[Bacterial and fungal co-infection: an association of criminals to look for]. / Co-infection bactérienne et fongique : une association de malfaiteurs à chercher.

INTRODUCTION: Mucorales are fungi that cause opportunistic infections. Its incidence increases. CASE REPORT: We report case of a 68-year-old woman with myelodysplastic syndrome responsible for prolonged neutropenia, hospitalized for pneumonia and sinusitis caused by Pseudomonas aeruginosa. But, despite antibiotic therapy, the patient's health deteriorated with discovery of systemic emboli on CT-scan and died. Sinus biopsies performed before her death diagnosed invasive fungal infection (Mucorales). CONCLUSION: Mucorales co-infections are rare but have already been described. Any invasive fungal infection should be searched on the event of any clinical suspicion: ground (neutropenia), lack of response to well-conducted antibiotic therapy, rapidly unfavorable outcome. The presence of other microbiological documentation do not must stop the search of invasive fungal infection, because it could have short-term life-threatening impact.

Nebulised liposomal amphotericin-B as maintenance therapy in allergic bronchopulmonary aspergillosis: a randomised, multicentre trial.

BACKGROUND: In allergic bronchopulmonary aspergillosis (ABPA), prolonged nebulised antifungal treatment may be a strategy for maintaining remission. METHODS: We performed a randomised, single-blind, clinical trial in 30 centres. Patients with controlled ABPA after 4-month attack treatment (corticosteroids and itraconazole) were randomly assigned to nebulised liposomal amphotericin-B or placebo for 6 months. The primary outcome was occurrence of a first severe clinical exacerbation within 24 months following randomisation. Secondary outcomes included the median time to first severe clinical exacerbation, number of severe clinical exacerbations per patient, ABPA-related biological parameters. RESULTS: Among 174 enrolled patients with ABPA from March 2015 through July 2017, 139 were controlled after 4-month attack treatment and were randomised. The primary outcome occurred in 33 (50.8%) out of 65 patients in the nebulised liposomal amphotericin-B group and 38 (51.3%) out of 74 in the placebo group (absolute difference -0.6%, 95% CI -16.8- +15.6%; OR 0.98, 95% CI 0.50-1.90; p=0.95). The median (interquartile range) time to first severe clinical exacerbation was longer in the liposomal amphotericin-B group: 337 days (168-476 days) versus 177 days (64-288 days). At the end of maintenance therapy, total immunoglobulin-E and Aspergillus precipitins were significantly decreased in the nebulised liposomal amphotericin-B group. CONCLUSIONS: In ABPA, maintenance therapy using nebulised liposomal amphotericin-B did not reduce the risk of severe clinical exacerbation. The presence of some positive secondary outcomes creates clinical equipoise for further research.

Evaluation of pneumococcal urinary antigen testing for respiratory tract infection investigations.

OBJECTIVE: The pneumococcal urinary antigen test enables rapid bacteriological diagnosis in respiratory tract infections. The objective was to identify factors associated with a positive pneumococcal urinary antigen test result. PATIENTS AND METHODS: This seven-year retrospective monocentric study was performed on consecutive patients presenting with respiratory tract infections reported as pneumococcal-positive. Epidemiological, biological, and radiological factors were analyzed, and severity scores were calculated. RESULTS: A total of 223 patients were included. Significant associations were observed between positive test results and age over 65years (P=0.01), positive test results and immunosuppression factors (blood disease [25% Ag+ group vs. 4% Ag- group, P=0.001], immunosuppressive therapy [10% Ag+ group vs. 0% Ag- group, P=0.02]). Clinically, fever (64% Ag+ group vs. 42% Ag- group, P=0.01) and cough (46% Ag+ group vs. 19% Ag- group, P<0.01) were associated with a positive result, as were radiological alveolar opacities (67% Ag+ group vs. 44% Ag- group, P=0.01). High PSI score was associated with the Ag+ group (79% vs. 56% Ag- group, P=0.001). CONCLUSION: Age, immunosuppressive factors, typical pneumococcal symptoms, and PSI scores were associated with a positive pneumococcal urinary antigen result.

