[Hot tub lung: A retrospective analysis of 14 cases]. / Poumon de jacuzzi : analyse rétrospective de 14 cas.

INTRODUCTION: Hot tub lung (HTL) is a hypersensitivity pneumonitis (HP) related to inhalation of non-tuberculous mycobacteria (NTM) when exposed to ejected jet droplets from a jacuzzi. The aetiological debate is not completely settled in the literature. METHOD: An observational study of 14 cases of HTL, diagnosed at the University Hospital of Besançon, France, between 2004 and 2018 according to the diagnostic criteria used in the clinic. RESULTS: This cohort corresponds to type I HP (inflammatory), with one case of type II HP. Decrease of lung transfer for carbon monoxide was present in 86% of examinations (n=12/14). In total, 84% of bronchoalveolar lavages showed a lymphocytic cellular pattern≥30% (n=11/13). The environmental survey enabled the identification of NTM in 93% of cases (n=13/14), mainly Mycobacterium avium. Serum precipitins directed against NTM were found in 10% of the cases (n=2/20). Three cases received corticosteroid therapy and none received antibiotics. Antigenic eviction has improved the symptomatology in all cases. CONCLUSIONS: Our cohort supports the hypothesis that HTL is predominantly a type I HP. Avoidance of the agent involved (NTM) is necessary. The diagnosis is difficult because serum precipitins against NTM are not easily demonstrable. An environmental survey could facilitate the identification of the NTM. Prevention of HTL depends on education of the clinician and the patient.

[Adenopathy and mammary carcinoma: It is sometimes in the details that one encounters hypersensitivity pneumonitis!] / Adénopathie et carcinome mammaire : c'est dans les détails que se cache la pneumopathie d'hypersensibilité !

INTRODUCTION: Hypersensitivity pneumonitis (HP) is an interstitial lung disease due to an immunological reaction to exposure, by inhalation, to a large variety of antigens. The patho-physiological mechanism remains poorly understood. The diagnosis can be challenging and requires a detailed medical history taking especially when the clinical presentation is atypical or when the causal agent remains unknown. CASE REPORT: We report the case of a 75-year-old woman with a history of mammary carcinoma who presented with recently identified intramammary adenopathy. Biopsy of the adenopathy revealed non-necrotising, giant cell epithelioid granuloma. A diagnosis of hot tub lung with extra-pulmonary granulomatous lymph node involvement was made based on the clinical, functional, radiological and microbiological investigations. The evolution was favorable following antigen avoidance. CONCLUSION: Extrapulmonary lymph node involvement is rare in HP, suggesting a systemic inflammatory involvement.

Quantitative and qualitative evaluation of spirometry for COPD screening in general practice.

INTRODUCTION: Proper diagnosis of COPD remains a challenge. Spirometry testing in primary care may help to reduce misdiagnosis, but its reliability as a diagnostic instrument needs to be assessed. OBJECTIVES: To investigate (1) the validity of spirometry testing performed in primary care and (2) the accuracy of the diagnostic of airflow limitation obtained by these tests. METHODS: Subjects attending a COPD screening programme had screening spirometry performed either by general practitioners (GPs) or by trained nurses or technicians, who had all received two 3-hour training sessions. Subjects with airflow limitation and a subset of subjects with normal spirometry at screening were invited to undergo confirmatory spirometry performed by trained nurses in a pulmonary function laboratory. RESULTS: Of the 4610 subjects who attended the screening sessions, 96.5% had a valid screening spirometry test. A total of 392 subjects attended the confirmatory sessions. Values measured by screening spirometry were satisfactory compared with those of confirmatory spirometry (rc=0.83). Taking confirmatory spirometry as reference, the positive predictive value of screening spirometry for the diagnosis of persistent airflow limitation was 93% with a specificity of 95%. Agreement for the diagnosis of persistent airflow limitation was substantial (k=0.80). CONCLUSION: Spirometry performed in primary care by trained personnel reliably identifies persistent airflow limitation. This may encourage pulmonologists to collaborate with primary care providers with the aim of improving appropriate diagnosis of COPD.

[Diagnosis of allergy in asthma]. / Le diagnostic de l'allergie dans l'asthme.

