[Legionella myopericarditis]. / Myopéricardite à Legionella.

Cardiac involvement in legionella infection is rare but it is the most common extra-pulmonary complication. It usually takes the form of pericarditis, but a case of legionella myoparicarditis with global left ventricular hypokinesia on echocardiography has been described. The authors report a case of myopericarditis with massive pulmonary oedema and respiratory distress which regressed clinically and on echocardiography with reduction in chamber dilatation and complete recovery of left ventricular function. Legionellosis was confirmed on serology. The infection was probably contracted during a previous hospital admission, therefore, probably a nosocomial infection. Following the description of this case, a review of the literature is proposed.

[Encephalopathy and memory disorders during treatments with mefloquine]. / Encéphalopathie et troubles mnésiques au cours des traitements par la méfloquine.

Benign psychiatric side effects have been frequently associated with mefloquine therapy. On the other hand, severe psychiatric disorders due to mefloquine are rare but must be detected by physicians. Two such cases are reported. In the first case, excessive curative mefloquine therapy caused an acute psychotic state which ultimately regress without treatment. The second report concerns a transient memory failure following prophylactic mefloquine treatment. The causative role of this compound is being discussed and the importance of a differential diagnosis of neuropsychiatric disorders from toxic or parasitic origin is underlined. Circumstances aggravating such neuropsychiatric side effects and actual recommendations concerning the prescription of mefloquine are recalled.

[Acute hepatic steatosis of pregnancy. Apropos of a case and review of the French literature]. / Stéatose hépatique aiguë gravidique. A propos d'un cas et revue de la littérature française.

Acute fatty liver of pregnancy, or Sheehan's syndrome, is a rare complication of pregnancy, occurring in about 0.5% cases of jaundice in pregnancy. The anatomo-clinical picture and the biology of the condition is described using as basis a personal case history and the 28 cases to be found in the French literature. The condition shows, vomiting, abdominal pain and tachycardia in an apyrexial patient in the 3rd trimester of the pregnancy in which the disease occurs. The date shows itself a few days after the prodromal symptoms and is characterised by the triad of pruritus, jaundice and encephalopathy. All cases show an increased white blood count and hyperbilirubinaemia. If the condition goes on to become very serious one has to look for signs of haemorrhage and of liver and renal failure. Liver biopsy confirms the diagnosis. Prognosis will be improved if moderate forms are recognized early and if the condition is watched carefully. It may be necessary to stop the pregnancy before the serious conditions of the illness show up. Labour induced at the 37th week after checks had been made for fetal pulmonary maturity seemed to be a good way of treating the condition even if it has not yet become desperate. The final prognosis for the mother and the baby is always favourable if the baby is born alive.

[Anaphylactic reaction with coronary spasm following coronarography]. / Réaction anaphylactique avec spasme coronarien. Au décours d'une coronarographie.

The authors report a case of anaphylactic shock following the injection of iodinated contrast medium for coronary angiography and complicated by two spasms affecting segments II and III of the right coronary. Vasospasm was relieved by the injection of linsidomine, revealing an angiographically healthy segment III. Such complications associated with various substances, notably iodinated contrast media, are rare. They should nevertheless always be borne in mind when evaluating anaphylactic type reactions. Vasoactive mediators (histamine, serotonin, arachidonic acid metabolites) released by the allergic reaction appear to play a major role. Treatment based upon pathogenesis can be proposed.

[Multiple sclerosis disclosed by spinal anesthesia]. / Sclérose en plaques révélée par une rachianesthésie.

A case is reported of an acute onset of previously undiagnosed multiple sclerosis, revealed by an oculomotor paralysis following spinal anaesthesia performed for minor orthopaedic surgery. The need for a complete preoperative physical examination is underlined by this case, looking for latent neuromuscular disorders before undertaking such techniques, and for a thorough neurological work-up should such a complication arise. The harmlessness of regional anaesthesia in multiple sclerosis patients is controversial; without entering into such a debate, the direct relationship between spinal anaesthesia and acute exacerbation of the disease in our patient seemed more than likely.

[Acute respiratory distress syndrome caused by tuberculosis]. / Syndrome de détresse respiratoire aiguë d'origine tuberculeuse.

