Severe adverse events during medical and surgical treatment of hip and knee prosthetic joint infections.

INTRODUCTION: The management of prosthetic joint infection requires a complex treatment procedure and can be associated with complications. However, the occurrence of severe adverse events during this intervention has been poorly evaluated. PATIENTS AND METHODS: A 5-year multicentric retrospective study including patients from 3 hospitals in the South-Western France referral center for complex bone and joint infections (Crioac GSO) and treated for hip or knee prosthetic joint infection with 1 or 2-stage implant exchanges. The objective was to describe grade≥3 adverse events, according to the CTCAE classification, occurring within 6 weeks after surgery and to identify their associated factors. RESULTS: One hundred and eighteen patients were identified. We observed 71 severe events in 50 patients (42.3%; 95% confidence interval [CI95%]: 33.8-51.4%). Sixteen severe events were an evolution of the infection. The remaining 55 others (47 grade 3 and 8 grade 4) occurred in 41 patients (34.7%; CI95%: 26.8-43.7%). They were distributed as follows: 27 (49.1%) medical complications, 21 (38.2%) surgical complications and 7 (12.7%) antibiotic-related complications. The main identified risk factor was a two-stage prosthetic exchange with OR=3.6 (CI95% [1.11-11.94], P=0.032). Obesity was limit of significance with OR=3.3 (CI95% [0.9-12.51], P=0.071). Infection with coagulase negative Staphylococcus was a protective factor with OR=0.3 (CI95% [0.12-0.99], P=0.047). CONCLUSION: Severe adverse events are frequent following prosthetic exchange for PJI (34.7%) and are related to the high frequency of comorbidities in this population and to the complex surgical procedures required. The risk factor significantly associated with these events was a two-stage exchange.

Campylobacter fetus infections.

BACKGROUND: Campylobacter fetus infections usually occur in immunodepressed patients or patients presenting with diabetes mellitus or cancer. They rarely cause diarrhea but frequently cause bacteremia or vascular diseases. The therapeutic management is not well codified and fluoroquinolone resistance is continuously increasing. METHODS: We conducted a retrospective study of C. fetus infections from January 2007 to August 2013 at the Limoges teaching hospital. The infections were defined by at least 1 bacteriological sample positive for C. fetus. RESULTS: Twenty patients were included (15 men), with an average age of 73 years (43-91). Sixteen presented with cancer, 12 with solid cancer including 9 of the urinary tract, and 9 patients with hematologic diseases. Five patients presented with diabetes mellitus, 9 with isolated bacteremia, 3 with cellulitis, and 3 with septic arthritis. The diagnosis was made by blood cultures for 17 patients. Twenty percent of the isolates were resistant to amoxicillin and 30% to fluoroquinolones. The therapeutic regimens and the treatment duration were quite different. The outcome was unfavorable for 3 patients whose implanted port had not been removed and 1 with subdural hematoma infection. 1 patient died. CONCLUSIONS: C. fetus infection occurs in case of underlying diseases, most frequently promoting urinary tract cancer. Fluoroquinolones must not be used without susceptibility testing and catheters should be removed.

[Historic malignant tumour: 27 observations]. / Tumeur maligne historique: 27 cas.

BACKGROUND: When used in the French medical literature to describe a pathological state, the word "historic" normally refers to tumours of startling appearance because of their size. It is difficult to understand how a patient can allow such tumours to continue to grow. We attempt to define this concept. PATIENTS AND METHODS: Two dermatologists carried out a retrospective, independent and comparative selection of photographs taken between 1978 and 2008 of malignant cutaneous tumours of unusual size given the histological diagnosis. Socio-professional, demographic, clinical, histological psychological data, and details of treatment history and progress were collected. RESULTS: Twenty-seven patients (11 M, 16 F) of mean age 74 years (34-99 years) presented a "historic" tumour. Twelve patients lived in rural regions. Five patients were company executives. The average duration of development of the "historic" tumours was 4.5 years (6-420 months). The tumours were classed histologically as epidermoid carcinomas (nine) and melanomas (seven). The mean size was 13 cm (6-30 cm). Psychiatric problems, membership of sects or dementia were noted for 13 patients. Treatment consisted of chemotherapy, radiotherapy or, less frequently, surgery. Eighteen patients died on average 13 months after diagnosis. DISCUSSION: "Historic" malignant tumour (also described in the literature as "giant" tumour) is a real-life fact. No studies have been made of a series of such patients. Despite histological diagnosis, the size was associated with slow tumoral progress and/or late treatment, chiefly accounted for by psychiatric disorders. Socio-professional data indicate that "historic" tumours are equally common in urban and rural areas.

[Photodynamic therapy for the treatment of extramammary Paget's disease]. / Traitement de la maladie de Paget extramammaire par photothérapie dynamique topique.

