[Paradoxical reaction following antituberculosis therapy in immunocompetent patient]

INTRODUCTION

The features of paradoxical reactions (PR) that occurred in non-HIV infected patients are rare and not well known.

CASE REPORT

The authors reported the case of a 21years old, non-immunocompromised, and HIV negative patient treated for disseminated tuberculosis. PR occurred after 8months after initiation of antituberculous treatment. PR presented as left cervical lymphadenopathy, pulmonary, pleural, costal and spinal location of the tuberculosis. The antituberculous drugs were prolonged. Patient's clinical symptoms improved initially. However, left inguinal lymphadenopathy appeared after 20months of antituberculous therapy. Inguinal lymph node biopsy revealed tuberculous lymphadenitis. The patient has a good compliance to the treatment. The patient was continued on same antituberculous treatment for a total of 28months. The cervical and inguinal lymphadenopathy disappeared and CT scan showed regression of thoracic, abdominal, costal and spinal lesions.

CONCLUSION

PR during antituberculous treatment must be considered after exclusion of other causes. No consensus on the therapeutic management of this entity has been developed to date.

[Malignant peripheral sheath nerve tumor: An exceptional mass of the anterior and middle mediastinum]

Malignant peripheral nerve sheath tumors (MPNST) are rare nervous tumors usually located in the posterior mediastinum in the paravertebral gutters. We report the case of a non-smoking 62-year-old man who was admitted with a 4 months history of cough, hoarseness and shortness of breath. Physical examination noted a superior vena cava syndrome. CT scan of the chest revealed a right anterior and middle mediastinal mass compressing the superior vena cava, the ascending aorta, the right pulmonary artery, invading the superior root of the pulmonary vein and the right auricle. Flexible bronchoscopy showed extrinsic compression of the right main bronchus, the right upper lobe bronchus and intermedius bronchus. The patient underwent surgical biopsy of the mass by mediastinoscopy. Histological examination revealed a malignant peripheral nerve sheath tumor. The patient received a single cycle of chemotherapy (ifosfamid-adriamycin). Clinical course was marked by the fast worsening of the dyspnea and the general state. Patient died three weeks after the cure of the chemotherapy. This case is original by the exceptional clinical presentation of MPSNT with a superior vena cava syndrome and the very rare location of this tumor in the anterior and middle mediastinum.

[Unusual location of an intrathoracic mesothelial cyst in the posterior and upper mediastinum]

BACKGROUND

Intrathoracic mesothelial cysts are congenital lesions due to an abnormal development of the pericardial coelom. They are usually asymptomatic and found incidentally on chest radiography or computed tomography. As their classic anatomical location is in the cardiophrenic angle, they are also referred to pleuropericardial cysts.

CASE REPORT

A 50-year-old male presented with a history of chest pain. Physical examination and chest X-ray were normal. Computed tomography (CT) scan revealed a cystic lesion in the posterior and upper mediastinum. The cyst was surgically removed through a posterolateral thoracotomy. Histopathological examination confirmed that it was a mesothelial cyst. The surgical resection of the cyst lead to relief of the thoracic pain over a three-year follow-up period. CT-scan showed an aberrant right subclavian artery or arteria lusoria, which is an anomaly of the aortic arch secondary to abnormal embryogenesis. We know no other report of concurrent ectopic coelomic cyst and aberrant right subclavian artery.

CONCLUSION

Although the majority of coelomic cysts needs only radiological and clinical follow-up, surgical resection should be performed when the patient is symptomatic or when the diagnosis is uncertain.

Endovascular treatment of haemoptysis: medium and long-term assessment

PURPOSE

To assess the short, medium and long-term results of bronchial artery embolisation (BAE) and identify the factors favouring the recurrence of haemoptysis.

PATIENTS AND METHODS

This is a retrospective study, between January 2001 and June 2010, comprising 53 consecutive patients with BAE. The mean age was 53.8 years. There were 15 women (28.30%) and 38 men (71.69%).

RESULTS

The aetiologies of haemoptysis were dominated by the residual signs of pulmonary tuberculosis: 18 cases (33.96%), bronchial dilations: 12 cases (22.64%) and aspergilloma: five cases (9.43%). The bronchial arteriography showed signs of bronchial hypervascularisation in 92.45% of the cases. Forty-six patients had a first embolisation (86.79%) with immediate efficacy in 84.90% of the cases (n=45). This efficacy was noted after more than 3 years in 60.08% of the cases. Short (< 30 days) and medium-term (> 30 days and < 3 years) recurrence of haemoptysis were noted in 17.39% and 8.69% of the cases respectively. A statistically significant correlation between aspergilloma and the immediate recurrence was found (P=0.013). The risk of medium and long-term recurrence (> 3 years) was correlated with age. The survival without recurrence was statistically higher when the age was less than 60 years (P=0.0041).

