[Imaging of the postoperative knee in athletes: articular cartilage, menisci, and ligaments]. / Imagerie du genou du sportif opéré: cartilage, ménisques et ligaments.

This article focuses on the common surgical procedures and reviews the clinical and imaging features of the postoperative knee following prior surgical treatment of meniscal, articular cartilage, and ligamentous injuries.

Centrofacial malignant granulomas. Clinicopathologic study of 40 cases and review of the literature.

An important problem in the treatment of centrofacial ulcerations is to establish a precise diagnosis, since similar clinical and microscopic findings can result from many different causes (as in the centrofacial malignant granuloma syndrome [CFMG]). A comprehensive surgical biopsy protocol (known as SNFMI/GMCF), involving microbiology, parasitology, immunology and pathology laboratories, allowed us to evaluate and to treat 40 cases of CFMG, who form the basis of this report. In 13 of them, specific diagnoses were found and curative treatments could be given. In the remaining 27, the optical microscopy pattern met the criteria for CFMG without identifiable origin or the presence of so-called lethal midline granulomas; however, a more precise evaluation with the help of immunofluorescence studies led to the recognition of malignant lymphoma (ulcerative lymphoma of the midface [ULM]). Most of these lymphomas belonged to the T cell lineage; the others were of B lymphoid origin, or, more rarely, of histiocytic origin. Patients with ULM received radiotherapy and chemotherapy with a response rate of 70.3%; however, the toxicity was significant, with frequent occurrence of chemotherapy-induced neutropenia followed by severe infectious facial cellulitis. Six patients were enrolled in a preliminary open trial of treatment with recombinant alpha-2b interferon with little success. Three patients were treated with radiation therapy only, and survived. Thus, CFMG is a syndrome with specific causes and treatments, requiring multiple extensive biopsies to make the correct diagnosis. The recognition of ULM as the cause of the previously called "lethal midline granulomas" leads logically to the use of chemotherapy with growth factors in order to ameliorate its bad prognosis.

Changes in systemic gonadal and adrenal steroids in asymptomatic human immunodeficiency virus-infected men: relationship with the CD4 cell counts.

Serum sex hormone-binding globulin (SHBG), testosterone, non-SHBG-bound testosterone, androstenedione, dihydrotestosterone (DHT), dehydroepiandrosterone (DHEA), follicle-stimulating hormone (FSH), luteinizing hormone (LH) and cortisol were measured in 58 homosexual men seropositive for human immunodeficiency virus (HIV), all clinically asymptomatic (Centers for Disease Control 1993 classification stage A). The HIV patients were divided into four groups according to the CD4 lymphocyte count--group 1 (more than 500/microliters, N = 14), group 2 (between 350 and 500/microliters, N = 16), group 3 (between 200 and 349/microliters, N = 22) and group 4 (less than 200/microliters, N = 6)--and compared with 11 antibody-negative men as controls. The SHBG levels were significantly increased in groups 1, 2, 3 (p < 0.01) and 4 (p < 0.05) compared with controls, with no differences between groups of patients. Compared with controls, testosterone concentrations were significantly lower in group 4 (p < 0.05) and non-SHBG-bound testosterone levels were significantly lower in groups 1 (p < 0.05), 2 (p < 0.01), 3 (p < 0.001) and group 4 (p < 0.001); DHT and androstenedione levels were significantly lower in group 4 (p < 0.05) and DHEA levels were significantly lower in group 2, group 3 (p < 0.01) and group 4 (p < 0.05) than in controls. Cortisol levels were significantly increased in groups 1 and 4 (p < 0.05) and FSH and LH concentrations were not significantly higher in HIV-infected men than in controls. Also, the DHEA, androstenedione, non-SHBG-bound testosterone and DHT levels were correlated with CD4 cell counts, showing that hypogonadism occurs as the CD4 lymphocytes decrease.(ABSTRACT TRUNCATED AT 250 WORDS)

Two familial cases of malignant Reiter's syndrome.

