Atypical celiac disease: from recognizing to managing.

The nonclassic clinical presentation of celiac disease (CD) becomes increasingly common in physician's daily practice, which requires an awareness of its many clinical faces with atypical, silent, and latent forms. Besides the common genetic background (HLA DQ2/DQ8) of the disease, other non-HLA genes are now notably reported with a probable association to atypical forms. The availability of high-sensitive and specific serologic tests such as antitissue transglutuminase, antiendomysium, and more recent antideamidated, gliadin peptide antibodies permits to efficiently uncover a large portion of the submerged CD iceberg, including individuals having conditions associated with a high risk of developing CD (type 1 diabetes, autoimmune diseases, Down syndrome, family history of CD, etc.), biologic abnormalities (iron deficiency anemia, abnormal transaminase levels, etc.), and extraintestinal symptoms (short stature, neuropsychiatric disorders, alopecia, dental enamel hypoplasia, recurrent aphtous stomatitis, etc.). Despite the therapeutic alternatives currently in developing, the strict adherence to a GFD remains the only effective and safe therapy for CD.

[Acute psychotic access following the administration of isoniazid]. / L'accès psychotique aigu secondaire à la prise d'isoniazide.

INTRODUCTION: Acute psychotic access is defined as the occurrence of a single, acute, and intense psychotic episode in a subject without a neurological or psychiatric history. Isoniazid (INH), a major antibacillar, is the drug most often involved in the occurrence of this psychiatric disorder. However, this side effect is rare and only a few cases have been reported in the literature. CASE REPORT: A 57-year-old female patient with diabetes mellitus presented miliary tuberculosis for which an antibacillar treatment was prescribed. Three days later, she presented an acute psychotic access requiring the withdrawal of the INH and the prescription of neuroleptic drugs, without any pyridoxine supplementation. The lab tests were normal. The good clinical evolution after the INH withdrawal confirmed its imputabilty. CONCLUSION: Acute psychotic access is a severe and exceptional complication following the administration of INH. Emergency treatment is the only guarantee of a good outcome.

[Pneumocystis jirovecii: what does this mean?]. / Pneumocystis jirovecii: ce nom, que signifie-t-il?

Pneumocystis was discovered nearly a century ago. It causes fatal pneumonia in immunocompromised individuals, especially in AIDS patients. Knowledge of the different species remained rudimentary until the mid-eighties when DNA analysis revealed its extensive diversity. In fact, it is no longer considered as a zoonosis. Pneumocystis organisms derived from different hosts have very different DNA sequences, indicating multiple species. Due to the genetic and functional disparities, the organism that causes human PCP is now named Pneumocystis jirovecii/Frenkel, 1999. We continue to call Pneumocystis carinii the species found in rats. This will allow for a single international language and avoid confusion. Changing the organism's name does not preclude the use of the well-known acronym PCP because it can also be read "PneumoCystis Pneumonia." The DNA sequences and genotypage have shown that variations exist among samples of P. jiroveci. Molecular biology is helpful in the study of the mechanisms of transmission, which can only occur in the same host and the different resistances as well as providing a better understanding of the relationship between host and pathogen. P. jirovecii pneumonia in immunosuppressed patients was previously thought to result from the reactivation of a latent infection acquired in early childhood. However, today, it is believed to result from a new infection from an exogenous source.

[Cardiac hydatidosis with dissemination to the pulmonary parenchyma and the pulmonary artery]. / Hydatidose cardiaque compliquée d'une dissémination parenchymateuse pulmonaire et vasculaire artérielle pulmonaire.

Multiple thoracic hydatic disease involving a cardiac and pulmonary localization is exceptional and prognosis is poor. We report a case in a 21-year-old male who presented repeated episodes of hemoptysis. The chest x-ray showed multiple opacities. The thoracic computed tomography and echocardiography visualized cystic formations in the heart and the pulmonary arteries. Hydatic serology was strongly positive. Medical treatment with albendazole was given but the patient died from massive hemoptysis before the cardiac and pulmonary artery cysts could be removed surgically (a procedure which requires extracorporeal circulation). A hydatic cyst of the pulmonary artery is usually secondary to a cardiac localization. The risk is dissemination into the pulmonary and eventually systemic circulation. An arterial localization must be carefully ruled out in all patients with multiple or cardiac hydatidosis. Treatment is surgical to avoid dissemination.

