[Symptoms and natural history of hospital chronic obstructive pulmonary disease]. / Symptômes et histoire naturelle de la broncho-pneumopathie chronique obstructive en milieu hospitalier.

BACKGROUND: Since few years, the data describing the chronic obstructive pulmonary disease (COPD) have changed and new concepts have emerged. AIM: To study the clinical characteristics and outcome of patients with COPD in a Tunisian population. METHODS: It is a retrospective study including 150 patients with COPD admitted at the pulmonary department of Charles Nicolle Hospital in Tunis, during a period of ten years. RESULTS: Data from 150 patients hospitalized at the pulmonary department of Charles Nicolle Hospital in Tunis, were analyzed. They were 126 men and 24 women with a mean age of 67 years. Tobacco was the predominant risk factor. Eighty-two (55%) patients were classified GOLD stage IV at diagnosis. The number of exacerbation varied from 1 to 7 with an average higher in patients classified as stage IV (p = 0.007). CONCLUSION: The COPD is pathology of smoking men. Comorbidities and exacerbations prevalence increase according the disease severity. In fact, better knowledge of exacerbations etiologies allows considering better measurement of prevention.

[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.

[Spirometric profile of narghile smokers]. / Profil spirométrique des fumeurs de narguilé

INTRODUCTION: Studies of the spirometric profile of narghile smokers are few, have some methodologic limits (ie. small sample size) and present contradictory conclusions. OBJECTIVE: (i) To determine the percentage of smokers having an obstructive ventilatory defect (OVD) and/or a restrictive ventilatory defect (RVD) or static hyperinflation (SHI). (ii) To compare the chronological and the estimated lung ages. INCLUSION CRITERIA: men aged 20-60 years smoking narghile (>1 narghile-year (NA). Non-inclusion criteria: cigar or cigarettes smoker and co-morbidity. Narghile consummation quantification: NA and kg of cumulated tobacco (1 NA=9.125 kg of cumulated tobacco). DEFINITIONS: large airway OVD: FEV1/FVCLLN and forced mid expiratory flowupper limit of normal. Spirometric measures (Vmax 22 Series/6200 Autobox, Yorba Linda, California, USA with measurement of functional residual capacity by nitrogen washout). Measurements were made according to international recommendations. RESULTS: 110 narghile smokers were included (34+/-10Yr; 1.76+/-0.07m; 84+/-14kg). 36% of subjects had SHI; 14% had small airway OVD; 14% had RVD and 6% had large airway OVD. (ii) Estimated lung age was higher than the chronological lung age (47+/-18Yr vs 34+/-10Yr, p<0.05). CONCLUSION: Narghile consumption accelerates ageing of the lung. This study provides the health authorities with valid arguments to fight this blight on society which increasingly involves children and pregnant women.

Assessment of EGFR mutation status in Tunisian patients with pulmonary adenocarcinoma.

BACKGROUND: Despite recent advances, non-small cell lung cancer carries a grim prognosis. For appropriate treatment selection, the updated guidelines recommend broad molecular profiling for all patients with pulmonary adenocarcinoma. Precise histological subtyping and targeted epidermal growth factor receptor (EGFR) and anaplastic lymphoma kinase (ALK) testing are mandatory. METHODS: Herein, we assessed the EGFR mutation status of 26 formalin fixed-paraffin embedded (FFPE) samples of lung adenocarcinoma. Mutational analysis concerned exons 18-21 of EGFR by real-time polymerase chain reaction (Real time-PCR) using the Therascreen EGFR RGQ PCR mutation kit. ALK status was established on 22 among 26 patients using D5F3 antibody with a fully automated Ventana CDx technique. RESULTS: Activating EGFR mutations were found in 3 men among 26 patients (11.5%). Positive ALK expression was found in 2 cases among 22 patients (9.09%). CONCLUSION: Frequency of EGFR mutations in pulmonary adenocarcinomas of our series is similar to that found in the European ones with some particularities. The mutations detected are uncommon. Whereas, we found a high frequency of positive ALK expression in our series compared to frequency reported in literature. Further studies with larger Tunisian series are required to obtain more conclusive results.

[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.

[Acute rhabdomyolysis during pneumococcal pneumonia: two cases]. / Rhabdomyolyse aiguë au cours des pneumonies à pneumocoque. A propos de deux observations.

