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Achalasia is a neurodegenerative motor disease of the esophagus resulting mainly from a loss of function of the lower esophageal sphincter, the pathophysiology of which is still poorly understood. Its incidence is rare-it is 1.6 per 100,000-and its occurrence in the context of paraneoplastic syndrome has been rarely described in the literature. We report a rare case of paraneoplastic achalasia associated with lung cancer.

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INTRODUCTION: Haemorragic pleurisy is fairly common. The etiology is dominated by tumors and tuberculosis. The rupture of intra-thoracic vessels into the pleural cavity is a much rarer cause and the diagnosis is often delayed. OBSERVATION: A 77-year-old patient without previously known hypertension was hospitalized for investigation of a fluid density opacity occupying the entire left hemithorax. Thoracentesis revealed a non-coagulable haemorrhagic fluid. A computed tomography scan showed a Stanford type B aortic dissection. The patient was given anti-hypertensive treatment for one year. CONCLUSIONS: Aortic dissection remains among the diagnoses to consider in the case of a haemorrhagic pleural effusion despite absence of the usual suggestive symptoms.

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Thrombosis of the superior vena cava is attached to several causes including deficiency of the protein S. It occurs gradually by a superior vena cava syndrome. We report a patient aged 22 years, no toxic habits or bipolar aphthosis, which presented for 3 months a superior vena cava syndrome. The radiological and biological assessments confirmed thrombosis of the superior vena cava and a deficit of the protein S for which the patient was put under anticoagulant therapy with good clinical and radiological improvement. Through this observation, the authors report a rare cause of thrombosis of the superior vena cava which is the isolated protein S deficiency and provide a review of the literature.

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Secondary location of lung cancer are frequent but the location heart is rare and often diagnosed postmortem. We report a case of a patient of 67 years without disease history, individuals smoking outside a chronic carrier of bronchial squamous cell carcinoma and the staging of which finds a secondary location within the left atrial. Through this observation, the authors propose an update on this rare and exceptional location.

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Carcinoma of unknown primary (CUP) is the metastasis of epithelial malignancy whose origin remains unknown. Bronchial carcinoma is the most common cause (45%), however, in more than a quarter of cases, its origin is unknown and the choice of therapy often justifies a histopathological precision brought by the immuno-histochemistry. We present a rare case of cerebral metastasis, revealing an unknown lung cancer after a comprehensive review. This is a patient aged 53 years, chronic smoker, who presented a year and a half ago a sudden loss of consciousness with afebrile tonic-clonic seizure of spontaneous resolution. Clinical examination was unremarkable. Brain imaging by MRI has objectified the presence of two parietal tissue formations, which stereotactic biopsy with histological and immuno-histochemical favored metastasis of lung adenocarcinoma origin. An etiologic in search of the primitive lung remained negative (chest X-ray of face, chest CT and bronchoscopy with sampling upper gastrointestinal endoscopy). The rest of the etiologic, looking for another primitive, remained negative. The diagnosis of a bronchogenic carcinoma with brain metastasis is therefore withheld. The patient received two brain radiotherapies (gamma kniff) with regression of the two nodular formations. We have not given specific treatment and have called for very close monitoring of the patient who remained stable after 18 months. Through this observation, we stress the interest of the histology and immuno-histochemistry of carcinoma of unknown primary (CUP) to the diagnosis, guide therapy and determine prognosis.

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Syndrome Doege-Potter is a paraneoplastic syndrome in which hypoglycemia is the result of tumors producing insulin growth factor-like (IGF-II) it is most often solitary fibrous tumor of the pleura (TFSP). These are rare and may be discovered incidentally, during non-specific respiratory symptoms or during hypoglycemia. Hypoglycemia occurs in tumors of large volume and it disappears after surgery, which is the treatment of choice for a permanent cure in most cases. We present a case of Doege-Potter syndrome whose interest is to consider the TFSP as a cause of hypoglycemia in patients with pleural tumors.

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INTRODUCTION: The purpose of this study was to assess the results of the surgical treatment of abdominal hydatid cysts ruptured in the thorax. PATIENTS AND METHODS: We collected data from 160 patients who experienced the intra-thoracic rupture of an abdominal hydatid cyst during the period 1997 - 2008: 158 located in the liver, one in the spleen and one in the kidney, which had been treated surgically in a single centre. Diagnosis was based on a history of surgery for abdominal hydatid cysts, specific symptoms including biliptysis (40% of the cases) and expectoration of hydatid cysts, as well as radiological findings (chest x-ray; abdominal ultrasound and CT-scan). All patients were operated on through a thoracotomy. RESULTS: In-hospital mortality was 7.5%. Postoperative complications occurred in 16% and mainly consisted of pleural and pulmonary disorders. CONCLUSION: Thoracotomy offers simultaneous and adequate access to address thoracic and abdominal injuries with a reasonable mortality and morbidity in patients with this condition.

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Paraoesophagial cyst is an extremely rare congenital malformation of the oesophagus often discovered incidentally in adults. We report the case of a paraoesophageal cyst in a 45 year old man revealed by recurrent chest infections and confirmed by examination at surgery.

