Profile of multiple system atrophy in Moroccan patients attending a movement disorders outpatient clinic in Rabat university hospital.

INTRODUCTION: Multiple system atrophy (MSA) is a sporadic and rapidly progressive neurodegenerative disorder of poor prognosis, characterised clinically by any combination of parkinsonian, autonomic, cerebellar, or pyramidal signs. We report our experience in movement disorders consultation concerning the clinical presentation and the course of MSA in Moroccan patients. METHODS: A retrospective review of the medical records of 17 patients with diagnosis of MSA seen in our outpatient clinic from January 2007 to December 2010. RESULTS: In our 17 patients, 76.5% were men and the mean age of onset was 52±9 years. MSA-P was the major clinical phenotype (82.4%). Eleven patients (64.7%) were classified as having probable MSA and six patients (35.3%) as possible MSA. Dysautonomic features were detected in all patients; urinary symptoms were found in 76.5% of cases and orthostatic hypotension in 64.7%. Treatment regimen included l-Dopa with a mean daily dose of 621.4±346.8mg/day and symptomatic treatment of dysautonomia. The mean duration of disease evolution was of 4.7±1.9 years. DISCUSSION: Our results show a male predominance and an early age of disease onset. MSA-P was the predominant subtype. Our results are similar to the European MSA series. CONCLUSION: Multicentre studies are needed to better characterise MSA in Morocco given the rarity of this disease.

[Anatomical snuffbox lipoma causing nervous compression. A case report]. / Lipome compressif de la tabatière anatomique. À propos d'un cas.

Lipomas are rarely localized at the hand, and more unfrequently at the anatomical snuffbox. We report a case of a lipoma that compressed the lateral branch of the superficial sensory branch of the radial nerve.

[Miliary tuberculosis]. / La miliaire tuberculeuse,une série rétrospective marocaine.

INTRODUCTION: Tuberculosis miliary is a severe and rare form of tuberculosis. It is often due to a haematogenous spread of the bacillus of Koch and represents less than 2 % of tuberculosis. PATIENTS AND METHODS: We conducted a retrospective study of 81 cases of tuberculous miliary collected at the Department of respiratory diseases of the Ibn Rochd university hospital in Casablanca between September 2003 and November 2016. RESULTS: A female predominance was noted with 58 % of the cases. The average age was 36 years. The history of tuberculosis was found in eight cases and tuberculous tuberculosis in eleven cases, postpartum in five cases, diabetes in three cases and trisomy 21 in one case. The clinical picture was dominated by altered general status in all cases, and fever in 69 cases (86 %). Chest x-ray showed a miliary aspect in all cases, cardiomegaly in two cases, pyopneumothorax in three cases, and opacities excavated in five other cases. The intradermal tuberculin reaction, performed in all cases, was positive in 26 cases, and sputum oscillations were positive in 21 cases. The dissemination report found cerebromeningeal involvement in nine cases, with cerebral tuberculomas in five cases, pericarditis in four cases, mediastinal and peripheral adenopathies in nine cases each. Bouchut tubercles were found in nine cases. Antibacillary therapy was started as a matter of urgency, according to the national TB control program with the old regimen (2SHRZ/7RH) and the new regimen (2RHZEb/7RH) in all cases. The outcome was good in 55 cases (68.9 %), 17 patients were lost to follow-up, and 11 deaths were reported. CONCLUSION: We insist on this work on the severity of the tuberculous miliary and the need for early and urgent therapeutic management.

[Evaluation of the vagal activity by the Deep-Breathing test]. / Evaluation de l'activité vagale par le test de la respiration profonde (Deep-Breathing).

