[Achilles tendinopathy in a hemodialysis patient complicated by rupture of the Achilles tendon due to self-medication with ciprofloxacin: about a case]. / Tendinopathie achilléenne compliquée d´une rupture du tendon d´Achille consécutives à une automédication par la ciprofloxacine chez une hémodialysée: à propos d´un cas.

This study aims to remind clinicians of fluoroquinolone-related tendinopathies. They are rare side effects, but which can result in functional disability. We report the case of a 79-year-old woman with a 11-year history of haemodialysis who had sudden left ankle pain and functional impairment in the ipsilateral member on day 5th after self-medication with ciprofloxacin. Comorbidities included chronic gonarthrosis, secondary hyperparathyroidism and ischemic heart disease. The diagnosis of bilateral Achilles tendinopathy and rupture of the left Achilles tendon was retained due to clinical features and confirmed by ultrasound of ankles. Ciprofloxacin-associated tendon rupture was evaluated using the French method of accountability for drug unexpected side effects or toxicity. Tendon rupture management was based on surgery followed by functional rehabilitation program with satisfactory outcome. The frequency of fluoroquinolone-related tendinopathies ranges from 15 to 20 accidents per 100,000 subjects treated, a third of whom are complicated by tendon rupture. Incidence is related to age, affecting mainly people > 60 years and involving tissular aging. Pefloxacin and ciprofloxacin are the most offending molecules. In our study, the delay in the onset of symptoms on day 5 after self-medication was consistent with literature. We detected some common contributing factors including chronic renal failure, hemodialysis and the assumption of statins and corticosteroids. Fluoroquinolone-related tendinopathies are characterized by common clinical features which allow diagnosis. They mostly affect Achilles tendon. They are bilateral in 40-66% of cases. Tendon rupture is the main complication. Management is based on surgery. It allows to restore anatomy and to prevent detrimental functional disability. We here report a rare but potentially serious fluoroquinolones-related side effect, exposing the patient to the risk of functional disability. Advanced age, chronic renal failure, chronic haemodialysis, concomitant use of statins and corticosteroids are common contributing factors confirmed in this study. Hemodialysis patients constitute a population at risk; hence the importance of remote monitoring after treatment with these molecules.

[A Case of Rupture of Esophageal Varices during a Course of CAPOX with Bevacizumab Therapy for Sigmoid Colon Cancer with Multiple Liver Metastases].

The patient was a 67-year-old man with multiple liver metastases from sigmoid colon cancer and had received capecitabine, oxaliplatin, and bevacizumab(CAPOX plus Bev)combination chemotherapy. After 11 courses of this therapy, he had a rupture of esophageal varices and was treated with endoscopic variceal ligation(EVL). Esophageal varices are rare during the course of oxaliplatin-based chemotherapy. More studies are necessary for early detection of esophageal varices during this therapy.

[Bladder Rupture during Intravesical BCG Therapy : A Case Report].

A 69-year-old man received transurethral resection (TUR) ofbladder tumor. The histopathological diagnosis was urothelial carcinoma, high grade, pT1＋pTis. The surgical specimens obtained by second TUR showed no residual malignancy histopathologically. Intravesical Bacillus Calmette-Guerin (BCG) instillation therapy was initiated 2 months after the second TUR. He complained of lower abdominal pain and painful urination on the day following the second instillation of BCG. Computed tomography and cystography demonstrated rupture ofthe urinary bladder. During 2 weeks ofconservative treatment, the symptoms persisted. Then, open repair ofthe bladder was performed. Intravesical BCG therapy has been a widely accepted treatment for bladder cancer with high grade Ta and T1, and carcinoma in situ. In the present case, thinning ofthe bladder wall, delayed wound healing caused by 2 TURs, and abdominal pressure may have been the factors leading to the bladder rupture in addition to inflammation of the bladder due to BCG instillation. Although bladder rupture caused by intravesical BCG therapy has not been reported, we must be aware ofthe possibility ofthis rare condition, especially after 2 consecutive TURs.

[A Case of a Rupture of the Carotid Artery Caused by the Lenvatinib Medication].

