Molecular diagnosis of disseminated adiaspiromycosis due to Emmonsia crescens.

Emmonsia crescens is a saprophytic fungus that is distributed worldwide, causing diseases mostly in rodents. It has also been described, though rarely, as an etiologic agent of pulmonary pathology in humans, potentially leading to death. A case of pulmonary adiaspiromycosis is reported in a 30-year-old immunocompetent man. The patient presented with a history of several weeks of weakness, cough, fever, and weight loss of 10 kg. Clinical and radiographic findings showed pulmonary lesions consistent with tuberculosis or histoplasmosis, but no pathogen was found with classical microbiological procedures. The diagnosis of adiaspiromycosis due to Emmonsia crescens was initially made using molecular biology techniques. Histological observations subsequently confirmed the presence of adiaspores in granulomas. To our knowledge, this is the first case of adiaspiromycosis diagnosed by PCR and sequencing. The patient was treated with itraconazole and was seen at 1 month with symptomatic improvement. Here we will discuss this rare fungal infection and its difficult treatment and diagnosis. As represented in this case, molecular biology is a powerful method to optimize diagnostic tests and therefore improve the care of the infected patient.

[Pulmonary involvement in the course of cytomegalovirus infection in an immunocompetent adult]. / Atteinte pulmonaire au cours d'une infection à Cytomegalovirus chez un adulte immunocompétent.

INTRODUCTION: Cytomegalovirus (CMV) infection in the immunocompetent is generally silent or it may present as a mononucleosis like syndrome but, rarely, it can lead to symptomatic manifestations. CASE REPORT: An immunocompetent and previously healthy 43- year-old woman presented with fever, dyspnoea, liver cell necrosis and a mononucleosis syndrome. The CT scan showed diffuse ground-glass opacity. BAL and blood cultures were sterile. Urinary antigens (Legionella pneumophila, Streptococcus pneumoniae) and serology for atypical respiratory pathogens (Mycoplasma pneumoniae and Chlamydia sp.) were negative. A diagnosis of CMV pneumonia was established on serology (presence of anti-CMV IgM) and PCR detection of viral DNA in the serum. Without antiviral therapy, there was a favourable clinical outcome 1 week later and 1 month later the CT scan was normal. CONCLUSION: CMV infection can lead, exceptionally. to a hypoxic pneumonia in the immunocompetent host. Antiviral therapy should not be prescribed systematically.

[An unusual paraneoplastic manifestation in lung cancer: eosinophilic erythroderma]. / Une manifestation paranéoplasique inhabituelle dans le cancer bronchique: l'érythrodermie hyperéosinophilique.

An 81-year-old man was admitted for generalized weakness, erythrodermia and eosinophilia. His chest CT showed nodules related to lung adenocarcinoma. Chemotherapy induced a tumour response with the disappearance of the erythrodermia and eosinophilia. A tumour relapse indicating the recurrence of the erythrodermia and eosinophilia was confirmed 2 months after completion of the chemotherapy. The outcome was rapidly fatal. The evolution of the symptoms suggests that eosinophilic erythrodermia is a paraneoplastic syndrome. Cutaneous paraneoplastic syndromes are rare but may be associated with lung cancer.

[Pleuro-pulmonary manifestations disclosing hepatic amoebiasis]. / Manifestations pleuropulmonaires révélatrices de l'amibiase hépatique.

During a mission in ex-Yugoslavia between 2001 and 2004, three French soldiers were sent home because of right pneumopathy, right pleurisy after appendicectomy, haemoptysis and liver haematoma, respectively. They previously were stationed in Africa and/or South America. The initial diagnosis was quickly modified: pleuropulmonary manifestations of amoebic hepatic abscess in two cases, and pleuropulmonary amoebiasis in the last case. The outcome was favourable with standard anti-amoebic treatment. The reports illustrate the possibility of hepatic amoebiasis with local pleuropulmonary manifestations and an exceptional case of pleuropulmonary amoebiasis with hepatobronchial fistula. The authors report this experience because it demonstrates that amoebiasis in European countries remains an often forgotten diagnosis. Although known for a long time in developing countries, amoebiasis in the military or in tourists should be systematically considered.

