Prevention of thromboses in human patients with Bothrops lanceolatus envenoming in Martinique: failure of anticoagulants and efficacy of a monospecific antivenom. Research Group on Snake Bites in Martinique.

Envenomation by the Bothrops lanceolatus, a snake found only in Martinique, leads to swelling and pain, and occasionally to systemic signs and/or coagulopathy. Severe thromboses at some distance from the site of the bite may appear within 48 hr. Uncertainties as to the actual development of thrombotic complications in patients appearing to be suffering from moderate poisoning and as to the availability and the toxicity of a monospecific antivenom (AVS) initially led us to reserve antivenom for the most severe cases, and to use anticoagulants to prevent thromboses in all patients. This approach was modified after we observed serious thromboses in patients with moderate poisoning. Of 50 adult snake bite cases hospitalized between June 1991 and August 1994, 11 developed serious thrombotic complications at 36 /+- 27 hr (mean +/- SD) (range 12-96) following envenomation, despite early preventive anticoagulant therapy. Those included pulmonary embolism (two cases), cerebral infarction (six cases), myocardial infarction (one case), and cerebral and myocardial infarctions (two cases). Sixteen patients were not treated with AVS: 10 of these recovered without complications and six developed systemic thrombosis causing permanent disability in three cases. Thirty were treated with an intravenous infusion of 2-6 vials of AVS given 2-48 hr after the bite. Of these, three died of cerebral infarction that developed before the initiation of serotherapy. All others recovered. Among patients treated with AVS, three presented with mild anaphylactic reactions, while one developed serum sickness that responded to steroids. These data indicate that preventive anticoagulant therapy is of limited efficacy in Martinique.(ABSTRACT TRUNCATED AT 250 WORDS)

Chiari Type I malformation with hydromyelia: findings at computerized metrizamide ventriculomyelography.

Computerized Metrizamide ventriculomyelography consists of CT exploration of the head and neck performed one hour after introduction of Metrizamide into the lateral ventricle via a frontal burr hole. This procedure permits visualisation of all soft-tissue anomalies present in Chiari malformation with hydromyelia as seen in two cases.

[Acute pancreatitis: prognostic value of early x-ray computed tomography coupled with Ranson's criteria and its role in surveillance of the course]. / Pancréatites aiguës: valeur pronostique de la tomodensitométrie précoce couplée aux critères de Ranson et son rôle dans la surveillance de l'évolution.

Fifty nine patients suffering from a first attack of acute pancreatitis were investigated during the first ten days of illness with computerized tomography (CT scan) and biological signs of Ranson. The prognostic value of the combination of these two classes of signs was evaluated. The grading of initial CT scan findings was accorded to the Ranson and Balthazar classification. In addition, the authors evaluated the presence and extent of necrosis and studied phlegmonous extrapancreatic spread. A high risk group of patients was determined: grade C, D, E, with at least three prognostic signs. Twelve of these high risk patients with grade D and E had a glandular necrosis as detected on initial contrast enhanced CT scan. This was an important prognostic value sign (sensibility 100 percent; specificity 92 percent) as all morbidity was 100 percent compared with 8.5 percent among the 47 other patients who did not exhibit this CT sign; mortality was 25 percent compared with 0 percent among the other patients. Phlegmonous extrapancreatic spread in three or more areas also influenced the prognostic but to a lesser extent (sensibility 100 percent; specificity 62 percent). Forty-four patients among the fifty-nine had a morphologic follow-up of the course of lesions by repeated CT scan. Local complications occurred only in patients at high risk: 9 pancreatic abscesses (20.4 percent) and 6 pseudocysts (15 percent). One-third of the twenty-one grade D and E patients had spontaneous resorption of the phlegmonous extrapancreatic areas.(ABSTRACT TRUNCATED AT 250 WORDS)

[Tomodensitometric semiology of Budd-Chiari syndromes]. / Séméiologie tomodensitométrique des syndromes de Budd-Chiari.

