The Z-score: A new tool in the interpretation of spirometric data.

Spirometry is an important tool in the diagnosis and management of patients with respiratory pathology. An appropriate interpretation of the spirometric data requires the use of a population-specific reference equation. However, the most widely used equations were established in European populations with limited age groups. The extrapolation of these equations, based on a specific population, and their uses for a different population led to measurement and interpretation biases. In 2012, an international working group conducted a multicenter study and published new reference equations called The Global Lung Initiative (GLI). These enabled the modeling of spirometric parameters from a very large sample collected in several ethnic groups using modern statistical techniques to establish continuous equations for all ages and in many countries. The GLI also recommends the use of a new statistical tool for the expression of results: The Z-score. This tool allows to express, in a simple way: how many standard deviations a subject is deviated from its reference value. The Z-score is calculated by the ratio of the difference between the measured value and that predicted with the residual standard deviation. This simple approach has reduced the false positive results found by the use of the conventional limits of 80% compared to a predicted value or 0.70 in absolute value for the definition of bronchial obstruction that remain still used.

Preoperative assessment in pulmonary resection surgery.

Pulmonary resection can be associated with a significant risk of morbidity and mortality, which depends on the nature and extent of pulmonary resection but also on the patient himself. This risk can be apprehended by a preoperative assessment which estimates the immediate operative risk as well as the physiological state and the post-operative quality of life which can require more conservative therapies. Currently, preoperative exploration of a patient is based on various technological tools, which can range from simple electrocardiogram or simple spirometry to a complex exploration such as a cardiorespiratory effort test. These multiple evaluation tools require the rationalization of good practice processes according to international recommendations, taking into account the patient's specificity and the country context. This approach makes it possible to prioritize examinations according to their availability and accessibility in order to identify patients with high operative risk and to offer them an appropriate therapeutic choice.

Role of metalloproteinases MMP-2 in asthma.

Background - Many metalloproteinases (MMPs) play a role in the pathogenesis and modulation of the severity of asthma. MMP-9 is the predominant in asthma but other MMPs are involved such as the MMP-2. Aim - To determine the role of single nucleotide polymorphism of the gene MMP2 in susceptibility to asthma and its severity. Methods - Study case-control with prospectively enrolled patients with asthma and healthy subjects. We determined within two groups genotypes corresponding to the MMP2 polymorphism in -735C / T position, using a polymerase chain amplification technique associated with a polymorphism in the length of restriction fragments. Results - We included 150 patients with asthma and 150 healthy controls. Comparison of allele and genotype frequencies of the studied polymorphisms between patients and controls showed that there was no association between the SNP-735C / T and susceptibility to asthma and its severity. Conclusion - The role of MMP 2 in asthma remains unclear and no study has been conducted till date, to determine the role of MMP-2 -735C/T gene polymorphism in asthma. This study does not disprove such association. Further studies are needed to clarify the exact role the pathogenesis of asthma.

Contribution of fixed-dose combinations in the treatment of tuberculosis.

Background - The introduction of fixed-dose combinations (FDCs) of TB treatment in Tunisia is recent (July 2009). WHO and the National Tuberculosis Programme recommend the use of fixed-dose combination (FDC) tablets for the treatment of tuberculosis (TB). The effectiveness of ADF has been demonstrated, however the risk of relapse and tolerance were controversial. Objective - Through a retrospective study, we evaluate, the contribution of FDCs compared with dissociated treatment (TD) (efficacy, tolerance and the occurrence of relapses). Patients and methods - This is a retrospective study conducted in the Department of Pneumology la Rabta. Are included patients with pulmonary tuberculosis (TB) first attack. Two groups were studied: Group I (TC) treated between July 2009 and June 2011 who received ADF. Group II (TD) treated between July 2008 and June 2009 who received TB dissociated treatment. Results - One hundred and seventy one patients were included: 122 in the TC group with an average age of 39.2 years and 49 patients in the TD group with an average age of 38.2 years. Male predominance was observed in the two groups (82/75.5%). The period of apyrexia was below 7 days at more than 80% of patients in the two groups. Sputum smears conversion were obtained between one and two months (median 52,8 vs 55,8 days) in both groups with no significant difference (p = 0.06). The rate of smears conversion at 2 months was 74% in TC group versus 65.3 % (p = 0.12). Eighty patients (65%) of the TC group and 29 patients (59%) of the TD group had one or more adverse effects to treatment without significant difference (p = 0.270). The most common adverse effects were those related to digestive system (17.2% vs 6.1%), liver toxicity (7.4% vs 4.1 %) and urticaria (9.8% vs 8.1%). The treatment successful rate was: 73.7 % in TC group and 77.5 % in TD group. There was no significant difference in treatment compliance, neither in relapse rate nor in the death rate. Conclusion - This study demonstrated non-inferiority of the effectiveness of ADF with a comparable safety. Its effects in the prevention of relapse and resistance BK remain unproven.

