La sclérothérapie est une technique très utilisée dans le traitement d’urgence d’hémorragie digestive secondaire à des varices gastro-œsophagiennes (VGO). Plusieurs complications liées à la sclérothérapie ont été décrites, dont la survenue d’embolies systémiques et ou pulmonaires lorsqu’il existe un shunt porto-systémique, fréquent chez les cirrhotiques. De multiples aspects parenchymateux pulmonaires ont été rapportés mais à notre connaissance l’aspect nodulaire suspect n’a pas été décrit. Le patient âgé de 55 ans, ayant une cirrhose éthylique, est adressé en consultation de pneumologie pour la prise en charge d’un nodule lobaire supérieur droit. Il a été hospitalisé deux mois auparavant en unité de soins intensifs pour une hématémèse massive secondaire à la rupture de VGO sous-cardiales de grade II. Il a été traité par sclérothérapie endoscopique utilisant une injection de 3 mL de solution histoacryl/lipiodole sans complication au décours. Un scanner thoracoabdominal de contrôle des VGO fait 2 mois plus tard a mis en évidence un nodule suspect lobaire supérieur droit alors que le patient était asymptomatique. Du fait de la disparition complète du nodule sur un scanner de contrôle, cette image a été attribuée à un infarcissement pulmonaire dû à une embolie pulmonaire non cruorique post-sclérothérapie. Aucun traitement n’a été réalisé. L’aspect nodulaire suspect est un des aspects radiologiques d’embolies pulmonaires non cruoriques post-sclérothérapie des VGO. Connaître cette présentation radiologique et réaliser un contrôle scanographique peuvent prévenir le recours à des biopsies pulmonaires inutiles. Sclerotherapy is a widely used as a lifesaving therapeutic option in cases of upper gastrointestinal bleeding (UGB) due to ruptured gastro-esophageal varices (GOV) in cirrhotic patients, especially when there exists a portosystemic shunt. This endoscopic technique can entail many complications, including systemic and non-thrombotic pulmonary embolism (PE). While multiple pulmonary parenchymal manifestations have been described following sclerotherapy of GOV, to our knowledge no solitary suspicious pulmonary nodule has been described. We report the case of 55-year-old man with heavy smoking history who was referred to our pulmonary clinic for work-up of a solitary pulmonary nodule. He was known to have liver cirrhosis with history of massive UGB due to rupture of GOV two months before. He was treated with sclerotherapy by injecting a 3 cc of Histoacryl/lipiodole solution. The post- endoscopic phase was unremarkable. An enhanced CT scan of chest and abdomen performed two months later showed a right upper lobe nodule, even though at that point, the patient was completely asymptomatic. This was ascribed to non-thrombotic PE secondary to sclerotherapy due to complete resolution of the nodule on a CT scan carried out at 2-month follow-up. At that point, his condition did not require any further treatment. Solitary pulmonary nodule is one of the radiologic manifestations of PE subsequent to sclerotherapy of GOV. Awareness and radiologic follow-up of this unusual radiologic presentation may prevent unnecessary biopsies.

INTRODUCTION:Sclerotherapy is a widely used as a lifesaving therapeutic option in cases of upper gastrointestinal bleeding (UGB) due to ruptured gastro-esophageal varices (GOV) in cirrhotic patients, especially when there exists a portosystemic shunt. This endoscopic technique can entail many complications, including systemic and non-thrombotic pulmonary embolism (PE). While multiple pulmonary parenchymal manifestations have been described following sclerotherapy of GOV, to our knowledge no solitary suspicious pulmonary nodule has been described. CASE PRESENTATION:We report the case of 55-year-old man with heavy smoking history who was referred to our pulmonary clinic for work-up of a solitary pulmonary nodule. He was known to have liver cirrhosis with history of massive UGB due to rupture of GOV two months before. He was treated with sclerotherapy by injecting a 3 cc of Histoacryl/lipiodole solution. The post- endoscopic phase was unremarkable. An enhanced CT scan of chest and abdomen performed two months later showed a right upper lobe nodule, even though at that point, the patient was completely asymptomatic. This was ascribed to non-thrombotic PE secondary to sclerotherapy due to complete resolution of the nodule on a CT scan carried out at 2-month follow-up. At that point, his condition did not require any further treatment. CONCLUSION:Solitary pulmonary nodule is one of the radiologic manifestations of PE subsequent to sclerotherapy of GOV. Awareness and radiologic follow-up of this unusual radiologic presentation may prevent unnecessary biopsies.

