[Systemic Rosai-Dorfman-Destombes disease associated with a myelodysplastic syndrome. Efficacy of hematologic treatment]. / Maladie de Rosai-Dorfman-Destombes (RDD) multifocale réfractaire associée à un syndrome myélodysplasique. Efficacité du traitement hématologique.

INTRODUCTION: We report an original observation of multifocal refractory Destombes-Rosai-Dorfman disease associated with a myelodysplastic syndrome. The treatment of myelodysplasia allowed a good and prolonged response of both pathologies. CASE REPORT: A 35-year-old patient was investigated for bilateral exophthalmia, histologically related to Destombes-Rosai-Dorfman disease. The extension workup showed sinus, kidney and lymph node involvement. It was treated unsuccessfully with corticosteroids, colchicine, methotrexate, infliximab, cladribine and tociluzimab. The secondary appearance of myelodysplasia (AREB IPSS score intermediate-2) led to induction treatment with aracytin and idarubicin, and maintenance with azacytidine for 2 years. With 5 years of follow-up, the patient is in remission both of the myelodysplastic syndrome and Destombes-Rosai-Dorfman disease. CONCLUSION: Our observation discusses the interest of the treatment of myelodysplastic syndrome for the management of associated extra-hematological manifestations.

Sense of identity in advanced Alzheimer's dementia: a cognitive dissociation between sameness and selfhood?

We looked at whether sense of identity persists in patients with Alzheimer's disease (AD) and if its profile remains the same between two examinations. A specifically designed protocol was administered to 16 AD patients in the mild to severe stages of dementia and to 16 matched healthy controls, both living in the same institution. We showed that sense of identity was broadly preserved in AD patients. The patterns of their responses were similar to those of controls, and remained consistent over a two-week period. However, some qualitative characteristics of sense of identity in AD patients differed significantly from those of controls, suggesting that AD patients may not be able to update their self-knowledge, probably because of their episodic memory deficit. These results are discussed in the light of both current models of the self and philosophical concepts such as sameness and selfhood.

[Pseudomembranous colitis revealing adult hemolytic-uremic syndrome]. / Colite pseudomembraneuse révélatrice d'un syndrome hémolytique et urémique de l'adulte.

A 33 year old woman presented with abdominal pain and bloody diarrhea. A subtotal colectomy was performed. Following surgery the haemolytic uraemic syndrome unmasked. Such surgical forms of haemolytic uraemic syndrome are rare. They demonstrate that the diagnosis is difficult at the initial abdominal period before renal insufficiency and anemia develop. Review of the literature confirms the severe nature of haemolytic uraemic syndrome associated lesions. Haemolytic uraemic syndrome and pseudomembranous colitis with capillary thrombosis would be two forms of a unique affection, i.e. thrombotic microangiopathy.

Chronic inhibition of enkephalinase induces changes in the antinociceptive and locomotor effects of the enkephalinase inhibitor acetorphan in rats.

The enkephalinase inhibitor thiorphan was infused intracerebroventricularly in rats during 14 days (25 micrograms/5 microliters/hr), inducing an average inhibition of cerebral enkephalinase of about 65%. Animals were tested during the infusion for their response to acetorphan, a parenterally active derivative of thiorphan. When administered intravenously on day 8 of the infusion, acetorphan (5 mg/kg) significantly increased locomotion in chronic saline-infused rats but not in animals receiving thiorphan. Furthermore, when injected at the same dose on day 10, acetorphan did not modify the latency to jump, in the hot plate test, in thiorphan-treated rats, whereas it elicited a significant analgesia in chronic saline-treated controls. These data show that the effects induced by the administration of an enkephalinase inhibitor were diminished after a period of chronic inhibition of the enzyme, suggesting the development of tolerance.

[Leptospirosis caused by Leptospira icterohaemorrhagiae of the pseudo-surgical type: a case]. / Leptospirose à leptospira ictero-hemorrhagiae à forme pseudo-chirurgicale: une observation.

The authors report a case of fatal leptospirosis due to Leptospira icterohaemorrhagiae revealed by typical signs of acute cholecystitis and associated with pancreatitis in a 73 year old patient presenting with gallstones. The initial clinical findings were highly suggestive of severe but typical cholecystitis and the final diagnosis was only considered when the patient's condition worsened despite surgery, with increasing obstructive jaundice and multiple organ failure. Pancreatitis was an autopsy finding. Misleading, especially gastrointestinal symptoms are frequent in leptospirosis. Hence an early diagnosis is an essential condition for a successful antibiotic management in severe cases of leptospirosis. This possibility should be considered whenever a patient presents with infectious obstructive jaundice. The patient has to be questioned concerning possible contact with contaminated animals and, when in doubt, the presence of specific antibodies should be investigated.

