Detection of Anaplasma phagocytophilum in an inflammatory pericardial effusion of a dog.

An 11-year-old female spayed German Wirehaired Pointer with a 1-week history of lethargy, hyporexia, diarrhea, and coughing presented with pericardial effusion causing cardiac tamponade. An echocardiogram revealed no structural cause for pericardial effusion. The pericardial effusion was an exudate with mixed macrophagic and neutrophilic inflammation. Morulae occasionally were found within neutrophils. The pericardial fluid and blood were qPCR and cPCR positive for Anaplasma phagocytophilum (NC State University, Vector-borne Disease Diagnostic Laboratory, Raleigh, NC). The dog's blood was negative by ELISA (Vetscan Flex4 Rapid Test, Zoetis, Parsippany, NJ) for A. phagocytophilum antibodies at initial presentation and subsequently positive (SNAP4DxPlus, IDEXX, Westbrook, ME) 7 days later. After pericardiocentesis and administration of doxycycline (5 mg/kg PO q12h for 14 days), a repeat echocardiogram performed 1 month later showed no recurrence of pericardial effusion.

Seminoperitoneum in a Dog with a History of a Vasectomy: Case Report.

An 8 yr old male German shorthaired pointer was presented on July 4, 2022, for acute abdominal and testicular pain. The dog was vasectomized at an unknown age under the care of his previous owners. The dog had an enlarged, painful left testis, scrotal edema, and an enlarged, nonpainful prostate. Abdominal ultrasound revealed mild peritoneal and retroperitoneal effusion, orchiepididymitis, enlarged ductus deferentes and testicles, and suspected benign prostatic hyperplasia versus prostatitis. Peritoneal effusion cytology revealed seminoperitoneum with marked neutrophilic inflammation. Peritoneal effusion aerobic culture and Brucella canis rapid slide agglutination test were negative. The dog was hospitalized overnight with IV antibiotic therapy and analgesics. The following day, the dog's abdominal pain, testicular pain, and scrotal edema were resolved. The dog was discharged and castrated after completion of antibiotic therapy and complete resolution of clinical signs. Testicular histopathology results were not available. Seminoperitoneum is uncommon in dogs and is a rare diagnosis for dogs with acute abdominal pain. This is the second known reported case of a seminoperitoneum in a vasectomized dog.

Respiratory distress in small animals: Pathophysiology and clinical approach.

BACKGROUND: Respiratory distress is a common reason for animals to present to the emergency room. An understanding of respiratory physiology is helpful to facilitate accurate localization of the patient's source of respiratory distress. This knowledge will aid implementation of more appropriate therapies. PHYSIOLOGY/PATHOPHYSIOLOGY SUMMARY: Respiratory distress can occur secondary to lesions at any location of the respiratory system. Diseases affecting different portions of the respiratory track (eg, upper airway, lower airways, parenchymal, or the pleural space) lead to distinguishing clinical signs as the patient's respiratory physiology is affected differently. CLINICAL IMPORTANCE: Respiratory distress can be life-threatening if it is not recognized and addressed in a timely matter. Prompt recognition of unique clinical signs may aid the clinician's ability to localize the disease process and implement targeted therapies. KEY POINTS: Diseases affecting different portions of the respiratory track (eg, upper airway, lower airways, parenchymal, or the pleural space) lead to distinguishing clinical signs as the patient's respiratory physiology is affected differently. Recognition of respiratory patterns allows clinicians to correlate clinical signs to the most likely affected region of the respiratory tract. Ideally, alveolar gas (ventilation) and blood flow (perfusion) are equally matched. However, even a normal lung does not have ideal ventilation/perfusion (V/Q) matching. There are a variety of conditions that lead to decreased lung compliance, from pathology of the pulmonary parenchyma (eg, pulmonary edema, alveolar infiltrates such as pneumonia or contusions, or pulmonary fibrosis), pleural space disease (eg, pneumothorax or pleural effusion), abdominal distension, or the inability to expand the rib cage (eg, pain, thoracic wall injury, constricting thoracic bandages). The five classic causes of hypoxemia include low FiO2 , diffusion impairment, hypoventilation, shunt, and V/Q mismatch. Being prepared to rapidly induce anesthesia and intubate dyspneic animals with upper airway obstruction may be required alleviate the risk of respiratory arrest.

