[Aspergillosis and sarcoidosis]. / Aspergillose et sarcoïdose.

INTRODUCTION: Diffuse fibrosing sarcoidosis represents an important predisposing factor for infection by Aspergillus sp. The clinical features and specific complications are illustrated by 3 case reports. BACKGROUND: Patients with chronic fibrosing sarcoidosis and cystic changes or cavitation in the upper lobes are the most prone to aspergillosis. Aspergilloma is the most common form and can be difficult to distinguish from chronic necrotising aspergillosis. Sarcoidosis with aspergillosis is associated with an increased incidence of respiratory failure and fatal haemoptysis. The 3 cases presented in this paper also illustrate the poor efficacy of oral antifungal drugs and bronchial embolisation. Surgery is often necessary but may be difficult on account of the extent of the lesions and poor respiratory function. VIEWPOINT: In the future the use of new drugs such as voriconazole and posaconazole may improve the prognosis of this complication. CONCLUSION: Aspergillosis represents a frequent complication of diffuse fibrosing sarcoidosis which warrants early detection and treatment on account of its poor prognosis.

[Acute encephalopathy after infusion of paclitaxel]. / Encéphalopathie aiguë après injection de paclitaxel.

INTRODUCTION: Paclitaxel is an anti-neoplastic agent commonly used in the treatment of primary bronchial carcinoma and tumours of the breast and ovary. Its toxicity, haematological and peripheral neuropathy, are well known. On the other hand central nervous system toxicity is rare. CASE REPORT: We report a case of acute encephalopathy, occurring eight hours after infusion of Paclitaxel, in a patient treated for adenocarcinoma of the lung. It included drowsiness, confusion and hallucinations, and resolved completely after ten days. The diagnosis of encephalopathy secondary to Paclitaxel injection was reached after exclusion of other possible aetiologies. CONCLUSIONS: Acute encephalopathy is a rare complication of intravenous Paclitaxel treatment. The pathophysiology of this toxic effect is discussed: a direct toxicity of Paclitaxel or of its solvent (polyoxethylated castor oil), and the role of a pre-existing alteration of the blood-brain barrier.

Evidence of cumulative gene losses with progression of premalignant epithelial lesions to carcinoma of the bronchus.

Human bronchial carcinoma is thought to develop through progressive stages from basal cell hyperplasia to squamous metaplasia, dysplasia, carcinoma in situ, and finally invasive cancer. In this study, we used tissue microdissection to examine loss of heterozygosity of chromosomes 3p21, 5q21, and 9p21 at each stage of the epithelial progression to invasive cancers. Forty-eight premalignant/malignant bronchial sites were biopsied from 13 patients (including 9 subjects without cancer) using fluorescence bronchoscopy. Eighteen sites with moderate/severe dysplasia in 6 patients were subjected to bronchoscopic and molecular follow-up during a 3-month to 2-year period. Seven separate cases of advanced non-small cell bronchial cancers were also analyzed. From the baseline biopsies, the prevalence of 3p and 9p deletions increased significantly from no deletion in the hyperplasia/metaplasia samples (n = 9) to 37 and 31% of the informative cases, respectively, in the dysplasia samples (n = 29), to 100 and 83%, respectively, for the carcinomas in situ (n = 6), and 100% in the invasive cancers (n = 11). Chromosome 5q deletion was significantly more frequent in invasive cancers (70% of the informative cases) as compared to carcinoma in situ (40%), dysplasias (33%), and hyperplasia/metaplasia samples (11%). The number of chromosome alterations also increased significantly from the lowest to the highest grade lesions, showing evidence of accumulation of genetic damage from one group to another. The molecular follow-up analysis showed that the same genomic alteration can persist in a given dysplastic bronchial area for several months or years, and that the persistence or the regression of the molecular abnormality is well correlated with the evolution of the disease on follow-up. Our results suggest that molecular analysis of bronchial biopsies obtained by fluorescence bronchoscopy may be a very useful means to study the natural history of preinvasive bronchial lesions and the outcome of interventions, such as with chemopreventive treatment.

