[Spontaneous streptococcal arthritis of the pubic symphysis]. / Arthrites septiques spontanées à streptocoques de la symphyse pubienne.

Septic arthritis of the pubic symphysis is uncommon, and usually occurs in patients with predisposing conditions (female incontinence surgery, sports). Staphylococcus aureus and Pseudomonas aeruginosa are the main bacteria responsible of these infections. Streptococcal infections of the pubic symphysis are uncommon. We report three cases of streptococcal infections of the pubic symphysis that occurred in the absence of predisposing condition such as surgery or endocarditis. The diagnosis of septic arthritis was difficult, particularly in one patient who underwent an orchidopexy for a suspected of spermatic cord torsion before diagnosis was corrected. All three patients had a favourable outcome after an antibiotic treatment combining amoxicillin and rifampicin. Septic arthritis of the pubic symphysis should be suspected in patients with sudden groin pain, pubic tenderness and fever to avoid traumatic treatments and useless investigations.

Role of coagulase-negative staphylococci in human disease.

Coagulase-negative staphylococci (CNS) are normal inhabitants of human skin and mucous membranes. They have long been dismissed as culture contaminants, but now the potentially important role of CNS as pathogens and their increasing incidence has been recognized. Approximately 55-75% of nosocomial isolates is methicillin resistant. CNS were the first organisms in which glycopeptide resistance was recognized. In the immunocompetent host, CNS endocarditis and urinary tract infections with Staphylococcus saprophyticus are the most common CNS infections. Other patients are usually immunocompromised, with indwelling or implanted foreign bodies. CNS account for approximately 30% of all nosocomial blood stream infections. The majority of these concern catheter-related sepsis. Other important infections due to CNS include central nervous system shunt infections, endophthalmitis, surgical site infections, peritonitis in patients with continuous ambulatory peritoneal dialysis and foreign body infections. CNS are rarely associated with mastitis in humans. Staphylococcus lugdunensis is more pathogenic than other CNS as it expresses several potential virulence factors. The distinction between clinically significant, pathogenic and contaminating isolates is a major problem. Several studies show clonal intra and inter hospital spread of Staphylococcus epidermidis strains which suggests that infection control measures may be necessary for multiresistant CNS isolates as for methicillin resistant Staphylococcus aureus. As a result of medical progress, mainly due to the use of invasive and indwelling medical devices, CNS are now a major cause of nosocomial and health-care related infections.

[What's new in internal medicine?]. / Quoi de neuf en médecine interne?

Among diagnostic progress over the last three years in internal medicine, Antisynthetase Syndrome is now more easily recognised with the diffusion of laboratory tests for research of antibodies against tRNA synthetases (Anti JO1, anti PL7, Anti PL12). In two third of cases, these antibodies are found despite absence of antinuclear antibodies. Hence, we have to search them specifically in patients with polyarthritis associated with myositis, cutaneous manifestations (Raynaud phenomenom and "mechanic'hands") and interstitial lung disease. Discovery of asymptomatic mutation in the L ferritin coding sequence help us to better understand the "unexplained" hyperferritinemia. Initially described by japonese gastroenterologists, auto immune pancreatitis in fact a part of a systemic sclerosing disease with a biochemical hallmark: in crease of a subclass of immunoglobulins G (IgG4). A new pediatric disease due to a deficiency of the interleukin1 receptor antagonist (multifocal aseptic osteitis, periostitis, stomatitis, disseminated pustulosis) help us to better understand unexplained auto inflammatory diseases. The therapeutic progress is primarily due to an explosion of biological therapies, particularly four of them very useful for internists (in an off label use) : Interleukin 1 inhibitors (anakinra, Canakinumab) to treat some auto inflammatory diseases (cryopirin associated periodic syndromes and deficency of interleukin 1 receptor antagonist), monoclonal antibody against interleukin 5 (mepolizumab) to treat some hypereosinophilic syndromes and Churg and Strauss angiitis, interleukin 6 inhibitiors to treat multifocal Castleman's disease and adult Still disease, a monoclonal antibody against vascular endothelial growth factor (Bevacizumab) to treat hereditary hemorrhagic telangiectasia.

[Usefulness of combined positron emission tomography and computed tomography imaging in Erdheim-Chester disease]. / Intérêt de la tomographie par émission de positons couplée au scanner dans la maladie d'Erdheim-Chester.

