[Effects of continuous positive airway pressure on depression, anxiety and quality of life in obstructive sleep apnea hypopnea syndrome patients]. / Effets de la ventilation en pression positive continue sur la dépression, l'anxiété et la qualité de vie au cours du syndrome des apnées-hypopnées obstructives du sommeil.

INTRODUCTION: The obstructive sleep apnea hypopnea syndrome (OSAHS) is a chronic stressor that may alter the emotional state and quality of life (QOL) of patients suffering from it. In this work, we proposed to estimate the prevalence of depression and anxiety, to assess the QOL in a Tunisian population of apneic patients, and to assess their evolution under continuous positive airway pressure (CPAP). METHODS: We conducted a prospective study, involving 33 apneic patients followed for SAHOS with moderate or severe class disease in the pneumology department at Hedi Chaker university hospital in Sfax, Tunisia. They received CPAP treatment for three months. We used an epidemiological record. Two scales, the Hospital Anxiety and Depression Scale (HADS) and the 36-item Short-Form Health Survey (SF-36), were completed before and after treatment to evaluate the effect of three months of treatment with CPAP. RESULTS: The prevalence of depression in the study's patients, according to the HADS, was 45.5% and that of anxiety was 21.2%. After 3months of CPAP, the prevalence of depression and anxiety had become 18.2% and 6.1%, respectively. QOL was impaired in 81.8% of cases before treatment, according to the SF-36. This figure had decreased to 69.7% after 3months of treatment with CPAP. Apart from the third dimension (physical pain), all other dimensions were significantly improved after 3months of CPAP treatment. The treatment with CPAP induced a significant improvement in the average scores of depression (P<0.001), anxiety (P=0.002) and QOL (P<0.001). CONCLUSIONS: These results attest to the importance of the frequency of anxio-depressive disorders as well as an altered QOL in patients with OSAHS. CPAP treatment was shown to be effective in improving these parameters, but this efficacy was partial. Specialized care may be needed in cases of residual anxio-depressive symptoms.

[Hydatid cysts of the liver ruptured into the thorax (about five cases)]. / Kystes hydatiques du foie rompus dans le thorax (à propos de cinq cas).

INTRODUCTION: Hydatid cyst of the liver remains a serious public health problem in Tunisia. This benign affection can sometimes cause fatal complications such as cyst rupture into the thorax. CLINICAL CASES: We report 5 cases of patients who experienced intrathoracic rupture of hydatic cyst of liver. There were four rural women and an urban man. Patients were between 60 and 75 years of age. We present 2 cases of cyst rupture into pleura, 3 cases of hydatid bronchial fistula and 3 cases of biliothoracic fistulas. Surgical treatment was performed by laparotomy in 3 cases, thoracic approach in one case and by thoracoabdominal approach in the other case. We deplore one case of early death by hemorrhagic shock. CONCLUSION: Authors emphasize the complexity of the management of hydatic cyst of liver ruptured into the thorax. Surgical treatment remains responsible of high perioperative morbidity and mortality. Early diagnostic and improvement of reanimation measures are important to improve the prognosis of this serious complication.

[Obstructive sleep apnea syndrome in the elderly]. / Le syndrome d'apnées obstructives du sommeil du sujet âgé

Obstructive sleep apnea/hypopnea syndrome (OSAHS) is a common disease in the general population. However, original works on the SAHS in the elderly are few and their results are discordant. Studies show an increased prevalence of OSAHS with age, and despite this high prevalence, it remains under-diagnosed due to lack of knowledge of geriatric features of this disease and the frequency of comorbidities that may worsen as a result of nocturnal breathing problems but can also mask the symptoms necessary for positive diagnosis. The functional symptoms are dominated by neurological signs such as daytime hypersomnia and cognitive impairment often reported by those around the patient. The treatment is based mainly on continuous positive airway pressure which tolerance in elderly patients suffering from sleep apnea is similar to that of younger patients. Mandibular implants can be discussed depending on the severity of the condition. Surgical treatment is not indicated because of the increased frequency of complications.

[Determinants of quality of life in chronic obstructive pulmonary disease]. / Déterminants de la qualité de vie dans la bronchopneumopathie chronique obstructive.