Performing an upper airway examination in dogs.

BACKGROUND: Increased airway resistance due to upper airway obstruction is a common cause of respiratory distress. An upper airway exam is an inexpensive and quick diagnostic procedure that can serve to localize a disease process, confirm a definitive diagnosis, and offer therapeutic benefits. DESCRIPTION: The upper airway examination consists of an external evaluation of the head and neck as well as a sedated examination of the oral cavity, the pharyngeal cavity, larynx, and nasal passages. SUMMARY: An upper airway examination should be performed in patients with increased inspiratory effort or increased upper respiratory noise (eg, stertor or stridor). A complete, sedated upper airway examination should be considered for patients with clinical signs of upper airway disease for which a cause is not obvious from the physical examination. KEY POINTS: Indications for an upper airway examination include sneezing, nasal discharge or epistaxis, reduced or absent nasal airflow, change in phonation, inspiratory difficulty, and audible respiratory sounds. Upper airway examination helps localize pathological processes and allows the clinician to confirm or exclude several differential diagnoses. Pre-oxygenation of the patient for 3-5 minutes prior to sedation will help increase the amount of time available before hypoxemia occurs, should complications arise. Upon completion of the upper airway examination, it is important to monitor the patient carefully and ensure a safe recovery. Careful planning to ensure the availability of necessary equipment and preparation of the team to react during and after the airway examination will minimize the risks of examination to patients with upper airway disease.

Thermographic imaging in a dog with macroglossia from an encircling, strangulating lingual linear foreign body.

A dog presented 16 hours after an acute onset of severe generalized lingual swelling from an unknown cause. The dog had recently chewed a deer carcass. Initial physical examination and diagnostic testing did not reveal an underlying cause, and supportive care was provided. After 16 hours of hospitalization strangulating organic foreign material was found at the base of the tongue and removed. Macroglossia and secondary superficial lingual necrosis were successfully managed with supportive care while the patient was hospitalized. Thermographic imaging was used and indicated lingual hypothermia and subsequent normothermia, before and after removal of the linear foreign body respectively. Histopathologic analysis revealed the foreign body consisted of degenerate and autolyzed collagenous connective tissue, likely representing tissues such as tendon, fascia or a large thick-walled blood vessel which was suspected to have been consumed from the deer carcass. Thermographic imaging was employed and demonstrated to be consistent with hypoperfusion (hypothermia) of the affected tissue. Thermographic imaging adds value as an additional diagnostic tool for conditions with compromised blood flow.

Clinical pharmacokinetics and outcomes of oral fluconazole therapy in dogs and cats with naturally occurring fungal disease.

This multi-institutional study was designed to determine the clinical pharmacokinetics of fluconazole and outcomes in client-owned dogs (n = 37) and cats (n = 35) with fungal disease. Fluconazole serum concentrations were measured. Pharmacokinetic analysis was limited to animals at steady state (≥72 hr of treatment). The mean (range) body weight in 31 dogs was 25.6 (2.8-58.2) kg and in 31 cats was 3.9 (2.4-6.1) kg included in pharmacokinetic analyses. The dose, average steady-state serum concentrations (CSS ), and oral clearance in dogs were 14.2 (4.5-21.3) mg/kg/d, 26.8 (3.8-61.5) µg/mL, and 0.63 ml min-1  kg-1 , respectively, and in cats were 18.6 (8.2-40.0) mg/kg/d, 32.1 (1.9-103.5) µg/mL, and 0.61 ml min-1  kg-1 , respectively. Random inter-animal pharmacokinetic variability was high in both species. Two dogs had near twofold increases in serum fluconazole when generic formulations were changed, suggesting lack of bioequivalence. Median CSS for dogs and cats achieving clinical remission was 19.4 and 35.8 µg/ml, respectively. Starting oral doses of 10 mg/kg q12h in dogs and 50-100 mg total daily dose in cats are recommended to achieve median CSS associated with clinical remission. Due to the large pharmacokinetic variability, individualized dose adjustments based on CSS (therapeutic drug monitoring) and treatment failure should be considered.

The red and the black: China's social credit experiment as a total test environment.

