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Background: The prevalence of pulmonary embolism (PE) in patients of acute exacerbation of chronic obstructive pulmonary disease (AECOPD) varies over a wide range. Early detection and treatment of PE in AECOPD is a key to improve patient outcome. The purpose of the study was to investigate the prevalence and predictors of PE in patients of AECOPD in a high burden region of North India. Materials and Methods: This prospective study included patients of AECOPD with no obvious cause of exacerbation on initial evaluation. Apart from routine workup, the participants underwent assessment of D-dimer, compression ultrasound and venous Doppler ultrasound of the lower limbs and pelvic veins, and a multidetector computed tomography pulmonary angiography. Results: A total of 100 patients of AECOPD with unknown etiology were included. PE as a possible cause of AE-COPD was observed in 14% of patients. Among the participants with PE, 63% (n = 9) had a concomitant presence of lower extremity deep venous thrombosis. Hemoptysis and chest pain were significantly higher in patients of AECOPD with PE ([35.7% vs. 7%, P = 0.002] and [92.9% vs. 38.4%, P = 0.001]). Likelihood of PE was significantly higher in patients who presented with tachycardia, tachypnea, respiratory alkalosis (PaCO2 7.45), and hypotension. No difference was observed between the two groups in terms of in-hospital mortality, age, sex distribution, and risk factors for embolism except for the previous history of venous thromboembolism (35.7% vs. 12.8% P = 0.03). Conclusion: PE was probably responsible for AECOPD in 14% of patients with no obvious cause on initial assessment. Patients who present with chest pain, hemoptysis, tachypnea, tachycardia, and respiratory alkalosis should be particularly screened for PE.

Chronic kidney disease (CKD) is has been rising over the past few years, and obstructive sleep apnea (OSA) is a prevalent comorbidity in this population.To determine the prevalence of OSA in patients with chronic kidney disease stages I-V and end-stage renal disease (ESRD).Patients with CKD of varying grades and ESRD routinely visiting outpatient nephrology clinic or admitted in department of nephrology were included in the study. Stages I-III were categorized as early stages of CKD and stages IV-V and ESRD as late stages of CKD. Patients were categorized into a high risk group based on STOP-BANG and Berlin questionnaires. Patients who were high risk were subjected to in-hospital overnight level III polysomnography. Student's independent t-test and analysis of variance (ANOVA) were employed for the comparison of continuous variables. Chi-square test and Fisher's exact test, as appropriate, were used for the comparison of categorical variables.Of 111 patients, 46 (41%) were found to have OSA. Of these patients, 15 (33%) had mild OSA (AHI 5-14/h), 13 (28%) had moderate OSA (15-29/h), and 18 (39%) had severe OSA (AHI ≥ 30/h). Overall, 31% of patients in the early stage of CKD and 45% in the late stage were found to have OSA.This study demonstrated a high prevalence of OSA in patients with CKD when compared to the general population affecting both genders equally. The risk of OSA was higher in the advanced stages of CKD compared to the early stages, and dialysis had no effect on prevalence. Since OSA increases the cardiovascular morbidity in CKD the leading cause of death in these patients, early diagnosis and treatment of OSA may have promise to affect the mortality.

The clinical manifestations of rickettsial diseases mimic other endemic infections with similar presentations thus posing a serious challenge to clinicians for their diagnosis. For the diagnosis of rickettsial disease serological tests like Weil Felix, ELISA and IFA are used. There are limited studies that have evaluated different serological tests for the diagnosis of rickettsial diseases. Therefore, the present study was undertaken to evaluate the ELISA and Weil Felix test for the diagnosis of rickettsial diseases prevalent in this region.Samples from 281 patients clinically suspected of rickettsial diseases were tested for spotted fever group (SFG), typhus group (TG) and scrub typhus group (STG) by Weil Felix, ELISA and IFA was taken as the gold standard. Baseline titers and cut-off ODs were calculated by taking samples from healthy blood donors.The sensitivity, specificity, positive and negative predictive value of Weil Felix test ranged from 30% to 44%, 83.46%-97.86%, 9%-77%, 92-96% respectively. The sensitivity and specificity, positive and negative predictive value of ELISA ranged from 80.77% to 96.15%, 96.33%-98.43%, 70.21%-88.64%, 92.89%-99.60% respectively. Maximum cross-reactions were observed between SFG and STG by the Weil Felix test and between STG and TG by ELISA.ELISA was found to be sensitive and specific for the diagnosis of rickettsial diseases. It is easy to perform, does not require a technical expert for result interpretation and a large number of samples can be processed at a time.