INTRODUCTION: Chronic obstructive pulmonary disease (COPD) is considered as a systemic disease with pulmonary starting point. The use of spirometry alone is certainly not the best way to reflect the impact of disease on quality of life for patients. PATIENTS AND METHODS: Prospective study concerning 70 patients treated for COPD. Quality of life was assessed using the French version of the Saint-George questionnaire. RESULTS: Our population was predominantly male (97%) with a mean age of 63 years. All patients were smokers with an average of 46 pack-years. The total score of the Saint-Georges respiratory questionnaire was 50.7%. The mean scores of different fields were 68% for the field activities, 49% for impact and 26% for the item of symptoms. The multidimensional BODE index was correlated with the quality of life and its various fields were more powerfully than the forced expiratory volume per second, the number of exacerbations, the six-minute walking test and dyspnea score. CONCLUSION: It is important to integrate the multidimensional classification indices in assessing the severity of the disease because only these indices can reflect the systemic aspect of the disease.

[Pseudotumor phenotype of sarcoidosis: about two cases]. / Phénotype pseudotumoral de la sarcoïdose: à propos de deux cas.

INTRODUCTION: Sarcoidosis is a multisystem benign granulomatous disease of unknown etiology. It can sometimes cause diagnostic confusion by presenting in the form of a pseudotumor, thus constituting a trap for the unwary. COMMENTS: The authors report two cases of pseudotumor sarcoidosis. In the first, the pseudotumor occurred in the context of multisystem disease in a 48-year-old man. The response to treatment with systemic corticosteroids was complicated by the development of disseminated tuberculosis, which was rapidly fatal. The second case, by contrast, was about a 58-year-old woman and the disease was self-limiting, resolving spontaneously in less than 3 months. CONCLUSION: Through these two cases, the authors focus on the particularities of the pseudotumor manifestation of pulmonary sarcoidosis. The diagnosis is often difficult. The mismatch between the clinical picture and the extent of radiological lesions should, however, suggest the diagnosis. Histological evidence is needed to eliminate other etiologies including malignant tumors. The condition usually resolves either spontaneously or after treatment with systemic corticosteroids. However, relapses are possible, including on discontinuation of corticosteroid therapy.

[Mediastinal mature teratoma with spontaneous malignant transformation]. / Tératome médiastinal mature avec transformation maligne spontanée.

INTRODUCTION: Malignant teratomas can be either immature teratomas or they can develop after treatment of other malignant germ cell tumors with chemotherapy or radiotherapy. Spontaneous malignant transformation of mature teratomas is very rare. OBSERVATION: We report the case of a patient complaining of atypical chest pain. Chest plain radiography showed a right anterior mediastinal mass. Computed tomography revealed a heterogeneous mediastinal mass with fat areas and calcification. There were hilar and mediastinal lymph nodes as well as lung parenchymal nodules. CT-guided and then surgical biopsies confirmed the diagnosis of a mature teratoma, which had degenerated into a digestive adenocarcinoma. CONCLUSION: Spontaneous malignant transformation of mature mediastinal teratoma is very rare. The diagnosis of malignant transformation is based on radiological examinations, laboratory tests and histological studies.

[Sero-fibrinous pleurisy and anterior mediastinal mass: a curious association]. / Pleurésie séro-fibrineuse et masse médiastinale antérieure : une association curieuse.

BACKGROUND: Thymic tumors are rare representing 19 % of mediastinal masses. They are associated with several parathymic conditions. The association of thymic tumors with systemic lupus erythematosus has rarely been described. OBSERVATION: We report the case of a 20-year-old woman who presented with a sero-fibrinous bilateral exudative pleural effusion operating in a context of alteration in general status. Diagnosis of systemic lupus erythematosus was made on the basis of the presence of cutaneous symptoms, pleural effusion, hematological abnormalities and strongly positive lupus serology. Otherwise, thoracic imaging revealed a tissue mass in the thymic lodge. A diagnostic thoracothomy was carried out. Histological examination confirmed the diagnosis of thymolipoma. The patient was treated by high-dose corticosteroids combined with synthetic antimalarials. Evolution was initially favorable. Lupus nephritis stage IV occurred a year later justifying immunosuppressive therapy. A complete remission was obtained with this treatment 30months of decline. CONCLUSION: The association between lupus and thymolipoma is exceptional but not accidental. Immunological disorders secondary to the decrease of the thymic function seem to be in the origin of this association.

[Flexible bronchoscopy as it is lived by the patient]. / La bronchoscopie souple comme elle est vécue par le patient.