Acute rhabdomyolysis is a clinical and biological syndrome generally with a toxic or traumatic cause. Only 5% of cases are infectious, and rarely in relation to a pneumococcal infection. We report two cases of acute rhabdomyolysis which developed in patients with severe Streptococcus pneumoniae pneumonia. No other cause could be identified in these two patients aged 32 and 37 years. Rhabdomyolysis was discovered in the first patient because of acute kidney failure and elevated serum transaminase levels. The second patient presented an inflammatory edema affecting the soft tissues. Blood cultures isolated a pneumococcus in both patients. The rhabdomyolysis regressed favorably in both patients despite the transient renal failure in the first patient. Prognosis is generally poor for rhabdomyolysis during the course of pneumococcal pneumonia, with increased morbidity and mortality for these infections. Early detection of bacteriemia enables rapid and adequate treatment and prevention of renal failure.

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.

[Venous thromboembolism in patients with acute tuberculosis]. / Maladie veineuse thromboembolique au cours de la tuberculose.

BACKGROUND: Studies have demonstrated a link between tuberculosis and hypercoagulable state, with reported rates of 0,6%-10% venous thromboembolism (VTE) in all adults with tuberculosis. The present study aimed to evaluate the current incidence and characteristics of VTE in a large sample of patients with acute tuberculosis. METHODS: We report a retrospective study about 26 patients who have confirmed tuberculosis complicated with VTE disease. RESULTS: Sixteen men and ten women were brought together. The mean age was 42.58 years. The thromboembolic complication revealed tuberculosis among 5 patients, appearing during hospitalization of 21 patients among which 16 of them receiving antituberculosis drug. We have listed 10 cases of immediate pulmonary thromboembolism and 16 cases of deep vein thrombosis complicated with pulmonary embolism in 6 cases. Oral anticoagulation drug were associated with heparin after a mean of 4.57 days. Duration average of achievement of an effective dose was of 21.05 days and we prescribe low molecular weight heparin for 6 months on 2 cases. There was favorable evolution among 14 patients, 4 of them have lost sight and the evolution was fatal by cataclysmic haemoptysis in one case, a patient died hepatocellular insufficiency and 6 died by pulmonary embolism. CONCLUSION: Immunological and hematological abnormalities are incriminated in the genesis of VTE disease during tuberculosis by creating hypercoagulate state. The accumulation of morbidity of these two affections as well as the difficulty of therapeutic care made by medical interaction ifampicin-anticoagulants aggravate the prognostic.

Recurrent iliac hydatidosis: A case report.

INTRODUCTION: Hydatid cysts may occur in any area of the body, but they usually localize to the liver and the lungs. Primary localization in bone is not common. PRESENTATION OF CASE: The authors report the case of multifocal hydatid disease appeared 3 years after the surgical treatment of a cyst of the hip. The patient presented with cough and chest pain of 2 months duration. Only the lung localization was symptomatic. The thoracic echography, the abdominal and chest scan allowed the diagnosis. DISCUSSION: Hydatid recurrence remain frequent, whatever is the nature of the treatment, surgical or chemical. CONCLUSION: The premature detection of recurrence is of great importance.

[Treatment of tuberculosis]. / Traitement de la tuberculose.

The aim of this article is to give practicing physicians a practical approach to the treatment of latent and active tuberculosis. Most patients follow TB standard treatment recommended by WHO that depend on category of patient. It is a combination of four essential tuberculosis drugs of the first group: isoniazid, rifampicin, pyrazinamid and ethambutol; in some cases streptomycin can replace ethambutol. This initial phase of intensive treatment is followed by a consolidation phase. Drugs should be administered in the morning on an empty stomach one hour before meals. Treatment of latent tuberculosis (TB) infection is an important component of TB control programs. Preventive treatment can reduce the risk of developing active TB.

[Smoking cessation program in Tunisia: experience of a respiratory service]. / Aide au sevrage tabagique en Tunisie: expérience d'un service de pneumologie.

A tobacco cessation programme was recently introduced into medical practice in Tunisia. The medical staff in the pulmonary disease ward at Charles Nicolle Hospital, Tunis, has been the first to implement such a programme for people motivated to quit smoking. This programme has been run for 3 years in the respiratory disease out-patient department. It acts essentially against psychological and pharmacological dependence on tobacco. The results obtained were very encouraging: 298 smokers have participated in this programme. The global success rate at 12 months of tobacco withdrawal was about 25% for people who were followed up, and 17% for the whole sample. Medical help for smoking cessation should be more widely promoted in Tunisia to increase the number of smokers who consult and improve the quality of medical intervention.

[Smoking dependence and symptoms of anxiety and depression among Tunisian smokers]. / Dépendance tabagique et troubles anxio-dépressifs chez le fumeur tunisien.

