Hydatid disease of the ribs: An exceptional location.

Background: Hydatid disease is a zoonosis caused by larval stages of cestodes belonging to the genus Echinococcus. The rib location is exceptional. It presents a real diagnostic and therapeutic challenge. Objectives: To describe the clinical, serological and radiological features and surgical management of rib hydatidosis. Methods: This is a retrospective study conducted over 4 years, on five cases of rib hydatidosis. We analysed the clinical and radiological presentations and the adopted therapeutic procedure. Results: The average age of our patients was 44 years, without gender predominance. The clinical signs were dominated by the presence of an immobile swelling of fluid consistency without inflammatory sign, accompanied by moderate and intermittent localised pain. The laboratory assessment was nonspecific. The radiological assessment, including chest X-ray and thoracic computed tomography, with and without contrast, was essential in order to assess the extent of the lesion. Thoracic magnetic resonance imaging was requested in one case because of suspicions of a spinal extension. All of our patients underwent a rib excision accompanied by medical treatment of albendazole 24 hours after the surgery. The follow-up ranged from 1 year to 4 years and did not show any recurrence. Conclusion: Hydatidosis of the ribs is an exceptional location of hydatid disease. The diagnosis was based on radiology and intraoperative exploration. The treatment remained essentially surgical by rib excision with anthelmintic drugs to prevent recurrence.

Expression of receptor for advanced glycation end-products (RAGE) in thymus from myasthenia patients.

OBJECTIVES: The receptor for advanced glycation end-products (RAGE) is a membranous immunoglobulin involved in the pathogenesis of numerous autoimmune diseases and tumors. The aim of this study was to investigate the possible involvement of RAGE in the pathogenesis of myasthenia gravis. MATERIAL AND METHODS: This prospective study included 41 cases of myasthenia gravis treated at our institution between 2010 and 2015. There were 18 men and 23 women, with an average age of 36.44±14.47 years. The majority of patients (24.4%) were classified as IIb, according to MGFA scoring, and 21 of them required corticosteroid and/or immunosuppressive treatment. Assessment of RAGE in thymus specimens was done by immunohistochemistry using RAGE antibody (C-term). RAGE expression was assessed according to various clinical, paraclinical and pathological parameters. RESULTS: Histopathological studies found 18 thymomas, 17 hyperplasias and six other types of pathology. Expression of RAGE was negative/weak in 19 cases and moderate/strong in 22 cases. It was more important in thymoma type B2 (P<0.001) and when the duration of myasthenia was short (P=0.04), and was not significantly related to either myasthenia clinical severity or preoperative treatment. CONCLUSION: Our results suggest that the RAGE pathway is involved in myasthenia gravis pathophysiology, especially at disease onset, and in forms with thymomas. Further studies would be indispensable to explore other aspects of this signaling pathway, especially the potential role of different ligands and soluble forms of RAGE.

[Intrapleural rupture of pulmonary hydatid cysts]. / La rupture intrapleurale des kystes hydatiques pulmonaires.

INTRODUCTION: Intrapleural rupture of pulmonary hydatid cyst (PHC) is a rare but dangerous complication. The purpose of this study was to report the characteristics of this form of thoracic hydatidosis and analyze the favoring factors. MATERIALS AND METHODS: Between 1996 and 2011, 75 patients were operated in our department for PHC ruptured in the pleura (PHCP). The characteristics of this group were compared with those of a control group of 300 patients randomly selected from patients operated during the same period for PHC. RESULTS: PHCP patients were younger than controls (23 years old vs. 27,56) (P=0.03) with male predominance (70% vs. 46%) (P=0.01). The PHCP were often located in the lower lobes (64% vs. 48%) (P=0.03). Anatomic resections were more used in control group (P=0.03) whereas decortication and pleurectomy were more frequently in PHCP (P=0.001). CONCLUSION: Young age, male sex, and basal locations of PHC promote their rupture in the pleura. Surgical treatment of these cysts requires less anatomic resections but more decortication and pleurectomy.

[Spontaneous bilateral chylothorax revealing a mediastinal and abdominal lymph node tuberculosis]. / Chylothorax spontané bilatéral révélant une tuberculose ganglionnaire médiastinale et abdominale.

