[Venous thrombosis, unrecognized complication of DRESS]. / Thrombose veineuse, complication méconnue du DRESS.

BACKGROUND: DRESS (Drug Reaction with Eosinophilia and Systemic Symptoms) is a rare syndrome triggered by an immunological reaction to certain drugs and which may be life-threatening as a result of the onset of severe organ involvement. It is characterised by a long period from the time of drug therapy to the onset of actual signs. Herein, we report the case of 42-year-old female patient who developed DRESS one month after beginning allopurinol treatment. PATIENTS AND METHODS: A 42-year-old woman was hospitalised for febrile exanthema with facial oedema, polyadenopathy, mononucleosis syndrome, major hypereosinophilia and hepatic cytolysis. A diagnosis was made of DRESS with a RegiSCAR score of 5. The implicated drug was allopurinol, which had been initiated one month earlier. HHV-6 IgM serology was positive. Two days after the start of systemic corticosteroids, the patient developed thrombosis of the internal jugular vein. Other than major hypereosinophilia, no other factors favouring thrombosis were detected. A favourable outcome was achieved under effective anticoagulants and corticosteroids. DISCUSSION: They have been rare reports of venous thrombosis during DRESS. Hypereosinophilia can be involved in the onset of this condition. Prophylaxis with systemic anticoagulants may be necessary in DRESS involving major hypereosinophilia.

The role of procalcitonin and N-terminal pro-B-type natriuretic peptide in predicting outcome after cardiac surgery.

OBJECTIVE(S): Determine the thresholds of procalcitonin (PCT) and N-terminal pro-B-type natriuretic peptide (Nt-pro-BNP) associated with poor prognosis after heart surgery with CPB. DESIGN: Prospective observational study. SETTING: Academic Medical Center Habib Bourguiba. PARTICIPANTS: Adult patients consecutively operated for coronary or valve surgery with CPB, elective or semi-urgent. INTERVENTIONS: Serum concentrations of PCT and Nt-pro-BNP were determined before and after CPB, in the fourth postoperative hour (H4) and every day during the first 4 days. Receiver-operating characteristic curves and cut-off values were used to assess the ability of these markers to predict length of intensive care unit (ICU) stay >3 days. MEASUREMENTS AND MAIN RESULTS: Forty patients were included in the study. Systemic inflammatory response syndrome (SIRS) occurred in 35 (87.5%) patients. Seventeen of them (42.5%) showed severe SIRS. Significantly higher serum concentrations of Nt-pro-BNP and PCT were found in patients with severe SIRS. Receiver operating characteristic (ROC) analysis showed that the threshold of PCT was 0.737 ng/mL and that of Nt-pro-BNP was 1235 pg/mL on day 1 could predict an ICU stay of more than 3 days. The association of Nt-pro-BNP to procalcitonin (p=0.009) better predicted the ICU stay than PCT alone (p=0.02) or Nt-pro-BNP alone (p=0.03). The best combination is Nt-pro-BNP + PCT + C-reactive protein (CRP) (p=0.007). CONCLUSIONS: PCT and Nt-pro-BNP on day 1 may be associated with severe SIRS and predict the length of stay. A biomarker approach combining PCT, CRP and BNP is superior to a traditional single marker for predicting ICU stay.

[Myoplasty by reversal of the pectoris major muscle in the treatment of mediastinitis. A case report and review of the literature]. / Myoplastie par retournement du grand pectoral dans le traitement des médiastinites. À propos d'un cas et revue de la littérature.

Mediastinitis are among the most dreadful infectious complications following cardiac surgery. Their prognosis depends essentially on the precociousness of the diagnosis. In most of the cases, the medical treatment associated with an irrigation drainage is sufficient. But in case of severe sternal dehiscence, plastic surgery becomes necessary in order to fill up the loss with a well-vascularized tissue. We report the case of a 78-year-old patient, chronic bronchitic who presented, after a coronary artery bypass, an aseptic sternal dehiscence necessitating an osteosynthesis, then a Klebsiella pneumoniae mediastinitis with an enlarged sternal necrosis which was treated by bone resection and a myoplasty via reversal of the right pectoris major muscle. The postsurgery course was favourable. Now, after one-year remote, cicatrisation is complete and we have not noticed any infectious recurrence.