China's social credit system is an unusually explicit case where technology is used by multiple actors to turn human behavior into a test object on behalf of the state's goal of modifying the larger social environment, making it an intriguing setting for thinking about the new sociology of testing. This article considers how China's search for a usable "credit" score to both allocate financial resources and explicitly measure a citizen's trustworthiness creates an emergent experimental system of governance similar to, yet not quite captured by, the kinds of experimental processes observed in literature on the platform as a form of market-based governance. As a site where "seeing like a state" and "seeing like a market" converge, the social credit system is a vantage point for observing the changing relationship between moral and economic domains in an era of digital platforms. The article highlights the experimental quality of the system and its emerging system of governance structured around reward and punishment and argues that strategic ambiguity, institutionalized through the affordances of digital platforms, is an important part of the design of this large-scale social experiment.

Growth of adenocarcinoma from canine pleural fluid on aerobic bacterial culture.

We report a case of canine adenocarcinoma with multi-organ metastasis in which colonies of adenocarcinoma cells grew upon aerobic bacterial culture of pleural effusion. Stained agar colonies were highly similar to rare suspicious cells seen on cytologic examination of the pleural effusion, as well as rare cells seen on cytologic examination of pancreatic and gastric wall fine-needle aspirates. Cells from colonies growing on agar media were mildly immunoreactive for cytokeratin. Histologic examination of tissues obtained at autopsy revealed pancreatic adenocarcinoma with vascular invasion and nodal, gastric, pulmonary, and pleural metastasis.

Temporary abdominal packing for management of persistent hemorrhage after liver lobectomy in three dogs with hepatic neoplasia.

OBJECTIVE: To describe the technique and outcome of temporary abdominal packing for control of persistent hemorrhage from liver lobectomy sites in 3 dogs with hepatic neoplasia. SERIES SUMMARY: Three dogs were treated with massive transfusion for hemoperitoneum secondary to bleeding hepatic tumors. Surgical resection of the affected liver lobe(s) was performed but hemostasis could not be achieved through conventional methods. All 3 dogs demonstrated acidosis, hypothermia, and coagulopathy. Temporary abdominal packing of liver lobectomy sites was performed and hemostasis was achieved in all dogs. One dog died prior to removal of the packing. The other 2 dogs had the packing removed with no evidence of rebleeding. One dog was euthanized after removal of the packing due to acute kidney injury and the remaining dog survived to discharge. NEW OR UNIQUE INFORMATION PROVIDED: Temporary abdominal packing combined with medical management was successful in achieving hemostasis in all 3 dogs, however, 2 dogs died of complications related to multiple organ dysfunction syndrome. Temporary abdominal packing may be considered when definitive surgical hemostasis cannot be achieved or in unstable patients not able to tolerate prolonged surgical times. Further research is needed to better define efficacy, optimal patient selection, packing technique, timing of removal, and complications associated with temporary abdominal packing.

Placement of a balloon for resuscitative endovascular balloon occlusion of the aorta without fluoroscopic guidance in canine cadavers.

OBJECTIVE: To determine whether a balloon for resuscitative endovascular balloon occlusion of the aorta (REBOA) could be accurately placed in the descending aorta between the left subclavian and celiac arteries (zone I) by using external anatomic landmarks in dogs. STUDY DESIGN: Cadaver study. SAMPLE POPULATION: Fifteen canine cadavers of 3 weight categories (10-20, 20-30, and ≥ 30 kg). METHODS: Percutaneous catheterization of the femoral artery was attempted under ultrasonographic guidance; when unsuccessful, an arterial cutdown was performed to place an introducer sheath. Distance was measured between the introducer sheath and the target region, located ventral to the epaxial muscles at the level of the 12th thoracic vertebra. The balloon was advanced the measured distance, and placement was confirmed with fluoroscopy. The volume of iohexol solution required to inflate balloons was recorded. Histopathology was performed on the aortas of the first 5 dogs. RESULTS: Three catheters were placed under ultrasonographic guidance. Balloons were successfully placed into zone I in 15 of 15 cadavers. Balloons were inflated with a median 0.4 mL/kg (range, 0.21-0.67) of iohexol solution. Minor changes were identified in 2 of 5 dogs examined with histopathology (linear defects in 1 dog, small focal dissection in the other). CONCLUSION: A balloon for REBOA was consistently placed in the target zone I without fluoroscopic guidance. CLINICAL SIGNIFICANCE: Fluoroscopy may not be required for zone I REBOA in dogs. Additional studies are warranted to evaluate the feasibility of REBOA in clinical dogs with hemoperitoneum.