[Pulmonary arterial hypertension due to tumor emboli]. / Hypertension artérielle pulmonaire postembolique tumorale.

INTRODUCTION: Pulmonary arterial hypertension (PAH) is rare in the presence of malignancy and tumour embolisation is one of several possible pathological mechanisms. CASE REPORTS: We report our experience of 5 clinical cases and undertake a literature revue of the pathophysiological mechanisms and of the possible diagnostic and therapeutic approaches. CONCLUSIONS: Neoplastic PAH due to tumour micro-emboli is rare and the diagnosis difficult to establish. Cytological examination of pulmonary arterial blood could allow early institution of appropriate chemotherapy and lead to an improvement in the grave prognosis of this condition.

[Pseudotumoral presentation of American pulmonary histioplasmosis]. / Présentation pseudo-tumorale de l'histoplasmose pulmonaire américaine.

In France, American pulmonary histoplasmosis is an imported deep mycosis, caused by inhalation of Histoplasma capsulatum. Clinical and radiological features of this exotic disease are multiple, simulating tuberculosis or cancer. We report two cases of American histoplasmosis with pseudo-tumoral form, in immunocompetent subjects working in Venezuela, with a multinodular pulmonary presentation.

[Positron emission tomography in thoracic radiography]. / Apport de la tomographie par émission de positons à la radiothérapie thoracique.

The optimisation of the field of irradiation is the aim of the radiotherapist. Pet-Scan provides information revealing a better cartography of node involvement and allowing a better delineation of the tumour zone. In the follow-up of irradiated patients, PET-Scan provides information on the nature of residual lesions and a possible recurrence.

[Acute renal failure following ingestion of Cortinarius orellanus in 12 patients. Initial presentation and progress over a period of 13 years]. / Insuffisance rénale aiguë après ingestion de Cortinarius orellanus chez 12 patients. Présentation initiale et évolution sur une periode de treize annees.

INTRODUCTION: This study reports the largest series of acute renal failure following collective poisoning by Cortinarius orellanus since 1957. PATIENTS: Twelve men, in whom altered renal function appeared following ingestion of mushroom soup (Cortinarius orellanus) when they were 20 to 23 year-old, were followed up for 13 years. RESULTS: After a period of latency of between 2 to 5 days, the patients complained of asthenia, intense thirst and digestive and neurological disorders. On admission, 4 were anuretic and two exhibited polyuria. Leukocyturia was detected in all patients but without proteinuria. Renal biopsy was performed on day 14 in seven patients. It revealed severe tubulo-interstitial lesions with polymorphous cell infiltration, oedema, loose fibrosis and epithelial necrosis. Eight patients required haemodialysis. Nine patients received corticosteroids for less than 6 months. Over a follow-up period of 13 years, seven patients recovered normal renal function, four underwent transplantation and one was still under haemodialysis and died, victim of a car accident. CONCLUSION: The incidence of acute renal failure varies from 30 to 46%. It depends on individual sensitivity, pre-existing nephropathy and the cumulated dose of toxin ingested. Early and severe interstitial fibrosis, marked interstitial oedema and tubular epithelial necrosis are the most characteristics renal lesions. Renal failure regresses progressively over several months in 60% of cases. In the other patients, terminal renal failure appears immediately or after several years. The evolution is not influenced by corticosteroid therapy.

[Laryngeal disorder revealing unrecognized pulmonary tuberculosis]. / Atteinte laryngée révélatrice d'une tuberculose pulmonaire méconnue.

