Feasibility of a home-designed respiratory rehabilitation program for chronic obstructive pulmonary disease.

BACKGROUND: According to international guidelines, respiratory rehabilitation (RR) for patients with chronic obstructive pulmonary disease (COPD) is a cornerstone of standard non-pharmacological treatment. AIMS: To evaluate feasibility of a home-designed RR program and analyze its medium-term impact on respiratory parameters and quality of life. METHODS: This was a prospective study involving 74 COPD patients enrolled in January 2019 and put on inhaled bronchodilator treatment associated with RR at home following a written protocol, for 16 weeks. The comparative statistical analysis highlights the difference before and after RR in terms of clinical and functional respiratory parameters as well as in terms of quality of life (assessed on the short form 36 (SF-36) questionnaire). The comparison involves RR-adherent patients versus non-adherent patients. RESULTS: Mean age was 66.7 ± 8.3 years with a median of 67 years. All patients were smokers, out of which 42 patients (57%) did not quit yet. Forty-one percent of patients were frequent exacerbators. The average COPD assessment test (CAT) score in our patients was 23. The average 6-minutes walk distance (MWD) was 304 m. The BODE index in our patients was 4.11 on average. The RR program was followed by 36 patients (48%). Thirty patients (40%) applied it at least twice a week. RR-adherent patients had an average CAT score decreasing from 23 to 14.5 (P = 0.011). Their average 6-MWD was 444.6 m by the end of the study, which would be 64.2% of the calculated theoretical value. The average FEV1 increase after RR was 283 mL. The majority (69%) of RR-adherent patients were ranked as quartile 1; BODE index ≤2. The average scores of physical, psycho-social, and general dimensions assessed on the SF-36 questionnaire improved in RR-adherent patients. CONCLUSIONS: RR is a key non-pharmacological treatment for COPD. Its interest originates from its multidisciplinary nature, hence its effectiveness in several respiratory parameters. Our study reflects the feasibility of home-designed protocols in the absence of contraindications. We highlight also the positive impact on quality of life after RR at home.

An unusual clinical manifestation of a relapsed typical pulmonary carcinoϊd tumor.

Typical carcinoid tumors of the lungs carry an excellent prognosis after complete surgical excision. However, recurrence of these cancers remains poorly described in the literature and may occur many years after surgery. We report a case of carcinoid tumor of the lung. Clinical presentation and follow-up were uneventful. The 55 years old patient had got a surgical removal of a huge typical carcinoid tumor of the left lung. A left pneumonectomy with a mediastinal lymph node resection were performed. Thirteen years later, paraneoplastic acromegaly revealed a pulmonary and extrapulmonary recurrence of the tumor. We prescribed a chemotherapy regimen including Cisplatin and Etoposide. Endocrine paraneoplastic syndromes are related to mutations in specifically known genes. Several mutations may become a promising therapeutic target in the future. In the case of neuro-endocrine pulmonary tumors, authors described BCOR gene mutation as an oncogenic development inducer and an eventual generator of ectopic tumoral secretions. The more we get familiar with carcinoid tumor mutations, the closer we get to targeted therapy for non-resectable tumors.

Switching to a Coronavirus Disease 2019 (COVID-19) Center: Lessons From Ariana Hospital Experience.

After the translating of the worldwide pandemic coronavirus disease 2019 (COVID-19) disease from South East Asia to Europe, North African countries accelerate their steps to follow WHO guidelines to prepare the outbreak response. In March 2020, the Tunisian Ministry of Health switched Abderrahmen Mami Hospital to a COVID-19 center. The main objectives were management of patients but also setting-up new rules to permit enough safety for the staff members and harmony between medical, nonmedical, and administrative departments within the facility. Organization and communication during the fast-paced preparation process were crucial to get enough qualified human resources, material resources, and clear procedural texts in place before cases arrived in huge numbers. A group of medical and administrative experts within a central crisis unit brought this challenge into reality.

[Pulmonary blastomycosis]. / Blastomycose pulmonaire.

