[Pulmonary actinomycosis with chest wall fistula formation in a child]. / Actinomycose pulmonaire fistulisée à la paroi thoracique chez un enfant.

INTRODUCTION: Actinomycosis is a suppurative infection caused by bacteria of the Actinomyces genus. It is a rare cause of pulmonary infection and can be difficult to diagnose because its presentation may mimic tuberculosis or cancer. In the absence of treatment of pulmonary lesions fistulae can develop. We report a case of thoracic actinomycosis with chest wall involvement in a child, managed in the pediatric department at Moulay Youssef University Hospital in Rabat, Morocco. CASE REPORT: We report the case of a 13-year-old boy with a history of trauma to the right chest 1 year earlier, admitted with right-sided chest wall swelling with cutaneous fistulae. Physical examination identified a parietal mass with fistulization to the skin. Laboratory tests showed an inflammatory syndrome. The chest x-ray revealed moderate right pleural effusion. The thoracic computed tomography scan showed a right parietal pleural mass and the percutaneous biopsy confirmed the diagnosis of actinomycosis. The patient underwent antibiotic therapy with favorable evolution. CONCLUSION: The diagnosis, the clinical, radiological and histological pattern, and the therapeutic features are described in this report.

[Hypothermia due to anti-tuberculosis drugs: first case]. / Hypothermie secondaire au traitement antibacillaire: 1(e) cas rapporté

Hypothermia - an adverse reaction of drug use potentially severe - requires an early diagnosis and an adapted management. We report the first case, to our knowledge of hypothermia due to anti-tuberculosis drugs.

[An unusual cause of hemoptysis: a leech]. / Cause inhabituelle d'hémoptysie: la sangsue.

We report an exceptional case of hemoptysis observed in a 71-year-old woman with an uneventful past history. After 48 hours of admission, the patient spontaneously expelled a leech from the nose. The parasite was examined in parasitology laboratory, which confirmed the hemiptera. The infestation of the airway by a leech is not uncommon; however, this diagnosis is rarely mentioned. The clinical symptoms are variable depending on location and the diagnosis should be made rapidly to prevent complications. Whatever the localization, removing the parasite is difficult. Evolution after treatment is rapidly favorable, with complete disappearance of symptoms.

[A rare form of rifampicin-induced skin toxicity: bullous pemphigoid]. / Une forme rare de toxidermie induite par la rifampicine: la pemphigoïde bulleuse.

INTRODUCTION: Rifampicin is an antituberculous drug causing minor cutaneous reactions. Rifampicin-induced bullous skin reactions are rare. CASE REPORT: We describe a 48-year-old man who was given rifampicin, streptomycin, isoniazid and pyrazinamide for pulmonary tuberculosis. Seventy-two hours later, he developed generalized pruritus, and an urticarial eruption developed 5 days later. He was admitted to hospital and the drugs were discontinued. He could remember no history of previous administration of antituberculous drugs and no other drugs had been taken recently. General physical examination yielded no relevant findings. On dermatological examination, Nikolsky's sign was negative. There were tiny symmetrical cutaneous vesicles overlying normal skin of all four limbs. These rapidly became confluent, forming large tense bullous lesions containing clear fluid, suggesting bullous pemphigoid. Blood tests showed a neutrophil leukocytosis and mild eosinophilia. Other biological tests were normal. Skin biopsy was refused by the patient. He was given intravenous antihistamine and dry bandages were applied to the forearms and legs. The antituberculous drugs were discontinued for two weeks and the lesions healed spontaneously. The drugs were then progressively reintroduced, streptomycin being excluded initially. A few hours after the first dose of rifampicin, a recurrence was noted and it was substituted by ethambutol. Subsequent introduction of streptomycin was uneventful. No recurrence occurred over 18 months follow up. CONCLUSION: The authors describe a rare case of rifampicin-induced skin toxicity and the related diagnostic and therapeutic difficulties.

[Pulmonary alveolar microlithiasis: report of four cases]. / La microlithiase alvéolaire pulmonaire: à propos de quatre cas.

INTRODUCTION: Pulmonary alveolar microlithiasis is a rare disease characterised by the formation and deposition of calcium phosphate microliths in the lung. It is an autosomal recessive disorder, for which mutation in the SLC34A2 gene was recently found to be responsible for the disease. OBSERVATIONS: We report on four cases of pulmonary alveolar microlithiasis. Three patients were asymptomatic. The diagnosis was made after histological confirmation in three patients. The outcome was marked by the death of one patient. CONCLUSION: Pulmonary alveolar microlithiasis is a rare disease. Diagnosis is made with high-resolution computed tomography, which exhibits the calcic character and distribution of the lesions, thus avoiding the need to perform lung biopsy. We suggest that a literature review be performed.

