Intrathecal antibody kinetics in neuroborreliosis: A report on three cases and a literature review.

Borreliosis is a common affliction in northern countries and its neurological manifestations often mislead trained clinicians. We present three cases of Lyme neuroborreliosis, with intrathecal synthesis of specific antibodies, lymphocytic meningitis and magnetic-resonance imaging (MRI) findings. Our description aims at illustrating the natural history of the infection, highlighting persistent intrathecal synthesis of anti-Borrelia antibodies months after treatment completion, and its clinical significance. We then review the literature on MRI findings in neuroborreliosis and the kinetics of intrathecal synthesis of specific anti-Borrelia antibodies.

[Multiple arterial dissections and inflammatory syndrome: apropos of 4 cases]. / Dissections artérielles multiples et syndrome inflammatoire: à propos de 4 observations.

We report four cases of multiple arterial dissection associated with an inflammatory syndrome. The features of lesions and the absence of histological inflammatory arterial disease suggest an arterial dysplasia complicated by an infectious disease.

[Long-term results of the treatment of diffuse systemic scleroderma with interferon-gamma]. / Résultats à long terme du traitement des sclérodermies systémiques diffuses par l'interféron gamma.

There are very few drugs effective in the treatment of diffuse scleroderma and therefore we conducted an open study with gamma interferon. Among 20 diffuse scleroderma, evolving since less than 3 years, an improvement was observed in 8 patients. There was no serious side effect. Survival of these 20 patients was 85% at 5 years.

[Role of antiphospholipid antibodies in fetal loss]. / Rôle des antiphospholipides au cours des pertes foetales.

A review of the literature and our own experience have shown that the three types of antibodies to phospholipids (APL) usually looked for (i.e. dissociated treponema serology, antiprothrombinase and anticardiolipin) increase the risk of foetal loss, irrespective of whether the mothers have or do not have systemic lupus erythematosus. The prevalence of APL may exceed 40 percent in some series of women who suffered at least 3 foetal losses. Conversely, the incidence of foetal loss (often late in pregnancy) in women with APL has been estimated at 25 to 75 percent, depending on the studies. The presence of lupus seems to increase the risk. There is no consensus on the best factor predictive of foetal loss (antiprothrombinase or one of the anticardiolipin isotypes). Foetal loss seems to be caused by thrombosis of the placenta, the origin of which remains controverted. The therapeutic escalade consists of abstention (in the first pregnancy), aspirin (about 100 mg/day), aspirin-corticosteroid combination or subcutaneous heparin, high-dose intravenous immunoglobulins and plasmapheresis. With these various methods, the birth of a normal child can be expected in almost every case.

[Acalculous cholangitis and cholecystitis in two AIDS patients]. / Cholangites et cholécystites alithiasiques chez deux malades atteints de SIDA.

Acalculous cholangitis and cholecystitis may occur in the course of AIDS. The symptoms are always the same: pain in the right upper quadrant, fever, nausea, vomiting, anorexia and diarrhoea, associated with biochemical signs of cholestasis, often without jaundice. Morphological explorations show thickening of the gallbladder wall and dilatation of the extrahepatic bile ducts, sometimes associated with stenosis of the major duodenal papilla and dilatation of the intrahepatic bile ducts.

[Multiple cholesterol embolism mimicking periarteritis nodosa]. / Embolies multiples de cholestérol simulant une périartérite noueuse.

Ten men aged 56 to 84 were hospitalized with a diagnosis of periarteritis nodosa, whereas they had multiple cholesterol embolism. The diagnosis was corrected post mortem in the first 3 patients and subsequently in live patients. The particularly misleading clinical manifestations were neurological (polyneuritis in 5 cases, mononeuritis in 1, central nervous system disorders in 3), pulmonary (alveolar haemorrhage in 2 cases, respiratory failure of unknown mechanism in 4) and pericardial (2 cases). Five patients had eosinophilia (more than 500 eosinophils/mm3). The elements that led to the correct diagnosis were the presence of vascular risk factors in all 10 patients (but hyperlipidaemia in only one), severe complications of the atheromatous disease in all cases, a precipitating or aggravating factor in 8 patients (anticoagulant therapy in 7, arteriography in 6) and the finding of purple or necrotic toes (6 cases). Histological (5 cases) and/or ophthalmological (2 cases) evidence was obtained in only 6 patients. Seven patients died 1 to 3 years after the onset of the disorders. Studies on low-density lipoprotein metabolism are in progress to determine the mechanism of clinical manifestations unexplainable by embolism.

[Bone marrow transplantation in the treatment of autoimmune diseases. ISAMAIR Group]. / Les greffes de moelle dans le traitement des maladies auto-immunes. Groupe ISAMAIR.

EXPERIMENTAL BASIS AND CLINICAL OBSERVATIONS: Remission of an autoimmune disease has been observed in certain patients after bone marrow allograft from a healthy donor. Autoimmune disease in the donor can also be transmitted to an unaffected recipient. These phenomena would be hematopoietic-dependent. BONE MARROW ALLOGRAFTS: Indications for the treatment of refractory autoimmune diseases are exceptional due to the related mortality even in patients without malignant hematologic disease. A NEW THERAPEUTIC CONCEPT: Therapeutic intensification, followed with autologous peripheral stem cell grafts, a procedure with a mortality below 3% in 1997, constitutes a therapeutic alternative in these difficult indication concerning severe refractory autoimmune diseases including: sclerodermia, vasculitis, lupus, inflammatory myositis, autoimmune cyopenia.

[100 essential drugs. An internal medicine approach]. / Les 100 médicaments essentiels. Une approche de médecine interne.

