[Tumor-bronchial actinomycosis simulating a recurrence of lung cancer 14 years after initial treatment: A case report]. / Actinomycose bronchique pseudo-tumorale simulant une ré-évolution d'un cancer bronchique 14ans après la prise en charge thérapeutique initiale : à propos d'un cas.

A patient with a history of squamous cell carcinoma of the right upper lung lobe treated 14 years before by concomitant chemo-radiotherapy was referred on account of dyspnea. Bronchial endoscopy revealed complete obstruction of the right main bronchus highly suggestive of a tumor recurrence. However, biopsy samples only showed inflammatory and necrotic tissue with no evidence of malignancy. Despite complete tissue resection by rigid bronchoscopy, a rapid and complete recurrence occurred requiring the placement of a Y-shaped bronchial prosthesis. Repeat histological, bacteriological and mycological analyses were negative. The patient was soon readmitted to hospital for a lung infection due to recurrence of obstruction inside and around the prosthesis. Bacterial examination of biopsy samples identified Actinomyces meyeri. Appropriate antibiotic therapy led to a complete regression of the bronchial obstruction. Unfortunately, the patient died a few months later due to massive hemoptysis after the removal of the prosthesis. Autopsy examination showed a fistula between the right main bronchus and pulmonary artery, with no evidence of neoplastic recurrence nor the persistence of lesions associated with actinomycosis.

[Early detection of COPD in primary care: which tools?]. / Sujets à risque de BPCO en médecine générale: comment favoriser la réalisation de spirométries et la détection précoce de l'obstruction bronchique?

INTRODUCTION: The early diagnosis of COPD in general practice is not satisfactory. OBJECTIVES: To evaluate the impact of different diagnostic tools (Piko-6, Software) in general practice (GP). METHODS: A multicentre, randomised, controlled study in GP assessing the effect of the tested strategies on the rate of referrals for spirometry and the rate of detection of airflow obstruction. RESULTS: One thousand one hundred and three patients (55 years old, 60% males, 31 years of smoking habits) were included by 248 GP. The rates of referal to a pneumologist were significantly higher in the Software (50% of patients), and Piko/Software (47%) groups than in the Control (22%) and Piko groups (28%). A high proportion (44%) of lung function tests recommended by the GP were not performed, often because of patient refusal. The confirmation rates were lower in the Software and Piko/Software groups (47% and 43%, respectively) compared with the Piko and Control groups (68% and 79%, respectively). Concordance between PFT and Piko-6 for the diagnosis of airflow obstruction was poor (about 50%). CONCLUSIONS: The use of software in association or not with the Piko-6 was useful for GPs to identify patients to refer for further lung function testing, but did not improve the confirmation of the obstructive syndrome, mainly due to reluctance of patients to go on to have further lung function tests. The use of a diagnostic tool (software and/or mini-spirometry) does however seem to improve early COPD detection.

[Associated factors for sleep apnea in heart failure]. / Facteurs associés au syndrome d'apnées du sommeil dans l'insuffisance cardiaque.

OBJECTIVE: Genesis of sleep apnoea syndrome (SAS) in chronic heart failure (CHF) is not well known. The aim of our study was to find associated factors to SAS in heart failure (HF) and to look for differences between central sleep apnea (CSA) and obstructive sleep apnea (OSA). PATIENTS AND METHODS: We realised a cross-sectional and retrospective study. Thirty patients with stable heart failure under medical optimal therapy were included. Polygraphy, echocardiography and cardiopulmonary exercise were systematically performed. RESULTS: Men were predominant (80%) in the group. Mean age, left ventricular ejection fraction (LVEF) were respectively 64.1±13.8years and 40±9.8%. SAS was present in 60% of patients (33.3% were classified as central sleep apnoea [CSA] and 26.7% as obstructive sleep apnoea [OSA]). Body mass index, blood pressure and left ventricular pressures estimated by the E/Ea ratio were significantly higher in the group with SAS (P<0.05) compared to the non SAS group. New York Heart Association class was significantly higher (P=0.04) and the predicted peak VO(2) was significantly lower in CSA patients compared to OSA patients. CONCLUSION: High left ventricular pressures estimated by the E/Ea are significantly associated with SAS in heart failure. CSA patients tend to have a worse functional state than OSA patients.

[Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia: a rare preneoplastic condition]. / L'hyperplasie neuroendocrine pulmonaire idiopathique: une lésion prénéoplasique méconnue.

