Comparison of epidemiological, clinical, and biological features of invasive aspergillosis in neutropenic and nonneutropenic patients: a 6-year survey.

BACKGROUND: Invasive aspergillosis is an opportunistic infection that occurs mainly among patients with prolonged neutropenia. Few data are available on invasive aspergillosis in nonneutropenic patients. METHODS: The aim of this survey was to compare neutropenic and nonneutropenic patients who had received a diagnosis of invasive aspergillosis at our institution during a 6-year period. RESULTS: Among the 88 cases of invasive aspergillosis analyzed here, 12 were histologically proven, 52 were probable, and 24 were possible. Forty-seven percent of cases were diagnosed in the intensive care unit, and 40% were diagnosed in hematology units. Neutropenia was a risk factor for 52 patients (59%), most of whom had hematological or solid malignancies. Among the 36 nonneutropenic patients (41%), the main underlying conditions were steroid-treated chronic obstructive pulmonary disease, asthma, rheumatoid arthritis, giant-cell arteritis, and microvascular disorders; 10 patients were recipients of solid-organ transplants, and 1 patient was seropositive for human immunodeficiency virus. The distribution of proven and probable invasive aspergillosis was similar for neutropenic and nonneutropenic patients. The mortality rate was 71.5% overall and was significantly higher among nonneutropenic patients than among neutropenic patients (89% vs. 60%; P<.05). Compared with neutropenic patients, nonneutropenic patients were significantly less likely to have symptoms of invasive aspergillosis and more likely to have frequent intercurrent pneumonia due to another microorganism. The sensitivity of mycological examination of bronchoalveolar lavage fluid specimens was higher for nonneutropenic patients than for neutropenic patients (85% vs. 58%; P<.05), whereas the sensitivity of antigenemia was the same for the 2 populations (65% vs. 64%). Findings on thoracic computed tomographs were similar, except that segmental areas of consolidation occurred more frequently among neutropenic patients. CONCLUSION: This survey at a whole institution underlines the high number of cases of invasive aspergillosis among nonneutropenic patients, with an overall mortality rate that was significantly higher than that for neutropenic patients.

Reduction of matrix metalloproteinase-9 activity by the selective phosphodiesterase 4 inhibitor, RP 73-401 in sensitized mice.

Matrix metalloproteinases are particularly potent in degrading basement membrane collagen and other extracellular matrix components. We have investigated the effects of a selective phosphodiesterase 4 inhibitor, RP 73-401 [N-(3, 5-dichloropyrid-4-yl)-3-cyclopentyloxy-4-methoxybenzamide], on gelatinase (matrix metalloproteinase-2 and matrix metalloproteinase-9) activity in ovalbumin-sensitized and -challenged mice. Twenty-four hours after the last challenge, matrix metalloproteinase activity was evaluated in the bronchoalveolar lavage fluids by a zymography technique, and a significant increase in matrix metalloproteinase-9, but not matrix metalloproteinase-2, activity was noted. When administered orally (0.3-3 mg/kg) 1 h before each ovalbumin challenge, the selective phosphodiesterase 4 inhibitor, RP 73-401, significantly reduced this increased matrix metalloproteinase-9 activity in bronchoalveolar lavage fluids. Our data suggest that RP 73-401 may modulate tissue remodelling associated with lung inflammatory processes including asthma.

[Value of the association of D-dimer measurement and the evaluation of clinical probability in a non-invasive diagnostic strategy of pulmonary embolism]. / Intérêt de l'association du dosage des D-dimères et de l'évaluation de la probabilité clinique dans une stratégie diagnostique non invasive de l'embolie pulmonaire.

New diagnostic tools in suspected pulmonary embolism complete the classical diagnostic strategy of pulmonary scintigraphy and pulmonary angiography to limit the indications of these two invasive investigations. In a prospective series of 204 consecutive patients with suspected pulmonary embolism the association of D-dimer measurement and clinical probability was assessed for the exclusion of the diagnosis of pulmonary embolism. The D-DI Liatest is a new generation, unitary, rapid and quantitative latex test with a comparative diagnostic performance to that of the reference ELISA test, and well adapted to emergency situations.The clinical probability was assessed by a quantitative score based on past history, clinical symptoms and signs. The positive diagnosis of pulmonary embolism was made by spiral CT scanner and/or pulmonary angiography, associated with Duplex ultrasonography of the leg veins in nondiagnostic results. The prevalence of pulmonary embolism was 42.6% and the absence of anticoagulation in patients considered not to have pulmonary embolism was associated with a thrombo-embolic incidence of 0.9% at 3 months. Fifty-six patients had D-dimer concentrations equal or inferior to the threshold of 500 microg/L; the sensitivity was 99% and the specificity 47% with a negative predictive value of 98% to 100% in cases with a low clinical probability. D-dimer measurement is reliable and has a high cost-benefit value in ambulatory patients with suspected of pulmonary embolism and is even more valuable when the clinical probability of this diagnosis is low.