Sarcoidosis. Retroperitoneal fibrosis, renal arterial involvement, and unilateral focal glomerulosclerosis.

In one patient with pulmonary sarcoidosis, hypertension occurred during the course of the disease. Aortography showed extensive narrowing of the right renal artery. Surgical exploration disclosed extensive periaortic and perirenal fibrosis. This fibrosis encircled the right renal artery and caused extrinsic compression. Pathological examination disclosed a large amount of histiocyte epithelioid infiltration in various samples of the fibrosis and particularly in the adventitia of the renal artery, highly suggestive of sarcoidal angiitis. Surgical biopsy was performed on both kidneys. The right kidney, protected by arterial stenosis, was little altered, while the left kidney showed extensive interstitial, tubular, and glomerular lesions. The glomerular lesions were focal and segmental hyalinosis.

[Methotrexate for the treatment of patients with chronic cutaneous sarcoidosis: 4 cases]. / Traitement de la sarcoïdose cutanée par le méthotrexate: 4 observations.

INTRODUCTION: Pathogenesis of sarcoidosis remains partially unknown. Cutaneous lesions are frequent (20 to 35% of cases). Their clinical features and follow-up data are highly variable. Numerous treatments have been proposed. The clinical features and follow up data of four patients with chronic cutaneous sarcoidosis treated with methotrexate are reported. CASE REPORT: Mean age of patients (3 female, 1 male) was 40 years old (34-49 years). One patient presented with a lupus pernio, two patients with papules and nodules, and the last with an annular lesion of the face. All patients had been previously treated with topical corticosteroids and/or hydroxychloroquine without any success. Patients were treated with methotrexate at doses ranging from 12.5 mg to 30 mg per week for at least 6 months. Complete remission of cutaneous lesions was observed in 3 of 4 patients after a mean treatment duration of 29 months (16 to 36). Methotrexate side effects were observed in one patient (elevated liver enzymes) leading to methotrexate discontinuation. DISCUSSION: Methotrexate seems to be an effective treatment of cutaneous sarcoidosis. It should be used namely in patients who failed to respond to previous treatments with topical corticosteroids or antimalarial drugs.

Preoperative chemotherapy in epidermoid bronchogenic carcinoma.

Palliative chemotherapy in cases of epidermoid bronchogenic carcinoma, initially judged to be inoperable, made it possible to perform operative resection in 50 cases. An association of cis-platinum and bleomycin was used, this combination having previously been considered synergistic. In certain cases the tumour seemed to have disappeared on macroscopic examination of the resected specimen, and in some instances no tumoral cells could be found on histological examination. This series brought out several positive features: chemotherapy made it possible to operate on patients previously judged to be inoperable; it ensured maximum local efficiency of drugs because of the absence of abnormal vascularity; and it made it possible to anticipate the cure of occult metastases. However, three negative aspects were also present: modification of postoperative TNM classification making it difficult to establish a prognosis; difficulty in determining therapeutic strategy for pNo; and inadequate long-term follow-up. On the whole the positive points appeared to outweigh the negative aspects, but a randomized study is necessary to confirm this.

Evaluation of large-needle biopsy for the diagnosis of cancer.

The arguments for a choice between a large or fine needle in the diagnosis of tumors are still unclear. This paper reviews the advantages and disadvantages of large-needle biopsy and fine needle aspiration. Reports indicate that although the procedures have the same diagnostic efficacy, the risk of tumor seeding is far higher following large-needle biopsy. For this reason it should be avoided for the diagnosis of cancer. The risk of tumor seeding after fine needle aspiration may be reduced by performance through a cover of normal parenchyma, by maintaining suction during withdrawal of the needle and by examining samples for quality during the procedure.

[Evaluation and utilization patterns of antibiotic therapy. A study in 4 hospital departments]. / Modalités d'utilisation et évaluation de l'antibiothérapie. Etude dans quatre services hospitaliers.