Allergy is a hypersensitivity reaction induced by immunological mechanisms. In asthma, allergy has a complex role and is usually IgE mediated. Allergy must be evaluated during the work up but evidence of IgE sensitivity does not mean that allergens play a role in the pathophysiology of the disease. The clinical relevance of the sensitivity has to be considered. This paper describes current available tools to screen for IgE sensitivity, allergen exposure and their role in asthma.

[A case of farmer's lung associated with allergic bronchopulmonary aspergillosis]. / L'association inhabituelle de deux maladies pulmonaires immunoallergiques : un cas de pneumopathie d'hypersensibilité associée à une aspergillose bronchopulmonaire allergique.

Hypersensitivity pneumonitis and allergic bronchopulmonary aspergillosis are two forms of lung disease with presumed distinct immunoallergic mechanisms. We report the observation of a 38-year-old French farmer who, for one month, had fever and dyspnoea resistant to antibiotic therapy. A diagnosis of farmer's lung, and allergic bronchopulmonary aspergillosis was made on clinical, biological, functional and radiological evidence and according to the criteria established. The evolution was favorable with antigenic eviction and corticosteroid therapy. This observation is to our knowledge the 5th case that describes the association of hypersensitivity pneumonitis and allergic bronchopulmonary aspergillosis. It suggests the existence of risk factors and immunoallergic mechanisms common to both diseases and discusses the hypothesis that the same antigen(s) is (are) responsible for them.

Effectiveness of omalizumab in severe allergic asthma and nasal polyposis: a real-life study

BACKGROUND: Omalizumab is a human anti-IgE antibody approved for the treatment of severe allergic asthma (SAA). However, its effectiveness in SAA associated with chronic rhinosinusitis with nasal polyposis (CRSNP+) is less well documented. OBJECTIVE: The aim of this study was to evaluate the real-life effectiveness of omalizumab in patients with SAA and CRSNP+ who tolerated and did not tolerate aspirin. METHODS: We performed a retrospective, observational, multicenter, real-life study of patients with SAA and CRSNP+ treated with omalizumab for 6 months. Asthma outcome parameters (symptoms, number of salbutamol rescues/wk, number of moderate/severe exacerbations, Asthma Control Test score, and lung function), sinonasal outcome parameters (symptoms, number of episodes of acute rhinosinusitis, sinus computed tomography images, nasal polyps endoscopy score), and serum eosinophil levels were analyzed 6 months before and after treatment with omalizumab. RESULTS: Twenty-four adult patients were included (9 with documented aspirin intolerance). All respiratory parameters were significantly improved by the treatment. In parallel, a significant improvement was observed in sinonasal clinical outcomes and sinus computed tomography images, with no major effect on the nasal polyps endoscopy score. The serum eosinophil count decreased significantly after 6 months of treatment with omalizumab. CONCLUSION: Treatment of SAA with omalizumab improves the outcome of associated CRSNP+, thus supporting the concept of a "one airway disease"

ANTECEDENTES: El omalizumab es un anticuerpo anti-IgE humanizado aprobado para el tratamiento del asma alérgica grave (SAA), si bien su eficacia, cuando ésta se asocia a la rinosinusitis crónica con poliposis nasal (CRSNP+), está menos documentada. OBJETIVO: El objetivo de este estudio fue evaluar en "vida real" la eficacia de omalizumab en pacientes con SAA y CRSNP+ con o sin intolerancia a la Aspirina. MÉTODOS: Se realizó un estudio retrospectivo, observacional y multicéntrico, en vida real que incluyó pacientes con SAA y CRSNP+ que fueron tratados con omalizumab durante 6 meses. Las variables de eficacia en relación al asma (síntomas, número de inhalaciones de rescate de salbutamol por semana, número de exacerbaciones moderadas/graves, puntuación de la prueba de control del asma (ACT) y función pulmonar), y de la rinosinusitis (síntomas, número de rinosinusitis aguda, puntuación en tomografía computarizada, puntuación del tamaño de los pólipos en la endoscopia nasal) y el nivel de eosinófilos en sangre se analizaron antes y después de 6 meses de tratamiento con omalizumab. RESULTADOS: Se incluyeron veinticuatro pacientes adultos (nueve con una intolerancia a la Aspirina documentada). Todas las variables de eficacia en relación al asma mejoraron significativamente con el tratamiento. Paralelamente, las variables clínicas de eficacia en rinosinusitis y la puntuación de las imágenes tomográficas de los senos paranasales mejoraron significativamente, si bien no se observó un efecto relevante en la puntuación de los pólipos en la endoscopia nasal. El nivel de eosinófilos en sangre disminuyó significativamente después de 6 meses de tratamiento con omalizumab. CONCLUSIÓN: El tratamiento con omalizumab en pacientes con SAA induce paralelamente una mejoría clínica y radiológica de la CRSNP+ asociada, lo que apoya el concepto de una única enfermedad de las vías respiratorias

[Evaluation of permanent disability levels in occupational pulmonary diseases]. / Comment évaluer en 2019 les taux d'incapacité permanente des pathologies professionnelles pulmonaires ?