Diffuse idiopathic pulmonary neuroendocrine cell hyperplasia (DIPNECH) is an uncommon preneoplastic condition, often associated with typical carcinoid tumours. The observations reported below concern two women, both suffering from chronic pulmonary symptoms. These patients underwent computed tomography that showed a solitary nodule in the first patient and multiple sub centimetre nodules in the second. In both cases histological studies of the pulmonary biopsies revealed: a proliferation of neuroendocrine cells dispersed in the bronchial and bronchiolar epithelium, more specifically superficial to the basement membrane; some tumourlets; a typical carcinoid tumour was also found in the first patient's biopsy. The choice of treatment remains difficult, mainly because the existing studies are restricted to small numbers of patients or isolated cases, a consequence of the low prevalence of this disease. Considering its slow evolution, management by long-term clinical, endoscopic and radiologic surveillance may be considered. If a carcinoid tumour is present or appears during the surveillance, the standard treatment is still surgical resection.

[Idiopathic constrictive péricarditis revealed by a massive left pleural effusion]. / Epanchement pleural gauche massif révélateur d'une péricardite constrictive idiopathique.

INTRODUCTION: We report a case of constrictive péricarditis initially revealed by a massive left sided pleural effusion. CASE REPORT: The patient was dyspnoeic without any associated clinical signs. Only cardiac catheterization gave the diagnosis with a characteristic dip-plateau of the right ventricle. After full assessment, no aetiology was found. CONCLUSION: After a treatment with corticosteroids, the progress has been favourable to date.

[Changes in inspiratory capacity during acute respiratory failure in COPD patients]. / Evolution de la capacité inspiratoire au cours de la BPCO décompensée.

INTRODUCTION: Inspiratory Capacity (IC), which reflects dynamic pulmonary hyperinflation, correlates with outcome in moderate exacerbation of COPD. Whether this is also true in COPD with acute respiratory failure (ARF) has not been studied. METHODS: A prospective multicenter assessment of IC measurement feasibility, reliability, time-course and relationship to outcome in COPD with ARF was conducted. Dyspnea (visual analogue scale) and IC were repeatedly measured. Outcome was classified as not favourable (death or intubation or non invasive ventilation increased or patient referred to ICU from respiratory ward) or favourable (none of the above criteria). RESULTS: Fifty patients were included and 48 analysed. IC measurement was possible in all but one patient and its coefficient of variation was 9+/-8%. Between inclusion into the study and discharge, IC increased from 39.9+/-15.5 to 50.2+/-14.5% pred (p<0.001) and dyspnea declined from 48+/-23 to 33+/-22 mm (p<0.001). Inclusion IC was not different on average between patients with or without favourable outcome. CONCLUSION: In COPD patients with ARF, IC measurement at bedside was feasible and reproducible. IC was low at entry and increased over time from inclusion to discharge tending to correlate with patient outcome.

[Oxidatif-stress and COPD. Role of infection. Prevention]. / Stress oxydatif et BPCO. Rôle des infections. Prévention.

For the next decade, COPD will become the third cause of mortality in the world. COPD is mainly due to cigarette smoking and presents different levels of severity according to people, probably linked to environmental and genetic factors, which are not well documented. Recent publications pointed out bacterial bronchial colonization and exacerbations of infectious origin as worsening factors through a pro-inflammatory effect and oxidative stress. This should lead to a comprehensive review of anti-infectious prevention tools and to discuss the role of prophylactic antibiotherapy and antioxidants.

The effect of tiotropium on hyperinflation and exercise capacity in chronic obstructive pulmonary disease.

BACKGROUND: Chronic obstructive pulmonary disease (COPD) is characterized by airflow limitation, which results in the progressive development of dyspnea and exercise limitation. OBJECTIVE AND METHODS: To compare the effect of tiotropium with placebo on forced vital capacity (FVC) in patients with moderate-to-severe COPD and lung hyperinflation, using exercise endurance, dyspnea and health-related quality of life (HRQoL) as secondary endpoints. One hundred patients were randomized to receive either tiotropium 18 mug once daily or placebo for 12 weeks. RESULTS: Trough (predose) FVC was significantly improved with tiotropium compared to placebo on day 42 (0.27 +/- 0.08 liters) and 84 (0.20 +/- 0.08 liters; p < 0.05 for both). Trough inspiratory capacity (IC) was also significantly improved with tiotropium compared to placebo on day 42 (0.16 +/- 0.07 liters) and 84 (0.15 +/- 0.07 liters; p < 0.05 for both). Tiotropium increased the mean distance walked during the shuttle walking test by 33 +/- 12 (day 42) and 36 +/- 14 m (day 84) compared to placebo (p < 0.05 for both). On day 84, 59% of the patients in the tiotropium group and 35% of the patients in the placebo group had significant and clinically meaningful improvements in the St. George's Respiratory Questionnaire total score (p < 0.05). Numerical decreases in the focal score in the Transition Dyspnea Index in patients receiving tiotropium versus placebo suggest that tiotropium also improved dyspnea during activities of daily living. CONCLUSION: Tiotropium 18 mug once daily reduced hyperinflation with consequent improvements in walking distance and HRQoL in patients with COPD and lung hyperinflation.