[Tracheobronchial amyloidosis: apropos of 2 cases]. / Amylose trachéobronchique: à propos de deux cas.

INTRODUCTION: Tracheo-bronchial amyloidosis is an uncommon localized form of amyloidosis. We report two new cases. EXEGESIS: Two patients had developed expiratory dyspnea for several months. CT-scan and flexible bronchoscopy confirmed tracheal narrowing and a diagnosis of tracheo-bronchial amyloidosis was made by tissue biopsies. The immunohistochemical type was AL in one case, undetermined in the other case. There was no argument for systemic involvement. The two patients benefited from bronchoscopic dilatation. This treatment improved clinical symptoms and pulmonary function tests with a follow up of 12 and 18 months respectively. CONCLUSION: Tracheo-bronchial amyloidosis is a localised form of amyloidosis with various respiratory symptoms. Diagnosis is made by CT-scan and flexible bronchoscopy that allows biopsies. Immunohistochemical type is more often AL. Recurrence, respiratory insufficiency and tracheo-bronchial metaplasia are the most important complications. Treatment consists of bronchoscopic dilatation or excision, and bronchoscopic laser-YAG. Pulmonary function testing allows precise follow-up.

[Diffusing capacity for carbon monoxide (T(LCO)) and oxygen saturation during exercise in patients with cystic fibrosis]. / Capacité de transfert du monoxyde de carbone (TLCO) et saturation artérielle à l'exercice chez les patients atteints de mucoviscidose.

OBJECTIVES: To estimate the value of diffusing capacity for carbon monoxide (T(LCO)) in patients with cystic fibrosis and to evaluate its ability to predict arterial desaturation during exercise. METHOD: Fourty-four patients (9-30 years) with cystic fibrosis performed pulmonary function tests with measure of T(LCO) and a bicycle incremental exercise test. They represent a wide variation in disease severity: mean Shwachman score: 77.8 (range: 40-100), mean FEV1%: 72.8 (range: 17-131). This study investigated the relationship between T(LCO), lung volumes and exercise data. RESULTS: T(LCO) remained normal for a long time in patients with cystic fibrosis: 82% of them show a normal T(LCO) (mean value: 91.3% of predicted). T(LCO) was significantly correlated with FEV(1), residual volume, maximal work load and maximum oxygen uptake. A fall in arterial oxygen saturation was uncommon in our study (five patients) and not significantly correlated with T(LCO). CONCLUSIONS: T(LCO) is a good criter of severity of cystic fibrosis but remains unreliable to predict values above which physical activity is safe, without arterial desaturation. Exercise tests should be proposed in order to evaluate exercise adaptation of each patient and determine which factor limits maximal performance.

[Adult bronchiectasis revealing familial ciliary anomaly]. / Dilatations des bronches localisées de l'adulte révélatrices d'une anomalie ciliaire familiale.

We report a case of bronchiectasis in a 26-year-old man associated with the following congenital abnormalities: deafness, purulent bronchorrhea, nasal polyps, dysmorphic physical pattern and chronic sinusitis. Situs inversus was absent. A sampling was performed on the posterior nasal mucous membrane and displayed structural ciliary abnormality: a deficiency of the intern dynein-arm. The patient's bother was affected and had similar features: congenital bronchiectasis, deafness, mental deficiency and sinusitis. Young's syndrome was relevant in this case. Hereditary ciliary dyskinesia should be considered in adults with bronchiectasis together with rhinologic and alimentary canal disorders. Nasal biopsies are safe and allow cilia examination.

[Pseudotumoral forms of sarcoidosis]. / Les formes pseudo-tumorales de la sarcoïdose.

We report 5 cases of sarcoidosis in 4 men and 1 woman who presented multinodular pulmonary lesions. Seldom described (1 to 4% of all cases of sarcoidosis), a multinodular pulmonary presentation is suggestive of metastatic disease. In our patients, the parenchymal opacities were multiple, peripheral and exhibited fuzzy limits, measuring 1 to 7 cm in size and frequently associated with mediastinal adenopathies. The radiographic pattern contrasted with the clinical manifestations (3 of the 5 cases were fortuitous discoveries). Pathological proof required to rule out other disease, especially tumor formation, was acquired; mediastinoscopy allowing the diagnosis in 3 out of 5 cases. The clinical course was favorable in all cases without treatment within 8 +/- 5 months and a mean follow-up of 5 years (range 9 months to 14 years).

