Chorea associated with anti-phospholipid antibodies: case report.

A seventeen year-old boy developed left sided chorea in a few days, subsequently involving the four limbs. Although he presented a marfanoid phenotype, genetic analysis of the Fibrillin 1 was normal. The genes for familial chorea and Huntington's disease were also negative. Biological tests showed normal serum homocystein, but revealed very high levels of anti-beta2-GP1 IgG, anticardiolipin and lupus anticoagulant, which remained at similar values for a period of over three months. Electroencephalogram and cerebral magnetic resonance imaging (MRI) showed no abnormalities. Brain PET-scan disclosed bilateral striatal hypermetabolism. The patient was treated with methylprednisolone and low dose of acetylsalicylic acid. He improved markedly after six weeks of treatment, and choreic movements disappeared completely after two months. A control PET-scan performed at this time showed reversion of striated hypermetabolism to a normal pattern. The pathogenic aspects of this relatively rare case of chorea are discussed.

[Demyelinating cerebral lesions in an immunocompetent HIV-1 patient]. / Lésions cérébrales démyélinisantes découvertes chez un patient immunocompétent VIH-1+.

We report the case of a 32-year-old immunocompetent HIV patient, presenting with acute demyelinating leukoencephalopathy. The patient displayed clinical and radiological features similar to multiple sclerosis. Histology revealed inflammation with necrosis, demyelination and destruction of axons. Serum tests were negative for various infectious agents as well as specific cultures and PCR. Corticotherapy and many antibiotic treatments failed. Resorption of the lesions occurred after partial excision and highly-active antiretroviral therapy (HAART). No recurrence was noted. This demyelinating cerebral disease was considered as the primary manifestation of HIV infection. HIV implication in the genesis of the process and its perpetuating this condition was suspected, but the mechanism is unclear. Dysimmune consequences related to the early course of HIV infection could be prevented by antiretroviral treatment. This study was the first description of tritherapy effectiveness on HIV related multiple sclerosis (MS)-like illness.

[New approaches to the treatment of the HIV-infected patient]. / Nouvelles approches dans la prise en charge de l'infection à VIH.

HIV infection remains a major problem of public health in Belgium as well as globally. The number of new diagnosies of HIV infection in Belgium remains between two and three daily. Given the dramatic effect of antiretroviral therapy on the mortality due to HIV infection, the number of patients is constantly increasing. The different problems related to HIV care are also changing. Aging of the patients and chronic exposure to antiretroviral medications have induced new complications. We will present in this brief article several new experimental and clinical approaches in which our centre has participated during the last two years.

Endemic alveolar echinococcosis in Southern Belgium?

Until now, Belgium has been considered as a low-risk country for alveolar echinococcosis. However it was recently demonstrated by necropsy series that, in some parts of southern Belgium (Wallonia), up to 51% of the red foxes (Vulpes vulpes) may be infected by E. multilocaris. The authors, working in a university hospital in southern Belgium, described in 2002 the first autochthonous Belgian case of hepatic alveolar echinococcosis. More importantly, in 2004, they diagnosed three other patients with alveolar echinococcosis. One underwent surgical resection, but two others had bilateral pulmonary involvement at time of definite diagnosis. Palliative albendazole therapy was initiated. These patients had been diagnosed with hepatic mass from unknown origin for several months. The previous experience with the first case allowed the authors to consider and to confirm alveolar echinococcosis diagnosis, made by pathology and/or serological tests and imaging. These four patients with alveolar echinococcosis were living either in the Liege or the Luxembourg province. Considering the high prevalence of E. multilocaris infection of red foxes and the recent increase of the fox population due to rabies vaccination in southern Belgium, and also the presence of E. multilocaris infection of red foxes in northern Belgium, it is likely that not only Wallonia, but also maybe the whole Belgium, may face endemic alveolar echinococcosis in the next years.

[Alveolar echinococcosis]. / L'echinococcose alvéolaire: une zoonose d'apparition récente en Wallonie.