Spontaneous chylothorax is a rare condition, lymph node tuberculosis is an exceptional etiology of chylothorax, we report an exceptional case of a patient with mediastinal and abdominal lymph node tuberculosis presenting with spontaneous bilateral chylothorax treated successfully by symptomatic medical treatment and antibacillary.

[Role of pulmonary resections in management of multidrug-resistant tuberculosis. A monocentric series of 29 patients]. / Le rôle des résections pulmonaires dans le traitement de la tuberculose multirésistante. Une série monocentrique de 29 patients.

INTRODUCTION: Multidrug-resistant tuberculosis (MDR-TB) is a worldwide health problem. Surgery is often used as an adjuvent therapy with anti-tuberculosis agents. The aim of this study is to present our results of pulmonary resections in the treatment of MDR-TB. MATERIAL AND METHODS: [corrected] This is a retrospective monocentric study of 29 patients operated on between 1995 and 2010 for MDR-TB. RESULTS: Tuberculosis was evolving from 9 to 108 months with a median of 34.77±19.88 months. The average number of tuberculosis relapses was 2.73 per patient. All patients had a destroyed and/or cavitary parenchyma and 17 had bacilli in sputum at the time of surgery. Lobectomy (51.17%) and pneumonectomy (41.37%) were the main interventions carried out. The operative mortality was 3.44%. Complications such prolonged air leaking and empyema had occurred in 9 patients. The rate of postoperative microbiological conversion was 88.23%. One patient had a relapse 5 months after surgery. CONCLUSION: Surgery associated with medical treatment provides a high cure rate to the detriment of an acceptable morbidity and mortality.

[Thymoma-associated myasthenia gravis: Clinical features and surgical results]. / La myasthénie associée aux thymomes : particularités cliniques et résultats chirurgicaux.

OBJECTIVE: The aim of this study was to compare the characteristics of myasthenic patients with and without thymoma, and the results of thymectomy in both types of patients. MATERIAL AND METHODS: A retrospective study was conducted among 66 patients who underwent thymectomy for myasthenia gravis in our department over a 10-year period (2000-2010). The surgical approach was sternotomy or anterolateral thoracotomy. Patients were divided into two groups according to the presence of thymoma: with (T-MG) and without (NT-MG) thymoma. Complete stable remission (CSR) was the primary endpoint. RESULTS: Median age was 35.09±9.89 years. The NT-MG group had 38 patients (57.57%) and the T-MG group 28 patients (42.43%). There was no difference between the two groups regarding the surgical approach (P=0.52). T-MG patients were older (40.54±15.16 vs. 31.37±9.46) (P=0.008) and predominantly male. There were more generalized forms (P=0.01) and more bulbar involvement (P=0.02) in the T-MG group. The rate of CSR at 5 years was 7% and 17% in the T-MG and NT-MG patients respectively (P=0.70). At 10 years, it was 36% and 94.73% respectively (P=0.03). CONCLUSION: Thymomatous myasthenia gravis is characterized by the severity of its clinical features. Remission rate at 10 years was significantly lower in the myasthenia with thymoma group.

Iatrogenic pneumothorax: experience of a Moroccan Emergency Center.

The incidence of iatrogenic pneumothorax (IPx) will increase with invasive procedures particularly at training hospitals, that is why we have made a retrospective study of the common diagnostic or therapeutic causes of IPx and its impact on morbidity. From January 2011 to December 2011, 36 patients developed IPx as emergencies, after an invasive procedure. Their mean age was 38 years (range: 19-69 years). Of the patients, 21 (58%) were male and 15 (42%) were female. The purpose was diagnostic in 6 cases and therapeutic in 30 cases. In 8 patients (22%) the procedure was performed due to underlying lung diseases and in 28 patients (78%) for other diseases. The procedure most frequently causing IPnx was central venous catheterization, with 20 patients (55%), other frequent causes were mechanical ventilation in 8 cases (22%) (of whom we reported 3 cases of bilateral pneumothorax), 6 cases of thoracentesis (16%) and 2 patients had life-saving percutaneous tracheotomy. The majority of our patients were managed by a small chest tube placement (unilateral n=30, bilateral n=3). The average duration of drainage was 3 days (range: 1-15 days), sadly one of our patients died of ischemic brain damage 15 days after tracheotomy. At training hospitals the incidence of IPnx will increase with the increase in invasive procedures, which should only be performed by experienced personnel or under their supervision.