Blastomycosis is a rare fungal disease in Africa which is often due to inhalation of "Blastomyces dermatitidis". Pulmonary blastomycosis is the most common clinical manifestation which presents with a variety of clinical features, ranging from asymptomatic to rapidly fatal. We report the case of a Tunisian patient aged 35 years with no previous medical history, hospitalized with chronic cough, bilateral basithoracic pain, fever and weight loss. Clincal examination showed fever and left paravertebral subcutaneous swelling next to the tenth thoracic vertebra (T10). Chest imaging objectified bilateral alveolar and nodular opacities with excavations in some places. Sputum stain for Koch bacillus (BK) was negative (direct examination and culture). Bronchial fibroscopy was normal. Anatomopathological examination of dorsal mass biopsy revealed blastomycosis. The diagnosis was confirmed by cultures of the biopsic fragments of the mass. Antifungal therapy with itraconazole was started with clinical and radiological improvement. This case study highlights challenges in the diagnosis of blastomycosis in our country, in particular when lesions mimick tuberculosis; hence delayed therapy.

[Bronchiectasis associated with chronic obstructive pulmonary disease: clinical and evolutionary profile]. / Dilatations des bronches associées à la broncho pneumopathie chronique obstructive: profil clinique et évolutif.

INTRODUCTION: in recent years, the combination of bronchiectases (BRs) and chronic obstructive pulmonary disease (COPD) has been described as a potential new phenotype of COPD due to its clinical features and different prognosis. The purpose of this study was to analyse the clinical profile and paraclinical features of COPD in patients with BRs and to determine the impact of BRs on disease progression. METHODS: we conducted a retrospective study of 100 patients diagnosed with COPD and treated in the Department of Pneumology 4 at the Abderrahmane Mami Hospital between 2014 and 2018. Patients were divided into two groups: group 1: patients with COPD associated with BRs (n=50) and group 2: patients with COPD without BRs (n=50). Both groups were matched based on their epidemiological characteristics. RESULTS: all patients were male, with an average age of 65,9 years. Patients with COPD associated with BRs had a higher rate of ischemic heart disease (p=0.037), more severe breathlessness assessed using the modified Medical Resaerch Council (mMRC≥2) (p=0.02), more severe bronchial obstruction (p=0.005) and a higher prevalence of acute exacerbations (p<0.001) and hospitalizations (p=0.004). In a multivariate study, independent factors associated with BRs were severe bronchial obstruction (OR=9.16), frequent exacerbator phenotype (≥2 exacerbations per year) (OR=1.91) and isolation of germs by cytobacteriological examination of sputum (OR=4.99). CONCLUSION: COPD associated with BRs could thus be a phenotype distinct from COPD and correlated with a more reserved prognosis.

Paraneoplastic limbic encephalitis revealing a small cell carcinoma of the lung.

INTRODUCTION: Paraneoplastic limbic encephalitis is a rare disease, usually associated with small cell lung cancer. CASE REPORT: We report in this publication the cases with different age brackets, who presented with various neurological symptoms such as repetitive seizures or anterograde amnesia. Cerebral CT-scan, cerebral MRI and anti onco-neural paraneoplastic antibodies were suggesting the diagnosis of paraneoplastic limbic encephalitis. Etiological exploration lead to the diagnosis of locally advanced small cell carcinoma of the lung. We started rapidly a curative protocol associating chemotherapy and sequential thoracic radiotherapy. CONCLUSIONS: we insist on the diversity of the imaging findings, immunological analyses and outcome on treatment of this entity. Prognostic impact remains also unclear.

About molecular profile of lung cancer in Tunisian patients.

