[Profile and management of patients consulting for a non severe exacerbation of chronic obstructive pulmonary disease (Pragma survey)]. / Profil et prise en charge de patients venant consulter pour une exacerbation de bronchopneumopathie chronique obstructive non sévère (enquête Pragma) Etude observationnelle sur 4763 patients.

OBJECTIVES: To evaluate, in patients with chronic obstructive pulmonary disease (COPD), stage 0 or 1, the percentage of patients who had spirometry, and to study their sociodemographic, clinical and epidemiological characteristics. PATIENTS AND METHODS: An epidemiological survey was conducted with 2389 general practitioners concerning 4769 patients with early COPD, consulting for the first time for exacerbation of COPD, presumed to be bacterial. RESULTS: Spirometry under stable conditions was performed in only 30% of patients. When the physician does not have access to this examination to guide antibiotic prescription for an exacerbation presumed to be bacterial, recent guidelines have established a correlation between dyspnoea and the degree of severity of COPD (GOLD classification). This correlation was not confirmed by the present study: 34% of patients with stage 0 or 1 COPD complained of dyspnoea and 52% of patients with stage 2 or 3 COPD did not complain of dyspnoea. The main criterion in favour of a bacterial cause of exacerbation, frank purulent sputum, observed in one out of three patients, did not influence the decision to prescribe antibiotics, given to 98% of patients. Therapy used bronchodilators (73%), even in patients with no signs of obstruction, and inhaled steroids (72%), although, according to guidelines, they are only indicated in the most serious forms (stage 3). This survey illustrates the effort needed to ensure better concordance between guidelines and practice, by taking into account the difficulties encountered by practitioners.

[Routine use of extended-release clarithromycin tablets for short-course treatment of acute exacerbations of non-severe COPD]. / Utilisation de la clarithromycine à libération modifiée en traitement court des exacerbations aiguës d'une BPCO peu grave en pratique médicale courante.

OBJECTIVE: This study was designed to confirm, in routine clinical practice conditions, the success rates and safety of extended-release clarithromycin tablets in patients with acute exacerbation of chronic obstructive pulmonary disease (COPD), according to the usual empirical criteria in routine clinical practice. PATIENTS AND METHODS: An open-label, pharmacoepidemiological, clinical study in community practice was performed with 180 practitioners. The bacterial origin was suspected when sputum was obviously purulent. RESULTS: Seven hundred and nineteen adult patients with acute exacerbation of mild or moderately severe COPD were included. A favorable clinical course of the exacerbation was observed in 92.5% of cases, with resolution of frankly purulent sputum in 99% of cases, associated with good tolerance. CONCLUSION: These results confirm the value of extended-release clarithromycin tablets as first-line treatment for presumed bacterial exacerbation of mild or moderately severe, stable COPD according to the Société de pathologie infectieuse de langue française consensus.

[Oxidatif-stress and COPD. Role of infection. Prevention]. / Stress oxydatif et BPCO. Rôle des infections. Prévention.

For the next decade, COPD will become the third cause of mortality in the world. COPD is mainly due to cigarette smoking and presents different levels of severity according to people, probably linked to environmental and genetic factors, which are not well documented. Recent publications pointed out bacterial bronchial colonization and exacerbations of infectious origin as worsening factors through a pro-inflammatory effect and oxidative stress. This should lead to a comprehensive review of anti-infectious prevention tools and to discuss the role of prophylactic antibiotherapy and antioxidants.

[Link between resistance and failure in community-acquired respiratory infections]. / Liens entre résistance et echec dans les infections respiratoires communautaires.

Resistance is one of failure's reasons. We tried, through clinical experience, to approach the magnitude and nature of the links, between phenotypically defined acquired resistance and clinical failure, in community acquired respiratory infections. An efficient resistance mecanism, able to suppress antibiotic action, is clearely associated to a risk of clinical failure (e.g. betalactamase secretion, target modification using methilation for macrolides, target mutation for fluoroquinoles). Resistance mecanism due to reduction of target affinity (pneumococcus and betalactams) progressively decreasing beta lactam activity depending on its expression, is at present time, not clearely associeted with clinical failure. Critical concentration, defining phenotypical resistance, is predictive of failure if it identifies a bacterial population owning an efficient resistance mecanism. It will not be predictive of failure if that concentration do not detect the resistance mecanism (e.g. parC mutation and levofloxacin) or if the link between antibiotic and resistant bacteria is not binary but depends also on pharmacokinetic parameters (pneumococcus and betalactam). Using resistance as a parametre for antibiotic choice, must integrate several elements: presence or not of a resistance mecanism, type and efficiency of the mecanism, links with clinical failure and antibiotic concentration, type and site of infection. Critical concentration is not allways the magic number that predict failure or success.

