I. Yangui

Carcinome à petites cellules du poumon et syndrome néphrotique d’évolution rapidement fatale

Nephrotic syndrome due to membranous glomerulonephritis is observed in 1 to 3% of patients with lung cancer. The nephrotic syndrome usually precedes the discovery of the causal tumor, but diagnosis can be concomitant or during the disease course. We describe a case of small-cell carcinoma of the lung without metastases revealed by a paraneoplastic nephrotic syndrome. Complete remission of the tumor was achieved with chemotherapy and radiotherapy with resolution of the nephrotic syndrome, but tumor progression occurred together with rapidly fatal renal failure. In this case, and the review of the literature, illustrate the association between paraneoplastic nephrotic syndrome and lung cancer, as well as the disease course and prognosis of the lung cancer and the accompanying glomerulopathy.Nephrotic syndrome due to membranous glomerulonephritis is observed in 1 to 3% of patients with lung cancer. The nephrotic syndrome usually precedes the discovery of the causal tumor, but diagnosis can be concomitant or during the disease course. We describe a case of small-cell carcinoma of the lung without metastases revealed by a paraneoplastic nephrotic syndrome. Complete remission of the tumor was achieved with chemotherapy and radiotherapy with resolution of the nephrotic syndrome, but tumor progression occurred together with rapidly fatal renal failure. In this case, and the review of the literature, illustrate the association between paraneoplastic nephrotic syndrome and lung cancer, as well as the disease course and prognosis of the lung cancer and the accompanying glomerulopathy.

Influence of Ramadan Observance on Sleep Pattern and Wakefulness at Workamong Medical Trainer in Tunisia

Introduction: Muslims practice intermittent Islamic fasting all over the globe each year during Ramadan. This practice induces several changes that may affect work performance. The aim of this study is to evaluate the impact of fast during Ramadan on eating behaviors, sleep habits, daytime sleepiness, and professional life. Methods: Target population was medical trainees who were working since at least 4 months at the beginning of the study. They were invited to complete an anonymous self-administered questionnaire during and apart from Ramadan. Results: Two hundred forty-three subjects (243) had correctly completed the questionnaire (mean age = 26.81 ± 2.17 years and sex-ratio = 0.69). During Ramadan, all Alcohol drinkers had stopped drinking (p<0.001), and daily tobacco consumption had significantly dropped from 14.82 ± 8.26 to 11.67 ± 8.64 cigarettes during Ramadan (0.002). Consumption of both coffee and tea was significantly reduced from 2.44 ± 1.3 to 1.03 ± 0.71 and from 1.06 ± 0.59 to 0.77 ± 0.66 cups a day, respectively (p<0.0001). The average number of meals per day dropped from 2.92 ± 0.49 before Ramadan to 1.79 ± 0.58 during Ramadan (p = 0.032). The average bedtime was significantly delayed until to 3.80 ± 5.37 am, while it was at 9.7 ± 10.93 pm during the previous month (p<0.0001). The percentage of subjects who went to bed after midnight also had significantly increased from 57.1% to 93.1% (p<0.001). The degree of dissatisfaction about sleep quality had substantially increased from 18.9% at baseline to 54.7% during Ramadan (p<0.0001). Fasted Trainees found more difficult getting up in the mornings (74.1% versus 79% respectively, p<0.0001). The percentage of trainees who often arrived late for work or missed it increased significantly, from 3.7% at baseline to 11.9% during Ramadan (p<0.0001). The majority (81.1%) reported feeling extra sleepy during the daytime of Ramadan month as compared to 60.1% during the previous month (p<0.0001). It was also noted a higher frequency of digestive disorders (46.9% versus 29.6%, <0.001), morning headaches (15.2% versus 6.6%), excessive nervousness (65% versus 57.6%, p<0.001) and concentration and memory disturbances (88.9% versus 77%, p<0.001). Both daily and weekly working hours had significantly decreased during the month of Ramadan (p<0.001). Trainees started their daily work 15 minutes later and left 20 minutes earlier, which results in 35 less minutes worked per day, and around 3 and half hours less per week. Most of participants (88.1%) thought that Ramadan had a negative effect on their sleeping pattern and affected their daytime functioning. Although, the percentage of those who took sedative-hypnotics for sleep disorders had significantly dropped from 7% at baseline to 3.3% during this month (p = 0.0001). Conclusion: The present study showed that Ramadan is associated with several changes in eating behaviors and sleep habits. These changes resulted in sleep pattern impairment, increased daytime sleepiness and reduced work performance. Healthy sleep and eating habits with a suitable work rhythm should be recommended to Fasted medical trainees to minimize the impact of Ramadan on their wellbeing and professional life.

