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Authors are the souls of any journal, and deserve much respect. To publish a journal manuscripts are needed from authors. Authors have a great responsibility for producing facts of their work in terms of number and results truthfully and an individual honesty is expected from authors in this regards. Both ways its true "No authors-No manuscripts-No journals" and "No journals–No manuscripts–No authors". Reviewing a manuscript is also a very responsible and important task of any peer-reviewed journal and to be taken seriously. It needs knowledge on the subject, sincerity, honesty and determination. Although the process of reviewing a manuscript is a time consuming task butit is expected to give one's best remarks within the time frame of the journal.
Salient features of the JCDR: It is a biomedical, multidisciplinary (including all medical and dental specialities), e-journal, with wide scope and extensive author support. At the same time, a free text of manuscript is available in HTML and PDF format. There is fast growing authorship and readership with JCDR as this can be judged by the number of articles published in it i e; in Feb 2007 of its first issue, it contained 5 articles only, and now in its recent volume published in April 2011, it contained 67 manuscripts. This e-journal is fulfilling the commitments and objectives sincerely, (as stated by Editor-in-chief in his preface to first edition) i e; to encourage physicians through the internet, especially from the developing countries who witness a spectrum of disease and acquire a wealth of knowledge to publish their experiences to benefit the medical community in patients care. I also feel that many of us have work of substance, newer ideas, adequate clinical materials but poor in medical writing and hesitation to submit the work and need help. JCDR provides authors help in this regards.
Timely publication of journal: Publication of manuscripts and bringing out the issue in time is one of the positive aspects of JCDR and is possible with strong support team in terms of peer reviewers, proof reading, language check, computer operators, etc. This is one of the great reasons for authors to submit their work with JCDR. Another best part of JCDR is "Online first Publications" facilities available for the authors. This facility not only provides the prompt publications of the manuscripts but at the same time also early availability of the manuscripts for the readers.
Indexation and online availability: Indexation transforms the journal in some sense from its local ownership to the worldwide professional community and to the public.JCDR is indexed with Embase & EMbiology, Google Scholar, Index Copernicus, Chemical Abstracts Service, Journal seek Database, Indian Science Abstracts, to name few of them. Manuscriptspublished in JCDR are available on major search engines ie; google, yahoo, msn.
In the era of fast growing newer technologies, and in computer and internet friendly environment the manuscripts preparation, submission, review, revision, etc and all can be done and checked with a click from all corer of the world, at any time. Of course there is always a scope for improvement in every field and none is perfect. To progress, one needs to identify the areas of one's weakness and to strengthen them.
It is well said that "happy beginning is half done" and it fits perfectly with JCDR. It has grown considerably and I feel it has already grown up from its infancy to adolescence, achieving the status of standard online e-journal form Indian continent since its inception in Feb 2007. This had been made possible due to the efforts and the hard work put in it. The way the JCDR is improving with every new volume, with good quality original manuscripts, makes it a quality journal for readers. I must thank and congratulate Dr Hemant Jain, Editor-in-Chief JCDR and his team for their sincere efforts, dedication, and determination for making JCDR a fast growing journal.
Every one of us: authors, reviewers, editors, and publisher are responsible for enhancing the stature of the journal. I wish for a great success for JCDR."
Thanking you
With sincere regards
Dr. Rajendra Kumar Ghritlaharey, M.S., M. Ch., FAIS
Associate Professor,
Department of Paediatric Surgery, Gandhi Medical College & Associated
Kamla Nehru & Hamidia Hospitals Bhopal, Madhya Pradesh 462 001 (India)
E-mail: drrajendrak1@rediffmail.com
On May 11,2011
Dr. Shankar P.R.
"On looking back through my Gmail archives after being requested by the journal to write a short editorial about my experiences of publishing with the Journal of Clinical and Diagnostic Research (JCDR), I came across an e-mail from Dr. Hemant Jain, Editor, in March 2007, which introduced the new electronic journal. The main features of the journal which were outlined in the e-mail were extensive author support, cash rewards, the peer review process, and other salient features of the journal.