[Efficacy and safety of extended-release clarithromycin (5-day short-course) vs telithromycin, in acute bacterial exacerbation of chronic bronchitis]. / Efficacité et tolérance de la clarithromycine, forme à libération modifiée en traitement court de cinq jours dans les exacerbations aiguës de bronchite chronique, comparativement à la télithromycine.

BACKGROUND: The extended-release formulation of clarithromycin (CLA-ER) allows using this macrolide as a single daily dose. The purpose of this study was to evaluate the efficacy and safety of the CLA-ER formulation (500 mgx2) vs telithromycin (TELI) (400 mgx2) as a short course 5-day treatment, once a day, in patients with AECB. METHOD: This randomized double-blind study was conducted in patients with AECB without severe airflow limitation (FEV1>35%), with sputum purulence (mandatory criterion), and with either increased sputum volume or increased dyspnea, or both (Anthonisen criteria I or II). RESULTS: Three hundred sixty-two patients were assessed (62.6 years of age+/-12.9, men: 58.8%) positive culture on inclusion for 53.8%, with Haemophilus influenzae (N=57), Moraxella catarrhalis (N=42), and Streptococcus pneumoniae (N=41). In the per protocol population, the clinical success rate at day 8 was 97% (161/166) vs 97% (146/151), 97.5% CI=[-4.12 -4.71], the clinical cure rate at day 30 was 78% (129/166) versus 77% (116/151), P=0.85, and mean time without recurrence was 62 days versus 61 days (P=0.51), in CLA-ER and TELI groups, respectively. Fourteen patients in the CLA-ER group (8.2%) and 20 patients in the TELI group (12.4%) experienced at least one treatment-related adverse event (P=0.21), upon which gastrointestinal events were the most commonly reported treatment-related ones. CONCLUSION: CLA-ER (1000 mg once a day) for 5 days is at least as effective as telithromycin in the treatment of AECB without severe airflow limitation and is well tolerated.

[Oxidative stress in bronchopulmonary disease: contribution of N-acetylcysteine (NAC)]. / Le stress oxydatif en pathologie broncho-pulmonaire: apport de la N-acétyl-cystéine (NAC).

Oxidative stress is a frequent mechanism involved in the pathogenesis of bronchopulmonary disease. The cause can be exogenous, in particular related to to atmospheric pollution and tobacco smoke, or endogenous, related to mobilization of inflammatory cells (macrophages and polymorphonuclear neutrophils). In this general review, we present work demonstrating this oxidative stress and activation of inflammatory cells. We discuss the effect of oxidative stress on the bronchial tree and the need to maintain an adequate balance between oxidants and anti-oxidants. This reviews focuses on experimental studies proving the anti-oxidant effect of NAC on glutathione synthesis and on different pharmacological models. We then discuss human trials, initially experimental then in different bronchopulmonary pathologies related to oxidative stress. Acetaminophen intoxication and pulmonary fibrosis are models for use of NAC. Recent work on COPD appears to show a decrease in exacerbations, improvement in symptoms and quality-of-life, and perhaps a reduction in the alteration of ventilatory function.

Balloon dilatation and self-expanding metal Wallstent insertion. For management of bronchostenosis following lung transplantation. The Toulouse Lung Transplantation Group.

