[Hemophagocytic syndrome secondary to cavitary pulmonary tuberculosis]. / Syndrome d'activation macrophagique secondaire à une tuberculose pulmonaire cavitaire.

Hemophagocytic syndrome is due to the activation and nonmalignant proliferation of macrophages and T lymphocytes. The purpose of this report is to describe a 25-year-old man who presented with fever, coughing, and weight loss over the past month. Laboratory findings demonstrated pancytopenia, hyperferritinemia, and cytolysis. The myelogram showed a hemophagocytic syndrome, and tuberculosis bacilli were found in the sputum. Chest radiography and thoracic computed tomography depicted a cavitary lesion suggestive of pulmonary tuberculosis. Treatment of tuberculosis alone, without an immunosuppressant agent, was effective and led to improvement. In a country where tuberculosis is highly endemic, hemophagocytic syndrome should be considered in the differential diagnosis of patients with active tuberculosis complicated by pancytopenia.

[Huge aspergilloma developed within a zone of scleroderma-related pulmonary fibrosis]. / Volumineux aspergillome développé au sein d'une lésion de fibrose pulmonaire secondaire à une sclérodermie.

In pulmonary aspergilloma, Aspergillus colonizes and proliferates as a saprophyte in deterged cavities deprived of local defense. Although pulmonary tuberculosis constitutes the one well-know predisposing factor, other causes can create favorable conditions. We describe a first published case of a huge aspergilloma which developed within a zone of pulmonary fibrosis secondary to systemic scleroderma. The patient was a 58-year-old woman in poor general health who experienced repeated episodes of hemoptysis and dyspnea. Physical examination disclosed sclerodactyly, generalized cutaneous sclerosis and Raynaud's phenomenon. There was no clinical history of pulmonary tuberculosis or bronchectasis. Aspergillosis serology was positive. Broncho-alveolar liquid was positive for Aspergillus fumigatus at direct examination and after culture. Immunological assessment confirmed scleroderma. The chest computed tomography scan showed a huge oblong-shaped opacity in the upper left lobe which had developed within a zone of pulmonary fibrosis. Medical management was instituted. The clinical course was marked by repeating hemoptysis and the stability of pulmonary lesions after two years. Management of scleroderma-related pulmonary aspergiloma remains difficult and complicated. Prognosis depends on the course of both conditions, scleroderma and aspergillosis.

[Disseminated pulmonary actinomycosis with hepatic injury: a misleading form mimicking a polymetastatic picture]. / Actinomycose pulmonaire disséminée avec atteinte hépatique: une forme trompeuse mimant un tableau polymétastatique.

INTRODUCTION: Thoracic actinomycosis, caused by bacteria of the Actinomyces genus, is a rare infection, with poor prognosis if untreated, whose clinical and radiological picture is misleading, which can simulate a tumoral or tuberculous disease. CLINICAL CASE: This is a case of generalised pseudotumoral pulmonary actinomycosis in a non-smoking, non-drinking 48-year-old man, who for one month has been presenting a cough with haemoptoic sputum, dyspnoea associated with fever and a deterioration in general condition. The clinical examination discovered weight loss, diffuse crackling rales and multiple dental caries. Biologically, he presented an inflammatory syndrome. The radiological imaging and lung and liver CT-scans discovered a peripheral lung mass right side associated with multiple nodular cannon-ball opacities, multiple liver lesions of metastatic appearance. The bacteriological examination of the bronchoalveolar lavage fluid (Gram stain and culture) and the transparietal biopsy of the lung mass confirmed the presence of Actinomyces. Progress under treatment with 10 million international units of parenteral penicillin G daily over a period of six weeks substituted by three grams of amoxicillin/clavulanic acid daily over a period of 12 months and following an oral preparatory procedure was favourable. The thoraco-abdominal scan carried out three months after the treatment showed that the lesions had completely disappeared. CONCLUSION: Our case illustrates the diagnostic difficulty of actinomycosis particularly faced with a picture of multiple lung and liver metastasis. Hence, the importance of a histological and bacteriological examination of samples. The prognosis of this complaint is generally good following well-managed, prolonged treatment; and the prognosis peculiar to disseminated forms is less certain.

