Case Report: The first reported case of pulmonary alveolar proteinosis with myasthenia gravis in a 27-year-old patient

Background: Pulmonary alveolar proteinosis is a very rare diffuse lung disease characterized by the accumulation of amorphous and periodic acid Schiff-positive lipoproteinaceous material in the alveolar spaces due to impaired surfactant clearance by alveolar macrophages. Three main types were identified: Autoimmune, secondary and congenital. Pulmonary alveolar proteinosis has been previously reported to be associated with several systemic auto-immune diseases. Accordingly, we present the first case report of pulmonary alveolar proteinosis associated with myasthenia gravis. Case: A 27-year-old female patient, ex-smoker, developed a dyspnea on exertion in 2020. The chest X-ray detected diffuse symmetric alveolar opacities. Pulmonary infection was ruled out, particularly COVID-19 infection. The chest scan revealed the "crazy paving" pattern. The bronchoalveolar lavage showed a rosy liquid with granular acellular eosinophilic material Periodic acid-Schiff positive. According to the lung biopsy results, she was diagnosed with pulmonary alveolar proteinosis. The granulocyte macrophage colony-stimulating factor autoantibodies were negative. Nine months later, she was diagnosed with bulbar seronegative myasthenia gravis, confirmed with the electroneuromyography with repetitive nerve stimulation showing significant amplitude decrement of the trapezius and spinal muscles. She was treated with pyridostigmine, oral corticosteroids and azathioprine. Given the worsening respiratory condition of the patient, a bilateral whole lung lavage was performed with a partial resolution of symptoms. Thus, this previously unreported association was treated successfully with rituximab, including improvement of dyspnea, diplopia and muscle fatigability at six months of follow-up. Conclusions: This case emphasizes on the possible association of auto-immune disease to PAP, which could worsen the disease course, as the specific treatment does not exist yet. Hence, further studies are needed to establish clear-cut guidelines for PAP management, particularly when associated to auto-immune diseases.

Assessment Tools for Pulmonary Involvement in Patients with Ankylosing Spondylitis: Is Diaphragmatic Ultrasonography Correlated to Spirometry?

Objective

Spondyloarthritis (SpA) is a chronic inflammatory rheumatic disease that can lead to spinal ankylosis and consequently, restrictive pulmonary dysfunction. Thus, the present study aimed to assess the accuracy of diaphragm ultrasound compared to spirometry in the screening of restrictive pulmonary disorders in radiographic SpA patients.

Methods

We conducted a cross-sectional study of 50 patients with radiographic SpA, over six months. Sociodemographic data, clinical characteristics of the disease, as well as biological, radiological, and therapeutic data, were collected. Spirometry and diaphragm ultrasound were performed.

Results

The mean age of the study participants (N= 50) was 42.7±11 years [range: 25-66] with male predominance (N= 41). Spirometry showed a restrictive disorder in 32% of cases. The mean chest expansion (CE) value was 3.9±1.81cm [range: 1-9] with a median of 4 cm. A pathological value (<5cm) was observed in 72% of cases. A significant positive correlation was found between the right inspiratory diaphragmatic thickness and forced vital capacity (FVC) (r= 0.36; p = 0.02) and the supine FVC (r=0.29; p = 0.04). The left inspiratory diaphragmatic thickness was correlated with the percentage of the FVC decrease (r= 0.35; p = 0.01) defined as the percentage of difference between FVC and supine FVC. The right expiratory diaphragmatic thickness was associated with the FVC (r=0.32; p = 0.02). A significant positive correlation was found between the CE and the presence of B lines (r=0.32; p = 0.02), but not between the CE and the FVC.

Conclusion

The present study showed that diaphragm ultrasonography is correlated with spirometric findings in radiographic SpA patients. Further studies are required to assess its reliability, specificity, and sensitivity in this pathology.

