[Factors predicting the need for invasive mechanical ventilation in patients with chronic obstructive pulmonary disease (COPD)]. / Facteurs prédictifs de la ventilation mécanique invasive chez les patients atteints de broncho-pneumopathie chronique obstructive (BPCO).

INTRODUCTION: the use of invasive mechanical ventilation (IMV) in acute exacerbations of chronic obstructive pulmonary disease (AECOPD) constitutes a negative turning point in the progression of the disease. The purpose of this study is to determine factors predicting the need for IMV in AECOPD. METHODS: we conducted a retrospective study by reviewing the medical records of patients with AECOPD hospitalized in our Department over a 18-year period (2000-2017). We compared 2 groups: G1: patients with AECOPD undergoing at least one IMV and G2: patients who had never undergone IMV following AECOPD. RESULTS: the study included 1152 patients with COPD: 133 in the G1 group (11.5%), and 1019 in the G2 group (88.5%). G1 patients were more symptomatic (p < 0.001), with more severe bronchial obstruction (p < 0.001). G1 patients had more exacerbations (p < 0.001), more hospitalizations and a higher need for non-invasive ventilation (NIV) (p < 0.001). Similarly, G1 patients more often developed chronic respiratory failure (p < 0.001) and had significantly lower survival rates. Independent risk factors associated with IMV were hypercapnia and decreased pH (in patients with severe AECOPD), a history of NIV, and chronic respiratory failure (CRF). CONCLUSION: respiratory function impairment, the severity of exacerbation and the need for NIV in a previous episode are factors predicting the need for IMV and poor outcomes.

Bilateral pleural metastases of a primary central nervous system neuroblastoma in an adult: First case in the world.

Primary central nervous system neuroblastoma (PCNS-NBL) is a rare and aggressive malignant tumour. Pleural metastases of PCNS-NBL have not been documented before. We report a case of a 30-year-old male patient, with a history of PCNS-NBL treated with surgery, radiation and chemotherapy. Three years later, he presented an aggravated dyspnoea with impaired general condition. The different investigations confirmed that his PCNS-NBL has relapsed with bone, lymph nodes and bilateral pleural metastases. Because of the disseminated disease and the poor general condition of the patient, only symptomatic treatment measures were preconized. The patient died 3 months later following cardiorespiratory arrest. To the best of our knowledge, this is the first case reporting bilateral pleural metastases of a PCNS-NBL in a young adult.

Miliary tuberculosis following intravesical Bacillus Calmette and Guérin therapy: A rare complication of a frequent procedure.

The standard treatment for superficial vesical tumors is transurethral resection (TUR) followed by intravesical instillation of Bacillus Calmette and Guérin (BCG). Pulmonary complications of BCG-therapy are rare but could be life threatening. We report the case of a 54-year-old patient who received BCG-therapy after TUR. After the sixth session of BCG instillations, the patient was diagnosed with a miliary tuberculosis secondary to BCG-therapy. We observed a progressive clinical and radiological improvement under specific tuberculosis treatment. Early diagnosis of pulmonary side effects of BCG-therapy and prompt treatment are the keys to complete recovery and survival.

[Effect of intensity of smoking intoxication on severity parameters of acute exacerbations of chronic obstructive pulmonary disease treated in a hospital milieu]. / Influence de l'intensité de l'intoxication tabagique sur les paramètres de sévérité des exacerbations aiguës de la broncho-pneumopathie chronique obstructive traitées en milieu hospitalier.

INTRODUCTION: smoking is the leading risk factor for chronic obstructive pulmonary disease (COPD). Disease evolution is characterized by the occurrence of acute exacerbations (AE). The purpose of our study is to assess the effect of intensity of smoking intoxication (in packs-years (PAs)) on the different severity parameters of AE in smoking patients with COPD treated in hospital. METHODS: we conducted a retrospective, monocentric study of 685 smoking patients with COPD who had been hospitalized at least once for an AE between 1990 and 2017. Patients were divided into 2 groups (G1: < 30PA, and G2: ≥ 30PA). The different severity parameters of COPD AE were compared between the two groups. RESULTS: the average age of our patients was 66 years. There were no significant differences between the two groups with respect to the severity of biologic inflammatory syndrome, length of stay in hospital and antibiotic treatment duration. G2 was characterized by lower PaO2 levels during AE (G1: 63.5, G2: 59.3, p: 0.007), longer length of stay in the emergency department (p < 0,001), increased use of non-invasive ventilation (p: < 0.001) and invasive ventilation (p: 0,008). G2 had more EA/year (G1: 2.06. G2: 2.72/patient/year, p: 0.001) with a shorter mean time for severe AE (p: 0.038). Conclusion: the intensity of smoking intoxication has a negative impact on several severity parameters of severe COPD EAs. Hence the role of smoking cessation in preventing this disease and its complications.