Here we report our experience on the use of balloon dilatation or self-expandable metal Wallstent implantation, or both, for the management of twelve bronchial stenoses in ten lung transplant recipients during the past two years. Both techniques were carried out endoscopically, under fluoroscopic guidance and without general anesthesia. Both methods were straightforward, well tolerated, and resulted in immediate symptomatic and functional improvement. The first-line treatment relied on Wallstent insertion (n = 4) or on balloon dilatation (n = 8). Early restenosis occurred in four of eight dilated stenoses and subsequently led to Wallstent insertion. Following Wallstent implantation, growth of granulation tissue occurred in one case and necessitated repeated balloon dilatations inside the stent during the following months. On two occasions, the stenosis was located such that the lower end of the Wallstent overlapped the upper lobe bronchus orifice. This necessitated laser therapy to eliminate the filaments of the stent crossing the lobar orifice, preventing subsequent obstruction. Laser therapy was followed, in one case, by a fibroinflammatory stenosis which was successfully treated by balloon dilatation inside the prosthesis. At the time of writing, the mean +/- SE of the follow-up after Wallstent implantation is 15.3 +/- 2.7 (range: 6 to 32) months. Most Wallstent prostheses are overgrown with bronchial epithelium. We conclude (1) that self-expanding metal Wallstent implantation is a safe procedure and good alternative to silicone stent insertion for the treatment of bronchostenosis following lung transplantation, provided granulomas are not present and (2) that balloon dilatation, although possibly leading to recurrences, can be used to allow inflammatory tissue to mature or to dilate restenoses inside the Wallstent.

Amyotrophic lateral sclerosis presenting with sleep hypopnea syndrome.

Described is a 67-year-old man whose initial symptoms evoked an obesity-hypoventilation syndrome. Polysomnography showed hypopneas associated with O2 desaturation episodes, and no apnea; maximal changes were noted during REM sleep. A few months later, in spite of marked weight loss, acute alveolar hypoventilation occurred and necessitated mechanical ventilatory support. Tracheostomy was performed. The patient appeared to be dependent on nocturnal ventilatory assistance. Diaphragmatic paralysis was noted in addition to clinical and electrodiagnostic evidence of amyotrophic lateral sclerosis. While the patient was not ventilated, a nocturnal recording of SaO2 again revealed desaturation episodes partly corrected by O2 2 L/min administered through the tracheostomy tube. With volume-controlled ventilation, desaturations completely disappeared, although no oxygen enrichment of the air was provided. We speculate that sleep disorders with hypopneas and O2 desaturation episodes were the initial symptoms of amyotrophic lateral sclerosis. This leads us to suggest that nonspecific respiratory muscle fatigue frequently seen in COPD might be included in the hypothetic causes of nocturnal hypoxemia.

Gemifloxacin once daily for 7 days compared to amoxicillin/clavulanic acid thrice daily for 10 days for the treatment of community-acquired pneumonia of suspected pneumococcal origin.

CONTEXT: Community-acquired pneumonia (CAP) is common among adults and contributes considerably to morbidity and mortality. OBJECTIVE: To compare the safety and efficacy of gemifloxacin to high-dose amoxicillin/clavulanate for the treatment of CAP of suspected pneumococcal origin. DESIGN: Randomized, multicentre, double-blind, double-dummy, parallel group Phase III study. SETTING AND PARTICIPANTS: From September 1998 to July 1999, 324 patients with CAP were randomized at 102 centers in France, Poland and the Republic of South Africa. INTERVENTION: Patients were double-blind randomized to receive either oral gemifloxacin 320 mg once daily for 7 days or oral amoxicillin/clavulanate 1 g/125 mg three times daily for 10 days. MAIN OUTCOME MEASURES: The main outcome measures were clinical, bacteriological, and radiological responses at the end of therapy (day 12-14) and follow-up (day 24-30) visits. RESULTS: In 228 PP patients, clinical resolution at follow-up was 88.7% for 7-day gemifloxacin and 87.6% for 10-day amoxicillin/clavulanate [95% CI, -7.3, 9.5]. In 249 PP patients, clinical resolution at end of therapy was 95.3% for 7-day gemifloxacin vs. 90.1% for 10-day amoxicillin/clavulanate [95% CI, -1.2, 11.7]. Bacteriologic response rates for the PP patients at end of therapy were 96.3% for 7-day gemifloxacin and 91.8% for the amoxicillin/clavulanate group [95% CI, -4.7, 13.6]. Bacteriologic response rates at follow-up were 87.2% for 7-day gemifloxacin and 89.1% for the amoxicillin/clavulanate group [95% CI, -15.0, 11.2]. Specifically gemifloxacin eradicated 95.7% of Streptococcus pneumoniae including penicillin and macrolide resistant strains. Radiological response rates for the PP patients at end of therapy were 89.1% for 7-day gemifloxacin and 87.6% for the amoxicillin/clavulanate group. The most frequently reported drug-related events were in the gemifloxacin group, diarrhea (6.0%) and rash (3.0%) and in the amoxicillin/clavulanate group, diarrhea (11.1%) and fungal infection, vaginitis and vomiting (each 2.0%). Overall there were statistically fewer withdrawals due to lack of therapeutic effect in the gemifloxacin group compared with the amoxicillin/clavulanate cohort, (95% CI, -8.8;0.6; P = 0.03). CONCLUSION: Gemifloxacin 320 mg once daily for 7 days was found to be clinically, bacteriologically, and radiologically as effective as 10 days of amoxicillin/clavulanate 1 g/125 mg three times daily for the treatment of suspected pneumococcal CAP.