[Spontaneous resolution of a giant pulmonary bulla]. / Disparition spontanée d'une bulle géante.

There are different causes leading to formation of pulmonary bullae, in particular tuberculosis. There is some debate concerning the pathophysiology of bullae extension although two mechanisms are put forward: partial obstruction of the airways and elastic recoil of adjacent lung parenchyma with a negative pressure in the bullae. Pulmonary function tests are highly perturbed in patients with giant bullae. The natural history of bullae is enlargement although spontaneous regression is rarely described. Bullae should be resected in selected patients, others require careful follow-up. We present the case of a man with tuberculosis who developed a giant pulmonary bulla that regressed spontaneously in a few years.

[Bronchial dilatation and rheumatoid arthritis: a little known association]. / Dilatation des bronches et polyarthrite rhumatoïde: une association méconnue.

Since Ellmann's description in 1948 numerous authors have studied the respiratory manifestations associated with rheumatoid arthritis. Amongst the numerous disorders described, dilatation of the bronchi, although one of the most frequent, remains largely under-estimated. The authors report a series of 21 patients presenting jointly with both rheumatoid arthritis and bronchiectasis which was documented using thoracic computed scanning. All the subjects were female. For 20 of these patients, the appearance of bronchial suppuration preceded that of the articular manifestations by several years. Bronchial dilatation in these cases can, only with difficulty, be considered as a complication of arthritis as has been previously suggested. Rather it appears as a possible pre-disposing factor in the occurrence of the rheumatoid disease. These hypotheses explain the pathophysiological mechanisms implicated in this association are discussed.

[Pulmonary metastases with a prolonged development. Two cases of thyroid cancers]. / Métastases pulmonaires d'évolution prolongée. A propos de deux cas de cancers thyroidiens.

The authors report two cases of differentiated carcinoma of the thyroid with pulmonary involvement showing as miliary shadowing radiologically which preceded the diagnosis of the thyroid neoplasm by 35 and 6 years respectively. The two patients had undergone cervical radiotherapy in infancy for lymphadenopathy whose aetiology had not been determined. The scintigraph with iodine 131 showed tht in two cases there was a bilateral and diffuse pulmonary uptake in keeping with pulmonary lesion of metastatic origin. Our observations recall the possibility of a slow evolution of pulmonary metastases and carcinoma of the thyroid and the role of cervical irradiation in the development of such cancers. With miliary shadowing a metastatic origin, in particular that of the thyroid, should be considered and in the majority of cases the proof could be supported using iodine 131 scintigraphy. The delay in appearance of pulmonary metastases during the course of cancer of the thyroid is variable. They occur most often after the initial diagnosis or more rarely preceding the discovery of a primary thyroid cancer. The pulmonary metastases may be asymptomatic. This neoplasm may benefit from a specific effective therapy and prolonged remissions have been described even with metastases.

[Prevention of infection transmitted by bronchial fibroscopes]. / Prévention des infections transmises par les endoscopes bronchiques.

A growing number of infectious complications are reported after bronchial fibroscopy procedures. The risk of nosocomial patient-to-patient or environment-to-patient infection is real via contaminated fibroscopes. Cross transmission can be caused by several microorganisms, the most frequently identified being Pseudomonas aeruginosa, Mycobacterium tuberculosis and other atypical mycobacteria. Fibroscopes can be contaminated via different mechanisms, generally related to poorly adapted cleaning and decontamination protocols. Identified errors include an insufficient cleaning phase, an inappropriate disinfecting agent (iodine derivatives, chlorhexidine), defective cleaning or disinfection of accessory equipment, or use of tap water for rinsing. Finally several episodes of Pseudomonas and atypical mycobacteria infections have been found to result from the use of automatic cleaning machines. Particular attention must be paid to the use of these devices. Official guidelines for the disinfection of endoscopic equipment must be rigorously applied in all centers. The personnel should have adequate training. It is also important to take regular samples and make regular bacteriology controls of the water and fibroscopic equipment.

[Fire-eater's lung: report of six cases]. / Le poumon du cracheur de feu: à propos de six cas.

Lung damage due to inhalation of inflammable products, especially Kerdane, is mainly observed in young subjects. Lung damage is rarely severe and the diagnosis is facilitated by the notion of inhalation. These conditions regress favorably in a few days. We report six cases.

[Isoniazid-induced pleuro-pericarditis]. / Pleuro-péricardite induite par l'isoniazide.

We report a case of pleuro-pericarditis related to administration of isoniazid. Drug-induced lupus is well known; we recall the principle clinical, biological and immunological characteristics.