OBJECTIVE: The Deep-Breathing (DB) test is of major importance in the evaluation of the vagal response (VR). We applied this test to assess the VR in a group of subjects with functional (neurological, cardiovascular or digestive) symptoms unexplained by standard cardiac examination and to compare it with the VR measured in a group of healthy controls. PATIENTS AND METHODS: The following groups were considered: a C-Group of healthy controls (n=50), and three groups each consisting of 50 symptomatic patients (S1, S2, S3). Subjects in the S1-Group had a postural orthostatic tachycardia syndrome (POTS), while members of the S2-Group had arterial hypertension, and members of S3-Group had neither POTS nor arterial hypertension. The VR was expressed as a percentage variation of RR intervals 100x[(RR(max)-RR(min))/RR(min)], and was correlated with age and sex in the C-Group before any comparison. RESULTS: In controls the VR was 31.0%+/-8.2. It was negatively correlated with age (r=-0.42, p=0.003) and there was no significant difference between males (31.2%+/-5.7) and females (30.9%+/-9.0) (p=0.12). Compared to the C-Group, the VR was 51.6%+/-20.4 in the S1-Group (p<0.001), 26.9%+/-11.3 in the S2-Group (p<0.001), and 47.2%+/-22.7 in the S3-Group (p<0.001). CONCLUSION: The VR was independent of sex but was negatively correlated with age. In comparison with healthy controls, it was significantly increased in the patients with POTS and significantly decreased in hypertensives.

[Silicotuberculosis]. / La silicotuberculose.

OBJECTIVE: Tuberculosis is a serious and common complication of silicosis. The aim of this study is to describe the epidemiological, clinical, radiological and progressive aspects of this pathological entity. PATIENTS AND METHODS: The study concerns 23 cases of silicotuberculosis which were collected at the service of respiratory diseases at CHU Ibn Rochd of Casablanca, Morocco during 12years (2003-2015). RESULTS: All patients were men. They were 7 diggers, 5 rock crushers, 7 miners and 4 masons. The mean duration of silica exposure was 11years. The symptomatology was dominated by dyspnea and persistent bronchial syndrome. Imagery showed tumor-like opacities in all cases, associated with mediastinal calcified lymphadenopathy in 9 cases, with micronodules in 8 cases and an excavated opacity in 2 cases. The diagnosis of tuberculosis was confirmed by isolation of the Koch's bacillus in sputum in 13% of cases in the bronchial aspirate in 52% and culture in sputum post-bronchoscopy in 13%. The bronchial biopsies confirmed the diagnosis in 2 cases. Tuberculosis had complicated silicosis 9years on average after the cessation of exposure to silica in 65% of cases. The antituberculous treatment was started in all patients with good clinical outcome in 22 cases. We had deplored a case of death by acute respiratory failure. CONCLUSION: Silicosis increases the risk of tuberculosis, hence the importance of TB screening in all patients with silicosis.

[Tuberculosis of the lung bases]. / La tuberculose des bases pulmonaires.

INTRODUCTION: Tuberculosis is a major public health problem in Morocco. Tuberculosis of the lung bases is a rare and atypical form and raises real diagnostic problems. PATIENTS AND METHODS: We report a retrospective study of 21 cases of basal pulmonary tuberculosis, collected at the service of respiratory diseases in Ibn Rushd hospital in Casablanca between 2004 and 2015 (11 years). RESULTS: From a total of 21 patients having basal pulmonary tuberculosis, 13 (62%) were women versus eight men (48%), the average age was 33 years. The average time of diagnosis was 25 days. The disease was unilateral in 20 cases (95%). The right lower lobe was the most frequently affected (71%). Inhomogeneous opacities (66%) and consolidation (28%) were the main radiological findings. Associated comorbidities were dominated by diabetes in six cases (28%). Bronchoscopy had recovered thickening spurs in eight cases, endobronchial granules in seven cases and bronchial inflammation in six cases. Bronchial biopsies had found a necrotizing granulomatous inflammation tuberculoide in seven cases (33%). The smear was positive in sputum in three cases (14%), in the bronchial aspirate in four cases (19%), in induced sputum in one case (4.7%) and in post-bronchoscopic sputum in six cases (28%). The antituberculous treatment was started in all patients with good clinical and radiological evolution. CONCLUSION: The basal localization of the pulmonary tuberculosis is misleading; source of diagnostic delay, hence the need to think about it especially in patients with comorbidities.

[Treatment of the first episode of spontaneous pneumothorax]. / Prise en charge du premier épisode de pneumothorax spontané.

