[Common fungal infections of the foot]. / Les infections fongiques communes des pieds.

Among the dermatological diseases affecting the foot, fungal infections are frequent in a daily practice. Treatments now available allow us to control most of them. However, multiple different clinical manifestations and the variety of fungal agents may lead to inappropriate diagnosis and treatments. The paper will consider cutaneous and nail manifestations of common fungal foot infections, their differential diagnosis and their local and systemic treatments.

Predictors of early ventricular fibrillation before reperfusion therapy for acute ST-elevation myocardial infarction.

BACKGROUND: Early VF accounts for the majority of deaths during the acute phase of acute MI. In patients treated with fibrinolytics, in-hospital VF occurs most frequently with inferior MI. Contrariwise, out-of-hospital VF seems to be associated with anterior wall MI and preinfarction angina (preconditioning) may protect against VF. AIM: To study clinical characteristics of patients with or without VF before or during reperfusion therapy. STUDY DESIGN AND METHODS: From January 1995 until December 2001, we treated 2826 patients for acute MI and reviewed the clinical records of all patients. Patients who developed early VF were classified according to the first episode of VF: either before or during the angioplasty procedure. RESULTS: VF developed in 219 (8%) patients. Early VF before reperfusion therapy (n=145, 5%) was independently related to anterior MI (RR 2.3 (95% CI 1.53-3.50), p<0.001), absence of preinfarction angina (RR 2.1 (95% CI 1.38-3.24), p=0.001) and Killip class >1 (RR 3.8 (95% CI 2.34-6.10), p<0.001). The majority of patients with VF during angioplasty (n=74, 3%) had inferior MI (61%). CONCLUSION: Early VF before reperfusion therapy is independently associated with anterior MI, absence of preinfarction angina and Killip class >1, whereas the majority of patients with VF during angioplasty have inferior MI.

Nail destruction in pemphigus vulgaris.

Involvement of the nails in pemphigus vulgaris (PV) is rare and is usually seen when the disease is severe. The most common clinical manifestations are chronic paronychia and onychomadesis. Finger nails are more frequently involved than toe nails. We report a case of severe and persistent PV in which an exacerbation was preceded by an erosive and destructive lesion of the right hallux nail unit. A nail bed biopsy was performed to rule out a subungual tumour. The image of suprabasal acantholysis yielded the diagnosis of PV. This localisation and clinical manifestation of PV have only been reported once.

Preinfarction angina protects against out-of-hospital ventricular fibrillation in patients with acute occlusion of the left coronary artery.

OBJECTIVES: The goal of this study was to evaluate the effect of preconditioning on out-of-hospital ventricular fibrillation (VF) in patients with acute myocardial infarction (AMI). BACKGROUND: More than half of the deaths associated with AMI occur out of the hospital and within 1 h of symptom onset. In humans, preinfarction angina (PA), which can serve as a surrogate marker for preconditioning, reduces infarct size, but the protective effect against out-of-hospital VF has not been investigated. METHODS: Preinfarction angina status and acute coronary angiographic findings of 72 consecutive patients with AMI complicated by out-of-hospital VF were compared with 144 matched controls without this complication. RESULTS: Preinfarction angina is associated with a lower risk for VF (odds ratio [OR]: 0.40, 95% confidence interval [CI]: 0.18 to 0.88). In patients with acute occlusion of the left coronary artery (LCA) (n = 136), the risk reduction is pronounced (OR: 0.25, 95% CI: 0.10 to 0.66), whereas, in patients with acute occlusion of the right coronary artery (RCA) (n = 67), the protective effect of PA on VF was not observed (OR: 2.25, 95% CI: 0.45 to 11.22). Subgroup and multivariate analyses show that the protective effect is independent of cardiovascular risk factors, preinfarction treatment with beta-adrenergic blocking agents or aspirin, the presence of collaterals or residual antegrade flow or the extent of coronary artery disease. CONCLUSIONS: Preinfarction angina protects against out-of-hospital VF in patients with acute occlusion of the LCA. This protection is independent of risk factors or coronary anatomy. A larger study is needed to examine the apparently different effect in patients with acute occlusion of the RCA.