[Renal failure in sarcoidosis: case report]. / Sarcoïdose et insuffisance rénale: à propos de deux cas.

Renal involvement in sarcoidosis is rare and more often related to calcium metabolism disorders or granulomatous interstitial nephritis, glomerulonephritis is exceptional. The two cases of renal failure reported in this article illustrate the gravity of this complication, whose treatment remains difficult.

[The pseudoalveolar form of sarcoïdosis: a diagnostic pitfall]. / La forme pseudo-alvéolaire de la sarcoïdose: un piège diagnostique à ne pas méconnaître.

BACKGROUND: Sarcoïdosis is a benign systemic granulomatosis whose aetiology remains unknown. Lung is the most frequently involved organ. The pseudoalveolar form of this disease is known to have an acute onset and is quite uncommon. Therefore, diagnosing such a rare variety of sarcoidosis is rather often challenging. OBSERVATIONS: In the present article, the authors report two cases of pseudoalveolar sarcoidosis. The patients, both young adults, showed no suggestive signs of sarcoidosis at first presentation. This resulted in a considerable delay to diagnosis and to the corticosteroid therapy. CONCLUSION: The authors emphasize the rarity of the pseudoalveolar form of sarcoidosis. They insist on its roentgenographic characteristics and demonstrate the functional benefits allowed by the precocious medical management. They also propose a current review of the literature.

[Multifocal tuberculosis (palpebral and pleural) in an immunocompetent woman]. / Tuberculose multi-focale (palpébrale et pleurale) chez une immunocompétente.

INTRODUCTION: Tuberculosis of the eyelid and its development in the setting of multifocal tuberculosis is exceptionally rare. CASE REPORT: The authors report a new observation of multifocal tuberculosis in a non-immunosuppressed woman of 28 years with histologically confirmed pleural and palpebral involvement. A paradoxical reaction was seen following the initiation of anti-tuberculous treatment with appearance of new manifestations (thoracic cold abscesses). CONCLUSION: The authors draw attention to this rare localisation and to the paradoxical reactions during treatment, emphasising the need for early diagnosis to avoid local and remote complications.

[Congenital esophagobronchial fistula in an adult. Case report]. / Fistule oeso-bronchique congénitale chez l'adulte. A propos d'un cas.

Congenital esophagobronchial fistulae are uncommon anomalies generally discovered during the neonatal period due to overt symptoms. Rarely symptoms are discrete, leading to discovery in adulthood; exceptionally the patients are totally symptom free or present minimal signs such as coughing at ingestion of fluids. Less than 200 adult cases have been reported in the literature. We report a new case of this type II congenital esophagobronchial fistula. A 59-year-old woman was hospitalized for exploration of cough at ingestion of fluids. The radiographic work-up reveal dilatation of the left bronchial tree and suspected esophagobronchial fistula. An esophago-gastro-duodenal barium study demonstrated a fistula between the mid esophagus and the left posterobasal bronchus. Fistulectomy and left lower lobectomy were performed. Outcome was favorable. The diagnosis of adult esophagobronchial fistula should be entertained in patients with an uneventful history who present localized bronchial dilatation associated with cough induced by fluid ingestion.

[Associated rhinosinus and pleural sarcoidosis]. / Association de localisations rhino-sinusienne et pleurale au cours d'un cas de sarcoïdose.

Sarcoidosis manifestations in the upper airways and pleura are exceptional, observed in 5% and 1% of cases. We report an exceptional observation of an association of these two localizations in addition to mediastinopulmonary involvement. After confirmation of the diagnosis obtained on bronchial biopsies and nasal mucosa biopsies, pleural sarcoidosis was retained because of the clinical context and the spontaneous resolution of the effusion. The major problem is the absence of a therapeutic consensus on proper management, oral corticosteroid therapy being proposed by some for these particular forms of sarcoidosis.

[Pulmonary leptospirosis. Two cases]. / Atteinte pulmonaire au cours de la leptospirose. A propos de deux cas.

Leptospirosis is a systemic infection transmitted to man by a variety of animals. Classical manifestations include fever, liver and renal involvement, meningoencephalitis and hemorrhage. Pulmonary involvement is less common, generally expressed by hemoptysis and bilateral reticulonodular infiltration on the chest x-ray. Pulmonary disease is one of the principal causes of mortality. We report the cases of two patients aged 22 and 32 years who were hospitalized for moderately abundant hemopysis and fever. The diagnosis of leptospirosis with pulmonary involvement, strongly suggested by the classical extrapulmonary signs and was confirmed later. The patients were given antibiotics (amoxicillin, cycline). Clinical, biological and radiological outcome was favorable.