Tuberculosis (TB) caused by Mycobacterium tuberculosis (MTB) is a chronic infectious disease. Interferon-gamma (IFN-γ) is an important cytokine imparting resistance to mycobacterial diseases. It is believed that IFN-γ and Interleukin-10 (IL-10) play divergent roles in the host immune system against MTB infection. IL-10 is an important inhibitory cytokine and helps balancing the inflammatory and immune responses. IL-10 is involved in down regulation of Th1 cytokines, MHC class II antigen and co-stimulatory molecular expression on macrophages, while IFN-γ results in macrophage activation allowing them to exert the microbicidal role. The objectives were to find out the association of IL-10 (−1082 A/G) and IFN-γ (+874 A/T) single nucleotide polymorphisms (SNPs) with extrapulmonary tuberculosis in ethnic Kashmiri population. A total of 100 extrapulmonary tuberculosis cases and 102 healthy controls were analyzed for IL-10 (−1082 A/G) and IFN- γ (+874 A/T) SNPs using Allele-Specific PCR. We found a significant association of IFN-γ + 874 ‘TT’ genotype with extrapulmonary tuberculosis (p = 0.006) and in case of IL-10 (−1082 A/G) we found a significant association with extrapulmonary tuberculosis under recessive model (GG vs GA + AA) (p = 0.03) in Kashmiri population. IL-10 (−1082 A/G) and IFN-γ (+874 A/T) have a significant association with extrapulmonary tuberculosis in ethnic Kashmiri population.

Data regarding the comparative profiling of HCAP and HAP from developing countries like India are scant. We set out to address the microbial aetiology, antibiotic resistance and treatment outcomes in patients with HCAP and HAP. 318 consenting patients with HCAP (n = 165, aged 16–90 years; median 60 years; 97 males) or HAP (n = 153; aged 16–85 years; median 45 years; 92 males) presenting to a tertiary care hospital in North India from 2013 to 2015 were prospectively recruited for the study. Data on patient characteristics, microbial aetiology, APACHE II scores, treatment outcomes and mortality were studied. Clinical outcomes were compared with various possible predictors employing logistic regression analysis. Patients in HCAP had more comorbidity. Escherichia coli (30, 18%) and Acinetobacter baumannii (62, 41%) were the most commonly isolated bacteria in HCAP and HAP, respectively. Multidrug-resistant bacteria were isolated more frequently in HCAP, only because the incidence of extensively drug-resistant bacteria was markedly high in HAP (p = 0.00). The mean APACHE II score was lower in HCAP (17.55 ± 6.406, range 30) compared to HAP (19.74 ± 8.843, range 37; p = 0.013). The length of stay ≥ 5 days (p = 0.036) and in-hospital mortality was higher in HAP group (p = 0.002). The most reliable predictors of in-hospital mortality in HCAP and HAP were APACHE II score ≥ 17 (OR = 14, p = 0.00; HAP: OR = 10.8, p = 0.00), and septic shock (OR = 4.5, p = 0.00; HAP: OR = 6.9, p = 0.00). The patient characteristics in HCAP, treatment outcomes, bacterial aetiology, and a higher incidence of antibiotic-resistant bacteria, suggest that HCAP although not as severe as HAP, can be grouped as a separate third entity.

Elevated VEGF mRNA (−ΔC T ) was significantly associated with adenocarcinoma histology (vs squamous) and advanced NSCLC clinical stages in a univariable analysis; however, this association did not remain significant in the multivariable analysis. Of interest, a Kaplan–Meier analysis showed that NSCLC patients with higher VEGF mRNA (−ΔC T ≥10) had a significantly poorer overall survival and shorter postoperative relapse time in adenocarcinoma and in stage III/IV than those with VEGF mRNA of −ΔC T