Idiopathic double tracheal stenosis mimicking asthma: a case report

Idiopathic tracheal stenosis (Idio-SS) is an extremely rare disease. Its diagnosis is of exclusion and could be misdiagnosed as asthma. Herein, we report the case of a 39-year-old woman who had been treated for asthma for several months. She has no history of endotracheal intubation or granulomatous disease. Flexible fiberoptic bronchoscopy and thoracic computed tomography revealed double tracheal stenosis. The patient had rigid bronchoscopy; the upper tracheal stenosis was dilated with insertion of a silicone airway stent at the level of the distal stenosis. The diagnosis of idiopathic stenoses was made according to the clinico-radiological features. Symptoms were completely relieved and no recurrence was observed after one year of follow-up. This case highlights the importance of clinical suspicion and early diagnosis of Idio-SS in patients with unexplained wheezing and dyspnea. It also illustrates the role of endoscopic procedures in this situation.

Evaluation of left ventricular systolic function in children with sickle cell anemia: contribution of 2D strain

BACKGROUND

Children with sickle cell anemia (SCA) are at an increased risk of cardiovascular complications. The aim of this study was to assess the role of speckle tracking echocardiography in detecting subclinical myocardial damage in children with SCA.

METHODS

A cross-sectional case-control study was conducted at the echocardiography laboratory of the military hospital of Tunis between July and December 2018. Thirty patients with SCA were included. A control(C) group including 30 normally developing children was selected and matched to the SCA group by sex and age. We compared between the two groups: conventional echocardiographic parameters including cardiac output, left ventricular ejection fraction (LVEF), thickness and the global longitudinal strain (GLS). The echocardiographic measurements were indexed according to body surface area. The left ventricular (LV) GLS association with clinical characteristics and echocardiographic parameters were also evaluated.

RESULTS

Patients and controls were matched for age and sex: the mean age was (11± 2years) in SCA group versus (12± 1 years) in C group with a sex ratio of (1.31 versus 1.27, respectively). Body surface area was comparable. LV hypertrophy and dilation were revealed in the SCA group, whereas measurements were normal in the C group. No significant differences were observed for cardiac output (p=0.4). LVEF were preserved in both groups. However, two-dimensional (2D) LVGLS was impaired in 46% of SCA group (n=14) with mean value of (-21%±3.07 vs -25%±2.98; p<0.01).In SCA group, impaired LVGLS was significantly associated with LV mass (r = - 0.399, p<0.01), LV tele diastolic diameter(r= -0.419, p<0.01) and left atrial volume (r= - 0.399, p< 0.04). In multivariate analysis, LV mass was the only independent factor.

CONCLUSIONS

In the present study, LVGLS measurement revealed subclinical LV systolic impairment in patients with SCA. Therefore, 2D strain could be beneficial to detect the natural history of LV dysfunction in SCA.

Spontaneous Resolution of a Pulmonary Cystic Amyloidosis Mass

Introduction

Amyloidosis is a rare illness characterized by the deposition in organs of amyloid, which can be detected by histological staining. Amyloidosis restricted to the lower respiratory tract is unusual.

Results

We reported the case of a 68-year-old woman with no history of chronic diseasewho presented with dyspnoea on exertion, cough and fatigue. The physical examination was unremarkable. A CT scan showed a cystic mass with a thickened wall in the apical segment of the left lower lobe. A biopsy of the mass was performed, and histological and immunohistochemical study confirmed the diagnosis of AL amyloidosis. The patient's clinical and radiological symptoms spontaneously improved without treatment after 3 years.

Conclusion

Amyloid-related cystic lung disease is a rare presentation of amyloidosis in the thorax. More case reports are required to determine if such masses can resolve without treatment and whether amyloid-associated cystic lung disease actually exists.

LEARNING POINTS

Dyspnoea and cough are a rare atypical presentation that can reveal pulmonary amyloidosis.A cystic lung mass should raise suspicion for pulmonary amyloidosis.Clinical symptoms and radiological findings of a cystic mass spontaneously resolved without treatment after 3 years in this patient with pulmonary amyloidosis.