Drug Rash with Eosinophilia and Systemic Symptoms to antituberculosis treatment.

Drug Rash with Eosinophilia and Systemic Symptoms (DRESS) syndrome reflects a serious hypersensitivity reaction to drugs. This syndrome is an uncommon adverse reaction due to antituberculosis drugs and is sometimes difficult to identify the culprit agent. We report a case of a 45-year-old woman who received combined antituberculosis drugs (RHZE) for lymph node tuberculosis. Clinical manifestations included fever, dyspnea, rash, hypereosinophilia and visceral involvement (liver involvment). After symptom resolution and biology normalization, anti-tuberculosis drugs were reintroduced successively one after another. Systemic symptoms reappeared with the four anti-tuberculosis drugs. The clinical outcome was favorable with second line antituberculosis treatment.

A rare coexistence of sarcoidosis with overlap syndrome and sarcoidosis with primary biliary cholangitis and Sjogren's syndrome: Two distinct case reports.

Sarcoidosis and the overlap syndrome of autoimmune hepatitis and primary biliary cholangitis (PBC) share common clinical, biological, and histological features. The simultaneous occurrence of these diseases have been reported in few cases and suggests that a common pathway which may contribute to granuloma formation in both conditions. We report the cases of two female patients having an association of sarcoidosis and inflammatory liver diseases. The first case is of a 61-year-old woman had been monitored for an overlap syndrome of PBC and autoimmune hepatitis (AIH). Therefore, treatment with azathiprine has been initiated associated with ursodeoxycholic acid (UDCA). Azathioprine had to be discontinued due to digestive intolerance, specifically chronic diarrhea and abdominal pain. The patient remained clinically stable on UDCA and her liver function tests were stable for years, until she developed symptoms of progressive dyspnea without any other associated signs. Chest computed tomography (CT) revealed mediastinal enlargement, bilateral pulmonary nodules, and symmetrical adenomegalies in the mediastinum. The bronchoalveolar lavage (BAL) revealed increased cellularity, with a notable elevation in lymphocyte count (48 %) and a CD4/CD8 ratio of 4. The patient underwent mediastinoscopy; a biopsy of the right laterotracheal (4R) adenomegaly was performed. Histological examination of the lymph node showed epithelioid and giant-cell tuberculoid lymphadenitis without necrosis, compatible with sarcoidosis. Ophthalmological and cardiac assessments were normal. Plethysmography test was normal and there was no need for corticosteroid treatment; a surveillance was planned. Treatment with UDCA was pursued. The second case is of a 50-year-old woman with no medical history presented symptoms including dry eyes and mouth, inflammatory-type polyarthralgia affecting knees and wrists, bilateral Raynaud's phenomenon, right hypochondrium pain, and worsening dyspnea over six months. Liver analysis showed elevation of alkaline phosphatase (ALP) to three times upper limit of normal (ULN) and gamma-glutamyltransferase (GGT) to 5 times ULN. This cholestasis was associated with an increase in transaminase activity to 5 times ULN for over six months. Immunological tests revealed positive anti-nuclear antibodies (ANA), anti-Ro52, anti-M23E, and anti-centromere antibodies. Chest-CT showed multiple bilateral bronchiolar parenchymal micronodules mostly in the upper and posterior regions without any mediastinal adenomegaly. Bronchial endoscopy was normal, and biopsies indicated chronic inflammation. The BAL revealed increased cellularity, characterized by a high lymphocyte count (51.7 %) and a CD4/CD8 ratio of 2.8. Biopsy of minor salivary gland revealed grade 4 lymphocytic sialadenitis. Skin biopsy revealed an epithelioid granuloma without caseous necrosis. Liver biopsy performed in the presence of cytolysis and moderate hepatic insufficiency, revealed granulomatous hepatitis and cholangitis lesions along with septal fibrosis suggestive of PBC. The diagnosis of cutaneous and pulmonary sarcoidosis with PBC and Sjögren's syndrome was retained. The spirometry and diffusing capacity for carbon monoxide value were normal. Treatment involved UDCA, corticosteroids, and azathioprine, leading to clinical and biological improvement. Sarcoidosis shares some clinical manifestations with autoimmune liver diseases, primarily PBC. A hepatic granuloma with a different appearance and location can guide the diagnosis. Early diagnosis and appropriate management can avoid serious complications and improve prognosis.