Diagnosis of pheochromocytoma can be simple when classic manifestations are present. It can also be challenging and complicated in some cases because of its wide array of faces and presentations. We present a case of a 30-year-old female patient who came with acute respiratory distress, chest pain, hemoptysis, asthenia, anorexia, weight loss of 20 kg, and paresthesia in her lower limbs. Clinical examination found high blood pressure, accelerated heart and respiratory rates, signs of acute right heart failure with jugular venous distention and ankle edema, reticularis livedo in the four limbs, ulcers in both knees and in the 3rd metacarpo-phalangeal articulations and necrotic lesions in both calcaneal tendons and in the right toes. Further investigations concluded on myocarditis associated with alveolar hemorrhage, pericardic and pleuritic effusions and a segmental pulmonary embolism of the right inferior lobe. Neuro-muscular biopsy was suggestive of myositis. Cutaneous biopsy found nonspecific chronic dermatitis. ANCA antibodies were tested twice and were negative. Cryoglobulinemia was also negative. Thoraco-abdomino-pelvic scan was performed showing a large right adrenal mass suggestive of pheochromocytoma. Diagnosis of right adrenal pheochromocytoma was confirmed by MIBG-I123 hyperfixation findings and urinary normetanephrin levels. The patient was treated surgically. Postoperative outcomes were remarkably favorable with a complete regression of the cutaneous lesions and normalization of the blood pressure. Paresthesia significantly decreased. Control echocardiography at 3 months showed an improved heart function with a persistent apical and septal akinesis.Le diagnostic du phéochromocytome peut être facile lorsque des manifestations classiques sont présentes, toutefois des présentations cliniques atypiques peuvent s’observer. Nous rapportons le cas d’une patiente âgée de 30 ans hospitalisée pour détresse respiratoire aiguë associée à des douleurs thoraciques, une hémoptysie, une asthénie, une anorexie, une perte de poids de 20 kg et des paresthésies des membres inférieurs. L’examen clinique a révélé une hypertension artérielle et une tachycardie sinusale, des signes d’insuffisance cardiaque droite aiguë, un œdème des chevilles, un livédo réticulaire des quatre membres, des ulcérations cutanées des deux genoux et en regard de la 3e articulation métacarpophalangiennes et des lésions nécrotiques des tendons calcanéens et des orteils droits. Les examens complémentaires ont conclu à une myocardite associée à une hémorragie alvéolaire, un épanchement pleural et péricardique et une embolie pulmonaire segmentaire du lobe inférieur droit. La biopsie neuromusculaire était en faveur d’une myosite. La biopsie cutanée a révélé une dermatite chronique non spécifique. Les anticorps anti-cytoplasme des polynucléaires neutrophiles (ANCA) étaient négatifs à deux reprises ainsi que la recherche d’une cryoglobulinémie. Le scanner thoraco-abdomino-pelvien a montré une importante masse surrénalienne droite évocatrice d’un phéochromocytome. Le diagnostic du phéochromocytome surrénalien droit a été retenu devant une hyperfixation à la scintigraphie au MIBG-I123 et l’élévation des normétanéphrines urinaires. Après traitement chirurgical, l’évolution était favorable avec disparition totale des lésions cutanées, diminution des paresthésies et normalisation de la pression artérielle. L’échocardiographie cardiaque de contrôle à 3 mois a montré une amélioration de la fonction cardiaque avec persistance de l’akinésie septo-apicale.

This review article aim to highlight the right ventricular function peri left ventricular assist device implantation, and to assess the incidence, physiopathology, predictors, management and prognosis, of right ventricular failure post-implant.

Abstract Background and aim Heart failure is still a leading cause of mortality and morbidity. Assist devices are reserved for advanced heart failure patients with no other therapeutic options. We aim in this paper to describe the characteristics and outcome of Lebanese left ventricular assist device (LVAD) patients. Results From 2010 till December 2019, 78 patients were implanted with assist devices at the Beirut cardiac Institute, 82 pumps were used. To the most recent follow up after 10 years, 26 patients died (34%). 24 patients of 35 (68%) survived more than 5 years. Seven patients only (9%) died during one month of surgery. One year mortality was 19% (15 patients). The leading cause of early mortality was infection, whereas cerebrovascular accidents CVA were the leading cause of late mortality. Pump thrombosis occurred in 12% of the cases. The most serious long term complication was haemorrhagic CVA. Only seven patients (9%) received heart transplantation, with a mean time on support prior to transplantation of 1303 ± 213 days. Conclusion In this manuscript we reported the characteristics and outcome of the largest population of LVAD patients in Lebanon. The survival rate was 81% at one year. These findings were comparable to the international registries except for rates of heart transplantation. More efforts should be made to encourage organ donation in Lebanon.

A 60 year old male patient was admitted to hospital with pulmonary and cerebral abscesses. A percutaneous lung biopsy under CT scanning showed actinomycosis. After 4 weeks antibiotic therapy with ceftriaxone and metronidazole there was an improvement in the pulmonary lesion but new cerebral lesions appeared. A neurosurgical cerebral biopsy showed evidence of metastatic squamous carcinoma, probably of pulmonary origin. The diagnosis had been delayed by the presence of the actinomycosis. His general condition did not permit anti-tumour treatment and the patient soon afterwards. In the presence of pulmonary actinomycosis an associated malignancy should be excluded.

A 60 year old male patient was admitted to hospital with pulmonary and cerebral abscesses. A percutaneous lung biopsy under CT scanning showed actinomycosis. After 4 weeks antibiotic therapy with ceftriaxone and metronidazole there was an improvement in the pulmonary lesion but new cerebral lesions appeared. A neurosurgical cerebral biopsy showed evidence of metastatic squamous carcinoma, probably of pulmonary origin. The diagnosis had been delayed by the presence of the actinomycosis. His general condition did not permit anti-tumour treatment and the patient soon afterwards. In the presence of pulmonary actinomycosis an associated malignancy should be excluded.