INTRODUCTION: Erdheim-Chester disease is a rare non-Langerhans form of histiocytosis. We report the use of combined fluorodeoxyglucose positron emission tomography and computed tomography (18F-FDG PET-CT) in this disease. EXEGESIS: Three men, aged from 55 to 74 years with confirmed Erdheim-Chester disease were included. 18F-FDG PET-CT allowed to detect visceral and vascular involvement of the disease which were overlooked with CT-scan or magnetic resonance imaging: left common carotid and ilio-femoral artery in one patient, coronary, femoral and tibia in the second, aortic, common carotid, femoral and mandibula in the remaining patient. Also, sequential 18F-FDG PET-CT was useful to appreciate treatment efficiency (decrease hyperfixation) and decide treatment modification (interferon alpha). CONCLUSION: 18F-FDG PET-CT combined imaging allows to assess the extent of involvement in Erdheim-Chester disease. 18F-FDG PET-CT may be also a useful tool in the management of Erdheim-Chester disease.

Temperature limit values for touching cold surfaces with the fingertip.

OBJECTIVES: At the request of the European Commission and in the framework of the European Machinery Directive, research was performed in five different laboratories to develop specifications for surface temperature limit values for the short-term accidental touching of the fingertip with cold surfaces. METHODS: Data were collected in four laboratories with a total of 20 males and 20 females performing a grand total of 1655 exposures. Each touched polished blocks of aluminium, stainless steel, nylon-6 and wood using the distal phalanx of the index finger with a contact force of 1.0, 2.9 and 9.8 N, at surface temperatures from +2 to -40 degrees C for a maximum duration of 120 s. Conditions were selected in order to elicit varying rates of skin cooling upon contact. Contact temperature (TC) of the fingertip was measured over time using a T-type thermocouple. RESULTS: A database obtained from the experiments was collated and analysed to characterize fingertip contact cooling across a range of materials and surface temperatures. The database was subsequently used to develop a predictive model to describe the contact duration required for skin contact temperature to reach the physiological criteria of onset of pain (15 degrees C), onset of numbness (7 degrees C) and onset of frostbite risk (0 degrees C). CONCLUSIONS: The data reflect the strong link between the risk of skin damage and the thermal properties of the material touched. For aluminium and steel, skin temperatures of 0 degrees C occurs within 2-6 s at surface temperatures of -15 degrees C. For non-metallic surfaces, onset of numbness occurs within 15-65 s of contact at -35 degrees C and onset of cold pain occurs within 5 s of contact at -20 degrees C. The predictive model subsequently developed was a non-linear exponential expression also reflecting the effects of material thermal properties and initial temperature. This model provides information for the protection of workers against the risk of cold injury by establishing the temperature limits of cold touchable surfaces for a broad range of materials, and it is now proposed as guidance values in a new international standard.

The SOBANE strategy for the management of risk, as applied to whole-body or hand-arm vibration.

OBJECTIVE: The objective was to develop a coherent set of methods to be used effectively in industry to prevent and manage the risks associated with exposure to vibration, by coordinating the progressive intervention of the workers, their management, the occupational health and safety (OHS) professionals and the experts. The methods were developed separately for the exposure to whole-body and hand-arm vibration. RESULTS: The SOBANE strategy of risk prevention includes four levels of intervention: level 1, Screening; level 2, Observation; level 3, Analysis and; level 4, Expertise. The methods making it possible to apply this strategy were developed for 14 types of risk factors. The article presents the methods specific to the prevention of the risks associated with the exposure to vibration. CONCLUSIONS: The strategy is similar to those published for the risks associated with exposure to noise, heat and musculoskeletal disorders. It explicitly recognizes the qualifications of the workers and their management with regard to the work situation and shares the principle that measuring the exposure of the workers is not necessarily the first step in order to improve these situations. It attempts to optimize the recourse to the competences of the OHS professionals and the experts, in order to come more rapidly, effectively and economically to practical control measures.

[Spontaneous hypothermia: a series of ten cases, place of Shapiro's syndrome]. / Hypothermies spontanées: dix observations, place du syndrome de Shapiro.