A Cambodian man and his son concomitantly developed malignant Reiter's syndrome soon after their arrival in France. In both cases generalized skin lesions of pustular psoriasis and systemic features were present. The son died after 2 years of unresponsive continuously progressive disease. The father received pulses of high dose immunosuppressants that worked rapidly and prevented a life threatening course. These 2 cases illustrate the pathophysiologic hypothesis of Reiter's syndrome, emphasizing the role of environmental triggering factors and the relationship between spondylarthropathies in B27 positive patients. Fatal cases of Reiter's syndrome are very rare in the review of the literature.

Cerebral infarction associated with vasculitis due to varicella zoster virus in patients infected with the human immunodeficiency virus.

Cases of herpes zoster ophtalmicus (HZO) with delayed contralateral hemiparesis caused by hemispheric stroke secondary to granulomatous angiitis have been reported and are a well-recognized complication of herpes zoster. Similar cases have been reported more recently during infection with human immunodeficiency virus (HIV). We describe two HIV+ patients without any clinical history of zoster dermatitis who developed a sudden hemiparesis followed 2 weeks later for one by an acute retinal necrosis. Computerized tomography (CT) scan, magnetic resonance imaging (MRI), magnetic resonance angiography (MRA), and digital subtraction angiography (DSA) were performed and showed a hemispheric stroke with evidence of a segmental arteritis of the carotid syphon. Varicella zoster virus (VZV) was found in the cerebro spinal fluid (CSF) in the two patients and after puncture of the vitreous fluid of the patient with the acute retinal necrosis. These two cases exemplify the difficulty of diagnosis of stroke in HIV+ patients, which seems to be more frequent than in similarly aged non-infected patients and demonstrates that VZV needs to be taken in consideration and identified even without any past history of zoster dermatitis.

[Access to social coverage of uninsured patients attending a hospital clinic: a historical cohort study at the Baudelaire outpatient clinic in Paris]. / Accès à une couverture sociale des patients non assurés consultant en milieu hospitalier: une étude de cohorte historique au sein de la consultation "Baudelaire" à Paris.

BACKGROUND: In France health insurance coverage is universal (see note at the end of the text), nevertheless some people remain uninsured. In this high-risk population, the lack of insurance coverage contributes to the aggravation of health, by reducing access to medical care. In 1992, the Baudelaire consultation was incorporated into the outpatient clinic of Saint-Antoine hospital (Paris, France), to provide the uninsured with the same access as any other patient--but free of charge--to medical care. Social care was also provided in particular by assisting the uninsured in applying for insurance coverage. Our objectives were to quantify the delay in obtaining insurance coverage and to study whether the sociodemographic characteristics of these patients were associated with inequalities in terms of delays. METHODS: All patients attending the consultation for the first time in 1994 were included (n = 623). Because of differences linked to the French social security system, analysis was performed into two groups according to the existence of a prior insurance coverage. Delay in obtaining or recovering insurance coverage was considered as the key variable. The socio-demographic factors linked to the rates of access to insurance coverage were determined using Cox proportional hazards regression models. We also examined the factors linked with the existence of a prior insurance coverage by logistic regression modeling. RESULTS: Within one year 96% of the patients who had had insurance coverage in the past, and 63% of the patients who had not, were insured. No factor, whether nationality, educational level, socio-professional category, family situation, type of housing, made of income was found to be linked with obtaining or recovering insurance coverage. However, nearly all these factors were related with the existence of prior insurance coverage. CONCLUSIONS: Our approach of systematically providing social care allows 70% of uninsured patients to obtain insurance coverage within one year. This approach probably contributes to an improvement by facilitating access to mainstream health care. Moreover, no difference in delay in obtaining insurance coverage was found associated with sociodemographic characteristics.

[Treatment with iloprost of critical ischemia of the lower limbs associated with cardiac insufficiency. Study of interaction with the pharmacokinetics of digoxin]. / Traitement par Iloprost des ischémies critiques des membres inférieurs associées à une insuffisance cardiaque. Etude de l'interaction avec la pharmacocinétique de la digoxine.