[Mediastinal paraganglioma with pleural metastasis. A case report]. / Paragangliome médiastinal avec métastase pleurale. A propos d'un cas.

Paraganglioma is rare tumor arising from chromaffine cells. We report a 39-year-old man who was diagnosed with anterior mediastinal paraganglioma. Computed tomography (CT) revealed a solid mass in the anterior mediastinum. Surgical biopsies obtained by sternotomy confirmed histologic and immunohistochemical features of paraganglioma. Surgical removal of this vascularized and invasive tumor was not possible to. External radiotherapy was performed. Three years later, the patient developed chest pain. CT findings showed right nodular pleural masses. Transparietal biopsy confirmed the same pathological aspect of paraganglioma. Chemotherapy was proposed without significant response. This observation confirmed the rare course of paraganglioma to pleural metastases. Treatment of paraganglioma is mainly surgery if the mass is resectable.

[Amoebic infections of the lung and pleura]. / Les atteintes pleuro-pulmonaires a Entamoeba histolytica.

INTRODUCTION: Pleuropulmonary involvement is the second most common extra-intestinal manifestation of entamoeba histolytica infection after liver abscess. CASE REPORT: We report 2 cases of pleuropulmonary disease occurring in two men aged 32 and 48 years following an episode of dysentery. Purulent pleural infection was noted in one case. In the other both lung and liver abscesses occurred. CONCLUSION: The diagnosis was confirmed by strongly positive serology in both cases. Treatment with metronidazole (1.5 g per day) for 15 days combined with pleural drainage led to a satisfactory outcome in both cases.

[Pulmonary actinomycosis. Two cases]. / Actinomycose pulmonaire. A propos de deux cas.

We report two cases of pulmonary actinomycosis in two young men. These observations are an opportunity to review the usual difficulties of diagnosis and the clinical, radiological and therapeutic characteristics in patients with this rare disease. Pulmonary actinomycosis often appears in a debilitated patient with significant disease of the teeth and gingival margins. High-dose penicillin G which is the standard treatment generally provides cure.

[Smoking in Casablanca hospitals: knowledge, attitudes and practices]. / Tabagisme dans les hôpitaux de Casablanca: connaissances, attitudes et pratiques.

This cross sectional study took place with a self administered questionnaire between June and September 1999 and involved 1,388 subjects of whom 62.4% were men and 37.6% women. The total prevalence of smoking was 14.9%, ranging from 12.5% in paramedical staff to 15.5% in manual workers, 16.2% in doctors, 17.1% in laboratory staff, and 22.2% in administrators. The prevalence was 35.9% among men as against 2.2% among women. The study of smokers showed that 51.5% had started before the age of 21. The most common motive for starting smoking was "pleasure". Among the 45.5% who smoked at the workplace 60.5% felt concerned about it. Evaluation of the degree of nicotine dependence using the Fagerstrom score found high dependence in 21.3% of subjects. Only 24.5% of doctors warned patients against smoking in the absence of smoking related diseases or symptoms. In more than 75% of cases doctors advised against smoking in the workplace and in the home. 66.8% of staff were aware of the anti-smoking law but the legislative measures were poorly understood. Only 9% of those interviewed had taken part in an anti-smoking campaign. In conclusion, the prevalence of smoking in the hospitals of Casablanca has definitely diminished in the past 10 years but it remains relatively high in men. Hospital staff should be more involved in the fight against smoking.

[Respiratory symptoms and ventilatory disorders among a group of cement workers in Morocco]. / Symptômes respiratoires et troubles ventilatoires chez les travailleurs dans une cimenterie au Maroc.