Over a span of over four years, we (I and my colleagues) have published around 25 articles in the journal. In this editorial, I plan to briefly discuss my experiences of publishing with JCDR and the strengths of the journal and to finally address the areas for improvement.
My experiences of publishing with JCDR: Overall, my experiences of publishing withJCDR have been positive. The best point about the journal is that it responds to queries from the author. This may seem to be simple and not too much to ask for, but unfortunately, many journals in the subcontinent and from many developing countries do not respond or they respond with a long delay to the queries from the authors 1. The reasons could be many, including lack of optimal secretarial and other support. Another problem with many journals is the slowness of the review process. Editorial processing and peer review can take anywhere between a year to two years with some journals. Also, some journals do not keep the contributors informed about the progress of the review process. Due to the long review process, the articles can lose their relevance and topicality. A major benefit with JCDR is the timeliness and promptness of its response. In Dr Jain's e-mail which was sent to me in 2007, before the introduction of the Pre-publishing system, he had stated that he had received my submission and that he would get back to me within seven days and he did!
Most of the manuscripts are published within 3 to 4 months of their submission if they are found to be suitable after the review process. JCDR is published bimonthly and the accepted articles were usually published in the next issue. Recently, due to the increased volume of the submissions, the review process has become slower and it ?? Section can take from 4 to 6 months for the articles to be reviewed. The journal has an extensive author support system and it has recently introduced a paid expedited review process. The journal also mentions the average time for processing the manuscript under different submission systems - regular submission and expedited review.
Strengths of the journal: The journal has an online first facility in which the accepted manuscripts may be published on the website before being included in a regular issue of the journal. This cuts down the time between their acceptance and the publication. The journal is indexed in many databases, though not in PubMed. The editorial board should now take steps to index the journal in PubMed. The journal has a system of notifying readers through e-mail when a new issue is released. Also, the articles are available in both the HTML and the PDF formats. I especially like the new and colorful page format of the journal. Also, the access statistics of the articles are available. The prepublication and the manuscript tracking system are also helpful for the authors.
Areas for improvement: In certain cases, I felt that the peer review process of the manuscripts was not up to international standards and that it should be strengthened. Also, the number of manuscripts in an issue is high and it may be difficult for readers to go through all of them. The journal can consider tightening of the peer review process and increasing the quality standards for the acceptance of the manuscripts. I faced occasional problems with the online manuscript submission (Pre-publishing) system, which have to be addressed.
Overall, the publishing process with JCDR has been smooth, quick and relatively hassle free and I can recommend other authors to consider the journal as an outlet for their work."
Dr. P. Ravi Shankar
KIST Medical College, P.O. Box 14142, Kathmandu, Nepal.
E-mail: ravi.dr.shankar@gmail.com
On April 2011 Anuradha
Dear team JCDR, I would like to thank you for the very professional and polite service provided by everyone at JCDR. While i have been in the field of writing and editing for sometime, this has been my first attempt in publishing a scientific paper.Thank you for hand-holding me through the process.
Dr. Anuradha
E-mail: anuradha2nittur@gmail.com
On Jan 2020
Original article / research
Full Version
Uncommon High Resolution Computed Tomography Features of Pulmonary Tuberculosis: A Case Series
Correspondence Address :
Dr. Shalabh Jain,
RR1, Department of Radiodiagnosis, Aakash Hospital, Sector 3, Dwarka, New Delhi, Delhi, India.
