[Lung metastases of pancreatic adenocarcinoma: Watch for the second train!]

Pulmonary metastases due to a pancreatic cancer are difficult to diagnose and demonstrate a wide range of radiological patterns. We report the case of a 37-year-old female patient, without past medical history, with multicystic lung disease in a context of chronic abdominal pain, fatigue and weight loss. After several months of diagnostic delay, pathological examination of surgical lung biopsies led to the diagnosis of secondary deposits of pancreatic cancer. The clinical and radiogical situation deteriorated quickly with the development of alveolar consolidation and Aspergillus superinfection was then diagnosed. This case illustrates the value of an early decision to undertake surgical lung biopsy in the work-up of multicystic lung disease when cancer is suspected. In addition, in the specific context of cancer, faced with clinical and/or radiological deterioration, it is essential to look for infection, particularly aspergillosis.

Purification of a Tumoral Marker Recognized by Monoclonal Antibody Po66 and Associated with Human Lung Squamous Cell Carcinoma

Monoclonal antibody (MAb) Po66, a murine IgG1, was raised by immunization against human lung squamous cell carcinoma. When injected intravenously, Po66 showed prolonged retention in the tumor. It recognized an intracellular antigen. The human lung squamous carcinoma cell line SK-MES-1 expresses the antigen recognized by MAb Po66 and was used as a source of biological material for its purification. The SK-MES-1 cell line was labeled in culture with [35S]methionine and its lysate was immunoprecipitated with Po66 immobilized on Protein G-Sepharose. The precipitate contained three proteins (47, 50 and 69 kDa) absent in the controls. The 69 kDa polypeptide was further purified by anion exchange and immunoaffinity chromatographies. To date, no other tumor marker expressed in non-small cell lung cancer with these characteristics has been described and as such this marker is interesting for future use in immunotherapy and in diagnosis.

[Interstitial lung disease and pancreatic cancer: Series of two cases]

INTRODUCTION

Pancreatic cancer is often not diagnosed until at a metastatic stage at which point the prognosis is very poor. Pulmonary metastases are pleomorphic, often present at the time of diagnosis and can lead to the discovery of an asymptomatic primary disease.

CASE REPORT

We describe two cases aged 60 and 74 years, where imaging identified what was thought to be an interstitial lung disease but which was actually metastasis from pancreatic cancer. In the first case, CT showed multiple excavated pulmonary nodules but the presentation with medullary compression led rapidly to pathological diagnosis on bone lesions. In the second patient, a history of rheumatoid arthritis and the lack of abdominal symptoms led to an initial search for disease related to the rheumatoid disease. Histopathology, from lung and bone biopsies, enabled a correct diagnosis to be achieved.

CONCLUSION

Where atypical interstitial lung disease occurs, biopsy should be considered in order not to delay a diagnosis of cancer, especially pancreatic cancer.

[The management of complicated parapneumonic effusions in France]

INTRODUCTION

There are no French guidelines for the management of complicated parapneumonic effusions. A national observational study was carried out to assess the main features of current clinical practice for this condition.

MATERIAL AND METHODS

A questionnaire was sent by email to the 1500 members of the Société de Pneumologie de Langue Française (SPLF) between 15th November and 15th December 2012.

RESULTS

There were 92 responders, i.e. a response rate of 6%. Of these, 87 physicians mentioned that they were involved in the management of patients with complicated parapneumonic effusions with a median number of cases of 10 per year (IQR: 5-20). Chest tube drainage was the main approach used for pleural fluid aspiration (n=51/87), followed by repeated thoracentesis (n=29/87) and early surgery (1/87). Five physicians answered both chest tube drainage or repeated thoracentesis and one physician either chest tube drainage or early surgery. Pleural fibrinolytics were never used by 20% of physicians, only in case of loculations by 70% and by 10% of respondents in all cases. Only 3 physicians combined fibrinolytics with DNAse. A double antibiotic dose was used by one third of physicians. All the physicians used respiratory physiotherapy during hospitalization and to aid recovery. Follow-up practices were heterogeneous.