Laryngeal tuberculosis is exceptional and identification in this localization can reveal clinically unrecognized pulmonary tuberculosis. We report two cases illustrating this situation. The pseudo-tumor aspect observed at endoscopy may be wrongly suggestive of neoplasia. Bacteriological examination provides the diagnosis. New methods of genomic diagnosis (Gen-Probe) and culture now allow particularly rapid diagnosis. Outcome is always favorable with standard anti-tuberculosis treatment.

[An unusual cause of acute respiratory distress: obstructive bronchial aspergillosis]. / Une cause inhabituelle de détresse respiratoire aiguë: l'aspergillose bronchique obstructive.

We report the case of a 77-Year-old immunocompetent woman who required intensive care for acute dyspnea revealing complete atelectasia of the left lung related to an aspergillus mycelium plug blocking the principal bronchus. The clinical course was favorable after deobstruction by thermocoagulation and oral itraconazole given for six Months. The patient was free of parenchymatous or endobronchial sequelae. Adjuvant oral corticoid therapy was given temporarily during the second Month of treatment when signs of transition towards allergic aspergillosis developed. Four Months after discontinuing the antifungal treatment, the patient developed a new episode of acute dyspnea caused by atelectasia limited to the right lower lobe. Treatment by itraconazole was resumed and continued as long-term therapy. No recurrence has been observed for eighteen Months. The diagnostic and therapeutic problems raised by Aspergillus fumigatus are well known in the immunocompromised subject, but can also be encountered in the immunocompetent subject.

[The risk of thromboembolism in airline passengers]. / Risque thromboembolique et voyage en avion.

Long carrier flights favor thromboembolism. The risk is well known to the general public but is probably really very low. The risk is however pertinent due to the volume of air travel in the world. Sitting in the same position for a long time induced venous stasis which is the principal factor favoring thrombosis in travelers, irrespective of the means of transportation. Long carrier flights also expose passengers to specific factors related to air travel: coagulation disorders and alterations of the endothelium related to hypobarism, hypoxia and low hygrometry in the cabin. Presence of pathogenic thrombophilia is not a constant factor. The prevention of venous thrombosis in air travelers calls upon simple measures: abundant hydration, avoiding use of alcohol and tobacco, walking and dorsal flexion of the feet. The only preventive option with proven efficacy is the use of elastic contention which reduces the risk of thromboembolic events. There is no consensus concerning the use of drugs proposed by certain authors; prudence should be the rule. All passengers should become aware of the risk of thromboembolism related to sitting in the same position for a long time.

[Pleomorphic adenoma with bilateral pulmonary metastasis]. / Adénome pléomorphe avec métastases pulmonaires bilatérales.

We report a new case of pleomorphous adenoma of the submaxillary glands with multiple lung metastases. Histological proof was obtained on the thoracoscopic surgical specimen. Clinically, this benign tumor presents as a malignant tumor. Diagnosis has been a subject of debate; surgical resection is indicated. Diagnosis is achieved by elimination in a patient with one or several nodules occurring in a context of recurrent pleomorphous adenoma.

[Perforation of the nasal septum: a rare complication of bevacizumab]. / Perforation de la cloison nasale : une complication rare du bévacizumab.

INTRODUCTION: Neovascularisation is a hallmark of cancer. Vascular endothelial growth factor (VEGF) is directly involved in the regulation of this tumoural neoangiogenesis, especially in lung cancer. Bevacizumab is a humanized monoclonal antibody targeting VEGF that is commonly used in thoracic oncology. Among the side effects, perforation of the nasal septum is rare. CASE REPORT: We report the case of a 50-year-old woman with adenocarcinoma of the right upper lobe, immediately metastatic, treated with five cycles of chemotherapy (cisplatin, gemcitabine, bevacizumab). She developed a perforation of the nasal septum after the third injection of bevacizumab given as monotherapy during the maintenance phase. CONCLUSIONS: This is, to our knowledge, the first description of this complication in the course of treatment of bronchial carcinoma. Its management is purely symptomatic. The action to be taken in using bevacizumab is not fully codified.