Alveolar echinococcosis is a serious parasitic disease, leading to large hepatic lesions. It must be distinguished from cystic echinococcosis, or hydatic cyst, caused by Echinococcus granulosus. Early diagnosis may allow surgical removal of the lesions by segmental hepatectomy, the only curative treatment. Parasitostatic medical treatment with albendazole may promote stabilization of the disease. Until recently, Belgium was considered a country at very low risk for alveolar echinococcosis, as no human case was reported, despite up to 51% of fox infection in southern Belgium autopsy series. Recently four patients presented with alveolar echinococcosis at the University Hospital Center of Liege, leading to the fear of a possible alveolar echinococcosis endemy in southern Belgium. Two of these patients underwent curative hepatectomy, but the other two had already pulmonary metastases at diagnosis and received palliative albendazole therapy. This article presents these cases, and reviews the clinical features of this parasitic disease.

[Identification of factors influencing the response of antiretroviral treatment]. / Identification de facteurs influençant la réponse à un traitement antirétroviral combiné.

OBJECTIVE: The authors had an aim to define the ideal patient profile by determining the factors responsible for an initial variation of CD4 lymphocytes and viral load, and the effect of these factors on the therapeutic response after 12 months of treatment in HIV infected patients. PATIENTS AND METHOD: A retrospective study was made on data concerning the clinical stage, the HIV phenotype strain, the therapeutic status, and the type of treatment. This data was compared to the CD4 count and the viral load before and after 12 months of treatment. RESULTS: Initially, CD4 lymphocytes values were low in case of: phenotype SI (p = 0.012), patient in clinical stage C (p < 0.0001), or treated with protease inhibitor (p < 0.0002). The viral loads were high for patients in stage C (p < 0.0002) and treated with protease inhibitor (p < 0.0001). After 12 months of treatment, the increase of CD4 count was lower in patients with phenotype SI (p = 0.05). Furthermore, the viral load was statistically more important in naive patient (p < 0.0001). CONCLUSION: According to our study, the ideal patient is naive and presents with phenotype NSI.

[Prevention of malaria in the adult]. / Prévention du paludisme chez l'adulte.

Great scourge of poor countries, malaria is the most important tropical parasitic disease. It is responsible for a large number of deaths in concerned countries and represents a real danger for travellers going to endemic regions. So, prophylactic measures are essential. On the one hand protective measures against mosquito bites, by wearing covering clothes, by using repellents and bed net (eventually impregnated with insecticide) will be useful. On the other hand, chemoprophylaxis is most often necessary, adapted to the possibility of chloroquine resistant P. falciparum, to the length or conditions of travel, and to the traveller's antecedents and age. Special concern about pregnant woman is necessary, due to potential severity of malaria. Chemoprophylaxis needs to be continued after coming back, for a duration depending on the drug used. Unfortunately, no prophylaxis is 100% effective, and the appearance of fever during the travel or two to three months after return requires medical advice. In some circumstances, it is necessary to prescribe a stand-by emergency treatment, if no quick medical advice is possible.

[Management of HIV infected patients. Experience of the Liege University Hospital Center]. / Prise en charge des patients infectés par le VIH. Expérience du CHU de Liège.

We present data from 112 patients followed in the Infectious Diseases Unit of the Liege University Hospital (CHU Sart-Tilman). The primary goal of this study was to evaluate the efficiency of highly active antiretroviral therapy (HAART) on surrogate immunological and virological parameters. The study also aimed at determining the prevalence of opportunistic infections and iatrogenic metabolical abnormalities in the era of HAART. Data from HIV infected patients under combined treatment were collected from March 1996 till July 1999. The follow-up focused on the variation of the CD4 cell counts and viral load, and the occurrence of opportunistic infections. The average age was 39 +/- 10 years and the sex ratio (M/F) was 2.3. At baseline, the CD4 count was 352 +/- 244/mm3 and the viral load was 4.1 +/- 1.2 log. After 12 months, the CD4 cells were at 540 +/- 374 and the viral load at 2.5 +/- 1.5 log. This favourable outcome was observed in 70% of patients (naive and experienced). Clinically, patients in therapeutic success presented few opportunistic infections, but many drugs related toxicity. Our data demonstrate the efficiency of combined treatment in the management of HIV infected patients. However, the apparition of toxicity problems could limit the benefit brought by these drugs.

[Horton's disease and extra-temporal vessel locations: role of 18FDG PET scan. Report of 3 cases and review of the literature]. / Maladie de Horton et atteintes artérielles extratemporales: utilité de la tomographie par émission de positons au 18FDG. A propos de trois observations et d'une revue de la littérature.