[Paradoxical lymphadenopathy during treatment of cavitary tuberculosis in an immunocompetent patient]. / Adénopathie paradoxale au cours du traitement d'une tuberculose cavitaire chez un malade immunocompétent.

The paradoxical reactions during antituberculosis treatment are defined as a transient, clinical and/or radiological increase in preexisting tuberculous lesions or as the emergence of new symptoms, while treatment is adapted and correctly taken. The authors report a case of paradoxical left axillary lymphadenopathy during the treatment of cavitary tuberculosis, which appeared after seven months of treatment. No consensus on the therapeutic management of this entity has been developed to date but many authors propose an extension of antituberculosis treatment, a short corticosteroid therapy, an aspiration puncture and/or a surgical excision of the lymphadenopathy.

[A rare case of huge aspergilloma developed within a lesion of pulmonary fibrosis secondary with a systemic scleroderma in an immunocompetent patient in Madagascar]. / Un cas rare d'aspergillome volumineux développé au sein d'une lésion de fibrose pulmonaire secondaire à une sclérodermie systémique chez une malade immunocompétente à Madagascar.

We report a rare case of a huge aspergilloma developed within a bronchiectasis due to pulling by a pulmonary fibrosis of systemic scleroderma. The patient is a 58-year-old woman presenting a deterioration of the general state associated with repeating hemoptysis, dyspnea, dysphagia, sclérodactylia, generalized cutaneous sclerosis and Raynaud's phenomenon. There was no antecedent pulmonary tuberculosis. The patient had a pulmonary arterial hypertension complicated by a chronic pulmonary heart at the stage of right cardiac decompensation. Aspergillosis serology was positive and the immunological assessment confirmed scleroderma. The computed tomography showed a huge oblong opacity in a small round bell shape ("signe du grelot", Monad's sign) in the left upper lobe developed within a bronchiectasis, and a bilateral pulmonary fibrosis. Although surgery remains the recommended treatment of an aspergilloma, the management of our patient was medical in front of contra-indication for surgery. The evolution was marked by repeating hemoptysis and stability of the pulmonary lesions 2 years later. The management of this entity remains difficult and complicated; the prognosis is in general unfavourable and depends at the same time on the evolution of scleroderma and the aspergilloma infection.

[Pulmonary abscess: a 111-case series in Madagascar]. / Abcès pulmonaires: 111 observations a Madagascar.

The purpose of this report is to present a series of 111 cases of pulmonary abscess observed over a 4-year period in Madagascar. There were 75 men (67.6%) and 36 women (32.4%) with a mean age of 38 years. Alcohol and tobacco use was found in 32.2% of cases. Thirteen patients (11.7%) used chewing tobacco and all patients were exposed to passive smoking. Eighty-eight patients (79.2%) had a history of bronchopulmonary disorders. Onset was progressive in 63% of cases. The main symptoms were fever (81.9%), pulmonary condensation (74.7%) and pleurisy (9.9%). Coughing was productive in 91.8% cases including 54% of patients having muco-purulent expectorations. In 49 patients (44.1%), chest radiography showed an opacity with a hydroaeric level. The abscess was solitary in 40 cases, multiple in 9, and bilateral in 5. In-hospital antibiotherapy was performed on a presumptive basis: tritherapy in 92 patients (82.9%), bitherapy in 18 (16.2%) and monotherapy in one (0.9%). Other treatment modalities inculuded respiratory kinesitherapy in 57 cases (51.3%), surgical drainage in four (3.6%) and pneumonectomy in one (0.9%). Outcome was favorable in 93 cases (8,7%) but there were 18 deaths (16.2%). This study emphasizes the value of achieving early diagnosis, identifying supporting factors and starting appropriate treatment promptly.

[Huge dorsolumbar cold abscess associated with Pott's disease]. / Volumineux abcès froid péripottique dorsolombaire.