[Epidural analgesia after thoracic surgery: morphine versus buprenorphine]. / Analgésie péridurale après chirurgie thoracique: morphine versus buprénorphine.

A double-blind study was carried out to assess the efficiency and possible side-effects of a single epidural injection of either morphine or buprenorphine at equipotent doses after elective thoracic surgery. The series included 24 patients aged 53.7 +/- 11.4 years; 13 underwent a lobectomy and 11 a pneumonectomy. 6 h after the last intravenous injection of fentanyl, the patients were randomly allocated to one of three equal groups. They received an epidural injection at T8-9 or T9-10 level of either 100 micrograms.kg-1 morphine (group M) or 6.6 micrograms.kg-1 buprenorphine (group B) or a subcutaneous injection of 0.1 ml.kg-1 normal saline placebo at the same level (group T). The following parameters were measured 20 and 60 min, and every 6 h up to 48 h after the injection: patient wakefulness, respiratory rate, blood gases, pain (according to a verbal scale), FVC and FEV1, adverse effects (euphoria, hallucinations, sweating, facial pruritus, nausea) and atelectasis. The duration of surgery, the anaesthetic protocol, the age, weight and height, as well as all the parameters before injection were similar in all three groups. There was a fall in pain intensity from the 20th min to the 24th hour in group M and from the 20th min to the 36th hour in group B, significant for both groups when compared with group T. Similarly, there was a prolonged increase in FEV1 in both groups M and B. There was no case of severe respiratory depression; PaCO2 was increased at the 1st hour (+0.3 +/- 0.6 kPa) in group B and at the 6th hour (+0.5 +/- 0.7 kPa) in group M.(ABSTRACT TRUNCATED AT 250 WORDS)

Tunnelling of two central venous catheters inserted via a single venipuncture.

Two central venous catheters were inserted into the subclavian or internal jugular vein using a single puncture and tunnelled with two different subcutaneous pathways in 32 critically ill patients; 15 of them underwent this procedure immediately after a tracheostomy. The procedure was carried out without significant technical difficulties. Separate removal of one of the catheters was performed easily in 5 cases. Cultures were positive in 21% of 42 catheters from 21 patients; Staphylococcus epidermidis was isolated from 7 catheters. Separate tunnelling of two central venous lines inserted via a single venipuncture can be used in critically ill patients needing multiple central venous access.

[Effects of intravenous naloxone on the secondary effects and analgesia after epidural injection of fentanyl]. / Influence de la naloxone intraveineuse sur les effets secondaires et l'analgésie après injection péridurale de fentanyl.

On demand intravenous naloxone reverses respiratory depression following epidural morphine but does not have any effect on analgesia. This study aimed to assess the action of a preventive naloxone infusion on the side-effects and analgesia induced by epidural fentanyl. Sixteen patients were studied. Three had isolated uncomplicated flail chest. The thirteen others had undergone thoracotomy, and were included in the protocol at least 6 h after extubation. All patients had two epidural injections, they received an intravenous infusion of either 10 micrograms.kg-1.h-1 naloxone after a 400 micrograms bolus (group F + N) or 5% dextrose (group F), which was randomly allocated. In group F, but not in group F + N PaCO2 increased from the 15th min to the 4th, and sedation occurred from the 15th min to the 6th h. A significant and similar pain relief was noted in both groups. Duration of analgesia was not statistically different in the two groups. This preventive action of intravenous naloxone on the supraspinal adverse effects of epidural fentanyl was not accompanied by a reduction in analgesia. This could lead to widespread use of this analgesic technique.

[Immune disorders during postoperative peritonitis]. / Exploration des troubles de l'immunité au cours des péritonites postopératoires.

Despite major diagnostic and therapeutic advances, postoperative peritonitis appeared to be still associated with a severe prognosis. The failure to react to delayed hypersensitivity skin tests was recently shown to identify patients at increased risk for sepsis. In an attempt to clarify the mechanisms of this anergy, cellular and humoral immunity was studied with in vitro tests in 12 patients treated for postoperative peritonitis. Complement was decreased in 33.3% of cases and normal in the others. No significant change was found in IgG and IgM titres, but IgA concentrations were increased in 80% of cases. A decrease in the total number of lymphocytes was observed in 41.7% of patients, related to the reduction in the total T lymphocyte count. Mitogen-induced lymphocyte transformation was studied with phytohaemagglutinin, concanavalin A, pokeweed-mitogen, and tuberculin purified protein derivative. Six patients had decreased or negative response to at least three mitogens; 91,7% had no response to tuberculin. The leukocyte migration inhibition test was negative in all cases. These abnormalities in cell mediated immunity may have been related to underlying diseases (severe nutrition depletion in 7 cases), to sepsis (septic shock in 10 cases), to repeated anaesthesias and surgical procedures, and even to drugs (e.g. antibiotics). The presence of serum inhibitors may have been the cause of the anergy and further studies are required.