PURPOSE: We report three cases of Horton's disease, in which F18-Fluorine-2-Deoxy-D-Glucose (18FDG) positron emission tomography (PET) demonstrated a clinically unsuspected extra-cranial vessels hypermetabolism. METHODS: Fully corrected whole-body PET was performed in three patients (two women, one man) for exploring a marked inflammatory syndrome. Scanning was acquired 60 min after i.v. injection of 222 MBq of 18FDG in average. RESULTS: In two patients with histologically proven Horton's disease, PET alone showed increased glucose metabolism involving the carotid and sub-clavian arteries as well as the ascending aorta, aortic arch, thoracic and abdominal aorta, and the iliac and femoral arteries. In the third patient, by detecting cervical, thoracic and abdominal vessel hypermetabolism, PET non-invasively contributed to the diagnosis of giant cell arteritis. All patients had complete clinical and biological response to corticoids. PET controls performed 3- to 6-months post-treatment, confirmed the disappearance of the metabolic stigma. CONCLUSION: 18FDG PET may show an increased glucose metabolism in asymptomatic extracranial vessels locations of Horton's arterities. If these observations are confirmed on controlled trials, PET could be particularly useful for non-invasive diagnosing, staging and monitoring atypical clinical forms of Horton's disease. The metabolic imaging could also contribute to a better understanding of the pathogenesis of GCA.

[Is prophylaxis for acute rheumatic fever part of current practice?]. / La prophylaxie du rhumatisme articulaire aigu est-elle encore d'actualité?

Since the sixties, the incidence of rheumatic fever has dramatically decreased. The main causes thereof are progress in the quality of housing and a decrease in the virulence and rheumatogenic potential of streptococcal strains. The primary prevention of rheumatic fever depends on approved antibiotic treatment of streptococcal pharyngitis, whether confirmed or judged likely on clinical grounds. About the secondary prevention by long action penicillins, it should be stressed that an increased level of anti-streptolysins does not support this treatment if revised clinical Jones' criteria are not met. As a matter of fact, this secondary prevention is rarely indicated at the present time in our country. However, if rheumatic fever would become epidemic again, as it happened abroad rather recently, this secondary prevention should be reactivated.

[Still's disease in the adult]. / La maladie de Still de l'adulte.

The Adult Onset Still's Disease (AOSD) is an entity of unknown origin characterised by fever, polyarthralgias or polyarthritis, a pharyngitis, a cutaneous eruption and elevation of leucocytes. We present observations of 17 patients diagnosed during the last thirteen years. Files of hospitalized patients with suspected AOSD have been examined in a retrospective study and Yamaguchi and Kahn's criterias applied in order to confirm the diagnosis. Treatments undertaken and the evolution have been noted. The sex ratio is 1.83; the middle age of intervening from 42 to 45 years. The middle delay for the diagnosis is 3 to 8 weeks. Fever, eruption and polyarthralgias are the most frequent clinical signs. Elevation of leucocytes, hepatic cytolysis and hyperferritinemia are usual. Constantly, inflammatory tests are increased and the rheumatoid factor and the antinuclear antibodies are negative. Yamaguchi's criterias have been met by all patients. The non steroïd anti-inflammatory drugs and corticoïds constituted the main treatment. In the evolutionary shield, 6 cases of remission have been noted. The other patients evolved toward the chronicity with either a systemic or an articular shape. In the two situations, a state of corticodependance got settled with necessity of association to immunosuppressive drugs. The diagnosis of AOSD is easily done on basis of Yamaguchi's criterias. Corticoïds can permit to control the bouts. There are 3 types of evolution: remission, chronic systemic or chronic articular shape.

A case of hepatic alveolar echinococcosis contracted in Belgium.

We report herein the case of a Belgian 76-year-old woman who developed a hepatic tumour suspected to be a breast cancer metastasis. Radiological imaging and guided biopsies were not contributive. The patient underwent an explorative laparoscopy with frozen sections that did not provide further diagnosis, and an open left bisegmentectomy was performed during the same anaesthesia. Histopathological examination of the hepatic mass showed Echinococcus multilocularis metacestodes, demonstrating alveolar echinococcosis. As our patient denied any travel in foreign countries and has undergone regular abdominal ultrasonographies since her mastectomy, it is highly likely that this alveolar echinococcosis had been contracted in Belgium. If some imported cases may be seldom managed in Belgium, to our knowledge, this case is the first occurrence of alveolar echinococcosis contracted in Belgium. This report, added to the demonstration of E. multilocaris infection of 50% of red foxes in Southern Belgium, and the potential infection of domestic cats and dogs, should attract attention of the medical community on the possible outbreak of endemic alveolar echinococcosis in Belgium, and on the related public health concerns.