INTRODUCTION: Flexible bronchoscopy is an indispensable complementary exam in respiratory medicine for both diagnosis of many pulmonary diseases and their treatment. Only a few studies in literature have been conducted to evaluate the safety and acceptability of this act. PATIENTS AND METHODS: Prospective, mono-center, non-comparative study involving 120 patients who underwent a flexible bronchoscopy for diagnostic. RESULTS: During the study, flexible bronchoscopy has caused neither deaths nor major complications. However, minor incidents have been deplored: hemoptysis (13.3%), epistaxis (3.3%), desaturation less than 90% (4.2%), laryngospasm (3.3%) and vagal discomfort (1.7%). 56.7% of patients were anxious before the exam and 24% of patients preferred to have general anesthesia. The patients reported cough in 78.3% of cases, difficulty in breathing in 55% of cases and pain in 13.3% of cases. The occurrence of nausea, noted in 15.8% of cases, was correlated with the pathway of the bronchoscope (P=0.002). At the end of the endoscopy, 67.5% of patients agreed to repeat the examination, if necessary, under the same conditions. CONCLUSION: The results of our study confirm that many complications during a flexible bronchoscopy are rare and generally mild failing in life-threatening. However, the occurrence of discomfort (cough, pain, vomiting, dyspnea) or incidents (asphyxia, vagal discomfort, laryngeal spasm) are likely to alter patient comfort during the exam.

[Muscle metastasis revealing bronchial adenocarcinoma]. / Métastase musculaire révélatrice d'un adénocarcinome bronchique.

INTRODUCTION: The diagnosis of nonsmall cell lung cancer is made at a metastatic stage in 25% of cases. The most frequent sites are the lung, liver, bone, the adrenal glands and the central nervous system. Skeletal muscle metastases are uncommon and are rarely the first manifestation of a neoplastic process. CASE REPORT: We report the case of 55 years old man presenting with a hard painless swelling of the left arm. A scan guided biopsy revealed infiltration of the muscle by a thyroid transcription factor 1 (TTF1) positive adenocarcinoma. A CT scan of the chest showed a partially necrotic tissue mass with moderate uptake of contrast. The patient was treated by chemotherapy with gemcitabine and carboplatine. The progress was unfavourable with the appearance of a second muscular metastasis in the thigh and the patient died 3 months after diagnosis. CONCLUSION: Skeletal muscle metastases are rarely described in lung cancer and they are an exceptional presentation of the tumour. Their symptoms can be misleading and delay diagnosis.

[Ovarian metastasis from bronchial carcinoma]. / Métastase ovarienne d'un carcinome bronchique.

INTRODUCTION: The ovary, being a richly vascular organ, may receive metastases from numerous tissues, particularly of gynecologic origin. Extragenital cancers are dominated by gastro-intestinal and breast tumors. The lung is exceptionally described as a primary site of ovarian metastasis. CASE REPORT: We report a 28-year-old woman who was found to have a right perihilar opacity. The diagnosis of small cell bronchial carcinoma was made by bronchial biopsy. A right-sided uterine mass was also identified. This was resected and histopathology identified it as an ovarian metastasis from the pulmonary tumor. CONCLUSION: We report, through this case, and present a review of the literature on ovarian metastasis originating from bronchopulmonary neoplasms.

[Intra-alveolar hemorrhage: rare presentation of fat pulmonary embolism]. / Hémorragie intra-alvéolaire : présentation rare du syndrome d'embolie graisseuse.

INTRODUCTION: Fat embolism syndrome is a severe complication of long bone fractures, corresponding to the obstruction of small vessels by microdroplets of fat, originating from medulla ossium. Pulmonary involvement, present in 90% cases, makes the severity of the disease. CASE REPORT: We report the case of a 22-year-old man who presented, two days after industrial accident causing an opened tibial fracture, acute dyspnea with hemoptysis. Angio-CT-scan didn't show any proximal vascular obstruction, but parenchymal sections showed diffuse, bilateral and multifocal hyperdensities predominating at the periphery. Broncho-alveolar lavage brought a hemorrhagic liquid, with a high macrophage content and lipid inclusions in macrophages. Exams for the etiologic diagnosis of intra-alveolar hemorrhage were negative: renal function, 24-hour proteinuria, antinuclear antibodies, antineutrophil cytoplasmic antibodies. The diagnosis of intra-alveolar hemorrhage secondary to fat embolism was established. The outcome was spontaneously favorable. CONCLUSION: The occurrence of intra-alveolar hemorrhage in the course fat embolism is rarely reported. Its pathogenic mechanisms are not understood. It is mandatory to eliminate the other causes of alveolar hemorrhage before holding the diagnosis of fat embolism. Treatment is only symptomatic, based on respiratory reanimation.