[Neurofibromatosis type 1 revealed by malignant peripheral nerve sheath tumor]. / Tumeur maligne des gaines nerveuses périphériques révélant une neurofibromatose type 1.

UNLABELLED: Neurofibromatosis type 1 or Von Recklinghausen's disease is an affection with variable clinical expression. Malignant transformation is rare and dangerous. OBJECTIVE: The aim of this work is to study diagnostic criterias as well as treatment of this malignant transformation. CASE REPORT: Sixteen years old patient presented with gradually progressive basicervical mass without compression nor dysthyroidy signs. Physical examination revealed a painless, hard and well limited mass measuring 4 cm. It was located in front of sternal manuhrium and associated to multiples "café au lait" spots, iris Lisch nodules and generalized neurofibromas. This mass was excised by cervical surgery. The histological exam concluded to a low grade malignant peripheral nerve sheath tumour Unfortunately despite a larger reoperation including resection of the manubrium, the limit of this excision were not safe. Early recurrence was observed, although treated by surgery, chemotherapy and radiotherapy, the patient died by mediastinal invasion.

Prosthetic valve endocarditis: management strategies and prognosis: A ten-year analysis in a tertiary care centre in Tunisia.

BACKGROUND: Prosthetic valve endocarditis (PVE) is a rare and serious complication after heart valve replacement; its optimal management strategy, though, still needs to be defined. OBJECTIVE: To study the clinical, microbiological and echocardiographic characteristics of PVE and to analyse the influence of the adopted therapeutic strategy (medical or surgical) on short- and midterm outcome in a tertiary care centre in a developing country (Tunisia). METHODS: All cases of PVE treated in our institution between 1997 and 2006 were retrospectively analysed according to the modified DUKE criteria. RESULTS: A total of 48 PVE episodes were diagnosed (30 men and 18 women), mean age was 37.93 years. Twenty-eight patients (58.33%) were exclusively medically treated, whereas 20 (41.66%) were treated by a combined surgical and medical strategy. Indications for surgery were haemodynamic deterioration in eight patients (40%), annular abscess in six (30%) and persisting sepsis in six (30%). In comparison with those from the medical group, operated patients had a longer delay to diagnosis (p=0.025), were more frequently in heart failure (p=0.04) and experienced more early complications (p=0.011); they also more frequently had prosthetic dehiscence (p=0.015), annular abscesses (p=0.039) and vegetations >10 mm (p=0.008). Conversely, no differences were found between the groups in terms of age, sex, or nature of involved organisms. In-hospital mortality for the medical group was 14.28% and for the surgical group 35% (p=0.09). CONCLUSION: PVE is a very serious condition carrying high mortality rates regardless of the adopted strategy. Our study demonstrates that, in selected patients, medical treatment could be a successful and acceptable approach. (Neth Heart J 2009;17: 56-60.).

[Study of correlation between radiological aspect of pulmonary hydatid cyst and postoperative course]. / Étude de corrélation entre les aspects radiologiques des kystes hydatiques pulmonaires et les suites opératoires.

Pulmonary Hydatid Cyst (PHC) may represent a real therapeutic challenge. Surgery remains the treatment of choice and postoperative course may be complicated in some cases. Several factors can be involved like the cyst's size and location. We aimed to study the existence of correlation between the radiological aspect of the PHC and the postoperative course through a retrospective study including 267 patients. Different radiological aspect of PHC found on the X-ray and/or computed tomography of the chest were classified according to Zidi et al. CLASSIFICATION: Analytical study showed that there is minor chance to have complications with simple cyst (P<0.05 and OR<1), while type VI cyst were more likely to cause complications (P=0.007 and OR=2.6). Considering these results, more attention should be paid to type VI of PHC to prevent postoperative complications. A multicentric study will be more precise to study correlation between different characteristics of the PHC and postoperative course.