Do inhaled corticosteroids increase the risk of Pneumocystis pneumonia in people with lung cancer

Pneumocystis pneumonia (PCP) is a life-threatening infection in immunocompromised patients. It is relatively uncommon in patients with lung cancer. We report a case of PCP in a 59-year-old man with a past medical history of chronic obstructive pulmonary disease treated with formoterol and a moderate daily dose of inhaled budesonide. He had also advanced stage non-small lung cancer treated with concurrent chemo-radiation with a cisplatin-etoposide containing regimen. The diagnosis of PCP was suspected based on the context of rapidly increasing dyspnea, lymphopenia and the imaging findings. Polymerase chain reaction testing on an induced sputum specimen was positive for Pneumocystis jirovecii. The patient was treated with oral trimethoprim-sulfamethoxazole and systemic corticotherapy and had showed clinical and radiological improvement. Six months after the PCP diagnosis, he developed a malignant pleural effusion and expired on hospice care. Through this case, we remind the importance of screening for PCP in lung cancer patients under chemotherapeutic regimens and with increasing dyspnea. In addition, we alert to the fact that long-term inhaled corticosteroids may be a risk factor for PCP in patients with lung cancer. Despite intensive treatment, the mortality of PCP remains high, hence the importance of chemoprophylaxis should be considered.

Une tumeur primitive rare du médiastin : le liposarcome pléomorphe

Resume Le liposarcome mediastinal constitue une tumeur rare, comportant plusieurs types histologiques. Il est souvent source de difficultes diagnostiques et therapeutiques. Nous rapportons un cas de liposarcome pleomorphe du mediastin, revele par des douleurs thoraciques et une alteration de l’etat general, chez un homme de 37 ans. La tomodensitometrie thoracique, qui a revele un processus expansif mediastinal anterieur, n’a pas permis d’evoquer le diagnostic en l’absence de densite graisseuse. Le diagnostic histologique a ete etabli par biopsie transthoracique sous controle scanographique. Une premiere cure de chimiotherapie a base de cisplatine et gemcitabine n’a pu empecher la progression tumorale rapide, qui a abouti au deces du patient 3 mois plus tard. Le liposarcome mediastinal pleomorphe constitue une tumeur exceptionnelle, touchant habituellement l’adulte d’âge moyen. Cette tumeur, souvent volumineuse, est habituellement symptomatique par compression des structures mediastinales. La chirurgie en constitue le traitement de choix, alors que la place des traitements associes reste controversee. Le pronostic depend essentiellement du grade de malignite et de la qualite de l’exerese.

Métastase musculaire révélatrice d'un adénocarcinome bronchique

INTRODUCTION The diagnosis of nonsmall cell lung cancer is made at a metastatic stage in 25% of cases. The most frequent sites are the lung, liver, bone, the adrenal glands and the central nervous system. Skeletal muscle metastases are uncommon and are rarely the first manifestation of a neoplastic process. CASE REPORT We report the case of 55 years old man presenting with a hard painless swelling of the left arm. A scan guided biopsy revealed infiltration of the muscle by a thyroid transcription factor 1 (TTF1) positive adenocarcinoma. A CT scan of the chest showed a partially necrotic tissue mass with moderate uptake of contrast. The patient was treated by chemotherapy with gemcitabine and carboplatine. The progress was unfavourable with the appearance of a second muscular metastasis in the thigh and the patient died 3 months after diagnosis. CONCLUSION Skeletal muscle metastases are rarely described in lung cancer and they are an exceptional presentation of the tumour. Their symptoms can be misleading and delay diagnosis.

Un nouveau cas de carcinome à petites cellules primitif de la plèvre

Small cell carcinoma (SCC) is commonly of pulmonary origin. Pleural small cell carcinoma is a very uncommon feature. We report here a case of small cell carcinoma of the pleura in a 36 year old man. The diagnosis of primary disease SCC of the pleura was established by transparietal pleural biopsy in absence of any mediastino-pulmonary or extrathoracic other lesions that could be the primary tumor. The treatment was based on chemotherapy with cisplatin and etoposide. The patient died four months in spite of cytotoxic chemotherapy. Extrapulmonary small cell carcinoma is a rare entity. Immunohistochemistry study is very useful for the diagnosis. The prognosis seems to be worse than the small cell lung cancer.

Atteinte trachéale révélatrice d’une maladie de Hodgkin: A propos d’un cas

Inaugural tracheobronchitis is a rare but known manifestation of Hodgkins disease. Clinical signs are often misleading, retarding diagnosis and treatment. We report a case of Hodgkins disease revealed by wheezing with minimal hemoptysis. Histology of the endoscopic biopsies demonstrated Hodgkin type infiltration of the trachea with mixed cellularity. The patient was given chemotherapy and mediastinal radiotherapy and achieved complete remission.

