[Diagnostic and therapeutic management of operable bronchopulmonary carcinoid tumours]. / Prise en charge diagnostique et thérapeutique des tumeurs carcinoïdes broncho-pulmonaires opérables.

INTRODUCTION: Bronchial carcinoid tumours (CT), divided into typical carcinoid (TC) or atypical carcinoid (AC), are rare tumours whose therapeutic management remains unspecified. METHODS: Retrospective study collecting cases of bronchial CT operated at the thoracic surgery department of Abderrahmane-Mami hospital of Ariana and recruited from the pneumology departments of Northern Tunisia, during a 12-year period. RESULTS: Ninety patients were collected (74 cases of TC and 16 cases of AC). The mean age was 45 years and the sex ratio H/F=0.5. The chest X-ray was normal in 11 cases, as well as flexible bronchoscopy in seven cases. The tumour was classified: stage IA (10 cases), IIA (28 cases), IIB (31 cases), IIIA (15 cases) and IIIB (six cases). Surgery resulted in a complete resection in 78 patients, an extensive resection in six patients, and a conservative resection in six patients. Adjuvant chemotherapy was given in 10 patients. The survival was 84% at five years and 42% at 10 years. CONCLUSION: The prognosis of CT depends directly on the histological subtype. It is excellent for TC after complete resection, unlike ACs that are similar to well-differentiated bronchial carcinomas.

[White hemithorax in a young women carrying coffee and milk spots]. / Un hémithorax blanc chez une jeune portant des tâches café au lait.

INTRODUCTION: Neurofibromatosis type 1 (NF1) or Von Recklinghausen disease is an autosomal dominant genetic disorder with multivisceral manifestations. We report the case of a spontaneous haemothorax in a young lady wearing this genetic pathology. CASE REPORT: A 31-year-old woman with kyphoscoliosis developed acute chest pain and dyspnea. The physical examination revealed a right pleuritic syndrome, coffee and milk spots and neurofibromas of the trunk. Biological assessment showed anemia at 6.4g/dl. Chest x-ray revealed a right side opacification. The pleural puncture showed an incoagulable hemorrhagic fluid. The chest CT scan showed no vascular abnormalities. The diagnosis of spontaneous haemothorax, revealing NF1, was retained. Transfusion and thoracic drainage were performed followed by haemostasis surgery. Pleural exploration showed pleural hematoma with regard to the 5th intercostal space. Electrocoagulation and declogging were performed. The evolution of the patient was favorable. CONCLUSION: Haemothorax is a rare and serious complication which may reveal NF1. It must be suspected when sudden and spontaneous white haemithorax occurs in NF1.

[Tuberculous pneumothorax: Diagnosis and treatment]. / Pneumothorax tuberculeux : prise en charge diagnostique et thérapeutique.

BACKGROUND: Pneumothorax is a serious complication of cavitary pulmonary tuberculosis. The aim of this study was to describe clinical futures, to highlight challenges of its management. METHODS: A retrospective multicentric and descriptive study including 65 patients treated for PT (1999-2015) was conducted to figure out clinical futures and its work-up. RESULTS: The mean age was 37.8 years. The sex ratio was 3.6. Smoking history and incarceration were noted respectively in 67.6 and 15.3% of cases. Acute respiratory failure and cachexia were reported in 26.1 and 10.7% of cases. The PT was inaugural in 41.5% of cases. Pyo-pneumothorax was noted in 69.2% of cases. The duration of antituberculous treatment ranged from 6 to 15 months for susceptible TB and was at least 12 months for resistant TB (4 cases). Thoracic drainage was performed in 90.7% patients. Its average length was 47 days. The drain drop was noted in 20% of cases. Bronchopleural fistula was diagnosed in 6 cases and pleural infection in 5 of cases. Surgery treatment was necessary in 6 cases. Mean time to surgery was 171 days. Six patients had pleural decortication associated with pulmonary resection in 4 cases. Persistent chronic PT was noted in 12.6% and chronic respiratory failure in 3% of cases and death in 15.3% of cases. CONCLUSION: The diagnosis of the PT is often easy. Its treatment encounters multiples difficulties. Duration of thoracic drainage and anti-TB treatment are usually long. Surgery is proposed lately.

Pulmonary tuberculosis: Diagnostic delay in Tunisia.