A recurrent side-changing febrile pleural effusion revealing familial Mediterranean fever: a case report

Familial Mediterranean Fever (FMF), characterized by recurrent polyserositis, is an autosomal recessive disease involving essentially Mediterranean populations. We report the case of a 30-year-old Tunisian military patient complaining of fever and chest pain recurring on board a Navy military vessel, due to side-changing pleural effusion. On landing, a marked improvement of symptoms was noticed. Gene testing was performed when the diagnostic survey ruled out common etiologies, revealing a homozygous mutation of the FMF gene type M680l/M680l. The prescription of colchicine and the exemption from boarding led to the resolution of the symptoms with no recurrence of pleural effusion. Therefore, the diagnosis of FMF should be considered in a context of a recurrent pleural effusion in the youth, with a negative etiological assessment, notably in an ethnic group at risk. Thus, early diagnosis and adequate treatment may prevent the development of secondary amyloidosis, a serious complication of FMF.

Parsonage-Turner syndrome of the brachial plexus secondary to COVID-19 vaccine: A case report

Parsonage-Turner syndrome (PTS) is a peripheral inflammatory neuropathy of unknown etiology. We present a rare case of a 50-year-old male patient with PTS post-COVID-19 BNT162b2 mRNA vaccine. Symptoms occurred 15 days after the second dose. He was treated with corticosteroids, analgesics, and physical rehabilitation with a partial recovery.

Mental health status of healthcare workers at a third line Tunisian hospital during COVID-19 pandemic

INTRODUCTION

During the COVID-19(coronavirus-19 disease) pandemic, health care workers (HCWs) faced the risk of infection and distressing work to meet health requirements. The aim of the present stud ywas to evaluate perceptions of HCWs of their security at work in COVID-19 units and their coping strategies, at the military hospital of Tunis, during the second wave of COVID-19.

METHODS

A cross-sectional study was conducted via an auto-questionnaire on February 2021.HCWs of the military hospital of Tunis were included. Participants were asked about their perceived security at work in COVID-19 units and their coping behaviors. Mental disorders were assessed, via qualitative questionnaires.

RESULTS

A total of 110 HCWs' responses were collected. Fifty-eight participants (52.7%) were females. The mean age was 33.7 years (SD 9.3). They were doctors at 45.5% and nurses at 39.1%. HCWs declared having worked in COVID-19 units in 81.8% of cases. The participants reported their fears about being infected in 58.2% and infecting family members in 85.5% of cases. Protective factors included information about the disease (80%), availability of personal protective equipment (PPE) (80.9%), support from colleagues(72.7%)or superiors at work (50.9%), and ability to communicate with others (63.6%). Depression, anxiety, and insomnia were found in respectively 25.5%, 30%, and 41.8% of HCWs. In multivariate analysis, suffering from a traumatic distress was significantly associated with anxiety and depression (p (p<0.01 and, p<0.05 respectively). In addition, insomnia severity was linked to age (p=0.05) and having colleagues infected with COVID-19 (p<0.05).

CONCLUSION

In the present study, HCWs of the military hospital of Tunis stated having high levels of insomnia, anxiety, and depression since the early outbreak of the COVID-19 pandemic. These mental disorders may have a negative impact on the quality of life of HCWs and should be enhanced by psychological support and preventive measures.

Precision of pleural puncture sites using thoracic ultrasound

INTRODUCTION

Lung ultrasound (LUS) has been recommended by the British Thoracic Society as a standard of care before performing pleural procedures since 2010. Indeed, the choice of the puncture site based only on physical examination and chest x-ray can lead to complications. The aim of this study was to compare the accuracy of pleural puncture sites using LUS as opposed to clinical examination.

METHODS

An evaluative prospective study including 43 patients hospitalized in the pneumology department at the Military Hospital of Tunis was conducted between January and November 2021.Pleural puncture sites were proposed by two groups involving 'senior' and 'junior' physicians, classified according to their experience and grades, based on the clinical examination and the chest x-ray findings. The accuracy of the proposed sites was then verified by an ultrasound-qualified "expert" using LUS.