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OBJECTIVE: Lung resection retains an important place in the treatment of certain forms of tuberculosis. The purpose of this review was to review the indications for and outcomes of pneumonectomy both in the management of active TB and the treatment of its consequences. MATERIALS AND METHODS: Between 2003 and 2007 85 patients underwent a pneumonectomy for TB; 48 men and 37 women with a mean (sd) age of 36.7 (10.9) years. Chronic sputum production and haemoptysis were the main presenting features. RESULTS: The indication for surgery was a single destroyed lung in 34 cases, an aspergilloma in 29 cases, tuberculous empyema in 14 and multidrug resistant TB in 5. The procedure undertaken was a pneumonectomy in 32 cases a pleurectomy and pneumonectomy in 45 cases and a completion pneumonectomy in 8 cases. There were 4 deaths (4.7%) and in 13 cases (15.3%) a pyothorax developed in the pneumonectomy cavity. In 4 cases a broncho-pleural fistula occurred. Long term results were satisfactory with a median follow up of 2.8years (range 3 months to 5 years). Male sex (p=0.02), right sided pneumonectomy (p=0.01) diabetes (p=0.001), a low level of haemoglobin (p=0.03) or serum protein (p<0.001) were associated with an increased risk of pneumonectomy cavity infection. Right sided surgery (p=0.01), post operative transfusion (p=0.01) and pre-operative empyema (p=0.05) were all associated with risk of bronchial dehiscence. CONCLUSION: Optimising preoperative condition and identification of patients at risk of complications are essential for reducing the burden of post-operative complications.

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Actinomycosis is a rare condition which, in the thoracic localisation, can mimic cancer or tuberculosis. We report a series of three case of thoracic actinomycosis treated in the Ibn Sina University Thoracic Surgery Unit in Rabat, Morocco. CASE N degrees 1: This 45-year-old patient presented a tumefaction on the left anterior aspect of the chest. Physical examination identified a parietal mass with fistulisation to the skin. Radiography demonstrated a left pulmonary mass. Transparietal puncture led to the pathological diagnosis of actinomycosis. The patient was given medical treatment and improved clinically and radiographically. CASE N degrees 2: This 68-year-old patient presented repeated episodes of hemoptysis. The chest x-ray revealed atelectasia of the middle lobe and bronchial fibroscopy demonstrated the presence of a bud in the middle lobar bronchus. Biopsies were negative. The patient underwent surgery and the histology examination of the operative specimen revealed pulmonary actinomycosis. The patient recovered well clinically and radiographically with antibiotic therapy. CASE N degrees 3: This 56-year-old patient presented cough and hemoptysis. Physical examination revealed a left condensation and destruction of the left lung was noted on the chest x-ray. Left pleuropulmonectomy was performed. Histological analysis of the surgical specimen identified associated Aspergillus and Actinomyces. The outcome was favorable with medical treatment. The purpose of this work was to recall the radiological, clinical, histological, therapeutic, outcome aspects of this condition and to relate the problems of differential diagnosis when can suggest other diseases.

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Scleroma is a specific granlomatous disease caused by an enterobacteria of the Klebsiella family (Klebsiella rhinoscleromatis), localized electively in the upper airways, particularly the nasal fossae, leading to the term "rhinoscleroma". Tracheal involvement is exceptional. The disease progresses slowly, leaving mutilating and stenosing scar tissue. Medical treatment using antibiotics and corticosteroids is the basic approach although surgical treatment may be needed for fibrosclerosis unresponsive to medical treatment. We report a case of rhinoscleroma which extended to the trachea. In light of this case, we examine the demographic, diagnostic, therapeutic and evolutive aspects of this disease.

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INTRODUCTION: Actinomycosis is a suppurative infection caused by bacteria of the genus actinomyces. It is a rare cause of pulmonary infection and can be difficult to diagnose as its presentation may mimic cancer or tuberculosis. In the absence of treatment of pulmonary lesions fistulae can develop. We report a case of pulmonary actinomycosis complicated by a chest wall fistula that was managed by the thoracic surgery unit at Chu Ibn Sina de Rabat. CASE REPORT: A 45 year old man who was previously fit and well presented with a left sided chest wall swelling with cutaneous fistulae. Pulmonary auscultation revealed evidence of left apical consolidation. Otherwise clinical assessment was unremarkable. Plain chest radiology revealed left apical opacification. CT scanning revealed a left pulmonary mass and percutaneous biopsy confirmed the diagnosis of actinomycosis. The patient was started on treatment and experienced a clinical and radiological improvement sustained at one year's follow up. CONCLUSION: We review the clinical and radiological characteristics of this condition as well as diagnostic difficulties, histological findings, therapeutic options and its natural history.

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INTRODUCTION: Primary pulmonary angiosarcoma (PPA) is a very rare tumour with a grave and short prognosis and whose primary site is difficult to confirm. The diagnosis is essentially histological and immunohistochemical because there are no specific clinical or radiological signs. OBSERVATION: We report a case of a man with PPA, discovered during the investigation of chest pain. Imaging (x-ray and CT) identified a right apical mass. The diagnosis was made by histological and immunohistochemical analysis of CT guided percutaneous biopsies. CONCLUSION: As a result of this observation we propose further studies on this extremely rare and grave condition.

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