[Should arterial hypertension in sleep apnea syndrome be stressed?]. / Doit-on individualiser l'hypertension artérielle du syndrome d'apnées du sommeil?

The frequent association of sleep apnea syndrome and essential hypertension led to think of sleep apnea as an etiology of hypertension, especially as a good correlation has been found between the severity of both diseases. Moreover, treating the apnea syndrome results in a decrease of blood pressure. The aim of our study is to depict the outlines of a severe hypertensive individual with sleep apnea by comparing 9 men primarily referred to the hypertension clinic with refractory hypertension and finally found to have sleep apnea (study group) to 23 men whose diagnosis of sleep apnea was made in the pulmonary unit (controls). Fifteen of these were hypertensives. Mean age of the study group was 47 +/- 7 years vs 60 +/- 11. Controls were less overweighted: BMI = 33 +/- 6 kg/m3 vs 39 +/- 5. Mean blood pressure was 171 +/- 16/107 +/- 4 mmHg in the study group vs 157 +/- 19/92 +/- 12 mmHg in controls. Prevalence of glucose metabolism disorders was significantly greater in the study group: 6 patients with maturity onset diabetes and 3 with proven glucose intolerance, vs respectively 4 and 6 controls. Triglycerides were elevated in both groups whereas mean cholesterol was slightly above normal values. Six patients of the study group could have an echocardiogram which showed left ventricular hypertrophy (mean left ventricular mass index = 206 +/- 31 g/m2 after the Penn convention).(ABSTRACT TRUNCATED AT 250 WORDS)

[Anaphylactic manifestations during protected sexual intercourse disclosing allergy to latex]. / Manifestations anaphylactiques au cours d'un rapport sexuel protégé révélant une allergie au latex.

Reports of allergy to latex have been increasingly frequent during the last few years. The culprit is the natural Hevea Brasiliensis latex which is present in numerous latex-containing materials for daily use. Clinical manifestations are usually benign. Systemic manifestations have been reported mainly in general anaesthesia. We report a case of severe anaphylactic manifestations that occurred during a condom-protected sexual intercourse. The responsibility of latex for this accident was demonstrated by skin and biological tests.

PIP: Numerous cases of immediate hypersensitivity to latex have been reported since 1979 involving household and surgical gloves, condoms, and sounds, usually with minor cutaneous symptoms; however, severe symptoms have also been reported during general anesthesia. A 34-year-old woman was hospitalized in October 1989 for Quincke's edema an generalized urticaria, accompanied by acute dyspnea, a few minutes after protected sexual intercourse. Clinical examination was normal with respect to respiration; however, an edema of the eyelids and generalized urticaria was found, which was treated with antihistamines and corticotherapy. The notion of a previous anaphylactic shock during an arteriography in August 1989 and contact urticaria of the hands when using surgical gloves was suggested, as she was an assistant pediatric nurse. Allergic tests indicated seasonal rhinitis. Cutaneous tests for pneumallergens according to the technique of Prick indicated polysensitivity to pollens, as papules of 4-4.5 mm size formed. Cutaneous test with a commercial latex extract was positive, producing a papule of 6 mm. Also tests with different latex-based products (surgical gloves, Durex and Trepharm brand condoms) were strongly positive, producing papules of 6.5 mm and 8.5 mm, respectively. The specific IgE (gamma-E globulin) to latex was of class 3 (8.3 PRU/ml). In the majority or cases reported, besides the positivity of skin tests, the specific IgEs were identified in the serum by the technique of RAST. The incriminated product was the latex derivative of Hevea brasiliensis. Therefore, the existence of allergy to latex was responsible for these symptoms of anaphylactic nature.