[Endobronchial tuberculosis. Report of 21 cases]. / La tuberculose endobronchique. A propos de 21 observations.

Since the advent of antituberculosis drugs, endobronchial tuberculosis has become an exceptional finding, often in a misleading context. Cases reported generally occur in patients with immune deficit. We report 21 cases of endobronchial tuberculosis in immunocompetent patients (mean age 37 years). Clinical and radiological signs were not specific. Bronchial fibroscopy was essential for certain diagnosis, particularly in budding forms. Early treatment reduced the risk of complications. Based on our experience with these 21 cases, we propose a discussion of the pathogenic mechanisms involved and the diagnostic difficulties encountered as well as the disease course and risk of complications that can be expected.

[Pleurisy and sarcoidosis. Apropos of 2 cases]. / Pleurésie et sarcoïdose. A propos de 2 cas.

Pleural involvement is uncommon in sarcoidosis, observed in less than 5% of cases. We report two cases. Both patients were women. In the first patient, signs of sarcoidosis included pleural, mediastinal node, and multiple joint involvement as well as nasal obstruction, sicca syndrome and subcutaneous nodules. Diagnosis was established on pleural and nasal biopsies. For the second patient, in addition to the pleural involvement, there was interstitial lung disease and cervical, epitrochleal and deep abdominal node enlargement. Diagnosis was established from serial bronchial biopsies, pleural biopsies and peripheral node biopsies. Pleurisy is generally observed in cases with extensive lung involvement with extrathoracic localizations. Blind pleural biopsy is not very sensitive for diagnosis of sarcoidosic pleurisy. Light yellow exsudative fluid with a high lymphocyte count in a patient with a radiological and clinical presentation suggestive of tuberculosis, which must be ruled out, is a characteristic feature.

Epidural steroids for treating "failed back surgery syndrome": is fluoroscopy really necessary?

UNLABELLED: Epidural steroids are commonly administered in the treatment of "failed back surgery syndrome." Because patient response is dependent on accurate steroid placement, fluoroscopic guidance has been advocated. However, because of ever-increasing medical expenditures, the cost-benefit of routine fluoroscopy should be critically evaluated. Therefore, 50 patients were enrolled into this institutional review board-approved, prospective, controlled, single-blinded study. At a predetermined intervertebral level, the epidural space was identified using an air loss of resistance technique. Thereafter, an epidural catheter was inserted 2 cm through the epidural needle. To determine the accuracy of the clinical placement, contrast medium was administered through the epidural catheter; antero-posterior and lateral lumbar spine radiographs were then obtained. The number of attempts required to successfully locate the epidural space, the reliability of the air loss of resistance technique in indicating successful epidural penetration in failed back surgery syndrome, the ability of the clinician to accurately predict the intervertebral space at which the epidural injection was performed, and the spread of contrast medium within the epidural space were recorded. A total of 48 epidurograms were performed. The number of attempts to successfully enter the epidural space was 2 +/- 1. In 44 cases, the radiological studies confirmed the clinical impression that the epidural space had been successfully identified. In three patients, the epidural catheter was in the paravertebral tissue. One myelogram was recorded. In 25 patients, the epidural catheter did not pass through the predetermined intervertebral space. In 35 cases, the contrast medium did not reach the level of pathology. IMPLICATIONS: The clinical sign of loss of resistance is a reliable indicator of epidural space penetration in most cases of "failed back surgery syndrome." However, surface anatomy is unreliable and may result in inaccurate steroid placement. Finally, despite accurate placement, the depot-steroid solution will spread to reach the level of pathology in only 26% of cases.

[Cerebromeningeal tuberculosis. X-ray computed tomographic aspects apropos of 36 cases]. / La tuberculose cérébro-méningée. Aspects tomodensitométriques à propos de 36 cas.

Thirty-six patients with different clinical and topographic forms of cerebromeningeal tuberculosis: meningitis, meningo-encephalitis, tuberculoma, abscess and their complications, were investigated by CT scans. Whereas standard films allow diagnosis of intracranial hypertension, other neurological examinations are very insufficient when compared with CT imaging, a non-invasive procedure which provides presumptive signs of a tuberculous lesion and thus assists diagnosis, and assessment and follow up of results of treatment. Meningitis and meningo-encephalitis are seen as isodense images of cisternae of base of skull with marked increase after contrast, which may provoke the appearance of hyperdense nodules. More or less widespread hypodensities are provoked by meningoencephalitis, cerebral tuberculosis appearing as an iso- or hyperdense mass forming an annular shape after contrast. Calcification is a rare finding and appears as punctiform zones in the center of a tuberculoma, while a tuberculous abscess has the identical appearance to that of a nodular tuberculoma.