[Disseminated nocardiosis caused by Nocardia nova with brain abscesses and osteomyelitis in an immunocompetent patient]. / Nocardiose disséminée à Nocardia nova avec abcès cérébraux et ostéomyélite chez un patient immunocompétent.

INTRODUCTION: Nocardia is an opportunist bacteria involved in patients with cellular immunodepression or chronic lung disease. The most frequent portals of entry are the respiratory tract by inhalation or direct inoculation through a cutaneous effraction. Nocardiosis may be localised or disseminated. CASE REPORT: We report a rare case of disseminated nocardiosis to Nocardia nova with pulmonary, cutaneous, cerebral attacks and femoral osteomyelitis. The diagnosis was confirmed by prolonged cultures of the bronchoalveolar fluid and the pus extracted from a cutaneous lesion. The outcome was favorable under adapted and prolonged antibiotherapy with imipenem and amikacine and then cotrimoxazole. CONCLUSION: This observation is original because it involves a immunocompetent patient with an association of two exceptional locations for N. nova: brain abscesses and femoral osteomyelitis. Screening for cerebral involvement should be systematic, even in the lack of neurological signs. An adapted and prolonged antibiotherapy must be conducted.

[Mycobacterial pulmonary infection due to Mycobacterium simiae]. / Mycobactériose pulmonaire à Mycobacterium simiae.

INTRODUCTION: Mycobacterium simiae pulmonary infections remain exceptional in France. CASE REPORT: We report a case of M. simiae lung infection and a 10-year follow-up in a non-immunocompromised host. CONCLUSION: This case emphasizes the difficulties of choosing the appropriate drugs and their side effects in the absence of any existing gold standard.

[Mycobacterium simiae pneumonia: a case report]. / Pneumopathie à Mycobacterium simiae: à propos d'un cas.

We report a case of Mycobacterium simiae pneumonia in an immunocompetent women aged 55 years, after a stay in Thailand. The diagnosis was based on culture isolation of non-tuberculous mycobacteria from bronchoalveolar lavage. The culture isolate was identified as M. simiae by biochemical and molecular methods. The patient was treated. Her condition remained stable for 5 years. During the sixth years, a relapse occurred, and a new treatment was prescribed. This is a rare case in view of the absence of any predisposing factor. M. simiae should be considered a possible causative agent of pulmonary disease, even in immunocompetent patients.

[Bifocal lung cancer: the same histology?]. / Cancer bronchique bifocal: une même histologie?

Whereas synchronous lung cancer is rare, synchronous small cell lung cancer (SCLC) and non-small cell lung cancer (NSCLC) are exceptional. The authors report the case of a 61-year-old man with synchronous unilateral adenocarcinoma and small cell lung cancer, raising the question as to the need for the histology of all of the lesions in the same lobe or same lung as well as the treatment. The medical history, biology, CT and (18)F-FDG TEP-CT did not support a diagnosis of synchronous lung cancer. The prognosis was poor and only surgery could improve the prognosis. This is a rare case and illustrates the difficulty in the diagnosis of multiple lung cancer and the difficulty in treating synchronous lung cancer with different histologies (SCLC and NSCLC).

[Pulmonary fibrosis and arterial hypertension revealing a chronic pulmonary schistosomiasis. An unusual diagnosis in Europe]. / Fibrose et hypertension artérielle pulmonaires révélant un poumon bilharzien chronique. Un diagnostic inhabituel en Europe.

We report on the case of a Senegalese woman who was hospitalised in Paris for dyspnea on exertion, revealing pulmonary fibrosis and arterial hypertension. With no evident etiology of this fibrosis, a surgical pulmonary biopsy was performed and revealed granulomatosis due to schistosomiasis. Diagnosis of chronic pulmonary schistosomiasis was obtained. The manifestations of the chronic pulmonary schistosomiasis include miliary and pulmonary arterial hypertension. Certain forms can lead to fibrosis as our case study illustrates and pose diagnostic problems outside parasitic endemic areas. Beside cases of acute schistosomiasis observed in tourists, the possibility of chronic forms of the disease in migrant originating from endemic areas should be recognised in industrialised countries.

