Les calcifications pulmonaires métastatiques [Pulmonary metastatic calcification].

INTRODUCTION: The lung is the organ most frequently involved by metastatic calcification. This condition is probably under-diagnosed, the patients usually being asymptomatic. This article summarizes the current knowledge concerning pulmonary metastatic calcification. BACKGROUND: The pathogenesis of pulmonary metastatic calcification is not well known, but it involves phosphate-calcium balance, renal function and pH. The most frequently encountered aetiologies are hyperparathyroidism, neoplastic bony lesions, and renal failure. The definitive diagnosis is achieved by histology, radiological examinations being insensitive. The clinical manifestations are various and can include a pulmonary restrictive syndrome, diffusion abnormalities, hypoxaemia and respiratory failure. The latter can be severe and influence the prognosis adversely: 19 cases of fatal pulmonary metastatic calcification have been reported. The treatment is aetiological and symptomatic. VIEWPOINT: The prognostic factors for a poor outcome of this potentially lethal condition remain to be determined. The management of asymptomatic patients is also uncertain. CONCLUSIONS: Pulmonary metastatic calcification is a rare condition of complex pathogenesis. The clinical manifestations are varied, ranging from asymptomatic to severe, even fatal.

Dominant TNF-α(+) Mycobacterium tuberculosis-specific CD4(+) T cell responses discriminate between latent infection and active disease.

Rapid diagnosis of active Mycobacterium tuberculosis (Mtb) infection remains a clinical and laboratory challenge. We have analyzed the cytokine profile (interferon-γ (IFN-γ), tumor necrosis factor-α (TNF-α) and interleukin-2 (IL-2)) of Mtb-specific T cells by polychromatic flow cytometry. We studied Mtb-specific CD4(+) T cell responses in subjects with latent Mtb infection and active tuberculosis disease. The results showed substantial increase in the proportion of single-positive TNF-α Mtb-specific CD4(+) T cells in subjects with active disease, and this parameter was the strongest predictor of diagnosis of active disease versus latent infection. We validated the use of this parameter in a cohort of 101 subjects with tuberculosis diagnosis unknown to the investigator. The sensitivity and specificity of the flow cytometry-based assay were 67% and 92%, respectively, the positive predictive value was 80% and the negative predictive value was 92.4%. Therefore, the proportion of single-positive TNF-α Mtb-specific CD4(+) T cells is a new tool for the rapid diagnosis of active tuberculosis disease.

Mortality, complications and loss of pulmonary function after pneumonectomy vs. sleeve lobectomy in patients younger and older than 70 years.

Retrospective single institution analysis of all patients undergoing sleeve lobectomy or pneumonectomy between 2000 and 2005. Seventy-eight patients underwent pneumonectomy (65 patients <70 years, 13 patients >70 years) and 69 sleeve lobectomy (50 patients <70 years, 19 patients >70 years). Pre-existing co-morbidity, surgical indication and induction therapy was similarly distributed between treatment by age-groups. In patients <70 years, pneumonectomy and sleeve lobectomy resulted in a 30-day mortality of 3% vs. 0 and an overall complication rate of 26% vs. 44%, respectively. In patients >70 years, pneumonectomy and sleeve lobectomy resulted in a 30-day mortality of 15% vs. 0 and an overall complication rate of 23% vs. 32%. In both age groups, pneumonectomy was associated with more airway complications (NS) and a significantly higher postoperative loss of FEV(1) than sleeve lobectomy (P<0.0001, P<0.03). Age per se did not influence the loss of FEV(1) and DLCO for a given type of resection. Sleeve lobectomy may have a therapeutic advantage over pneumonectomy in the postoperative course of elderly patients.

Pulmonary thrombembolism as cause of death on unenhanced postmortem 3T MRI.