La miliaire tuberculeuse : a propos de 29 cas

La miliaire tuberculeuse (MT) est une forme grave de tuberculose; secondaire a la dissemination hematogene de Mycobacterium tuberculosis. Le but de ce travail est d'evaluer les aspects epidemiologiques; cliniques et evolutifs des MT. Il s'agit d'une etude retrospective portant sur 29 malades atteints de MT et ages en moyenne de 38 ans. Les principaux facteurs favorisants ont ete le diabete (24) et l'ethylisme (17). Les principaux signes respiratoires ont ete la toux; les expectorations et la dyspnee ; et extra-thoraciques; les cephalees; les signes urinaires et les douleurs abdominales. Sur la radiographie thoracique; l'image de miliaire a ete notee chez 72des malades. D'autres aspects associes ont ete notes a type de cavernes (24); d'adenopathies mediastinales (17;3) et d'opacites sequellaires (10;3). Les recherches de bacilles de Koch (BK) dans les crachats se sont revelees positives dans 55des cas. Le diagnostic positif a ete porte sur des donnees bacteriologiques dans 17 cas; histologiques dans 4 cas; des arguments de presomption dans 9 cas ; un patient ayant une confirmation bacteriologique et histologique. Le traitement a comporte quatre antituberculeux; sauf dans trois cas ou elle a ete triple. La corticotherapie a ete prescrite dans 6 cas. L'evolution a ete bonne dans 28 cas avec amelioration clinique et negativation des recherches de BK dans les crachats. Un deces est survenu suite a une hepatite fulminante. La MT necessite une demarche diagnostique reflective et une prise en charge rapide afin d'ameliorer son pronostic

[A new case of pleural small cell carcinoma]. / Un nouveau cas de carcinome à petites cellules primitif de la plèvre.

Small cell carcinoma (SCC) is commonly of pulmonary origin. Pleural small cell carcinoma is a very uncommon feature. We report here a case of small cell carcinoma of the pleura in a 36 year old man. The diagnosis of primary disease SCC of the pleura was established by transparietal pleural biopsy in absence of any mediastino-pulmonary or extrathoracic other lesions that could be the primary tumor. The treatment was based on chemotherapy with cisplatin and etoposide. The patient died four months in spite of cytotoxic chemotherapy. Extrapulmonary small cell carcinoma is a rare entity. Immunohistochemistry study is very useful for the diagnosis. The prognosis seems to be worse than the small cell lung cancer.

[Pulmonary fibrosis as a presentation of Wegener's granulomatosis]. / Une fibrose pulmonaire révélant une granulomatose de Wegener.

INTRODUCTION: Pulmonary fibrosis secondary to antineutrophil cytoplasmic antibodypositive vasculitis is rarely reported. Most cases have occurred in association with microscopic polyangiitis. CASE REPORT: We report the case of an 82-year-old man presenting with pulmonary fibrosis. The CT scan showed honeycombing and traction bronchiectasis with peripheral and basal predominance. The diagnosis of Wegener's granulomatosis was based on the association of positive antineutrophil cytoplasmic antibodies, urinary sediment abnormalities and renal biopsy findings. CONCLUSION: We emphasize, through this case, the rarity of interstitial fibrosis as a pulmonary manifestation of vasculitis and we discuss the pathogenesis of this association.

[Postpartum pericardic tamponade revealing systemic lupus erythematosus]. / Tamponnade péricardique en postpartum révélatrice d'un lupus érythémateux systémique.

Pericarditis is the most common manifestation of systemic lupus erythematosus and is clinically found in 62% of the autopsies. Cardiac tamponade is a deadly but rare complication found in less than 1% of all lupus cases. It is highly revealing. The authors report the case of a 29-year old woman presenting postpartum cardiac tamponade. The diagnosis of systemic lupus erythematosus was based on the association of haematological disorders (anaemia and leukopenia), pericarditis, pleurisy and positive anti-nuclear and anti-native DNA antibodies. The patient was treated with pericardiac drainage and cortisone therapy. The evolution was favourable after 22 months. Using this case study, the authors note the rarity of cardiac tamponade as a manifestation inaugurating lupus and discuss the relationship between pregnancy and lupus disease.

