Treatment of Q fever endocarditis: comparison of 2 regimens containing doxycycline and ofloxacin or hydroxychloroquine.

BACKGROUND: Q fever endocarditis, caused by Coxiella burnetii, is fatal in 25% to 60% of patients. Currently, treatment with a long-term tetracycline and quinolone regimen for at least 4 years is recommended, although relapses are frequent. METHODS: Between January 1987 and December 1997, the reference treatment of Q fever endocarditis was compared with one of doxycycline and hydroxychloroquine sulfate. Patients were treated by conventional therapy until May 1991 and then by the new regimen. Microimmunofluorescence was used for antibody-level determination for diagnosis and follow-up. RESULTS: Thirty-five patients were included in the study, 26 males and 9 females. Of 14 patients treated with a doxycycline and quinolone combination, 1 died, 7 relapsed (3 were re-treated and 4 switched to the new regimen), 1 is still being treated, and 5 were considered cured using this regimen only. The mean duration of therapy for cure in this group was 55 months (median, 60 months). Twenty-one patients received the doxycycline and hydroxychloroquine regimen: 1 patient died of a surgical complication, 2 are still being treated, 17 were cured, and 1 is currently being evaluated. Two patients treated for 12 months but none of the patients treated for longer than 18 months relapsed. The mean duration of treatment in this group was 31 months (median, 26 months). No significant differences were observed between the 2 regimens in terms of death, valve surgery, or tolerance. The mortality rate for both regimens in this study was 5%. CONCLUSION: Prescription of the doxycycline and hydroxychloroquine combination for at least 18 months allows shortening of the duration of therapy and reduction in the number of relapses.

Neurologic onset of Behçet's disease: a diagnostic enigma in childhood.

Neuro-Behçet's disease, which is uncommonly reported in childhood, encompasses a wide variety of clinical features since any part of the neuraxis may be involved. It carries a serious prognosis and represents a leading cause of death or severe disability. Neuro-Behçet's disease may occur in 5% to 50% of adults with Behçet's disease and is usually subsequent to other systemic manifestations. In this report, we express the possibility of a primary neurologic presentation of Behçet's disease in childhood with pseudotumor cerebri and meningoencephalitis as exclusive initial features. We focus on diagnostic problems when major features of Behçet's disease are missing at the outset. We emphasize the high sensitivity of magnetic resonance imaging to make the diagnosis of cerebral vasculitis or thrombosis with a good reliability to clinical features.

[Occlusion of the central retinal vein after vaccination against viral hepatitis B with recombinant vaccines. 4 cases]. / Occlusion de la veine centrale de la rétine après vaccination contre l'hépatite virale B par vaccin recombinant. Quatre observations.

OBJECTIVES: Hepatitis B vaccination has been proven to be effective and well-tolerated. Certain neurological, ocular or systemic complications have, however, been reported to be induced by the vaccine. Clinicians should be aware of exceptional ocular complications. CLINICAL REPORT: Four patients under 50 years of age developed occlusion of the central vein of the retina after vaccination with recombinant hepatitis B vaccine. None of the classical causes of occlusion of the central vein of the retina could be evidenced. DISCUSSION: Several pathophysiological hypotheses have been proposed to explain these ocular manifestations after vaccination: role of immunocomplexes, antigenic cross-reactions, role of immediate hypersensitivity, simulation of a pathogenic lymphocyte repertoire. None of these hypotheses is entirely satisfactory. It is important however to emphasize the need for a complete general evaluation, including an ophthalmological examination in the presence of unexplained ocular manifestations following hepatitis B vaccination.

[Retinal vascular closure using laser photocoagulation]. / Occlusion vasculaire rétinienne par photocoagulation laser.

The aim of this experimental work was to produce a vascular occlusion of the retina by laser photocoagulation. Three types of lasers were used: argon green (514 nm), yellow laser (574 nm) and double frequency Neodymium YAG (514 nm) (DF-Nd: YAG) (532 nm). Pigmented retinas from 18 rabbits were photocoagulated using the three mirror technique under general anaesthesia. A fluorescenin angiogram of the retina was done after the photocoagulation to verify vessel occlusion. The rabbits were sacrificed at one day, one week and three weeks after photocoagulation for histology examinations. In most cases, laser photocoagulation did not cause vessel constriction. The angiograms showed that flow was slower but not interrupted. Yellow and DF-Nd: YAG lasers were more effective in creating vascular occlusions. The three lasers caused similar histological lesions which varied only in their extension to the different layers of the retina. The endothelium was destroyed and red cells aggregated in the vessel lumen. These findings suggest that yellow and DF-Nd: YAG laser should be used in all situations requiring coagulation of a vessel in the retina.

[Ocular toxoplasmosis: value of immunoblotting for the determination of an intra-ocular synthesis of antibodies]. / Toxoplasmose oculaire: intérêt de l'immunoblot pour la mise en évidence d'une synthèse intra-oculaire d'anticorps.

The aim of this study was to demonstrate the intraocular synthesis of specific antibodies in case of Toxoplasma retinochoroiditis on the basis of immunoblot analysis. Vitreous or aqueous and serum were analyzed by immunoblot in four cases of toxoplasmic chorioretinitis. The same assays were performed on samples from 16 control subjects. Immunoblot analysis of serum and ocular fluid from patients with toxoplasmic chorioretinitis showed IgG and IgA specific antibodies. Recognition patterns were different and demonstrated neo-antibodies in ocular fluid. In control samples only IgG were found and the same patterns were observed in the two compartments. Immunoblot is a useful technique to demonstrate the local synthesis of antibodies in ocular toxoplasmosis by comparison of recognition patterns between serum and ocular fluids. Integration of immunoblot patterns allows quantification of antibodies specific for each Toxoplasma antigen in the two compartments.