We report a case of a rupture of the common carotid artery caused by the medication of lenvatinib. The patient, 70-yearold female, was referred to our hospital by unresectable papillary thyroid cancer infiltrated the left common carotid artery. Externalbeam radiotherapy and radioiodine therapy were undergone after totalthyroidectomy. After 1 year 7 months from operation, she admitted our hospital due to left shoulder pain and dysphagia caused by the growing left cervical tumor. The medication of lenvatinib was decided after the careful informed consent. Computed tomography on the eighth day of lenvatinib medication showed the existence of air infiltration into the tumor surrounded left common carotid artery. So, a discontinuance of lenvatinib medication was decided immediately. But, on the ninth day, a rupture of the left common carotid artery occurred and on the tenth day, she died. Lenvatinib medication for the patient with the tumor surrounded artery should be decided carefully.

Results of SMSNA Survey Regarding Complications Following Intralesional Injection Therapy With Collagenase Clostridium Histolyticum for Peyronie's Disease.

INTRODUCTION: Intralesional injection of collagenase clostridium histolyticum (CCH) for Peyronie's disease (PD) can result in serious adverse events such as hematoma formation and corporal rupture. AIM: To investigate the prevalence of complications from CCH and management trends among CCH prescribers. METHODS: A survey was sent to all 693 members of the Sexual Medicine Society of North America (SMSNA) with valid email addresses. Responders were asked to participate if they were prescribers of CCH. Data regarding prescriber experience with CCH, procedural preferences, and rates and management strategies of complications were collected. MAIN OUTCOME MEASURE: One hundred SMSNA members completed the survey, with 36%, 23%, and 41% of responders having performed ≤10, 10 to 20, and >20 CCH injections, respectively. RESULTS: Of the responders, 94% reported hematomas in <25% of patients, with 63% preferring to observe and 37% treated with a combination of observation, application of a compressive dressing, and/or drainage of the hematoma. Corporal ruptures were encountered by 34% of physicians at a median of 5 days (0.5 to 30 days) from the last CCH injection. Rupture was located over the treated plaque in 84% of cases, and surgical intervention was the preferred management option by 67% of members. A distal circumcising degloving incision was used in 76% of cases, and 62% of responders reported the quality of tissue to be worse than would be expected with a non-CCH penile fracture. There were no significant differences in erectile function, ability to have intercourse, change in penile curvature, and patient satisfaction among patients who underwent surveillance vs surgery. One observed patient developed a penile abscess. CONCLUSION: A wide variation exists among SMSNA members' strategies to prevent and manage complications of CCH. One in 3 prescribers reported encountering a corporal rupture during CCH therapy, and it is currently undetermined if there is a benefit of surgery vs conservative management.

Pneumothorax in neonates: Trends, predictors and outcomes.

OBJECTIVE: To examine rates, trends, predictive risk factors, and outcomes associated with pneumothorax in neonates. STUDY DESIGN: Retrospective analyses were used to estimate rates and assess trends in pneumothorax among early preterm (GA <32 weeks), moderate-late preterm (GA 32-36), and term (GA ≥37 weeks) neonates admitted to neonatal intensive care units (NICUs) participating in the Canadian Neonatal Network™ from 2005 to 2011. For each GA group, multivariable logistic regression models were derived to predict pneumothorax using risk factors with known clinical relevance. Additional logistic regression analyses assessed associations between pneumothorax and mortality, bronchopulmonary dysplasia, and intraventricular hemorrhage. RESULTS: The study included 71,237 neonates; of them 16,985 (24%) early preterm, 27,709 (39%) moderate-late preterm, and 26,543 (37%) term neonates. The overall rate of pneumothorax by GA was bimodal with estimates of 4.0%, 2.6%, and 6.7% respectively. No significant temporal trends were detected. Risk factors for pneumothorax included: a) for the overall lpopulation- Score for Neonatal Acute Physiology, version II >20, surfactant use, and respiratory distress syndrome; b) for early preterm infants-chorioamnionitis; c) for moderate-late preterm infants-higher birth weight, male sex, rupture of membranes >24 hours, and outborn status; and d) for term infants- male sex, outborn status, and meconium aspiration in term neonates. In early preterm neonates, pneumothorax was associated with mortality, bronchopulmonary dysplasia, severe intraventricular hemorrhage, and prolonged NICU stay. CONCLUSIONS: Pneumothorax rates were higher among term and early preterm neonates admitted to the NICU. Predictors of pneumothorax varied between GA groups. Pneumothorax-associated mortality and morbidity were significantly greater in early preterm infants.