OBJECTIVE: Early diagnosis and prompt effective therapy are crucial to fight against tuberculosis (TB), particularly in regions with a high prevalence. We aimed to evaluate TB diagnostic delays and identify the associated risk factors. METHODS: We conducted a survey in various health facilities in Tunisia between March 24th and October 30th, 2014. We included all patients aged ≥ 18 years who presented with pulmonary TB (PTB) and who had been initiated on an anti-TB treatment. We evaluated the time between respiratory symptom onset and treatment initiation. Treatment delays were divided into three categories: delays due to the patient, to the healthcare system, and overall delays. RESULTS: We included 352 patients in the study (242 men and 110 women). The mean age was 42.2 years±17.7. The median time from symptom onset to treatment initiation was 52.56 days. Patient delays were longer for men, for patients presenting with alcohol dependence, and for patients who already knew they were sick. Healthcare system delays were associated with older age, female patients, patients consulting a private physician, and outpatients. CONCLUSION: TB symptoms should be better explained to the population and healthcare professionals should be better trained to both reduce such delays and initiate treatment as early as possible.

[New methods of diagnosis in tuberculosis]. / Nouvelles méthodes de diagnostic de la tuberculose.

Bacteriological diagnosis of tuberculosis has benefited in recent years from many technological advances to improve rapidity and sensitivity of the techniques. Thus, new LED fluorescence microscopes are in the process of replacing the optical microscopes and the Ziehl-Neelsen technique, making the examination more precise, faster and easier. The manual and automatic liquid culture has improved Lowenstein-Jensen culture and helped shorten antibiotic sensitivity test, allowing appropriate management of patients. The development and standardization of molecular biology methods led to the rapid detection and identification of mycobacterium directly in clinical samples but also of resistance genes for early diagnosis of MDR-TB and dealing with them quickly. However, the performance of these techniques does not sufficiently cover the diagnosis of smear-negative tuberculosis, extrapulmonary forms, children- and immune-compromised tuberculosis where sensitivity is limited. The diagnosis of latent tuberculosis is reinforced by the in vitro release testing of gamma interferon overcoming the lack of specificity of the tuberculin skin test. Despite considerable progress, more amelioration is still needed to improve these techniques in order to extend them to the paucibacillary tuberculosis and to facilitate their access to low-resource countries.

[Management of multidrug-resistant tuberculosis]. / Prise en charge de la tuberculose multirésistante.

The emergence of drug-resistant TB in many countries has become a major public health problem and an obstacle to effective tuberculosis control. Multidrug-resistant tuberculosis (MDR-TB), which is most often the result of poor adherence, is a particularly dangerous form of tuberculosis because it is caused by bacilli resistant to at least isoniazid and rifampicin, the two most effective anti-tuberculosis drugs. Techniques for rapid diagnosis of resistance have greatly improved the care of patients by allowing early treatment which remains complex and costly establishment, and requires skills and resources. The treatment is not standardized but it includes in all cases attack phase with five drugs (there must be an injectable agent and a fluoroquinolone that form the basis of the regimen) for eight months and a maintenance phase (without injectable agent) with a total duration of 20 months on average. Surgery may be beneficial as long as the lesions are localized and the patient has a good cardiorespiratory function. Evolution of MDR-TB treated is less favorable than tuberculosis with germ sensitive. The cure rate varies from 60 to 75% for MDR-TB, and drops to 30 to 40% for XDR-TB. Mortality remains high, ranging from 20 to 40% even up to 70-90% in people co-infected with HIV.

[Case report of pulmonary biphasic tumor with unusual follow-up]. / À propos d'une tumeur biphasique du poumon d'évolution inhabituelle.

BACKGROUND: Pulmonary blastoma, a rare primary lung malignancy is subdivided in 3 categories: well-differentiated fetal adenocarcinoma (WDFA), classic biphasic pulmonary blastoma (CBPB) and pleuropulmonary blastoma (PPB). Classic pulmonary blastoma is composed of a mixture of immature epithelial and mesenchymal tissue resembling fetal lung tissue. CASE REPORT: We described a case of a 48-year-old male, cigarette smoker, who presented with left thoracic pain and hemoptysis for 2 months. Chest radiography showed a well-delimited, homogeneous 4cm mass in the left lung periphery. Bronchoscopic examination revealed left endobronchial bleeding. Computed tomography of the chest revealed a tumor shadow measuring 7cm in the left upper lobe and bilateral nodules with no lymphadenopathy. A systemic evaluation demonstrated no metastatic lesion. Patient underwent a left upper lobectomy. The diagnosis of CBPB was affirmed on anatomopathology of the tumor resection. Immunohistochemical studies showed that tumor cells were positive for vimentin, desmin, actin, Pan Cytokeratin and TTF-1. The final diagnosis was BPB classified as pathological T3N0M0 and no adjuvant treatment was associated. The patient showed good objective response with no evidence of disease recurrence still in 5 years surgery resection. CONCLUSION: This case reiterates the importance of pathomorphological or immunohistochemical features in diagnosis of BPB.

[Management of spontaneous pneumomediastinum in the adult: 14 cases and a review of the literature]. / Prise en charge du pneumomédiastin spontané chez l'adulte: à propos de 14 cas avec revue de la littérature.