Acute respiratory distress syndrome and septic shock in a cat with disseminated toxoplasmosis.

OBJECTIVE: To describe acute respiratory distress syndrome (ARDS) and septic shock in a cat with disseminated toxoplasmosis. CASE SUMMARY: A 2-year-old neutered male domestic shorthair cat was presented for acute respiratory distress. At the time of presentation it had been receiving cyclosporine for treatment of eosinophilic dermatitis. Thoracic radiographs revealed severe mixed nodular interstitial and alveolar patterns. An endotracheal wash was performed, which confirmed a diagnosis of pulmonary toxoplasmosis. Despite initial treatment with oxygen supplementation and intravenous clindamycin, the cat developed refractory hypoxemia and hypotension requiring mechanical ventilation and vasopressor support within 24 hours of hospital admission. Cardiac arrest occurred 56 hours after admission. Necropsy was performed and histopathology revealed protozoal organisms disseminated throughout the heart, lungs, liver, and brain. NEW OR UNIQUE INFORMATION PROVIDED: The clinical and necropsy findings presented here are consistent with ARDS secondary to disseminated toxoplasmosis in a cat. This is the first detailed report of ARDS in a cat. Toxoplasma titer testing and antimicrobial prophylaxis should be considered in cats prior to immunosuppressive treatment with cyclosporine.

Comparison of the efficacy of small and large-bore thoracostomy tubes for pleural space evacuation in canine cadavers.

OBJECTIVE: To determine if there is a difference in the amounts of air (A), low-viscosity fluid (LV), or high-viscosity fluid (HV) that can be aspirated from the pleural cavity of canine cadavers using small-bore (SB) or large-bore (LB) thoracostomy tubes. DESIGN: Prospective experimental ex vivo study. SETTING: University teaching hospital. ANIMALS: Thirty-six canine cadavers. INTERVENTIONS: Each cadaver was randomly assigned to 1 of 6 groups (SB-A, LB-A, SB-LV, LB-LV, SB-HV, LB-HV). In each cadaver bilateral thoracostomy tubes (either SB or LB) were placed and 20 mL/kg of air, LV fluid, or HV fluid was instilled via 1 thoracostomy tube. Both tubes were aspirated and the volume aspirated was recorded and analyzed as a percentage of instilled air or fluid volume. The procedure was repeated on the contralateral hemithorax. MEASUREMENTS AND MAIN RESULTS: There was no significant difference in air or fluid recovery when SB and LB groups were compared. Median (range) air recovery volumes in the SB-A and LB-A groups were 101.5% (94.4-115.8%) and 102.8% (94.1-107.8%), respectively (P = 0.898). Recovery of LV fluid was 93.5% (79.2-99.0%) for SB-LV and 85.8% (77.1-101.8%) for LB-LV cadavers (P = 0.305) and recovery percentages of HV fluid were 92.6% (86.1-96.2%) and 91.4% (74.2-96.4%) for SB-HV and LB-HV groups, respectively (P > 0.999). There was no significant difference between SB and LB groups when all substances were combined (94.1% [79.2-115.8%] and 93.5% [74.2-107.8%], respectively, P = 0.557). CONCLUSIONS: SB and LB thoracostomy tubes demonstrated similar efficacy in removing known amounts of air, LV fluid, and HV fluid from the pleural space of canine cadavers. Further study is necessary to determine if SB and LB thoracostomy tubes demonstrate similar efficacy in clinical veterinary patients.

Evaluation of the effects of time, temperature, and specimen storage on in vitro lactate concentrations in healthy dogs.