The isokinetic assessment of peripheral muscle function in patients with coronary artery disease: correlations with cardiorespiratory capacity.

OBJECTIVE: We aimed to determine whether diminished cardiorespiratory capacity in patients with coronary artery disease (CAD) is accompanied by impaired skeletal muscle function as measured by isokinetic dynamometry. We also evaluated the correlation between isokinetic strength and aerobic capacity in these patients. MATERIALS AND METHODS: Fifteen CAD patients and 15 age-matched healthy subjects (mean age 60+/-6 vs. 57+/-3.5 years) underwent maximal laboratory exercise testing, a 6-min walking test and an assessment of peripheral skeletal muscle function by use of an isokinetic apparatus. Quadricep and hamstring function was tested at two angular velocities, 150 and 180 degrees s(-1) with simultaneous electrocardiography monitoring. The cardiorespiratory and mechanical parameters (VO(2), ventilatory threshold [VT], heart rate [HR], and power) were measured at VT and at maximal effort. RESULTS: Quadricep and hamstring peak torque was impaired in CAD patients, with quadriceps peak torque at 180 degrees being 71.13 +/- 14 vs. 91.13 +/- 23 Nm (P<0.01) and hamstring peak torque 46.50+/-10 vs. 59.86+/-12 Nm (P<0.01). CAD subjects presented a deficient aerobic capacity as compared with the healthy subjects at maximal effort. At VT, the VO(2), ventilation, and HR were significantly lower in CAD patients, at 13.77+/-2.33 vs. 17.08+/-3.59 ml min(-1) kg(-1) (P<0.05), 29.64 +/- 664 vs. 37.76 +/- 7.2 ml min(-1) (P<0.05), and 86+/-14 vs. 111+/-15 beats min(-1) (P=0.001), respectively. The 6-min walking distance was significantly shorter for CAD patients than healthy subjects (425.93+/-52.77 vs. 551.46 +/- 57.94 m; P<0.01). In CAD patients quadriceps and hamstring strength was not correlated with VO(2) at maximal effort and at VT. Total distance walked during the 6-min walk and VO(2)max were correlated (r=0.869; P<0.001) but not at VT. CONCLUSION: CAD patients showed impaired cardiorespiratory capacity accompanied by increased muscle fatigability as compared with healthy subjects. An isokinetic muscle assessment in these patients must be achieved systematically and seems to have value in cardiovascular rehabilitation.

[Multilevel costovertebral echinococcosis: effectiveness of a combined approach]. / Hydatidose costovertébrale pluriétagée: intérêt d'un abord combiné.

Hydatid disease generally involves the liver and the lung, but rarely can be encountered in bones. The disease predominantly occurs in vascularized areas, involving in descending order: vertebrae, long bones, ilium, skull, and ribs. Vertebral and rib hydatidosis may result from vascular or lymphatic migration of a fertile cell from a hepatic focus. In humans, the two main forms are due to Echinococcus granulosis and less frequently, E. multilocularis (alveolaris). The hydatid cysts usually grow slowly asymptomatically and compression of the involved or the neighboring organ causes clinical manifestations. In this patient, hydatid disease occurred in the chest wall with secondary spinal canal involvement successfully treated by removal of cysts via T7, T8, T9, T10, and T11 laminectomies via a posterior approach, followed by resection of the involved ribs. Total removal of cysts without rupture appears to provide effective protection against late recurrences.

[Clinical case of the month. Histological discovery of a lung cancer in an enormous emphysematous bulla]. / Le cas clinique du mois. Découverte histologique d'un cancer du poumon dans une énorme bulle d'emphysème.

The development of a lung cancer in young patients with emphysematous bullae is a classical, albeit rare, event. These patients can however be operated upon for the resection of a giant bulla causing respiratory distress. We report the case of a 41 year old male patient who was submitted to the resection of a giant right apical emphysematous bulla. The histopathological examination of the fragment revealed an undifferentiated lung carcinoma the diameter of which was less than one centimeter. This observation underlines the need for a systematic examination of the resected material and for a careful radiological follow-up of such patients.