Acute double flexor tendon ruptures following injection of collagenase clostridium histolyticum (Xiapex) for Dupuytren's contracture.

We report a case of acute (24 h) double flexor tendon rupture of the little finger after a single injection of collagenase clostridium histolyticum into a palmar Dupuytren's contracture cord which caused metacarpophalangeal joint contracture. Tendon surgery was performed 48 h postinjury with primary repair and standard rehabilitation but it resulted in poor active flexion due to adhesions. Previous papers have suggested that a needle inserted into the flexor tendon can be detected prior to the injection of collagenase by asking the patient to actively move the finger, but our test on an awake patient showed that when a 27-gauge needle was inserted into the flexor tendons through a thick palmar cord, the syringe did not move significantly when the patient moved the finger, and therefore this test does not minimise the risk of iatrogenic tendon injury when using collagenase (Xiapex) for Dupuytren's contracture.

Bupivacaine induces short-term alterations and impairment in rat tendons.

BACKGROUND: Toxicity of the local anesthetic bupivacaine (BV) has been a matter of debate across medical fields. Numerous in vitro studies demonstrate considerable toxicity of BV on various cell types. PURPOSE: This study addresses the question of how tendon tissue responds to BV in vivo and in vitro. STUDY DESIGN: Controlled laboratory study. METHODS: In vitro studies on cultured rat Achilles tendon-derived cells were performed with cell viability assays and cleaved caspase 3 immunocytochemistry. Quantitative reverse transcription-polymerase chain reaction, Western blotting, gelatin zymography, and a biomechanical testing routine were applied on rat Achilles tendons at 1 and 4 weeks after a single unilateral peritendinous injection of 0.5% BV. The BV-mediated cell death in tendons was estimated with terminal deoxynucleotidyl transferase dUTP nick end labeling (TUNEL) staining and immunohistochemical detection of cleaved caspase 3. RESULTS: Treatment of rat tendon-derived cells with 0.5% bupivacaine for 10 minutes had detrimental effects on cell viability, which can be reduced by N-acetyl-L-cysteine or reduction of extracellular calcium. In vivo, single peritendinous injections of BV caused apoptosis in endotenon cells and an increase of pro-matrix metalloproteinase-9 after 6 hours. The collagen ratio shifted toward collagen type III after 6 hours and 2 days; scleraxis messenger RNA (mRNA) expression was reduced by 87%. Maximum tensile load was reduced by 17.6% after 1 week. CONCLUSION: Bupivacaine exerts a severe, reactive oxygen species-mediated effect on tendon cell viability in vitro in a time- and dose-dependent manner, depending on extracellular calcium concentration. Culture conditions need to be taken into account when in vitro data are translated into the in vivo situation. In vivo, administration of BV elicits a marked but temporary functional damage. CLINICAL RELEVANCE: Local anesthetics cause short-term alterations in rat tendons, which, if occurring in humans to a similar extent, may be relevant regarding decreased biomechanical properties and increased vulnerability to tendon overload or injury.

Spontaneous distal biceps tendon ruptures: are they related to statin administration?

The purpose of this study is to identify a possible correlation between statin administration and incidence of spontaneous distal biceps tendon ruptures. We retrospectively reviewed 104 patients with distal biceps tendon rupture that were treated surgically from 2004 to 2010, 102 males and two females with mean age 47 years (range, 22-78). Patients were divided based on the mechanism of injury and statin administration. After statistical analysis, it was found nearly two times more likely to have spontaneous distal biceps tendon rupture with use of statins. Patients in Group 1 (spontaneous tendon rupture) compared to Group 2 (provoked tendon rupture) were older, had weaker postoperative strength but similar postoperative ROM. Patients taking statins compared to those that were not taking statins were older, had same postoperative strength and similar postoperative ROM. Based on the results of our study we conclude that there is a trend of association of spontaneous distal biceps tendon ruptures with statin administration.

Flexor tendon rupture after collagenase injection for Dupuytren contracture: case report.

Rupture of both flexor tendons after collagenase injection for Dupuytren contracture is a rare and problematic complication. We performed a 2-stage tendon reconstruction to treat this problem, with an acceptable result.

[Successive ruptures of patellar and Achilles tendons. Anabolic steroids in competitive sports]. / Mehrzeitige Rupturen von Patellar- und Achillessehnen. Anabole Steroide im Leistungssport.