CONCLUSION

BAE is an effective treatment. Aspergilloma is a major risk factor in the recurrence of haemoptysis. Repeated embolisation may be proposed for these patients.

[Silicoproteinosis: a specific clinical and radiological entity]

INTRODUCTION

Silicoproteinosis is a rare disease, which can cause the rapid onset of respiratory failure following massive exposure to silica dust.

CASE REPORT

A 25-year-old patient presented with altered state and dyspnea. The diagnosis of military pulmonary tuberculosis was first considered and antituberculous treatment was started. The diagnosis was reconsidered due to a lack of improvement and the discovery of an 18-month history of exposure to silica. The patient had stopped work 6 months prior to hospitalization. High-resolution CT showed air space condensation associated to centrilobular nodules throughout the lungs and multiple mediastinal lymph nodes, suggesting sarcoidosis. Bronchoalveolar lavage (BAL) suggested the diagnosis of lipoproteinosis. Because of discordance between the bacteriological, radiological and the BAL results, a surgical lung biopsy was performed which led to the diagnoses of a secondary lipoproteinosis. The diagnosis of silicoproteinosis was then considered. Over a one-year follow up, the patient's respiratory failure has progressed markedly despite treatment with corticosteroids.

CONCLUSION

Silicoproteinosis is a distinct pathological entity, the diagnosis of which depends on clinical and radiological features as well as BAL findings, which may avoid the need for more invasive investigations.

[Treatment of recurrent pulmonary tuberculosis]

INTRODUCTION

Tuberculosis (TB) is a greatest public health problem of the world. This work aims to study the antituberculous treatment and the evolution of the patients with recurrent tuberculosis.

PATIENTS AND METHOD

The study is a retrospective study on 64 patients with recidivant pulmonary TB: A1 group: at the first TB attack; A2 group: at the time of recidivant TB, and 105 controls patients with confirmed TB without recidive.

RESULTS

Multidrug-resistant TB is more frequent with recidivant TB (21.1% vs 3%, P<0.05) and also extensively drug-resistant. Antituberculous treatment duration in group A1, A2 and T was respectively 8.63 months, 9.79 months, and 7.08 months. Antituberculous drug complications were more frequent in group A2 compared to group T (76.1% vs 41.2%; P<0.001).

CONCLUSION

All tuberculous patients, specially recidivant TB, should benefit of particular care and drug protocol adaptation.

[Pain and primary lung cancer in the elderly]

The study of pain in elderly patients with a primary lung cancer (PLC) deserves special attention particularly because this symptom is frequently associated with the condition and influences the management and prognosis. To study the characteristics of pain due to PLC in the elderly, we prospectively evaluated pain in all patients aged over 65 years admitted for PLC. Thirty-nine elderly patients were enrolled in 15 months (62% of all PLC). The average age was 72 years. The cancer was advanced NSCLC in most cases. Pain was present in 74.3%. It was significantly less common among those over 75 years (50% versus 85.1%; P<0.05). The pain, mild in most cases, worsened during follow-up in 55.5%. The last mean visual analogue scale score was significantly lower than the first (1.3 versus 3.6; P=0.001). The pain treatment required was based on level I in 20.6%, level II in 48.2% and level III in 31% of cases. Pain management in the elderly should be early, adequate and continued in order to preserve to a maximum the quality of life of these patients with PLC.

[Solitary fibrous tumour of the pleura: about five cases]

BACKGROUND

Pleural solitary fibrous tumour (PSFT) is a rare, usually benign tumour, with unpredictable behaviour.

PATIENTS AND METHODS

Five cases of PSFT were diagnosed in our department over a 12-year period from January 1999 to December 2010. Clinical, radiological, histological, therapeutic and follow-up information were provided in all cases.

RESULTS

Our series comprised four men and one woman. The mean age of the patients at presentation was 55 years. All patients were symptomatic. Radiologic investigations showed a pleural lesion with a mean size of 10.6cm ranging from 3 to 17cm. Histologic diagnosis was made from resected parietal pleura in three cases and visceral pleura in two cases. The histologic features were suggestive of malignancy in two cases and benign in three cases. Immunohistochemical study showed that the tumour cells expressed vimentin, CD34, CD99 and Bcl2. Complete resection was obtained in all patients. The evolution was marked in the two patients with malignant PSFT by the recurrence of the tumour after 6 and 21 months respectively. Both died from the condition. The three patients with a benign form are disease-free after 3, 11 and 2 and half years of follow-up.