[What is the role of FDG-PET in thoracic oncology in 2010?]. / Quelle place en oncologie thoracique pour la tomographie par émission de positons au 18FDG (TEP-FDG) en 2010 ?

18F-Fluorodeoxyglucose-Positron Emission Tomography (FGD-PET) has been considered to have a major impact on the management of lung malignancies since the beginning of this century. Its value has been demonstrated by many publications, meta-analysis and European/American/Japanese recommendations. PET combined with computed tomography has provided useful information regarding the diagnosis and staging of lung cancer and allows for the delivery of adaptive radiotherapy. In its more common uses, PET has been shown to be cost-effective. With the widespread use of new radiotracers, PET will play an increasing role in the evaluation of response to treatment.

[Role of chest physician in the management of patient with thoracic trauma]. / Place du pneumologue dans la prise en charge d'un traumatisé du thorax.

Thoracic traumas are frequent and potentially fatal, because of the associated neurological and abdominal lesions. They are observed in car crashes, combat environments and urban terrorist bombings. The mechanisms of the traumatic injury are complex and account for the diversity of the lesions. The management of a chest trauma patient is a model of multidisciplinary collaboration where the chest physician can make a significant contribution.

[Second-line therapy in patients with malignant pleural mesothelioma. A French retrospective study (2005-2006)]. / Traitement de seconde ligne dans le mésothéliome pleural malin. Étude rétrospective française (2005-2006).

BACKGROUND: The role of second-line chemotherapy (SLC) has still not been established in malignant pleural mesothelioma (MPM) but SLC is increasingly used because many patients are still fit at the time of the progression of the disease. METHODS: In this retrospective study, the authors reviewed their experience with SLC in pemetrexed-pretreated patients with MPM at two French thoracic oncology units (institut Gustave-Roussy, Villejuif, and hôpital d'Instruction des Armées Percy, Clamart). RESULTS: Between January 2005 and December 2006, 84 consecutive patients with progressing MPM after pemetrexed chemotherapy were enrolled. Forty-four patients received an SLC. There were 30 men and 14 women. The median age was 58 years (range: 34 to 76 years). Most patients had a performance status (PS) less than or equal to 1 (82%) and an epithelial histological subtype (91 %). The median time to progression (TTP) after first-line chemotherapy was 6.1 months. The SLC was a pemetrexed therapy in 21 patients and a new regime in 20 patients (gemcitabine alone or with oxaliplatin). The other three patients were enrolled in a phase I study. According to the Recist criteria, a partial response was observed in four patients and the disease was stabilised in six patients after SLC. The median TTP after SLC was 3.8 months. The median survival was 12.2 months (range: 2 to 72 months). Four of these 44 patients then received third-line (4.8 %) and two received fourth-line therapy (2.4 %). CONCLUSIONS: This experience indicates the feasibility of administering SLC in patients with MPM who are healthy at the time of the progression of the disease. The optimal treatment has not been defined to date and prospective trials are needed.

[Epidemiological and clinical features of enteroviral meningitis: a case series of 59 adult patients]. / Caractéristiques clinicobiologiques des méningites à Enterovirus de l'adulte : étude de 59 cas.

PURPOSE: To describe the epidemiological and clinical features of enteroviral meningitis as well as the biological profile of the cerebrospinal fluid (CSF). METHODS: A retrospective study conducted in a single centre between 2004 and 2008. All aseptic meningitis due to Enterovirus were included. RESULTS: Fifty-nine patients were included. The triad including fever, headache and neck stiffness was reported in 62% of patients. Twelve patients (20%) had a neutrophilic leukocytosis and 23 (39%) an elevated CRP level. Twenty-eight patients (47%) had a prominent neutrophilic reaction in the CSF and nine (15.2%) had a low glucose concentration. A presumptive anti-bacterial treatment was initiated in 47 patients (80%) for an average of 3.2 days. CONCLUSION: Due to the lack of specificity of clinical features and biological manifestations of Enterovirus meningitis, the widespread use of real-time Enterovirus PCR is a priority for reducing the number of unnecessary anti-bacterial treatment. Guidelines based on clinical and biological features may be associated to help physicians in the differential diagnosis between bacterial and viral meningitides.

