Opportunistic infections have been frequently reported in patients with acquired immunodeficiency syndrome (AIDS) or other conditions with compromised host defenses, such as malignancy and transplantation. More recently, opportunistic infections have also been increasingly reported in patients with connective tissue diseases, including systemic lupus erythematosus, systemic sclerosis and polymyositis/dermatomyositis.1, 2 Many factors, especially immunosuppressive medications, have been mentioned to account for the elevated frequency of opportunistic infections in these patients.1, 2 We report a case of Actinomyces meyeri pneumonia in a patient with diffuse cutaneous systemic sclerosis (dcSSc), which occurred shortly after institution of anti-tumor necrosis factor α (anti-TNF-α) therapy. A 44-year-old woman was diagnosed as having dcSSc in 1999. Systemic manifestations of dcSSc included: (i) Raynaud's phenomenon, pitting scars; (ii) esophageal involvement, with both absence of peristalsis in the lower two-thirds of the esophageal body and low pressure in the lower esophageal sphincter; (iii) mild bibasilar interstitial lung disease (ILD) on computed tomography (CT)-scan; and (iv) joint impairment, with erosive polyarthritis involving the hands, wrists, feet, ankles and knees. Autoantibody screening tests were positive for antinuclear antibodies (1:1200), anti-Scl 70 and anti-CCP …

this was a coincidental occurrence or whether the etanercept caused exacerbation of an active subclinical infection. The chronic steroid therapy with 25mg of prednisone daily should also be considered as an additional contributing factor in masking the infection. In our review of the literature only two cases of fatal sepsis associated with tumour necrosis factor alpha (TNF) blockers were reported [1, 2]. Baghai et al. [1] reported a case of fatal pneumococcal sepsis occurring in a 37-yr-old woman with rheumatoid arthritis treated with etanercept, and Herrlinger et al. [2] reported the case of a 40-yr-old woman who after six infusions of infliximab for perianal Crohn’s disease developed staphylococcal pneumonia resulting in fatal adult respiratory distress syndrome. Kroesen et al. [3] reviewed patient charts and records of the infectious disease unit for serious infections in patients with RA in the 2 yr preceding anti-TNFtherapy and during therapy. Serious infections affected 18.3% of patients treated with infliximab or etanercept. In several cases, only a few signs or symptoms indicated the severity of developing infections and sepsis; therefore a high level of suspicion of infection is necessary in patients under anti-TNFtherapy. Our experience with TNFblockers at the American University of Beirut Medical Center (a tertiary-care teaching hospital, one of the largest medical centres in Lebanon), dates back to October 2000; up to the present time around 90 patients with various rheumatic diseases have received this drug [4]. No serious infections in our series have been reported except for a case of miliary tuberculosis [5]. A thorough screening for any latent infections, besides tuberculosis, is warranted in patients prior to the initiation of TNFblocker therapy.

Un homme de 25 ans, sans antecedent, est hospitalise pour une pleuro-pneumophathie recidivante et enkystee thoracique droite. La ponction pleurale ramene un liquide exsudatif riche en lipase. Devant la persistance d'une volumineuse poche apres plusieurs ponctions evacuatrices, une sternotomie a visee diagnostique est realisee. L'intervention permet de resequer une formation kystique mediastinale necrosee constituee de massifs tissulaires polymorphes bien differencies comportant des territoires de tissu pancreatique, de tissu nerveux, des sections glandulaires de type digestif ou respiratoire et un massif epidermoide avec des annexes pilo-sebacees. Il est porte le diagnostic de teratome mediastinal benin mature. Nous suggerons que l'epanchement pleural chronique etait entretenu par une fistulisation de la masse tumorale dans la plevre, secondaire a la secretion d'enzymes proteolytiques par le tissu pancreatique tumoral bien differencie.