BACKGROUND: Molecular profile of lung cancer is well known in developed countries. These countries reached the era of liquid biopsies, immunotherapy, and urine circulating tumor DNA. The discrepancies between developed countries and developing ones are becoming deeper. Because of a lack of data in Tunisia, we tried to analyze the molecular profile of non-small-cell carcinomas and to assess the morphologic subtype of adenocarcinomas according to their mutational profile. METHODS: We performed molecular analyses in Tunisia and in France of 84 patients who were able to afford the cost of the diagnostic techniques carcinomas diagnosed between 2012 and 2015. The diagnosis was established in our Department of Pathology and the percentage of the tumor cells was estimated by the pathologists. The paraffin-embedded blocks were sent to France, in 41 cases and were analyzed in Tunisia in 43 cases. A next-generation sequencing was performed in France and a real-time polymerase chain reaction (PCR) was performed in our country. RESULTS: During the period of study, 1122 lung cancers were diagnosed and 87 patients were able to afford the molecular analyses cost. The mean age of these patients was 53 years. The sex ratio reached 1.9. The molecular analyses were not performed in three cases because of a low tumor cell rate. EGFR mutations were present in 16 cases: 3 men and 13 women. The adenocarcinomas were classified as acinar in 11 cases and solid in 5 cases. ALK-EML4 translocation was present in six cases. Mutations of BRAF, KRAS, P53, and ERBB4 genes were, respectively, detected in two cases, five cases (3 codon 12), three cases, and one case. CONCLUSION: This study made us wonder about the possibility of implementing molecular techniques in low-income countries and about the necessity of optimizing the financial resources.

[Impact of tobacco on bronchopulmonary affections: magnitude of the problem]. / Impact du tabagisme sur les affections brochopulmonaires : ampleur du problème.

BACKGROUND: Tobacco smoking is frequent in the world affecting 20 à 50% of the population but with a decrease in occidental countries due to a huge effort based on sensiblisation and anti-tobacco decisions. AIM: To review the impact of tobacco on bronchopulmonary affections. METHODS: A narrative review of literature RESULTS: In the next future, yearly tobacco-related deaths could increase from 4.2 millions in 2000 to 10 millions in 2025-2030 making smoking as the main evitable cause of deaths by respiratory diseases. Lung cancer is the leading killer cancer. Tobacco is the most frequent cause of respiratory diseases. It is responsible of 80 to 90% of deaths by chronic obstructive pneumobronchopathiy (COPD) and 80 to 85% deaths by bronchopulmonary cancer. CONCLUSION: Tobacco is a « chronic disease ¼ necessitating management with advices and medical treatment.

[Palliative chemotherapy of non small lung cancer in Tunisia. Prospective study of the cost and impact on the quality of life]. / Chimiothérapie palliative des cancers bronchiques non à petites cellules (CBNPC) métastatiques en Tunisie: etude prospective du coût et impact sur la qualité de vie.

BACKGROUND: Bronchopulmonary cancer is actually the first cancer in the world. In Tunisia, recent statistics are alarmous. The most bronchopulmonary cancer in tunisian series are diagnosis at metastatic states. AIM: To evaluate the cost of the global treatment by chemotherapy in patients with metastatic non small lung cancer and its impact over the quality of life in Tunisia. METHODS: It's a prospective study lead between January 2006 and Juin 2007 to evaluate the quality of life for patients hading metastatic non small lung cancer treated by palliative chemotherapy in Ibn Nafiss department in Abderrahmen Mami hospital.The evaluation of the quality of life is inspired by the questionnaire of EORTC: QLQC30 version 3 translated in en Arab language, filled before chemotherapy, after the le 3rd cycle, and at the end of the first ligne. The study of the cost is effected for the 2 protocols whose the most used in first ligne : Cisplatin-Vinorelbine (P-V) and Cisplatin- Gemcitabine (P-G) RESULTS: 30 patients had benefit from palliative chemotherapy based on P-V (18 cases) or P-G (12 cases). All patients had responded for the questionnaire in the opportunity moments. After 3 cycles of chemotherapy, we note an improve of the symptomatic, physical, activity, emotional and global health scales. In opposition, we note a deterioration of cognitive and social scales without any supplementary improvement(no significant difference) if we add other cycles in the twice protocols. At the same level of the benefit in term of quality of life and survival without supplementary toxicity, the choice is made by the less cost's protocol in other words P-V. CONCLUSION: Our results confirm the benefit from chemotherapy in term of survival and quality of life in our context, however, the important cost of the chemotherapy necessitate to rationalize the indications and the le choice of the treatments in this palliative indication.

[Allergic bronchopulmonary aspergillosis. A review of 3 cases]. / L'aspergillose broncho-pulmonaire allergique. A propos de 3 cas.

