Screening for childhood lead poisoning in the industrial region of Fez, Morocco

The study objectives were to estimate lead poisoning prevalence among children living next to an industrial area, to compare it to that in a control population, and to establish clinical and biological follow-up of the poisoned children. This is a descriptive cross-sectional study including 150 children (exposed and unexposed) performed between January 2012 and April 2013. It was meant to determine blood lead levels (BLLs) in children considered to be an exposed population (EP N 90), living in the industrial area Ain Nokb Fez compared with BLLs of children of other areas belonging to the same city supposed to be unexposed [UP (N = 60)]. A sociodemographic questionnaire was obtained, and a blood lead analysis was performed. Clinical and biological follow-up has been performed of poisoned children. The sample consisted of 90 EP children with an average age of 6.82 ± 3.32 years and male-to-female sex ratio (SR) of 1.5 and 60 UP children with an average age of 6.45 ± 3.29 years and an SR of 1.2. Among the 150 children recruited, the average of BLLs was 58.21 ± 36 µg/L (18-202.3 μg/L). The average of BLLs in EP children (71 ± 40 µg/L) was statistically greater (p < 0.0001) than that registered in UP children (38 ± 13 µg/L). All poisoned children belonged to the EP group at a prevalence of 21.1 %. The clinical and biological examinations of poisoned children showed a few perturbations such as anemia, hypocalcaemia, and deficiencies in magnesium and iron. No renal disease or objective neurological disorders were observed. In the follow-up of the children with BLL ≥100 µg/L (19 cases). BLL monitoring showed a significant decrease in average of blood concentration ranging from 136.75 ± 32.59 to 104.58 ± 32.73 µg/L (p < 0.0001) and in lead poisoning prevalence (p < 0.001), which decreased to 7.8 % from 21.1. Our study showed a high prevalence of lead poisoning (21.1 %) in EP children. The relocation of the industrial site associated with corrective and preventive measures has contributed to a decrease of exposure and lead poisoning prevalence in the aforementioned population.

[Overdose or hypersensitivity to vitamin D?]

Vitamin D intoxication with severe hypercalcemia is rare in the neonatal and infancy period. Through nine cases of hypercalcemia, secondary to taking 600,000 units of vitamin D (Sterogyl(®)), a review of vitamin D requirements and possible mechanisms of toxicity including hypersensitivity to this vitamin will be discussed. We report nine cases of babies admitted to our department between the ages of 25 and 105 days for treatment of severe dehydration. The pregnancies were normal, with no incidents at delivery. Clinical signs were dominated by weight loss, vomiting, and fever. Examination on admission revealed dehydration whose degree ranged from 8 to 15% with preserved diuresis and loss weight between 100 and 1100 g. Laboratory tests objectified hypercalcemia between 113 and 235mg/L, hypercalciuria (urinary calcium/creatinine mmol/mmol >0.5), and a low-level of parathyroid hormone. The vitamin D values in nine patients were toxic (344-749 nmol/L; normal >50 nmol/L; toxicity if >250 nmol/L). Abdominal ultrasound objectified renal nephrocalcinosis in seven patients. The DNA study, performed in eight patients, did not reveal a mutation of the vitamin D 24-hydroxylase gene (CYP24A1). The treatment consisted of intravenous rehydration with treatment of hypercalcemia (diuretics and corticosteroids). Serum calcium returned to the normal range within 4-50 days, with weight gain progressively over the following weeks. The follow-up (2 years for the oldest case) showed the persistence of images of nephrocalcinosis. Genetic susceptibility and metabolic differences appear to modulate the threshold of vitamin D toxicity. However, respect for recommended doses, recognized as safe in a large study population, reduces the risk of toxicity.

[Choriocarcinoma: a hidden face of pemphigoid gestationis]

Gestationis pemphigoid is an autoimmune subepidermal blistering dermatosis occurring predominantly in pregnancy, more seldom in early puerperium, and exceptionally in post-abortion. The association of gestationis pemphigoid with choriocarcinoma is extremely rare. We report this association in a patient of 35 years in which the diagnosis of gestationis pemphigoid was made on clinical, histological and immunological criteria, and the one of choriocarcinoma was made on clinical, biological radiological and histological criteria. Through this article, we put the item on this association reported for the first time in post-abortion.

Post-menopausal endometrial tuberculosis mimicking carcinoma: An important differential diagnosis to consider

We report the case of a menopausal 74-year-old patient who presents pyorrhoea for 6months. We suspect initially a carcinoma process, but the anatomopathological examination takings obtained by biopsy curettage of the endometrial under hysteroscopy is in favor of an inflammatory infiltrate with epithelioid and giant cells of type Langhans and type Muller without caseous necrosis. The bacteriological direct examination after coloring of Gram, Ziehl-Neelsen and Sabouraud was negative. The bacteriological culture in the Löewenstein and Coletsos environment identified Mycobacterium tuberculosis. The searches for another source of the infection was negative both at the pulmonary and urinary levels. An antituberculous quadritherapy allows the fast clinical improvement. The tuberculosis remains frequent but rarely genital. It is especially the case of young women, from non industrialized countries, consulting for infertility. It is necessary to know how to evoke it front in pelvic symptoms, whatever the age is and to realize easily mycobacteriological examinations.