RESULTS

The mean age was 60 ± 17 years. LUS revealed the presence of pleural effusion in 88% of the cases (n=38). Differential diagnosis was therefore excluded in 12% of the cases (n=5), including pleural thickening (5%, n=2) and atelectasis (7%, n=3). Compared to LUS, clinical examination and chest x-ray had lower sensitivities, estimated at 74% and 83%, respectively. The clinical identification error rate was significantly higher in junior (77%) compared to senior physicians (49%) (p<0.05). LUS prevented possible accidental organ puncture in 36% of the cases (n=31). The risk factors associated with inaccurate clinical site selection included right-sided effusion and minimal pleural effusion on chest radiography, with an estimated relative risk (RR) of 1.44 [CI95%:0.56-3.72] and 1.82 [CI95%:0.52-6.40], respectively. The experience of the senior physicians influenced the choice of the clinical sites with moderate agreement (Kappa index: 0.4-0.6).

CONCLUSION

Compared to the ACPA- group, the ACPA+ one had more lung-hyperinflation and OVI, and comparative percentages of RVI, MVI, and NSVI.

CONCLUSION

LUS significantly improves the accuracy of pleural puncture sites, thus minimizing the risk of complications regardless of the operator's level of clinical experience.

Impact psychologique de la maladie à coronavirus 2019 sur les patients ayant un asthme allergique

Introduction (contexte de la recherche)

Objectif

Méthodes

Résultats

Conclusions

Évaluation des troubles de sommeil à long terme chez les patients hospitalisés pour pneumopathie à SARS-CoV-2

Introduction

La maladie à coronavirus 2019 (COVID-19) est une maladie émergeante grave responsable d’un retentissement important sur la qualité de vie des patients. Les troubles de sommeil ont été bien décrits chez les patients hospitalisés pour COVID-19. Néanmoins leur prévalence à long terme reste mal connue. L’objectif de notre étude était d’évaluer la prévalence des troubles de sommeil 3 mois après hospitalisation pour pneumopathie à SARS-CoV-2.

Méthodes

Étude transversale incluant 50 patients suivis à la consultation externe de pneumologie de l’hôpital militaire de Tunis après hospitalisation pour pneumopathie à SARS-CoV-2. Tous les patients ont répondu au questionnaire index de sévérité de l’insomnie (ISI). Un score supérieur à 7 témoigne de la présence d’insomnie. La Hospital Anxiety and Depression Scale (HADS) a été utilisé pour évaluer la symptomatologie anxieuse et dépressive chez ces patients.

Résultats

L’étude a inclus 50 patients. L’âge moyen était 56 ± 20 ans. Une prédominance masculine était notée dans 66 % des cas. Les troubles de sommeil ont été trouvés chez 68 % des patients et ont été dominé par l’insomnie (80 %). Cette dernière était significativement associée à l’obésité (p = 0,03), aux antécédents de séjour en service de réanimation (p = 0,001) et à une durée d’hospitalisation plus importante (p = 0,04). Par ailleurs, notre étude ne trouve pas de corrélation entre les troubles du sommeil et l’étendu de l’atteinte pulmonaire à la tomodensitométrie thoracique faite à l’admission ainsi qu’au contrôle à 3 mois (p = 0,2 et p = 0,8 respectivement). Les troubles de sommeils étaient associés à un score de dépression élevé (p = 0,0119).

Conclusion

L’insomnie est fréquente après une pneumopathie à SARS-CoV-2. Une évaluation de la qualité du sommeil est nécessaire afin d’améliorer la qualité de vie des patients.

Les symptômes du bas appareil urinaire et pneumopathie COVID-19 : quels liens ?

Introduction

Les pneumopathies infectieuses liées au COVID-19 présentent actuellement un motif fréquent d’hospitalisation aux services de pneumologie. Il s’agit d’une pathologie potentiellement grave notamment sur le plan respiratoire. Par ailleurs, plusieurs autres atteintes peuvent être associées pouvant altérer la qualité de vie des patients. Peu d’études se sont intéressées à décrire les symptômes du bas appareil urinaire au cours de l’infection à COVID-19. L’objectif de notre travail était de dépister les symptômes urinaires associés à l’infection COVID-19 et de déterminer leur prévalence en fonction de la sévérité du tableau clinique.