[Disseminated actinomycosis]. / Actinomycose disséminée.

INTRODUCTION: We report the case of a patient suffering from disseminated actinomycosis. CASE REPORT: A fifty-two year old man, who was both a heavy smoker and an alcoholic, was admitted to hospital with confusion associated with a pseudo-tumoral right upper lobe pneumonia. Brain computed tomography was normal on the day of admission but when repeated fifteen days later four lesions were seen with appearances suspicious of metastatic malignant disease. The isolation of Actinomyces odontolyticus in the bronchoalveolar lavage culture and the absence of evidence for neoplastic disease despite extensive investigation led to a diagnosis of disseminated actinomycosis with pulmonary and cerebral involvement. The patient's clinical condition improved with antibiotic therapy. The disseminated form of this infection as well as presentation with multifocal brain abscesses is rare. CONCLUSION: The diagnosis of actinomycosis is problematic because it is an uncommon infection and microbiological identification is often difficult and delayed. It should be considered when clinical presentation suggests malignant disease but there is no histological confirmation.

[Oxidative stress in bronchopulmonary disease: contribution of N-acetylcysteine (NAC)]. / Le stress oxydatif en pathologie broncho-pulmonaire: apport de la N-acétyl-cystéine (NAC).

Oxidative stress is a frequent mechanism involved in the pathogenesis of bronchopulmonary disease. The cause can be exogenous, in particular related to to atmospheric pollution and tobacco smoke, or endogenous, related to mobilization of inflammatory cells (macrophages and polymorphonuclear neutrophils). In this general review, we present work demonstrating this oxidative stress and activation of inflammatory cells. We discuss the effect of oxidative stress on the bronchial tree and the need to maintain an adequate balance between oxidants and anti-oxidants. This reviews focuses on experimental studies proving the anti-oxidant effect of NAC on glutathione synthesis and on different pharmacological models. We then discuss human trials, initially experimental then in different bronchopulmonary pathologies related to oxidative stress. Acetaminophen intoxication and pulmonary fibrosis are models for use of NAC. Recent work on COPD appears to show a decrease in exacerbations, improvement in symptoms and quality-of-life, and perhaps a reduction in the alteration of ventilatory function.

["Spontaneous" resolution of two severe methotrexate-induced pneumonias]. / Résolution spontanée de deux pneumopathies sévères au méthotrexate.

The beneficial role of corticosteroid therapy for the treatment of methotrexate-induced pneumonia remains controversial. We report two cases of acute severe interstitial pneumonia induced by methotrexate in patients with non-Hodgkin lymphoma given a polychemotherapy protocol (M'BACOD). The first signs appeared on the eleventh day of the first cycle in patient one and on the tenth day of the third cycle in patient two. The causal implication of methotrexate was based on the history, the clinical and radiological presentation, and the negative tests in both patients: lymphocyte alveolitis with granulomatous lesions on the transbronchial biopsy in patient one and positive leukocyte migration test in the presence of methotrexate in patient two. Early acute respiratory failure required high flow rate oxygen therapy with positive expiratory pressure ventilatory assistance. The course was rapidly favorable both for blood gases and radiographic presentation without corticosteroids. These two cases illustrate that pulmonary disease can be cured without corticosteroids despite severe respiratory failure at onset. This provides a further argument on reservations about using corticosteroids for suspected methotrexate-induced pneumonia.

[Psychological profile of patients with COPD: contribution of Semiometry]. / Profil psychologique des malades porteurs de BPCO. Apport de la Sémiométrie.

Patients with chronic bronchitis often ignore, or pretend to ignore, their disease and generally consult very late. The physician's advice is often quite vague and centered on smoking. One of the objectives of this study was to better understand the psychological profile of patients with chronic bronchitis in order to better apprehend the patient-physician relationship and therapeutic options. Semiometry was designed to overcome the problem encountered by physicians who would like to understand who their patients are without directly asking them. The concept is based on submitting very ordinary words to these subjects and asking them whether they like the word or not. An analysis of their responses allows a very deep understanding of their psychological profile. Briefly, the patient-physician relationship is quite difficult in COPD. The patient "brings" the disease to the physician, "putting" it in his hands and asking him to cure it without having to do anything concerning himself, his life or his behavior. The physician is called on to answer this challenge that can be expressed as "trying to get the patient to play the game without getting caught".

[Mediastinal adenopathies and presence of anti-cytoplasmic antibodies of diffuse type polynuclear neutrophils]. / Adénopathies médiastinales et présence d'anticorps anti-cytoplasme des polynucléaires neutrophiles de type diffus.