A Rare Case of Haemoptysis Revealing Aortic Coarctation in an Adult.

Haemoptysis is a frequently occurring but sometimes life-threatening condition. Congenital cardiovascular abnormalities are rare causes of haemoptysis. We report a case of a 33-year-old man without any past medical history complaining of haemoptysis with no other associated clinical manifestations. A contrast-enhanced chest computed tomography scan revealed aortic coarctation with dilation of the internal mammary, intercostal and bronchial arteries. He underwent stent placement after balloon angioplasty with favourable outcomes. LEARNING POINTS: Adult patients with congenital cardiovascular abnormalities such as aortic coarctation may rarely, due to the high pressure and dilation in the bronchial arteries, present with recurrent haemoptysis as the sole clinical sign.A multidetector computed tomography scan contributes significantly to the aetiological diagnosis of haemoptysis in cases of congenital cardiovascular abnormalities.Interventional procedures such as stenting are currently the preferred approach for the treatment of aortic coarctation in adults, with good outcomes.

Inflammatory myofibroblastic tumor of the lung: A rare entity.

Inflammatory myofibroblastic tumor (IMT) is a rare mesenchymal tumor usually seen within the first and second decade. They are extremely rare in adults, constituting less than 1% of adult lung tumors. It's usually benign, but it had a tendency for local recurrence. We report a case of asymptomatic inflammatory myofibroblastic tumor of lung in a 46-year-old non-smoker woman.

Mounier-Kuhn syndrome: A variable course disease.

Mounier-Kuhn syndrome or tracheobronchomegaly is a rare disease characterized by marked dilation of the trachea and proximal bronchi with recurrent lower tract respiratory infections. Computed tomography and bronchoscopy are the key tools to accomplish the diagnosis. This is a condition with a clinical polymorphism, symptoms vary from minor with preserved respiratory function, to very severe with life threatening exacerbations leading to respiratory failure and premature death. The treatment is mainly symptomatic, stenting or surgery are reserved to extreme cases.Herein, we report two cases of the same condition with different clinical signs and diverse outcome.

Simultaneous bilateral spontaneous pneumothorax as the first manifestation of primary pulmonary MALT lymphoma.

Primary pulmonary lymphoma is a rare entity. Furthermore, simultaneous bilateral spontaneous pneumothorax (SBSP) is a very rare condition which is often related to therapeutic complications. We present, to the best of our knowledge, the first case of primary pulmonary mucosa associated lymphoid tissue (MALT) lymphoma revealed by SBSP. A 50-year-old female was diagnosed with organizing pneumonia. One month later, she presented with sudden chest pain and shortness of breath due to SBSP. Bilateral chest tubes were inserted. A scan- guided right lung biopsy led to the diagnosis of primary pulmonary MALT lymphoma. The patient was treated with R-CHOP chemotherapy. The association between lymphoma and pneumothorax is extremely rare, often related to therapeutic toxicity. We report the case of SBSP as the first manifestation of primary pulmonary MALT lymphoma.

Pleural effusion revealing a ruptured mediastinal mesothelial cyst.

Mesothelial cysts are uncommon benign cysts of the mediastinum. Rarely, they are discovered after complications or unusual presentations. This report describes a rare case of pleural effusion revealing a ruptured mediastinal mesothelial cyst in a 28-year-old man. The diagnosis of this complicated mesothelial cyst relied on intraoperative and anatomopathological findings. He underwent videothoracoscopy with resection of the cyst. Outcomes were favourable.