BACKGROUND: Allergic bronchopulmonary aspergillosis (ABPA) is a rare affection, initially described in 1952. Its pathophysiology incriminate several mechanisms in relation with the organism of the patient and the bronchial colonisation by the fongic agent. AIM: To report three cases of ABPA. CASES REPORT: Three patients had been treated for ABPA in Ibn Nafiss department in Abderrahmen Mami hospital in Ariana. ABPA had been discovered in the three cases by a cortico dependant asthma, refractory for different therapeutics. Positive diagnosis reposed in the 3 patients at 6 major and one minor criterion. Treatment was essentially based in corticotherapy. CONCLUSION: Positive diagnosis of ABPA is actually well established, however, its treatment, although based on corticotherapy, remind not clearly codified. Association of antifongic treatment may improve the prognosis.

[Thoracic manifestations of systemic lupus erythematosus]. / Manifestations thoraciques du lupus érythémateux systémique.

BACKGROUND: Systemic lupus erythematosus (SLE) is an autoimmune disease. The respiratory system is more commonly involved in SLE than in any other collagen vascular disease. AIM: To study the pleuropulmonary manifestations of SLE. METHODS: Retrospective study including 10 patients hospitalized between January 2000 and December 2008 for pleuro-pulmonary manifestation revealing or complicating the SLE. RESULTS: Nine women and only one man aged between 21 and 67 years-old were included in this study. Two patients had already SLE and for the other patients the pleuro-pulmonary manifestations were revealing the SLE. Pleural effusion was the most common manifestation witch represents 50% of the patients. For the other patients we find one case of interstitial pneumonia, one case of pulmonary embolism, on case of pneumonia, on case of pulmonary haemorrhage and on case of pulmonary hypertension. All these patients were treated by corticoids and only one patient takes high doses of corticoids for managing a massive pulmonary haemorrhage. The evolution was favourable for 9 patients, one patient dead because of massive pulmonary haemorrhage complicated with acute respiratory failure. CONCLUSION: Pleuro-pulmonary involvement in SLE is common and may be life threatening, in which case prompt and aggressive treatment is mandatory.

[Adjuvant chemotherapy in resected non small cell lung cancer: preliminary results about 8 cases]. / Chimiothérapie Adjuvante Des Cancers Bronchopulmonaires Non A Petites Cellules Opérés: Résultats Préliminaires A Propos De 8 Cas.

AIM: Report the preliminary results of adjuvant chemotherapy in patients surgically treated for non small lung cancer. METHODS: It's a prospective study about 12 patients surgically treated between January 2005 and December 2007.8 patients had benefit of adjuvant chemotherapy. The protocol had been based at 4 cycles of Cisplatine. RESULTS: Our 8 men patients, aged for the mean of 59 years with a Performans Status at 1, had benefit of adjuvant chemotherapy after curative surgery. Six patients considered us II B stage, had benefit immediately for surgically treatment. Adjuvant chemotherapy protocol had been based of Cisplatin and Vinorelbine (5 patients) and Cisplatin and Gemcitabine (1 patient). The 4 cycles can be administered without any limiting toxicity only for one patient who's received 2 cycles of Cisplatin and Gemcitabine in front of the severity of digestive side effects. Two patients considered us IIIB stage, had been surgically treated after neo adjuvant chemotherapy based at Cisplatin and Vinorelbine. Histological response was complete for twice of them. The same chemotherapy was stopped after 2 cycles us adjuvant, in front of haematological side effects. Two patients did at 4 and 15 months of neoplasic progression. The six other patients had been still on life with a move back of 33 months. CONCLUSION: Post operative adjuvant chemotherapy is the standard treatment for the II A and II B stages and probably for IB stage. For none immediately operative patients (IIIA and some III B), articulation of chemotherapy with surgery must be clarified.

Pulmonary metastases revealing choriocarcinoma.

BACKGROUND: Uterin choriocarcinoma is a trophoblastic tumour characterised by high metastasis potential. Pleuropulmonary metastasis can reveal rarely the neoplasm. AIM: Repport a new case. CASE REPORT: We report the case of a 31-years-old woman, with no pathological antecedent, admitted in our department for thoracic pain and haemoptysis occurring two months after delivery of a did in child-birth. Chest X ray and thoracic CT scan showed several bilateral opacities. A diagnosis of metastatic choriocarcinoma was confirmed by plasmatic level of beta human chorionic gonadotrophin (beta HCG) superior to 4000 UI/ml. Gynaecological exam revealed latero-uterine mass. Abdomino-pelvien ultra sound and CT scan showed tissular latero uterine and hepatic masses. Brain CT scan had been normal. Patient died after 3 cures of chemotherapy because of acute respiratory failure caused by massive pulmonary embolism. CONCLUSION: Diagnosis of choriocarcinoma must be evocated in front of several pulmonary opacities occurring in genital activity women and necessities the dosage of level of BHCG.