BACKGROUND: Lactate concentrations increase significantly under certain storage conditions, except for when glycolysis-arresting agents are used. Evaluation of time and storage conditions on heparinized whole blood lactate concentrations without glycolysis-arresting agents have not been evaluated in dogs. OBJECTIVES: The purpose of the study was to determine the effects of preanalytic storage conditions on the in vitro concentration of lactate in heparinized canine venous blood specimens. METHODS: In this prospective study, blood collected from 30 healthy dogs was aliquoted and stored under different conditions: anaerobic refrigerated (3°C), aerobic refrigerated, anaerobic room temperature (RT), and aerobic RT. Whole blood lactate was analyzed at 15-25, 30-40, 60-70, and 120-130 minutes from time 0 (T0) under all storage conditions. Percent increases from the T0 specimen were calculated. RESULTS: There were significantly increased lactate concentrations at all time points within the anaerobic refrigerated specimens compared to T0, and in the anaerobic RT specimens after 15-25 minutes. The aerobic refrigerated specimens did not have significant changes in lactate when compared to anaerobic refrigerated specimens, while the aerobic RT specimens had significant increases at all time points. Anaerobically refrigerated specimens stored < 40 minutes and aerobically refrigerated specimens stored < 25 minutes had in vitro lactate increases of < 20%. CONCLUSIONS: Results support analyzing lactate specimens immediately. If lactate analysis is delayed, anaerobic refrigerated specimens should be analyzed within 40 minutes, and aerobic refrigerated specimens should be analyzed within 25 minutes. Room temperature specimens stored either aerobically or anaerobically should be avoided as lactate concentrations may be falsely increased.

A Quick Reference on Hypoxemia.

This article describes the calculation of the alveolar-arterial gas gradient and its clinical application in determining the cause of hypoxemia. It also outlines the analysis of arterial blood gases and the clinical approach toward diagnosis and treatment of respiratory disease.

Prospective study evaluating the incidence of bacteraemia and bacteruria in afebrile and febrile neutropaenic dogs undergoing chemotherapy.

The purpose of this prospective study was to determine the incidence and character of bacteraemia and bacteruria in afebrile and febrile neutropaenic dogs undergoing cytotoxic chemotherapy. Fifty-five neutropaenic dogs presenting to the University of Wisconsin Veterinary Medical Teaching Hospital were enrolled for a total of 57 neutropaenic episodes. The overall incidence of bacteraemia was 12.3% (n = 7/57). Three afebrile dogs and four febrile dogs were bacteraemic; this difference was not significant (P = 0.6968). The overall incidence of bacteruria was 7.5% (n = 4/53). Two afebrile dogs and two febrile dogs were bacteruric; this difference was not significant (P = 1.0). Of the positive blood cultures, the majority of organisms cultured (n = 6/7) were gram-positive organisms with one gram-negative organism. Three of the positive blood cultures showed in vitro resistance to more than one antimicrobial agent. Clinical parameters (age, body weight, heart rate, rectal temperature, neutrophil count, haematocrit and platelet count) were not predictive of bacteraemia. The results of this study were not sufficient to justify the use of blood cultures as a first-line diagnostic test for neutropaenic patients. Blood cultures may have utility in individual case management for a minority of patients in guiding antibiotic choice in the case of resistant bacterial infections. Blood cultures may serve as a tool for antimicrobial de-escalation, although further study is needed.

Retrospective comparison of costs between medical and surgical treatment of canine pyothorax.

This study compared costs of treating dogs with pyothorax medically versus surgically. Medical records from the University of Wisconsin School of Veterinary Medicine were searched for cases of pyothorax that underwent either medical or surgical treatment. Patients undergoing surgery were subdivided into early (ES; < 48 h) and late (LS; > 48 h) surgery groups. Costs and length of stay were compared between treatment groups. Treatment costs were adjusted for inflation. Nineteen dogs were included in analysis; 7 in the medical group (MG), 5 in the ES group, and 7 in the LS group. Total costs were significantly lower in the MG than in the LS group. Total costs were less for the MG than the ES group, and for ES than LS, but the differences did not achieve significance. Preoperative costs were higher in the LS than the ES group. We conclude that surgery for canine pyothorax is less costly if pursued earlier than later.

Comparaison rétrospective des coûts entre le traitement médical et chirurgical d'un pyothorax canin. Cette étude a comparé les coûts de traiter les chiens souffrant d'un pyothorax par voie médicale par opposition à une voie chirurgicale. Une recherche a été effectuée dans les dossiers médicaux du College of Veterinary Medicine, University of Wisconsin pour trouver des cas de pyothorax où les animaux avaient subi soit un traitement médical ou chirurgical. Les patients subissant une chirurgie ont été subdivisés en des groupes de chirurgie précoce (ES; < 48 h) et tardive (LS; > 48 h). Les coûts et la durée du séjour ont été comparés entre les groupes de traitement. Les coûts de traitement ont été ajustés pour l'inflation. Dix-neuf chiens étaient inclus dans l'analyse; sept dans le groupe médical (MG), cinq dans le groupe ES et sept dans le groupe LS. Les coûts totaux étaient significativement inférieurs dans le MG par rapport au groupe LS. Les coûts totaux étaient inférieurs pour le groupe MG par rapport au groupe ES et pour le groupe ES par rapport au groupe LS, mais les différences n'étaient pas significatives. Les coûts préopératoires étaient supérieurs dans le groupe LS par rapport au groupe ES. Nous tirons la conclusion que le coût de la chirurgie pour le pyothorax canin est inférieur si la chirurgie est réalisée tôt.(Traduit par Isabelle Vallières).

