Pneumocystis jirovecii pneumonia in a healthy immunocompetent patient: A case report and literature review.

Pneumocystis jirovecii pneumonia, typically an opportunistic infection, is commonly associated with risk factors such as low CD4+ lymphocyte count, underlying malignancies, organ transplantation, or immunosuppressive medications. However, occurrences in healthy individuals without known risk factors are exceptionally rare and sparsely documented. In our retrospective analysis of a 42-year-old male without past medical history at Abderrahmane Mami Hospital, Tunisia, Pneumocystis jirovecii pneumonia was diagnosed. The patient presented with fever, productive cough, hemoptysis, and a decline in general health. Clinical examination revealed fever and hypoxemia, and imaging studies demonstrated bilateral necrotic alveolar opacities. Despite empirical antibiotics, nonresponse necessitated bronchoscopy, confirming Pneumocystis jirovecii. Treatment with oral Sulfamethoxazole-Trimethoprim yielded excellent outcomes. This case highlights the potential occurrence of Pneumocystis jirovecii pneumonia in immunocompetent individuals, underscoring the importance of direct microbiological methods in assessing suggestive clinical and radiological features.

Challenges and recommendations for the management of asthma in the Middle East and Africa.

Clinical presentation of asthma is variable, and its diagnosis can be a major challenge in routine health-care practice, especially in low-and-middle-income countries. The aim of asthma management is to achieve optimal asthma control and to reduce the risk of asthma exacerbations and mortality. In the Middle East and in Africa (MEA), several patient- and physician-related factors lead to misdiagnosis and suboptimal management of asthma. A panel of experts comprising of specialists as well as general health-care professionals met to identify challenges and provide recommendations for the management of asthma in MEA. The major challenges identified for diagnosis of asthma were lack of adequate knowledge about the disease, lack of specialized diagnostic facilities, limited access to spirometry, and social stigma associated with asthma. The prime challenges for management of asthma in MEA were identified as overreliance on short-acting ß-agonists (SABAs), underprescription of inhaled corticosteroids (ICS), nonadherence to prescribed medications, and inadequate insurance coverage for its treatment. The experts endorsed adapting the Global Initiative for Asthma guidelines at country and regional levels for effective management of asthma and to alleviate the overuse of SABAs as reliever medications. Stringent control over SABA use, discouraging over-the-counter availability of SABA, and using as-needed low-dose ICS and formoterol as rescue medications in mild cases were suggested to reduce the overreliance on SABAs. Encouraging SABA alone-free clinical practice in both outpatient and emergency department settings is also imperative. We present the recommendations for the management of asthma along with proposed regional adaptations of international guidelines for MEA.

Subcutaneous sarcoidosis with thoracic involvement: A very rare presentation of the disease.

Subcutaneous sarcoidosis is a very rare manifestation of sarcoidosis and its association with parenchymal lung involvement is rarer. We report the twentieth case in the literature published on PubMed. It is the case of a 61-year-old caucasian, non-smoker lady, who presented to a dermatology department with a 7-month history of asthenia, anorexia, weight loss, fever, exertion dyspnea, dry cough, arthralgia of the large joints and non-tender multiple subcutaneous tumefactions. Biopsy of the nodules established the diagnosis of subcutaneous sarcoidosis. Bronchioloalveolar lavage revealed alveolitis with lymphocyte predominance and the CD4/CD8 ratio was 8.5. Chest computed tomography scan revealed peribronchovascular thickening, micronodules of lymphatic distribution and mediastinal lymphadenopathies which were bilateral, asymmetric, and non-compressive. We therefore concluded the involvement of the lung and the mediastinal lymph nodes. The angiotensin-converting enzyme level was high. The patient was successfully treated with prednisone at the dose of 1mg/kg/day.

Implementation of the WHO Framework Convention on Tobacco Control in Tunisia: Progress and challenges.

INTRODUCTION: The World Health Organization Framework Convention on Tobacco Control (WHO FCTC) was the first health treaty that requires state parties to adopt and implement the MPOWER package. The aim of this study is to review the current status of tobacco control policies in Tunisia according to the WHO FCTC recommendations. METHODS: This paper is a critical narrative literature review in which information was obtained from peer-reviewed articles, official government documents, reports, decrees and grey literature in French, Arabic and English. RESULTS: Modest progress in FCTC implementation in Tunisia was noted. The smoking ban in public places is not regularly or largely enforced. The advertising and promotion for tobacco and its products is prohibited by law, but, the ban does not cover the display and visibility of tobacco products at points-of-sale, through the internet, and the depiction of tobacco or tobacco use in entertainment media products. Health warnings on tobacco products consist only of text and do not exceed 30% of the main display areas but are expected to increase to 70% with graphics and text when the new law is passed. CONCLUSIONS: Effective intervention efforts are urgently required. These actions should include accelerating the adoption of a new law, enforcing the present law and the new one once adopted, developing an advocacy and argument about the positive impact on state budget balance, increasing taxes, combating smuggling and illicit manufacturing and counterfeiting, increased education, increased smoking cessation support and implementing periodic surveillance.