CONCLUSIONS

The management of complicated parapneumonic effusions varies significantly in France. National guidelines may be helpful to define best practice and aid in its implementation.

[Parapneumonic pleural effusions: Epidemiology, diagnosis, classification and management]

Parapneumonic pleural effusions represent the main cause of pleural infections. Their incidence is constantly increasing. Although by definition they are considered to be a "parapneumonic" phenomenon, the microbial epidemiology of these effusions differs from pneumonia with a higher prevalence of anaerobic bacteria. The first thoracentesis is the most important diagnostic stage because it allows for a distinction between complicated and non-complicated parapneumonic effusions. Only complicated parapneumonic effusions need to be drained. Therapeutic evacuation modalities include repeated therapeutic thoracentesis, chest tube drainage or thoracic surgery. The choice of the first-line evacuation treatment is still controversial and there are few prospective controlled studies. The effectiveness of fibrinolytic agents is not established except when they are combined with DNase. Antibiotics are mandatory; they should be initiated as quickly as possible and should be active against anaerobic bacteria except for in the context of pneumococcal infections. There are few data on the use of chest physiotherapy, which remains widely used. Mortality is still high and is influenced by underlying comorbidities.

[Hydroxyurea-induced pneumonia]

INTRODUCTION

Hydroxyurea is an antimetabolite drug used in the treatment of myeloproliferative disorders. Common adverse effects include haematological, gastrointestinal cutaneous manifestations, and fever. Hydroxyurea-induced pneumonitis is unusual.

CASE REPORT

A female patient was treated with hydroxyurea for polycythemia vera. She was admitted 20 days after commencing treatment with a high fever, productive cough, clear sputum and nausea. A chest CT-scan showed diffuse ground-glass opacities. Microbiological investigations were negative. The symptoms disappeared a few days after discontinuation of the drug and rechallenge led to a relapse of symptoms.

CONCLUSION

Our case and 15 earlier cases of hydroxyurea-induced pneumonitis are reviewed. Two patterns of this disease may exist: an acute febrile form occurring within 1 month of introduction of hydroxyurea and a subacute form without fever. Even if uncommon, one should be aware of this complication of hydroxyurea.

[An unusual cause of cystic lung disease: light chain deposition disease]

INTRODUCTION

Light chain deposition disease is a rare clinical entity characterized by deposition of monoclonal immunoglobulin light chains in organs. The kidneys are almost always affected, while the lung manifestations that have been reported, including nodular or diffuse disease, especially cystic lesions, are unusual.

CASE REPORT

We report the case of a 60-year-old man with a diffuse infiltrative lung disease characterized by numerous apical cysts. The diagnosis of light chain deposition cystic lung disease was obtained by surgical lung biopsy. Light chain deposits in the salivary glands were the only extrapulmonary manifestation. Despite 12 chemotherapy cycles, the patient's lung function and radiological appearances worsened.

CONCLUSION

This is the fourth case describing a cystic lung disease due to light chain deposition in the literature. It highlights the need for comprehensive investigations so as not to miss this rare cause of cystic lung disease, which appears to be related to a primary pulmonary lymphoproliferative disorder. The only treatment that appears to be effective is lung transplantation.

Which patients should be tested for viruses on bronchoalveolar lavage fluid?