Vascular endothelial growth factor ( VEGF ) is one of the most predominant mediators of angiogenesis, plays a critical role in lung carcinogenesis. We performed a case–control study of 209 non-small cell lung cancer (NSCLC) patients and 189 sex, age and smoking matched healthy controls; genotyped 9 VEGF single-nucleotide polymorphisms (SNPs) in patients and controls selected from Kashmiri population and evaluated the NSCLC risk conferred by individual SNPs and haplotypes. In single-locus analysis, alleles of rs699947, rs833061, rs13207351, rs2010963 and rs3025021 showed association with NSCLC [P value = 6.00e − 04 , 2.54e − 11 , 6.38e − 09 , 0.0082 and 0.0024]. However permutation test revealed association of only three markers (rs83306, rs13207351 and rs699947) with NSCLC [P value = 0.000e 0 , 0.000e 0 and 0.0086], Haplotype analysis of case-control subjects identified one block of two SNPs (rs3025020 and rs3025021) having linkage disequilibrium [D′ = 0.26]; NSCLC subjects formed two blocks of four SNPs in promoter, 5′-un-translated and intronic region (rs2010963, rs833061, rs13207351 and rs1413711) and four polymorphisms downstream of the coding sequence, in intron and 3′ un-translated region (rs2146323, rs3025020, rs3025021 and rs3025039) with highest linkage disequilibrium [D′ = 0.89] between rs13207351 and rs3025020. There were no significant differences in the tested single-nucleotide polymorphisms (SNPs) and haplotypes in patients with non-small cell lung cancer.

Background: Combination of vitamin C, hydrocortisone and thiamine have recently been used in sepsis but data of efficacy are conflicting and no data are available from developing countries. We soug...

Tuberculosis (TB) is a chronic infectious disease caused by Mycobacterium tuberculosis (MTB). Vitamin D deficiency and vitamin D receptor (VDR) gene abnormalities confer susceptibility to tuberculosis. Toll-like receptors (TLRs), such as TLR-2, are also important mediators of inflammatory response against Mycobacterium tuberculosis. We evaluated VDR, TLR-2 and TLR-4 gene polymorphisms in patients with extrapulmonary tuberculosis (EPTB).To find out a possible association of Vitamin D receptor (VDR) (rs731236), TLR-2 (196-174 Ins Del) and TLR-4 (Thr399Ile) gene polymorphisms with extrapulmonary tuberculosis in ethnic Kashmiri population.A total of 100 extrapulmunary tuberculosis cases and 102 healthy controls were analyzed for Vitamin D receptor (VDR) (rs731236), TLR-2 (196-174 ins del) and TLR-4 (Thr399Ile) gene polymorphisms using PCR-RFLP and Allele-Specific PCR methods.We found increased frequency of TLR-4 Thr/Ile heterozygous genotype in cases as compared with healthy controls (22% vs 5.8%). Thus acting as a risk factor for extrapulmonary tuberculosis, as was elucidated from statistical analysis [OR, 4.5; 95% CI (1.74-11.68); P 0.001]. In case of TLR-2 (196-174 ins del) we observed significant differences in the homozygous variant (Del/Del) genotype of cases and controls (28% in cases2.94% in controls). Thus, TLR-2 (Del/Del) genotype acts as a strong risk factor for extrapulmonary tuberculosis predisposition [OR, 12.2; 95% CI (3.5-42.69); P 0.001]. We did not find any significant differences in the genotypic distribution of (VDR) (rs731236) T C SNP between cases and controls (P 0.05).TLR-4 (Thr/Ile) and TLR-2 (Del/Del) act as significant risk factors for extrapulmonary tuberculosis predisposition in ethnic Kashmiri population.

Background: There is a paucity of literature regarding the microbial etiology of community-acquired pneumonia (CAP) in India. The current study was aimed to study the microbial etiology of hospitalized adults with CAP. Methods: The study was conducted in a 700-bedded North Indian hospital. Consecutive adults admitted with CAP over a period of 2 years from 2013 to 2015 were recruited for the study, and apart from clinical evaluation underwent various microbiological studies in the form of blood culture, sputum culture, urinary antigen for pneumococcus and Legionella, serology for Mycoplasma and Chlamydia and real-time reverse transcriptase polymerase chain reaction for influenza viruses. Radiographic studies were performed in all patients and repeated as required. The patients were treated with standard antibiotic/antiviral therapy and outcomes were recorded. Results: A total of 225 patients (median age: 59 years) were enrolled. Streptococcus pneumoniae was the most common organism found (30.5%), followed by Legionella pneumophila (17.5%), influenza viruses (15.4%), Mycoplasma pneumoniae (7.2%), Chlamydia pneumonia (5.5%), Mycobacterium tuberculosis (4.8%), Klebsiella pneumoniae (4.8%), methicillin-resistant Staphylococcus aureus (3.5%), Pseudomonas aeruginosa (3.1%), methicillin-sensitive S. aureus (1.7%), and Acinetobacter sp. (0.8%) with 4% of patients having multiple pathogens etiologies. High Pneumonia Severity Index score correlated with the severity and outcome of the CAP but was not predictive of any definite etiological pathogen. In-hospital mortality was 8%. Conclusion: Streptococcus pneumoniae, Legionella, and influenza constitute the most common etiological agents for north Indian adults with CAP requiring hospitalization. Appropriate antibiotic therapy and preventive strategies such as influenza and pneumococcal vaccination need to be considered in appropriate groups.

