[Multi-resistant tuberculosis at the hôpital d'instruction des armées de Libreville (Gabon) about 16 cases]. / Tuberculose multirésistante à l'hôpital d'instruction des armées de Libreville (Gabon) à propos de 16 cas.

According to WHO estimates, between 1 and 20% of tuberculosis cases in the world are multiresistant. In Gabon, this prevalence is estimated at 1.9%. In this forward-looking study from March 2006 to August 2010, we report 16 cases of multi-resistant tuberculosis out of 24 suspected resistant samples (persistence of the clinical and radiological signs after three months of well conducted treatment with first-line anti-tuberculous drugs). This study is realized in association with the laboratory of mycobacterium of the Percy military teaching hospital, Clamart, France.

[Aetiology of AFB negative pneumonias in hospitalized HIV patients in Dakar]. / Étiologie des pneumonies BAAR négatives chez les patients infectés par le VIH hospitalisés à Dakar (étude ANRS 1260).

A prospective study was carried out in two tertiary hospitals in Dakar to determine the main causes of sputum acid-fast bacillus (AFB) smear-negative pneumonia in HIV-infected patients. All clinical and microbiological records were reviewed by experts. Seventy patients were finally enrolled. Most of them were hospitalized at an advanced stage of AIDS. The median CD4 cell count was 62/mm(3) and the median body mass index (BMC) was 18 kg/m(2). Thirty-one patients (44 %) were known as seropositive for HIV infection prior to admission. Radiological opacities were localized in 70 % of patients and diffuse in 21 %. Fiberoptic bronchoscopy was performed in 50 patients (71 %). A definite or probable diagnosis was obtained in 55 patients (79 %). Bacterial pneumonia (usually due to Enterobacteriaceae and Pseudomonas aeruginosa), tuberculosis, Pneumocystis pneumoniae and other causes (Kaposi's sarcoma, atypical mycobacteria) were diagnosed in 67 %, 24 %, 5 %, and 13 % of these patients respectively. In conclusion, pneumonia of bacterial origin and tuberculosis can be incriminated in the majority of cases of AFB negative pneumonia observed in HIV patients in Dakar.

[Pleuro-pulmonary manifestations disclosing hepatic amoebiasis]. / Manifestations pleuropulmonaires révélatrices de l'amibiase hépatique.

During a mission in ex-Yugoslavia between 2001 and 2004, three French soldiers were sent home because of right pneumopathy, right pleurisy after appendicectomy, haemoptysis and liver haematoma, respectively. They previously were stationed in Africa and/or South America. The initial diagnosis was quickly modified: pleuropulmonary manifestations of amoebic hepatic abscess in two cases, and pleuropulmonary amoebiasis in the last case. The outcome was favourable with standard anti-amoebic treatment. The reports illustrate the possibility of hepatic amoebiasis with local pleuropulmonary manifestations and an exceptional case of pleuropulmonary amoebiasis with hepatobronchial fistula. The authors report this experience because it demonstrates that amoebiasis in European countries remains an often forgotten diagnosis. Although known for a long time in developing countries, amoebiasis in the military or in tourists should be systematically considered.

[Spontaneous regression of hepatic and splenic involvements during sarcoidosis]. / Nodules hépato-spléniques d'évolution spontanément favorable au cours d'une sarcoïdose.

Splenic and hepatic involvements are frequent and usually clinically silent during systemic sarcoidosis. Imaging findings are extremely rare. We report hepatic and splenic nodules diagnosed on abdominal computed tomography with spontaneous regression.

[Lung cancer in Senegal]. / Le cancer bronchique au Sénégal.

In Africa the incidence of lung cancer is rising rapidly. The purpose of this prospective study was to analyze clinical, therapeutic, and prognostic features of lung cancer patients treated at the Principal Hospital in Dakar between 2002 and 2007. A total of 72 cases were compiled over the 5-year study period. In 88% of cases the patient was a male smoker with a mean age of 59.2 years. Histological samples were obtained in 79.1% of cases by bronchial fibroscopy (n=33), CT-guided transthoracic needle biopsy (n=17), or from a metastatic site (n=7). The histological diagnosis was squamous cell carcinoma in 23 cases, adenocarcinoma in 14, large-cell carcinoma in 17, small-cell lung cancer in 2, and bronchiolo-alveolar cancer in 1. Tumor staging demonstrated grades I-II in 6 cases, grade II in 17, and grade IV in 49. Symptomatic management was performed in 68% of patients. In the remaining cases management consisted of chemotherapy in 22 cases, radiotherapy for pain relief in 5, and surgery in 1. Ten patients were lost from follow-up. Median survival was 7 or 3 months depending on whether or not chemotherapy was performed. The much higher rate of histological diagnosis than in the sub-region is due mainly to the availability of trained personnel with access to bronchial endoscopy and CT-scan needle biopsy since September 2003. Administration of cytotoxins is feasible but the cost is excessive due to the lack of universal health care coverage: two-thirds of cases were abandoned whereas chemotherapy significantly improved median survival by 4 months (p < 0.0001). Prognosis of the disease is poor because management is undertaken at an advanced stage. Lung cancer is a health issue in Dakar, Senegal. It is urgent to develop therapeutic standards adapted to the African socio-economic setting as well as an anti-tobacco prevention policy.

