[Eosinopenia in 2018]. / L'éosinopénie en 2018.

Since 1893, eosinopenia is a biological test to help a diagnosis of bacterial infection. Several publications have confirmed this hypothesis, particularly in the intensive care, pneumology and pediatric units. The value of this marker has been identified in vascular cerebral diseases and coronary bypass. Its contribution seems as relevant as procalcitonin, without extra cost. The diagnostic performance of this test was reinforced by a composite score (CIBLE score) that may improve its value in daily routine. Finally, monitoring eosinopenia appears to be a reliable mortality marker.

[A predictive bacterial infection score according to eosinophil level: An observational study]. / Proposition d'un score prédictif d'infection bactérienne selon le taux d'éosinophiles : étude observationnelle.

INTRODUCTION: Several studies have shown that eosinopenia less than 0.04g/L is a marker of bacterial infection in the presence of unexplained inflammatory syndrome. The aim of our study was to test this hypothesis and to propose a predictive score for bacterial infection (score CIBLE, C reactive protein, bacterial infections, levels of leucocytes and eosinophils). PATIENTS AND METHODS: This was a single-center observational study of patients admitted to an internal medicine department in the year 2015 and presenting with an inflammatory biological syndrome. Patients were divided into 2 groups: bacterial infections (group 1) and nonbacterial inflammatory diseases (group 2). RESULTS: One hundred and ninety patients were included: 92 men (48.4 %) and 98 women (51.6 %). Mean age was 73.5±18.2 years [19-104]. Group 1 consisted of 124 patients (65.2 %) and group 2 of 66 patients (34.8 %). ROC analysis confirmed a cut-off level for eosinophils count at 0.04g/L as discriminant to predict bacterial infection. In a multivariate analysis, the eosinophil/neutrophil ratio, a history of COPD, the C reactive protein concentration, patient age and initial temperature were the most significant variables. They were used to build the CIBLE score. For a score higher than or equal to 87, the probability of a bacterial infection is at least 70 %. CONCLUSION: The CIBLE score appears to be a relevant and inexpensive tool to establish a probability for bacterial infection.

Screening of human papillomavirus infection in women with systemic sclerosis.

OBJECTIVES: High risk human papilloma-viruses (HR HPV) are associated with risk of cervical dysplasia and carcinoma. The risk is increased in patients with immune deficiency or auto-immune disease as systemic lupus erythematosus. Currently, no data are available about the human papillomavirus status in women with systemic sclerosis (SSc). METHODS: Thirty-one women with SSc were evaluated for cervical HPV infection and dysplasia, and compared to fifty age-matched control. Cervical swabs were tested by the INNO-LiPA assay®. Serum antibodies against HPV 16 and 18 were assessed using enzyme-linked immunosorbent assay in the SSc group. RESULTS: The overall HPV frequency was comparable between SSc and controls (32% vs. 38%), as well as the HR HPV frequency (28% vs. 34%), but infection by ≥2 HPV was two times more frequent in the SSc group (50% vs. 26% of the HPV positive samples). The most prevalent genotype was 52 in the SSc group (12%), and 52/53 in the control group (8% for both). Pap smears were within the normal range. Seropositivity for HPV 16 and 18 was 13% and 6.5%, respectively. A diffuse systemic sclerosis and a younger age at first intercourse were more frequent in cases of overall HPV positivity. Current smoking and a higher number of sexual partners were only observed in cases of seropositivity. CONCLUSIONS: This is the first study to evaluate HPV status in women with SSc. HR HPV52 was the most common genotype with a greater multi-HPV infection rate. This result needs to be confirmed in a larger study.

[Contribution of cerebral magnetic resonance imaging to etiological investigation of uveitis]. / Place de l'imagerie par résonance magnétique cérébrale dans le bilan étiologique des uvéites.