[Diagnosis approach of pulmonary embolism]. / Strategie diagnostique au cours de l'embolie pulmonaire.

BACKGROUND: Pulmonary embolism (PE) is a fairly common condition that can be fatal. The variability of presentation sets clinician up for potentially missing the diagnosis. Routine laboratory findings are nonspecific and are not helpful in diagnosis of PE.Diagnosis is based on clinical prediction rule in combination with laboratory tests such as the D-dimers test leading to the realization ofa confirming examination. AIM: To precise the confirming examinations of PE and propose analgorithm based on clinical prediction rules in combination with D-Dimers. METHODS: A Pub Med search was conducted using the following keywords: pulmonary embolism,computed tomogramphy pulmonary angiography, scintigraphy and D Dimer. The study was based on are view of 18 studies including meta analysis, reviews and original articles referring recent strategy diagnosis of pulmonary embolism. RESULTS: Ventilation/perfusion scan is a type of examination that is used less often because it is not a widespread technology. However,it may be useful in patients who have an allergy to iodinated contrast.Ultrasonography of the legs, also known as leg doppler, in search of deep venous thrombosis (DVT) may help the diagnosis approach particularly when other exams are not available or contraindicated.This may be a valid approach in pregnancy. The gold standard for diagnosing PE is pulmonary angiography. It is used less often due to wider acceptance of multi detector CT scans, which are non-invasive.A normal ventilation/perfusion scan rules out the diagnosis of PE with negative predictive value of 97%. There is no consensus in pregnancy. Finally, the MRI has a low and insufficient sensibility to diagnose PE. CONCLUSION: D Dimers, multidetector CT, ventilation/ perfusion scintigraphy and ultrasonography of the legs are the most useful examinations to diagnose PE. Many algorithms were established depends on medical experience and examination availability

[Sarcoidosis in Tunisia: epidemiologic and clinical study]. / Sarcoïdose en Tunise: partcularités épidémiologiques et cliniques.

BACKGROUND: The epidemiologic study of sarcoidosis is problematic and differing incidences across the world are reported. In Tunisia, the incidence of this affection is yet unknown. This is at least attributable to the lack of large series and the overshadowing presence of tuberculosis. AIM: To determine presenting signs, symptoms and investigations particularities. METHODS: We report a retrospective series patients with sarcoidosis followed up in the Rabta university hospital between 1991 and 2005 and try to determine presenting signs, symptoms and investigations particularities. RESULTS: 131 patients (79 women and 52 men) with a median age of 47 ± 14 years were reviewed. They were symptomatic in 95 % of cases. Cutaneous symptoms were present at onset in 56.8 %, respiratory symptoms in 48.6 % and general symptoms in 41.6 %. Thoracic presentation was observed in 81.3%. Chest X-ray changes and tomodensitometry showed that type II and III were predominant. Lung function was disturbed in 58.5% of the cases. Extrathoracic involvement, observed in 89.3 % of the cases, was largely dominated by cutaneous lesions. Histopathological lesions provided diagnosis in 66.6%. CONCLUSION: The relative high frequency of dermatological lesions suggests genetic or even environmental predisposition to develop sarcoidosis such as sunlight exposition.

[Sugar tumor]. / Tumeur sucre.