[Endoscopic management of broncho-pleural fistula in a patient with acute respiratory distress syndrome after pneumonectomy]. / Prise en charge endoscopique d'une fistule bronchopleurale chez un patient en syndrome de détresse respiratoire aiguë après pneumonectomie.

We report the management of endobronchial a patient admitted to the ICU for respiratory distress in the consequences of an surgical recovery of his left pneumonectomy complicated by bronchopleural fistula as part of a bronchial carcinoma non-small cell type adenocarcinoma. Endobronchial treatment by gluing of the fistula may be an alternative to surgery. We discuss its indication in the treatment of bronchial fistula.

[PET-scan in orbital Malt lymphoma and its value in diagnosis and management: a series of four cases]. / Diversité clinique du lymphome de Malt orbitaire et intérêt du PET-scan. A propos de quatre cas.

INTRODUCTION: The orbital location of mucosa associated lymphoid tissue (Malt) lymphoma (ML) is rare and can appear in very different forms. Biopsy is decisive for diagnosis. Although the positron emission tomography (PET) scan is rarely used in ophthalmology, it appears useful in our experience. We report four cases illustrating the diversity of the orbital localization in ML. Case 1 is a 41-year-old woman presenting unilateral corticosteroid-resistant dacryoadenitis. The PET-scan clearly fixed at the orbit. After anatomopathologic confirmation, a 36-Gy orbital radiotherapy was carried out, leading to the clinical and tomographic remission. CASE REPORTS: Case 2 is a 61-year-old patient, presenting a small cell carcinoma of the lung, initially referred for unilateral exophthalmia. MRI highlighted a bilateral orbital infiltration, with a hot spot on the PET-scan. The clinical suspicion of orbital metastasis was not confirmed: the biopsy concluded in ML. Case 3 is a 64-year-old woman, referred for unilateral and resistant conjunctival hyperemia. Clinical diagnosis was myositis of the superior rectus muscle. The PET-scan did not fix in the orbit but revealed a pleural location. The muscular biopsy concluded once again in ML. Case 4 is a 68-year-old woman who had a history of sinusal ML. Diplopia with a second orbital location, non specific in CT but fixed in PET, was found. The biopsy concluded in ML with transformation toward an aggressive lymphoma. CONCLUSION: Although the lacrimal gland location is well-known, unspecific orbital infiltration and orbital myositis are less common, which highlights the value of a non invasive exploration before biopsy. The advantages of the PET scan in orbital ML has not been sufficiently studied. In our experience, it was useful in these four cases. Orbital ML can take on different aspects that are sometimes misleading. PET is very useful in diagnosis before the biopsy, in therapeutic decisions, and in follow-up after treatment even if it does not always fix in the orbit.

[Scar sarcoidosis: an exceptional entity in ophthalmology]. / Scar sarcoidosis: une entité exceptionnelle en ophtalmologie.

INTRODUCTION: Scar sarcoidosis is a cutaneous demonstration of sarcoidosis arising on old cutaneous scars and generating nodular erythematous lesions. CASE REPORT: We report the case of a 55-year-old patient sent for a multinodular erythematous tumefaction, at the level of the right eyebrow arch. The pathologic exam of the surgical specimen found a noncaseating inflammatory granulomatous reaction with no caseous necrosis. The diagnosis of sarcoidosis was retained based on a number of diagnostic arguments including the thoracic scanner and bronchoscopy results. DISCUSSION: Scar sarcoidosis is a cutaneous sarcoidosis expression but exceptionally leads to discovery of this disease, which then requires a search for visceral lesions because of their frequent association. The location is essentially facial and the peak of frequency is in the 5th decade. This pathology highlights the problem of its differential diagnosis, based on biopsy, which will eliminate cutaneous metastases, lymphoma, as well as other cutaneous granulomas.