[Epidemiological and pathological features of cancer in Fez Boulemane region, Morocco]

In Fez-Boulemane, Morocco, there is no cancer registry so there is a lack of information about the incidence and characteristics of cancer in the region. In this retrospective study we examined the epidemiological and pathological features of 5532 cases of cancer collected from the Department of Pathology in Hassan II University Hospital of Fes from 2004 to 2010. The mean age of the patients was 53.5 years and 52% were male. Digestive cancers and skin cancers were the most common. Digestive cancers were predominantly colorectal and stomach. Cancers of the urinary bladder and colorectal cancers were the leading cancers in men accounting respectively for 9% and 8% of all male cancers. In women, cancers of the breast (62%) and uterine cervix (22.6%) predominated. As a first step in cancer control in our area, establishment of a regional cancer registry is recommended.

[Desmoid tumor of mediastinum revealed by superior vena cava syndrome and tamponade]

Desmoid tumors are rare forms of low grade malignancies. They are characterized by a strong potential of local invasion. Although they are considered histologically benign they behave aggressive locally. They typically occur in the abdominal wall or within the abdomen. Mediastinal localisation is very rare. The only curative treatment is wide surgical excision but the surgery is difficult and the risk of local recurrence is high.

[Epidemiological and biologic profile of breast cancer in Fez-Boulemane, Morocco]

In a retrospective study of 265 patients with breast cancer over 3 years (January 2007-September 2009) we examined the epidemiological profile of breast cancer to determine the impact of biological and prognostic factors on survival over 3 years and on the epidemiology of this cancer. Estrogen (RE), progesterone (RP) and human epidermal growth factor receptors (HER2) were evaluated and RE/RP/HER2 status determined. The patients were young (median age 45 years). Invasive tumours were found in 95.5% of the women. The average tumour size was big [3.6 (SD 2.6) cm] and only 14% were histological grade 1. Large tumour size and high histological grade were independent of patient's age. Overall survival at 3 years was only 49% for the RE-/RP-/HER2- subtype and 75% for the RE-/RP-/HER2+ subtype, while it was 96% for the RE+/RP+/HER2- subtype. The young age, large tumour size and high histological grade in our population suggest a lack of awareness of women about breast cancer.

[Rare bone tumour of the hand: capillary haemangioma of the second finger: case report]

Primary vascular tumours of bone are rare. Haemangiomas occur as incidental findings in the skull or in the spine. A solitary haemangioma of the hand skeleton is rare and difficult in radiological and histological differential diagnosis. We report a case of a 23 year-old patient presenting with a capillary hemangioma of the left second finger of few months duration for which he underwent amputation. Postoperative evolution was good and showed no recurrence. We discuss this through observation and a review of the literature including the different clinical, radiological and pathological diagnostic problems associated with an unusual site for vascular proliferation.

[Cutaneous tuberculosis: a 36-case series from Morocco]

Tuberculosis is still endemic in Morocco. Cutaneous tuberculosis is the fifth most common form after pleuropulmonary, glandular, digestive and urogenital tract tuberculosis. The purpose of this single-center prospective study is to describe all cases of cutaneous tuberculosis treated between May 2006 and June 2009. Diagnosis was suspected based on clinical, immunological and histological features. The main clinical presentations, i.e., scrofuloderma and gumma, were consistent with endemicity of tuberculosis in Morocco. Since definitive diagnosis by detection of the tubercle bacillus was rarely possible, therapy was usually undertaken presumptively based on clinical and laboratory findings and therapeutic response.

[Bile duct dilatation associated with pancreatic heterotopia: a case report]

Pancreatic heterotopia or aberrant pancreas is a rare congenital anomaly, usually asymptomatic. Its diagnosis is difficult. We report an original observation in an 8-month-old infant, operated in the neonatal period for esophageal atresia type III in the context of VACTERL syndrome, cystic dilatation of the bile duct, and pancreatic heterotopia.