Derivatives of testosterone or of 19-nor-testosterone are used as anabolics for the purpose of improving performance although the effect of anabolics is known still to be under discussion. The use of anabolic steroids continues among competitive athletes despite increased controls and increasingly frequent dramatic incidents connected with them. Whereas metabolic dysfunction during anabolic use is well documented, ruptures of the large tendons are rarely reported. Within 18 months, a 29-year-old professional footballer needed surgery for rupture of the patellar tendon and of both Achilles tendons. Carefully directed questioning elicited confirmation that he had taken different anabolic steroids regularly for 3 years with the intention of improving his strength. After each operation anabolic steroids were taken again at a high dosage during early convalescence and training. Minimally invasive surgery and open suturing techniques led to complete union of the Achilles tendons in good time. Training and anabolic use (metenolon 300 mg per week) started early after suturing of the patellar tendon including bone tunnels culminated in histologically confirmed rerupture after 8 weeks. After a ligament reconstruction with a semitendinosus tendon graft with subsequent infection, the tendon and reserve traction apparatus were lost. Repeated warnings of impaired healing if anabolic use was continued had been given without success. In view of the high number of unrecorded cases in competitive and athletic sports, we can assume that the use of anabolic steroids is also of quantitative relevance in the operative treatment of tendon ruptures.

Colonic rupture in a patient on combination chemotherapy for metastasized carcinoma of the esophagogastric junction. Case report and review of the literature.

BACKGROUND: Cecal perforation due to neutropenic colitis is a known and described side effect of many chemotherapy regimens. We present a case of a patient with gastric adenocarcinoma who developed spontaneous cecal perforation during chemotherapy without the classic pattern of typhlitis. CASE REPORT: A 58-year-old woman was on chemotherapy for an adenocarcinoma of the gastric junction, when she developed a cecal perforation. There was neither evidence for leucopenia nor for typhlitis. Laparotomy was performed and cecostomy was established using the perforated bowel. Postoperative course was uneventful. The patient died from tumor progression 8 months after the diagnosis was made. CONCLUSION: There is no evidence for a connection between this event and chemotherapy treatment but neither can it be excluded. Even if unusual, colon toxicity could be a potential life-threatening complication associated with more drugs than usually thought.

Intra-amniotic corticosteroids for preterm lung maturation in sheep.

OBJECTIVE: The purpose of this study was to compare efficacy on fetal lung maturation of intra-amniotic betamethasone or budesonide with the efficacy of maternal intramuscular betamethasone. STUDY DESIGN: Pregnant ewes received intra-amniotic betamethasone (0.5 mg/kg or 2 mg/kg fetal weight), intra-amniotic budesonide (0.5 mg/kg or 2 mg/kg), maternal intramuscular betamethasone (0.5 mg/kg maternal weight), intra-amniotic saline solution, or maternal saline solution. Lambs were delivered 2 or 7 days later, at 124 days of gestation for measurement of respiratory system compliance, ventilatory efficiency index, and surfactant levels. RESULTS: Lung function increased 2 days after maternal betamethasone, intra-amniotic betamethasone (2 mg/kg), and intra-amniotic budesonide (2 mg/kg) administration and 7 days after maternal betamethasone or intra-amniotic budesonide (2.0 mg/kg) administration. Lung function was not improved 7 days after intra-amniotic betamethasone (2.0 mg/kg) administration or 2 days after intra-amniotic betamethasone (0.5 mg/kg) or intra-amniotic budesonide (0.5 mg/kg) administration. Intra-amniotic corticosteroid administration increased fetal death and respiratory morbidity. CONCLUSION: Intra-amniotic corticosteroid administration improved preterm lung function, but the associated morbidity and mortality rates suggest that they are not suitable for clinical use.

Plantar fasciitis: a degenerative process (fasciosis) without inflammation.

The authors review histologic findings from 50 cases of heel spur surgery for chronic plantar fasciitis. Findings include myxoid degeneration with fragmentation and degeneration of the plantar fascia and bone marrow vascular ectasia. Histologic findings are presented to support the thesis that "plantar fasciitis" is a degenerative fasciosis without inflammation, not a fasciitis. These findings suggest that treatment regimens such as serial corticosteroid injections into the plantar fascia should be reevaluated in the absence of inflammation and in light of their potential to induce plantar fascial rupture.