The Impact of Obstructive Sleep Apnea and Daytime Sleepiness on Work Performance: An Observational Cross-Sectional Study in a North African Population

Background: Obstructive sleep apnea hypopnea syndrome (OSAHS) has been shown to be associated with many serious health conditions. The impact on occupational health is still unclear as it was scarcely studied. Purpose: The aim of this study was to assess the association of work performance with OSAHS and daytime sleepiness. Methods: A cross-transversal study was conducted including Tunisian active adult subjects referred for suspected sleep disordered breathing. All subjects completed the Epworth Sleepiness Scale (ESS), the Work Productivity and Activity Impairment Questionnaire (WPAI), and the Patient Health Questionnaire 9 (PHQ9). They all underwent polygraph testing level 3. Result: One hundred thirty-nine subjects completed the survey, including 107 (77%) blue-collar workers, and 32 (23%) white-collar workers. Participants were classified as following: 50 patients with apnea hypopnea index (AHI) ≥ 30 and 89 with AHI <30. Among the four outcomes of the WPAI scale, only presenteeism was associated with AHI (p=0.012). A significant association has been found between daytime sleepiness and three outcomes of WPAI. Sleepy patients with ESS ≥ 11 had lower work performance in terms of presenteeism (42.46 ± 28.40 vs. 24.71 ± 24.77 p=0.0001), absenteeism (12.26 ± 25.51 vs. 6.05 ± 18.32, p=0.101), overall work productivity loss (47.43 ± 31.65 vs. 26.58 ± 28.47, p= 0.0001), and decline in activity (46.67 ± 30.75 vs. 32.14 ± 27.02, p=0.004) in comparison with non-sleepy participants. A strong correlation of presenteeism and overall work productivity loss scores with ESS was demonstrated among white-collar workers (r=0.624, p=0.0001; r=0.602, p=0.0001 respectively). PHQ9 score was significantly higher in sleepy subjects (p=0.0001). Near miss accidents in the workplace and work related accidents were significantly more frequent in those with ESS ≥ 11 (p=0.012, p=0.026; respectively). Conclusion: The most relevant finding of this study was the involvement of daytime sleepiness in performance impairment, while the impact of AHI was less clear.

How does serum brain natriuretic peptide level change under nasal continuous positive airway pressure in obstructive sleep apnea-hypopnea syndrome?