[Management of isolated iliac aneurysms: A Tunisian center experience]. / Traitement des anévrismes iliaques isolés : expérience d'un centre tunisien.

Isolated aneurysms of the iliac arteries are rare. The diagnoses of these aneurysms become easier with non-invasive radiologic investigations. The development of endovascular treatment is a recent alternative to surgical treatment. We report our experience in the management of 8 cases of isolated iliac aneurysms in the department of cardiovascular and thoracic surgery of the Habib Bourguiba Hospital of Sfax.

[Surgical and endoluminal management of the inflammatory aortitis: A Tunisian center experience]. / Traitement chirurgical et endovasculaire des atteintes aortiques inflammatoires : expérience d'un centre tunisien.

Non-infectious aortitis is usually due to giant-cell arteritis, Takayasu disease or Behçet disease. The main aortic lesions are stenoses, occlusions and aneurysms in the Takayasu disease and aneurysms in the Behçet disease and giant-cell arteritis. Treatment is based on corticosteroid therapy and surgery. Endoluminal management is now the rule. We report a retrospective descriptive study of 10 patients who underwent surgical or endoluminal management of inflammatory lesions of the aorta between January 2000 and December 2015. There were 4 cases of Takayasu disease and 6 cases of Behçet disease. The aortic lesions were aneurysmal in all of the patients with Behçet disease. In the patients with Takayasu disease, aortic occlusions predominated, associated with other arterial lesions. Four patients with Behçet disease were managed surgically, and 2 patients underwent endovascular repair. All of the patients with Takayasu disease underwent surgery. Two patients died in the postoperative period, and two patients died during long-term follow-up. Systematic screening, as well as regular monitoring of the entire aorta during the follow-up, is necessary due to the frequency of aortic aneurysms.

[Post-traumatic carotido-jugular fistula: Case report and review of the literature]. / Fistule carotido-jugulaire post-traumatique : à propos d'un cas opéré.

The neck, being not protected by skeleton, is vulnerable to external trauma and injury which can involve blood vessels, muscles, nerves, and trachea. Carotid injuries can be potentially life-threatening by hemorrhage and stroke. We present a case of a 26-year-old manual worker who presented a neck injury caused by a metallic projectile. The injury involved the right common carotid artery with an internal jugular vein fistula, and tracheal damage. The patient was managed with surgical repair of the tracheal lesion, reconstruction of the carotid section using a PTFE graft bypass, and ligation of the internal jugular vein. In the immediate postoperative period, the patient presented with no neurological deficits, but he did develop a pulmonary infection that resolved with antibiotic therapy. The follow-up is now 3months. The patient is doing well without any neurological disorder.

[Arterial injury as a complication of lumbar disc surgery]. / Le cas clinique du mois. Plaie artérielle compliquant une chirurgie discale lombaire.

Vascular complications are unusual after lumbar disc surgery. Iliac artery injury is the most common. The vascular injury may cause severe bleeding and hypotension. If the injury is missed, an arteriovenous fistula may develop. This complication is fortunately the most common. We describe the case of a 41 year-old man who was operated on for lumbar disc herniation. A few hours after surgery, he had developed prolonged hypotension leading to the diagnosis of iatrogenic vascular injury. The CT scan confirmed the diagnosis of right common iliac tear with voluminous retroperitoneal haematoma. Emergent surgery was carried on with success.

[Massive hemoptysis: experience of a surgical unit]. / Hémoptysies massives: expérience d'une unité chirurgicale.

Massive hemoptysis is a clinical entity characterized by its unpredictable and potential lethal course. We studied retrospectively the observations of 25 patients hospitalized in our surgical unit. We collected all the demographic, clinical and surgical data. A male predominance with a sex-ratio of 2,1 was noted. The average age was 45 years, with extremes of 17 and 75. The dominant cause was bronchiectasis. Twenty patients were operated on. The surgery consisted of a pulmonary resection in 9 cases (45%), an atypical lung resection in 4 cases (20%), a resection of an aspergilloma in 2 cases (10%), a kystectomy of hydatic cyst in 4 cases (20%) and one arterial ligature (5%). Five patients (25%) had emergent surgery, and 15 (75%) delayed surgery. Hospital mortality was 20% in the first group and 6.66% in the second. No recurrence of bleeding was observed after an average follow-up of 7 months. Surgery remains a therapy of choice for massive hemopysis. It must as far as possible be avoided during active bleeding.