PURPOSE: Uveitis is a disorder for which etiologic assessment procedures are still not codified. Clinical presentation is heterogenous, with poor correlation between symptoms and neurological involvement. The aim of our study was to assess the contribution of cerebral magnetic resonance imaging (MRI) in the management of uveitis. METHODS: Seventy-one patients, 26 men and 45 women, were included between January 1st, 2000 and March 31st, 2008, in two groups "contributory MRI" and "not contributory MRI" according to diagnostic contribution of MRI. Clinical characteristics of uveitis, inflammatory, immunological and infectious biological features, and cerebral MRI were analyzed. RESULTS: A diagnostics was established in 38 (53.5%) patients. Five patients with multiple sclerosis and one case of Behçet's disease were diagnosed using cerebral MRI. CONCLUSION: This study points out cerebral MRI contribution as a second-line examination for the etiological diagnosis of uveitis especially in case of suspicion of multiple sclerosis or Behçet's disease.

[Clinical features of pulmonary embolism in elderly: a comparative study of 64 patients]. / Particularités cliniques de l'embolie pulmonaire chez la personne âgée : étude comparative de 64 patients.

PURPOSE: To date only a few studies regarding pulmonary embolism (PE) in elderly have been published. The aim of this study was to determine the clinical features of PE in elderly patients (≥ 75 years). METHODS: All patients hospitalized for PE in our internal medicine department from January 2005 to December 2010 were included in the study. The aim was to compare the features of PE in elderly patients (≥ 75 years) to those of patients younger than 75 years. The following data were recorded: past medical history, risk factors for venous thrombo-embolism (VTE), clinical features, and PE etiologies. RESULTS: The population was composed of 64 patients (women 56%) with a median age of 82 years (IQR: 13.5). There was no statistical difference for risk factors of VTE. Syncope was more frequent in elderly patients (33% versus 7%, P=0.04) whereas thoracic pain predominated in younger patients (36,5% versus 7%, P=0.005). Chronic obstructive pulmonary disease was more frequent in the past medical history of elderly patients. The diagnostic of PE was less suspected in elderly patients (47% versus 72%, P=0.035). The etiologies were similar between the two groups. CONCLUSION: Our study highlights the frequency of syncope as the presenting feature of PE in elderly, whereas thoracic pain is uncommon. We confirmed the difficulty to diagnose PE in elderly population.

[Guidelines for the probabilistic treatment of community-acquired pneumonia: compared experience between internal medicine and emergency departments in the University Hospital of Besançon, France]. / Application des référentiels concernant la prise en charge probabiliste des pneumopathies communautaires non sévères: expérience comparée du service de médecine interne et du service des urgences adultes du CHU de Besançon.

INTRODUCTION: The objective of this study was to assess the application of local and national recommendations in the management of community-acquired pneumonia in an internal medicine department with an antibiotic referent physician and in an emergency department. PATIENTS AND METHODS: This was a retrospective single-center study including patients admitted with community-acquired pneumonia in the internal medicine department of the University Hospital of Besançon after an initial admission in the emergency department. RESULTS: One hundred patients (58 women and 42 men) were included. The mean age was 79 ± 11 years. The prescriptions done in the emergency department were in accordance with local recommendations or Société de pathologie infectieuse de langue française (SPILF) recommendations in 62% of cases. The prescriptions followed the recommendations in 94% of cases in internal medicine department (P<0.05). The lack of initial antibiotic treatment had no influence on morbidity and mortality. CONCLUSION: The guidelines for infectious diseases treatment were significantly more often applied in a department where a referent physician was designated for this.

[Acquired ichthyosis and livedoid palmoplantar keratoderma: two unusual skin manifestations of systemic lupus erythematosus]. / Ichtyose acquise et hyperkératose livédoïde palmoplantaire: deux manifestations cutanées initiales atypiques de lupus systémique.

Acquired ichthyosis and livedoid palmoplantar keratoderma have rarely been described in systemic lupus erythematosus (SLE). In the first case, a 51-year-old man presented with generalized acquired ichthyosis associated with renal glomurelosclerosis and neurolupus. rituximab allowed total resolution of the acquired ichthyosis. A livedoid palmoplantar keratoderma was observed in a 45-year-old woman as the initial clinical manifestation of a systemic lupus erythematosus associated with Raynaud's phenomenon, photosensitivity and inflammatory polyarthralgia. Although the pathophysiology is not well-defined, these unusual cutaneous manifestations should be considered by physicians when diagnosis of SLE is suspected.

[Role of cyclosporine in the occurrence of neuro-Behçet's disease?]. / Responsabilité de la ciclosporine dans la survenue d'un neuro-Behçet ?