Aortic tear and dissection related to connective tissues abnormalities resembling Marfan syndrome in a Great Dane.

Aortic tears and acute aortic dissection are rarely reported in dogs. This report describes a case of aortic dissection and probable sinus of Valsalva rupture in a young Great Dane with associated histopathologic findings suggestive of a connective tissue abnormality.

Primary hypodipsia in a cat with severe hypernatremia.

CLINICAL SUMMARY: A 4.5-year-old male castrated domestic shorthair cat presented with a 2-month history of muscle tremors progressing to weakness, pelvic limb ataxia, mild facial twitching, poor appetite and polyuria. Primary hypodipsia and resultant hypernatremia was diagnosed. Intensive fluid therapy and monitoring were initially required for stabilization, and the cat's condition was successfully managed long-term using canned food supplemented with additional water. PRACTICAL RELEVANCE: Primary hypodipsia is rare in clinical practice, but experience with this case suggests that associated hypernatremia can be successfully managed using a water-enriched diet to provide maintenance hydration.

Incidence of acute lung injury in dogs receiving transfusions.

OBJECTIVE: To document the existence and incidence of acute lung injury (ie, veterinary acute lung injury [VetALI] per the 2007 consensus definition) in a population of client-owned dogs receiving transfusions for various clinical reasons. DESIGN: Prospective observational study. ANIMALS: 54 client-owned dogs. PROCEDURES: Arterial blood gas analysis was performed for dogs receiving a transfusion (blood and plasma products) at 0 to 12 hours before and 24 to 48 hours after transfusion; dogs also underwent thoracic radiography 0 to 24 hours before and 24 to 48 hours after transfusion. The ratio of PaO2 to fraction of inspired oxygen (FIO2) was calculated. Dogs with posttransfusion radiographic signs of pulmonary infiltrates, a PaO2:FIO2 ratio < 300, or clinical signs of respiratory compromise were suspected of having VetALI and underwent echocardiography to exclude left-sided heart failure. The incidence of VetALI was calculated, and χ(2) tests were used to compare the incidence in study dogs with the historical reported incidence of acute respiratory distress syndrome (ARDS) in ill dogs (not receiving transfusions) and transfusion-related acute lung injury (TRALI) in humans. RESULTS: The incidence of VetALI (2/54 [3.7%]; 95% confidence interval, 0% to 8.73%) in study dogs was significantly less than the reported incidence of TRALI in humans (25%) and not significantly different from the reported incidence of ARDS in ill dogs (10%). CONCLUSIONS AND CLINICAL RELEVANCE: VetALI occurred in dogs that received transfusions at a frequency similar to that previously reported for ARDS in ill dogs that did not receive transfusions.

A case of necrolytic migratory erythema managed for 24 months with intravenous amino acid and lipid infusions.

A 9-year-old castrated male Shetland sheepdog was diagnosed with necrolytic migratory erythema and hepatocutaneous syndrome. Necrolytic migratory erythema was treated with intermittent intravenous amino acids as needed to control cutaneous lesions. The addition of lipid infusions extended the treatment interval. The patient had a favorable response for 24 months.

Cas d'érythème migratoire nécrolytique géré pendant 24 mois à l'aide d'infusions intraveineuses d'amino-acides et de lipides. Un chien berger Shetland mâle castré âgé de 9 ans a été diagnostiqué avec un érythème migratoire nécrolytique et un syndrome hépatocutané. L'érythème migratoire nécrolytique a été traité par des amino-acides intraveineux intermittents au besoin pour contrôler les lésions cutanées. L'ajout d'infusions de lipides a prolongé l'intervalle de traitement. Le patient a manifesté une réponse favorable pendant 24 mois.(Traduit par Isabelle Vallières).