Le cancer bronchique au Senegal

En Afrique; l'incidence du cancer bronchique (CB) est en forte progression. Nous avons realise une analyse prospective des caracteristiques cliniques; therapeutiques et evolutives des CB observes a l'Hopital Principal de Dakar entre 2002 et 2007. En 5 ans; 72 cas ont ete colliges. Dans 88des cas; il s'agit d'un fumeur de sexe masculin; age en moyenne de 59;2 ans. L'histologie est obtenue dans 79;1des cas apres fibroscopie bronchique (n=33); ponction transthoracique scano-guidee (n=17) ou a partir d'un site metastatique (n=7). Il s'agit de 23 carcinomes epidermoides; 14 adenocarcinomes; 17 carcinomes a grandes cellules; 2 CB a petites cellules; 1 cancer bronchiolo-alveolaire. Ces tumeurs se repartissent en 6 stades I-II; 17 stades III et 49 stades IV. La prise en charge est symptomatique pour 68des malades ; dans les autres cas; elle associe : chimiotherapie (n=22); radiotherapie antalgique (n=5); chirurgie (n=1). Dix patients sont perdus de vue. La survie mediane est de 7 mois ou de 3 mois; selon qu'une chimiotherapie est administree ou non. Le taux de confirmation histologique largement superieur aux donnees dans la sous-region illustre l'apport d'une unite d'endoscopie bronchique entrainee et l'acces a la ponction scanno-guidee depuis septembre 2003. L'administration de cytotoxiques est possible mais trop couteuse faute de couverture sociale generalisee : 2/3 des indications sont abandonnees alors que la chimiotherapie ameliore significativement la surviemediane de 4 mois (p0;0001). Le pronostic reste severe car la maladie est prise en charge a un stade avance. Le CB est une realite a Dakar. Il est desormais urgent de promouvoir des standards therapeutiques adaptes au contexte socio-economique africain; et une politique de prevention du tabagisme

[The problem of oxygen in developing countries]. / Le problème de l'ovoxygène dans les pays en voie de développement.

Availability of a reliable oxygen (O2) supply is critical for hospitals in developing countries. The AIDS pandemic that is associated with severe pulmonary infections has further enhanced this problem. Today in 2006, even though a number of financially viable solutions adapted to conditions in developing countries are available, lack of oxygen is still a cause of death in Africa including in some capital cities. Hospitals in industrial countries have wall outlets supplied from liquid O2 storage tanks (-183 degrees C). However this solution requires advanced cryogenic technology with storage as well as transportation of liquid O2. In developing countries, O2 is supplied from pressurized O2 cylinders (200 bars) sometimes stored in racks to supply wall outlets but more often moved from bed to bed as needed. This solution is expensive because of the cost of transportation on poor roads in all areas outside capital cities. Frequent supply shortages lead to major disruptions in care quality. Properly maintained O2 concentrators can provide a highly effective low-cost easy-to-use solution for health facilities in developing countries. The pressure swing adsorption (PSA) process based on reversible nitrogen adsorption is a reliable economical autonomous oxygen production process ideally suited to hospitals in developing countries. It can be used to supply wall outlets or fill cylinders. Return on investment is achieved within one to two years.

[Respiratory dysfunction in burned patients]. / Lésions respiratoires et brûlures.

INTRODUCTION: Smoke inhalation and respiratory complications are still the major causes of mortality in severely burned patients. STATE OF THE ART: The diagnosis is suspected clinically on the basis of history and physical examination and can be confirmed bronchoscopically. Respiratory failure in burned patients occurs through a number of associated mechanisms. Pneumonitis and adult respiratory distress syndrome (ARDS) are common early complications. New pulmonary treatments and advances in ventilation have reduced the incidence of both barotrauma and infectious complications. Tracheal stenosis can occur as a late complication of prolonged mechanical ventilation. PERSPECTIVES: Clinical and experimental studies have shown that damage to the mucosal barrier and the release of inflammatory mediators are the most important pathophysiological events following smoke inhalation. Manipulation of the inflammatory response following inhalation may be a treatment option in the distant future. CONCLUSION: Inhalation injury occurring in burned patients can produce severe respiratory and systemic complications.

[18-FDG positon emission tomography and distal metastasis from lung cancer]. / Tomographie à émission de positons au [18F]-FDG et métastases distales dans les cancers broncho-pulmonaires.