OBJECTIVES: To investigate unenhanced postmortem 3-T MR imaging (pmMRI) for the detection of pulmonary thrombembolism (PTE) as cause of death. METHODS: In eight forensic cases dying from a possible cardiac cause but with homogeneous myocardium at cardiac pmMRI, additional T2w imaging of the pulmonary artery was performed before forensic autopsy. Imaging was carried out on a 3-T MR system in the axial and main pulmonary artery adapted oblique orientation in situ. In three cases axial T2w pmMRI of the lower legs was added. Validation of imaging findings was performed during forensic autopsy. RESULTS: All eight cases showed homogeneous material of intermediate signal intensity within the main pulmonary artery and/or pulmonary artery branches. Autopsy confirmed the MR findings as pulmonary artery thrombembolism. At lower leg imaging unilateral dilated veins and subcutaneous oedema with or without homogeneous material of intermediate signal intensity within the popliteal vein were found. CONCLUSIONS: Unenhanced pmMRI demonstrates pulmonary thrombembolism in situ. PmMR may serve as an alternative to clinical autopsy, especially when consent cannot be obtained. KEY POINTS: ? Postmortem MRI (pmMRI) provides an alternative to clinical autopsy ? Fatal pulmonary thrombembolism (PTE) can now be diagnosed using postmortem MRI (pmMRI). ? Special attention has to be drawn to the differentiation of postmortem clots.

Tuberculosis y odontología

Se presenta en este artículo una revisión de los aspectos fundamentales de la tuberculosis y sus implicaciones en odontología. La tuberculosis, un importante problema de salud pública en la primera mitad del siglo pasado, disminuyó progresivamente su incidencia desde entonces a consecuencia de la mejoría en las condiciones de vida, las medidas de prevención y los progresos en el tratamiento. Sin embargo, la aparición de nuevas cepas de Mycobacterium tuberculosis resistentes a varios fármacos utilizados en el tratamiento y el aumento de su incidencia en inmunodeprimidos y otros grupos de población, agrava este problema. La tuberculosis se transmite, principalmente, por vía aérea. Cabe pues la posibilidad de que sea transmitida en el ejercicio de la profesión y aunque parece que el riesgo de transmisión es bajo, está indicado la introducción de medidas preventivas que reduzcan el riesgo.

Superficial femoral vein as substitute for pulmonary artery reconstruction after resection for bronchovascular fistula

Post-lobectomy bronchovascular fistula (BVF) associated with massive hemoptysis is a rare but life-threatening complication. Surgical options include completion pneumonectomy or BVF resection with end-to-end anastomosis of the airways and reconstruction of the pulmonary artery (PA) by interposition of an appropriate substitute. We report PA resection and successful reconstruction by interposition of an autologous reversed superficial femoral vein (SFV) segment for this purpose.

15-OR: Multi-phase postmortem CT angiography of pulmonary embolism: technique-related artefacts or real findings?

Multi-phase postmortem CT angiography (MPMCTA) is recognized as a valuable tool to explore the vascular system, with higher sensitivity than conventional autopsy. However, a limitation is the impossibility to diagnose pulmonary embolism (PE) due to post-mortem blood clots situated in pulmonary arteries. The purpose of this study was to explore an eventual possibility to distinguish between real PE and artefacts mimicking PE. Our study included 416 medico-legal cases. All of them underwent MPMCTA, conventional autopsy and histological examination. We selected cases presenting arterial luminal filling defects in the pulmonary arteries. Their radiological interpretation was confronted to the one of autopsy and histological examination. We also investigated an eventual correlation between artefacts in pulmonary arteries and those in other parts of the vascular system. In 123 cases, filling defects of pulmonary arteries were described during MPMCTA. In 57 cases, this was interpreted as artefact and in 4 cases as suspected PE. In 62 cases only a differential diagnosis was made. Autopsy and histology could clearly identify the artefacts as such. Only one case of real PE was radiologically misinterpreted as artefact. In 6 of the 62 cases with no interpretation a PE was diagnosed. In 3 out of 4 suspected cases, PE was confirmed. We found out that filling defects in pulmonary arteries are nearly always associated to other vascular artefacts. Therefore, we suggest following some rules for radiological interpretation in order to allow a reliable diagnosis of pulmonary embolism after MPMCTA.

Pulmonary hypertension complicating isolated atrial septal defect.