INTRODUCTION: The aim of this study was to describe the incidence of depression and anxiety, and their relationship with smoking dependence, in patients attending a Tunisian smoking cessation clinic. METHODS: We studied 72 Tunisian smokers attending the smoking-cessation clinic at the Charle Nicolle Hospital in Tunis. Nicotine dependence was assessed by the Fageström Test for Nicotine Dependence. Anxiety and depression symptoms were measured using the HAD (Hospital Anxiety Depression) Scale. RESULTS: The prevalence of anxiety and depression was 22.9% (16 patients) and 20% (14 patients) respectively with four patients (7.1%) exhibiting symptoms of both. Overall, 50% of the group had emotional morbidity with high HAD scores for depression or anxiety, or both. Smokers with symptoms of anxiety and/or depression had higher physical and psychological dependence, smoked more at times of stress, had a reduced quitting rate and endured more withdrawal symptoms than those smokers without anxiety or depression. CONCLUSIONS: The data of this survey from Tunisia, a country that has just put in place a tobacco control strategy, underline the high rates of anxiety and depression that exist in patients attending a smoking cessation clinic. It confirms the association between anxio-depressive disorders and a high level of smoking dependence.

[Chylothorax caused by thrombosis of the superior vena cava in Behçet's disease]. / Chylothorax par thrombose de la veine cave supérieure au cours d'une maladie de Behçet.

The occurrence of chylothorax due to thrombosis of the subclavicular venous drainage is reported. This occurred in a young adult with previously undiagnosed Behçet's disease which had been developing over three years. Venous thromboses during the course of Behçet's disease are extremely frequent and are currently one of the diagnostic criteria. When these thromboses involve the central veins, in particularly the superior vena cava or one of its branches a chylothorax is possible due to blockage of the lymphatic circulation and may be a grave complication, given its location.

[Reexpansion pulmonary edema]. / Oedèmes pulmonaires à vacuo.

Reexpansion pulmonary edema is an uncommon complication which sometimes occurs after evacuation of a large amount of air or fluid from the pleural space. We report two cases that illustrate the diversity of the clinical expression, severe in one case and latent in the other. The pathophysiology of reexpansion pulmonary edema remains obscure. Increased pulmonary capillary permeability, favored by previous atelectatic parenchyma and rapid reexpansion appears to be the main cause. Treatment is basically preventive. Curative treatment is based on adequate oxygenation and circulation. Lower aspiration pressure and oxygenation were sufficient in our patients. Severe clinical prognosis has been reported in the literature with a 15 to 20% mortality despite use of mechanical ventilation in particularly serious situations.

[Broncho-pulmonary cancer associated with pulmonary tuberculosis. Report of 4 cases]. / Association cancer broncho-pulmonaire et tuberculose pulmonaire. A propos de 4 cas.

The association between bronchopulmonary carcinoma and pulmonary tuberculosis would not be fortuitous but related to increased susceptibility to opportunistic infections and tuberculosis in cancer patients. We present four cases demonstrating the gravity of the situation and the difficulties encountered in diagnosis and treatment. Diagnosis of tuberculosis in patients with bronchopulmonary carcinoma requires pathological evidence from histology biopsies or bacteriology samples. The diagnosis is further complicated in early stage neoplasms. In case of tuberculosis, surgical treatment of bronchopulmonary carcinoma may have to be postponed or even contraindicated. Inversely, chemotherapy and radiotherapy may favor extension of the tuberculosis.

[Bilateral pleural thickening]. / Épaississement pleural bilatéral de la plèvre.

The authors report the case of a 20-year-old man in whom pulmonary and bone tuberculosis presented as bilateral pleural thickening without effusion.

[Lung mycosis in non neuropenic patients]. / Infections pulmonaires mycosiques chez des patients non neutropéniques.

UNLABELLED: Lung mycosis is rare. Diagnosis and treatment must be done the earliest possible. METHODS: It is about a retrospective study on clinical records including patients hospitalized for lung infection. RESULTS: From 2008 to 2011, 16 patients (13 men and three women, average age 42 years) developed a pulmonary infection. Twelve of our patients had respiratory or extrarespiratory histories. None of our patients had a neutropenia. The diagnoses were lung aspergilloma in four cases, invasive lung aspergillosis in three cases, allergic bronchopulmonary aspergillosis in three cases, mucormycosis in three cases, trichosporonosis in a case, actinomycosis in one case and penicilliosis in one case. An antifungal treatment consisting in amphotericin B or itraconazole was given to four patients and six patients, respectively. Surgery was chosen for six patients. The evolution was good for 12 patients, one presented renal failure, and three patients died.