What pulmonologists need to know about extrapulmonary tuberculosis.

Extrapulmonary tuberculosis (EPT) can affect all organs. Its diagnosis is often challenging, especially when the lung is not involved. Some EPT locations, such as when the central nervous system is involved, are a medical emergency, and some have implications for treatment options and length. This review describes clinical features of EPT, diagnostic tests and treatment regimens.

Is there a link between exertional heat stroke and susceptibility to malignant hyperthermia?

OBJECTIVE: The identification of a predisposition toward malignant hyperthermia (MH) as a risk factor for exertional heat stroke (EHS) remains a matter of debate. Such a predisposition indicates a causal role for MH susceptibility (MHS) after EHS in certain national recommendations and has led to the use of an in vitro contracture test (IVCT) to identify the MHS trait in selected or unselected EHS patients. The aim of this study was to determine whether the MHS trait is associated with EHS. METHODS: EHS subjects in the French Armed Forces were routinely examined for MHS after experiencing an EHS episode. This retrospective study compared the features of IVCT-diagnosed MHS (iMHS) EHS subjects with those of MH-normal EHS patients and MH patients during the 2004-2010 period. MHS status was assessed using the European protocol. RESULTS: During the study period, 466 subjects (median age 25 years; 31 women) underwent MHS status investigation following an EHS episode. None of the subjects reported previous MH events. An IVCT was performed in 454 cases and was diagnostic of MHS in 45.6% of the study population, of MH susceptibility to halothane in 18.5%, of MH susceptibility to caffeine in 9.9%, and of MH susceptibility to halothane and caffeine in 17.2%. There were no differences in the clinical features, biological features or outcomes of iMHS EHS subjects compared with those of MH-normal or caffeine or halothane MHS subjects without known prior EHS episode. The recurrence rate was 12.7% and was not associated with MH status or any clinical or biological features. iMHS EHS patients exhibited a significantly less informative IVCT response than MH patients. CONCLUSIONS: The unexpected high prevalence of the MHS trait after EHS suggested a latent disturbance of calcium homeostasis that accounted for the positive IVCT results. This study did not determine whether EHS patients have an increased risk of MH, and it could not determine whether MH susceptibility is a risk factor for EHS.

Report of 182 cases of exertional heatstroke in the French Armed Forces.

OBJECTIVES: Exertional heatstroke (EHS) remains a major problem for the military. The aim of our study was to describe medical history and clinical and biological features of EHS in a large military cohort. METHODS: We conducted a retrospective study among military subjects admitted to the Military Teaching Hospital Laveran for EHS from 2004 to 2006. RESULTS: Of the 182 subjects, EHS occurred most often at the end (80%) of a timed race of 8 km in battle clothes (84%) between the months of May and October (87%). The subjects were physically fit. Motivation was the primary intrinsic factor reported. A previous episode of EHS was reported by 15.4% of the subjects. Comas or seizures occurred more frequently in subjects whose temperatures exceeded 41°C (p = 0.03). Alanine aminotransferase was consistently increased in subjects who experienced EHS. We observed acute renal failure in 31.3% of the subjects, liver insufficiency in 12%, and disseminated intravascular coagulation in 1%. High creatine kinase levels alone did not correlate with renal failure. CONCLUSIONS: Detection of severe EHS in the field before the onset of multiple organ failure is challenging. The determination of the factors contributing to recurrence is urgently needed as EHS remains a life-threatening condition.

Is muscle energy production disturbed in exertional heat stroke?

BACKGROUND: Exertional heat stroke (EHS) is a life-threatening disease that shares some clinical similarities with malignant hyperthermia (MH). By use of (31)Phosphorus magnetic resonance spectroscopy (MRS), EHS patients with MH susceptibility and MH patients shared common metabolic abnormalities. The aim of this study was to determine whether subjects who suffered from an EHS episode had disturbed muscle energetics. METHOD: This retrospective study was performed within the French database of military subjects that were explored from 2004 to 2010 after they suffered an EHS. All subjects had both in vitro contracture test to determine their MH susceptibility and (31)Phosphorus MRS at 4.7 Tesla to assess muscle energetics by means of MRS score, a composite score corresponding to the sum of metabolic abnormalities recorded during a standardized rest-exercise-recovery protocol. RESULTS: 437 subjects were investigated and 32.5% of them exhibited abnormal MRS score. MRS score did not segregate subjects on demographic, clinical, or biological grounds. No clear correlation could be done between MH status and MRS score. DISCUSSION: These results did not confirm the potential relationship between calcium homeostasis and muscle energetics previously reported. However, muscle energy production was disturbed in a significant number of EHS subjects.

Delayed focal lipoatrophy after AS03-adjuvanted influenza A (H1N1) 2009 vaccine.

Intramuscular vaccination may lead to loss of subcutaneous fat resulting in skin depression at the site of injection. We report for the first time a delayed lipoatrophy after with AS03-adjuvanted influenza A (H1N1) 2009 vaccine. Inadequate administration into the adipose tissue may be causative. During next pandemic, education to optimal intramuscular administration and prolonged monitoring of adverse effects could be proposed.

A woman with forearm amyotrophy.

We present the case of a 33-year-old woman with benign sporadic monomelic amyotrophy of the distal part of the arm, called Hirayama disease. Clinical features included forearm amyotrophy sparing the brachioradialis muscle, cold paresis and causalgia. Neck magnetic resonance imaging was normal in neutral and flexion position. Electromyography showed denervated patterns in the extensor digitorum communis, and conduction studies ruled out multifocal motor neuropathy. Motor evoked potentials were normal. Serum IgG anti-GM1 antibodies were moderately raised but were negative 8 months later. Outcome was favourable within 15 months, with partial motor recovery. Pathogenesis remains controversial: neck flexion induced myelopathy via chronic anterior horn ischaemia due to forward displacement of the posterior wall of the dura mater, or benign variant of lower motor neuron disease? Whatever the pathomechanism is, the clinical features and outcome are the same.