[Solid pseudotumoral tubo-ovarian actinomycosis. A case report in Morocco]

Tubo-ovarian actinomycosis is a rare location for infection by actinomyces. Only around 50 cases have been described in the world literature since 1963. Diagnosis can be difficult due to the highly misleading solid pseudotumoral appearance of this infection. The purpose of this report is to describe the case of a 40-year-old patient with an intrauterine device who presented abdomino-pelvic pain associated with guarding in the right iliac fossa. Pelvic ultrasound revealed an ovarian mass. Histological examination of the surgical specimen after annexectomy demonstrated tubo-ovarian actinomycosis. Based on this case involving a rare clinical form of the actinomycosis, we review the various clinical aspects of this infection and underline the importance of histology in achieving diagnosis. We also provide a general review of the literature.

[Role of cervical smear in the diagnosis of cervical cancer in Fes-Boulemane region of Morocco]

A retrospective study was conducted between 2000 and 2003 on 1620 women (mean age 39.6 years) in northern Morocco to determine the incidence of cervical cancer and assess the value of cervical smear in the diagnosis. Patients were interviewed using a questionnaire before carrying out a gynaecological examination and taking a cervical smear sample. Of the total sample, 23.1% had an abnormal cervical smear, of whom 5.6% showed intraepithelial lesions, both low and high grade. The women presenting with cervicitis represented the highest percentage with suspect smears (30.8%); 90.9% of the smears showing high grade lesions were histologically confirmed as cervical cancer. A screening programme is a matter of urgency in northern Morocco.

[Chondrosarcoma of the nasal septum]

INTRODUCTION

A chondrosarcoma is rarely located in the nasal septum with only fifty cases reported in the literature.

CASE REPORT

We report a new case of a seventy years old woman presenting with a large facial midline mass extending to the nasal cavity, having evolved for six months. Subsequent computed tomography revealed a mass destroying the nasal septum and extending to the endocrane. Intranasal biopsy revealed a chondrosarcoma. The extended work up revealed pulmonary metastasis. The course was not favourable and the patient died after one year.

DISCUSSION

The bones of the pelvis and of the lower extremities are the most common localizations for chondrosarcoma. It is rarely located in the nasal septum. Histological analysis is required for the diagnosis. It is characterized clinically by local aggressiveness, frequent metastatic evolution, and poor prognosis. Surgical resection is reserved to operable cases. Chemotherapy and radiotherapy used as adjuvant treatment and palliation are not effective.

Chondroblastome métaphyso-diaphysaire du fémur

Chondroblastoma is a rare benign tumor of cartilage tissue accounting for less than 1% of all bone tumors. The epiphysis of long bones is the typical localization, often extending to the metaphysis. Metaphyseal, metaphysodiaphyseal or pure diaphyseal forms are exceptional. We report a case in a 15-year-old boy who presented a metaphyso-diaphyseal chondroblastoma of the distal portion of the left femur. The inaugural signs were pain and limited joint motion. We discuss the anatomic aspects and the clinical course of this rare tumor and present current knowledge of the histogenesis.

Lymphome T révélé par une mononeuropathie multiple : étude d’un cas avec revue de la littérature

INTRODUCTION

Lymphoma occasionally affects the peripheral nervous system. Neuropathy usually appears in patients with known lymphoma but rarely represents the initial manifestation of underlying malignancy. We report a case in which mononeuritis multiplex (MM) was the dominant feature in the clinical presentation of a peripheral T-cell non-Hodgkin lymphoma (NHL).

OBSERVATION

A 32-year-old man suffered from an asymmetric progressive sensory-motor peripheral neuropathy. The left peroneal nerve was affected first, then the left median nerve after one month, followed by the left trigeminal nerve ten months later. The electrophysiological study confirmed the diagnosis of axonal sensory-motor MM. Mediastinal adenopathies, splenomegaly, pancytopenia and inflammatory syndrome were also found. An osteo-medullary biopsy showed a T-cell NHL. Nerve biopsy study found an inflammatory lymphoid infiltration without malignant cell supporting the hypothesis of an inflammatory pathogenic process. Chemotherapy including cyclophosphamide, hydralazine, vincristine and prednisone were administered monthly during 8 months. No improvement was obtained.

DISCUSSION

It must be emphasised that this case is an uncommon one. On the one hand, NHL is rarely associated with MM and on the other hand, it can exceptionally be revealed by a MM. We were able to find 30 reported cases of distal neuropathy revealing a NHL including, 8 mononeuritis simplex, 9 MM and 13 polyneuropathies. Polyradiculoneuritis cases were excluded from this study because the neuropathy is usually caused by a meningeal infiltration. The neuropathy was in the majority of the cases chronic and axonal. The lymphoma was more often B-cell than T-cell. The B-cell lymphoma was frequently associated with a poor prognosis. All mechanisms were present with a predominance of neurolymphomatosis.

[Synovial sarcoma of the head and neck: two cases report]

Synovial sarcomas are soft tissue tumors that rarely occur in the head and neck The purpose of this report is to accrue data on this sarcoma at a rare site, and to highlight the histopathological differential diagnosis with other cervical tumors.