BACKGROUND: Clear cell tumor of the lung is a rare and very unusual benign pulmonary tumor. This tumor is called sugar tumor because of the abundance of glycogen on its cells. AIM: To report a case of sugar tumor and discuss clinical, evolutive features and diagnosis difficulties of this tumor. CASE REPORT: A case of 75 years old woman presenting as a round pulmonary opacity. Computed tomography (CT) scans showed in the left lower lobe a solitary pulmonary solid tumor with central calcifications. The patient underwent tumor resection. Pathologic examination, including immunohistochemical studies, revealed a benign clear cell tumor, so-called "sugar tumor". CONCLUSION: It's the second case reported in Tunisia. This very rare tumor of the lung is characterized by some immunohistological features. Its evolution is favourable after surgery.

Anxiety and depression in Tunisian patients with COPD.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is a chronic lung disease with a multi-systemic impact that can be complicated by psycho-affective disorders. AIM: To determinethe frequency of anxiety and depression in patients followed for stable COPD in a university hospital-center in Tunisand to determine the predictors of their onset. METHODS: This was an analytical cross-sectional studyof patients followed for stable COPD at the pulmonology department of the Mongi Slim La Marsa Hospital. The symptoms of COPD were assessed by the Chronic obstructive pulmonary disease Assessment Test (CAT), its severity by the GOLD 2020 classification and the screening of psycho-affective disorders by the HAD scale. RESULTS: One hundred and three patients were enrolled, with an average age of 64 years. The prevalence of anxiety was 44.7% and that of depression was 33.9%with 26.2% of patients with a major depressive episode. In multivariate analysis by binary logistic regression, the highest values of CAT score were associated with anxiety, depression, and the onset of a major depressive episode. Other factors associated with anxiety and the onset of a major depressive episode were associated heart rhythm disorders and the lowest BMI values. In addition, the female gender was associated with the onset of a major depressive episode. CONCLUSION: Anxiety and depression are common in Tunisian patients with COPD, hence the interest of their systematic screening.

Case Report: Allergic Bronchopulmonary Aspergillosis Revealing Asthma.

Allergic bronchopulmonary aspergillosis (ABPA) is an immunological pulmonary disorder caused by hypersensitivity to Aspergillus which colonizes the airways of patients with asthma and cystic fibrosis. Its diagnosis could be difficult in some cases due to atypical presentations especially when there is no medical history of asthma. Treatment of ABPA is frequently associated to side effects but cumulated drug toxicity due to different molecules is rarely reported. An accurate choice among the different available molecules and effective on ABPA is crucial. We report a case of ABPA in a woman without a known history of asthma. She presented an acute bronchitis with wheezing dyspnea leading to an acute respiratory failure. She was hospitalized in the intensive care unit. The bronchoscopy revealed a complete obstruction of the left primary bronchus by a sticky greenish material. The culture of this material isolated Aspergillus fumigatus and that of bronchial aspiration fluid isolated Pseudomonas aeruginosa. The diagnosis of ABPA was based on elevated eosinophil count, the presence of specific IgE and IgG against Aspergillus fumigatus and left segmental collapse on chest computed tomography. The patient received an inhaled treatment for her asthma and a high dose of oral corticosteroids for ABPA. Her symptoms improved but during the decrease of corticosteroids, the patient presented a relapse. She received itraconazole in addition to corticosteroids. Four months later, she presented a drug-induced hepatitis due to itraconazole which was immediately stopped. During the monitoring of her asthma which was partially controlled, the patient presented an aseptic osteonecrosis of both femoral heads that required surgery. Nine months after itraconazole discontinuation, she presented a second relapse of her ABPA. She received voriconazole for nine months associated with a low dose of systemic corticosteroid therapy with an improvement of her symptoms. After discontinuation of antifungal treatment, there was no relapse for one year follow-up.

[Paraneoplastic limbic encephalitis complicating pulmonary adenocarcinoma: a case report]. / Encéphalite limbique paranéoplasique compliquant un adénocarcinome pulmonaire: à propos d'un cas.