[Recurrence score to predict the risk of recurrence after first episode of primary spontaneous pneumothorax]. / Score de prédiction de récidive après un premier épisode de pneumothorax spontané primitive.

INTRODUCTION: the relationship between computed tomography (CT) scan findings and the risk of recurrence of primary spontaneous pneumothorax (PSP) is controversial. The purpose of this study is to determine the relationship between the Dystrophy Severity Score (DSS) and PSP recurrence after an initial episode. METHODS: we conducted a retrospective study including patients admitted to the hospital with PSP (first episode) between 2005-2017. The study population was divided into 2 groups, G1: PSP recurrence, G2: No recurrence. We undertook univariate analysis including various variables such as the DSS score followed by multivariate analysis. RESULTS: eighty-six patients were included in this study. Forty-eight percent of cases had PSP recurrence. Although the DSS score was significantly associated with PSP recurrence (p=0.008), multivariate analysis showed that the presence of bubbles on chest CT scan was the independent risk factor associated with PSP recurrence after a first episode (risk report: 3.26, p < 0.008). CONCLUSION: the risk of PSP recurrence is significantly associated with the presence of bubbles on chest CT scan. Further studies are needed for better assessment of the DSS score.

[Asthma and obesity: relationship and therapeutic implications in patients with asthma at the Department of Pneumology in Monastir, Tunisia]. / Asthme et obésité: relation et implications thérapeutiques auprès des patients asthmatiques du Service de Pneumologie de Monastir, Tunisie.

INTRODUCTION: Obesity and asthma are two chronic diseases affecting millions of people around the world. A causal relationship has been suggested. The purpose of our study is to examine the profile in obese people with asthma and to determine the relationship between the different severity parameters in asthma and the degree of obesity. METHODS: We conducted a retrospective, monocentric, analytical study involving 450 asthmatics with a body mass index (BMI) ≥ 30 kg/m2 having follow up visit at less than 6 months. The study was conducted in the Department of Pneumology and Allergology at the Fattouma Bourguiba Hospital in Monastir. RESULTS: The average age at diagnosis was 45±12.8 years. Mean BMI was 34.8±4.2 kg/m2. Asthma was well-controlled in 55.3% of patients. Severity criteria were reported in 37.4% of cases. According to GINA 2016, 24.2% of patients received treatment at step 4. Two asthma phenotypes associated with obesity were reported. The first phenotype (52.4%) was characterized by early-onset asthma associated with a higher incidence of allergic disease and manifestations of atopy. The second phenotype (47.6%) was characterized by late onset asthma, commonly occurring in female sex as well as a higher rate of comorbidities and hospitalizations. Patients with class II and III obesity had significant ventilatory deficiency (CVF: p = 0.002 and FEV1: p = 0.007). CONCLUSION: Obesity is one of the key factors involved in poor asthma control. Its management, which has not yet been codified, should be multidisciplinary.

[Influence of co-morbidities on the progression and prognosis of patients with chronic obstructive pulmonary disease in a Tunisian Hospital]. / Influence des comorbidités sur l'évolution et le pronostic des patients porteurs de broncho-pneumopathie chronique obstructive dans un centre tunisien.

INTRODUCTION: chronic obstructive pulmonary disease (COPD) has been frequently associated with co-morbidities. The purpose of our study is to analyze the impact of co-morbidities on the progression and prognosis of COPD. METHODS: we conducted a retrospective study of patients with COPD hospitalized and/or followed up in the Department of Pneumology at the Fattouma Bourguiba University Hospital in Monastir over the period January 2000-December 2017. The patients were initially divided into two groups, the G0 group (isolated COPD) and the G1 group (with at least one comorbidity). Patients in the G1 group were divided in two subgroups: A group (patients with 1-2 co-morbidities) and B group (≥ 3 comorbidities associated). Different parameters of COPD severity were compared between the different groups. RESULTS: a total of 1152 patients with COPD were enrolled. Seventy-nine percent of patients had at least a chronic disease associated with COPD. The presence of at least one co-morbidity was associated with an increase in the number of severe exacerbations (p = 0.004), in the use of Long-term oxygen therapy (p = 0.006) and with reduced survival (p = 0.001). Similarly, a greater number of co-morbidities (≥ 3 co-morbidities) were associated with more severe systemic inflammation, more frequent use of mechanical ventilation or non-invasive ventilation (p=0.04) and reduced survival (p = 0.05). CONCLUSION: the presence of co-morbidities in patients with COPD is associated with higher severity and poorer prognosis.