Fibrinogen and C-reactive protein on admission as markers of final infarct size after primary angioplasty for acute myocardial infarction.

BACKGROUND: In acute myocardial infarction (AMI) treated conservatively or with thrombolysis, marked increases of C-reactive protein (CRP) and fibrinogen have been observed. No data are however available concerning a possible relation between CRP and fibrinogen levels on admission and markers of infarct size after obtaining thrombolysis in myocardial infarction (TIMI) flow III by primary angioplasty. METHODS: We studied 34 patients with a first AMI (29 men, mean age 54+/-11 years) who were treated with primary angioplasty (TIMI flow III in all patients, no concomitant treatment with glycoprotein IIb-IIIa antagonists) within 6 h of onset of pain. CRP and fibrinogen levels on admission were determined and related to the following markers of infarct size: peak creatine kinase MB (CKMB) levels, radionuclide left ventricular ejection fraction (LVEF) at discharge and thallium-201 single-photon emission computed tomography (SPECT) infarct size at 1 month. RESULTS: Median CRP levels were 0.4 mg/dl (range 0.09-3 mg/dl), median fibrinogen levels 412 mg/dl (range 198-679 mg/dl), mean CKMB was 178+/-151 U/l, mean LVEF 52+/-8% and mean thallium-201 infarct size 7+/-6%. Although CRP levels were related to fibrinogen levels on admission (r=0.56, P=0.002), only fibrinogen levels were related to markers of infarct size (r=0.58, P=0.001 for CKMB, r=-0.44, P=0.01 for LVEF and r=0.64, P=0.001 for thallium-201 infarct size). No relation was found between CRP or fibrinogen levels on admission and the extent of coronary artery disease or the myocardial area at risk. In multiple regression analysis, the relation between fibrinogen and markers of infarct size was independent of CRP levels and the duration of pain on admission. CONCLUSIONS: These findings indicate a relation between fibrinogen levels on admission and myocardial infarct size in patients treated with primary angioplasty for AMI. This relation seems to be independent of CRP levels and the duration of pain on admission. If confirmed in larger patient populations, fibrinogen levels on admission could have an important value for risk stratification and more aggressive reduction of infarct size in patients who are treated with primary angioplasty.

Out-of-hospital ventricular fibrillation in patients with acute myocardial infarction: coronary angiographic determinants.

OBJECTIVES: The study intended to compare the acute coronary anatomy of patients with acute myocardial infarction (AMI) complicated by out-of-hospital ventricular fibrillation (VF) versus patients with AMI without this complication. BACKGROUND: More than half of the deaths associated with AMI occur out of the hospital and within 1 h of symptom onset. The angiographic determinants of out-of-hospital VF in patients with AMI have not been investigated in detail. METHODS: Acute coronary angiographic findings of 72 consecutive patients with AMI complicated by out-of-hospital VF were compared with findings from 144 matched patients with AMI without this complication. RESULTS: Patients with an acute occlusion of the left anterior descending coronary artery (LAD) or left circumflex coronary artery (LCx) had a higher risk for out-of-hospital VF compared with patients with an acute occlusion of the right coronary artery (RCA) (odds ratio and 95% confidence interval, respectively, 4.82 [2.35 to 9.92] and 4.92 [2.34 to 10.39]). With regard to extent of coronary artery disease (CAD), the location of the culprit lesion in the coronary arteries (proximal vs. mid or distal), the flow in the infarct related artery (IRA), the presence or absence of collaterals to the IRA and chronic occlusions, there were no differences between the two groups. CONCLUSIONS: Acute myocardial infarction due to occlusion in the left coronary artery (LCA) is associated with greater risk for out-of-hospital VF compared to the RCA. The location of occlusion within LCA (LAD, LCx, proximal or distal), amount of myocardium at risk for necrosis and extent of CAD are not related to out-of-hospital VF.

Reverse redistribution on thallium-201 single-photon emission tomography after primary angioplasty: a one-year follow-up study.