Diffuse choroidal hemangioma: report of a clinicopathological study in a 4-year-old boy.

The authors examined the clinicopathologic features of a 4-year-old boy with a diffuse choroidal hemangioma, yet without any features of the Sturge-Weber syndrome. The tumor occurred as a grayish intraocular mass with an overlying retinal detachment and was highly reflective in the ultrasonic examination. After contrast, the CT scan revealed diffuse thickening of the ocular wall associated with an enhanced irregular orbital mass. The pathologic examination revealed a cavernous hemangioma involving the entire choroid with extrascleral extension. Diffuse choroidal hemangioma occurring in childhood and unrelated to the Sturge-Weber syndrome is a rare condition that should be included in the differential diagnosis of retinoblastoma.

[Ataxic hemiparesis and simultaneous supra- and subtentorial hematomas]. / Hémiparésie ataxique et hématomes simultanés sus et sous-tentoriels.

In a chronically hypertensive woman with a rapidly developing right ataxic hemiparesis syndrome, computed tomography and magnetic resonance imaging (MRI) revealed two small unrelated hemorrhages: one in the posterior limb of the left internal capsule, the other in the right cerebellar hemisphere. In this patient, the ataxic hemiparesis syndrome might have resulted either from the association of the two lesions or from the capsular hemorrhage alone. The rarity of simultaneous hypertensive hematomas and the value of MRI in the diagnosis are underlined.

[Bilateral serous detachment of neuroepithelium of the posterior pole disclosing acute leukemia]. / Décollement séreux bilatéral du neuroépithélium du pôle postérieur révélant une leucémie aiguë.

A 51 year-old woman presented with sudden loss of vision secondary to serous neuroretinal detachments of both maculas. Fluorescein angiography revealed multiple hyperfluorescent pin-point dots in the early phases. The areas of fluorescein hyperfluorescence became more diffuse as dye leaked into the subretinal space. The diagnostic of acute monoblastic leukemia was made. Following treatment, her vision improved. Fundus examination at that time showed resolution of the bilateral serous retinal detachment. She died one month after the onset of visual complaints and autopsy was refused. There have been 14 previous reports of acute leukemia with serous retinal detachment. In most cases, retinal detachment occurred as the presenting sign or during relapse of the systemic disease. It was often bilateral and located in the posterior pole. Histopathologic studies showed leukemic infiltration of the choroid with areas of degeneration and proliferation of the retinal pigment epithelium. Angiographic findings are similar to what is observed in choroidal ischemia. The relationships with macular serous retinal detachment and choriocapillaris occlusion are discussed.

[Colloid cysts of the third cerebral ventricle. Computed x-ray tomography, MRI and stereotaxic puncture. Apropos of 9 cases]. / Kystes colloïdes du 3e ventricule. Scanner, I.R.M. et ponction stéréotaxique. A propos de 9 observations.

The authors report their experience with Colloid Cysts of the third ventricle (9 cases treated between 1983 and 1989). Eight of them were punctured using stereotactic approach; five cysts were completely evacuated and the patients are free of recurrence. In three cases, tapping was impossible or the cyst insufficiently evacuated and the patients were secondary operated on (open microsurgical approach). The last case was directly operated on. Colloid cysts cured by stereotactic puncture were all hypo or iso-dense at C.T. scan and had a diameter of more than 1 cm. All these cases have had a M.R.I. exploration and the image of the cyst was always the same increased T1 and T2 signal. Unfortunately, we did not have the opportunity to realize M.R.I. in colloid cysts of a small size and hyperdense at C.T. scan. These results can help to the indication of a stereotactic puncture at the first attempt in some well defined colloid cysts.

[Paralysis of the right arm caused by vertebral arteriovenous fistula]. / Paralysie du membre supérieur droit par fistule artérioveineuse vertébrale.

Traumatic vertebral arteriovenous fistulas rarely result in neurological disorders. We report a case of upper limb paralysis caused by a C5-C6-C7 radiculopathy, 44 years after a trauma and successfully treated by surgery and embolization.

[Endogenous bacterial endophthalmitis. Report of 3 cases]. / Endophtalmie bactérienne endogène. A propos de trois observations.

Since the antibiotic era, endophthalmitis has been a rare complication of bacterial septicemia. The authors report hereby 3 cases of endogenous bacterial endophthalmitis. Both eyes were involved in one case. Causative bacteria were identified in blood. Cultures were positive respectively for Streptococcus pneumoniae, Staphylococcus aureus and Klebsiella pneumoniae. All patients received intravenous antibiotherapy, once intravitreal antibiotic was injected. Clinical manifestations were three times panophthalmitis with dramatic course. In one case, only the anterior segment was involved. The course became complicated with a cataract, but the patient finally recovered. Although several clinical types with distinct prognoses can be defined, endogenous bacterial endophthalmitis remains a devastating situation. Treatment is controversial because of the uncertainty about the value of intravitreal antibiotics and vitreous surgery.

Capsular ataxic hemiparesis. Early diagnosis with MRI.

The Authors report a case of ataxic hemiparesis caused by a lacunar infarct involving the posterior limb of the right internal capsule, in a 64-year-old hypertensive man who completely recovered in about two weeks. The lesion was detected by MRI four days after the onset of illness, when the CT scan was normal. In patients presenting with ataxic hemiparesis, MRI is the most accurate tool in locating very small causative infarcts of the brainstem or the subcortical white matter.