E-mail: drshalabh003@yahoo.co.in
Classical imaging manifestations of pulmonary Tuberculosis (TB) include consolidation, cavitation, necrotic mediastinal lymphadenopathy and pleural effusions. On the other hand, atypical imaging findings of pulmonary TB are sometimes encountered which create a diagnostic dilemma; three such patients are reported here. The predominant finding in the first patient (24-year-old female) was diffuse cystic lung disease with associated bilateral secondary spontaneous pneumothoraces. The subacute onset of symptoms, associated nodules and ground glass opacities were a pointer towards an infective aetiology of the diffuse cysts in this case. The second patient (41-year-old female) presented with peribronchovascular and perifissural nodules with the galaxy or cluster sign leading to an erroneous diagnosis of sarcoidosis. However, the patient’s serum Angiotensin Converting Enzyme (ACE) levels were within normal limits; whereas her bronchial washings culture was positive for Mycobacterium TB. Therefore, this was actually a case of pulmonary TB with lymphatic involvement mimicking sarcoidosis. In the third patient (20-year-old female), there were pulmonary parenchymal lesions with the reversed halo sign classically described in cryptogenic organising pneumonia. Micronodularity in the wall and central part of the reversed halo lesion clinched the diagnosis of TB in this case. Laboratory investigations revealed acid fast bacilli or caseating granulomas consistent with TB in all these patients. Therefore, awareness regarding the atypical Computed tomography (CT) findings and a high index of suspicion is necessary to avoid delays in diagnosis and enable early institution of appropriate Antitubercular Therapy (ATT) in such cases.
Cystic lung disease, Galaxy sign, Reversed halo sign
Tuberculosis is a global health problem and the second leading infectious cause of death after Human Immunodeficiency Virus (HIV). India is the country with the highest burden of TB cases; it accounted for 26% of all TB cases worldwide in 2019 (1). Pulmonary TB is divided into primary and postprimary forms. Primary TB occurs mostly in children due to inhalation of Mycobacterium TB. It presents as gangliopulmonary TB, tubercular pleuritis, miliary TB, and tracheobronchial TB (2). Postprimary TB occurs due to reactivation or reinfection; and presents with additional features of fibrosis, cavitation, scar caseation and miliary nodules. Classical imaging manifestations of pulmonary TB include consolidation, cavitation, necrotic mediastinal lymphadenopathy and pleural effusions in patients presenting with fever, malaise and weight loss (2). However, with the advent of the newer era of high resolution CT scanners, we are able to appreciate various atypical imaging manifestations of TB which were previously thought to be related to some other diseases. Three such cases of atypical pulmonary TB in non smoker adult females are reported here.
Case 1
A 24-year-old female patient presented with shortness of breath and right-sided chest pain for one month. She also had fever, decreased appetite and significant weight loss for the past two months. She was a non smoker with no known co-morbidities. On examination, she was febrile with tachycardia, tachypnea and bilateral crepitations on chest auscultation. Arterial Blood Gas (ABG) analysis showed partial oxygen (paO2): 42 mmHg, partial carbondioxide (pCO2): 44 mmHg, Bicarbonate (HCO3): 27.1 mmol/L, potential of hydrogen (pH): 7.406.
Her chest radiograph showed diffuse reticular opacities with small cystic lesions scattered in bilateral lung fields without any zonal predominance. Small pneumothorax was seen on the right-side. Contrast Enhanced CT (CECT) of the thorax revealed multiple tiny cysts and random nodules along with thickening of interlobular septae in bilateral lung parenchyma in a background of diffuse Ground Glass Opacity (GGO). There was also peripheral consolidation in the left lung with bilateral pneumothoraces (Right>Left). However, there was no mediastinal lymphadenopathy or pleural effusion (Table/Fig 1).
Possible differential diagnosis of diffuse cystic lung diseases include Lymphoid Interstitial Pneumonia (LIP), Lymphangioleiomyomatosis (LAM), Pulmonary Langerhans Cell Histiocytosis (PLCH), infective conditions like Pneumocystis Carinii Pneumonia (PCP) and Staphylococcal pneumonia, and cystic presentation of TB. The intervening lung parenchyma is relatively preserved in LAM and PLCH; whereas there were diffuse GGO and nodules in this case. Acute or subacute onset of multiple cysts is usually of infective aetiology, and as the patient was not immunocompromised, atypical cystic presentation of TB was the top differential diagnosis (3).