BACKGROUND: The usual treatment for extramammary Paget's disease (EMPD) is surgery, but this approach may have grave functional and physical consequences, as well as high recurrence rates. Topical photodynamic therapy (PDT) offers an optional approach for EMPD; it has a high complete response rate and there is no dose restriction. The aim of this study was to evaluate the efficacy and safety of PDT in the treatment of EMPD. PATIENTS AND METHODS: This series of patients was seen at a single centre between 1 December 2005 and 31 December 2010. All patients with histologically confirmed EMPD were included. Patients received two courses of PDT 21 days apart: 3 hours after topical application of methyl aminolevulinic acid emulsion, they underwent illumination with red light (570-670 nm) at a dose of 37 J/cm(2) for 10 minutes. In the event of relapse, a further cycle was given at week 6. RESULTS: Eight patients (seven female, one male) of a mean age of 69 years were included. After two series of two illuminations, seven patients were in complete clinical remission at 3 months and one patient was in partial remission. Five patients were still in complete clinical remission at 6 months. All patients had relapsed after a mean 8.4 months (4-14 months). The limiting factor appears to be pain occurring during illumination. Patients reported satisfaction with the disappearance of symptoms and a notable improvement in quality of life. DISCUSSION: The complete clinical response rate to PDT at month 6, after two series of two illuminations, was equivalent to that for surgery. Although the recurrence rate was high, this treatment may be repeated without functional or physical consequences. PDT resulted in disappearance of pain and improved quality of life.

High prevalence and risk factors of thromboembolism in stage IV melanoma.

BACKGROUND: Patients with cancer are at a high risk of thromboembolism (TE), which contributes to morbidity and mortality. Several case reports of thromboembolic events have been reported in patients with melanoma in the literature. OBJECTIVE: The aim of this study was to evaluate the prevalence of venous thromboembolism (VTE) in stage IV melanoma and determine risk factors, outcomes associated with the development of VTE and the number of haemorrhagic complications in patients under anti-coagulant treatment. PATIENTS AND METHODS: In this retrospective study, we included all consecutive patients with stage IV melanoma among 290 patients followed-up in the department of Dermatology each year between January 2005 and 31 December 2007. The diagnosis of VTE was confirmed by venous ultrasound, pulmonary perfusion-ventilation technetium scan and angiography. The primary outcome was to evaluate the number of TE diagnosed in stage IV melanoma patients. The secondary outcomes were to study the influence of TE on survival, its prevalence according to metastatic sites and to evaluate the number of haemorrhagic complications. RESULTS: Twenty-four VTE events were found [25.2% (CI: 16.5-34)]. Eighteen VTE were deep venous thrombosis in lower limbs associated with pulmonary embolism (PE) in 50% of cases. Twenty-five percent were asymptomatic and were revealed in the pulmonary scan performed for follow-up. Eight percent of VTE events revealed stage IV melanoma. Seventeen patients developed thrombosis at home after stopping heparin prophylaxis. Seven thrombotic events occurred during oral anti-coagulant therapy. CONCLUSION: We found as high a prevalence of VTE in stage IV melanoma as in lung and gastrointestinal cancers. All patients suffered thrombotic events when they were treated with chemotherapy and at home when they stopped heparin prophylaxis. Therefore, heparin prophylaxis should be maintained at home.

[Calciphylaxis treated by cinacalcet: a medical alternative to parathyroidectomy]. / Le traitement de la calciphylaxie par cinacalcet: une alternative médicale à la parathyroïdectomie.

Calciphylaxis is a rare necrotizing calcifying arteriolopathy, with a poor prognosis, for which there is currently no effective treatment. One of the major challenges of the therapy is normalizing the calcium-phosphate balance. Therefore, cinacalcet, which inhibit the production of parathormone by negative feedback, was considered a treatment option to control the evolution of calciphylaxis in a dialysed patient suffering from cholangiocarcinoma.

[Ulcerated nodular lesions on extremities of patient undergoing treatment for glioblastoma on French Caribbean island of Martinique]. / Lésions nodulaires et ulcérées des membres chez un Martiniquais traité pour un glioblastome. Phaéohyphomycose à Exophiala spinifera.

Phaeohyphomycosis comprises a disparate group of cutaneous and systemic mycotic infections caused by dematiaceous fungi. The Exophiala genus includes more than 20 species. The purpose of this report is to describe a case of phaeohyphomycosis due to Exophiala spinifera in a patient under treatment for cerebral glioblastoma on the French Caribbean island of Martinique. A 73-year-old man who was undergoing treatment for a cerebral glioblastoma using radiotherapy, chemotherapy and systemic corticosteroids presented with ulcerated nodular lesions on all four extremities for several months. Histological and mycological examinations led to diagnosis of cutaneous phaeohyphomycoseis due to Exophiala spinifera. Treatment using itraconazole was initiated but the patient died from complications of glioblastoma. Phaeohyphomycosis is a rare and cosmopolitan mycosis. Infection due to Exophiala spinifera is uncommon in humans. It usually but not always occurs in immunocompromised hosts. Although cutaneous involvement is usually localized and has a favorable prognosis, disseminated forms may occur and can be life-threatening. Histological and mycological examinations are useful to confirm the diagnosis. Systematic antifungals with or without surgical resection are often effective. To our knowledge, only 15 reported cases of phaeohyphomycosis due to Exophiala spinifera have been reported up to now.