Specific computed tomography findings in Budd-Chiari's syndromes are described, based on an analysis of images from five cases. Recognition of these signs assists diagnosis when little evidence of the disease exists or when atypical images are produced. The performance of an angioscan and the study of the changes on repeated imaging provides essential data for liver exploration: on the one hand these emphasize or even unmask the lesions (peripheral multi-lacunar images in the obstructed territory), and on the other hand they assess possible lesions of the inferior vena cava as well as lack of filling of the hepatic veins. Furthermore, they assist avoidance of the trap of pseudo-metastatic images by the particular kinetic of the attenuation of contrasts and the systematization of the lesions. The typical appearance of the liver in Budd-Chiari's syndromes probably results from the conjunction of histopathologic and hemodynamic modifications, notably localized inversions of portal flow and particular by-pass pathways. Computed tomography can be included in exploratory procedures as a non-invasive method capable of confirming the diagnosis of Budd-Chiari's syndrome and of orientating vascular explorations essential for pre-operative evaluation.

[Computed tomography in the evaluation of recent articular fractures of the calcaneus]. / Apport de la tomodensitométrie dans le bilan des fractures articulaires récentes du calcanéum.

After mentioning the results of a survey carried out on 28 patients suffering from recent calcaneus articular fractures, the authors point out 9 main points to take into account when a TDM analysis of these lesions is to be done: they recommend to practice a double obliquity incidence that seems to be an efficient guide for a therapeutic decision. They insist on the usefulness of the TDM examination provided it is undertaken after the operation and the removal of the osteosynthesis equipment.

[Radiological aspects of the duodenum and small intestine in severe strongyloidiasis. Apropos of 4 cases]. / Aspects radiologiques du duodénum et du grêle dans l'anguillulose sévère. A propos de 4 observations.

Four cases of severe strongyloidiasis in Martinique patients are reported. Clinical features were typical of the affection, and the outcome was fatal in two cases. Fibroscopy findings were negative but larvae were demonstrated in biopsy specimens in 3 out of the 4 cases. A barium meal follow-through examination showed the different radiological images of the infestation: non-specific parasitic duodenitis and pseudo-stenosis of D3 with duodenal dilatation, barium reflux into the main bile duct, and absence of jejunal folds, these images being very suggestive of strongyloidiasis.

[Value of the angioscan in the etiological diagnosis of cerebromeningeal hemorrhage]. / Intérêt de l'angioscan dans le diagnostic étiologique des hémorragies cérébro-méningées.

Etiologic diagnosis of cerebromeningeal hemorrhage was suspected on CT scan without contrast imaging as a function of distribution of cisternal hyperdensities and/or topography of intracerebral hematomas and/or distribution of parenchymatous hypodensities. It was established in 90% of cases by results of angioscan (type and site of vascular malformation causing the cerebromeningeal hemorrhage are defined with this percent exactitude). Cerebral arteriography provides indispensable precise morphologic data on the vascular malformation: exact site of aneurysm or arteriovenous malformation, orientation of the aneurysm and presence or absence of a collar. It is therefore irreplaceable and will be guided by data from the angio-CT scan.

[X-ray computed tomographic aspects of gelatinous disease of the peritoneum. Apropos of 5 cases]. / Aspects tomodensitométriques de la maladie gélatineuse du péritoine. A propos de 5 cas.

Gelatinous disease of the peritoneum, designated by Anglo-Saxon authors as peritoneal pseudomyxoma is a rare affection characterized by the presence in the peritoneal cavity of a mucoid substance corresponding to an acid mucopolysaccharide. It develops secondary to an acid mucopolysaccharide. It develops secondary to mucosecreting malignant tumors, particularly of ovarian or appendicular origin, and its capacity to provoke multiple recurrences makes it of fairly poor prognosis. Diagnosis has been improved by the availability of non-aggressive investigations such as ultrasound and particularly computed tomography imaging. Suggestive CT scan signs are hepatic scalloping and a partitioned intraperitoneal effusion. Follow up scans can give data on the course of the disease and detect any complications (renal and digestive lesions, intraperitoneal abscess).

[Diagnostic value of the CT scan in suppurative abdominal lesions (author's transl)]. / Apport de la tomodensitométrie dans de diagnostic des suppurations abdominales.