[Can aminopenicillin be prescribed as monotherapy in case of community-acquired pneumonia?]. / Peut-on prescrire une aminopénicilline en monothérapie en cas de pneumonie communautaire?

In France the current consensus for the treatment of community-acquired pneumonia is based on the French Society for Infectious Diseases 1991 guidelines. In healthy adults without signs of severe disease, oral amoxicillin is recommended at the dose of 3 g per day for 8 to 10 days. This empirical choice is warranted by the prevalence of pneumococcal infections, found as causal agents in half to two-thirds of the bacteriologically proven cases. The 3 g dose is recommended due to the increasing risk of penicillin-resistant S. pneumoniae with MIC > 1 microgram/ml and exceptionally > 2 micrograms/ml. Clinical experience has shown that with a threshold at 2 micrograms/ml, 3 g of amoxicillin is a safe and sure choice. The duration is undoubtedly too long for most patients, but is a prudent measure due to the lack of clinical signs distinguishing between patent infection and its prolongation by inflammatory processes. Indiscriminate prescription of amoxicillin alone is however unacceptable as aminopenicillin is not effective against all microbial agents responsible for community-acquired pneumonia. The risk of selecting resistant strains is very real. Use of a large spectrum antibiotic could be indicated as first line treatment in patients with risk factors (underlying chronic disease, institutionalization, exposure to Gram negatives or S. aureus). For such patients, combination with a beta-lactamase inhibitor (coamoxiclav) or a cephalosporin with a MIC similar to that for penicillin G (cefpodoxime proxetil, cefuroxime axetil) could be recommended. In case of severe disease, Legionella pneumophila must be taken into consideration, implicating adjuction of a macrolide. Wide spectrum fluoroquinolones such as the soon to be available trovafloxacin offer a safe alternative, covering the main microorganisms responsible for community acquired pneumonia. Widespread use would however increase the risk of microbial resistance. In the current epidemiological situation in France, prescription of an aminopenicillin alone for alveolar community-acquired pneumonia in healthy adults remains the gold standard for first line therapy.

[Antibiotics during pregnancy and breast feeding: consequences for the treatment of respiratory infections]. / Antibiotiques au cours de la grossesse et de l'allaitement: conséquences sur le traitement des infections respiratoires.

Respiratory infections are the second most frequent cause for antibiotic prescriptions during pregnancy, after genito-urinary infections. Overall, antibiotics are relatively innocuous. The following should be avoided: the tetracyclines, cotrimoxazole, chloramphenicol, metronidazole and the quinolones. Aminoglycosides should be administered controlling the plasma level. The beta-lactones (principally the penicillins) and the macrolides sold in France, are without any danger. Nevertheless, the rise in distribution volume and the overall physiological changes which accompany the developing pregnancy, particularly in the third trimester lead to a diminution in the serum concentration of these antibiotics and imply an adaptation, often a doubling, of the therapeutic dose administered. From the epidemiological data concerning the organisms involved in the respiratory infections, nearly the totality of extra-hospital infections may be cured by macrolides or penicillins (ampicillin). During more serious infections (nosocomial, or the immuno-depressed) the maternal prognosis should take precedence, adjusting the antibiotic to the organism, before the toxic risk to the child. All the antibiotics are excreted in the mother milk, but in very small quantities; they are generally destroyed in the digestive tract of the child so that the risk of any secondary effect during lactation is minimal.

[Levofloxacin in the treatment of community-acquired pneumococcal pneumonia]. / La lévofloxacine dans le traitement des pneumonies communautaires à pneumocoque.