Asthma is a chronic immunological disorder of the lungs characterized by reversible airway obstruction, airway inflammation, and increased airway hyper responsiveness in response to provocative challenges. Objective: The aim of this study is to assess the level of serum vitamin D in patients with bronchial asthma and its correlation with disease severity. Methods: The present study, included 120 patients diagnosed as bronchial asthma. The patients were grouped on the basis of vitamin D sufficiency and vitamin D levels were correlated with disease severity and lung function. Results: Vitamin D deficiency was highly prevalent in asthmatic patients, and there was a direct and a significant relationship between serum vitamin D levels, severity of asthma, control of asthma, serum IgE levels, sputum eosinophils and lung function. Conclusions: Measuring serum levels of vitamin D followed by supplementation could be considered in the routine assessment of patients with bronchial asthma.

Background: Chronic obstructive pulmonary disease (COPD) is characterized by an interaction of various environmental influences especially cigarette smoking and genetic determinants. The prevalence of this disease is ever increasing and characterization of the genetic determinants of the disease has been undertaken globally. The ‘A disintegrin and metalloprotease 33’ (ADAM 33) gene is one candidate gene that has been studied. Objective: Our objective was to investigate whether single nucleotide polymorphisms in ADAM33 gene are associated with COPD in long-term tobacco smokers in the ethnic Kashmiri population of northern India. Materials and Methods: This was a randomized case-control study, which included 78 stable COPD (GOLD stage11-IV) patients, who were compared with 77 age- and sex-matched long-term tobacco smokers (>20 pack years) without any evidence of COPD. Polymorphic analysis for three single nucleotide polymorphisms (SNPs), (T1, T2, and Q1) of the ADAM33 gene was done by polymerase chain reaction-restriction fragment length polymorphism (PCR-RFLP) followed by sequencing. The data were analyzed by descriptive statistics and comparative evaluation was done by parametric/non-parametric tests. Results: The analysis of the T1, T2, and Q1 SNPs, revealed that the frequencies of the T2GG, T1GG, and the Q1AG genotypes were significantly higher in patients with COPD in comparison with the controls (P < 0.001). Similarly, the T1G and T2G allele frequency was higher in the patients than in the controls (p = 0.177 and 0.43, respectively). Conclusion: Three SNPs of the ADAM33 gene were significantly associated with COPD in the Kashmiri population of India. This study establishes the possible role of ADAM33 SNPS in the causation of COPD. Further studies across different geographical areas in the country will unravel the contribution of this gene in the causation of COPD in India.

Vascular endothelial growth factor (VEGF) is a major mediator of angiogenesis involving tumor growth and metastasis. In this large case-control study, we investigated whether functional polymorphisms (+405C>G, +936C>T) in the VEGF gene are associated with the risk of lung cancer. The study investigates the association between variants of VEGF gene and lung cancer. We performed single nucleotide polymorphism (SNP), haplotype and linkage disequilibrium studies on 100 patients and 128 healthy controls with 2 SNPs in the VEGF gene. The results were analyzed using logistic regression models, adjusted for age and sex. No Significant association was detected between individual SNPs and lung cancer using all the models of inheritance (codominant, dominant, recessive, over dominant and additive) for finding an association between genotypes and the cancer risk. The P values obtained for two markers were non-significant (P>0.05). Haplotype analysis produced additional support for the non-association of individual haplotypes/all haplotypes with the cancer risk (Global association P=0.56). Our findings suggest the non-involvement of genetic variants (+405C>G, +936C>T) of the VEGF gene in the etiology of lung cancer.