Well-differentiated fetal adenocarcinoma: a very uncommon malignant lung tumor.

Well-differentiated fetal adenocarcinoma (WDFA) is a very uncommon malignant tumor originating in the lung. This report describes the case of a 38-year-old woman with a WDFA treated by surgery. The malignancy is low grade and associated with a good prognosis, and so it is important for clinicians to be aware of and to identify this rare variant of adenocarcinoma.

[Hydatid disease of the ribs]. / Hydatidose costale.

OBJECTIVES: Hydatid disease is a zoonosis resulting from the growth in man of the larval form of Echinococcus granulosus. Involvement of the bones is rare and localisation to the ribs is exceptional. The aim of our study is to present the pathophysiological and diagnostic characteristics of hydatid disease of the ribs and to define the radiological features. PATIENTS AND METHODS: We undertook a retrospective study, over a period of 10 years, of 12 cases of hydatid rib disease. We have analysed the demographic, clinical and biological parameters and we examined the radiological details as well as the effect of surgery on the progress of the disease. RESULTS: The mean age of the patients was 33.5±10 years. There was no sexual predominance. The clinical picture was characterised by chest pain in ten cases and by swelling in five. General health was satisfactory in all patients. The chest X-rays showed a shadow of water density with lytic rib lesions. Thoracic CT scans showed the relationships with the neighbouring structures, particularly the spinal column. In three cases T1- and T2-weighted MRI scans showed the extent of intraspinal extension and in two cases excluded medullary involvement. Hydatid serology was positive in five cases. All our patients were operated on, with rib resection and vertebral curettage in three cases, and resection of the transverse process in two. Histological examination of the surgical specimens confirmed the diagnosis. Eight patients were treated with albendazole. All patients were reviewed for a mean of 3 years and the progress was favourable. CONCLUSION: Hydatid disease of the ribs is a very rare disorder and the diagnosis is difficult. It is sometimes an unexpected surgical finding but careful examination of the chest X-ray, supplemented by a CT scan, thanks to the liquid density of the lesions, is a great help in diagnosis. However, in the light of the results of our series, the radiological picture may be atypical and the interpretaion difficult.

[Boerhaave's syndrome and pleural tuberculosis]. / Syndrome de Boerhaave et tuberculose pleurale.

INTRODUCTION: Boerhaave's syndrome is a rare condition involving spontaneous rupture of the oesophagus. The diagnosis is difficult and the prognosis depends on early diagnosis and treatment. CASE REPORT: We report a case of spontaneous rupture of the oesophagus in a 70-year-old woman where the diagnosis was delayed. Initial treatment comprised dual antibiotic therapy and feeding via a jejunostomy. Three months later, direct suture of the oesophagus was performed successfully. A routine pleural biopsy performed during the surgery revealed pleural tuberculosis. Antituberculous treatment was given for 6 months with good progress after 16 months follow up. CONCLUSION: Boerhaave's syndrome is a rare condition, the diagnosis of which remains difficult. The prognosis is related essentially to the speed of diagnosis. The treatment is always surgical within the framework of appropriate medical management (intensive care, antibiotic therapy). There should be a systematic search for associated pathology.

[Filling of the thymic space after chemotherapy for ovarian cancer]. / Comblement de la loge thymique après chimiothérapie pour cancer de l'ovaire.

INTRODUCTION: Enlargement of the thymus following remission of a cancer treated by chemotherapy poses a problem of differential diagnosis between benign thymic hyperplasia and relapse of a mediastinal tumour. CASE REPORT: We report the case of a thymic tumour developing 6 months after chemotherapy for ovarian cancer in a woman of 31 years. Because of the risk of a mediastinal recurrence, the patient was submitted to thymectomy by mediastinotomy. Histopathological examination revealed benign thymic hyperplasia in reaction to the chemotherapy. The postoperative course was uneventful. CONCLUSION: Benign thymic hyperplasia may develop after chemotherapy. It is an inflammatory reaction that subsides after a few months. A multidisciplinary discussion to consider the possibility of benign hyperplasia may save the patient unnecessary surgery.