Limbic encephalitis (LE) is a rare disease often of paraneoplastic origin. It is frequently associated with bronchopulmonary cancer. Diagnosis is based on brain magnetic resonance imaging (MRI). We here report the case of a 54-year-old female patient with a history of active smoking, presenting with chronic dry cough. Chest X-ray showed suspicious right lung opacity. Bronchial fibroscopy and bronchial biopsies were not contributory. Thoraco-abdomino-pelvic computed tomography (CT)-scan and brain CT-scan showed a mass in the right upper lobe classified as T4N2M1a. CT-guided lung biopsy confirmed the diagnosis of bronchopulmonary adenocarcinoma. The patient had reported a recent history of memory disturbances associated with depressed mood, anxiety and paroxysmal confusion. Metabolic screening and tests for detecting infection were normal and brain MRI suggested limbic encephalitis. The evolution was characterized by rapid disease progression; the patient died in about ten days.

Transitory, spontaneously recovering, peripheral facial nerve palsy after vionorelbine administration.

BACKGROUND: Vinorelbine is a semi-synthetic vinca alkaloid that has demonstrated a broad spectrum of activity. It is widely used in non small cell lung cancer. CASE REPORT: We report the case of a 50 year old man, having stage IV lung carcinoma with a unique cerebral metastasis in the right hemisphere. Focal cerebral radiotherapy was first administrated followed by intravenous chemotherapy associating vinorelbine to cisplatin. He has developed multiple subsequent and transitory episodes of monolateral peripheral facial nerve palsy in the left side during vinorelbine administration. The palsy has completely and spontaneously resolved at a short interval, around twenty minutes, after the end of the drug infusion. Obvious cerebral tumor progression was excluded by means of CT scan; the drug was thereby administrated as scheduled until the end of the treatment. CONCLUSION: We describe an unusual side effect, until now reported in only two cases, having brain-stem gliomas, among English and French literature, dealing with vinorelbine as adjuvant treatment. We discuss possible neurological and oncological implications.

Esophageal leiomyomas presenting as a mediastinal mass.

Although benign tumors of the esophagus are very rare, the leiomyomas are frequently recorded. Most of them are small, asymptomatic and without risk of malignant degeneration. These benign tumors are usually discovered fortuitously on endoscopy. Sometimes, they may manifest clinically by dysphagia, hematemesis or other signs. They may mimic the esophageal cancer, which is more frequent, or some mediastinal tumors. The diagnosis can be oriented by the barium swallow esophagogram or other imaging methods, yet, only the histological examination gives the confirmation of the diagnosis. We report the case of a 50-year-old man, non-smoker, complaining of dysphagia, epigastric pain and deterioration of general condition. The clinical and radiological presentation mimicked a mediastinal tumor. Surgery was performed, and histological examination concluded to two leiomyomas of the esophagus.

[Confusion in the diagnosis of endobronchial tumor]. / Une tumeur endobronchique déroutante.

Bronchopulmonary cancer is the leading cause of death in men and the second in women. Some endoscopic or radiological features may guide histological diagnosis and thus facilitate therapeutic management. We here report the case of a 54-year old man, with a history of smoking and recent coronary stent implantation, presenting with haemoptysis and worsening of dyspnea which had evolved over the last month. Chest x-ray showed left pulmonary hemifield lucency with signs of retraction. Bronchial fibroscopy objectified raspberry bud formation spontaneously bleeding, originating from the left main bronchus and suggesting carcinoid tumor. Chest computed tomography (CT) scan showed poorly enhanced endoluminal tissue process at the level of the left main bronchus, located four cm from the carina and complicated with atelectasis. Diagnostic and therapeutic surgery helped to adjust to a diagnosis of endobronchial amartocondroma.

Rosai and Dorfman disease with pleural involvement: case report.

Sinus histiocytosis with massive lymphadenopathy (SHLM) disease is considered to be an indolent and self-limiting pathology. However, severe morbidity and mortality have been attributed to complications of SHLM. Lower respiratory tract involvement is rarely reported and is often unfavorable, and carries a particularly grave prognosis. A case of SHLM is reported, in which the patient had lower respiratory and pleural involvement.

[Pulmonary tuberculosis in child]. / Les particularités de la tuberculose pulmonaire chez l'enfant.

Pulmonary tuberculosis is a major public health problem in the world and particularly in Tunisia. Child is not saved by this illness. The pulmonary tuberculosis present epidemiological and diagnosis specificity in child, especially characterized by difficulty diagnosis at this age. It is also characterised by therapeutic difficulties.