BACKGROUND: Atherosclerosis remains the major cause of death and premature disability in developed countries. OBJECTIVES: To assess the prevalence of early (accelerated) atherosclerosis in Rheumatoid Arthritis (RA) patients in the absence of traditional risk factors and influence of various other parameters on it. METHODS: The study was carried at a tertiary care university hospital in northern India (Kashmir) in year 2008-2009. Thirty nine patients in the age group of 25- 55 years with RA fulfilling the American College of Rheumatology (ACR) Modified criteria 1987 and a purposive sample of twenty healthy volunteers that served as controls were enrolled to judge any difference in the studied parameters. Subjects with other risk factors for atherosclerosis were excluded from the study. Disease Activity Score (DAS-28) was used to measure the disease activity. B-mode ultrasonography was used to measure carotid artery intima media thickness (CIMT) in both the groups. RESULTS: RA patients presented with elevated CIMT in the age group of 41-50 years (p = 0.665) whereas volunteers had such tendency in the 5th decade of life (p = 0.550). Duration of disease greater than 5 years also positively influenced the development of increased CIMT in the patient group (p 0.64).Patients in the RA group had a higher erythrocyte sedimentation rate (ESR) and mean CIMT as compared to the controls(p = 0.000). RA patients had lower hemoglobin concentration when compared to age and sex matched controls. Intergroup comparison in patients with normal and increased CIMT showed that increased BMI, elevated triglyceride (TG) concentration and raised ESR influenced the development of CIMT which on binary logistic regression showed that TG (p = 0.043) and BMI (p = 0.053) had influence in progression of CIMT. CONCLUSION: Rheumatoid Arthritis patients have definite evidence of early (accelerated) atherosclerosis due to inflammation even in this ethnic population. BMI and serum triglycerides even in normal range have noteworthy influence in acceleration of atherosclerosis in them. B-mode ultrasonography is simple, non-invasive, and one of the sensitive methods to detect earlier atherosclerotic changes in them. JMS 2012;15(2):106-110

Adult onset Still's disease (AOSD) is a rare rheumatic condition. It is characterized by diverse clinical and laboratory findings which may lead to errors in the differential diagnosis. Adult Still's disease is a diagnosis of exclusion. We describe herein a patient with Adult Still's disease, who presented with fever, rash and arthralgias. JMS 2012;15(2):175-78

1. Pischon N, Pischon T, Kroger J, Gulmez E, Kleber BM, Bernimaulin JP, et al. Association among rheumatoid arthritis, oral hygiene, and periodontitis. J Periodontol 2008; 79: 979–86. 2. Georgiou TO, Marshall RI, Bartold PM. Prevalence of systemic diseases in Brisbane general and periodontal practice patients. Aust Dent J 2004; 49: 177–84. 3. Mikuls TR, Payne JB, Reinhardt RA, Thiele GM, Maziarz E, Cannella AC, et al. Antibody responses to Porphyromonas gingivalis (P. gingivalis) in subjects with rheumatoid arthritis and periodontitis. Int Immunopharmacol 2009; 9: 38–42. 4. Rosenstein ED, Greenwald RA, Kushner LJ, Weissmann G. Hypothesis: the humoral immune response to oral bacteria provides a stimulus for the development of rheumatoid arthritis. Inflammation 2004; 28: 311–8. 5. Lundberg K, Kinloch A, Fisher BA, Wegner N, Wait R, Charles P, et al. Antibodies to citrullinated alpha-enolase peptide 1 are specific for rheumatoid arthritis and crossreact with bacterial enolase. Arthritis Rheum 2008, 58: 3009–19.

Vitamin D deficiency state is endemic to the Kashmir valley of the Indian subcontinent. Physicians often treat patients with high doses of vitamin D for various ailments and on occasion the prescribed doses far exceed the requirements of the patients. Ten cases of hypercalcemia due to vitamin D intoxication are presented with features of vomiting, polyuria, polydipsia, encephalopathy and renal dysfunction. All the patients had demonstrable hypercalcemia and vitamin D levels were high in nine of the 10 cases. The patients had received high doses of vitamin D and no other cause of hypercalcemia was identified. Treatment of hypercalcemia resulted in clinical recovery in nine cases. We conclude that hypervitaminosis D must be considered in the differential diagnosis of patients with hypercalcemia in endemically vitamin D deficient areas. A careful history and appropriate biochemical investigation will unravel the diagnosis in most of the cases.

