[Management of myocardial infarction in patients over 75 years of age from 1983 to 1999]. / Prise en charge de l'infarctus du myocarde du suiet de plus de 75 ans de 1983 a 1999.

Elderly patients are often excluded from therapeutic methods which have been shown to improve the prognosis of myocardial infarction (MI). The aim of this study was to describe the changes in management of MI in the elderly and to analyse the factors associated with hospital mortality due to MI during this period. All cases of acute MI in patients over 75 years of age from 1983 to 1999 and admitted to the Centre Hospitalier du Val d'Ariège were reviewed. The clinical features, the modalities of initial management and their treatment on discharge were compared by periods: 1983-88, 1989-93 and 1994-99. The changes in hospital mortality and the factors associated with this mortality were studied. Five hundred and forty-four cases of patients with an average age of 81 years were reviewed. The proportion of patients who were treated medically alone decreased over the 3 periods whereas treatment by angioplasty and thrombolysis increased (1.2% in 1983-88 versus 18.2% in 1994-99). Betablockers, ACE inhibitors and aspirin were much more prescribed on discharge from hospital. In parallel, the hospital mortality from MI decreased by half (50.8% in 1983-88 versus 24.9% in 1994-99). The independent factors associated with hospital mortality were age, anterior infarction (OR = 2.08 [1.39-3.13]), revascularisation of the culprit artery by thrombolysis or angioplasty (OR = 0.24 [0.09-0.61]) and the period of hospital stay (OR = 0.22 [0.12-0.38] in 1994-99 compared with 1983-88). The authors' experience reflects an improved prognosis of MI in the elderly partially due to the benefits of treatment by angioplasty and thrombolysis. Improvement of pre-hospital treatment, better diagnostic methods and more aggressive management of the elderly with MI also contribute to these results.

[Severe Legionnaire's disease revealing an invasive aspergillosis in an apparently immunocompetent patient]. / Légionellose grave révélant une aspergillose invasive chez un sujet immunocompétent.

INTRODUCTION: Invasive aspergillosis, a sever disease, usually occurs in immuno-depressed patients. However, it may also develop in presumably immuno-competent patients. OBSERVATION: A 54-year-old man, smoker, was hospitalised for hypoxemia of the right lung and septic shock, rapidly requiring mechanical ventilation combined with administration of vasopressors, and followed by dialysis because of the rapid worsening of an acute kidney failure. The diagnosis of pulmonary Legionnaire's disease was made on the second day in view of the positivity of the urinary legionella antigen. The progression of the disease was marked by the discovery of a histologically documented gastric aspergillosis and three abscessed intracerebral lesions within the context of a strongly positive aspergillus antigenemia. The disease worsened and the patient died on D 17, despite the antibiotic and anti-aspergillus treatments, haemodynamic support and dialysis. DISCUSSION: To our knowledge, the association of invasive aspergillosis and severe Legionnaire's disease has never been described in an presumably immunocompetent patient. This clinical case suggests the existence, other than the usual risk factors of invasive aspergillosis that characterise profound states of immunodepression, of more subtle alterations in the immune system that may enhance this type of infection.