[Primary pulmonary leiomyosarcoma revealed by spontaneous pneumothorax]. / Léiomyosarcome pulmonaire primitif révélé par un pneumothorax spontané

We report the case of a 57-year-old patient admitted for dyspnea and dry cough. Thoracic radiograph showed a right pneumothorax and right paracardiac opacity. Thoracic drainage was carried out allowing the return of the lung at the wall. Chest CT-scan revealed right upper mediastinopulmonary mass taking contrast material associated with a nodular thickening of the pleura. CT-guided biopsy of the mass and the pleural nodules concluded to pulmonary leiomyosarcoma. Death occurred one month after diagnosis confirmation. Pneumothorax is a usual mode of revealing sarcoma's pulmonary metastases; however, it is exceptionally associated with primitive pulmonary sarcomas. Our case is the second published case, to our knowledge, of primitive pulmonary leiomyosarcoma presenting with pneumothorax.

[A rare localization of solitary plasmocytoma]. / Une localisation rare de plasmocytome solitaire.

INTRODUCTION: Solitary bone plasmocytoma is rare, characterized by malignant plasmocyte proliferation, derived from a sole B lymphocyte clone located on a bony segment without medullar invasion. It, above all, affects the thoracolumbar spine. Costal involvement is rarely described. CASE REPORT: The authors report the case of a 60-year-old man who complained of dyspnea, dry cough, and thoracic pain four months before admission. Thoracic imaging revealed a left apical tissue mass with osteolysis of the first rib. A transparietal biopsy of the mass was not helpful. Surgical biopsy concluded as to the diagnosis of costal plasmocytoma. All of the examinations carried out to search for other localizations were negative confirming the solitary nature of the tumor. The treatment consisted of complementary radiotherapy at a dose of 45Gy. The patient was in remission after eight months. CONCLUSION: Solitary costal plasmocytoma should be called to mind when confronted with a lytic tumor of the rib. The treatment is based on surgery and radiotherapy. The prognosis is dominated by the risk of progression to multiple myeloma.

[An anterior mediastinal mass of rare etiology]. / Masse médiastinale antérieure d'étiologie rare.

Hydatid cyst of the mediastinum is very uncommon. The diagnosis, usually evident in endemic regions in the case of a typical clinical-radiological presentation, is rather more difficult in certain atypical forms. We report a case of a 19-year-old man who presented with a mass of tumour like appearance in the anterior mediastinum. The diagnosis of mediastinal hydatid cyst was established by transthoracic needle biopsy and endoscopic bronchial aspiration revealed hydatid membranous debris. The diagnosis was confirmed when the mediastinal cyst ruptured into a bronchus. Thoracotomy was carried out with an uneventful post-operative recovery. This observation illustrates the diagnostic difficulties when a mediastinal hydatid cyst presents the appearances of a tumour. This possibility must be included in the differential diagnosis of every mediastinal mass, particularly in endemic regions.

[Thymoma associated with pure red cell aplasia and Kaposi's sarcoma]. / Association thymome, érythroblastopénie et sarcome de Kaposi.

INTRODUCTION: Thymoma is a rare tumor which represents about 20% of mediastinal tumors. It is associated with several parathymic conditions. A second cancer frequently occurs during long term follow up. CASE REPORT: We report the case of a 59 year-old woman who presented with a two month history of a dry cough. Thoracic imaging revealed a soft tissue mass in the anterior mediastinum with associated bilateral pleural effusion and mediastinal lymphadenopathy. Fibreoptic bronchoscopy was normal. CT guided-biopsy was not contributive. A diagnostic mediastinoscopy was carried out. Histological examination confirmed the diagnosis of thymoma. The patient was treated with 4 cycles of chemotherapy which led to a partial regression of the mass. The course was marked by the occurrence of a pure red cell aplasia requiring corticosteroid therapy which caused the disappearance of the anemia. However, bluish nodules appeared on the patients legs which when biopsied were found to represent Kaposi's sarcoma. The patient was treated with chemotherapy (vinblastine) without any improvement of the cutaneous lesions. CONCLUSION: Our case describes the association of a thymoma, pure red cell aplasia and Kaposi's sarcoma. Immunologic disorders seem to be in the origin of this association.

[Tracheal involvement revealing Hodgkin's disease. A case report]. / Atteinte trachéale révélatrice d'une maladie de Hodgkin.

Inaugural tracheobronchitis is a rare but known manifestation of Hodgkin's disease. Clinical signs are often misleading, retarding diagnosis and treatment. We report a case of Hodgkin's disease revealed by wheezing with minimal hemoptysis. Histology of the endoscopic biopsies demonstrated Hodgkin type infiltration of the trachea with mixed cellularity. The patient was given chemotherapy and mediastinal radiotherapy and achieved complete remission.