[The value of photodynamic therapy in the treatment of Bowen's disease]. / Intérêt de la photothérapie dynamique topique dans la prise en charge de la maladie de Bowen.

BACKGROUND: While the standard treatments for Bowen's disease (BD) (surgery, cryotherapy and antimitotic agents) are efficient, they are associated with extensive scarring. In this paper we confirm that photodynamic therapy using topical aminolevulinic acid provides effective treatment for this disease. PATIENTS AND METHODS: Twenty-two patients with a total of 38 cases of BD were included in this retrospective single-centre study between 2001 and 2006. They were treated with photodynamic therapy using topical aminolevulinic acid (Metvix. The study criteria consisted of patient age and gender, site and area of lesions, number of patients with multiple patches of BD and/or large lesions, tolerance of the treatment, clinical response and quality of wound healing at 3, 6 and 12 months. Annual follow-up was conducted for five years. The probability of remission up to 60 months after treatment was determined by means of survival analysis based on the variable-interval actuarial method. RESULTS: Seven men and 15 women of median age: 76 years (interquartile range: [69-82]) with 38 cases of Bowen's diseases were treated with photodynamic therapy. In terms of frequency, lesions were seen predominantly on the lower limbs (N=24) and face (N=10). Other lesions were seen on the trunk or back (N=4). The mean surface area of lesions was 8.62 cm2 (1-96 cm2). Eight patients were presenting multiple patches of BD (> or = three lesions), and large lesions were noted in 11 cases. The most common adverse effect was an immediate burning sensation, described by 32% of patients (n=7). Treatment was effective, with remission being achieved in all patients at 3 months of follow-up. Wound healing was optimal and without atrophy or cosmetic sequelae. The remission rate was 100% at 6 months, 95% at 12 months and 85% at 24 months. DISCUSSION: This open retrospective study confirmed the good efficacy of photodynamic therapy in the treatment of BD in terms of both clinical remission and cosmetic results. It enables easier treatment of large and/or multiple lesions than surgery. It is more suitable for elderly patients than either topical anticancer drugs, which require prolonged compliance, or surgery and cryotherapy, both of which result in slow-healing postoperative wounds. CONCLUSION: Since photodynamic therapy is a very costly therapeutic method, we feel that dynamic phototherapy should be used only for large and/or multifocal lesions or for lesions of the lower limbs in patients with chronic venous insufficiency.

[Verrucous carcinoma of the lower limbs]. / Carcinomes verruqueux des membres inférieurs.

BACKGROUND: Verrucous carcinoma is a rare, low-grade, slow-growing, well-differentiated squamous cell carcinoma affecting the skin (particularly on the foot) and mucosa. The diagnosis is often delayed. We report a study of twelve cases of verrucous carcinoma of the lower limbs. PATIENTS AND METHODS: We retrospectively studied a series of 12 patients (8 women, 4 men) who developed verrucous carcinoma of the lower limbs between 1978 and 2005 and we analyzed their follow-up data. RESULTS: The mean age of patients was 78 years (66-97 years). Eleven patients exhibited verrucous carcinoma in a previous lesion comprising varicose ulcer (5 cases), mixed ulcer (3 cases), burn (2 cases) or traumatic lesion (1 case). The mean time from onset of lesions to diagnosis was 28 years. Nine patients showed locoregional extension (8 bone involvement, 3 lymph node involvement). No visceral metastasis was detected. Three patients received medical treatment that proved ineffective. Two received secondary surgical treatment. Nine patients underwent surgery (6 amputations, 3 local excisions). Four patients were lost to follow-up, 4 died, 3 showed no recurrence and 1 had a chronic unhealed wound after surgery. DISCUSSION: Verrucous carcinoma of the lower limbs is a disease of the elderly, affecting both men and women, and occurring mainly on chronic venous ulcerations. The clinical presentation is evocative although histopathological diagnosis is difficult, particularly in the event of superinfection. Repeated and deep biopsies are needed to avoid delay in diagnosis. Extension is chiefly locoregional and visceral involvement is rare. Medical treatment is ineffective and may even be harmful, with surgery the best option. Regular monitoring is necessary because of the risk of relapse, although verrucous carcinoma does not seem to directly affect patient survival.