The patient was admitted in the intensive care unit and a right-sided intercostal drainage tube was placed for pneumothorax. Transbronchial lung biopsy showed granulomatous inflammation consistent with TB; and culture of bronchial washings were also positive for Mycobacterium TB. Thereafter, first-line ATT of isoniazid (H), rifampicin (R), ethambutol (E) and pyrazinamide (Z) daily for two months, followed by four months of Isoniazid, Rifampicin and Ethambutol (2HREZ/4HRE) was initiated and the patient showed good clinicoradiological response on six months follow-up. Her follow-up CT scan showed that the pneumothoraces, consolidation and ground glass opacities had resolved completely. However, the lung parenchymal cysts still persisted (Table/Fig 2).
Case 2
A 41-year-old female patient presented to the respiratory outpatient department with chief complaints of low grade fever, dry cough and dysponea for 2 months. She was neither a current nor past smoker. On physical examination, respiratory rate was 48/min and chest auscultation revealed bilateral crepitations. Patient’s chest radiograph revealed bilateral reticulonodular opacities. High-resolution computerised tomography (HRCT) thorax showed nodular peribronchovascular thickening, nodular septal thickening and subpleural nodularity. Multiple areas of confluent micronodules similar to galaxy sign or cluster sign were also seen. However, there was no significant mediastinal lymphadenopathy (Table/Fig 3).
Based on the demographic profile of the patient and corroborative imaging features of perilymphatic nodules and galaxy/cluster sign, imaging diagnosis of sarcoidosis was made. However, serum ACE levels were within normal limits; whereas bronchial washings culture was positive for Mycobacterium TB; and sputum examination also showed presence of acid-fast bacilli. Therefore, this was actually a case of pulmonary TB with lymphatic involvement mimicking sarcoidosis. Subsequently, first-line ATT (2HREZ/4HRE) was initiated and the patient showed clinical response at two months in the form of symptomatic relief and sputum negative status for acid-fast bacilli. Repeat CT scan was planned at six months post ATT. However, the patient was subsequently lost to follow-up.
Case 3
A 20-year-old non smoker female patient presented to the medicine outpatient clinic with low grade fever, cough and malaise for 1 month. Physical examination was normal. Chest radiograph showed few ill-defined air space opacities in bilateral lungs.
HRCT thorax showed multiple patchy areas of central GGO surrounded by peripheral consolidation scattered in bilateral lungs, akin to the reversed halo sign. The wall as well as the central part of these lesions showed micronodularity. Multiple scattered random nodules were also present in both lungs; some with cavitation. No enlarged mediastinal lymph nodes were seen (Table/Fig 4).
Reversed halo sign has been classically described in Cryptogenic Organising Pneumonia (COP). However, the clinical profile of the patient was not in favour. Also, micronodularity in the wall and central part of the reversed halo was a pointer towards TB as the cause in this case (4). This was confirmed on the patient’s sputum examination which was positive for acid fast bacilli. Thereafter, the patient was put on first-line ATT (2HREZ/4HRE), and a follow-up CT scan at six months showed only fibrotic bands in both lower lobes (Table/Fig 5).
Classical imaging manifestations of pulmonary TB include upper lobe consolidation, cavitation, necrotic mediastinal lymphadenopathy and pleural effusions in patients presenting with fever, malaise, weight loss (2). However, the present three cases had atypical imaging presentations which could be mistaken for other diseases.
Several authors have described atypical radiological appearances of pulmonary TB. For instance, involvement of lung bases and non-cavitary lesions may be encountered in pulmonary TB, especially in the immunocompromised (5). Endobronchial spread of TB, round pneumonia mass-like appearance and non-necrotic lymphadenopathy are other unusual manifestations of pulmonary TB (6),(7),(8). Research into how the ongoing Coronavirus Disease 2019 (COVID-19) pandemic may affect the imaging appearances of pulmonary TB is still in a nascent stage (9).
