[Tuberculous pyothorax. 28 cases]. / Le pyothorax tuberculeux. 28 cas.

OBJECTIVES: Despite the efforts in the fight against tuberculosis (Tb) and the decrease in its incidence, severe forms persist. Tubercular pyothorax (TP), which was a frequent complication, is still difficult to treat. We studied the epidemiological, diagnostic, therapeutic and progressive aspects of this particular localization. METHODS: Retrospective study collecting all the TP reported between 1990 and 1999 in the department of pneumology in Ariana. The inclusion criterion was any patient presenting with pleural-parietal empyema of tubercular origin. We excluded patients presenting with negative bacilliferous pyothorax cultures. RESULTS: Twenty-eight cases of TP were retained among 875 cases of tuberculosis, i.e., 3.2%. The mean age of patients was of 44 years (range: 15-75) and they were moderate smokers: 27 PA. Infectious fever concomitant to a pleural syndrome was the typical clinical manifestation. In some patients empyema (3 cases) or cutaneous fistula (2 cases) were the circumstances in which the disease was discovered. Thoracic imaging is a very useful tool: standard radiography, tomodensitometry and magnetic resonance imaging permit analysis of the pleural wall and cavity. In 9 cases, pneumothorax was concomitant. A co-infection with pyogenic germs was present in 4 patients. Treatment of TP is triple; it associates specific poly-chemotherapy, thoracic draining and respiratory physiotherapy. The progression was satisfactory in the recent forms concomitant to a bacilliferous pulmonary Tb. Complications such as pleural-pulmonary after effects are inherent to the severe forms. Surgery was necessary for 9 patients (5 drainages, 2 rib resections and 2 decortications). CONCLUSION: TP is a menace for functional prognosis. Treatment is double: early, curative and effective, and preventive of Tb and its risk factors.

[Primary malignant melanoma of the trachea. Apropos of a case]. / Mélanome malin primitif de la trachée. A propos d'une observation.

Primary malignant melanoma of the lower airways is very rare. 24 cases have been collected over the past century. Our case was a patient of 52 years of age who had been discovered to have a tracheal tumour which was found to be a malignant melanoma and was treated with a Laser. The major problem is to establish that the tumour is primary. The combination of clinical evidence, paraclinical, subsequent outcome and in certain cases the autopsy enables the diagnosis of a primary tumour to be retained without having absolute certainty because a cutaneous melanoma can disappear after having metastasised.

[Eosinophilic pleural effusion]. / Apport diagnostique de l'éosinophilie pleurale.

Eosinophilic pleural effusion accounts for 5 to 10% of all clear liquid pleurisies. Its pathogenic significance is unclear and its relation to the causative diagnosis of pleural eosinophilia is diversely evaluated. In this study, 86 cases of eosinophilic pleural effusion observed at the Ariana Pneumophthisiology Hospital over a 5-year period are reviewed. At first aspiration, the proportion of pleural fluid eosinophils varied from 12% to 85% (54% on average). Blood eosinophilia was present in 60% of the patients. The main cause of effusion was tuberculosis (39.6%, but many other diseases were observed; despite numerous investigations, no cause could be found in 23.2% of the cases. The discovery of a pleural eosinophilia has an impact on the probable cause of the pleurisy, and this can be determined by applying Bayes' rule. The probability of tuberculous being the cause falls from 70.3% for clear liquid pleurisies generally to 44.6% for eosinophilic pleurisy. The probability of cancer as a cause falls from 4.5% to 0.66%; whereas that of "idiopathic" pleurisy rises from 13.5% to 59.56%. These findings are concordant with Adelman's conclusions. In other words, the finding of a pleural eosinophilia decreases the probability of tuberculous or malignant pleural effusion and increases the probability of benign or "idiopathic" effusion. Clinicians confronted with an eosinophilic pleural effusion should be particularly careful and accurate since this diagnosis may spare the patient an unnecessary exploratory thoracotomy and an unwarranted antituberculous treatment.

[Pneumomediastinum in dermatopolymyositis]. / Pneumomédiastin au cours d'une dermatopolymyosite.

The authors report the occurrence of a pneumomediastinum occurring in a young female aged 25 who had already been under treatment for 3 years for dermatomyositis and who had a pulmonary involvement with fibrosis. This association did not seem fortuitous. The pneumomediastinum would be due to a cystic degeneration of the fibrosis producing "pseudoblebs".