Transudative chylothorax in liver cirrhosis; an underappreciated entity.

Chylothorax is a rare pathology with potentially severe consequences. Transudative chylothorax remain an extremely rare entity. Cirrhosis is often an underappreciated cause. We report a case of transudative chylothorax in 62-year-old woman with cirrhosis due to hepatitis C.

Trends and health burden of hospitalized acute respiratory infections and impact of Haemophilus influenza immunization in a Tunisian university hospital: a twelve-year study.

BACKGROUND: We aimed to describe the episodes and trends of admissions for community-acquired Respiratory Infections (RI) over a 12-year period and to assess the impact of Haemophilus influenza type b (Hib) vaccine on RI admissions in children aged up to 3 years. METHODS: We conducted a twelve-year retrospective observational study on all community-acquired RI admitted to Fattouma Bourguiba Hospital in Monastir Governorate (Tunisia) from 1 January 2002 to 31 December 2013. RI cases were selected from the Regional Registry of Hospital Morbidity. Data were coded according to ICD-10. To assess the impact of the Hib vaccine, three cohorts were defined based on vaccine status (unvaccinated cohort, first vaccinated cohort (VC) by monovalent form and second VC by pentavalent combination). RESULTS: Admissions for RI represented 17.6% (CI95%: 17.3-18.1) of all communicable diseases hospitalizations (n = 6 061/34 289). The crude incidence rates (CIR) per 100,000 inh were 24.2 for upper RI (URI) and 77.5 and for Lower RI (LRI) (p < 0.0001). Pneumonias represented 53.9% of LRI. Sex-ratio (male/female) was 1.12 for URI and 1.64 for LRI (p < 0.0001). At admission, the median age was 22 years (IQR: 3-52). Admission for Pneumonia increased significantly during study period (slope 'b' = 5.16; p < 0.0001) especially in children up to 5 years old (slope 'b' = 5.53) and in elderly (slope 'b' = 2.13). Among children up to 3 years old, the CIRs per 100,000 for Hib pneumonia admission were 11.6 in Non-Vaccinated Cohort (NVC), 10.6 in Vaccinated Cohort (VC) by protocol 1 (Hib Vaccine monovalent) and 0.80 in VC by protocol 2 (pentavalent vaccine combination).The relative risk reduction was 99% for protocol 2 (p < 0.001). CONCLUSION: Admissions for RI in a  tertiary level hospital were common with an increasing trend. The Hib immunization program, in particular the pentavalent combination, has had a positive impact on the reduction of related acute diseases.

Thyroid metastasis revealing a lung adenocarcinoma.

Thyroid metastasis revealing a primary lung cancer is an extremely rare condition. Only few cases have been reported in the literature. A multidisciplinary approach is essential for the diagnosis. The prognosis is generally poor. We report a case of a 50-year-old man presented with cervical nodules corresponding to a thyroid nodule and lymph nodes. The ultrasonography-guided fine-needle aspiration cytology of the thyroid nodule and a cervical lymphadenopathy concluded to a poorly differentiated adenocarcinoma. Cervical lymphadenopathy biopsy with immunohistochemistry and additional imaging explorations contributed to the diagnosis of a lung adenocarcinoma stage IVB. He died few days after the diagnosis.

[Survival and prognostic factors of non-small-cell lung cancer among young people in central Tunisia]. / Survie et facteurs pronostiques du cancer bronchique non à petites cellules chez le sujet jeune au centre tunisien.