Pott's disease, or tuberculosis of the spine, is the most common osteoarticular tuberculosis. Among them, dorsolumbar impairment is predominant. The authors report the case of a patient with a huge cold lumbar abscess associated with Pott's disease. The patient is a 32-year-old man presenting dorsolumbar tumefaction associated with an alteration in his general condition and fever for three months. Treatment by "traditional healers" did not provide any improvement. He consulted for mild lumbar pain triggered by fatigue appearing one week before and after the failure of the traditional practitioner. The clinical examination found a temperature of 38.5°C, cachexia, mild lumber kyphosis and impressive, soft, painless and non inflammatory dorsolumbar bruised tumefaction, 40 cm high, 15 cm wide and 7 cm deep. He did not present any neurological signs. The dorsolumbar X-ray of the spine revealed a lesion associated with Pott's disease in the first and second lumbar vertebrae with pinching of the disc, punched-out lesions and osteocondensation. The ultrasound examination of the soft tissue revealed the presence of a laterovertebral collection of fluid diffusing in the subcutaneous region. The psoas major and the paravertebral muscles were not affected. A scan or MRI of the spine was not carried out. Examination of the tissue sample and drainage of the abscess confirmed the tubercular origin. Treatment with tuberculostatic drugs for 12 months associated with immobilisation resulted in a cure with sequelae of mild kyphoscoliosis vertebral statics.

[Acute community acquired pneumonia: 96 cases in Madagascar]. / Pneumonie aiguë communautaire: 96 observations à Madagascar.

The purpose of this report is to describe a study on acute community-acquired pneumonia (CAP) carried out in the Pneumology Department of the Antananarivo University Hospital Center. This prospective one-year study included patients presenting symptoms of acute CAP. Patients with chronic lung disease and tuberculosis were excluded. Study parameters included epidemiological, clinical and laboratory findings as well as data on the efficacy of the therapeutic treatments used. A total of 96 patient charts were analyzed. Males were predominant with a sex ratio of 1.5. Mean age was 41.8 years. A history of pulmonary tuberculosis was noted in 7.2% of cases. Clinical examination showed pulmonary condensation in 93.7% of cases. Radiological examination depicted alveolar syndrome in 97.6%. Betalactamines were the most frequent class of antibiotic agents used for treatment (90.6%). The most frequently prescribed agent was amoxicillin (60.4%) at a dose of 3 g/day. Single-agent therapy was used more often than double-agent therapy (93.7% vs. 6.3%). The oral route was used more frequently than the intravenous route (62.5% vs. 37.5%). The outcome was favorable in 97.9% of cases and lethal in 2.1%. The prevalence of acute CAP in patients hospitalized in our department was low in comparison with that tuberculosis. Since single-agent therapy using amoxicillin at a dose of 3 g/day was effective, this antibiotic can be recommended as the first-line treatment after ruling out tuberculosis.

[Hemoptysis in Madagascar: etiologies of 114 cases]. / Hémoptysie à Madagascar: étiologies de 114 observations.

A prospective study of patients presenting hemoptysis was carried out over a 12-month period in Madagascar. A total of 114 cases were recorded during the study period. Mean patient age was 37 years. Patients were predominantly male. Pulmonary tuberculosis with positive bacilloscopy was the most common etiology (66.66%). Bronchopulmonary cancer accounted for only a small number of cases (1.75%). Etiology was undetermined in a significant number of cases (15.78%).

[Severe systemic lupus erythematosus induced by isoniazide]. / Lupus érythémateux systémique grave induit par l'isoniazide.

The authors report a rare case of low register systemic lupus erythematosus with renal attack and neurological armature by isoniazid. The patient was a 23-year-old woman presenting a lupus induced by isoniazid 1 month after the treatment of pleural tuberculosis. Antinuclear antibodies, anti-native DNA, anti-ENA, anti-Sm, anti-SSa, anti-SSb and antihistone were present. The symptoms included arthralgia, fever, anaemia, pleural effusion, pericarditis and anasarca. She presented a renal and neurological attack, accounting for the gravity of the disease. The treatment consisted of the interruption of the isoniazid and a bolus of methyl-prednisolone during 3 days relayed by an oral corticosteroid. The evolution was favourable after 8 months of corticosteroids.