Allergy to anti-tuberculosis treatment: Place of reintroduction drug test.

BACKGROUND: Allergy to antitubercular drugs is a real hindrance to the management of TB. AIM: To access the contribution of the reintroduction drug test in the exploration of allergy to anti-tuberculosis treatments. METHODS: Retrospective study of 34 patients treated for tuberculosis who presented a hypersensitivity reaction during a period from January 2011 to December 2017. RESULTS: Our study included 31 women (91%) and three men (9%). The average age was 37 years old. The average time to onset of allergic manifestations compared to the start of TB treatment was 23± 19 days (1-85). They were dominated by cutaneous involvement (76.4%). The reintroduction test achieved in 27 patients, allowed to make the diagnosis of allergy to pyrazinamide in 12 patients (44.4%), to Rifampicin in five cases (18.5%), to Ethambutol in one case (3.7%) and isoniazid in one patient (3.7%). A polyallergy was noted in six patients (22.2%). The average time to onset of these reactions was five hours [15mn-90h]. The drug incriminated in the allergy was stopped definitively in 18 patients or 52.9%. It was substituted by a drug of first line in two patients (5.8%) and a second-line drug in three patients (8.8%). Drug dependence was achieved in five patients. It concerned Isoniazid in one patient, Rifampicin in three patients, pyrazinamide in two patients. It allowed the reintroduction of the allergenic treatment noted in two patients. The evolution of tuberculosis was favorable in 26 cases (77%). CONCLUSION: The identification of the allergenic drug is the key to establishing a new protocol for effective anti-tuberculosis treatment that is less risky for hypersensitivity.

Pulmonary Sarcomatoid carcinoma: a surgical diagnosis and prognostic factors.

INTRODUCTION: Pulmonary Sarcomatoid Carcinoma (PSC) is a rare group of tumors accounting for about 0.4% of non-small cell lung carcinoma (NSCLC). Five subtypes were described: pleomorphic carcinoma, spindle cell carcinoma, carcinosarcoma, giant cell carcinoma and pulmonary blastoma. The diagnosis is pathological but requires a good quality sampling of the tumor. METHODS: On a series of 1582 patients operated on for lung cancer from 1992 to 2016, 43 patients were retrospectively identified as having been treated surgically for pulmonary sarcomatoid carcinoma. RESULTS: The population consisted of 33 males and 10 females with mean age of 55 years. Imaging findings showed a peripheral mass in the majority of cases (n=29). Careful investigation failed to discover a primitive lesion elsewhere. Six patients received induction therapy for wall involvement. Lobectomy or bilobectomy was performed in 30 patients and pneumonectomy in 11 patients. A wedge resection was performed in one patient and an exploratory thoracotomy in another. In macroscopy, the mean tumor's size was 5.2 cm (1-17.5cm). The histologic diagnoses were: pleomorphic carcinoma (n=30), carcinosarcoma (n=5), spindle cell carcinoma (n=1), giant cell carcinoma (n=3) and blastoma (n=4). Two patients died within 1 month of surgical complications and 5 died of disease within 17 months. Adjuvant therapy was performed in 6 patients. Recurrence happened in 4 patients within 12 months after operation. Median survival for all patients was 8months. CONCLUSIONS: Resection of primary pulmonary sarcomatoid carcinoma is associated with an acceptable survival rate if the resection is complete. The size of the tumor is the most important prognosis factor. Nevertheless, a carefully follow-up is essential.

Conservative management of postoperative bronchopleural fistulas.

OBJECTIVE: A bronchopleural fistula (BPF) is a serious complication after pulmonary resection and carries a high mortality rate. It remains a therapeutic challenge. The lack of a consensus suggests that no optimal therapy is available; however, endoscopic closure of a fistula may avoid extensive and potentially risky surgery. METHODS: Seventeen patients (15 men and 2 women) with a BPF after a pneumonectomy (n = 2) or a lobectomy (n = 15), seen between 1995 and 2010, were reviewed. Their median age was 50 years (range, 14-75 years). Underlying diseases were malignant (n = 4) and nonmalignant (n = 13). RESULTS: The mean interval between surgery and fistula development was 20 days (range, 5-270 days). Clinical symptoms leading to a diagnosis of BPF were a persistent air leak (n = 2), a persistent air leak associated with pleural empyema (n = 3), pleural empyema alone (n = 11), and dyspnea (n = 1). Mean fistula size was 3.3 mm (range, 2-9 mm). Treatment consisted of oriented pleural drainage, adequate antibiotic therapy, and endoscopic closure of the fistula with local application of silver nitrate through a flexible bronchoscope (3-15 sessions, 3 times per week). Fistula closure was successful in 16 patients, but failed in 1 patient, who died from acute respiratory distress. CONCLUSIONS: BPF is a severe complication in thoracic surgery. The combination of pleural drainage, adequate antibiotic treatment, and mucosal application of silver nitrate, through a flexible bronchoscope, is an efficient alternative and avoids extensive surgical intervention.

What outcome after the prescription of neoadjuvant chemotherapy in lung cancer?

BACKGROUND: The treatment of patients with locally advanced non-small-cell lung cancer is controversial. Surgery remains the gold standard, even in this group. Neoadjuvant chemotherapy could allow surgical resection in patients initially judged inoperable. METHODS: From January 2009 to May 2010, neoadjuvant chemotherapy was indicated in 27 patients with NSCLC (25 men, 2 women). Their mean age was 65 years. The stages were: IIB in 5, IIIA in 17 (6 in stage IIIAN2), IIIB in 2, and IV in 3. RESULTS: 23 patients received neoadjuvant chemotherapy, 2 refused induction treatment, and 2 had impaired status. The neoadjuvant chemotherapy regimen was gemcitabine-cisplatin in 17 patients and vinorelbine-cisplatin in 6. Only 5 patients underwent complete surgical treatment after induction: 1 in stage IIB, 1 in stage IIIAN0, 1 in IIIB, and 2 in stage IV (1 operated brain metastasis, and 1 operated adrenal metastasis). Surgical treatment was not achieved after neoadjuvant chemotherapy in 18 patients because of progressive disease. CONCLUSION: Neoadjuvant chemotherapy offers several potential benefits, but it may delay surgery or eliminate eligibility as a surgical candidate. Rigorous patient selection for this type of multimodal treatment is essential.

Surgery in thoracic actinomycosis.

BACKGROUND: Diagnosis and treatment of thoracic actinomycosis is difficult. In most cases, surgery is performed to rule out lung cancer or to control severe symptoms such as hemoptysis. METHODS: 6 patients with a mean age of 42 years underwent pulmonary resection and were given a pathologic diagnosis of thoracic actinomycosis at our institution between 2003 and 2010. We reviewed preoperative clinical characteristics, computed tomography findings, surgical indication, postoperative clinical course and outcome. RESULTS: All patients were symptomatic. One patient had a history of cervical actinomycosis. The mean interval between radiographic identification of the abnormality and surgical intervention was 8 months (range, 4-17 months). Radiographic findings in all cases included a mass-like appearance, simulating lung malignancy or chronic suppuration. The various histological and bacteriological examinations had failed to make the diagnosis. Thoracic actinomycosis was confirmed after thoracic surgery. All patients received penicillin-based antibiotic treatment for at least 2 to 3 months. Good clinical results were observed in 5 patients. In one patient, we noted recurrence of actinomycosis after 10 months; it was a multidrug-resistant form. CONCLUSION: Diagnosis of actinomycosis can be problematic because of difficulty in isolating actinomyces. In these cases, surgery is very helpful.