INTRODUCTION: Non-small cell lung cancer (NSCLC) is a public health problem that usually affects the elderly. Currently and for some years now, this disease is increasingly affecting the young population. The purpose of this study was to analyze the features of NSCLC in young subjects and to assess survival as well as the various prognostic factors. METHODS: We conducted a retrospective study of all patients under the age of 50 years treated in the Department of Pneumology at the Fattouma Bourguiba University Hospital, Monastir for NSCLC. Survival and prognostic factors have been analyzed according to Kaplan Meier method. RESULTS: The average age of patients was 43.8 ± 5.29 years. The most common histological type was lung adenocarcinoma (66.1%). NSCLC was discovered at an advanced or metastatic stage in 79.7% of cases. The median overall survival was 8 ± 0.72 months. Univariate analysis showed that survival was significantly influenced by patients' general status, assessed according to the "Performance Status (PS)" index of the World Health Organization on admission, tumor stage and CRP concentrations. Multivariate analysis was performed, which enabled us to use PS index ≥ 2 and high CRP concentrations as factors of poor prognosis. CONCLUSION: Despite the therapeutic progress, prognosis in young subjects with NSCLC is poor. Early diagnosis and management can improve survival in these patients.

Choroidal metastasis as the initial presentation of lung adenocarcinoma: A case report.

Clinical reports of symptomatic choroidal metastasis as the initial presentation of lung cancer are rare. Here, we report such a presentation in a female patient of non small cell lung cancer. She presented with loss of vision in her left eye. On further analyses, the patient was diagnosed with a lung adenocarcinoma.

Rare case of cavernous hemangioma of the thymus.

Cavernous hemangioma (CH) of the thymus is an extremely rare congenital venous malformation. Related symptoms are non-specific and patients are often asymptomatic. The diagnosis is difficult to make either by non-invasive or mini-invasive procedures. Surgical resection is usually required for diagnosis and treatment. We report a case of a 46-year-old men with an incidental finding of an anterior mediastinal tissue mass on chest computed tomography scan. A complete surgical resection of the mass was performed. Histopathological examination concluded to a thymic CH.

[Bronchial dilatations in patients with chronic obstructive pulmonary disease in a Tunisian center: effect on disease progression and prognosis]. / Dilatations des bronches chez les patients porteurs de bronchopneumopathie chronique obstructive au centre Tunisien: impact sur l'évolution et le pronostic.

INTRODUCTION: bronchial dilations (BDs) seem to have a major role in the natural history of chronic obstructive pulmonary disease (COPD). The purpose of our study was to evaluate the impact of BDs on the severity and progression of COPD as well as on patients' prognosis. METHODS: we conducted a retrospective, single-center, analytical study over the period 1995- 2017. The study was based on data from the medical records of patients with COPD who had undergone chest CT scan during the follow-up period. We compared two groups (G) of patients: G1: COPD with BDs; G2: COPD without BDs. RESULTS: our study included 466 patients with COPD. Among them 101 (21.6%) had BDs associated with COPD. G1 patients had lower maximum expiratory volume in the first second (FEV1) (G1: 1.21 L, G2: 1.37 L, p = 0.015), lower forced vital capacity (FVC) (p = 0.014), a lower PaO2 at steady state (p = 0.049), a higher rate of acute exacerbations (AE) per year (G1: 3.31, G2: 2.44, p = 0.001) and a higher rate of hospitalizations in the Intensive Care Unit per year (p = 0.02). G1 patients with AE receiving treatment in hospital had lower PaO2 3) on admission (G1: 60 mmHg, G2: 63.7 mmHg, p = 0.02 G2: 63.7 mmHg, p = 0.023), more elevated carbon dioxide (CO2) levels (p = 0.001) and were characterized by a higher use of non-invasive ventilation (NIV) (p = 0.044) and invasive mechanical ventilation (p = 0.011). G2 patients had better overall survival (p = 0.002). CONCLUSION: bronchial dilatations are an indicator of poor prognosis in patients with chronic obstructive pulmonary disease, expecially because of the higher rate and severity of exacerbations, airway obstructions and mortality.

Rare case of primary extranodal marginal zone lymphoma of the thorax.

Primary lymphoma presenting a solitary lesion of the chest wall is extremely rare, as the majority of chest-wall tumors arise from metastasis. We report a case of a 64-year-old man with no history of HIV infection or pyothorax who presented with dry cough, right pleuritic pain and dyspnea. A computed tomography scan revealed an irregular pleural mass invading his right chest wall with pleural effusion. CT-guided needle biopsy revealed extranodal marginal zone B-cell lymphoma. The patient was treated with chemotherapy and radiotherapy. The patient has 9 years of follow up with 2 relapse's episodes.