[Skin and mucosal erosions revealing secondary syphilis with otologic and eye disorders]. / Érosions cutanéo-muqueuses révélant une syphilis secondaire avec atteintes otologique et ophtalmologique.

BACKGROUND: The clinical polymorphism of syphilis leads to diagnostic issues. We report a case of secondary syphilis revealed by skin and mucosal erosions, and responsible for sensorineural hearing loss and asymptomatic papillitis. PATIENTS AND METHODS: A 55-year-old man presented oral and peri-anal erosions as the initial symptoms of secondary syphilis. He reported hypoacusis and a pure-tone audiogram revealed bilateral sensorineural hearing loss. Ophthalmological investigation revealed isolated right papillitis and superior temporal scotoma with blind-spot enlargement. TPHA-VDRL serology was strongly positive for plasma (TPHA 1/10,240 and VDRL 1/64) but doubtful for cerebrospinal fluid. For his hearing and eye disorders, considered as related to neurosyphilis, the patient received a 14-day course of intravenous penicillin G, associated with systemic corticosteroids with gradual reduction over a period of fifteen weeks. The patient's skin and mucosal erosions resolved, as did his papillitis. His hearing loss remained stable. Serological monitoring at three months showed a sixteen-fold decrease in VDRL titre. DISCUSSION: The re-emergence of syphilis has led to increasing incidence of related ophthalmological and otological disorders. This report highlights the first-line role of the dermatologist in systematic diagnosis and in screening for associated involvement.

[Relapse in schizophrenia: an exploratory study of the joint conceptions of patients, parents and caregivers]. / Regards croisés sur les signes précoces de rechute des sujets schizophrènes.

INTRODUCTION: The question of the course of schizophrenia relapses, is of considerable interest in different clinical and social areas such as prognosis, quality of life, therapeutic relationship, psychoeducation, rehabilitation and so on. The more the schizophrenic relapses, the higher the level of handicap. Although there is a widespread agreement that it is essential to detect early signs of relapses in order to prevent them, there still remain theoretical and methodological difficulties in identifying these signs because they are personal, heterogeneous and not always specific to psychosis. That is why the notion of "relapse signature" seems relevant by taking into account differentiated and personal assessment of early signs of relapse. This implies the consideration of the different visions of relapse given by patients, parents and caregivers. OBJECTIVE: We propose a qualitative study of the joint appraisal of patients, patients' parents and medical staff. The aim of this study is to regroup the expertises in order to further our understanding of the early signs of relapse. We assume that patients and parents are able to describe signs that are not considered as pathological symptoms, but refer to a personal manner of initiating the relapse process. This should then help in designing early intervention and provide reinforced therapeutic alliance and more positive responses to psychoeducation programs. METHOD: We have interviewed 30 subjects divided in three groups: 10 schizophrenic patients, 10 caregivers (including physicians, psychologists and nurses) and 10 parents of schizophrenics. The patients met the following criteria: patients with a diagnosis of schizophrenia (DSM IV criteria), under neuroleptic treatment, and stabilized. The mean duration of illness was 15 years. The patients as well as caregivers were recruited in two external hospital structures. All the subjects gave their written consent for this study and its methods. We did not recruit parents who were not living with their schizophrenic child or who did not see or have frequent contact with him or her for this study. We conducted a semistructured interview and analysed the transcripts of the narratives provided by our three groups on the definition of relapse and early signs of relapse. Recorded interviews were processed using the Alceste Method, a computer program of textual analysis that identifies the word patterns most frequently used by the subjects. Alceste creates classes of words using a hierarchical descending classification. The description of each class is presented in the form of a word list (with the value of the word's Chi(2) association in this class). We assessed the awareness of problems using the 8-Q. RESULTS: The three groups described relapses as a distressed, even traumatic experience. This experience is shared by the patients' siblings who sometimes mention violent situations and difficulties at home. The analysis showed that each group uses a compartmentalized universe of speech. This raises the question of the communication and the sharing of information between the different groups. Parents who didn't live the relapse of their children and the caregivers gave prepsychotic or psychotic symptoms of relapse. Conversely, parents who had lived relapse(s) of their children gave nonspecific and very personalized signs of relapse (e.g., "When she relapses, our daughter eats much more cheese than usually"). The patients with a low level of awareness of his/her problem were able to describe early signs of relapse. They described mood and sleep disturbances. This is an unexpected result and calls for a debate on the need or not to have good insight in order to follow a psychoeducation program. CONCLUSION: This study insists on the complementarity of different conceptions of all persons involved in schizophrenic relapse in order to identify as accurately as possible the "relapse signature" of patients. According to us, and in order to promote suitable subjective data to increase insight, compliance and therapeutic alliance, psychoeducation programs should rely on these personal criteria rather than propose systematic programs. Then the relapse signature could be the first step to the appropriation of the course of illness and control of psychotic symptoms by schizophrenic patients.