OBJECTIVES: Levofloxacin is a new fluoroquinolone active against S. pneumoniae. Oral and intravenous administration is available. The aim of this study was to determine its efficacy in community-acquired pneumonia. PATIENTS AND METHODS: Five clinical trials included 1989 patients eligible for analysis. The dosage was 500 mg once or twice a day depending on the studies. Levofloxacin was compared with amoxicillin (3 g/d), amoxicillin/clavulanic acid (1500 mg/d), ceftriaxone (1-4 g/d combined or not with a macrolide and/or relay cefuroxime axetil). RESULTS: In these studies and among the patients eligible for analysis, microbiologically proven S. pneumoniae pneumonia occurred in 170 of the patients treated with levofloxacine and in 140 treated with the comparator. Bacteriemia was evidenced in 51/170 of the levofloxacin-treated patients (30%) and in 45/140 (32%) of the comparator-treated patients. At treatment end, clinical success rate was 93.5% (159/170) for levofloxacin and 90.7% (127/140) for comparators. S. pneumoniae eradication rate was comparable for levofloxacin (94.9%) and comparators (95.3%). In patients with bacteriemia, the clinical success rate was 86.2% (44/51) for levofloxacin and 84.4% (38/45) for comparators. DISCUSSION: These findings establish the efficacy of levofloxcin for the treatment of pneumococcal pneumonia, a major treatment challenge in community-acquired pneumonia. This compound has its place in the context of good use of antibiotics. Levofloxacin should be used in priority for patients with risk factors for complications with rapidly unfavorable course or as second intention treatment when re-evaluating insufficient therapeutic response.

[Cytokines and pulmonary fibroses]. / Cytokines et fibroses pulmonaires.

Pulmonary fibrosis corresponds to an accumulation of collagens and other proteins of the extracellular matrix in the interstitium and alveoli. Biochemical and cellular mechanisms of pulmonary fibrogenesis remain poorly understood. The cells of the alveolitis (macrophages, lymphocytes and neutrophils) play a key role in producing the factors which regulate the proliferation, chemotactism and secretory activity of the fibroblasts. Amongst these factors the cytokines (interleukins, interferons and growth factors) play a definite but very complex role. Certain cytokines stimulate in vitro the attraction and activation of cells of the alveolitis, as well as the multiplication, migration and secretory activity of fibroblasts. The following cytokines are involved: tumour necrosis factor alpha: (TNF alpha), interleukin 1 (IL-1), interleukin 6 (IL-6) interleukin 8 (IL-8) transforming growth factor beta (TGF beta), platelet derived growth factor (PDGF), insulin like growth factor 1 (IGF-1), fibronectin, monocyte chemotactic protein 1: (MCP-1). Other cytokines, principally the interferons (of alpha, beta or gamma type: IFN alpha, IFN beta, IFN gamma) inhibit in vitro and in vivo the proliferation and the production of collagen by fibroblasts. During the course of human pulmonary fibrosis or in experimental situations, the majority of the cytokines mentioned above are produced in excess in the lung. Without doubt they play an important role in the pathogenesis of fibrosis, even if it is not yet very well known how they interact and contribute in vitro to the process of fibrogenesis. Certain cytokines potentially regulating in the fibrosis are yet to be identified. In the future the use of cytokines and of their inhibitors will perhaps provide new therapies in pulmonary fibrosis.

[Pneumonia caused by resistant pneumococci]. / Pneumonies à pneumocoques résistants.

During the last few years, acquired resistance of pneumococci to the main families of normally active antibiotics has appeared. This resistance is now worldwide but unevenly distributed: in Europe, for instance, it predominates in Spain and Hungary. In France, according to the national Registry, resistance to penicillins, which was less than 5 percent in 1988, rose to 16.9 percent in 1991. More than 80 percent of resistant strains are found among 4 stereotypes (6, 9, 19, 23) and more than 50 percent belong to stereotype 23F exclusively. The incidence of penicillin-resistant has been evaluated at 8.5 percent in the year 1991-92. The most significant risk factor is a previous treatment with beta-lactam antibiotics, but some authors also blame frequent pneumonias in the previous year, nosocomial pneumonia, or hospitalization during the previous 3 months. There are no specific clinico-radiological features. The incidence of resistant strains is said to be higher in HIV seropositive subjects. Amoxicillin administered in high doses remains the reference treatment for strains with intermediate susceptibility (minimal inhibitory concentration [MIC] between 0.1 and 1.0 microgram/ml). Strains with a more than 1 microgram/ml MIC require beta-lactam antibiotics such as ceftriaxone, cefotaxime of imipenem in high doses. Pristinamycin still has good in vitro activity on resistant strains. Prevention rests on isolation of infected patients, treatment of healthy carriers and wide prescription of anti-pneumococcus vaccine.