CONCLUSIONS

PSFT is rare tumour, the diagnosis of which is based on histologic investigations. These tumours require long-term monitoring due to the possibility of local recurrence and malignant transformation.

[Predictive factors for recurrence of pulmonary tuberculosis in Tunisia: a retrospective study]

INTRODUCTION

Tuberculosis is still endemic in Tunisia. Even though recurrent TB (RT) is rare, there is an increased risk of resistance. The purpose of this study is to investigate predictors of RT.

PATIENTS AND METHODS

This was a case controlled retrospective study, comparing two groups of patients with confirmed pulmonary tuberculosis: a relapse group (GR) of 64 patients with RT and a control group (GT) of 105 patients.

RESULTS

Between September 1995 and December 2007, the incidence of RT was 9.48%. All the patients were male. There was no difference in the average age of the two groups. A smoking history of greater than 20 pack-years was more common in the GR (44.89% versus 21.4%, P=0.055). No difference was found regarding the history and clinical signs except that chest pain and dyspnoea were more frequent in the GR. A low haemoglobin was more common in the GR (11.33 ± 1.57g/dL versus 12.41 ± 1.66g/dL, P=0.008). The tuberculin skin test was negative in 73.7% of GR versus 31.1% of GT (P=0.001). Adverse liver reactions are more frequent in the GR (27.3% versus 8.6%, P<0.05). Discontinuation of TB treatment was more common in the GR (36.7% versus 3.8%, P<0.001). The achievement of sputum negativity was delayed in the GR (46.32 ± 54.01 versus 9.35 ± 11.84 days, P<0.001). Despite this, we have noted no significant difference in drug resistance. In multivariate analysis, hepatic cytolysis and a negative tuberculin skin test were independent predictive factors for RT.

CONCLUSION

All tuberculous patients should have a carefully adapted treatment regimen, particularly the presence of factors predictive for recurrence.

[Anaphylaxis due to chicken meat]

Acute anaphylaxis due to chicken meat is very rare; only a few cases have been reported in the literature. We report the case of a 13-year-old girl, with a past history of allergic urticaria due to eggs, who presented immediately after ingestion of lightly grilled chicken meat with facial edema, dysphonia, acute dyspnoea and a feeling of suffocation. A few months later, the patient developed asthma in the vicinity of poultry and after contact with chicken feathers.

[A case of costal haemangioma]

Costal primary tumors are rare and dominated by malignant tumors. Haemangioma of the bone represents only 1% of bone tumors. Costal localization accounts only for 1% of the cases and only about fifty cases have been reported in the literature.

AIM

The authors aim to describe a rare costal tumor, its histological features and the main differential diagnoses.

OBSERVATION

The authors describe the case of a 46-year-old woman who presented with chest pain. Radiological findings did not permit a malignant tumor to be ruled out and the treatment consisted of a resection of the posterior arch of the rib. Microscopic examination concluded that the patient had a costal haemangioma and the patient didn't present any recurrence after a six-year follow-up.

CONCLUSION

The costal haemangioma is a very rare tumor with a debated etiology. Some radiological features are specific such as the "soap bubble" or "honeycomb" aspect. However, the basis for diagnosis remains microscopic examination. These tumors have a good prognosis and no cases of recurrence have been reported following complete resection.

[Isoniazid-induced myopathy]

Drug-induced muscle disorders are now well known and vary from a simple isolated increase in muscle enzymes to severe drug-induced myopathy. The list of drugs inducing myopathy is very long and continues to grow. The onset of muscle disorders under isoniazid often falls within a drug-induced neuropathy or a drug-induced lupus. However, the occurrence of isolated isoniazid-induced drug myopathy without neuropathy is an extremely rare condition especially with non-toxic doses. The authors report the case of a 28-year-old man, without a previous medical history, hospitalized for pulmonary tuberculosis. After initiating tuberculosis treatment for five days, he presented muscle pain, fasciculation and weakness initially involving the lower left limb that quickly propagated to all four limbs. The physical examination noted a left ankle flush, a swollen left calf and fasciculation of both calves while the neurological examination was normal. The CPK was normal. Electromyography confirmed the myopathy without neuropathic findings. Isoniazid withdrawal was marked by the rapid disappearance of the symptoms. The reintroduction of a half-dose of isoniazid only induced a few transitional muscular fasciculations. The onset of the symptoms under tuberculosis treatment, the absence of later muscle disorders, the absence of any other cause of myopathy and the total disappearance of the symptoms after isoniazid withdrawal confirmed the diagnosis of isoniazid-induced myopathy.