[Popliteal artery pseudoaneurysm caused by femur exostosis: A pediatric case]. / Faux anévrisme de l'artère poplitée secondaire à une exostose fémorale chez un enfant : à propos d'un cas opéré.

Exostoses, or osteochondromas are benign bone tumors that have developed on the bone surface. These benign tumors can be asymptomatic or lead to complications, for instance arterial pseudoaneurysm. We report a case of a pseudoaneurysm of the popliteal artery treated surgically in a 17-year-old girl with a solitary exostosis of the right femur. Surgery was closure of the pseudoaneurysm and a bypass using a venous graft.

[Cardiac multifocal hydatid cyst]. / Localisation cardiaque d'une hydaditose multifocale. A propos d'un cas.

Hydatid cysts in the heart are rare, with an unpredictable outcome and numerous complications, requiring rapid surgical management. We report the case of a 19 year old female patient, who underwent surgery with extra corporeal circulation for a hydatid cyst of the interventricular septum of the heart, complicated by secondary pulmonary echinococcus infection, confirmed on CT and MRI. Resection of the cyst was performed via a right auriculotomy. The post operative period was favourable; the other pulmonary sites were treated medically. We emphasise the methods of diagnosis and management.

[Mediastinal localisation of a thoracic duct lymphocele--account of a surgical case]. / Localisation médiastinale d'une lymphocèle du canal thoracique: apropos d'un cas opéré.

INTRODUCTION: Lymphocele of the thoracic duct is a rare pathological entity occurring as a consequence of deterioration and cystic dilation wall of this vessel. It may be of congenital or degenerative origin. OBSERVATION: We report the case of a 47 year old patient, operated on for a symptomatic cyst localised by CT scan to the inferoposterior mediastinum. At postero-lateral thoracotomy it was identified as a lymphocele and completely resected. Chemical analysis of the liquid and histopathology study of the cystic wall confirmed the diagnosis. The patient's post operative course was uneventful. CONCLUSION: This case demonstrates the clinical characteristics of this entity and describes diagnostic techniques and surgical management.

[Pulmonary myofibroblastoma: the role of primary surgery]. / Tumeur myofibroblastique pulmonaire: intérêt de la chirurgie première.

INTRODUCTION: Myofibroblastic tumours or pulmonary pseudotumours are rare and, though benign, they may become invasive and recur after excision. CASE REPORT: We report the case of a child aged 14, presenting with mild haemoptysis, who had a solitary nodule at the base of the left lung. CT scanning suggested a hypervascular tumour. Fibreoptic bronchoscopy was normal and it was not possible to perform percutaneous biopsy on account of its proximal situation. A lobectomy was performed via a postero-lateral thoracotomy with a successful outcome. Histological examination revealed a myofibroblastic tumour. CONCLUSION: Recourse to primary surgery is essential to confirm the diagnosis of a myofibroblastic pulmonary tumour. Complete resection is the only guarantee to prevent recurrence.

An unusual tumour of the lung.

We report a case of a 51-year-old woman with a solitary mast cell tumour of the lung, a rare neoplasm with only three previously-reported cases reported in the literature. Unlike previous cases, the tumour in the present case was bulky, measuring 14 cm in diameter and budding into the segmental bronchus. Histologically, it showed proliferation of typical metachromatic mast cells intermingled with undifferentiated cells with a ratio of 3:1. The neoplastic mast cells stained strongly with tryptase, CD117, CD68 and CD45, CD14 and CD33; whereas the undifferentiated cells lacked all these markers and expressed EMA and cytokeratin. Histological examination of bone marrow and laboratory data were unremarkable. To our knowledge, this is the fourth case of solitary extracutaneous mastocytoma of the lung. The differentiating features of this neoplasm and a review of literature are presented.