The authors report a series of 14 patients hospitalized for spontaneous pneumomediastinium between 1992 and 2006. They included 10 men and four women with an average age of 27.84 years. Dyspnoea dominated the symptoms. The pneumomediastinum was idiopathic in five patients and secondary in the other nine patients, involving an attack of severe asthma in half of the patients, polymyositis in one patient and idiopathic pulmonary fibrosis in one patient, respectively. The patients presenting polymyositis and pulmonary fibrosis died due to respiratory distress. The other patients benefited from asthma treatment or thoracic drainage, and were kept at rest. Their outcome was good. No cases of relapse were observed after an average follow up of 2.11 years.

[Hydatid cyst of the chest wall mimicking metastatic colon cancer]. / Kyste hydatique de la paroi thoracique mimant une métastase de cancer colique.

Chest wall hydatidosis, rare even in the endemic countries, represents 0.09 to 0.3 % of all cases of thoracic echinococcosis. The authors report the case of a 76 year-old man presenting a chest wall mass 4 years after surgery for colic carcinoma. The mass presented both hypoechoic and hyperechoic structures in the ultrasound chest echography. Therefore, metastastic colon cancer was suspected. The pathological study of the mass revealed hydatid membranes. Thoracic tomodensitometry supported the diagnosis of costovertebral and soft tissue hydatid cysts. The patient underwent the surgical resection of two rib arches, a transverse apophysis and the neighbouring soft tissue associated with pre- and post-surgical albendazole. No clinical manifestations were noted in the follow-up after 1 year.

[Congenital cystic adenomatoid malformation of the lung. Report of 3 cases with late presentation]. / Malformation adénomatoïde kystique congénitale du poumon: à propos de trois cas de révélation tardive.

Congenital cystic adenomatoid malformation (CCAM) of the lung is a rare congenital developmental abnormality, representing about 25% of all congenital lung lesions. In many cases, respiratory distress occurs during the neonatal period, and in about 80- 85% of patients, CCAM is diagnosed before the age of two years due to respiratory infection. It is very rare that presentation is delayed until adulthood. We report three cases of CCAM presenting in adults. The diagnosis was based on clinical and radiological findings in one case and two patients were not diagnosed until surgery. The lesion was present in the right lung in two and in left lung in one patient. All patients underwent surgical resection. The result of histopathological examination confirmed CCAM Stocker type 1, without malignancy. The post operative follow up showed an excellent recovery. Clinicians and pathologists need to be aware of the fact that CCAM can be present for the first time in adolescents or in adults. The clinical diagnosis is suggested by radiographic findings and is confirmed at pathology as surgery is generally indicated.

[Acute respiratory failure as the sol inaugural sign of Arnold-Chiari malformation. Two cases]. / Insuffisance respiratoire aiguë isolée révélant une malformation d'Arnold-Chiari.

Arnold-Chiari malformation is an occipitocervical malformation where the cerebellar amygdales descend below the occipital foramen. Acute respiratory failure is an exceptional inaugural sign. We report two cases disclosed by alveolar hypoventilation associated with type I Arnold-Chiari malformation. The two patients age 51 and 52 years had an uneventful past history and presented with hypercapnic encephalopathy with acute respiratory failure requiring ventilatory assistance. Respiratory function tests, helicoidal thoracic computed tomographic angiography, electromyogram, cardiac echography, and thyroid and immunological tests were normal. Blood gases and polysomnography were in favor of central hypoventilation without sleep apnea. Magnetic resonance imaging demonstrated type I Arnold-Chiari malformation. The course was complicated by recurrent respiratory failure in both patients. Surgical decompression performed for the first patient provided no improvement. This patient died two months after surgery subsequent to aspiration pneumonia. The second patient was treated with continuous positive pressure noninvasive ventilatory assistance and had a good outcome at 25 months. These two cases illustrate the absence of any neurological sign, acute respiratory failure being the only sign of Arnold-Chiari malformation.

[Bronchoesophageal fistula with late revelation]. / A propos d'une fistule broncho-oesophagienne de révélation tardive.

Bronchoesophageal fistula is an uncommon clinical problem which can either occur as a congenital or acquired condition. A 40-year-old male had productive cough with production of sputum mixed with food particles and cough when eating and drinking. There was no weight loss nor weakness. Clinical examination led to the diagnosis of a fistula between the lower esophagus and the Nelson bronchus associated with bronchiectasis. The congenital nature of this fistula was suggested by the clinical, operative and pathology findings. Postoperative recover was uneventful. Esophageal respiratory tract fistula presenting in adult life are rare and can cause severe debilitation and suppurating lung disease. Surgical treatment provides complete resolution of the symptoms. Endoscopic obliteration can be considered as an alternative to surgery.