Cold abscess in the immunocompetent subject.

INTRODUCTION: Tuberculous cold abscesses are a rare and unusual form, accounting for 1% of extrapulmonary tuberculosis (TB). AIM: To describe clinical, diagnostic, therapeutic and prognostic aspects of cold tuberculous abscesses. METHODS: Retrospective multicentre study of 26 patients followed for cold abscesses tuberculous in respiratory departments of AbderrahmenMami hospital between 2009 and 2017. RESULTS: We included 24 patients. Mean age was 36.9 years. Six patients had a personal history of pulmonary TB. Circumstances of the discovery were chronic pain (n = 15), parietal swelling (n = 7) and parietal fistulization (n = 2). The mean duration of the symptoms was 2.8 months. Fever was absent in 15 patients. The cold abscess was multifocal in 3 patients, associated with pleuropulmonary TB in 16 patients and extrapulmonary TB in 9 patients. Thoracic wall was the most frequent localization (n=13), followed by subcutaneous and intramuscular localization (n = 6). The surgical flattening of the abscess with biopsy of the edges was performed in 15 patients. The positive diagnosis was pathological in 15 patients and bacteriological in 12 patients. GeneXpert was positive in 2 patients. All patients received anti-tuberculosis treatment. The mean duration of TB was 10.7 months. Evolution was marked by the cure of 20 patients and tuberculous relapse in 1 patient after 6 months. CONCLUSION: Tuberculous cold abscess should be evoked in front of any chronique collection occurring especially in a context of risk factors of TB. Early diagnosis is the best guarantee of a cure without complications.

About molecular profile of lung cancer in Tunisian patients.

BACKGROUND: Molecular profile of lung cancer is well known in developed countries. These countries reached the era of liquid biopsies, immunotherapy, and urine circulating tumor DNA. The discrepancies between developed countries and developing ones are becoming deeper. Because of a lack of data in Tunisia, we tried to analyze the molecular profile of non-small-cell carcinomas and to assess the morphologic subtype of adenocarcinomas according to their mutational profile. METHODS: We performed molecular analyses in Tunisia and in France of 84 patients who were able to afford the cost of the diagnostic techniques carcinomas diagnosed between 2012 and 2015. The diagnosis was established in our Department of Pathology and the percentage of the tumor cells was estimated by the pathologists. The paraffin-embedded blocks were sent to France, in 41 cases and were analyzed in Tunisia in 43 cases. A next-generation sequencing was performed in France and a real-time polymerase chain reaction (PCR) was performed in our country. RESULTS: During the period of study, 1122 lung cancers were diagnosed and 87 patients were able to afford the molecular analyses cost. The mean age of these patients was 53 years. The sex ratio reached 1.9. The molecular analyses were not performed in three cases because of a low tumor cell rate. EGFR mutations were present in 16 cases: 3 men and 13 women. The adenocarcinomas were classified as acinar in 11 cases and solid in 5 cases. ALK-EML4 translocation was present in six cases. Mutations of BRAF, KRAS, P53, and ERBB4 genes were, respectively, detected in two cases, five cases (3 codon 12), three cases, and one case. CONCLUSION: This study made us wonder about the possibility of implementing molecular techniques in low-income countries and about the necessity of optimizing the financial resources.

Spontaneous pneumothorax secondary to tuberculosis.

INTRODUCTION: Spontaneous pneumothorax (SP) is a frequent complication of pulmonary tuberculosis (TB) and a severe form of the disease. In spite of the fact that TB is a common cause of pneumothorax, a very few series, have been reported. METHODS: We retrospectively analysed the experience of SP secondary to TB in patients who were hospitalized in our department between 2005 and 2015. RESULTS: The mean age of patients was 38,5±19 years. Two patients had a history of pulmonary tuberculosis. The chest x-ray showed a pneumothorax in 5 cases, a hydropneumothorax in 5 cases and cavitary lesions accompanying SP in 5 cases. Acido-alcoolo-resistant bacilli were isolated in the expectorations in all patients. Treatment associated antitubercular chemotherapy in compliance with the national plan of struggle against tuberculosis, chest drainage and respiratory physiotherapy. The average duration of chest tube drainage was 23 days. Two patients underwent surgery. The course was favourable in 5 cases. A delay (>1month) to bacilli negativation was noticed in 2 patients and pachypleuritis requiring surgical pleural decortications in 2 patients. CONCLUSION: In our study, tubercular pneumothorax was always associated with active cavitated tuberculosis. The course was most of the time favourable with antitubercular chemotherapy and chest drainage. However, pleural sequelae such as pachypleuritis persisted sometimes.

Use of the concept mapping in teaching during a medical rotation of interns: an exploratory study.