Computed tomography, a relatively non-aggressive method of radiological investigation, can establish diagnosis, and, more particularly, define the site of suppurative lesions in the peritoneal cavity, the retroperitoneal space, and in solid organs (liver, kidneys, spleen). This method was employed to explore the abdomen in 52 patients. Intraperitoneal suppurations were diagnosed in 15 cases after demonstration of a low density mass, which may contain clear pockets of gas or be limited by a higher density wall. In 4 cases, a retroperitoneal lesion was detected (psoas or perinephric abscess). A parenchymatous abscess was present in 6 cases, 4 in the liver, one in the kidneys, and one in the spleen. Using the angioscan technique, after a bolus injection of an iodised contrast medium, improved definition of the limits of the abscess can be obtained. Differential diagnosis of intraperitoneal suppurative lesions in cases of developing haematomas, or in the presence of an intrahepatic abscess, which may be confused with necrotic metastases or post-traumatic ischaemic foci, may be difficult.

[Contribution of computed tomography to radiological investigation of the adrenals (author's transl)]. / Apport de la tomodensitométrie à l'exploration radiologique des surrénales.

Computed tomography examinations of the liver, kidneys, and pancreas were conducted in 466 patients over a period of one year, and both adrenals were visualized in 94 p. cent of cases. The adrenals were investigated during examination of the posterior submediastinal space in certain types of cancer, and clinically silent adrenal metastases were demonstrated in 14 patients with bronchial or pancreatic cancer. When computed tomography is employed for specific investigation of the adrenals (22 cases), the technique varies (5 mm thick sections, "angioscan"), and results are comparable with those of early renal tomography, ultrasonography, and scintigraphy. Computed tomography provides clearer evidence of small tumors (less than 2 mm in diameter) and hyperplasia, and can provide images that are perfectly correlated with operative findings, but not always with the histology of the lesions. A method for exploring the adrenals radiologically, including the use of computed tomography, is proposed as a function of the biological nature and size of the tumors.

[Contribution of computed tomography to the diagnosis of benign tumors of the liver]. / Apport de la tomodensitométrie au diagnostic des tumeurs bénignes du foie.

Computed tomography is a recently introduced, nonaggressive method of radiological investigation that can contribute to the study of hepatic tumors. Information obtained by using a third generation apparatus in six cases of benign hepatic tumor is reported, and compared with operative findings in five cases. The principal aspects, common to both ultrasonography and computed tomography examinations, are compared within the context of the pathological findings. Computed tomography is of value as a complementary investigation to reduce any possible insufficiency of ultrasonography examinations or to supply supplementary information during pre-operative tests.

[Computer tomography examination of the diaphragmatic pillars. Value during the study of the postero-inferior mediastinum (author's transl)]. / Examen tomodensitométrique des piliers du diaphragme. Apport à l'étude du médiastin postéro-inférieur.

The authors review the results of 100 computer tomography examinations of the normal thoraco-abdominal region and define the radiological anatomy of the posterior submediastinal space limited by the pillars of the diaphragm, which can almost always be investigated by computer tomography. Study of this posterior submediastinal space in 276 cases, by means of a strictly defined procedure, was used to illustrate the elementary signs encountered: effacement of the pillars, loose appearance of the pillars with absence of the median arcate ligament, presence of an abnormally sized structure in the middle of the space. The main indications for computer tomography examination of this region are for diagnosis of an opaque tumor of the postero-inferior mediastinum, and the investigation of extensions of bronchial cancers, regionally located neoplasms and lymphomas.

[Bullous images of Pneumocystis carinii infection in AIDS]. / Images bulleuses à Pneumocystis carinii au cours du SIDA.

We report a case of bullous disease associated with a Pneumocystis carinii pneumonia which regressed completely. This occurred in a patient who was suffering from the human immuno deficiency virus.

[Use of tomodensitometry in the evaluation of the extension of certain laryngeal cancers]. / Utilisation de la tomodensitométrie dans le bilan d'extension de certains cancers laryngés.