Compensation for occupational pulmonary diseases requires the establishment of guidelines based on standardized and objective criteria, in order to provide compensation that is as fair as possible to patients who suffer from them. A review of the elements necessary for the examination of an individual file was carried out by a working group. It is accepted that respiratory functional exploration is the key element in assessing the level of permanent disability in all of these conditions, with the exception of thoracic malignancies. Guiding scales have been developed for the respiratory impairment of three types of conditions: occupational asthma, thoracic malignancy, and other respiratory diseases. Additional criteria for increasing the permanent disability level are also proposed in order to take into account professional prejudice, in particular the possibility or not of continuing the occupational activity, in the same job or after changing to another. For certain respiratory diseases, a periodic reassessment of the initially attributed permanent disability level is recommended as well as the initial one at the time of definitive cessation of occupational activity.

[Two cases of hot tub lung disease: Environmental investigations]. / Deux cas de pneumopathie d'hypersensibilité du jacuzzi : enquête environnementale.

INTRODUCTION: Hot tub lung is a hypersensitivity pneumonitis (HP) due to exposure to inhaled non-tuberculous mycobacteria, the most frequent being Mycobacterium avium complex (MAC). CASE REPORT: A French couple developed typicalHP in the context of a repeated use of hot tubs. The husband had a severe hypoxemic form whereas his wife had a micronodular form with patchy ground glass on the thoracic scan, with less severe functional impairment. MAC was recovered in the hot tub water, but not in broncho-alveolar lavage fluid, and serologies were negative. Samples taken at home showed unusual exposure to Aureobasidium pullulans and Aspergillus flavus, as well as the presence of potentially responsible domestic molds. Blood precipitins for these microorganisms were identified. The evolution was favorable after removal of the hot tub. CONCLUSIONS: These cases represent two of the typical presentations of hot tub lung, with a possible HP to an antigen other than MAC, which may have been enhanced by chronic exposure to multiple microorganisms.

[Pneumothorax in young cannabis smokers: A propos of three cases]. / Prise en charge des pneumothorax chez les fumeurs de cannabis : à propos de trois cas.

INTRODUCTION: Cannabis consumption is common among adolescents and young adults in France. In addition to its neurological effect, cannabis smoking can induce severe pulmonary emphysema, even in young patients. When a spontaneous pneumothorax occurs in a cannabis smoker, the possibility of a secondary spontaneous pneumothorax should be considered. This may be of importance as management of secondary spontaneous pneumothorax may differ from the well-codified handling of primary spontaneous pneumothorax. OBSERVATION: Clinical and radiological data from three young cannabis-using patients with spontaneous pneumothorax were collected. Given the presence of emphysema, they were all considered secondary spontaneous pneumothorax. Two patients underwent surgical treatment, with simple postoperative follow-up in one case and prolonged air leak in the other case. The management of the third patient, exclusively medical, was prolonged and complicated. CONCLUSION: The presence of emphysema in young cannabis smokers complicates the management of spontaneous pneumothorax. In this context, a first-line surgical intervention may be an option to be considered.

Second hypersensitivity pneumonitis in the same patient caused by chinchillas

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[Differences and similarities between occupational and tobacco induced COPD]. / BPCO professionnelles et BPCO post-tabagique : similarités et différences.

Chronic obstructive pulmonary disease (COPD) most often results from the inhalation of toxic agents. Cigarette smoking still remains the principal cause but the pertinence of occupational COPD is now clearly established. After a brief overview of the epidemiology of this "other COPD", the clinical and functional characteristics are summarized, taking into account recent advances in this field. The combined effects of occupational exposure and tobacco are also considered, providing evidence of the need to continuously reinforce campaigns of education and prevention in occupational COPD.