[Influenza and asthma]. / Grippe et asthme.

The relationship between infections of the respiratory tract and exacerbations of pulmonary symptoms in individuals with asthma is well established on clinical grounds. Patients having an acute attack of asthma often give a history of a "cold" before the onset of the exacerbation. The identification rate of viruses during exacerbations of asthma (10-30%) is much higher than the viral identification rate generally found during asymptomatic periods in asthmatics (3%). The mechanisms whereby upper respiratory viruses might induce or contribute to attacks of asthma are currently unknown: epithelial damage, increased cytokines releasability, mouth breathing.... Influenza vaccination is recommended in patients with chronic pulmonary diseases. However, bronchial hyperreactivity has been reported after influenza vaccination in asthmatics. Reactions to these vaccines may be due to non-immunogenic impurities, which are not present in the more recently developed subunit vaccines. In spite of the lack of double-blind studies between subunit and killed influenza virus vaccines, and because of the potential bad prognosis of influenza infection on airway obstruction, influenza vaccination should be recommended in asthmatics with stable respiratory function but influenza vaccination rate remains low.

[Idiopathic subacute pulmonary eosinophilia]. / Pneumopathie éosinophilique subaiguë idiopathique.

We report a case of pneumonia with hypoxaemia and a swinging fever which was resistant to antibiotics, but was associated with a hypereosinophilia (44%) noted in the bronchoalveolar lavage. Investigations as to the cause of the eosinophilic pneumonia were negative; a lung biopsy confirmed the eosinophilic infiltration and the absence of any angiitis. There was a rapid and favourable clinical outcome following steroid therapy, which was maintained for three months. No relapse has been noted in the ten months of follow up since ceasing the cortico-steroids. The diagnosis appears to be that of a sub-acute, idiopathic eosinophilic pneumonia. The similarities and differences between this case and the chronic idiopathic eosinophilic pneumonia of Carrington were discussed.

[A unilateral hyperlucent lung...]. / Un poumon clair unilatéral...

The occurrence in a young patient of a chronic cough with dyspnoea and restrictive ventilatory failure as shown by respiratory function tests suggested the possibility of a Mac Leod syndrome. However, other aetiologies could be considered such as vascular malformations, bronchial malformations and also tumours. If the chest X-ray sometimes enables an aetiological slant, bronchoscopy remains a first line investigation.

[Current aspects of Goodpasture's syndrome]. / Actualité du syndrome de Goodpasture.

Goodpasture's syndrome is an auto-immune disorder with antibodies directed against alveolar and glomerular basement membrane. These antibodies are usually present in the serum but their detection is difficult, requiring a radio-immunological technique which remains uncommon. The fixed antibodies are detected more easily and more constantly in the kidney tissue than in the lung; they appear on a kidney biopsy in the form of linear deposits of immunoglobulins on the basement membrane. Thus, the renal biopsy appears to be the essential requirement to establish a diagnosis of Goodpasture's syndrome, and one should not hesitate to perform a biopsy in the presence of diffuse alveolar haemorrhage without an evident aetiology and even in the absence of any biological evidence of renal disease. Alveolar lavage may be used to confirm a haemorrhage which has been purely alveolar. The treatment for respiratory and renal recovery, using immunological therapy includes corticosteroids, cytotoxic drugs and plasmapheresis. The exact methods are not yet fully defined during the course on certain clinical forms of the disease: for oliguric patients, dialysis is the single treatment; the isolated pulmonary forms have often been treated and improved by corticotherapy alone. The responsible antigen, probably unique, has been recently been identified as collagen type IV of the glomerular basement membrane. The pathogenesis of Goodpasture's syndrome remains unknown. The inhalation of hydrocarbons has been frequently noted. The dismal prognosis in the natural history of the disease and the therapeutic possibilities available make diagnosis an urgency. Currently, renal biopsy represents the most reliable and rapid mean of diagnosis.