INTRODUCTION: Concept mapping is an excellent learning toolallowing to stimulate active learning.For this reason, the concept mapping is currently used increasingly in the medical and paramedical field. The aim of our study is to determine the contribution of teaching of medical interns by the concept mapping. METHODS: Fourteen students enrolled at the same time in a medical rotation in Pulmonology were recruited for this exploratory study. Interns are divided into two groups (A and B).Both groups are taught by the clinical case method, illustrated by a concept mapping for group A interns. RESULTS: The evolution of the knowledge accuracy at post-testing has been greater in the group taught by the method of concept mapping: the number of correct responses increased in all participants of group A versus only 4 of group B. All students taught by concept mapping had at the post-test a note higher than or equal to 10/20 versus only three of the group taught by the method without concept map. The average score was 13 (11-15) in group A versus 10.28 (6-14) in group B. CONCLUSION: We emphasize the use of concept mapping in teaching especially in the faculty of medicine and we encourage clinicians to use this method in teaching interns in the hospital.

Particularities of community- acquired pneumonia in the elderly.

BACKGROUND: Acute community-acquiredpneumonia in olderadults has averysevereprognosiswith a mortality rate whichcanreach 10%. Knowing the clinical, etiological, therapeutic and progressive features of thisdiseasecan help to establish management rulesthatcanimprove the prognosis. The aim of ourstudywas to compare the community-acquiredpneumonia profile in olderadults and youngerthem. METHODS: Retrospective comparative studyincluding patients hospitalized for community-acquiredpneumonia. Two groups of patients weredefined: group 1 subjectsagedbetween 18 and 64 years and group 2 subjectsaged 65 years and older. RESULTS: The meanage of elderlywas 76±6,18. COPD was five times more common in group 2 (p = 0.0001). Symptomsweredifferent in the two groups withpredominance of dyspnea in the group of elderly. Prognosisfactors scores (PSI and CURB_65) in elderlywerehighercompared to youngersubjects. Sputum culture wascontributory in third cases in both groups. Pseudomonas aeruginosawas the mostcommonpathogenidentified in the elderly. Empiricaltreatmentwas the mostprescribed in both groups. Evolution was more favorable in group 1 (p = 0.006). Complications, hospitalization in ICU and delay of recoveryweremostcommon in the group 2. CONCLUSION: Our studyconfirmedsomecharacteristics of community-acquiredpneumonia in elderly; it has mostlyrevealed the importance of microbiological tests in this population.

Particularities of COPD exacerbations in different phenotypes of the disease in Tunisia.

BACKGROUND: Chronic Obstructive Pulmonary Disease is defined by a limitation of airflow. This disease is characterized by exacerbations that threaten the patient's life and worsens his prognosis. Moreover, COPD patients are different according to many parameters that define different phenotypes. Characteristics of exacerbations may depend on these phenotypes according to few recent studies. AIM: To determine the characteristics and the prognosis of the exacerbations in each phenotype of COPD patients phenotype in Tunisia. METHODS: Retrospective study including 153 male patients hospitalized for COPD exacerbation from January 2009 to June 2012. Patients were classified into 4 phenotypes according to Burgel's classification. RESULTS: Patients were divided into four phenotypes: phenotype (PH)1: (n=68), PH2: (n=33), PH3: (n=25) and PH4: (n=27). Mean age for PH1, 2, 3 and 4 was: 61, 74, 56 and 72 years. The number of exacerbations per year was higher in PH1. Dyspnea was more important in PH1 and 4. Hypercapnia on admission was higher in PH4. Non invasive ventilation and transfer to resuscitation unit were more frequently mandatory in PH3 and 4.   Death occurred 2% of PH1 and 5% of PH4. Hospitalization duration was more important in PH4. CONCLUSION: COPD patients are heterogenous and belong to different phenotypes. The characteristics of the exacerbations and their prognosis widely differ according to these different groups. In Tunisia, it seems that patients who had moderate respiratory functional tests impairment are the lowest responders to treatment with a higher frequency of resuscitation unit transfer.

Patient taking chemotherapy for a small cell lung cancer: not every cerebral nodule is a metastasis: the tree that hides the forest.

We report the case of a 53- year-old man in whom the diagnosis of small cell lung cancer (SCLC) was made by the biopsy of a mass of the right trapezius muscle. A tumor was revealed on flexible bronchoscopy which pathological study showed tuberculosis (TB). Chest computed tomography (CT) scan revealed findings related to the SCLC associated to micronodules and nodules compatible with pulmonary TB. Cerebral CT scan revealed a nodule of 4.5 mm in diameter presenting enhancement after contrast material injection thought to be a metastasis. The patient was administered antitubercular treatment. Fiveteen days later, the patient started chemoptherapy with etoposid and carboplatin. A control cerebral CT scan realized after the end of the chemotherapy (2 months and a half of antitubercular treatment) revealed numerous cortical and subcortical infracentimetric nodules with contrast enhancement with a tentorial and subtentorial location considered to be in relation with cerebral miliary TB. The nodule discovered on the first cerebral scan was therefore a posteriori considered to have been of tubercular origin. The PS of the patient rapidly worsened. He presented mental confusion and died in some days.