The adult respiratory distress syndrome (ARDS) is rarely due to tuberculosis. Two new cases are reported here. Both were female patients, aged 33 and 41 years. The first, of North African origin, was admitted for epigastralgia, hyperpyrexia and intestinal problems. She underwent an exploratory laparotomy, which only showed oedematous mesenteries. Hepatic and lymph node biopsies revealed an ongoing tuberculosis. On the 4th postoperative day, she developed ARDS. Despite an initial period of improvement after proper treatment (antituberculous drugs, steroids, positive pressure ventilation) had been started, she died 27 days later. In the other patient, smoker and alcoholic, the diagnosis of tuberculosis relied only on bacterial culture of various excretions. She also died after 8 days of treatment. In both patients, the symptoms were atypical. The febrile non cardiogenic pulmonary oedema of sudden onset masked the typical miliary mottling pattern on chest X-rays. The life-threatening character of this condition requires that rapid histological studies are carried out to obtain an early diagnosis. Indeed, the precociousness of appropriate treatment seems to be the essential element of the prognosis.

[Torsades de pointes and hypomagnesemia]. / Torsades de pointe et hypomagnésémie.

The authors report a case of "Torsades de pointe" occurring in a patient subjected to intensive surgical care and presenting several causes of magnesium loss: mutilating abdominal surgery, exteriorized gastric fistula, administration of Henle's loop diuretics, electrolytic disorders and exclusive parenteral nutrition without any magnesium Mg supplement. The arrhythmia appeared in the third week and the usual treatment was ineffective. The level of plasma magnesium was below the measurable values on three separate occasions. The administration of magnesium sulphate corrected the dysrhythmia which did not recur. Experimental and clinical data demonstrating the antiarrhythmic effect of magnesium are recalled. The electrophysiological explanation is based on the inhibition of potassium and calcium flow across the cell membrane; magnesium ion has a stabilizing membrane effect and an antagonistic effect on ectopic automaticity. They are particularly important on slowly depolarizing tissue (nodal cells) or partially depolarized cells (ischaemic or digitalis treated cardiac tissue). In intensive care, circumstances for magnesium depletion by digestive or renal losses and by lack of parenteral magnesium supplement are frequently combined. Systematic intravenous administration of magnesium is necessary when such conditions are found and whenever ventricular or auricular dysrhythmias occur.

[Postoperative pernicious malarial attack in a subject, a native of an endemic zone]. / Accès pernicieux palustre postopératoire chez un sujet originaire d'une zone d'endémie.

The case of an Angolan woman who underwent, in her country, an hysterectomy requiring the transfusion of two whole blood units is reported. In the immediate postoperative period, acute renal failure with anuria set in, justifying the patient's transfer to an intensive care unit in France. Upon admission, she had a thick blood film and serology work-up for Plasmodium falciparum, both of which were negative. On the 20th day, the patient presented a pernicious malarial crisis with a concurrent rise in IgG and IgM titres, indicating recent contamination. The mode of infection is discussed: contaminating anopheline bites associated with the interruption of chemoprophylaxis rigorously followed up till then; post transfusion malaria, almost unavoidable in an endemic country; accidental inoculation by Plasmodium falciparum of the dialysis equipment. Finally, the possibility of pernicious malaria aggravating the initial acute renal failure and hypocalcaemia is also discussed.

[Voluntary poisoning by intravenous injection of caustic soda]. / Intoxication volontaire par injection intraveineuse de soude caustique.

A voluntary intoxication by injection in the left basilic vein of 10 ml of concentrated caustic soda is reported. The main effects were, besides local necrosis, haemolysis, acute renal failure with initial anuresis, intravascular coagulation and cyanosis with a normal Pao2 due to methaemalbuminaemia. This was confirmed by using the usual spectrophotometric methods as well as electrophoretic methods.

[Primary ulcerations of the small intestine]. / Les ulcères primitifs du grêle.

The authors report a recent case of primary ulceration of the small intestine revealed by spontaneous perforation. This is a rare condition with a non specific semiology which only exceptionally permits diagnosis before complications occur. The latter are dominated by perforation, gastrointestinal hemorrhage and a sub-acute obstructive syndrome. The lesion, generally single, is found on the anti-mesenteric border of the jejunum or terminal ileum on a short only slightly inflammed segment and pathological examination does not reveal any specific process. Treatment is surgical. It confirms the diagnosis and enables a segmentary resection or simple suture to be carried out. The condition does not recur. A complete etiological investigation is required to exclude other causes of small intestinal ulceration before its "spontaneous" nature may be inferred. Infectious and vascular theories are most often proposed among the pathophysiological hypotheses. Far from being exclusive, these theories may interact and enable a coherent multi-factorial mechanism to be proposed as to the origin of the ulceration (regardless of its initial cause). Spontaneous ulcers are therefore included in a wider nosological classification ranging from stress ulcer to necrosing enteritis.