[A rare biphasic pulmonary tumor, carcinosarcoma. A separate entity or differentiation variant of spindle-cell carcinoma?]. / Une tumeur pulmonaire biphasique rare, le carcinosarcome. Entité à part entière ou variante de différenciation du carcinome à cellules fusiformes?

We report a case of pulmonary carcinosarcoma. Surgery is required for this rare mixed type, biphasic tumor. It is generally considered to be a malignant formation issuing from a single cell line but with a two-way differentiation into epithelial and conjunctive components. There is a differentiation continuum between spindle-cell carcinomas (also called monophasic sarcomatoid carcinoma) and carcinosarcoma (or biphasic sarcomatoid carcinoma) leading to debate concerning the immunohistochemical and ultrastructural features.

[Treatment of tracheobronchomegaly with an Ultraflex prosthesis. A case report]. / Traitement de la trachéobronchomégalie par la mise en place d'une prothèse Ultraflex.

Tracheobronchomegaly is defined as a dilatation of the trachea and the large bronchi. It may occur as a familial condition or in association with a connective tissue disease, e.g. Ehlers-Danlos syndrome. Tracheobronchomegaly occurs late in adults. The predominant symptoms are bronchial irritation and recurrent bronchopulmonary infections (because of ineffective cough). Diagnosis is provided by thoracic imaging, particularly computed tomography that enables measuring the precise diameter of the trachea. We report the case of one patient with tracheobronchomegaly who was greatly improved after implantation of Ultraflex tracheobronchial prostheses.

[Mature teratoma of the mediastinum: apropos of 2 cases]. / Tératome mature du médiastin: à propos de deux cas.

Mature teratoma is the most frequent primary germ-cell tumor occurring in the mediastinum. These tumors present characteristic mature cells derived from all three types of embryogenesis tissues. We report two cases. The typical presentation is a cyst-like noninvasive, heterogeneous and calcified formation in the anterior mediastinum, usually in young subjects. Tumor markers, alpha-fetoprotein and beta-gonadotropin, are contributive as they rule out mature tumors if positive. Surgery is the treatment of choice, although adherence to neighboring structures usually makes complete excision difficult. Pathology provides the precise diagnosis, ruling out an immature component.

[Pleural amyloidosis. Apropos of a case and review of the literature]. / Amylose pleurale. A propos d'un cas et revue de la littérature.

The main respiratory manifestations of amylosis are tracheobronchial involvement and modular or diffuse parenchymal disease. Amyloid deposits in the pleura are exceptional. We observed transsudative pleural effusion and heart failure in a patient with multiple myeloma, leading to the discovery of pleural amylosis. Amyloid deposits in the pleura may be fortuitous discoveries since pleural effusion is not necessarily observed. It is however important to be aware of this possibility since the localization is easily accessible for diagnosis. Specific stains are effective diagnostic tools even for transsudative effusions, particularly in suggestive clinical conditions such as multiple myeloma.

[Interstitial pneumonia and mitomycin C. Apropos of a case with analysis of the bronchoalveolar lavage]. / Pneumopathie interstitielle et mitomycine C. A propos d'un cas avec étude du lavage broncho-alvéolaire.

Mitomycin C is an antibiotic used for its alkylizing effect in the treatment of broncogenic cancer. Haematologic, renal or pulmonary complications are sometimes severe. We report a case in a patient with poorly differentiated epidermoid bronchogenic carcinoma who developed clinical and radiological signs of bilateral infiltrating pneumonia due to mitomycine. This observation emphasizes the importance of bronchoalveolar lavage which implicated the immunological toxicity of mitomycine and explained the efficacity of corticosteroid treatment. Pulmonary lesions due to mitomycine were discussed.

[Idiopathic diffuse lung diseases with alveolar infiltration]. / Pneumopathies diffuses idiopathiques avec comblement alvéolaire.

Diffuse idiopathic pneumonia with alveolar filling gather disorders whose clinical and radiological aspects are varied. It is important to precisely identify them because of the prognostic and therapeutic implications suitable for each one of them. Among these, it is necessary to distinguish the eosinophilic pneumonias, wether acute or chronic, which are characterized by circulating and (or) alveolar hypereosinophilies; the diffuse alveolar haemorrhages whose potential severity requires an early recognition in order to institute a treatment without delay; the pulmonary alveolar phospholipoproteinosis can be easily evoked because of their particular radiological features, associated with a lactescent aspect of bronchoalveolar lavage. Lastly, bronchiolo-alveolar carcinoma and more exceptionally the pulmonary alveolar microlithiasis must be considered.