[The case of temporal lobes dysfunction in atypical psychiatric episodes]. / Dysfonctionnement des lobes temporaux et tableau psychiatrique atypique : à propos d'un cas.

CASE-REPORT: A thirty-seven-year-old man, with temporal epilepsy, had transient, atypical psychiatric states with periods of time without any symptom. These episodes included hypersexuality with qualitative changes of sex drive, obscene behavior, exhibitionism, masturbation and modified sexual orientation. Blunted affect, inability to recognize significant persons (visual agnosia) were also detected. Magnetic resonance imaging was normal and interictal single-photon emission computed tomography (SPECT) showed decreased cerebral perfusion in both temporal lobes. DISCUSSION: The principal hypothesis is a Klüver-Bucy syndrome (KBS). In animals and human beings, this syndrome can be produced by bilateral temporal lobectomy. It is characterised by hypersexuality, visual agnosia, strong oral tendency, dietary changes, hypermetamorphosis and blunted affect. A minimum of three KBS elements suggests bilateral temporal dysfunction and supports the diagnosis. The syndrome may occur in herpes encephalitis, head trauma, Pick disease and temporal epilepsy. A single case of a patient, without any evidence for structural lesion in temporal lobes, is presented with many KBS symptoms, behavioral changes being due to complex partial seizure. Bitemporal dysfunction for this patient was confirmed by SPECT scan. On the other hand, the detected behavioral changes cannot be explained by temporal epilepsy alone. Postictal hypersexuality in temporal epilepsy consists in sexual arousal but not sexual aberrations as found in KBS. CONCLUSION: KBS following complex partial status epilepticus is a rare phenomenum. The case described here shows how atypical psychiatric episodes can cover complex neurologic disorders.

[The tolerability and efficacy of combined antidepressant therapy: literature review]. / Tolérance et efficacité des associations d'antidépresseurs: revue de la littérature.

There are many pharmacological strategies in order to manage depressed patients with treatment resistance. Combined antidepressants therapy is currently prescribed, mostly for depressions which resist to a single antidepressant, or to another therapeutic, such as electric-convulsive-therapy. Combined treatments are usually considered to have a more rapid action than monotherapy, although mainly is based on personal experience. It is generally admitted that the better efficacy of combined antidepressants therapy with different biochemical characteristics is explained by the synergic action of both norepinephrine and serotonin systems. The combination treatment of MAOI and tricyclic agents has been widely studied, sometimes on hundreds of patients. Numerous studies showed a good efficacy, and the toxicity of such an association was exaggerated, thus they are nevertheless rarely prescribed. As reversible MAOI-A are now available, combination treatment with tricyclic antidepressants is theoretically safer. The combination treatment of SSRI and tricyclic antidepressants is more frequently reported in the recent literature. Studies analysing such an association are however insufficient, and cannot lead to any clear conclusion. The combined treatment of mianserin and tricyclic antidepressants have also been quoted, with an efficacy that has been confirmed on randomized placebo-controlled studies. Resistant depressions are the main indication for combined antidepressants therapy. Anxious disorders have recently been considered as interesting new indications, such as panic disorder or obsessive compulsive disorder, with or without a comorbid mood disorder. In conclusion, controlled studies devoted to the analysis of combined antidepressants therapy are relatively few, and do not allow to draw any conclusion about their efficacy. Nevertheless, as this type of prescription is frequent, scientific evaluation of their specific efficacy is needed.

[Chronic crisis or recurrence of emergencies]. / Crise chronique ou répétition de l'urgence.

The authors have studied the characteristics of a group of chronic crisis patients among those who were treated in the psychiatric emergency unit of René-Dubos General Hospital (Pontoise, France). The population was defined as patients who visited the unit four times or more during one year (from 01/07/1991 to 30/06/1992). These 70 patients represent 4.3% of the total number of individuals who were treated in the emergency setting during the same year. 1568 patients were treated as out patients, or hospitalized for a short time, not exceeding 48 hours). Two sub groups can be distinguished. The first one is composed of patients who repeat their visits during a total period of less than 3 months. The second sub group is composed of repeaters who are seen regularly but for a longer period of time. The socio demographic and clinical characteristics (DSM-III R) of the two sub groups are discussed.