcyclists and tricyclists, all males, accounted for 62.5% of the patients (p=0.0001) and motorcycle and tricycle accidents accounted for 78.1% of the causes (p=0.005). Respiratory function was adversely affected by chest pain and got improved when the pain was controlled as shown by the following respective pre and post analgesic means of percent predicted lung function test parameters with statistical significance: FVC (80.3% vs. 93.3%), FEV1 (79.7% vs. 93.5%), FEV 1 /FVC ratio (FEV 1 %) (79.9% vs. 90.6%), FEF (84.8% vs. 92.2%), and FEF 25-75 (79.9% vs. 92.0%). Before analgesic, 44 (68.7%) of the patients rated their chest pain as severe, but by one hour after the first dose of analgesic only four (6.3%) patients still had severe chest pain (p < 0.0001) and at 24 hours the difference in chest pain improvement was also statistically significant (p=0.02). Conclusion: Analgesic is capable of reversing the abnormal lung function test parameters associated with chest pain of blunt chest injury.

BACKGROUND: Vascular trauma is a significant cause of morbidity and mortality following trauma. Injury to a major blood vessel may worsen the prognosis of trauma. Avoidable mortality may result from massive haemorrhage. Available data in Nigeria is scanty. AIM: This retrospective study was carried out to review the pattern and outcome of vascular trauma patients in the University of Calabar Teaching Hospital. METHODOLOGY: The Hospital records of all patients managed in the facility for vascular injuries during the study period were retrieved and data collected retrospectively. RESULTS: Forty – two patients, with a male: female ratio of 5:1 and a mean age of 31.15 years were studied. The age range 21 – 30 years were most affected. Mean interval between injury and presentation at the hospital was 7.05 hours. The mean duration between presentation to the hospital and surgical intervention for the rest of the patients was 13.32 hours. The most commonly injured vessel was the brachial artery. Prompt presentation and intervention are critical to successful outcome. CONCLUSION: Most vascular trauma in Calabar occur predominantly in young males who lead an active life.

Objective: This study was carried out to compare the efficacy of intravenous tramadol injection and intercostal nerve block with 0.5% bupivacaine injection for control of chest pain in multiple rib fractures. Methods: Prospective randomized study of intercostal nerve block (ICNB) with 0.5% bupivacaine group (n=30) and the intravenous tramadol (IVT) injection group (n=34). Results: There were 64 adult patients who were studied with multiple rib fractures caused by blunt chest trauma. Before analgesia, 33.3% and 66.7% of patients in the ICNB group rated their pain as moderate and severe respectively while 29.4% and 70.6% of patients in the IVT group rated their pain as moderate and severe respectively (p= 0.917). However at one hour post commencement of analgesic, 13.3%, 70%, 16,7%, and 0% rated their chest pain as no pain, mild pain, moderate pain and severe pain respectively among the ICNB group while in the IVT group the respective figures were 0%, 23.5%, 64.7% and 11.8% (p value <0,0001); and at 24hours post commencement of analgesic the equivalent figures were 0%, 90%, 10% and 0% in ICNB group against 0%, 76.6%, 23.4% and 0% in the IVT group (p=0.002). Comparison of efficacy based on improvement in pain scores among the two groups of intervention showed that ICNB was superior to IVT at both the one hour and 24 hours re-assessment periods. Conclusion: This study shows that ICNB is superior to IVT in chest pain control in multiple rib fractures of blunt chest trauma.

The aim of this study was to determine the correlation between findings of palpation of pedal vessels and duplex Doppler ultrasonography, which has been proved to be a more reliable method of evaluating blood flow. This was a double-blind prospective cross-sectional study of adult diabetics aged 18 years and above, with no history of previous or current foot lesions. Each enrolled patient was assigned a number and then interviewed to obtain pertinent clinical information. The vascular status of the lower limbs of the patients was evaluated by palpation of the posterior tibialis and dorsalis pedis arteries. The patients then had duplex Doppler ultrasonography of the vessels of the legs and feet by an independent examiner using the Mindray M7/M7T Diagnostic Ultrasound System with Colour Doppler mode. Data obtained was analysed using IBM SPSS Statistics Version 20. There were 14 males and 33 females; mean age was 56.74 years (range 32–82). Ninety four feet of adult diabetics were examined clinically. Palpation of the right and left posterior tibial artery was normal in 51 % of the patients. Palpation of the right and left dorsalis pedis artery was normal in 74.5 and 80.9 % of the patients, respectively. All 47 patients had duplex Doppler ultrasonography. Spearman’s and kappa correlations demonstrated no correlation between the findings on palpation and duplex Doppler ultrasound of the pedal vessels. There is no correlation between results of palpation of pedal pulses and duplex Doppler ultrasonography.

BACKGROUND:Cases of discrete subaortic stenosis are rare in adults. To our knowledge, no case has been reported in Nigerian literature. Cases are thus likely to be missed or wrongly managed.OBJECTIVE:To present a case of discrete membranous subaortic stenosis in an adult Nigerian with a view to creating awareness of the existence of this entity in our milieu.METHODS:The patient a 46-year-old Nigerian presented with symptoms of angina pectoris and near syncope. Transthoracic 2-Dimensional / M-mode echocardiography demonstrated thickened and calcific aortic valves and laboratory investigations showed that he also had artherogenic dyslipidaemia. He was initially managed as a case of severe valvular aortic stenosis of rheumatic origin with associated dyslipidaemia and was referred for further evaluation and management abroad.RESULTS:On further assessment at the referral centre, the diagnosis was reviewed to subaortic stenosis with severe left ventricular outflow tract obstruction (LVOTO) arising from a fibro muscular subaortic membrane after a repeat 2-D/M-mode and Doppler echocardiography. Coronary angiography showed normal coronaries. He had excision of the membrane with marked reduction in gradient across the left ventricular outflow tract. He has remained symptom free and stable thereafter.CONCLUSION:Discrete membranous subaortic stenosis though rare in adults should be suspected in patients with clinical features of valvular aortic stenosis. Doppler echocardiography is thus mandatory in the evaluation of these patients.