Spontaneous bilateral rupture of the Achilles tendon in a patient with chronic obstructive pulmonary disease.

A 69-year-old man with chronic obstructive pulmonary disease (COPD) presented with an exacerbation of cough and breathlessness, as well as a 5 day history of sudden-onset bilateral calf tenderness. He had been commenced on inhaled steroids 41/2 years earlier and then received maintenance oral prednisone. Upon examination, there was a haematoma inferior to the medial malleolus with no Achilles tenderness on the left side. On the right side, there was focal tenderness over the mid-portion of the Achilles tendon with pain accentuated upon dorsi flexion. A venous duplex study confirmed superficial venous thrombosis involving the left gastrocnemius vein extending proximally to the popliteal vein junction. The major axial deep veins of the left lower leg were patent. Findings on the right side were normal. A subsequent diagnostic ultrasound demonstrated unequivocal bilateral Achilles tendon ruptures. The patient subsequently underwent corrective surgery. There have been several reports of bilateral Achilles tendon rupture associated with long-term corticosteroid use. It is likely that this entity is underdiagnosed because of a lack of awareness of this association by physicians. Recognition and surgical intervention are likely to reduce morbidity and improve outcome.

Keratitis, ulceration, and perforation associated with topical nonsteroidal anti-inflammatory drugs.

PURPOSE: To report corneal complications associated with topical nonsteroidal anti-inflammatory drugs (NSAIDs). DESIGN: Retrospective, noncomparative interventional case series. PARTICIPANTS: Eighteen eyes of 16 patients with adverse corneal events associated with NSAID use. METHODS: Evaluation of 16 patients referred for management of corneal complications during use of topical NSAIDs (ketorolac tromethamine [Acular], diclofenac sodium [Voltaren], diclofenac sodium [Falcon DSOS]). MAIN OUTCOME MEASURES: Type and severity of corneal complications. RESULTS: Of the 16 patients, two experienced severe keratopathy, three experienced ulceration, six experienced corneal or scleral melts, and five experienced perforations. Eleven patients had recent cataract surgery; nine of these were on concurrent topical steroids and antibiotics. Another patient who did not have recent surgery was using concurrent topical steroids without antibiotics for sarcoid uveitis. Systemic associations included two patients with rheumatoid arthritis, one patient with asymptomatic Sjogren's syndrome, and two with rosacea. CONCLUSIONS: Topical NSAIDs were associated with corneal complications in 18 eyes of 16 patients. Potential risk factors include conditions that predispose the patient to corneal melting, concurrent topical steroids, and epithelial keratopathy in the early postoperative period.

Rupture of the myocardial histoskeleton and its relation to sudden death after infusion of glycine 1.5% in the mouse.

Hypoxic lesions in the subendocardium and long-standing dilatation of the interstitium have been described after exposure of the heart to glycine 1.5%, which is a widely used irrigating medium in endoscopic surgery. To study if the hypo-osmotic properties of the fluid cause these morphological changes, whether their long duration can be explained by rupture of the histoskeleton and whether they promote sudden death, 75 mice received an intravenous infusion of 200 ml/kg or 300 ml/kg over 60 min of either glycine 1.5%, glycine 1.5% in normal saline, normal saline, or no fluid (controls). The animals were decapitated when they were dying from the infusion, or else 7 days later, and 69 hearts were examined by light microscopy and 4 by electron microscopy. Rupture of the histoskeleton and hypoxic lesions in the subendocardium were observed in 47% and 35%, repectively, of the mice given glycine 1.5%, while the incidence averaged 20% in the two other groups. Rupture occurred in 38% of the mice that died, in 23% of those that survived an infusion, and in 0% of the controls. Hypoxic changes correlated with bradycardia, which is a sign of glycine absorption in the clinic. In conclusion, rupture of the histoskeleton and hypoxic changes occur in the subendocardium of mice after volume loading. These morphological changes were aggravated by the hypo-osmotic properties of glycine 1.5%.

Common extensor tendon rupture following corticosteroid injection for lateral tendinosis of the elbow.

Corticosteroid injections are commonly administered to athletes to relieve symptoms of lateral elbow tendinosis. This report presents a case of almost total rupture of the common extensor origin in a 45 year old female squash player secondary to such a procedure.