INTRODUCTION: The management of a first episode of spontaneous pneumothorax is controversial and the best technique to be used as an initial intervention, aspiration or intercostal drainage, is still debated. PATIENTS AND METHODS: We present a retrospective case series during two and a half consecutive years describing the immediate management of spontaneous pneumothoraces, comparing aspiration versus thoracic drainage. RESULTS: One hundred and thirty-three clinical files from patients with spontaneous pneumothoraces were analyzed (17 primary and 116 secondary). The pneumothoraces were of varying size and different etiologies. Patients were initially treated with simple aspiration in 68 cases, with an immediate success rate of 37.5%, intercostal drainage in 49 cases, and by rest alone in 16 cases. CONCLUSION: In case of secondary pneumothorax, aspiration appeared to offer advantages as an initial strategy over intercostal drainage in terms of hospital stay (11 versus 22 days), and with significant effectiveness (37.5%).

[Autonomic profile of patients with migraine]. / Profil autonomique des patients migraineux.

OBJECT: Dysfunction of autonomic nervous system (ANS) is implicated in the genesis and persistence of migraine. The objective of this study was to compare autonomic nervous system (ANS) profile of migraineurs during headache-free periods to a group of normal subjects based on cardio-vascular reactivity. METHODS: Patients with migraine according to the criteria of IHS 2004 were selected for the study. After a 30 min resting blood pressure (BP), the following standard tests were performed: deep-breathing (DB), hand grip (HG) of 15 s and 3 min, valsalva maneuver, echo stress, (ES) and tilt test (TT). Results were compared to 44 normal subjects, age similar, 37 female, (84.1%) using the Student test, with P < 0.005 as significant. RESULTS: Thirty-two patients (27 female (84.38%), 16-51 years, mean 40.41 +/- 7.8) were studied. Twenty-two patients (69%) had systolic blood pressure below 94 mmHg and 25 patients (78%) had diastolic blood pressure below 60 mmHg. Compared to normal, migraineurs exhibited a significantly higher vagal response (P < 0.001) and a significantly lower alpha sympathetic response, central by using ES as well as peripheral by using HG of 3 min (P < 0.001). CONCLUSIONS: Autonomic cardiovascular reactivity of patients with migraine showed a vagal hyperactivity and a deficiency of the alpha sympathetic system. This leads to further studies with new therapeutical approaches.

[Rhabdomyosarcoma of the salivary glands. Report of 3 cases]. / Le rhabdomyosarcome de la glande parotide. A propos de trois cas et revue de la littérature.

Rhabdomyosarcoma of the salivary glands is rare. Tumours develop mostly in children and young patients but can be diagnosed in older people. We report three new cases in women 7, 14 and 75 years old. Tumefaction of the parotid region and facial paralysis were the principle clinical symptoms. Two patients underwent a total parotidectomy and radiotherapy. The third patient had a locally advanced tumour and received chemotherapy followed by radiotherapy. Loco-regional recurrence was observed in all cases and median survival was 12 months. Rhabdomyosarcoma of the salivary glands is locally aggressive. Treatments include surgery and radiotherapy. The role of chemotherapy remains to be discussed.

[Clear cell carcinoma of the parotid gland]. / Carcinome à cellules claires de la glande parotide.

OBJECTIVES: Clear cell carcinomas of the parotid gland are hardly reported only fifty cases are known. They are characterized by a proliferation of acinic epithelial cells and of clear myo epithelial cells. What makes them remarkable is a slow process of evolution. MATERIAL AND METHODS: Three cases which were treated in the Ibn Rochd center of oncology are gathered from the 1999-2003 period into a review in order to discover the epidemic and anatomopathological characteristics of these tumours. The goal of study is to contribute to a best knowledge of the clinical features, pare clinical, anatomopathological and therapeutic characteristic of this tumour. RESULTS: Two men, aged of 62 and 71 and a 82-years-old-woman were concerned. Growing cervical mass was the most revealing symptom. The diagnosis was established by the parotid biopsy in 2 cases and after surgery in the third case. The treatment consisted in a total parotidectomy with conservation of the facial nerve and postoperative radiation at the extend of 65 Gy for the first patient. After 12 months the patient is still alive. As for the two other patients, given the extend of advancement of the tumour, palliative treatment was decided. It resulted in stabilization of the disease and a receding of 22 months for one patient and no trace of the second one because of a loss of the evolutionary pursuit. CONCLUSION: With an in-depth analysis we can notice that clear cell carcinomas of the parotid gland are rare and mostly occur to old patients. Immunohistochemistry is the essential first step to sort these tumour with other salivary ones. Basic treatment is surgery. Radiation therapy linked to surgery seems to improve the local control of the disease. The prognosis remains relatively good despite discusses. Because of the few published cases, it's hard to analyze these tumours.

