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BACKGROUND: A guide-sheath (GS) is conventionally used as a conduit for biopsy forceps under the guidance of radial endobronchial ultrasound (REBUS) for sampling the peripheral pulmonary lesions (PPLs). As compared with forceps, the cryoprobe has the advantage of obtaining larger samples. There is a paucity of literature on the use of cryobiopsy for PPL. We evaluated the diagnostic yield and safety of the REBUS-guided cryobiopsy (REBUS-CB) without using GS for the diagnosis of PPL. METHODS: We retrospectively analyzed the database of 126 patients with PPL between November 2015 and December 2019. The REBUS-CB was performed using a flexible bronchoscopy without GS. Multidisciplinary consensus diagnostic yield was determined and procedural complications were recorded. RESULTS: The histopathologic diagnosis by REBUS-CB, which is the primary objective of the study was obtained in 99 (78.6%) of total 126 cases. Yield was significantly higher in central lesions as compared to adjacent lesions visualized by the REBUS probe (81.4% versus 53.8%, P=0.021) but not significantly different between large (≥30 mm) and small (<30 mm) lesions (81.6% versus 71.8%, P=0.214). The average largest diameter of biopsy specimens was 6.9 mm (range 1-12, SD 2.132). We witnessed moderate bleeding in 7 (5.6%) and post procedure hypoxic respiratory failure in 4 (3.2%) cases which could be managed without escalation of care. CONCLUSION: The REBUS-CB from peripheral lung lesions are feasible even without using GS and significantly large samples can be obtained.

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Diffuse alveolar hemorrhage (DAH) is a rare but life-threatening disease. Mortality is very high in those patients who require mechanical ventilation. Traditionally, active bleeding has been considered a contraindication for extracorporeal membrane oxygenation (ECMO) support. There is limited evidence for ECMO in DAH as rescue therapy. Herein, we describe a case of antineutrophil cytoplasmic antibodies-associated DAH with intractable hypoxemic respiratory failure. An appropriate ventilator strategy failed to improve her hypoxemia leading to imminent risk to her life. The patient was rescued with veno-venous ECMO targeting lower than usual range of anticoagulation. ECMO proved to be lifesaving in our patient who was initiated on prompt immunosuppressive therapy and plasmapheresis along with continuous veno-venous hemodiafiltration and hemodynamic support. We feel that ECMO could be considered as adjunctive therapy in severe hypoxemic respiratory failure associated with DAH after careful consideration of the risk of bleeding and a restrictive anticoagulation strategy. How to cite this article: Goel MK, Chauhan M, Kumar A, Wadwa P, Maitra G, Talegaonkkar M, et al. A Case of Refractory Hypoxemic Respiratory Failure due to Antineutrophil Cytoplasmic Antibodies-associated Diffuse Alveolar Hemorrhage Rescued by Extracorporeal Membrane Oxygenation. Indian J Crit Care Med 2020;24(9):879-881.

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Roots of Rauwolfia serpentina, also known as "Sarpagandha" possess high pharmaceutical value due to the presence of reserpine and other medicinally important terpene indole alkaloids. Ever increasing commercial demand of R. serpentina roots is the major reason behind the unsystematic harvesting and fast decline of the species from its natural environment. Considering Agrobacterium rhizogenes-mediated hairy root cultures as an alternative source for the production of plant-based secondary metabolites, the present optimized protocol offers a commercially feasible method for the production of reserpine, the most potent alkaloid from R. serpentina roots. This end-to-end protocol presents the establishment of hairy root culture from the leaf explants of R. serpentina through the infection of A. rhizogenes strain A4 in liquid B5 culture medium and its up-scaling in a 5 L bench top, mechanically agitated bioreactor. The transformed nature of roots was confirmed through PCR-based rol A gene amplification in genomic DNA of putative hairy roots. The extraction and quantification of reserpine in bioreactor grown roots has been done using monolithic reverse phase high-performance liquid chromatography (HPLC).

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Hairy root cultures of Rauwolfia serpentina induced by Agrobacterium rhizogenes have been investigated extensively for the production of terpenoid indole alkaloids. Various biotechnological developments, such as scaling up in bioreactors, pathway engineering etc., have been explored to improve their metabolite production potential. These hairy roots are competent for regenerating into complete plants and show survival and unaltered biosynthetic potential during storage at low temperature. This review provides a comprehensive account of the hairy root cultures of R. serpentina, their biosynthetic potential and various biotechnological methods used to explore the production of pharmaceutically important terpenoid indole alkaloids. The review also indicates how biotechnological endeavors might improve the future progress of research for production of alkaloids using Rauwolfia hairy roots.

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A 57-year-old male presented with hemoptysis of 4 years duration and a gradually increasing pleural mass on chest X-ray. The mass was causing pressure effects on the liver and the lungs. To rule out malignancy, thoracotomy was performed, which revealed large, thick-walled hematoma. Complete excision of mass was performed. Post-operative course was complicated by massive pleural bleeding requiring massive blood transfusions and re-exploratory thoracotomy. Subsequent tests revealed factor IX deficiency and, hence, he was managed with recombinant factor IX concentrate. This case stresses upon the fact that hereditary bleeding disorders may be diagnosed even in late adulthood with atypical presentations such as pseudotumor in pleural space. Moreover, hemophilia B may present with normal APTT levels making the diagnosis even more difficult.

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A 57-year-old diabetic and hypertensive man presented with a short history of fever, dry cough and right side chest pain. A chest radiograph showed right pleural based homogenous shadow in middle and lower zones with obliteration of right costo-phrenic angle suggestive of right side effusion. Aspiration of pleural fluid revealed frank pus for which inter-costal tube drainage was performed. Due to persistence of empyema, the patient was subjected to thoracoscopy. Thoracoscopy showed multiloculated empyema. Thoracoscopic pleural biopsy and fluid showed septate fungal hyphae. Thoracotomy and parietal pleurectomy, with resection of part of right lower lobe, was carried out. Pleural fluid, pleural and lung tissue culture grew Aspergillus fumigatus. The patient showed good recovery with voriconazole after thoracotomy.