Atrial septal defect (ASD) typically is asymptomatic in infancy and early childhood and elective defect closure usually is performed at an age between 4 - 6 years. Severe pulmonary hypertension (PHT) complicating an ASD is seen in adulthood and has only occasionally been reported in small children. A retrospective study was undertaken to evaluate the incidence of severe PHT complicating an isolated ASD and requiring early surgical correction in the fi rst year of life. 355 pediatric patients underwent treatment for an isolated ASD either surgically or by catheter intervention during a 10 year period (1996 - 2006) at two tertiary referral centers. 297 patients had secundum ASD and 58 primum ASD with mild to moderate mitral regurgitation. 8 infants were found with isolated ASD (six with secundum and two with primum ASD) associated with signifi cant PHT, accounting for 2.2% of all ASD patients in our centers. These 8 infants had invasively measured pulmonary artery pressures between 50 and 100% of systemic pressure. Median size of the ASD at the time of surgery was 14mm (7 - 20). They were operated in the fi rst year of life and had complicated postoperative courses requiring specifi c treatment for PHT for up to 16 weeks (median 12) postoperatively. Compared to ASD patients without PHT these infants had prolonged postoperative ICU stay of 5 - 9 days (median 8) and prolonged perioperative overall hospital stay of 8 - 32 days (median 15). Ultimate outcome in all 8 infants was good with persistent normalization of pulmonary pressures during mid-term follow-up of between 8 to 60 months (median 28). All other ASD patients had normal pulmonary pressures and mean age at defect closure was higher being 6.2 years for secundum ASD and 3.2 years for primum ASD. In conclusion, ASD is rarely associated with signifi cant PHT in infancy but then requires early surgery to normalize the prognosis of the patients.

Fibrose pulmonaire idiopathique: nouveautés diagnostiques et thérapeutiques [Idiopathic pulmonary fibrosis: recent diagnostic and therapeutic advances].

Idiopathic pulmonary fibrosis (IPF) is the most frequent of the idiopathic interstitial pneumonias. It is a progressive disorderwith a poor prognosis. Its diagnosis requires the careful exclusion of potential causes, and a pattern of usual interstitial pneumonia at high-resolution computed tomography or video-assisted surgical lung biopsy. Several recent randomized trials have profoundly modified the therapeutic management of IPF. The combination of prednisone and azathioprine, often prescribed until recently, has been shown to be harmful and is no longer indicated. N-acetylcystein, also used in the past decade, failed to show an efficacy. However, two new antifibrotic drugs, pirfenidone and nintedanib, have for the first time proven effective in slowing disease progression.

Frequency of severe pulmonary hypertension complicating "isolated" atrial septal defect in infancy.

Atrial septal defects (ASDs) are typically asymptomatic in infancy and early childhood, and elective defect closure is usually performed at ages of 4 to 6 years. Severe pulmonary hypertension (PH) complicating an ASD is seen in adulthood and has only occasionally been reported in small children. A retrospective study was undertaken to evaluate the incidence of severe PH complicating an isolated ASD and requiring early surgical correction. During a 10-year period (1996 to 2006), 355 pediatric patients underwent treatment for isolated ASDs either surgically or by catheter intervention at 2 tertiary referral centers. Two hundred ninety-seven patients had secundum ASDs, and 58 had primum ASDs with mild to moderate mitral regurgitation. Eight infants were found with isolated ASDs (6 with secundum ASDs and 2 with primum ASDs) associated with significant PH, accounting for 2.2% of all patients with ASDs at the centers. These 8 infants had invasively measured pulmonary artery pressures of 50% to 100% of systemic pressure. They were operated in the first year of life and had complicated postoperative courses requiring specific treatment for PH for up to 16 weeks postoperatively. The ultimate outcomes in all 8 infants were good, with persistent normalization of pulmonary pressures during midterm follow-up of up to 60 months (median 28). All other patients with ASDs had normal pulmonary pressures, and the mean age at defect closure was significantly older, at 6.2 years for secundum ASDs and 3.2 years for primum ASDs. In conclusion, ASDs were rarely associated with significant PH in infancy but then required early surgery and were associated with excellent midterm outcomes in these patients.