Chronic pulmonary aspergillosis: a frequent and potentially severe disease.

INTRODUCTION: Chronic pulmonary aspergillosis is a pulmonary fungal infection with various presentations that can occur on a pre-existing cavity, often a sequel of tuberculosis. The objective of our study was to report the diagnostic and therapeutic management of pulmonary aspergilloma in our structure. PATIENTS AND METHODS: We retrospectively studied 81 cases of pulmonary aspergilloma having occurred in the respiratory diseases unit of the Casablanca Ibn Rochd hospital, over 11 years. RESULTS: We included 48 male and 33 female non-immunocompromised patients, with an average age of 51 years (27-75). A history of tuberculosis was recorded in 78 cases. Hemoptysis was the revealing symptom in 73 cases. A characteristic "bell-like" image was observed in 25 cases. The serological results were positive for aspergillus in 54 cases. The treatment was surgical in 50 cases and medical in 24 cases. Five patients died. DISCUSSION: A significant number of pulmonary aspergilloma cases were recorded in our study, occurring most frequently on sequels of tuberculosis. This disease is currently common in countries highly endemic for tuberculosis; early and adequate management is required. CONCLUSION: Aspergillosis is a frequent and potentially severe disease occurring on pre-existing lesions, most often in our context sequels of tuberculosis. Surgical resection is the reference treatment but is the cause of a significant morbidity and mortality. Preventive measures are mandatory.

Interstudy reproducibility of biplane cine nuclear magnetic resonance measurements of left ventricular function.

Cine nuclear magnetic resonance (NMR) imaging, as a noninvasive and high-resolution imaging modality, has been shown to be reliable for determining absolute left ventricular (LV) volumes and ejection fraction. A relatively new gradient echo cine NMR approach using 2 orthogonal long-axis planes (2- and 4-chamber) aligned with the true axes of the left ventricle has been previously developed and validated against radiographic biplane LV cineangiography. The aim of the present investigation was to determine the reproducibility of this more rapid cine NMR approach for the measurement of LV volumes and ejection fraction. Eighteen normal subjects underwent 2 cine NMR studies, on different days, using a 1.5-tesla clinical imaging system. Studies were analyzed on-line and blindly by 2 independent observers. Intraobserver error was also determined in a blinded manner. Mean values of measurements determined by this method in this group of normal subjects were end-diastolic volume (120 +/- 20 ml), end-systolic volume (39 +/- 9 ml) and ejection fraction (67 +/- 4%). Paired analysis of data revealed no significant bias between interstudy, interobserver or intraobserver measurements, except for interobserver end-diastolic volume, where the first observer measurements were slightly elevated (5.6 +/- 7.8 ml) compared with the second. This resulted in a small difference in ejection fraction (1.7 +/- 2.3%) between observers. The absolute variation between measurements (square root of variance components) was low for all interstudy, interobserver and intraobserver comparisons: end-diastolic volume was less than +/- 6.7 ml, end-systolic volume less than +/- 3.5 ml and ejection fraction less than +/- 2.4%.(ABSTRACT TRUNCATED AT 250 WORDS)

Rapid assessment of aortic regurgitation and left ventricular function using cine nuclear magnetic resonance imaging and the proximal convergence zone.