SUBJECT: Hypothermia (defined as a core temperature lower than 35 degrees C) may result from accidental causes (exposure to cold, drug intoxications), from endocrine disorders (hypothyroidism), or from central or peripheral neurological disease. Among the causes of spontaneous hypothermia, the place of spontaneous periodic hypothermia or Shapiro's syndrome, of which less than 50 cases in children or adults have been reported, remains unclear. METHODS: Case series of spontaneous hypothermia in adults, from a register of the French Society of Internal Medicine (SNFMI). RESULTS: The ten collected cases of spontaneous hypothermia are heterogeneous. In half of the cases, an often ill-labeled psychiatric illness and/or epilepsy and/or anti-psychotic medication were found contributive. Only 5 cases at best seem to conform to the pattern of spontaneous periodic hypothermia or Shapiro's syndrome (in which agenesis of corpus callosum is typically found). In such cases, the episodes of hypothermia start with profuse hyperhidrosis suggesting a paroxystic reset of the hypothalamic thermostat with a lower temperature set point. In none of the cases was found a significant encephalic lesion. None of the treatment trials with anti-epileptics or cyproheptadine were found useful. Spontaneous hypothermia, whether periodic or not, seems to have an unpredictable course, with long periods of remission, and a benign long-term outcome. CONCLUSIONS: Spontaneous hypothermia is a symptom of likely multifactorial etiology. Even in cases conforming to the definition of Shapiro's syndrome, central nervous system anomalies are not unequivocal. No specific treatment for spontaneous hypothermia, whether periodic or not, can be recommended in the current state of knowledge.

[Crowned dens syndrome: three new cases]. / Syndrome de la dent couronnée : à propos de trois nouveaux cas.

INTRODUCTION: Crowned dens syndrome is due to a microcrystalline infringement (hydroxyapatite or calcium pyrophosphate) of the retro-odontoidal ligament of atlas, often leading to the erroneous diagnosis of meningitis or spondylitis. We report on three new cases diagnosed from 1996 to 1999. EXEGESIS: The patients complained of cervicalgies, headaches or fever. The initially evoked diagnoses were meningitis, spondylodiscitis or endocarditis. Clinical exam found meningism and an inflammatory syndrome in all patients. Analysis of the cerebro-spinal fluid realised in two cases was normal. The diagnosis of crowned dens syndrome was assessed in two cases by cervical CT scan of C1/C2. In the third case, chondrocalcinosis of a wrist allowed this diagnosis. We report a probably non fortuitous case of crowned dens syndrome associated with genetic hemochromatosis. A non steroidal anti-inflammatory treatment allowed a dramatic regression of clinical symptoms. CONCLUSION: This entity should be better known; it can mimick numerous diagnosis and be responsible for fever in the long course.

Spontaneous resolution of hemophagocytic syndrome associated with acute parvovirus B19 infection and concomitant Epstein-Barr virus reactivation in an otherwise healthy adult.

Reported here is the case of a patient who spontaneously recovered from hemophagocytic syndrome associated with acute B19 infection and concomitant Epstein-Barr virus reactivation. The previously healthy 37-year-old-man was hospitalized after 10 days of high fever, arthralgia and arthritis and was determined to have hemophagocytic syndrome. Immunoglobulin (Ig) M antibodies to Epstein-Barr virus (EBV) capsid antigen, early antigen and parvovirus B19 (B19) were found. B19 DNA and low-level EBV DNA were detected in bone marrow, serum and peripheral blood mononuclear cells. The patient recovered spontaneously without any treatment. Two months later anti-B19 IgG antibodies were detected, while at 9-month follow-up, anti-B19 IgM antibodies were no longer detectable and B19 DNA had disappeared from serum. To the best of our knowledge, this is the first report of spontaneous resolution of hemophagocytic syndrome associated with acute B19 infection and concomitant EBV reactivation in an otherwise healthy adult.

Co-ordinated strategy of prevention and control of the biomechanical factors associated with the risk of musculoskeletal disorders.