Méthodes

Nous avons mené une étude descriptive faisant inclure 51 patients hospitalisés au service de pneumologie de l’hôpital militaire de Tunis entre mars et août 2021. Le recueil des données clinicobiologiques et radiologiques a été rétrospectif. Le dépistage des signes urinaires a été réalisé en utilisant le Questionnaire de Symptômes Urinaires USP (Urinary Symptom Profile), à travers un entretien téléphonique. Les données ont été saisies et analysées à l’aide du logiciel SPSS version 25.

Résultats

Notre population comportait 22 femmes (41,5 %) et 29 hommes (54,7 %), avec un âge moyen de 54,86 ± 16 ans. Aucun de nos patients n’avait un antécédent urinaire antérieur à l’infection COVID-19. Les signes du bas appareil urinaires retrouvés chez nos patients étaient : une incontinence urinaire (58 %), une hyperactivité vésicale (68,3 %) et une dysurie (14,6 %). L’étendue des lésions pulmonaires scanographiques étaient réparties comme suit : étendue légère (10–25 %) : 13,5 % ; étendue modérée (25–50 %) : 11,5 % et étendue sévère (> 50 %) : 69,2 %. Sur le plan clinique l’hyperactivité vésicale, la dysurie et l’incontinence urinaire étaient significativement corrélées à une prévalence plus importante de formes sévères (p = 0,003, p = 0,03 et p = 0,01 respectivement). L’hyperactivité vésicale a été significativement associée à une atteinte scanographique étendue (p = 0,003), à une procalcitonine positive (p = 0,001) et à une hyperfibrinogénémie (p = 0,03). Aucune corrélation n’a été retrouvée entre l’hyperactivité vésicale et l’augmentation de la C reactive protein (CRP).

Conclusion

Notre étude a mis l’accent sur la prévalence des symptômes du bas appareil urinaire chez les sujets atteints de pneumopathie type COVID-19. D’autres travaux prospectifs sont nécessaires afin de déterminer le mécanisme physiopathologique et la valeur pronostique des atteintes urinaires.

Une étude de corrélations entre la sévérité clinique et l’intensité de l’inflammation

Introduction

Le coronavirus 19 peut être à l’origine d’un spectre varié de manifestations cliniques. Le défi actuel est de déterminer des biomarqueurs fiables pour identifier les formes sévères.

Méthodes

C’est une étude prospective, longitudinale, incluant 143 patients infectés par le SARS2-COVID (confirmés par une PCR), admis au service de pneumologie de l’hôpital militaire, entre le mois de septembre 2020 et le mois de janvier 2021. Ils ont bénéficié d’un examen, d’un bilan sanguin, d’un scanner thoracique et d’un test PCR.