There are 8 cement works in Morocco employing 3 600 people and producing 8 million tons annually. The aim of our study is to determine the prevalence of respiratory symptoms and to propose some preventive measures. The study involved a group of workers of whom 280 were exposed to cement dust (who were further subdivided into three categories according to the intensity of exposure) and 73 who were not. It included a medical history with a standardised questionnaire, a clinical examination and spirometry. 65% of those exposed had clinical symptoms as opposed to 34.2% of the non-exposed. Cough, expectoration rhinitis, chronic bronchitis and asthma were significantly more common with incidences of 56.1%, 52.5%, 49.3%, 29.3% and 14.3% respectively in the exposed against 19.2%, 24.6%, 26%, 9.6% and 6.8% in the non-exposed. Among the exposed the prevalence of chronic bronchitis increased significantly with the degree of exposure, from 11.4% in category 1 to 41.6% in category 3. Age did not seem to influence the development of chronic bronchitis but on the other hand a smoking history of more than 10 years did. Exposure is responsible for the development of respiratory problems because among non smokers the exposed (55.6% are more symptomatic than the non-exposed (13.3%). Tobacco smoking potentiates the effects of occupational airborne contamination because exposed smokers (73.6%) and ex-smokers (67.8%) have more respiratory problems than exposed non-smokers (55.6%). The incidence of abnormalities of respiratory function is significantly higher in the exposed than in the non-exposed (32.5% against 13.7%). Among the exposed workers presenting disorders of ventilatory function 72.5% have no more than a disorder of the small airways or a slight deficit. Among the exposed the prevalence of impaired respiratory function is greater in smokers and ex-smokers (47.9% than in non-smokers (10.4%). Tobacco smoking augments the impairment of respiratory function. Prevention depends therefore on a programme of technical (collective and individual) and medical protection of the workforce.

[Respiratory risk in carpenters and cabinet makers]. / Risques respiratoires chez les ouvriers des menuiseries-ébénisteries artisanales.

They are many risks relating to the wood; they are caused by natural components of wood, products of conservation, chemical agents and parasites of wood. We have carried out a retrospective survey which concerned exposed workers and controls in twenty small handicraft workshops in the joiners' souk of Marrakesh, it has enabled us to evaluate the prevalence of the clinical symptoms and disorders of respiratory function in 242 exposed subjects to the wood dust and 121 controls. This enquiry consisted of a questionnaire (European Coal and Steel Community: ECSC and the World Health Organisation: WHO), a clinical examination and a spirometry. Sixty-one point nine % of those exposed had clinical respiratory symptoms versus only 21.5% of controls. Rhinitis, asthma, conjunctivitis, chronic bronchitis and dermATitis were significantly more frequent in those exposed than among the non-exposed, with respectively 55.8%, 14.5%, 24.8%, 21.1% and 12.8% versus 16.5%, 6.6%, 8.3%, 5.8% and 4.9%. Exposure was the cause of respiratory symptoms because among non-smokers, exposed workers were more symptomatic than controls. Smoking exhibited a potentializing effect on airborne occupational contaminants because among exposed workers disorders were 1.8 times more frequent in smokers than non-smokers. A variable degree of respiratory obstruction was found among 30.1% of the exposed individuals versus 12.4% of the unexposed subjects. The effect of exposure was certain because among the non-smokers, 15% of exposed subjects had altered respiratory function versus 4% of unexposed persons. It is imperative to implement an occupational health service and to develop means for collective and individual prevention to maximally reduce the risk.

[Smoking knowledge, attitudes, and behaviors of patients in Morocco]. / Connaissances, attitudes et comportements de patients vis-à-vis du tabagisme au Maroc.

Smoking is a serious public health problem. In Morocco, the number of smokers varies from 24% to 52% depending on different social categories (school children, university students, public health workers, industrial workers, civil servants). The aim of our descriptive study was to analyze knowledge about smoking and smoking habits in patients hospitalized or followed by two units in the Ibn Rochd Hospital, cardiology and respiratory diseases. A questionnaire was given to a consecutive series of 200 patients between January and March 1997 (100 patients in each unit). Twenty percent of the patients were smokers and 23% were former smokers. The most well known health risks of smoking in the two groups of patients were respiratory and cardiovascular risks (88% and 71% respectively). Smokers and former smokers were more aware of these health risks. 86% of the smokers and former smokers had attempted to stop smoking at least once, mainly for a "health" reasons. 60% of smokers and former smokers decided to never smoke or never take a cigarette again. 66% of the patients said they had not been advised at the hospital about the risk of smoking. Our study provides a basis for further studies. It points out the importance of the smoking phenomena and the minimal role played by health personnel in advising patients. Health care workers should participate in antismoking activities during their consultation activities at the hospital in order to help patients stop smoking and also help implement rigorous antismoking laws in Morocco.