The prognostic significance of reverse redistribution (RR) on thallium-201 single-photon emission tomography (SPET) images after acute myocardial infarction (AMI) has not been studied in detail. Moreover, RR data in patients treated with primary angioplasty are lacking. Fifty consecutive patients (including 40 men with a mean age of 54+/-11 years) with a first AMI were treated with primary angioplasty and followed up for 13+/-5 months for the following end-points: death, reinfarction and recurrent angina requiring revascularisation. Admission and peak creatine kinase myocardial enzyme (CKMB) and ejection fraction (EF) at discharge were studied as markers of myocardial damage. Thallium-201 stress-redistribution SPET studies at 1 month were analysed using a 13-segment, 4-point scoring system. Segments showing a worsening of perfusion by at least 1 point on redistribution studies were defined as showing RR. RR was present in 13 (26%) patients (group 1) and absent in 37 (74%) (group 2). Both groups were comparable for age, sex, peak CKMB release, EF and Q-wave myocardial infarctions. TIMI flow 3 was obtained in 92% in group 1 and 95% in group 2 (P = 0.95). On admission, CKMB was significantly lower in group 1 (18+/-14 vs 44+/-41 U/l, P = 0.03). Also, segments showing reversible perfusion were significantly more frequent in group 2 (1/169 vs 57/481, P = 0. 01). During follow-up, no death occurred and the combined documented endpoint of reinfarction and recurrent angina requiring angioplasty or coronary artery bypass grafting was significantly more frequently reached in group 2 (0/13 vs 10/37, P = 0.046). In conclusion, RR is common (26%) after primary angioplasty for a first AMI and is associated with lesser myocardial damage on admission. Patients with RR rarely have reversible segments on 201Tl SPET and tend to have a favourable outcome after 1 year of follow-up.

An unusual case of squamous cell carcinoma of the nose.

A 49-year-old man presented with a tumoral lesion of the tip of the nose which had been manifest for 2 months. Within a few weeks, the tumour increased in size and became infiltrated. The biopsy showed a squamous cell carcinoma. Treatment consisted of a radical surgical excision.

Primary pulmonary hypertension with fatal outcome in a young woman and review of the literature.

A 32-year-old female is described, who was admitted with symptoms of severe right heart failure. The most likely diagnosis of pulmonary embolism was excluded. Echocardiography and left-right catheterisation confirmed the diagnosis of primary pulmonary hypertension. A possible mediator in the process of PPH could be the appetite suppressants she had taken for some months after her second pregnancy. Before further pharmacologic tests could be performed the patient died in circulatory collapse. Postmortem pathological examination confirmed the diagnosis of PPH by the presence of narrowed pulmonary arterioles, media hypertrophy, thrombotic lesions and normal surrounding pulmonary parenchyma. The literature on primary pulmonary hypertension is revised with special emphasis on diagnosis and treatment algorithms.

The Selvester 32-point QRS score for evaluation of myocardial infarct size after primary coronary angioplasty.

In patients treated successfully with primary angioplasty for a first myocardial infarction, the Selvester 32-point score correlates well with infarct size measured with quantitative thallium-201 perfusion imaging. Therefore, it is a useful parameter for infarct sizing, particularly in patients with anterior infarction or reduced ejection fraction at discharge.

[Clinical aspects of leg ulcers]. / Aspects cliniques des ulcérations des membres inférieurs.

Clinical aspects of leg ulcers are reviewed. Among the most important factors to be kept in mind are: localisation, features of the ulcers and surrounding skin, clinical history and general physical examination. Leg ulcers are most frequently caused by vascular diseases.

[Local treatment of leg ulcers]. / Traitements locaux des ulcères des membres inférieurs.

Local treatments of leg ulcers require necrotic tissues destruction and preventing and reducing surinfection with local antiseptics. Local and general antibiotherapy are proposed in defined circumstances. Choice of local dressings are dependent on necrosis, degree of exustion, global cost and compliance of the patient.

Embolic stroke after unanticoagulated cardioversion despite prior exclusion of atrial thrombi by transoesophageal echocardiography.