The use of antibiotics in 480 cases in 4 hospital wards during 1988 was assessed by examination of medical records. Only the first antibiotic therapy administered during the first stay in the ward for each patient was included. Antibiotics were administered to 163 in-patients (37% of hospitalizations) for infections in 113 (26%) cases. Amoxycillin and macrolides were the drugs most frequently used. Sixty-eight percent of the treatments were administered in the absence of microbiological data. Single drug therapy was used in 60% of treatments. Fifty in-patients (11% overall; 41% of patients undergoing surgery) received antibiotics for prophylaxis. The exact indication(s) for the choice of therapy was not given in the medical records of 39% of cases. Treatment started within 48 hours of infection in 15% of the cases. Overall, 93% of the treatments given were indicated, but 53% were inappropriate because they were too expensive, unlikely to be effective or were multiple drug therapy without justification. There are a variety of factors that cause such inappropriate administration of antibiotics.

[Primary pleural lymphoma after collapse therapy: modern aspects of an historic disease]. / Lymphomes pleuraux primitifs après collapsothérapie: aspects modernes d'une maladie historique.

INTRODUCTION: Pleural lymphomas after long standing pyothorax due to pulmonary tuberculosis are now well identified. Most cases have been described by Japanese investigators and it seems rare or unrecognised in Western countries. We report the study of six cases observed in a single institution. PATIENTS AND METHODS: Six pyothorax-associated pleural lymphomas, among 1,038 lymphoma (0.6%) collected during a period from 1989 to 1998, are described. Diagnosis was established by two pathologists with the usual histologic and immunohistochemical methods, according to the working formulation. The in situ hybridization method for Epstein-Barr virus was performed. RESULTS: The average age of the patient was 73 years. Presenting symptoms combined chest pain and constitutional symptoms more than 45 years after artificial pneumothorax or tuberculous pleuritis. Computerized tomography revealed a pleural mass which involved the adjacent chest wall. Open biopsy by thoracotomy show a diffuse B-cell non-Hodgkin-lymphoma in all cases. Though the lymphoma was initially localized, many poor prognostic factors (age, performance status, LDH, histology) explain the pejorative evolution (average survival of five months). Patients died from an uncontrolled tumoral proliferation or by infectious complications. In situ hybridization confirms the presence of Epstein-Barr virus in tumoral cells. CONCLUSION: Pleural lymphoma is an established complication of artificial pneumothorax. Even if the Epstein-Barr virus plays a crucial role in the pathogenesis, and despite the number of artificial pneumothorax operations that have been widely performed, this lymphoma remains rare, suggesting additional oncogenic factors.

[Late empyema after pneumonectomy. Demonstration in x-ray computed tomography]. / Empyème tardif après pneumonectomie. Démonstration en tomodensitométrie.

The authors describe CT signs of a thoracic empyema, developed several years after a pneumonectomy. The disappearance of the concavity of post-pneumonectomy space in contact with mediastinum, associated to the absence of retraction of the hemithorax are the main signs of the diagnosis.

[Idiopathic spontaneous pneumomediastinum: a not to be mistaken diagnosis in chest pain]. / Pneumomédiastin spontané idiopathique: un diagnostic à ne pas méconnaître devant une douleur thoracique.

We report two cases of mediastinal emphysema occurring without etiologic factor. Chest pain and subcutaneous emphysema are the most prevalent symptoms. In the absence of oesophagus related symptoms, a single chest radiograph is usually sufficient to make the diagnosis. In this paper, we recall the main radiographic signs, physio-pathological mechanisms, and differential diagnosis of spontaneous pneumomediastinum.

[Unrecognized causes of chronic cough]. / Causes méconnues de toux chronique.

Chronic cough is defined as persistence of the symptom for longer than one month. It is a common reason for consultation. A systematic diagnostic approach based on the history, clinical examination and a number of investigations (chest x-ray, lung function tests, oesophageal pH monitoring and sinus x-rays) reveals the cause in most cases. The main aetiologies are post-nasal drip, gastro-oesophageal reflex, asthma, chronic bronchitis, and the use of angiotensin converting enzyme inhibitors. Nevertheless, in some cases, the cause is not found. In this situation it is necessary to search for less common pathologies where cough is just a symptom of systemic disease, such as connective tissue disorder (Sjogren's syndrome, atrophic polychondritis), vasculitis (Wegener's granulomatosis), Horton's syndrome (cluster headaches), amyloidosis and inflammatory bowel disease. It may also be a matter of local pathology of the tracheo-bronchial tree, such as tracheo-bronchomegaly, tracheopathia osteoplastica, rare or unrecognized infections (whooping cough, post-viral cough, bronchial tuberculosis), reactive bronchial dysfunction, eosinophilic bronchitis or radiologically occult bronchial carcinoma. Il is also necessary to consider vocal cord dysfunction and cough due to medication before accepting a diagnosis of psychogenic cough.