Radiopathological examinations were conducted on a frozen laryngeal specimen to determine its characteristics as seen on the CT scan image. Results of CT scan imaging of 37 patients with laryngeal cancer were then compared with results of clinicopathological examination in 20 cases (after fixation and decalcification, the 20 samples were sectioned in axial planes reproducing those of the CT scan as for as possible). The results of computed tomography are conclusive for investigation of tumoral extension to the hyothyo-epiglottic space, and may lead to modification of therapy; they are of marked value for assessment of tumoral extension to the laryngeal cartilages, with the reservation that ossification of these cartilages must be taken into account. Furthermore, they enable assessment of subglottal extension when the respiratory state of the patient or the size of tumor makes it impossible to perform direct laryngoscopy.

[Value of x-ray computed tomography in the study of the inferior vena cava in urologic practice]. / Apport de la tomodensitométrie dans létude de la veine cave inférieure en pratique urologique.

The CT scan provides a reliable evaluation of the inferior vena cava, especially since the development of second and third generation scanners. It can readily detect congenital malformations and obstructive anomalies complicating renal cancer and it is also able to determine the tumoral or thrombotic nature of the venous obstruction. This excellent definition of the vessel reduces the indications for caval angiography to a few exceptional cases.

[Sinusitis during nasotracheal intubation]. / Sinusites au cours de l'intubation naso-trachéale.

Sinusitis is mentioned as one complication of nasotracheal intubation. 30 patients admitted to the I.C.U. and prolonged intubated (+5 days) underwent clinical examination and C.T. scan: 23 C.T. scan revealed anomalies and 5 sinusitis. One patient had blood cultures positive for the organism present on nasal cultures. Patients nasally intubated are at risk for sinusitis which can have adverse effects.

[Contribution of computed tomography to the exploration of aortic aneurysms (author's transl)]. / Apport de la tomodensitométrie à l'exploration des anévrysmes de l'aorte. 50 observations.

A technique for exploring aortic aneurysms is described, and the results analysed in 50 cases (11 thoracic, 32 abdominal, 3 multiple, and 4 with both thoracic and abdominal aneurysms). The diagnostic value of this method appears evident for aneurysms in the thorax, and it can reduce the need for conventional radiological examinations. Results of examination of abdominal aneurysms were compared with those of ultrasonography and angiography. Angiography was more effective for studying collateral lesions, while ultrasonography is still a reliable, non-aggressive, low cost investigational procedure. Computed tomography, however, represents the most polyvalent, non-aggressive technique for evaluating the size of the aneurysm, its thrombotic components, and its extension to neighbouring organs.

[Computed tomography in renal trauma (author's transl)]. / Apport de la tomodensitométrie dans l'étude des traumatismes fermés et récents du rein.

On the basis of a series of 25 cases of closed recent trauma of the kidney examined by scanner, the authors analyzed the information provided by the method and its correspondence with the various lesions encountered. In the course of this study, the scanner appeared to be the method of investigation which, at the present time, offers the best information concerning the severity of parenchymatous damage, as well as the size, nature and course of the perirenal blood or urine collections. Such data being fundamental to therapeutic decisions, the place of the scanner is essential in the evaluation of renal trauma, and, in severe forms, should be performed immediately after the irreplaceable I.V. urography performed as an emergency.

Non-Hodgkin's lymphoma presenting with primary adrenal insufficiency. A disease with an underestimated frequency?

Adrenal involvement in the course of a non-Hodgkin's lymphoma (NHL) appears to occur relatively often, but only seven cases of NHL-induced adrenal insufficiency were found in a recent review of the literature. The authors report four cases of hypoadrenalism in 127 patients treated for NHL; the cases were staged and classified according to the Working Formulation and were investigated for endocrine function by the cosyntropin stimulation test. The involvement was bilateral in four patients; all of the patients had high grade, mostly widespread NHL. These observations suggest that adrenal insufficiency may be underestimated in NHL. Basal hormonal serum levels may be borderline; consequently, only stimulation tests can prove the hormonal failure. The authors suggest that such tests are essential if the staging of the NHL shows bilateral adrenal enlargement, and that the tests should be performed before chemotherapy begins because of the risk of acute adrenal insufficiency.