Pleural effusion is one of the commonest presentations of tuberculosis, the clinical manifestations being typically abrupt resembling bacterial pneumonia. Since delayed hypersensitivity is the underlying immune response, bacterial load is very low. Owing to these facts, tuberculous pleurisy as an extra-pulmonary disease poses a diagnostic dilemma. The conventional bacteriological methods rarely detect Mycobacterium tuberculosis in pleural fluid and are of limited use in diagnosis of tuberculous pleurisy. We evaluated the efficacy of polymerase chain reaction (PCR) in the diagnosis of tuberculous pleurisy by targeting the gene segment coding for MPB64 protein specific forMycobacterium tuberculosis. Based on the clinical criteria, 82 patients with lymphocytic exudative pleural effusion were included in the study. Patients were analyzed in two groups; one group consisting of 48 patients of tubercular pleural effusion confimed by various diagnostic procedures and another group of 34 patients comprising of non-tubercular pleural effusion. There were no false positive results by PCR and the specificity worked out to be 100%. Twenty two patients tested positive for Mantoux with a sensitivity of 45%. ZN-staining for AFB was found in samples from 15 patients (20% sensitivity). ADA was positive for 28 patients with a sensitivity of 53%. PCR was positive for 32/48 patients (67% sensitivity). Thus, PCR was found to be more sensitive than any other conventional method in diagnosis of clinically suspected tubercular pleurisy.

Idiopathic hypereosinophilic syndrome (IHES) is a disorder characterized by increased eosinophil count (eosinophilia) along with organ dysfunction secondary to organ infiltration of eosinophils and release of inflammatory markers [1-4], with no obvious cause for eosinophilia. The onset of symptoms is insidious in most of the cases and eosinophilia is detected incidentally. However, in others, the initial manifestations are severe and life-threatening due to the rapid evolution of cardiac or neurologic complications [5]. Renal involvement is rarely reported [6] in IHES. Herein we reported a case of IHES with predominant renal involvement as nephrotic syndrome with focal necrotizing IgA nephropathy.

Background: Overt hypothyroidism is associated with abnormalities of lipid metabolism, but conflicting results regarding the degree of lipid changes in subclinical hypothyroidism (SCH) exist. Objectives: The aim of this study was to assess differences in lipid profile parameters between subjects with and without SCH in a north Indian population. Patients and Methods: Serum lipid parameters of 70 patients with subclinical hypothyroidism and 100 age and sex matched euthyroid controls were evaluated in a cross-sectional study. Results: Mean serum total cholesterol (TC), triglycerides (TG) and very low-density cholesterol (VLDL) were significantly higher in patients with SCH than controls (P < 0.05). Mean TC, TG and low-density cholesterol (LDL) concentrations were higher in patients with serum thyroid stimulating hormone (TSH) greater than 10 mU/L than those with serum TSH equal to or less than 10 mU/L, but this difference was not statistically significant. No association was found between serum high-density cholesterol (HDL-C) concentration and serum TSH level. Conclusions: High TC, TG and VLDL were observed in our patients with SCH.

Objective: This study was undertaken to study the correlation between imprint cytology, crush smears and histopathology in endobronchial growths using fiberoptic bronchoscopy. Methods: The study was conducted in the Department of Internal Medicine and Pathology at Sher-i-Kashmir Institute of Medical Sciences. Eighty-one patients with clinical and radiological evidences of lung lesions were enrolled. From all patients five pieces of tissue were obtained during fiberoptic broncoscopy which revealed an endobronchial growth. From each bit of tissue an imprint and crush smear were prepared by imprinting the tissue on a clean surface of glass slide without compressing the tissue while as crush smear was made by gently crushing the tissue between two glass slides. The tissue specimens were then placed in formaldehyde solution for histological examination. Standard statistical methods were used to analyze the data (chi-square (χ2) analysis; a Fisher’s exact test was used to evaluate the data if more than 25% of the expected values were

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Primary tuberculosis of the ribs is rare. A 70-year-old male presented with a 6-month history of a chest wall swelling that ruptured over few weeks to lead to a chronic discharging sinus. He had been administered multiple antibiotics, but the discharge continued. Clinical examination revealed anaemia, cervical lymphadenopathy and a 2-cm splenomegaly. Investigations revealed a normochromic and normocytic anaemia (Hb 7.0 g/dl), an ESR of 60 and a positive tuberculin sensitivity test of 25 mm. Surgical excision of the sinus along with the underlying revealed a caseous rib with histopathological features of a caseating granuloma. The patient was put on antitubercular therapy and is doing well on follow-up.