Magnetic resonance imaging for abnormally invasive placenta: the added value of intravenous gadolinium injection.

OBJECTIVES: To assess the added value of intravenous gadolinium injection to magnetic resonance imaging (MRI) -based diagnosis of abnormally invasive placenta (AIP) and to examine this in relation to the radiologist's experience. DESIGN: Retrospective study. SETTING: Between March 2009 and October 2012, 31 pregnant women who had previous caesarean delivery together with a placenta praevia and suspected placenta accreta on ultrasound in the third trimester of pregnancy. POPULATION: All were offered MRI examination, and made aware of the limited (but so far reassuring) data regarding fetal safety of gadolinium. Twenty pregnant women agreed to undergo prenatal MRI (1.5 T), with and without gadolinium injection. METHODS: Two sets of MRI examinations without and with gadolinium were reviewed independently 2 months apart by two senior and two junior radiologists; all were blinded to the outcome (known in all cases). Histopathological findings and clinical signs of AIP were considered as the defining criteria of diagnosis. MAIN OUTCOME MEASURE: accuracy of MRI with and without gadolinium was assessed. RESULTS: Eight of the 20 women had confirmed abnormal placental invasion. The overall performance of both sets of readers in detecting AIP increased with gadolinium-sensitivity and specificity of 75.0% (42.0-100%) and 47.9% (19.9-75.9%) increasing to 87.5% (57.1-100%) and 60.4% (33.9-86.9%), respectively (P = 0.04). The added value of gadolinium remained irrespective of radiologist's experience, although senior radiologists performed better overall (sensitivity and specificity of 87.5% and 62.5% versus 62.5% and 33.3%, respectively, increasing with injection to 93.8% and 70.8% versus 81.3% and 50%, respectively; P < 10-4 ). CONCLUSION: There was an association between gadolinium use and improvement in MRI-based diagnostic accuracy for the diagnosis of AIP, for both junior and senior radiologists. TWEETABLE ABSTRACT: Gadolinium injection improves MRI performance of radiologists for the diagnosis of placenta accreta.

[Cystic and cavitary lesions of the lung: imaging characteristics and differential diagnosis]. / Kystes et cavités du poumon: description sémiologique et approche étiologique.

Gas containing lesions of the lung can be differentiated into cystic and cavitary lesions based on their imaging characteristics, which is helpful for differential diagnosis. The imaging features include number, size, thickness and smoothness of the walls, content, lesion distribution and occasional associated lesions. Some imaging features have characteristic diagnostic implications: mural nodule and meniscus sign. Cysts are characterized by thin and regular walls, less than 2 mm in thickness. The differential diagnosis includes: histiocytosis X, lymphangioleiomyomatosis, cystic metastases, septic emboli, pulmonary sequestration. Emphysema, honeycombing and cystic bronchiectases should also be considered. Cavitary lesion have thicker walls. The most frequent etiologies include abscess, cavitary tumors, mycobacterial infections and fungal infections.

[Pleurisy induced by atorvastatin]. / Pleurésie induite par l'atorvastatine.

INTRODUCTION: Whereas numerous case reports have described statin-induced lung injuries, statin-induced pleural effusions are uncommon. CASE REPORT: An 84-year-old man presented with bilateral pleural effusions two years after starting treatment with atorvastatin. No other cause of pleural effusion was found and all symptoms and radiological signs resolved rapidly after discontinuation of the drug. Furthermore, an accidental reintroduction of the treatment resulted in recurrence of the same clinical picture, reinforcing the hypothesis that atorvastatin was responsible for this pleural effusion. CONCLUSION: Pleuropulmonary manifestations in a patient treated with atorvastatin should rapidly evoke an iatrogenic origin and the discontinuation of the drug should be discussed.

[Invasive pulmonary aspergillosis complicating septic shock]. / Aspergillose pulmonaire invasive compliquant un choc septique.

INTRODUCTION: Invasive pulmonary aspergillosis (IPA) is an opportunistic infection with a poor prognosis, occurring primarily in patients who are severely immunocompromised. CASE REPORT: We report a case of IPA that occurred in a 37-year-old woman with no history of previous immunosuppression or significant co-morbidity. She was admitted to our intensive care unit (ICU) with septic shock and multi-organ failure complicating a bacterial pneumonia. After an initial improvement, her condition deteriorated on the 10th day after admission with fever and lesions consistent with IPA seen on high-resolution computed tomography (HRCT). IPA was confirmed by isolating Aspergillus fumigatus from bronchoalveolar lavage and by a positive circulating galactomannan test (sandwich ELISA). First line therapy with voriconazole had to be stopped after 12 days due to hepatic toxicity. The patient was successfully treated with caspofungine for 2 months then itraconazole for 4 months with progressive improvement of HRCT abnormalities. Her galactomannan test became negative at 6 months. CONCLUSION: The diagnosis of IPA must be considered in critically ill patients even in the absence of underlying immunosupression where suggestive HRCT abnormalities occur in the context of septic shock and multiple organ failure.