Bronchoalveolar lavage (BAL) is a major diagnostic tool in lung diseases, including viral respiratory infections. We aimed to better define the situations where viral tests should be performed on BAL fluid (BALF). We retrospectively studied all cases where viral tests [immunofluorescence, immunocytochemistry, viral culture, and/or polymerase chain reaction (PCR)] were performed on BALF during a period of 1 year (2008) in our institution. We compared the characteristics of patients with virus-positive versus virus-negative BALF. Of the 636 BALF samples sent to the microbiology laboratory, 232 underwent viral tests. Of these, 70 (30 %) were positive and identified 85 viruses: herpes simplex virus (HSV)-1 (n = 27), cytomegalovirus (CMV, n = 23), Epstein–Barr virus (EBV, n = 18), human herpesvirus (HHV)-6 (n = 12), respiratory syncytial virus (RSV, n = 3), rhinovirus (n = 1), and adenovirus (n = 1). The variables associated with positive viral tests on univariate analysis were immunosuppression [human immunodeficiency virus (HIV), corticosteroids >10 mg/day for ≥3 weeks, or other immunosuppressive therapy], ground-glass attenuations on computed tomography (CT) scanning, late-onset ventilator-associated pneumonia (VAP), and durations of (i) hospital stay, (ii) intensive care unit (ICU) stay, and (iii) mechanical ventilation before BAL (p < 0.01 for each comparison). On multivariate analysis, only immunosuppression [odds ratio (OR) 6.4, 95 % confidence interval (CI) [2.8–14.3], p < 0.0001] and ground-glass attenuations (OR 3.7, 95 % CI [1.8–7.7], p = 0.0004) remained associated with virus-positive BAL. None of the viral tests performed on BALF for the initial assessment of diffuse infiltrative lung disease (n = 15) was positive. PCR improved the diagnostic yield of viral tests on BALF by 50 %. Testing for viruses on BALF should be mostly restricted to immunocompromised patients with acute respiratory diseases and/or patients with unexplained ground-glass attenuations on CT scanning.

[Pancytopenia in disseminated tuberculosis: Think of macrophage activation syndrome]

INTRODUCTION

The macrophage activation syndrome (MAS), also known as haemophagacytosis, is a non-specific clinical syndrome, which includes, among other things general debility, fever and hepatospleneomegaly. The most frequent pathological abnormalities are pancytopenia, hypertryglyceraemia, and hyperferrititinaemia. These clinical and biological criteria, which determine the severity of MAS, must be associated with a histological criterion - haemophagocytosis (with histiocytosis), which is usually medullary but can more rarely be splenic, hepatic or ganglionic. MAS can be primary or secondary. In the latter case, it is frequently associated with an infection of which tuberculosis is the most common.

OBSERVATION

We describe the case of a young immunocompetent patient who had disseminated tuberculosis complicated by MAS.

CONCLUSION

It is important to be aware of MAS, because its occurrence is associated with a poor prognosis and its optimal treatment, which requires a multidisciplinary approach, has not been fully defined. The optimum strategy in relation to specific aetiologies remains to be clarified.

[Swallowing disorders, pneumonia and respiratory tract infectious disease in the elderly]

Swallowing disorders (or dysphagia) are common in the elderly and their prevalence is often underestimated. They may result in serious complications including dehydration, malnutrition, airway obstruction, aspiration pneumonia (infectious process) or pneumonitis (chemical injury caused by the inhalation of sterile gastric contents). Moreover the repercussions of dysphagia are not only physical but also emotional and social, leading to depression, altered quality of life, and social isolation. While some changes in swallowing may be a natural result of aging, dysphagia in the elderly is mainly due to central nervous system diseases such as stroke, parkinsonism, dementia, medications, local oral and oesophageal factors. To be effective, management requires a multidisciplinary team approach and a careful assessment of the patient's oropharyngeal anatomy and physiology, medical and nutritional status, cognition, language and behaviour. Clinical evaluation can be completed by a videofluoroscopic study which enables observation of bolus movement and movements of the oral cavity, pharynx and larynx throughout the swallow. The treatment depends on the underlying cause, extent of dysphagia and prognosis. Various categories of treatment are available, including compensatory strategies (postural changes and dietary modification), direct or indirect therapy techniques (swallow manoeuvres, medication and surgical procedures).

Fatigue and respiratory disorders

OBJECTIVES

To analyze the factors at the origin of fatigue in respiratory disorders. To assess fatigue and its functional impact on patients affected from respiratory diseases. To evaluate the results of comprehensive care on fatigue and functional capacity.

MATERIALS AND METHODS

We systematically reviewed the literature in Medline and the Cochrane Library, using the following keywords: fatigue, respiratory disorders, questionnaire, evaluation, assessment, randomized controlled trial, meta-analysis.