OBJECTIVES: To propose a cost-effective set of methods (strategy) to improve biomechanical working conditions and prevent the development of musculoskeletal disorders. METHODS: The strategy was developed according to the philosophy already used for other aspects of working conditions. It was then tested in ten industrial situations with various characteristics, to check its understanding, its usability, and its efficiency. RESULTS: The strategy includes a five-page leaflet ( screening) aimed at motivating the operators to check the problems and bring about immediate solutions if possible. A stage-2 observation checklist is then proposed to guide the discussions during a meeting of the protagonists (workers and management). The assistance of an occupational health practitioner might become indispensable at stage 3 to deepen the analysis of the remaining problems, while experts are requested only in exceptional cases (stage 4, expertise). This strategy was positively judged by the users and proved to be effective in motivating and co-ordinating the protagonists. CONCLUSION: The strategy proved to consider effectively all biomechanical aspects that might contribute to the development of musculoskeletal disorders (MSDs). It proved also to be participatory, placing the operators and their management at the centre of the intervention as the main actors, and organising when to turn to an occupational health practitioner or an expert for assistance.

Temperature limit values for gripping cold surfaces.

OBJECTIVES: At the request of the European Commission and in the framework of the European Machinery Directive, research was conducted jointly in five different laboratories to develop specifications for surface temperature limit values for the gripping and handling of cold items. METHODS: Four hundred and fourteen experiments were run where male and female subjects were invited to grip for up to 20 min cold bars of different contact coefficients, i.e. polished wood, nylon, stone, steel and aluminium. The air temperature and the bars' initial surface temperatures ranged between 0 and -30 degrees C for the various experiments. While gripping the bars, either only the hand or the whole body was exposed to cold. RESULTS: The data were used to develop a prediction formula and a graph of the surface temperature limit values in order for the skin contact temperature not to reach <15 degrees C. This duration is shown to offer a significant degree of safety with respect to the minimal surface temperature spontaneously tolerated by the subjects. CONCLUSIONS: Experiments and modelling must be pursued to extend these data to other conditions of exposure.

Assessment of the risk of heat disorders encountered during work in hot conditions.

OBJECTIVE: To co-ordinate the work of the main European research teams in the field of thermal factors in order to develop and improve significantly the methods presently available for assessing the risks of heat disorders encountered during work in hot conditions. METHOD: Each item from the required sweat rate model was reviewed on the basis of the most recent literature. A database with 1,113 laboratory and field experiments, covering the whole range of hot working conditions, was assembled and used for the validation. RESULTS: Influence of clothing ensemble on heat exchange: methods and formulas were developed that take into account the dynamic effects associated with forced convection and the pumping effect associated with body movements and exercise. Prediction of the average skin temperature: the model used in the required sweat rate standard ISO 7933 was extended to cover more severe conditions with high radiation and high humidity and different clothing and take into account the rectal temperature for the prediction of the skin temperature. Criteria for estimating acceptable exposure times in hot work environments: criteria were reviewed and updated concerning the maximum increase in core temperature and the acceptable water loss, for acclimatised and nonacclimatised subjects. These limits are intended to protect 95% of the population. Measuring strategy: a strategy was developed to assess the risks in any working situation with varying conditions of climate, metabolic rate or clothing. A detailed methodology was developed in three stages: an "observation" method for the recognition of the conditions that might lead to thermal stress; an "analysis" method for evaluating the problem and optimising the solutions; and an "expert" method for in-depth analysis of the working situation when needed. VALIDATION: the different results were used to prepare a revision of the interpretation procedure proposed in the ISO standard 7933. We validated the modified approaches using the database. This involved the whole range of conditions for which the model was extended, namely conditions with high and low radiation, humidity and air velocity as well as fluctuating conditions. Based on these results, the predicted heat strain model was developed: it is presently proposed as an ISO and CEN standard.

Thromboembolic events after endovascular treatment of unruptured intracranial aneurysms in two patients with antiphospholipid-antibody syndrome.

Antiphospholipid antibodies (APAs) are circulating immunoglobulins associated with a hypercoagulable state. The antiphospholipid syndrome combines APAs and clinical manifestations, including arterial or venous thromboses and/or recurrent spontaneous fetal loss. The main risk incurred by endovascular treatment of intracranial aneurysms is the occurrence of thromboembolic events. We report two cases of patients with antiphospholipid syndrome who developed thromboembolic complications after the endovascular treatment of unruptured intracranial aneurysms.

Intracranial aneurysm associated with relapsing polychondritis.

We describe a 50-year-old man with relapsing polychondritis (RP) involving auricular cartilage, uveitis and hearing loss, who had an aneurysm of the anterior cerebral artery. Intracranial aneurysm is a rare manifestation of RP.