[An unusual cause of pulmonary cysts]. / Une cause inhabituelle de kystes pulmonaires.

INTRODUCTION: Multiple pathologies may be associated with cystic appearances in the lungs. Lymphangioleiomyomatosis, Langerhans cell histiocytosis and lymphocytic interstitial pneumonia are the principal causes of thin walled pulmonary cysts. CASE REPORT: We report the case of a non-smoking woman of 71 years, a retired farmer, who was admitted on account of cough, increasing dyspnoea, fever and loss of weight that developed following exposure to hay. The thoracic CT scan revealed diffuse ground glass opacities and centrilobular nodules. Multiple thin walled cystic shadows were distributed homogeneously throughout both lung fields. Broncho-alveolar lavage revealed a marked lymphocytosis (63%) and precipitins for Microsporum Faeni were strongly positive (6 arcs). The respiratory symptoms resolved spontaneously during the stay in hospital, allowing the patient to be discharged after 3 weeks with the advice to avoid all contact with hay. One month later she remained symptom free, the repeat CT scan showed a diminution ofthe ground glass opacities and the nodules but persistence of the pulmonary cysts. CONCLUSION: The diagnosis of hypersensitivity pneumonitis should be considered in the presence of a diffuse pulmonary infiltrate with multiple thin walled cysts in a patient with a suggestive history and clinical picture.

[Treatment of a compressive bronchogenic cyst by computed tomography-guided needle aspiration]. / Traitement d'un kyste bronchogénique compressif par ponction sous tomodensitométrie.

INTRODUCTION: Bronchogenic cysts are benign tumours of the posterior or middle mediastinum. Treatment usually consists of complete surgical resection. We report the case of an elderly woman presenting with an inoperable bronchogenic cyst causing tracheal compression which was treated successfully using computed-tomography (CT)-guided needle aspiration. CASE REPORT: A 92 years old woman was admitted for inspiratory dyspnoea associated with stridor. She reported the incidental discovery of a right paratracheal mass, 2 years previously. Thoracic CT scan and bronchoscopy revealed a large mediastinal bronchogenic cyst causing tracheal compression. Surgery was contraindicated because of the patient's age and cardiac disease. CT-guided needle aspiration of 250 ml of viscous fluid was performed, followed by rapid clinical improvement. The patient remained symptom free for several months. The procedure was repeated successfully one year later because of a recurrence of compression. CONCLUSION: This observation supports the potential use of CT guided transthoracic needle aspiration as an alternative to surgical treatment in cases of inoperable symptomatic bronchogenic cyst.

[Pulmonary aspergillosis complicating atypical mycobacterial infection in two patients suffering from chronic obstructive pulmonary disease]. / Aspergillose pulmonaire compliquant une infection à mycobactérie atypique chez deux patients atteints de bronchopneumopathie chronique obstructive.

INTRODUCTION: Atypical mycobacteria and Aspergillus are opportunistic organisms responsible for severe pulmonary diseases whose development is encouraged by the presence of chronic obstructive pulmonary disease (COPD) and related immunosuppression. CASE REPORTS: We report the cases of two patients, both alcoholics with emphysematous COPD, who developed chronic pulmonary aspergillosis following atypical mycobacterial infection. Patient 1 developed chronic necrotising aspergillosis several months after the diagnosis of infection with Mycobacterium avium. Patient 2 developed an aspergilloma several weeks after the diagnosis of infection with Mycobacterium xenopi. The association of these two pathologies presents diagnostic and therapeutic problems that are discussed. CONCLUSION: The development of Aspergillus pulmonary disease may complicate atypical mycobacterial infections and explain a poor response to treatment. Our two case reports suggest that a systematic search should be made for pulmonary aspergillosis during the follow-up of patients with atypical mycobacterial infection.

[Type B Niemann Pick disease: clinical description of three patients in a same family]. / Maladie de Niemann-Pick de type B: description clinique de trois cas familiaux.

INTRODUCTION: The Niemann Pick disease type B is a rare deficiency in sphingomyelinase activity, autosomal recessively inherited. CASE REPORTS: We report three patients (two men, one woman) of the same family, who showed pulmonary and hepatosplenic lesions, usually present in the disease but also adrenal gland lesions confirmed by tomodensitometry. CONCLUSION: The current treatment of Niemann Pick disease is purely symptomatic awaiting the use of enzymatic replacement therapy which has been successfully experimented in animal model.