"Whole body" FDG-PET usually covers the body from the base of the skull to the upper third of the thighs, arms in abduction. Thus, the upper part of the head and the lower limbs are not included in the acquisition field. We report the cases of three patients with non-small-cell lung cancer who developed secondary distal localizations beyond the acquisition field of "whole body" FDG-PET. Lung cancer is known to favor hematogenic dissemination, raising the possibility of early distal metastasis. A pretherapeutic PET scan which includes the extremities can be useful to search for distal extension. These true whole body scans are time consuming and can thus limit machine availability. Furthermore, the diagnostic yield of this type of examination may be low since it can be estimated that about 1% of patients will develop isolated distal metastases (3 out of 293 patients in our series initially treated for non-metastatic non-small-cell lung cancer). In the current context of technical availability, systematic inclusion of the lower limbs in the PET scan acquisition field would not appear warranted for the initial work-up of patients with non-small-cell lung cancer. However, clinicians must be aware that distal metastases (brain, lower limbs) may not be detected.

[Pseudotumoral presentation of American pulmonary histioplasmosis]. / Présentation pseudo-tumorale de l'histoplasmose pulmonaire américaine.

In France, American pulmonary histoplasmosis is an imported deep mycosis, caused by inhalation of Histoplasma capsulatum. Clinical and radiological features of this exotic disease are multiple, simulating tuberculosis or cancer. We report two cases of American histoplasmosis with pseudo-tumoral form, in immunocompetent subjects working in Venezuela, with a multinodular pulmonary presentation.

[An unusual cause of acute respiratory distress: obstructive bronchial aspergillosis]. / Une cause inhabituelle de détresse respiratoire aiguë: l'aspergillose bronchique obstructive.

We report the case of a 77-Year-old immunocompetent woman who required intensive care for acute dyspnea revealing complete atelectasia of the left lung related to an aspergillus mycelium plug blocking the principal bronchus. The clinical course was favorable after deobstruction by thermocoagulation and oral itraconazole given for six Months. The patient was free of parenchymatous or endobronchial sequelae. Adjuvant oral corticoid therapy was given temporarily during the second Month of treatment when signs of transition towards allergic aspergillosis developed. Four Months after discontinuing the antifungal treatment, the patient developed a new episode of acute dyspnea caused by atelectasia limited to the right lower lobe. Treatment by itraconazole was resumed and continued as long-term therapy. No recurrence has been observed for eighteen Months. The diagnostic and therapeutic problems raised by Aspergillus fumigatus are well known in the immunocompromised subject, but can also be encountered in the immunocompetent subject.

[Laryngeal disorder revealing unrecognized pulmonary tuberculosis]. / Atteinte laryngée révélatrice d'une tuberculose pulmonaire méconnue.

Laryngeal tuberculosis is exceptional and identification in this localization can reveal clinically unrecognized pulmonary tuberculosis. We report two cases illustrating this situation. The pseudo-tumor aspect observed at endoscopy may be wrongly suggestive of neoplasia. Bacteriological examination provides the diagnosis. New methods of genomic diagnosis (Gen-Probe) and culture now allow particularly rapid diagnosis. Outcome is always favorable with standard anti-tuberculosis treatment.

[The risk of thromboembolism in airline passengers]. / Risque thromboembolique et voyage en avion.

Long carrier flights favor thromboembolism. The risk is well known to the general public but is probably really very low. The risk is however pertinent due to the volume of air travel in the world. Sitting in the same position for a long time induced venous stasis which is the principal factor favoring thrombosis in travelers, irrespective of the means of transportation. Long carrier flights also expose passengers to specific factors related to air travel: coagulation disorders and alterations of the endothelium related to hypobarism, hypoxia and low hygrometry in the cabin. Presence of pathogenic thrombophilia is not a constant factor. The prevention of venous thrombosis in air travelers calls upon simple measures: abundant hydration, avoiding use of alcohol and tobacco, walking and dorsal flexion of the feet. The only preventive option with proven efficacy is the use of elastic contention which reduces the risk of thromboembolic events. There is no consensus concerning the use of drugs proposed by certain authors; prudence should be the rule. All passengers should become aware of the risk of thromboembolism related to sitting in the same position for a long time.

[Complications of implantable sites]. / Complications des sites implantables.

Approximately 50,000 implantable sites are prepared each year in France because of the undeniable advantage for the treatment of patients requiring long-duration intravenous infusions. The benefits of this technique must not overshadow the mechanical risks inherent in their installation and complications related to their use: infections, thromboembolic events. Clear, precise, and adapted treatment protocols must be established and rigorously implemented by the healthcare team. Information notes for the patients concerning the risks involved and warning signs must be written in order to be able to institute appropriate treatment rapidly.