Recent studies in patients with atrial fibrillation, not on anticoagulation, suggest that if transoesophageal echocardiography (TEE) excludes the presence of thrombi, early cardioversion can be performed safely without the need for anticoagulation before the procedure. Immediately after successful cardioversion, however, left atrium or left atrial appendage stunning may be present, potentially carrying a risk for de novo thrombus formation. Furthermore, the presence of spontaneous contrast is considered as a contraindication for unanticoagulated cardioversion since it has been associated with postcardioversion thromboembolism. We present a case in which stroke developed in relation to unanticoagulated cardioversion regardless of careful prior evaluation with TEE.

Acute hemorrhage from a pyelocaliceal diverticulum of a native kidney in a renal transplant patient.

A 28-year-old renal transplant patient developed a shock due to an acute bleeding from his right native kidney. An urgent nephrectomy was performed. Macroscopic and histological examination revealed a pyelocaliceal diverticulum as the cause of the hemorrhage. This rare event must be taken into account in every case of an unexplained acute renal bleeding.

[Streptococcus beta hemolytic necrotizing fasciitis. 5 cases in the Brussels area]. / Fasciite nécrosante à streptocoque beta hémolytique du groupe A. Cinq cas dans la région bruxelloise.

In the Brussels area five cases of necrotizing fasciitis occurred during the past two years in patients devoid of any pathology likely to lower the immune defence mechanisms. Alcoholism and the use of non-steroidal anti-inflammatory drugs seem to act as contributory factors. Necrotizing fasciitis develops alone or as complication of a pre-existent dermo-hypodermic infection. A massive use of antibiotics and a wide surgical slitting up failed to prevent a fatal issue in all five patients. Extremely early massive surgery remains vital in this disease.

Florid cutaneous papillomatosis, malignant acanthosis nigricans, and pulmonary squamous cell carcinoma.

A 72-year-old man had florid cutaneous papillomatosis (FCP), which is an obligatory paraneoplastic syndrome always associated with an internal malignancy. The cancer, which is usually intraabdominal and most often gastric in origin, evolves parallel to the FCP. This patient is the first case of FCP occurring in association with a lung malignancy. An association of FCP with other signs of internal cancer is common, with malignant acanthosis nigricans usually appearing many times with the sign of Leser-Trélat. FCP, malignant acanthosis nigricans, and the sign of Leser-Trélat are part of a continuum, developing by a common or similar pathogenic pathway due to an underlying malignancy producing a factor possibly similar to human epidermal growth factor.

Plasma and erythrocyte lipids in two families with heterozygous hypobetalipoproteinemia.

Erythrocyte morphology, kinematic viscosity, and membrane lipid composition have not been well documented in heterozygous hypobetalipoproteinemia (HBL). In our study of nine subjects with HBL from two kindreds, three presented with schistocytes (3-6%) while two of them also showed acanthocytosis (25-35%) on their peripheral blood films. The other affected family members had a normal RBC morphology despite a decreased kinematic viscosity of RBC suspension at 37 degrees C (log eta = 0.20 +/- 0.02 vs. log eta = 0.26 +/- 0.02) in all nine subjects; erythrocyte osmotic fragility however was normal. Although some subjects showed acanthocytosis total cholesterol (0.63 +/- 0.05 mol x 10(-6)/mg membrane protein) and sphingomyelin/lecithin ratio (0.905 +/- 0.042) of RBC membranes were normal while plasma from the subject with schistocytosis had a significantly decreased sphingomyelin/lecithin ratio in plasma (17.2 +/- 2.4 vs. 29.1 +/- 3.3) suggesting that sphingomyelin and lecithin are not freely exchangeable between plasma and the outer surface of RBC membranes.

Creatine determinations as an early marker for the diagnosis of acute myocardial infarction.

In the acute phase of acute myocardial infarction (3-8 h after onset of symptoms) an early transient increase in the creatine concentration of serum, saliva, and especially of urine can be observed. Due to the renal threshold, urine values give a much better discrimination between infarction patients and controls than do serum determination. In some patients secondary peaks of serum and urine creatine concentrations can be seen about 24-36 h after hospital admission. Intramuscular injections of 5.0 mL of a saline solution and muscular trauma interfere with the test, but with angina pectoris interference is absent or limited. Creatine leakage from myocardium is insufficient to explain the observed creatinuria in infarctions, and intact extra-cardiac tissues are believed to be involved in creatine release.