We have treated with intravenous iloprost twelve patients suffering from cardiac insufficiency compensated under oral digoxin (NYHA class II) associated with severe limb ischaemia due to arterial insufficiency. Our aim was to study its possible interaction on digoxin levels and to evaluate the long-term efficacy of iloprost. Although iloprost slowed the digoxin absorption by approximately one hour, we found no clinically significant difference between the digoxin pharmacokinetic data before and during treatment by iloprost. Moreover, 11 out of the 12 patients had a good clinical fate after the treatment, which persisted at 6 months. The pain disappeared in 4 and diminished in 7; and all skin ulcers healed. This improvement has lasted up to two and a half years in two patients. The clinical tolerance of iloprost was acceptable despite frequent headache and flushing associated with hypotension and nausea. We conclude that iloprost seems to be a very promising treatment of severe limb ischaemia when no intervention on the proximal arteries is possible. The patients on digoxin can continue their treatment without dose alteration while starting on iloprost.

[Treatment of chronic postinfectious fatigue: randomized double-blind study of two doses of sulbutiamine (400-600 mg/day) versus placebo]. / Traitement de l'asthénie en période postinfectieuse: étude randomisée en double aveugle de deux doses de sulbutiamine (400-600 mg/j) versus placebo.

PURPOSE: Chronic fatigue remains a medical mystery and a therapeutic failure. The subgroup of chronic fatigue postinfectious fatigue (CPIF) is an interesting one since it is quite frequent in general practice. METHODS: We studied sulbutiamine (Su), isobutyryl-thiamine disulfide in this context. We included 326 general-practice patients suffering from CPIF: they received randomly either Su, 400 mg daily (n = 106), or Su, 600 mg daily (n = 111), or placebo (n = 109) for 28 days in a double-blind, parallel-group study. 315 patients completed the study. RESULTS: The evaluation of fatigue, by multiple means including mainly MFI, a validated multidimensional fatigue scale, showed overall no significant difference between the groups. On the 7th day, however, women receiving Su, 600 mg had less fatigue (P < 0.01), but the figures were quite diverse and no persistent effect was noted at the 28th day. CONCLUSION: Thus, we showed for the first time that a high level general-practice study of fatigue is feasible using specific tools. Whether the effect observed after 1 week in women represents a true finding needs additional research. Further studies are in progress in order to characterize better the potential usefulness of Su in chronic fatigue.

[Specific respiratory manifestations of Horton disease]. / Les manifestations respiratoires spécifiques de la maladie de Horton.

Several respiratory manifestations have been described in patients with temporal arteritis. These complications may develop at the onset of the disease or later. Cough is the most frequent of them. Other complications include pleural effusions, interstitial pneumonitis, pulmonary vasculitis. Hyperreactive airways, hoarseness, diaphragm paralysis have been noted. Generally, corticosteroids cause a prompt improvement. Physicians should be aware of respiratory symptoms in patients with temporal arteritis in order to avoid delays in diagnosis and therapy.

[Risk of nosocomial Pneumocystis carinii pneumonia in immunosuppressed patients non-infected by human immunodeficiency viruses]. / Le risque de pneumocystose nosocomiale chez les immunodéprimés non infectés par le virus de l'immunodéficience humaine (VIH).

We report four cases of Pneumocystis carinii pneumonia (PCP) in Human Immunodeficiency Virus (HIV)-seronegative patients. Two of them had been hospitalized for polymyositis treatment near AIDS patients, respectively 1 and 4 months before PCP. The two others suffered from localized cancer. Their evolution was complicated by respiratory distress and death in two of them. A telephone survey among 19 hospital units yielded nine cases of similar patients. They were only observed in wards caring for AIDS patients at the same time, thus raising the question of a possible nosocomial transmission of PCP between AIDS patients and immunocompromised HIV-seronegative patients. This adds to the growing concern for hospital-acquired infections, including resistant tuberculosis and other opportunistic pathogens. We propose some practical measures to limit this risk by simple means such as no-contact between at-risk populations, enhanced disinfection procedures of the rooms and masking of the coughing PCP patients.

[Treatment of Still disease in adults with intravenous immunoglobulins]. / Traitement de la maladie de Still de l'adulte par immunoglobulines intraveineuses.