[Sarcoidosis simulating a pulmonary veno-occlusive disease]. / Sarcoïdose simulant une maladie veino-occlusive pulmonaire.

We report the case of a man of 43 years old presenting with sarcoidosis which produced pulmonary hypertension and respiratory failure without radiological evidence of interstitial fibrosis. In spite of treatment with steroids and corticosteroids (1 mg/kg) there was progression over 2 1/2 years to respiratory failure and irreversible right heart failure and the death of the patient. At autopsy the pulmonary veins were obliterated by non caseating granulomas and there were minimal fibrotic parenchymal lesions. To our knowledge this is only the second case of sarcoidosis resulting in a veno occlusive pulmonary disorder.

[Mesothelial cyst of pleuro-parietal origin]. / Kyste mésothélial à développement pleuro-pariétal.

This is a case report of two mesothelial cysts, both with liquid contents. They had developed in the thoracic wall; in spite of their perfectly benign character, both were eroding the ribs at the point of contact. These ectopic cysts are probably of coelomic origin.

[Acute respiratory distress syndrome due to pneumonitis following intrathecal methotrexate administration]. / Insuffisance respiratoire aiguë avec pneumopathie après administration intrathécale de méthotrexate.

INTRODUCTION: Methotrexate, given orally or systemically, is associated with pneumonitis in 7% of cases. CASE REPORT: This case report describes acute respiratory distress syndrome, due to diffuse pneumonitis, in a patient with malignant non-Hodgkin's lymphoma being treated with combination chemotherapy which included doxorubicin, cyclophosphamide, bleomycin, vindesin and intrathecal methotrexate with G-CSF (filgrastine- Neupogen). The clinical course, the lack of an identifiable infectious agent and the complete response to corticosteroids suggested a drug-induced cause. After ruling out the other chemotherapy agents, methotrexate was considered to be the causal agent. The unusual feature of this case was that pneumonitis developed after intrathecal administration of methotrexate. CONCLUSION: Methotrexate-associated respiratory complications can occur with whichever route the drug is administered.

[Low grade pulmonary sarcoma preceding the discovery of a uterine primary]. / Sarcome pulmonaire de bas grade précédant la découverte d'un primitif utérin.

INTRODUCTION: Low grade pulmonary sarcomas are very rare tumours. We report the case of a low grade sarcoma of the lung occurring two years prior to the finding of a uterine primary. CASE REPORT: Complete surgical excision of a low grade pulmonary sarcoma was performed. The initial search for dissemination was negative. Two years later a follow-up scan discovered a uterine mass as well as a para-aortic shadow that proved to be the primary tumour (low grade uterine sarcoma) and a metastasis. CONCLUSION: This is the second case of a pulmonary metastasis discovered before a primary low grade uterine sarcoma. The first was found during the investigation of a pulmonary sarcoma. The main differential diagnosis to consider is metastatic leiomyosarcoma. In both cases their finding justifies the search for a uterine primary by immunohistochemical examination for oestrogen and progesterone receptors as well as pelvic ultrasound or even magnetic resonance imaging.

[Meteorological conditions and spontaneous pneumothorax. Retrospective study of 165 cases in the Rouen area]. / Conditions météorologiques et pneumothorax spontanés. Etude rétrospective sur 165 cas de la région rouennaise.