Background Obstructive sleep apnea-hypopnea syndrome (OSAHS) is associated with cardiovascular morbidity and mortality, which can be improved by using continuous positive airway pressure (CPAP) therapy. However, the pathophysiological links between the two kinds of disease and the mechanism of the CPAP effect remain incompletely understood. We aimed to inquire into the myocardial involvement in this relationship. We suggested that serum brain natriuretic peptide (BNP) is sensitive enough to detect myocardial stress caused by OSAHS. Design and methods Sixty-four subjects without cardiovascular disease (21 controls, 24 normotensive OSAHS patients, and 19 hypertensive OSAHS patients) were analyzed for serum BNP at baseline and serially over 6 months. CPAP was applied to 23 patients with severe OSAHS. Results At baseline, the serum BNP levels were significantly higher (p=0.0001) in the OSAHS group (22.3±14.79 pg/ml) than in the control group (9.2±6.75 pg/ml). Increased serum BNP levels were significantly associated with mean transcutaneous oxygen saturation (SpO2) (p<0.0001), minimal SpO2 (p=0.002), oxygen desaturation index (p=0.001), and total sleep time spent with SpO2 lower than 90% (p=0.002). All patients with elevated BNP levels (≥37 pg/ml) had moderate or severe OSAHS (11/43 OSAHS patients). The more severe the OSAHS, the higher the BNP levels were. However, only the difference between severe and mild OSAHS was statistically significant (p=0.029). Hypertensive OSAHS patients had the highest baseline BNP levels (27.7±16.74 pg/ml). They were significantly higher (p=0.001) than in normotensive OSAHS patients (18±11.72 pg/ml) (p=0.039) and the controls (9.2±6.75 pg/ml). As compared with baseline, treatment with CPAP significantly decreased BNP levels in both hypertensive and normotensive OSAHS patients (respectively, from 36±16.10 to 29.7±14.29 pg/ml, p<0.001, and from 20±10.09 to 16±8.98 pg/ml, p<0.001). In contrast, the BNP levels slightly increased in the controls (from 9.2±6.75 to 9.5±7.02 pg/ml, p=0.029), but there was no statistically significant difference in comparison with the baseline value. The effect of CPAP on BNP levels was more marked in patients with higher baseline BNP levels and those with the most prolonged nocturnal desaturation (p=0.001, r=0.65). It was also more marked in hypertensive OSHAS patients (p=0.015, r=0.72) in comparison with normotensive OSAHS patients (p=0.03, r=0.62). Conclusion BNP seems to be sensitive enough to detect myocardial stress caused by OSAHS. As such, it is a potential marker for screening of preclinical cardiovascular damage in patients with untreated OSAHS. Application of CPAP decreases levels significantly in normotensive and particularly in hypertensive OSAHS. These findings are consistent with previous results suggesting the potential benefits of CPAP on cardiovascular outcome in OSAHS patients.Background Obstructive sleep apnea-hypopnea syndrome (OSAHS) is associated with cardiovascular morbidity and mortality, which can be improved by using continuous positive airway pressure (CPAP) therapy. However, the pathophysiological links between the two kinds of disease and the mechanism of the CPAP effect remain incompletely understood. We aimed to inquire into the myocardial involvement in this relationship. We suggested that serum brain natriuretic peptide (BNP) is sensitive enough to detect myocardial stress caused by OSAHS. Design and methods Sixty-four subjects without cardiovascular disease (21 controls, 24 normotensive OSAHS patients, and 19 hypertensive OSAHS patients) were analyzed for serum BNP at baseline and serially over 6 months. CPAP was applied to 23 patients with severe OSAHS. Results At baseline, the serum BNP levels were significantly higher (p=0.0001) in the OSAHS group (22.3±14.79 pg/ml) than in the control group (9.2±6.75 pg/ml). Increased serum BNP levels were significantly associated with mean transcutaneous oxygen saturation (SpO2) (p<0.0001), minimal SpO2 (p=0.002), oxygen desaturation index (p=0.001), and total sleep time spent with SpO2 lower than 90% (p=0.002). All patients with elevated BNP levels (≥37 pg/ml) had moderate or severe OSAHS (11/43 OSAHS patients). The more severe the OSAHS, the higher the BNP levels were. However, only the difference between severe and mild OSAHS was statistically significant (p=0.029). Hypertensive OSAHS patients had the highest baseline BNP levels (27.7±16.74 pg/ml). They were significantly higher (p=0.001) than in normotensive OSAHS patients (18±11.72 pg/ml) (p=0.039) and the controls (9.2±6.75 pg/ml). As compared with baseline, treatment with CPAP significantly decreased BNP levels in both hypertensive and normotensive OSAHS patients (respectively, from 36±16.10 to 29.7±14.29 pg/ml, p<0.001, and from 20±10.09 to 16±8.98 pg/ml, p<0.001). In contrast, the BNP levels slightly increased in the controls (from 9.2±6.75 to 9.5±7.02 pg/ml, p=0.029), but there was no statistically significant difference in comparison with the baseline value. The effect of CPAP on BNP levels was more marked in patients with higher baseline BNP levels and those with the most prolonged nocturnal desaturation (p=0.001, r=0.65). It was also more marked in hypertensive OSHAS patients (p=0.015, r=0.72) in comparison with normotensive OSAHS patients (p=0.03, r=0.62). Conclusion BNP seems to be sensitive enough to detect myocardial stress caused by OSAHS. As such, it is a potential marker for screening of preclinical cardiovascular damage in patients with untreated OSAHS. Application of CPAP decreases levels significantly in normotensive and particularly in hypertensive OSAHS. These findings are consistent with previous results suggesting the potential benefits of CPAP on cardiovascular outcome in OSAHS patients.

Une pneumopathie récidivante bilatérale et fébrile

Resume La polyangeite microscopique (PAM) est une affection rare, se traduisant habituellement par un syndrome pneumo-renal. Nous rapportons l’observation d’un jeune de 35 ans, qui s’est presente pour hemoptysie recidivante avec, a la tomodensitometrie thoracique, des opacites alveolo-interstitielles bilaterales en mosaique et a predominance apicale. Le lavage broncho-alveolaire a permis de confirmer le diagnostic d’hemorragie intra-alveolaire. La biopsie renale, realisee devant une proteinurie, a mis en evidence des lesions de glomerulonephrite extra-capillaire. Devant l’association d’hemorragie intra-alveolaire, d’atteinte renale et de positivite des p-ANCA, le diagnostic de polyangeite microscopique a ete retenu. Un traitement a base de corticoides et d’immunosuppresseurs a permis une remission de la maladie. Les auteurs discutent, a travers cette observation, la diversite des presentations radio-cliniques de la polyangeite microscopique, qui peut etre parfois source de difficultes diagnostiques.