[Outcomes after thoracotomy for intra-abdominal hydatid cysts ruptured into the thorax (a 160 case series)]. / La place de la thoracotomie dans le traitement des kystes hydatiques abdominaux rompus dans le thorax.

INTRODUCTION: The purpose of this study was to assess the results of the surgical treatment of abdominal hydatid cysts ruptured in the thorax. PATIENTS AND METHODS: We collected data from 160 patients who experienced the intra-thoracic rupture of an abdominal hydatid cyst during the period 1997 - 2008: 158 located in the liver, one in the spleen and one in the kidney, which had been treated surgically in a single centre. Diagnosis was based on a history of surgery for abdominal hydatid cysts, specific symptoms including biliptysis (40% of the cases) and expectoration of hydatid cysts, as well as radiological findings (chest x-ray; abdominal ultrasound and CT-scan). All patients were operated on through a thoracotomy. RESULTS: In-hospital mortality was 7.5%. Postoperative complications occurred in 16% and mainly consisted of pleural and pulmonary disorders. CONCLUSION: Thoracotomy offers simultaneous and adequate access to address thoracic and abdominal injuries with a reasonable mortality and morbidity in patients with this condition.

[Bilateral hydatid bilio-bronchial fistula]. / Fistule biliobronchique bilatérale d'origine hydatique.

INTRODUCTION: Bilio-bronchial fistula of hydatid origin is a rare but serious complication of hepatic hydatid cyst, the treatment of which is now well established. CASE REPORT: We report a case of bilateral bilio-bronchial fistula, successfully managed by bilateral thoracotomy with an interval of one week, and complicated by dyspnoea that resolved quickly. CONCLUSION: If the indication for thoracotomy is indisputable in case of unilateral bilio bronchial fistula, an initial laparotomy should be considered in the case of bilateral bilio-bronchial fistula.

[Paraoesophageal cyst revealed by repeated infections]. / Kyste para-oesophagien révélé par des broncho-pneumopathies récidivantes.

Paraoesophagial cyst is an extremely rare congenital malformation of the oesophagus often discovered incidentally in adults. We report the case of a paraoesophageal cyst in a 45 year old man revealed by recurrent chest infections and confirmed by examination at surgery.

[Pneumonectomy for active and sequelae forms of tuberculosis]. / La pneumonectomie pour les formes actives et séquellaires de la tuberculose.

OBJECTIVE: Lung resection retains an important place in the treatment of certain forms of tuberculosis. The purpose of this review was to review the indications for and outcomes of pneumonectomy both in the management of active TB and the treatment of its consequences. MATERIALS AND METHODS: Between 2003 and 2007 85 patients underwent a pneumonectomy for TB; 48 men and 37 women with a mean (sd) age of 36.7 (10.9) years. Chronic sputum production and haemoptysis were the main presenting features. RESULTS: The indication for surgery was a single destroyed lung in 34 cases, an aspergilloma in 29 cases, tuberculous empyema in 14 and multidrug resistant TB in 5. The procedure undertaken was a pneumonectomy in 32 cases a pleurectomy and pneumonectomy in 45 cases and a completion pneumonectomy in 8 cases. There were 4 deaths (4.7%) and in 13 cases (15.3%) a pyothorax developed in the pneumonectomy cavity. In 4 cases a broncho-pleural fistula occurred. Long term results were satisfactory with a median follow up of 2.8years (range 3 months to 5 years). Male sex (p=0.02), right sided pneumonectomy (p=0.01) diabetes (p=0.001), a low level of haemoglobin (p=0.03) or serum protein (p<0.001) were associated with an increased risk of pneumonectomy cavity infection. Right sided surgery (p=0.01), post operative transfusion (p=0.01) and pre-operative empyema (p=0.05) were all associated with risk of bronchial dehiscence. CONCLUSION: Optimising preoperative condition and identification of patients at risk of complications are essential for reducing the burden of post-operative complications.