In most cases, the treatment of adult's Still disease presents difficulties, in view of its undesirable side-effects. For this reason, we made an open trial of the effects of high-dose intravenous immunoglobulins (IVIg), a therapy with low iatrogen risk, and whose effectiveness in the treatment of other multisystemic diseases has been acknowledged. Seven patients suffering from adult Still's disease were given between one and eight IVIg infusions with a dose of 1 g/kg/day for two consecutive days. All seven responded positively, with clinical improvement. It lasted between 1 and 90 days in three patients, who subsequently relapsed; it has been continuing for an average of 13 months (2 to 24 months) in the other four patients. There were no clinical features making it possible to distinguish, after the trial, the patients who responded positively to intravenous immunoglobulins. This data, which needs to be confirmed with a controlled trial, provides hope of improved therapy for the one half of patients suffering from adult Still's disease who respond positively to intravenous immunoglobulins.

[Disseminated intravascular coagulation associated with prostatic cancer]. / Coagulation intravasculaire disséminée associée au cancer de la prostate.

Disseminated intravascular coagulation (DIC) associated with prostate adenocarcinoma is a bad prognostic sign. Most of the cases are limited to biological abnormalities. Some, however, come to medical attention due to thromboembolic or hemorrhagic complications. We report 4 such cases and review the pertinent literature. The characteristic features are low platelets and coagulation factors in an elderly man. In two out of the four cases, bleeding due to the DIC revealed the cancer. All patients received hormonotherapy and heparin. The worst fate (case 3) was a subacute one with no effect of the drugs and death in a short time. The other cases went into a five- to seven months remission before uncontrollable bleeding led to death. No favorable effect of the chemotherapy was observed. Thus, new treatments are sought for this rare but ominous complication of prostate cancer.

[Treatment with iloprost of critical ischemia of the lower limbs associated with cardiac insufficiency. Study of the interaction with pharmacokinetics of digoxin]. / Traitement par iloprost des ischémies critiques des membres inférieurs associées à une insuffisance cardiaque. Etude de l'interaction avec la pharmacocinétique de la digoxine.

Twelve patients with critical ischaemia of the lower limbs were treated with iloprost. The purpose of this study was to investigate for a possible iloprost-digoxin interaction and to evaluate the clinical benefit provided by short- or long-term iloprost therapy. The pharmacokinetics of digoxin were studied before and during iloprost treatment. Under iloprost the absorption of digoxin was delayed by about one hour, but the area under the plasma digoxin concentration curve remained unmodified. In 11 of our 12 patients the clinical effect of iloprost was satisfactory both immediately and after 6 months. Pain vanished in 6 patients and diminished in 6 patients. All skin ulcers were healed. In most cases this improvement persisted beyond the study period: 2 patients treated at the beginning of the study and who are still followed up have remained improved after 2 1/2 years. Two patients with pain relapse received iloprost in repeated 10 days' courses with successful results. The treatment was relatively well tolerated (headaches, flushing, abdominal pain). Thus, iloprost can avoid amputation in severe arteritis unsuitable for revascularization and for which there is no effective treatment. Patients under digoxin may continue to take this drug in the same doses during treatment with iloprost.

[Periarteritis nodosa with heart valve disease disclosed by occlusion of the central artery of the retina]. / Périartérite noueuse avec atteinte valvulaire cardiaque révélée par une occlusion de l'artère centrale de la rétine.

We report a case of periarteritis nodosa revealed by blindness due to occlusion of the central retinal artery. The disease appeared after a serous otitis and was accompanied by thrombocytosis. Its outcome was favourable under corticosteroid therapy, but it was complicated by aortic valve regurgitation. Lesions of fibrinoid necrosis were found on the aortic cusps removed during surgical replacement. It seems highly probable that the ocular and valvular lesions were specific, although this cannot be directly demonstrated. The case presented here is exceptional, and the relevant literature is reviewed.

[A paraneoplastic acrosyndrome]. / Un acrosyndrome paranéoplasique.