RESULTS

Fatigue is a high frequency symptom (90%) and takes an important place, as much as dyspnea, in the genesis of the respiratory induced handicap. Its assessment is varied, according to the studies. It originates from multiple causes, as shown from clinical and experimental studies. The main treatment consists in rehabilitation, using physical exercises. Its efficacy is demonstrated on physical endurance, but is not clear in terms of general fatigue.

CONCLUSION

Although fatigue is very frequent complaint, along with a major disabling condition, the comprehensive assessment of fatigue, in respiratory disorders, including its physical and cognitive components, is not still really codified. Rehabilitation is the main treatment. Its efficiency has been demonstrated on the physical and functional components of fatigue. Its results on perceived fatigue remains to be evaluated.

[Diffusing capacity for carbon monoxide (T(LCO)) and oxygen saturation during exercise in patients with cystic fibrosis]

OBJECTIVES

To estimate the value of diffusing capacity for carbon monoxide (T(LCO)) in patients with cystic fibrosis and to evaluate its ability to predict arterial desaturation during exercise.

METHOD

Fourty-four patients (9-30 years) with cystic fibrosis performed pulmonary function tests with measure of T(LCO) and a bicycle incremental exercise test. They represent a wide variation in disease severity: mean Shwachman score: 77.8 (range: 40-100), mean FEV1%: 72.8 (range: 17-131). This study investigated the relationship between T(LCO), lung volumes and exercise data.

RESULTS

T(LCO) remained normal for a long time in patients with cystic fibrosis: 82% of them show a normal T(LCO) (mean value: 91.3% of predicted). T(LCO) was significantly correlated with FEV(1), residual volume, maximal work load and maximum oxygen uptake. A fall in arterial oxygen saturation was uncommon in our study (five patients) and not significantly correlated with T(LCO).

CONCLUSIONS

T(LCO) is a good criter of severity of cystic fibrosis but remains unreliable to predict values above which physical activity is safe, without arterial desaturation. Exercise tests should be proposed in order to evaluate exercise adaptation of each patient and determine which factor limits maximal performance.

Two cases of 'asthma' revealing a diverticulum of Kommerell

Among embryonic aortic vascular malformations, persistence of a right aortic arch and aberrant left subclavian artery associated with a diverticulum of Kommerell is rare, and is estimated to occur in 0.1% of the general population. We report two cases of diverticulum of Kommerell in which tracheal compression due to the vascular ring induced respiratory symptoms such as asthmatic dyspnoea. This reminds us that at least a chest X-ray should be performed in newly diagnosed asthmatic patients, focusing on the trachea and upper mediastinum. In case of vascular abnormality, angiography and magnetic resonance are the best investigations to define the abnormal anatomy and guide surgery.

Immunohistochemical expression of the intracellular component of galectin-8 in squamous cell metaplasia of the bronchial epithelium in neoplastic and benign processes

Specified galectins are known to play a role in regulating cell proliferation, differentiation, adhesion and migration. Po66, a mouse IgG1 monoclonal antibody produced by immunization against squamous cell cancer, reacts against a carbohydrate-binding protein (Po66-CBP), recently shown to be a member of the galectin family with a strong homology with galectin-8 (PCTA-1), identified as a human tumor-associated antigen. We studied Po66 in squamous metaplasia of the bronchi in order to determine whether it could be specifically involved in neoplastic conditions and if so, if it would be helpful in distinguishing metaplasia at risk of cancer. Twenty-eight formalin-fixed, paraffin-embedded archival tissues of 17 metaplasias with SCC, 3 metaplasia with distant neoplastic disease and 8 metaplasias with an inflammatory process, were immunostained using a streptavidin biotin peroxydase method. The squamous metaplasias were positively stained in non-neoplastic disease as well as in neoplastic processes. Expression was also observed in stromal and normal cells. Po66-CBP was not associated with a pre-neoplastic character. We discussed the expression of this intra-cellular component of galectin-8 according to the functions of galectins in cellular differentiation, host reaction against tumor, and inflammation.