L'asthme est une maladie fréquente dont le diagnostic ne nécessite habituellement pas le recours à l'imagerie. Celle-ci occupe en revanche une place clé dans les formes sévères.Un épaississement pariétal, de discrètes dilatations ou réductions de lumière des bronches sont habituels dans l'asthme sévère. L'épaisseur pariétale est corrélée au degré d'obstruction ainsi qu'au remodelage et à l'inflammation pariétale. De nombreuses affections pouvant mimer un asthme doivent être reconnues sur le scanner, incluant tumeurs endobronchiques, pneumopathies interstitielles, maladies bronchectasiantes, bronchiolites. Des plages d'hyperdensité peuvent témoigner d'infiltrats éosinophiles transitoires, d'une infection ou d'une forme associée. Des bronchocèles denses sont très évocateurs d'aspergillose bronchopulmonaire allergique.La morphométrie des voies aériennes, la mesure du piégeage aérique et des défects ventilatoires, en scanner ou en IRM, permettent d'identifier certains sous-groupes morphologiques de patients ayant des caractéristiques fonctionnelles ou inflammatoires distinctes et émergent en tant que biomarqueurs.Le scanner thoracique est indiqué chez tout asthmatique sévère afin d'écarter un diagnostic alternatif. Le développement d'outils quantitatifs a ouvert la voie au phénotypage des patients par l'imagerie.Asthma is a common disease whose diagnosis does not typically rely on the results of imaging. However, chest CT has gained a key place over the last decade to support the management of patients with difficult to treat and severe asthma.Bronchial wall thickening and mild dilatation or narrowing of bronchial lumen are frequently observed on chest CT in people with asthma. Bronchial wall thickening is correlated to the degree of obstruction and to bronchial wall remodeling and inflammation. Diverse conditions which can mimic asthma should be recognized on CT, including endobronchial tumours, interstitial pneumonias, bronchiectasis and bronchiolitis. Ground-glass opacities and consolidation may be related to transient eosinophilic infiltrates, infection or an associated disease (vasculitis, chronic eosinophilic pneumonia). Hyperdense mucous plugging is highly specific for allergic bronchopulmonary aspergillosis.Airway morphometry, air trapping and quantitative analysis of ventilatory defects, with CT or MRI, can help to identify different morphological subgroups of patients with different functional or inflammatory characteristics. These imaging tools could emerge as new biomarkers for the evaluation of treatment response.Chest CT is indicated in people with severe asthma to search for additional or alternative diagnoses. Quantitative imaging may contribute to phenotyping this patient group.

A 25 year old man with no previous history was admitted for a recurrent right sided encysted pleural effusion. Thoracocentesis revealed an exudative lipase-rich-fluid. Because of the persistence of abundant pleural fluid after several thoracocentesis a diagnostic mediastinotomy was performed. This revealed a necrotic cystic mediastinal tumor composed of well differentiated pancreatic tissue, nervous tissue, digestive and respiratory glands, and a dermoid mass with hair and sebacious glands. This led to a diagnosis of benign, mature mediastinal teratoma. We suggest that the chronic pleural effusion was maintained by a fistula from the tumour into the pleural cavity and the secretion of proteolytic enzymes by the well-differentiated pancreatic tissue.

The authors report a case of a patient presenting with a bronchogenic mediastinal cyst, which presented as a super-infection of the cyst. The cyst was associated with malformation of the cervical vertebre, cardiovascular abnormalities and congenital deafness, placing this in the group of rare complex polymalformation syndrome with Klippel-Feil Syndrome. The authors also stress the value of computed tomography, and above all of nuclear magnetic resonance in the analysis of mediastinal tumours and in particular, of bronchogenic cysts.

An exceptional case of incarcerated parahiatal hernia with gastric necrosis, developing 7 years a Toupet procedure, is reported. To our knowledge, this is the first reported case of this complication after a surgical anti-reflux procedure without diaphragmatic counter incision. The mechanism, diagnostic difficulties and treatment are discussed.

The authors report a case of a patient presenting with a bronchogenic mediastinal cyst, which presented as a super-infection of the cyst. The cyst was associated with malformation of the cervical vertebra, cardiovascular abnormalities and congenital deafness, placing this in the group of rare complex polymalformation syndrome with Klippel-Feil Syndrome. The authors also stress the value of computed tomography, and above all of nuclear magnetic resonance in the analysis of mediastinal tumours and in particular, of bronchogenic cysts.

A propos d'un patient hospitalise pour dyspnee et tachycardie. Les differents diagnostics evoques par la densitometrie sont analyses