In patients with aortic regurgitation (AR), knowledge of the severity of AR, and the degree of left ventricular (LV) dysfunction are important for optimal management. Previous nuclear magnetic resonance (NMR) studies to assess these parameters used multiple tomographic planes that are time-consuming to obtain and analyze, and thus not cost-effective. In addition, these studies assessed the severity of AR by looking simply at the size of the regurgitant jet, a parameter that relates only poorly to regurgitant volume. The present study evaluates a rapid, single-plane, cine NMR approach (scan time < 10 minutes), and a new grading system for AR that is based on the presence, size and persistence of not only the regurgitant jet, but also the zone of proximal signal loss. Compared with color Doppler echocardiography (n = 42), the NMR approach detected AR with a specificity of 100% and a sensitivity of 95%. NMR regurgitant jet area correlated well with color Doppler regurgitant jet area (n = 20; r = 0.81; p < 0.01), but did not discriminate well between all grades of AR as compared with x-ray contrast aortography (n = 14). Using the new NMR grading criteria, AR grade by NMR was in accordance with aortographic grade in 12 patients, differing by only 1 grade in the remaining 2 patients. NMR grade was in accordance within 1 grade of Doppler in all patients compared (n = 20). LV volumes and ejection fraction using this single-plane approach correlated well with a previously validated, NMR biplane approach (r > 0.87; n = 18).(ABSTRACT TRUNCATED AT 250 WORDS)

Discriminant analysis of thallium-201 myocardial scintigrams.

In a group of 207 patients undergoing coronary angiography, myocardial scintigrams have been performed at rest (n = 95), after exercise testing (n = 50) or after dipyridamole vasodilation (n = 62). Pictures recorded in anterior and 45 degrees left anterior oblique projections have been analysed according to a model which divides each projection into 5 territories. Thallium uptake has been visually assessed using a three grade scale: 0 = normal uptake, + = sightly abnormal uptake, ++ = evident hypoactivity. With reference to angiography, sensitivity and specificity for prediction of coronary artery disease have been calculated in a classical way using three different criteria of positivity of increasing severity, and by a computerized method based on discriminant analysis. In the first case, sensitivity and specificity were highly dependent one on the other and, as could be expected, varied in opposite directions, a high sensitivity (89 to 100%) being only achieved by accepting a lack of specificity (33 to 57%). Discriminant analysis, on the contrary, provided for each type of protocol: rest, stress, dipyridamole and redistribution, a single optimized combination of sensitivity (74 to 87%) and specificity (92 to 100%). The corresponding point, when located on the receiver operating characteristics (ROC) diagram, demonstrated a clear improvement in diagnostic accuracy. The same method has been applied for discrimination, not only between normals and abnormals, but also between normals and patients with and without myocardial infarction (correct diagnosis in 50 to 68% of cases), and between normals and patients with single-, double- or triple-vessel disease (correct diagnosis in 17 to 65% of cases) with a high specificity (correct classification of normals in 86 to 100% of cases).

[Salivary duct carcinoma of the parotid gland: report of two cases and literature review]. / Carcinome canalaire de la glande parotide. A propos de deux cas et analyse de la littérature.

Salivary duct carcinomas are scarce tumour developed mainly in the male in the 6th or 7th decades of their life. Authors report two new cases developed 43 and 60 years-old in females. Because this tumour was localised, a radical treatment associating surgery and radiotherapy was performed. Follow-up were 115 and 137 months, and the two patients remain free of disease. These two cases were opportunity to discuss literature data.

[Radioisotopic quantification of isolated mitral insufficiency]. / Quantification radio-isotopique des insuffisances mitrales isolées.