[Pseudo tumoral bronchial tuberculosis]. / Tuberculose bronchique pseudo tumorale: a propos de 4 cas.

Bronchial lesion is a rare site for tuberculosis. It can mimic lung cancer especially when sputum- smear is negative, and this be a cause of a delay in diagnosis, that can be made later on by a culture of Koch bacillus or after a bronchial biopsy. Through these 4 cases reports, the authors recall the ethiopathogenic hypotheses of this lesion and review the radiologic, clinical and prognostic features of these unusual forms of TB.

[Bronchectasis in Horton's disease: fortuitous association?]. / Bronchectasies au cours de la maladie de Horton: association fortuite?

Respiratory manifestations in Horton's disease are uncommon. We report the case of 63 year-old man with Horton disease diagnosed 2 months before, who was hospitalised for fever, deterioration in general health, cough and hemoptysis. Chest X-ray showed an infiltrate in the right upper lobe and bilateral cystic opacities predominant on basal suggesting bronchectasis who was confirmed secondary in CT-scan. Even though cortico sensible clinical manifestations and radiologic infiltrate were previously described in Horton's disease, association with bronchectasis was never been reported in literature and her etio pathogenic mechanism must be clarified.

[Diagnosis of non-severe pulmonary embolism by a decision analysis-based strategy in pulmonary hospital recruted-patients]. / Application d'un algorithme decisionnel au diagnostic de l'embolie pulmonaire non grave en milieu pneumologique: Résultats d'une étude prospective de 40 cas.

We have study prospectively cases of non severe pulmonary embolism in a pulmonary department by an analysis based strategy associating radio-clinical probability, venous ultra sonography, D-Dimers value followed, if no performed diagnosis, by pulmonary scintigraphy or angio-CT scan. 64 cases of pulmonary embolism suspicion have been hospitalised in our department between October 1998 and July 2001; 40 patients was included in our study and have been classified in 3 groups regarding pre test clinical probability. Anticoagulant treatment has been initialised only in the third group (probability >80%) Clinical probability associated with venous ultra sonography and D- Dimeres value allow or exclude pulmonary embolism diagnosis in 27 patients. In the others, scintigraphy and angio CT scan were necessary for establishing diagnosis. Application of this algorithm allow diagnosis of pulmonary embolism in 29 patients and exclude this pathology in the other 11. None of this patient complained from recurrent thrombo embolic accident during 17 to 42 months observance period.

[Manifestations of rifampicin-induced hypersensitivity]. / Manifestations d'hypersensibilité à la rifampicine.

INTRODUCTION: The side effects of rifampicine due to an immunoallergic mechanism are rare and usually observed during discontinued treatment or administration of high doses. OBSERVATIONS: An immediate hypersensitivity reaction with anaphylactic manifestations and increase in IgE occurred in a 39 year-old man suffering from resistant tuberculosis. The reaction occurred within the first hour following a low dose of rifampicin administered in a desensitisation attempt, the outcome of which was favourable after administration of corticosteroids and antihistamines. A type II hypersensitivity reaction occurred in a 76 year-old male patient in the form of thrombopenia on D76 of a twice weekly treatment, diagnosed because of hemoptysis with normalisation of platelet level on withdrawal of rifampicin. An immune complex hypersensitivity reaction was responsible for hepato-renal failure on D68 of twice weekly treatment and required permanent withdrawal of rifampicin and dialysis, which led to subsequent improvement. COMMENTS: These clinical cases illustrate the variability of the hypersensitivity mechanisms observed with rifampicin, the difficulty in imputability tests and methods for immunological confirmation, the interest of continuous treatment which avoids a certain number of these accidents, and that of desensitisation during immediate hypersensitive reactions which permits the continuation this major anti-tuberculosis drug.