Central neurological involvement in Behcet's disease (neuro-Behcet) occurs in 10 to 20% out of the patient. We report a 47-year-old man treated with cyclosporine who presented with neurologic manifestations of Behçet's disease. Relationship between cyclosporine and neuro-Behcet's disease are discussed.

[Recurrent aphthosis: safety of low dose thalidomide]. / L'aphtose récurrente: innocuité du thalidomide à faible dose.

PURPOSE: Thalidomide is an effective treatment for recurrent aphthosis but its effectiveness at low dose has been rarely assessed. METHODS: Single-centre non-randomized retrospective open study. RESULTS: Forty-seven patients were treated with thalidomide for recurrent aphthosis (41 patients) or Behçet disease (six patients). Remission was obtained with a dose of 25 mg daily. Discontinuation of treatment for side effects was not observed in this case series. CONCLUSION: Low dose thalidomide below 50 mg daily is an effective and well tolerated treatment of aphthosis.

[Thromboprophylaxis assessment in an internal medicine department]. / Evaluation de la thromboprophylaxie dans un service de médecine interne.

PURPOSE: There is a lack for French official guidelines for prophylaxis of venous thromboembolism. Therefore an internal referential based on MEDENOX study inclusion criteria was proposed in our internal medicine department. The main goal of this study was to assess the appropriateness of thromboprophylaxis prescriptions regarding the internal referential. METHODS: A retrospective and observational study included all the patients older than 18 years hospitalized in February and July 2007 in our internal medicine department for at least 48 hours and receiving no anticoagulant treatment. For each patient the following criteria were recorded: admission diagnosis, past medical history, current treatment, creatinine clearance, duration of hospitalisation, thromboprophylactic treatment and course during hospital stay. RESULTS: Eighty-nine patients were included. Forty-two (47.2%) patients had a thromboprophylaxis indication. Among them 40 (95.2%) actually received a thromboprophylaxis. Ten of the 47 patients (21.2%) without thromboprophylaxis indication also received a thromboprophylaxis. The most frequent indications for thromboprophylaxis were an infectious disease with an age greater than 75 years old and a cardiac failure stage III or IV of the NYHA. CONCLUSION: Most of the studies concerning medical thromboprophylaxis highlight its underutilization in the absence of a referential. In our study the referential use increased the percentage of patients with appropriate thromboprophylaxis but was associated with over-prescriptions in 21.2% of the cases. The use of electronic alerts may increase the number of patients receiving the appropriate treatment.

Rituximab treatment of stiff-person syndrome in a patient with thymoma, diabetes mellitus and autoimmune thyroiditis.

Stiff-person syndrome (SPS) is an autoimmune neurological disorder characterized by stiffness of the skeletal muscle with superimposed spasms and production of autoantibodies to glutamic acid decarboxylase (GAD) and amphiphysin. The disorder results from B cell-mediated clonal production of autoantibodies, requiring treatment with immunosuppressors; however, treatment results have been somewhat inconsistent. We report the results of rituximab treatment in a patient with SPS associated with a thymoma, diabetes mellitus, autoimmune thyroiditis and the presence of anti-GAD and anti-amphiphysin autoantibodies. The patient experienced a partial improvement following a thymectomy and the administration of prednisone, intravenous immunoglobulins and mycophenolate mofetil. Treatment with rituximab was followed by a complete sustained remission and the disappearance of serum anti-amphiphysin antibodies.

[Kappa light chain deposition disease, presenting as Sjögren's syndrome, successfully treated by high-dose melphalan and autologous blood stem transplantation]. / Maladie de Randall, simulant une maladie de Gougerot-Sjögren, traitée avec succès par chimiothérapie et autogreffe de moelle osseuse.

INTRODUCTION: Light chain deposition disease is a systemic disorder characterised by tissue deposition of monoclonal immunoglobulin light chains without tinctorial properties. It has been exceptionally reported with salivary involvement mimicking Sjögren's syndrome and peripheral neuropathy. CASE REPORT: We report a case of light chain deposition disease associated with plasma cell dyscrasia presenting as sicca syndrome with salivary glands hypertrophy and polyneuropathy successfully treated by high dose melphalan and autologous blood stem transplantation. CONCLUSION: Light chain deposition disease should be recognized as an aetiology of sicca syndrome and peripheral neuropathy. Further studies should assess the prevalence of sicca syndrome in light chain deposition disease and better characterise the neurological manifestations.