MATERIALS AND METHODS

Two cases of cervico-facial tumors were reported in 26 and 27 year old women.

RESULTS

Histologically, these tumors were classified into monophasic and biphasic variants. Immunohistochemistry plays a major part in the differential diagnosis, enabling the demonstration of epithelial differentiation. Radical surgery was the mainstay of treatment with post-operative radiotherapy for residual disease in one case. Local recurrence was developed in the patient who had only surgical treatment.

DISCUSSION

Synovial sarcomas are a rare soft tissue malignancies and the head and neck region location accounts for 3-5% of them. The rarity of this tumor in the head and neck and its multitude of his histopathologic features are responsible for frequent initial misdiagnosis. Histologic, immunohistochemic and characteristic chromosomal translocation findings are necessary for diagnosis. The poor prognosis of this sarcoma justified a radical surgery with post-operative radiotherapy.

[Primitive intracranial adenoid cystic carcinoma. A case report]

We report the case of a 50-year-old woman presenting a primitive adenoid cystic carcinoma of the middle part of skull base diagnosed by transphenoidal biopsy. She was treated by exclusive radiation therapy with cobalt 60 1.25 MeV and the dose received was 66 Gy in 33 fractions. Our patient remains alive 50 months after the completion of treatment. Adenoid cystic carcinoma is a slow growing malignant tumor with perineural invasion which arises more frequently from salivary glands. The occurrence of primary intracranial adenoid cystic carcinoma is exceptional. The best treatment is radical surgery followed by radiotherapy. Chemotherapy is rarely used. Prognosis is worse than for salivary glands.

[Dedifferentiated chordoma of the skull base. A case report]

Sarcomatous transformation in chordoma is a very rare condition and has been emphasized as a distinct entity because of its more aggressive clinical course. Here we describe a case of dedifferentiated chordoma arising from the skull base region of an 11-year-old boy, with tumor recurrence within one year. This tumor showed features of pleomorphic cell sarcoma with areas more typical of chordoma. Most of tumor cells expressed cytokeratin, epithelial membrane antigen, vimentin and S-100 protein, thus confirming the diagnosis of dedifferentiated chordoma.

[Cerebellar primary germinoma. Case report]

Germinoma cell tumors account for 1% of all primary cerebral tumors. They occur in pineal and in supra-sellar regions, and rarely, in basal ganglia and thalami. Germinoma cell tumors originating in the posterior fossa are very rare. We report a case of primary germinoma found in the cerebellar hemisphere in a 45-year-old immunocompetent man presented with intracranial hypertension and cerebellar ataxia. The CT scan revealed a heterogeneous mass in the cerebellar right hemisphere with a cystic component. Intense and heterogeneous enhancement after contrast infusion was observed. Two other nodules were identified in the frontal and occipital lobe. The pineal region was normal. Total resection was performed. The histological finding were a germinoma. Extensive systemic examination indicated that the intracranial lesion had not metastasized from a primary extracranial tumor.

[Chronic inflammatory demyelinating polyradiculoneuropathy with hypertrophy of spinal roots, brachial plexus and cranial nerves]

We report two patients who presented an atypical chronic inflammatory demyelinating polyradiculoneuropathy with massive nerve root and brachial plexus hypertrophy, and pseudotumoral supraclavicular mass. They also presented an hypertrophy of oculomotor and trigeminal nerves causing an exophthalmos and ocular palsy. Spinal root enlargement and cranial nerve hypertrophy was demonstrated by CT scanner and MRI. Brachial plexus biopsy showed a similar aspect of sural nerve, with an extensive onion bulb formation and perivascular inflammatory cell infiltration. There was an excellent response to steroids in both patients.

Thoracic epidural hemangiopericytoma. Case report

Hemangiopericytoma is an uncommon mesenchymal neoplasm that rarely affects the spinal canal. We report a case of thoracic epidural hemangiopericytoma in a 39-year-old man with symptoms of spinal cord compression studied by myelo-computed tomography (CT) and magnetic resonance imaging (MRI). Total resection was followed by complete recovery. Postoperative radiotherapy was performed. The clinical, radiological, and histological findings of epidural spinal hemangiopericytoma are reviewed in the light of relevant literature

[Thyroid tuberculosis associated with papillary microcarcinoma of the thyroid gland: a case report]

Tuberculosis of the thyroid gland is extremely uncommon. The infection may present first in the thyroid gland or appear secondary to a tuberculous process elsewhere in the body. The diagnosis is rarely made clinically because the different presentations of the disease often mimick malignancy or euthyroid nodular goitre. It is of interest to report a case of tuberculosis of the thyroid associated with papillary microcarcinoma of the gland. No tuberculous process elsewhere in the body has been found. The frequency of MCP on thyroidectomy specimens suggest that this association is incidental.