PURPOSE: Up to 4600 drugs in about 15,000 pharmaceutical forms are available in France which may be a source of misuse with increased occurrence of side effects and costs. While the World Health Organization is encouraging each developed country to work out its own list of essential drugs. The list provided in 2008 by the French Office for the safety of health products has had so far limited impact on practice, so it became obvious to a group of internists to work out a "wise list" of 100 essential medicines covering 95% of the disorders observed in France. METHODS: In June 2011, 10 internists agreed to each provide a list of 100 essential medicines, according to individual experience. In December 2011, a meeting of the participants provided a list as initial consensus and mandated five among them to make proposals for those areas neglected by too many participants or in which needless dispersion of medicines was stated. After internet-facilitated exchanges, an additional list was validated in mild-January 2012. RESULTS: Fifty-four drugs were included in the list of initial consensus (including nine selected by all 10 participants), and 46 in the additional list. So the final "wise list" included 100 drugs. In June 2012, 56 of these drugs were available as generics. This list was compared to those lists set out by five countries in the European Union. CONCLUSION: Generating such a list is feasible. Undoubtedly still non-comprehensive, this list will benefit from the expertise of 14 general practitioners who are currently working out a similar list across France. The final list will be submitted for validation by the French associations of generalist teachers and Internists.

Immunological disorders in C virus chronic hepatitis.

Hepatitis C virus infection can be accompanied by a number of systemic, non-specific or autoimmune disorders and by extra-hepatic biological abnormalities. Their exact prevalence remains to be determined, together with their association with certain pathologies such as non-Hodgkin lymphoma. The most frequent biological peculiarity is cryoglobulinaemia, found in more than 50% of patients. It is only symptomatic in less than one-third of cases (as purpura, Raynaud's syndrome, neuropathy or renal failure), and could be the origin of benign lymphoproliferative haematological pathology, then of a malignant one (non-Hodgkin lymphoma). Rheumatoid arthritis may develop in 20-25% of cases. Periarteritis nodosa is a rare but possible occurrence. Autoimmune disorders proper include hepatitis with anti-LKM1 antibodies, thyroiditis, skin manifestations, complex connectivitis and Gougerot-Sjögren's syndrome. This syndrome is histologically detected in 15-50% of patients. It affects women preferentially and is usually not accompanied by anti-SSA or anti-SSB antibodies. Thyroidites are different from those occurring under Interferon-alpha therapy, and should be systematically investigated before initiating that therapy. Lichen planus can be associated to HCV infection. The proven induction of autoimmune disorders by Interferon therapy requires that immune disorders be fully assessed before treatment initiation, and close monitoring for their occurrence is necessary throughout the treatment course. TSH and thyroid hormone in particular should be closely monitored.

Diagnosis of 22 new cases of Bartonella endocarditis.

BACKGROUND: Bartonella species are emerging pathogens that are seldom reported as a cause of blood culture-negative endocarditis. OBJECTIVE: To report the occurrence of, risk factors for, and clinical features of Bartonella endocarditis and to evaluate the diagnostic tools available for this condition. DESIGN: Case series and comparison with past series. SETTING: Multicenter international study in Halifax, Nova Scotia, Canada; Lyon, France; and Marseille, France. PATIENTS: 22 patients from France, England, Canada, and South Africa were investigated for blood culture-negative endocarditis. MEASUREMENTS: Titer of antibodies to Bartonella species by microimmunofluorescence assay, blood or vegetation culture, and amplification of Bartonella DNA from valvular tissue by polymerase chain reaction. Cross-adsorption was done for patients with antibodies to Chlamydia species. RESULTS: 22 patients had definite endocarditis. Five were infected with B. quintana, 4 with B. henselae, and 13 with an undetermined Bartonella species. These cases were compared with the 11 previously reported cases. Of the patients with the newly reported cases, 19 had valvular surgery and 6 died. Nine were homeless, 11 were alcoholic, 4 owned cats, and 13 had preexisting valvular heart disease. Bartonella species caused 3% of the cases of endocarditis seen in the three study centers. The patients with these cases could have previously received a diagnosis of chlamydial endocarditis because of apparently high levels of cross-reacting antibodies to Chlamydia species. CONCLUSIONS: Bartonella species are an important cause of blood culture-negative endocarditis and can be identified by culture, serologic studies, or molecular biology techniques. Alcoholism and homelessness without previous valvular heart disease are risk factors for B. quintana infection but not for infection with other Bartonella species.

Ribavirin in hepatitis C related cryoglobulinemia.

OBJECTIVE: An open, uncontrolled trial of ribavirin, an oral guanosine nucleoside analog for treatment of hepatitis C, in patients with hepatitis C virus (HCV) associated cryoglobulinemia intolerant to interferon. METHODS: Five patients with cryoglobulinemia related to HCV infection unresponsive to interferon therapy received oral ribavirin (100 to 1200 mg daily) for 10 to 36 months. RESULTS: Patients treated with ribavirin had prompt decrease in serum aminotransferase levels and marked improvement of manifestations of cryoglobulinemia within a few weeks. Ribavirin did not eradicate HCV RNA from the sera, but a decrease in viral load was observed in 3 patients, from 232 to 86 x 10(5) copies HCV/ml. Relapse occurred within 3 months once therapy was discontinued. The drug was well tolerated, but mild dose related hemolysis was common. CONCLUSION: Ribavirin monotherapy may be effective in patients with symptomatic cryoglobulinemia related to HCV infection, but this effect is not sustained when ribavirin therapy is discontinued.