BACKGROUND: Paraneoplastic digital ischemia is an uncommon complication of metastatic adenocarcinomas. CASE REPORT: Two years after remission of an uterine adenocarcinoma, the patient developed an acrosyndrome involving all four limbs with digital ischemia. Recurrent carcinoma was evidenced by a very high antinuclear antibody titer. Chemotherapy improved the acrosyndrome. DISCUSSION: Vasomotor disorders which developed in older subjects with no other signs of autoimmune disorders should suggest a neoplastic origin. Icshemia of the fingers would be caused by vasculitis. An elevated antinuclear antibody titer may be a supplementary argument suggesting a neoplastic etiology.

[Primary Gougerot-Sjogren syndrome. Spontaneous one-year course of clinical, biological and histological signs]. / Syndrome de Gougerot-Sjögren primaire. Evolution spontanée sur un an des signes cliniques, biologiques et histologiques.

OBJECTIVES: The natural clinical course of primary Sjögren's syndrome was followed in 8 patients to identify the concomitant functional, clinical, biological, scintigraphic and histological manifestations of the disease. METHODS: The diagnosis of primary Sjögren's syndrome was made on the basis of functional signs (ocular or salivary sicca syndrome) and 2 positive tests among the 3 objective ocular tests (Schirmer's test, break-up time, Rose Bengale). Work-up included recording of functional and clinical signs, ophthalmologic examination and laboratory tests at diagnosis and every 3 months for 12 months. Scintigraphy of the salivary glands was performed together with a biopsy at diagnosis and at 12 months. RESULTS: No one parameter varied significantly over a 1 year period demonstrating the lack of need for renewed examinations for diagnosis or regular follow-up. CONCLUSION: This is the first report providing a homogeneous series studied by one team over a determined period of time. It demonstrates that clinical, biological and anatomic criteria for primary Sjögren's syndrome do not show any correlation between functional signs and objective ocular tests.

[Mixed corticomedullary tumor]. / Tumeur mixte corticomédullaire.

BACKGROUND: Pheochromocytoma and primary hyperaldosteronism rarely occur simultaneously. Few cases have been reported in the literature. CASE REPORT: A patient explored for hypertension was found to have hypokalemia related to primary hyperaldosteronism. Pathology examination of the ablated adrenal showed a co-existing pheochromocytoma suspected at history taking although urine catecholamines were normal. DISCUSSION: Different pathogenic hypothesis have been proposed. Such dual tumors could be a simple coincidence, occur in a particular genetic setting, be related to direct contact between cortical and medullary tissue leading to reactional cortical hyperplasia, pheochromocytoma produced factors stimulating aldosterone synthesis, or factor X, a substance produced by cortical adenomas and favoring growth of the pheochromocytoma.

[A follow up study of "geometric" total knee arthroplasty with special reference to the improved "anametric" model]. / Le recul à 5 ans et l'évolution des prothèses à glissement du genou: De la prothèse "geometric" à la prothèse "anametric".

The authors have analyzed the results obtained with 63 "Geometric" total knee arthroplasties with a follow-up of more than five years. Four septic complications and nine loosenings were observed. Three main causes that have been noted were 1) unsatisfactory operative indications, 2) poor positioning of the prosthesis, 3) poor design of the prosthesis. The last point has led to a new design of prosthesis called "anametric" because its design is closer to that of normal anatomy. The "geometric" model should be considered as a first generation of prosthesis.

[Severe contact dermatitis caused by mephenesin]. / Dermite de contact grave à la méphénésine.

INTRODUCTION: Mephenesin is a muscle relaxant, mostly applied locally in trauma. It is a component of Traumalgyl cream in association with phenylbutazone. Contact dermatitis due to mephenesin is exceptional. CASE REPORT: We report here a case of a woman who developed after application of Traumalgyl cream purpuric dermatitis, erythema multiforme-like and urticarial lesions. Patch-tests were strongly positive (+ + +) for both Traumalgyl cream and mephenesin and (+) for phenylbutazone. Improvement of the lesions was observed within 3 weeks. DISCUSSION: Physicians must be aware of the risk of severe contact dermatitis after application of products including mephenesin because of their widely prescription.