Expression of Po66-CBP, a galectin-8, in different types of primary and secondary broncho-pulmonary tumors

The monoclonal antibody Po66 is an IgG1 immunoglobulin isolated from a human bronchial squamous carcinoma and directed against a carbohydrate binding protein, Po66-CBP, belonging to the galectin family involved in neoplastic processes. This Po66 antibody has been shown to be useful for immunoscintigraphic detection of squamous cell carcinoma metastasis. We examined the expression of Po66-CBP in a wider range of primary or secondary malignant tumors of the lung of various histological types. We studied 52 specimens of broncho-pulmonary tumors including 41 primary squamous, glandular or neuro-endocrine tumors and 11 secondary tumors of glandular, connective tissue, melanocytic or germinal origin as well as 9 extra-pulmonary primary tumors with histological types similar to lung metastases. An immunohistochemical study was performed using an amplification system on paraffin-embedded sections. All histological types were positive for Po66 antibody, the cell origin giving no influence on the expression of Po66-CBP. There was however a relation between Po66-CBP expression and the degree of differentiation notably for squamous cell cancer and neuro-endocrine tumors. The metastatic character of the tumor tissue did not affect Po66-CBP expression.

[Prevention of infection transmitted by bronchial fibroscopes]

A growing number of infectious complications are reported after bronchial fibroscopy procedures. The risk of nosocomial patient-to-patient or environment-to-patient infection is real via contaminated fibroscopes. Cross transmission can be caused by several microorganisms, the most frequently identified being Pseudomonas aeruginosa, Mycobacterium tuberculosis and other atypical mycobacteria. Fibroscopes can be contaminated via different mechanisms, generally related to poorly adapted cleaning and decontamination protocols. Identified errors include an insufficient cleaning phase, an inappropriate disinfecting agent (iodine derivatives, chlorhexidine), defective cleaning or disinfection of accessory equipment, or use of tap water for rinsing. Finally several episodes of Pseudomonas and atypical mycobacteria infections have been found to result from the use of automatic cleaning machines. Particular attention must be paid to the use of these devices. Official guidelines for the disinfection of endoscopic equipment must be rigorously applied in all centers. The personnel should have adequate training. It is also important to take regular samples and make regular bacteriology controls of the water and fibroscopic equipment.

[Adult care centers for patients with cystic fibrosis: prerequisites and practical organization. Cystic Fibrosis Care Centers of Rennes and Lille]

In the past 40 years there has been an increase in the median age of survival of patients with cystic fibrosis (CF), attributed to advances in the diagnosis and treatment of patients with this disease. This progress was also due to the level of care provided by pediatricians and now by adult physicians in CF care centers. They centralize and integrate knowledge and skills of pulmonary medicine, gastroenterology, nutrition, nursing, respiratory therapy, social work, and genetics to provide specialized care to patients with CF from childhood to adulthood. They are also expected to develop teaching and research, particularly the development of new life-extending therapies. The continuity of care of this multisystemic disease is best carried out through a close collaboration between the patient's primary care physician or pulmonologist and the specialized staff of the CF care center.

Expression of Po66-CBP, a type-8 galectin, in different healthy, tumoral and peritumoral tissues

A monoclonal antibody, Po66, recognized an antigen named Po66 carbohydrate binding protein (PO66-CBP), which was homologous to the galectin-8 protein. Two additional isoforms previously not described were characterized. The aim of this study was to compare the expression of Po66-CBP and its isoforms in different healthy, tumoral and peritumoral tissues and at last to determine the localization of the protein in tumors and distant tissues.

MATERIALS AND METHODS

Reverse transcriptase PCR of Po66-CBP was performed on total RNA extract from eleven healthy and eleven tumoral and peritumoral tissue specimens. Antibody Po66 was used to localize the protein in the tumors and distant tissues by an immunohistochemistry method.

RESULTS

Po66-CBP was expressed by half of the healthy tissues. One of the isoforms, the last often present in healthy tissues, was found in all tumoral and peritumoral tissues studied. Immunohistochemistry evidenced a gradient of protein expression in normal cells depending on the vicinity of tumoral tissue. Po66-CBP expression was modified in cancerous tissue, suggesting the implication of galectins in carcinogenesis.