[Aneurysms of the pulmonary artery in Behçet disease. Apropos of 5 new cases]. / Anévrysmes e l'artére pulmonaire au cours de la maladie de Behçet. A propos de 5 nouvelles observations.

Behçet's disease is a systemic vascularitis generally involving the venous system. Many organs may be involved, but pulmonary localizations are uncommon. We report 5 cases of pulmonary artery aneurysms observed in a series of Behçet's disease collected over a 10-year period. All patients were males, age range 18-41 years. Hempotysia was the inaugural event in all cases. Behçet's disease was recognized in only 2 of the patients initially. The diagnosis was made after recognition of the pulmonary artery aneurysms in the others. Chest x-ray showed round perihilar opacities varying in number from 2 to 4. Computed tomography with vascular opacification was performed in 4 patients and confirmed the aneurysmal nature of the opacities. Angiography was performed in 3 cases. Medical treatment with corticosteroids and/or colchicine was prescribed in all cases. One patient had left inferior lobectomy. In one case regression of the aneurysms precluded embolization. Two patients refused surgery and in one, surgery was not retained due to the large number of aneurysms. Outcome was fatal in one patient who died after cataclysmic hemoptysia. These findings underline the uncommon nature of pulmonary aneurysms in Behçet's disease and the diagnostic difficulties encountered in absence of specific signs as well as the poor prognosis of such localizations.

[Pancoast-Tobias syndrome of hydatid etiology]. / Syndrome de Pancoast et Tobias d'étiologie hydatique.

The authors report a case of right-sided complete Pancoast and Tobias syndrome related to a multivesicular extrapleural hydatid cyst developing at the cervico-thoracic area with involvement of the first rib. This occurred in a 27 year old country dweller who was a non-smoker who presented with a progressive history of right sided cervico-brachial neuralgia some four months before hospitalisation, there was a subclavicular tumour swelling (8-10 cm), solid, non-inflammatory and a right sided Claude-Bernard-Horner syndrome. Screening of the thorax showed an opacity at the right apex, dense and homogeneous, with a pseudo-fracture of the first right rib. A cervical echo showed a multiloculated liquid filled mass without connection to the thyroid. Computer tomographic scanning showed a multiloculated voluminous liquid filled mass in the right cervico-thoracic area with a regular polycyclic outline, the lungs were normal. The serology was positive for hydatid disease (haemagglutination and ELISA). The patient was operated on by an exclusively supraclavicular approach with excision of the hydatid membranes and vesicles as well as the right first rib. The immediate outcome resulted in the disappearance of the neuralgia and the persistence of the Claude-Bernard-Horner syndrome.

[Purulent pleurisy due to Salmonella typhi associated with a splenic abscess]. / Pleurésie purulente à Salmonella typhi associée à un abcès splénique.

We report a case of 25 year old man who presented with a febrile illness and bilateral lower chest pain a pain in the left hypochondrium with fever and weight loss; investigations revealed a left sided empyema. The cause of the empyema was confirmed following the isolation in the pleural pus of Salmonella typhi. There was also a mass in the left hypochondrium which was shown on ultrasound to be a splenic abscess. After antibiotic therapy with Cotrimoxazole, repeated pleural aspirates and physiotherapy, there was a satisfactory outcome and the pleural effusion dried up and there was a significant reduction in the volume of the splenic abscess. In the light of their observations, the authors report the rare presentation of empyemas due to Salmonella typhi, the late presentation during the course of the third septenaire and the often favourable outcome under general antibiotic therapy associated with pleural aspirates to evacuate the pus and respiratory physiotherapy.