[Pulmonary malignant melanoma: primary or metastatic?]. / Mélanome malin pulmonaire: primitif ou métastase ?

Primary pulmonary malignant melanoma is rare (0.01% of pulmonary cancers); only 25 cases are published in the literature. The diagnosis of primary pulmonary malignant melanoma is controversial, the pathogenesis is unknown and a pulmonary metastasis from a mucocutaneous melanoma is the main differential diagnosis. The diagnosis is based on the strict application of the Jensen criteria published in 1967. We report the case of an asymptomatic 82-year-old man presenting with a fortuitously discovered primary pulmonary malignant melanoma according to the Jensen criteria and treated by lobectomy (cT1N0M0). Surgery seems to be the gold standard treatment on account of the poor sensitivity of melanoma to chemotherapy and radiotherapy. Surgical resection and the absence of nodal involvement suggest a good prognosis even though the small number of cases does not produce useful statistical data. This observation raises the question of (18)FDG CT-PET in this situation, particularly of the whole body, by extrapolation from the recommendations in mucocutaneous melanoma. The lack of increased uptake on (18)FDG CT-PET could be a new paraclinical diagnostic criterion to add to the clinical criteria of Jensen. This report is the first, which shows the results of (18)FDG CT-PET (standard and whole-body) under this situation.

[Duodenal ulcers caused by chloroquine-proguanil association]. / Ulcérations duodénales dues à l'association chloroquine-proguanil.

Chloroquine-proguanil association is recommended for prophylaxis against falciparum malaria in countries with a low prevalence of chloroquine resistance. It is usually well tolerated with mild side effects consisting mainly of transient digestive discomfort and buccal manifestations (mouth sores or ulcers). The purpose of this report is to describe a case of duodenal ulcers presenting as epigastric pain with 10-kg weight-loss in a 32-year-old man taking chloroquine-proguanil for malaria prophylaxis during a stay in Haiti. No other causes of duodenal ulcers or weight-loss were found. Chloroquine-proguanil prophylaxis was discontinued and replaced by omeprazole for four weeks. Symptoms improved quickly and full recovery was observed within one month. To our knowledge, the occurrence of duodenal ulcers under chloroquine-proguanil association is quite rare, but possibly severe. Upper digestive endoscopy should be performed if a patient under chloroquine-proguanil develops abdominal pain especially in association with weight-loss. If endoscopy reveals duodenal ulcers, chloroquine-proguanil should be discontinued and replaced by another prophylactic regimen.

Cardiovascular rehabilitation in patients with diabetes.

PURPOSE: The cardiovascular disease risk profile and exercise capacity of coronary heart disease patients with type 2 diabetes mellitus (DM) were measured and compared with those of nondiabetic (NDM) patients before and after a 6-week multidisciplinary cardiac rehabilitation program. METHODS: Subjects included 413 patients with DM (56.9 +/- 7.9 years) and 614 patients with NDM (56.8 +/- 10.3 years). RESULTS: At program entry, DM patients had a higher prevalence of risk factors (hypertension, hypercholesterolemia, hypertriglyceridemia, obesity, excess abdominal fat, and depression), had a lower peak oxygen uptake (14.3 +/- 4.4 vs 16.6 +/- 5.4 mL . kg . min; P < .001), and covered a shorter distance in the 6-minute walk test (404 +/- 117 m vs 445 +/- 116 m; P < .001) than NDM patients. At the end of the exercise program, all patients achieved significant improvements in physical capacity, which were similar in DM and NDM patients (+27.6 +/- 28.2% vs +30.5 +/- 27.7% for peak oxygen uptake and +21.0 +/- 31.5% vs +21.3 +/- 53.2% for the 6-minute distance test). CONCLUSION: DM patients with coronary heart disease had a higher prevalence of cardiovascular disease risk factors as well as lower physical capacity than NDM patients at the beginning of rehabilitation. All patients demonstrated improvement in exercise capacity after rehabilitation. More importantly, the extent of the improvement was similar in DM and NDM patients. This study, which involved a large population, emphasizes the capacity of DM patients to fully benefit from a multidisciplinary risk factor management program, including exercise training and educational programs.