[Usefulness of antineutrophil cytoplamic antibodies in giant cell arteritis]. / Valeur des anticorps anticytoplasme des polynucléaires neutrophiles dans la maladie de Horton.

PURPOSE: The relevance of antineutrophil cytoplasmic antibody (ANCA) during giant cell arteritis is not established. The purpose of our study was to estimate the ANCA frequency and their impact on disease course of giant cell arteritis. METHODS: Thirty patients were followed-up for giant cell arteritis and had a detection of ANCA. RESULTS: Nine patient had positive ANCA (30%). These patients had no significant differences regarding clinical and biological data or number of relapses in comparison with patients having negative ANCA testing. However, the relapse occurred earlier in the presence of ANCA (six months versus 31.5 months). CONCLUSION: In giant cell arteritis, detection of ANCA seems predictive of a premature relapse and should be associated with an acute monitoring of ANCA positive patients.

[Stiff person syndrome associated with thymoma. Efficacy of thymectomy]. / Syndrome de la personne raide associé à un thymome: efficacité de la thymectomie.

INTRODUCTION: Stiff person syndrome is a rare autoimmune neurologic disorder characterized by axial muscular rigidity and intermittent painful spasms. Three distinct forms are described: auto-immune, paraneoplastic and idiopathic. EXEGESIS: We report the case of a 51-year-old man with an history of Stiff Person Syndrome with typical clinical, electrophysiological and immunological findings. Anti-glutamic acid decarboxylase antibodies were present, as well as anti-amphiphysin antibodies, commonly reported in the paraneoplastic syndrome. CT scan revealed a thymoma. Surgical resection was followed by reduction of the neurologic symptoms, without lowering the auto antibodies titer. CONCLUSIONS: The association between Stiff Person Syndrome and thymoma is exceptional. Thymectomy is an effective treatment and may act without change of the autoantibodies titer. Patients with Stiff Person Syndrome should be systematically tested for thymoma.

[Pseudo-myasthenic myopathy in a woman with anorexia nervosa]. / Pseudomyasthénie grave chez une anorexique.

Skeletal myopathy, although foreseeable in severe malnutrition, has been rarely reported in patients with anorexia nervosa. We report a case of oculo-oropharyngeal myopathy mimicking myasthenia in a 42-year-old woman with an history of anorexia nervosa, completely reversible after refeeding with carbohydrate diet, mainly chocolate. Nutritional myopathies are not well known and therefore rarely looked for in patients with anorexia nervosa. Classical presentation is a myogenic syndrome with severe type 2 fibre atrophy and biochemical characteristics similar to Mac Ardle's disease. A clinical form mimicking myasthenia gravis has never been reported. Refeeding programme leads to total recovery within a few days.

[Pronostic value of C-reactive protein measure in elderly patient with acquired pneumonia: correlation with Fine's score]. / Valeur pronostique du dosage de la protéine C réactive (CRP) dans les pneumopathies aiguës infectieuses du sujet âgé: corrélation avec le score de Fine 97.

UNLABELLED: The Fine's score, a predictive score of infectious pneumonia gravity, does not integrate inflammatory parameters, which are routinely used in the management of infectious pneumonia. The aim of our study was to establish a correlation between the Fine's score and C reactive protein. PATIENTS AND METHODS: One hundred patients hospitalized for infectious pneumonia, 57 men and 43 female, with an average age of 85 years were retrospectively recorded. RESULTS: The median level of C reactive protein was 157 mg/L. Global mortality rate was 26% and respectively 5, 16 and 45% in the grades III, IV, V of the Fine's score. Beyond 75,5 mg/L C reactive protein concentration, the mortality rate was contained between 28 and 32%. The comparison of the ROC curves of the Fine's score and C reactive protein did not showed any difference. CONCLUSION: C-Reactive protein is less precise than the Fine's score to assess infectious pneumonia gravity but seems to be an indicator of the potential gravity of the pneumonia.