A group of 23 consecutive patients with isolated mitral regurgitation confirmed by angiography, 8 of whom had normal and 15 abnormal coronary arteriographies, were compared with a control group of 27 subjects without valvular heart disease (normal coronary arteriography in 7 cases, abnormal coronary arteriography in 20 cases). After injection of technetium 99m labelled albumin, gamma-angiocardiography was performed in the left anterior oblique plane at equilibrium with electrocardiographic synchronisation. Fourier's analysis of the images excluded hepatic pulsation and dephasing of the two ventricles: amplitude images were used to trace the right and left ventricular zones of interest. The ratio of right to left ventricular ejection fraction was calculated in these zones from the radioactive count at end diastole and end systole. The ratio of the ejection fractions was 1.15 +/- 0.18 in subjects without valvular disease compared to 2.66 +/- 0.47 in patients with mitral regurgitation and normal coronary arteries, and 2.50 +/- 1.28 in mitral regurgitation with coronary artery disease (no significant difference between these two sub-groups). When compared with angiographic quantification of the mitral regurgitation, the ratio of ejection fractions increased progressively with the severity of the leak: 1.81 +/- 0.44 for grade I (9 cases), 2.37 +/- 0.80 for grade 2 (5 cases), 3.02 +/- 1.07 for grade 3 (4 cases) and 3.73 +/- 1.50 for grade 4 (5 cases). The differences between each sub-group are not statistically significant because of the small number of patients in each sub-group but all the values are significantly higher than the reference values.(ABSTRACT TRUNCATED AT 250 WORDS)

[Syphilitic aortitis and "accelerated" atherosclerosis]. / Aortite syphilitique et athérosclérose "accélérée".

The authors present the case of a 42 year old patient admitted for surgery of massive aortic regurgitation. Investigation of this patient who had no significant cardiovascular risk factors, showed diffuse and accelerated atherosclerosis (severe stenosis at the origin of both subclavian arteries at both superficial femoral arteries). Tertiary syphilis with neurological involvement and aortitis was confirmed by histological examination (peroperative biopsy of the aortic wall). This case is unusual due to the association of early atherosclerosis with tertiary syphilis and raises the question of the causality of syphilis in the generation of these atherosclerotic lesions.

[Ultrasonography of the whole abdomen in non-Hodgkin's lymphoma of the small intestine in children. Apropos of 9 cases]. / Apport de la pansonographie abdominale dans le lymphome non Hodgkinien du grêle de l'enfant. A propos de 9 cas.

The value of ultrasonic tomography exploration of the abdomen in non-Hodgkin's lymphoma of the small intestine is illustrated by findings in 9 children. Performed as the initial examination for an abdominal mass (sometimes after a straight radiograph), a positive diagnosis was established by ultrasonography in all cases. Moreover, extensions of the lesion were identified in the liver in two cases, in the two kidneys in four cases, and retroperitoneal adenopathies detected in one case. Ultrasonic findings in the case of intestinal localizations were a hypoechogenic mass with a hyperechogenic zone or a gaseous acoustic shadow in its center. Kidney, liver, and retroperitoneal lesions were seen as hypoechogenic nodules. In one case, there was an increase in echogenicity of both kidneys, these being more echogenic than the liver. This atypical appearance is emphasized as it does not appear to have been reported previously in the published literature. Results of ultrasonic and conventional radiological examinations are compared, and ultrasonic differential diagnosis discussed.

[Ultrasonic diagnosis of renal lymphoma in children. A series of 18 cases]. / Diagnostic échotomographique des lymphomes rénaux chez l'enfant. Une série de 18 cas.

Ultrasound tomography imaging is a very effective diagnostic examination for lymphoma of the kidneys, organs which are frequently the site of these tumors (51,5% of cases). A total of 18 cases of renal lymphoma explored by ultrasound tomography over the last 2 years were reviewed, the first patients seen in this series also undergoing intravenous urography and two others a CT scan. In most cases diagnosis from ultrasound imaging was based on findings typical of renal lymphoma and on the almost constant detection of other parenchymatous localizations (liver, spleen, pancreas) or lymph node and/or serous lesions. Tumors were bilateral in 13 cases and unilateral in 5. Ultrasound images showed: a) nephromegaly that was usually bilateral (9 cases) or sometimes unilateral (2 cases), while the kidney or kidneys were of normal size in 4 patients; b) the almost constant presence of hypoechogenic nodules scattered throughout the kidney or kidneys (16 cases); c) global hypoechogenicity of the kidney or kidneys (3 cases)--a sign not reported it the literature--; d) hydronephrosis that was either isolated (2 cases) or associated with the renal lymphomatous lesion (3 cases). The diagnostic reliability, cost and safety of ultrasound imaging make in the examination of choice for the exploration of this affection.