The occurrence of a spontaneous "idiopathic" pneumothorax in 165 patients admitted to hospital could be precisely dated over a 5-year period. An analysis of the meteorological conditions recorded at these dates (mean atmospheric pressure, mean temperature, relative and absolute humidity) and of their seasonal distribution demonstrated two peaks of frequency, one in the summer, the other in the winter, and a significant correlation between the occurrence of pneumothorax and a low relative humidity. These results, particularly clear during the exceptionally dry summer of 1976, confirm some data in the literature and suggest that bronchoconstriction induced by moistening of air in the airways might play a role in the pathophysiology of pneumothorax.

[Surgery of intracranial metastases of bronchial origin]. / La chirurgie des métastases intra-crâniennes d'origine bronchique.

Forty-six out of a series of 76 patients with intracranial metastases from lung cancer underwent a surgical operation for complete macroscopic resection. 44 cases presented with a single metastasis. In 2 cases, there were 2 cerebral metastases. Most of the lesions were situated in the frontal lobe (41%). In more than one half of cases, the primary lung cancer was squamous carcinoma. The mean survival was 9 months. It was shorter in the case of anaplastic cancers (6 months) and adenocarcinomas (8 months) than in the squamous carcinomas (12 months). The five patients still alive 2 years after surgery all belong to this histological group. The results suggest that surgical treatment of single cerebral metastases from lung cancer, in the absence of extracranial dissemination, allows a considerable improvement in the quality and duration of the survival.

[Evaluation and symptomatic treatment of surinfectious exacerbations of COPD: preliminary study of antibiotic treatment combined with fenspiride (Pneumorel 80mg) versus placebo]. / Evaluation du traitement symptomatique des poussées de surinfection de BPCO: étude préliminaire Pneumorel 80 mg versus placebo en association avec une antibiothérapie.

UNLABELLED: Exacerbations of chronic obstructive pulmonary disease (COPD) have an inflammatory component in addition to the possible infectious component. The antiinflammatory properties of fenspiride (Pneumorel(R) 80 mg) should be evaluated in this frequent clinical situation. OBJECTIVES: Assess the supplementary therapeutic benefit provided by fenspiride administered in combination with antibiotics in COPD patients presenting an episode of bronchial infection. PATIENTS AND METHODS: A preliminary randomized placebo-controlled double-blind study was conduced in 7 centers. Patients under 80 years of age of both sexes were included. All patients had COPD and presented a bronchial infection defined as the presence of at least 2 of the 3 criteria defined by Anthonisen. Patients were randomly assigned to group F or group P. Group F received an antibiotic therapy from day 1 to day 11 plus fenspiride (3 x 80mg/d from day 0 to day 30). Group P received the same antibiotic therapy plus placebo. Amoxicillin 500mg plus clavulanic acid 125, 3 tablets/day, was administered in both groups. RESULTS: Thirty-nine patients were included (group F 19 patients, group P 20 patients; 6 women and 33 men; mean age 61.1 +/- 9.8 years). The 3 Anthonisen criteria were present in 79% and 75% of the patients in group F and P respectively (NS). On day 11, expectoration resolved in 39% and 32% (NS) and cough in 44% and 16% (NS) of the patients in groups F and P respectively. Lung auscultation returned to normal in 83% of the patients in group F compared with 47% in group P (p=0.05). A composite clinical score including expectoration cough and auscultation findings showed that 28% of the patients in group F were symptom-free on day 11 compared with 0% in group P (p=0.04). On day 30, the two groups were comparable. CONCLUSION: In this preliminary study of patients with COPD presenting a bronchial superinfection, there was a significant improvement in lung auscultation and in the composite clinical score in patients given fenspiride. Fenspiride was thus found to provide an early clinical benefit.

[Acute paraffin oil pneumopathies. Apropos of a case in a fire-eater]. / Les pneumopathies pétroliques aiguës. A propos d'un cas chez un cracheur de feu.

A case of acute paraffin oil-induced pneumonia due to accidental inhalation by a fire-eater of kerdane, a petroleum derivative is reported. The symptoms and course of respiratory manifestations of acute paraffin oil poisoning are reviewed. The physical properties of the petroleum derivative inhaled account for the pathogenesis of the pneumonia. Pulmonary lesions, usually fully reversible, result from the joint effects of an inflammatory phase with exudate and a proliferative phase.