[Morphological and metabolic abnormalities related to antiretroviral therapy]. / Les anomalies morphologiques et métaboliques liées aux traitements antirétroviraux.

The long term use of antiretroviral therapy is associated with metabolic and morphological abnormalities named lipodystrophy. The understanding of its epidemiology is in progress. NRTIs and Pls are involved in the origin of these abnormalities. So, NRTIs inhibit mitochondrial gamma polymerase and induce body fat distribution disorders. PIs interfere with lipid metabolism, leading to hyperlipidaemia and insulin resistance symptomatology. The diagnosis is made by clinical (far wasting or accumulation, or mixed syndrome) and biological signs (hyperlipidaemia, hyperglycaemia, hyperlactacidaemia). Radiological exams can quantify morphological abnormalities. The management consists in drug substitution, diet and exercise, and corrective drugs. Plastic surgery can be useful.

[Pharma-clinics how I treat ... an HIV infection. IV. Protease inhibitors]. / Pharma-clinics comment je traite ... une infection par le VIH. IV. Les inhibiteurs de protéase.

Protease inhibitors constitute the last class of antiretroviral drugs appeared on the market. They raised an enormous enthusiasm, reinforced by recent studies results. These molecules prevent the formation of infectious viral particles, while inhibiting a viral enzyme that plays a key role in the cycle of replication of the HIV. Their efficiency, especially in association, is recognized for all stages of the infection and the intervening of a resistance often requires many mutations. However, the unexpected adverse events such as lipodystrophy and some interactions can limit their utilization in first intention.

[Hydroxyurea and HIV infection]. / Hydroxyurée et infection par le VIH.

Hydroxyurea is an anticancerous product, used recently in the treatment of HIV-1 infection thanks to its inhibitory action in viral replication, potentialization of the nucleosides activity (particularly ddI or didanosine) and its cytostatic properties on CD4 and CD8 lymphocytes. Many studies showed its efficiency, as further drug, in initial regimen of a tritherapy (containing ddI) and salvage therapy. The dosage of 500 mg bid seems tolerated well by adults, and 20 mg/kg by children. Long-term tolerance remains unknown. With ddI, it could be proposed in developing countries.

[Prevention strategies against malaria]. / Stratégies de prévention contre la malaria.

In the absence of an efficacious vaccine, malaria prophylaxis remains important for the traveller in endemic areas. In addition to classical measures to protect against malaria vectors, chemoprophylaxis should be selected according to the geographic area. Besides a chemoprophylaxis scheme for the traveller, prevention modalities in pregnant women and in the general population living in an endemic area will also be briefly described.

[Malaria: from diagnosis to curative treatment]. / La malaria: du diagnostic au traitement curatif.

Malaria is a parasitic disease, with variable severity, provoked by the Plasmodium. It is present in tropical zones. The diagnosis is evoked by a fever occurring in a subject coming from a zone at risk, and is confirmed by microbiology. Considering the high prevalence of resistance to chloroquine, the treatment rests on quinine (or its derivatives) associated (or not) with an antibiotic. The severe forms of malaria, due to Plasmodium falciparum, are responsible for a high mortality rate. It requires urgent hospital management is required. Criteria defining this form deserve to be perfectly known.

[Guidelines for the management of patients with HIV infection. I. Adolescents and adults. Liege Working Group on HIV Infection]. / Recommandations pour la prise en charge du patient infecté par le VIH. I. L'adolescent et l'adulte. Groupe de Travail de Liège sur l'Infection par le VIH.

The management of HIV infected patient requires an approach that must put in balance profits expected from a tritherapy (suppression of viral replication, immune reconstitution) and problems related to treatment (difficulty of adherence, side effects, long-term toxicity, resistance). Controversies appear currently on the institution of a precocious treatment, on the use of protease inhibitors at initiation, in order to preserve choices when a modification is necessary. Many concepts, in investigation, are described in the management of a therapeutic failure. Resistance testings progressively find their place in the follow-up. Modes of prophylaxis-interruption of opportunistic infections are established, as well as is the management of professional postexposure. The question remains on how best to advise seropositive couples, about conception, and to elaborate recommendations after non-professional postexposure.