First case was an immunocompetent adult who presented with multiple lung cysts with bilateral secondary spontaneous pneumothoraces. ‘Lung cyst’ is a well circumscribed rounded/irregular lesion with a visible wall; it has a wide range of differentials. Chronic cysts are likely to occur in non-infectious infiltrative processes like LAM, PLCH, LIP, and Birt-Hogg-Dube syndrome; most of these diseases have near normal intervening lung parenchyma (3). Cystic lung disease in pulmonary TB similar to the first case has been infrequently reported (10),(11). In TB, thin-walled cavities are documented in healed stage; but cystic lesions at the time of diagnosis are less known. Mechanisms of cyst formation in TB may be due to caseous necrosis of bronchial walls, granulomatous inflammation of bronchioles leading to cyst formation by check-valve mechanism, or due to leakage of air into the interstitium if a tubercle ruptures. The cysts may be reversible, or may even persist after completion of TB treatment (10).
The second case was a young adult with perilymphatic distribution of nodules and presence of the galaxy/cluster sign on HRCT. These findings in a case of TB represent the lymphatic spread of infection. In a retrospective study by Ko JM et al., they analysed the CT scans of 111 patients with active pulmonary TB and found the prevalence of perilymphatic nodules to be 58% and that of galaxy/cluster sign to be 16%. They postulated that the micronodules were granulomas in the pulmonary interstitium that develop in the perivascular and peribronchiolar connective tissue corresponding to pulmonary lymphatics (12). Galaxy sign seen in the second case was similar to that seen in pulmonary sarcoidosis; it can be explained by the fact that both are granulomatous diseases and the sign represents a cluster of tiny granulomas.
Authors described the reversed halo or atoll sign in pulmonary TB in the third case. Ko JM et al., reported a prevalence of 4% for reversed halo sign in their study on active pulmonary TB (12). Reversed halo defined as central GGO with peripheral consolidation on HRCT is typically seen in COP. However, if there is nodularity in the wall of the lesion or in the centre, the differential should be of a granulomatous disease like TB or sarcoidosis. Nodularity in the wall of reverse halo has been reported by Marchiori E et al., as a statistically significant pointer to differentiate TB from COP (4). In these cases, other signs and clinical profile of the patients need consideration. As this case had nodularity in the reversed haloes without any features of sarcoidosis such as perilymphatic nodules or mediastinal lymphadenopathy, authors gave the diagnosis of pulmonary TB. Certain limitations of the present study have to be acknowledged. As this was a small case series, the other atypical manifestations of pulmonary TB could not be illustrated. Also, follow-up scan of one of the three patients could not be obtained. Lastly, authors only did microbiological confirmation but not radiological-histopathological correlation in any of the cases.
Pulmonary TB presenting as cystic lung disease, perilymphatic nodules mimicking sarcoidosis, or reversed halo sign is uncommon and atypical, and may be mistaken for other diseases. Awareness regarding the atypical CT findings, a high index of suspicion and early initiation of therapy is crucial in management of such cases.
10.7860/JCDR/2021/48674.15213
Date of Submission: Jan 24, 2021
Date of Peer Review: May 06, 2021
Date of Acceptance: Jun 04, 2021
Date of Publishing: Aug 01, 2021
AUTHOR DECLARATION:
• Financial or Other Competing Interests: None
• Was informed consent obtained from the subjects involved in the study? Yes
• For any images presented appropriate consent has been obtained from the subjects. Yes
PLAGIARISM CHECKING METHODS:
• Plagiarism X-checker: Jan 25, 2021
• Manual Googling: May 05, 2021
• iThenticate Software: Jun 04, 2021 (3%)
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