Résultats

Nous avons inclus 143 patients d’âge moyen de 62 ans, avec une nette prédominance masculine (69 %). Quant aux comorbidités, un diabète de type 2 était retrouvé dans (36 cas), une hypertension dans (56 cas), une insuffisance coronaire dans (5 cas), une dyslipidémie dans (28 cas) et une BPCO dans (8 cas). Une obésité morbide était retrouvée dans (38 cas). La fièvre était le motif principal de consultation (91 cas [64,1 %]). Par ailleurs, les frissons ont été rapportés dans 35 cas (24,5 %), un syndrome grippal dans 59 cas (41,3 %), une anosmie-agueusie dans 23 cas (16,1 %) et des troubles digestifs (une diarrhée dans 30 cas [21 %] et des vomissements dans 17 cas [12 %]). Donc, l’infection était donc classée comme : minime chez 33 patients (25,8 %), modérée chez 25 patients (19,5 %), sévère chez 60 patients (46,9 %) et critique chez 10 patients (7,8 %). Concernant les données biologiques, une hyperleucocytose était notée dans 36 cas (25 %). La CRP était élevée dans 108 cas (75,52 %). Les D-Dimères étaient élevées dans 117 cas (81,81 %). Le fibrinogène était élevé dans 12 cas (8,4 %). L’interleukine 6 étaient élevée dans 6 cas (4,2 %). Il est pertinent de noter qu’il existe une forte corrélation entre la sévérité clinique et le tabagisme (p = 0,033), l’obésité (p = 0,023), la présence d’une insuffisance cardiaque (p = 0,02) ou d’une néoplasie préexistante (p = 0,01) et l’intensité de l’inflammation (CRP [p = 0,031], fibrinogène [p = 0,011]). Concernant le traitement, une antibiothérapie était prescrite chez 135 cas (95,4 %). De plus, certains cas ont nécessité le recours à : la VNI (14 cas) ou à l’Optiflow (9 cas). Une intubation trachéale était pratiquée dans (3 cas). Par ailleurs, 23 cas ont présenté des complications nécessitant le transfert en réanimation. Nous rapportons désormais 13 cas de décès.

Conclusion

Notre étude soutient l’hypothèse d’une inflammation « auto-entretenue » chez les patients atteints du COVID-19 à l’origine d’un pronostic plus péjoratif.

Does incarceration change the profile of pulmonary tuberculosis in Tunisia?

INTRODUCTION

Tuberculosis of the prisoner remains unknown in Tunisia. The aim of our study was to establish the clinical, radiological, bacteriological and prognostic features of pulmonary tuberculosis in patients with a history of incarceration.

METHODS

Case-control study conducted between 2010 and 2016 in two pulmonology departments of Abderrahmane Mami Hospital. The cases were male patients, hospitalized for pulmonary tuberculosis with a history of incarceration. Three controls for one case were randomly selected from the list of male patients hospitalized for pulmonary tuberculosis in the same departments as the cases but with no history of incarceration.

RESULTS

The study included 58 cases and 174 controls. The average age of cases was lower than in controls (36,5 years vs 43,4 years; p <0.001). The cases had a significantly worse socioeconomic conditions and educational level with no more frequent social coverage of the disease. Risk factors for TB (smoking, alcoholism, substance abuse, unprotected sex, tuberculosis contagion, viral hepatitis C) were significantly higher among cases. Weight loss and night sweats were significantly more common in both cases, as was undernutrition. Positive bacilloscopies prevailed in the cases (36,5 vs 43,4;p = 0.047). In controls, the institution delay was longer (4.38 days vs 10.24 days; p= 0.004) and the total duration of treatment was lower (7.16 mounths vs 6.55 mounths; p = 0.048).

CONCLUSION

Pulmonary TB in prisoner predominates in young people with poor socio-economic status and poor educational attainment. It is associated with several risk factors for TB and malnutrition. Health education in prisons is needed to combat this condition.

[Evaluation of inhaler techniques in patients with asthma and chronic obstructive disease]

INTRODUCTION

The correct method for using inhalation devices (DI) is essential to optimize treatment efficacy.

OBJECTIVE

To evaluate the method of inhalation technique, study the correlations with patient characteristics, disease, treatment and measure the impact of direct and individual educational method, centered on the use of technical DI, on improving this technique and control of the disease.

METHOD

Prospective study of 54 patients. The therapeutic education program included 3 levels of action: identifying errors in the inhalation technique, demonstrating the inhalation technique and evaluation of therapeutic education.

RESULT

The most used DI was metered-dose inhalers (AD) (66.67%). The average error was 4.63 errors/patient for AD and 5.11 for dry powder inhalers. The main factors related to the misuse of DI were lower advanced level of education and age. The therapeutic education has significantly improved the number of errors/patient with improved asthma control (P<0.05) and COPD assessment test (CAT) in the case of COPD.

CONCLUSION

Our study confirms the important role of therapeutic education focused on inhalation techniques in improving the use of DI technology and the evolution of asthma and COPD.