We report a case of sarcoidosis with mediastinal and pulmonary localizations associated with diffuse antineutrophil cytoplasmic antibodies (c-ANCA). This led to discuss the differential diagnosis with vascularitis and the specificity of c-ANCA in Wegener's granulocytosis.

Effectiveness of low doses (50 and 100 microg b.i.d) of beclomethasone dipropionate delivered as a CFC-free extrafine aerosol in adults with mild to moderate asthma. Study Group.

The objective of this study was to evaluate the efficacy and safety of low doses (50 and 100 microg b.i.d.) of hydrofluoroalkane-134a (HFA) beclomethasone dipropionate (BDP) extrafine aerosol in improving asthma control. Reformulation of BDP in a new chlorofluorocarbon (CFC)-free propellant (HFA) has produced an extrafine aerosol with increased delivery of the drug to the airways of the lung. The study population comprised 270 steroid-naive patients with mild to moderate asthma (mean baseline forced expiratory volume in 1 sec [FEV1] as a percentage of predicted normal of 65%-85%). This was a 6-week, blinded, placebo-controlled, multicenter study. Patients were randomized to receive 50 or 100 microg b.i.d. HFA-BDP or HFA-placebo. Treatment with either 50 or 100 microg b.i.d. HFA-BDP resulted in a significantly greater improvement compared with placebo in FEV1 (mean change from baseline as percentage of predicted normal of 6.7%, 8.6%, and 0.4%, respectively; p < or = 0.01 active treatment groups vs. placebo), with a significant trend toward increasing improvement with increasing doses (p < or = 0.0001). Treatment also resulted in significantly greater mean changes from baseline in morning peak expiratory flow compared with placebo (29.5, 33.8, and 5.0 L/min, respectively; p < or = 0.01 active treatment groups vs. placebo). All other pulmonary function and asthma symptom measures supported these data. The study treatments were well tolerated. These results show that low doses of HFA-BDP extrafine aerosol effectively improve asthma control in adult patients with mild to moderate asthma. However, it is important that inhaled corticosteroid therapy is still given at a dose high enough to control airway inflammation as well as asthma symptoms.

[Rare pulmonary complication in intravesical BCG treatment]. / Complication pulmonaire rare d'un traitement par BCG intravésical.

We report a case of epithelioid granulomatous allergic lung disease in a patient given intra-bladder BCG therapy for treatment of a tumor. This uncommon complication is sometimes related to bacterial dissemination or to an immunoallegic reaction occurring from the third to eigth week after onset of the instillation. Clinically, the patient presents a flu-like syndrome. The standard chest X-ray followed by computed tomography, demonstrates the extension of the pulmonary lesions. Miliary dissemination is rarely reported (10 cases in the literature). Histological proof can be obtained from an endoscopic bronchial biopsy or a surgical specimen of the pulmonary parenchyma. Treatment is based on corticosteroid therapy in combination with antituberculosis antibiotics. Prognosis is generally good with treatment.

[Post-cardiac injury syndrome: an rare cause of pleurisy, value of pleural fluid analysis]. / Syndrome de post-agression cardiaque: une étiologie rare de pleurésie, intérêt de l'analyse du liquide pleural.

The post-cardiac injury syndrome is an inflammatory process concerning the pericardium, the pleura and/or the pulmonary parenchyma, that develops after different kinds of cardiac aggression. The diagnosis can be evoked when some clinical and biological results are present but remains one of exclusion. We report a case of post-cardiac injury syndrome for which we demonstrate an immunologic involvement of the pleura. The antimyocardial antibodies and the low complement index found in the pleura strongly support an immunologic process, and this suggests that the analysis of the pleural fluid could be useful for the diagnosis of the post-cardiac injury syndrome.

[Fortuitous discovery of infiltration of the lung bases]. / Découverte fortuite d'un aspect infiltratif des bases pulmonaires.

We report a case of interstitial pneumonia found by a woman who suffered from a gastroesophageal reflux unamenable to usual treatments. The HR-tomographic discovery of a tone esophagus lead to a manometric study. The association of high autoantibodies levels and radiographic and manometric data were characteristic of esophageal and pulmonary scleroderma.

[Anaphylactic reactions to systemic corticosteroids. Review of the literature concerning 3 cases]. / Réactions anaphylactiques aux corticostéroïdes systémiques. Revue de la littérature à propos de trois cas.

Despite their antiinflammatory and antiallergic properties, corticosteroids can nevertheless cause adverse allergic reactions. This is currently accepted for local corticosteroids and there have also been about a hundred reports of variable pertinence concerning hypersensitivity reactions to systemic corticosteroids. Based on three cases of immediate hypersensitivity reactions after taking methylprednisolone, we propose a critical review of the literature, focusing particularly on methylprednisolone-induced reactions. The means of investigation currently available in drug-induced hypersensitivity reactions are also discussed.