[Pyopneumothorax in rheumatoid arthritis]. / Pyopneumothorax au cours d'une polyarthrite rhumatoïde.

INTRODUCTION: Rheumatoid arthritis (RA) is a chronic inflammatory disease affecting the joints but which frequently includes extra articular effects, including pulmonary nodules, which grow faster under immunosuppressive treatment. CASE REPORT: A 74 years old man, with mild asbestosis, underwent treatment with methotrexate then leflunomide (LEF) for seropositive RA. In February 2014, during monitoring of his asbestosis, chest CT scan showed the appearance of thick-walled cavitating lung nodules, with a central and sub pleural distribution. The patient was asymptomatic. Bronchoalveolar lavage excluded infection and tumor. LEF was stopped but in May 2014, the patient was admitted with respiratory infection and a pyopneumothorax which required surgical management. The postoperative course was complicated with a persistent pneumothorax. CONCLUSIONS: We describe a case of RA complicated by a pyopneumothorax after treatment with LEF. The risk of this complication could be reduced by regular chest imaging.

Rheumatologic manifestations of pachydermoperiostosis and preliminary experience with bisphosphonates.

OBJECTIVE: Pachydermoperiostosis is manifested by finger clubbing, hypertrophic skin changes, and periosteal bone formation. We describe 5 cases revealed primarily by their rheumatologic manifestations. Also reported are preliminary experiences on the use of intravenous pamidronate as a treatment. METHODS: This is a retrospective study including the analysis of clinical manifestations, laboratory results and morphological examinations gathered from patients' medical records. We evaluated efficacy of treatment with 1 mg/kg iv pamidronate in the 3 new cases. RESULTS: Before treatment with iv pamidronate, the patients' global assessment was poor (twice) and very poor (once). The physician's global assessment was poor in 3 patients. After treatment with iv pamidronate, 2 patients had significant improvement. Physician and patient global assessments were very good, good, and moderate. No side effects were observed. All biological variables were within normal ranges at 12 month followup visit. CONCLUSION: Pachydermoperiostosis must be recognized by the rheumatologist, since it can present symptomatically through articular manifestations. When conventional treatment modalities fail, iv pamidronate might be useful.

Malignant acetabular osteolyses: percutaneous injection of acrylic bone cement.

Percutaneous osteoplasty with acrylic bone cement was performed in 12 acetabular osteolytic lesions in 11 patients with inoperable metastases (n = 8) and myeloma (n = 3). Complementary radiation therapy was started 15-30 days after injection in each case. Pain diminished within hours to 4 days in nine patients, and walking improved in each patient within 1-5 days. Five patients died during the follow-up period. Clinical improvement was maintained in all but two patients.

Percutaneous vertebroplasty with acrylic cement in the treatment of a Langerhans cell vertebral histiocytosis.

A 25-year-old man developed multiple eosinophilic granuloma of bone including vertebral and sacral localization. Radiotherapy was initially administered. One year later, a relapse occurred in another vertebrae which was previously irradiated. Percutaneous vertebroplasty was, for the first time to our knowledge performed, in this indication, with a good clinical result with follow-up now for one year. We emphasize that such treatment is permissible only in symptomatic, progressive lesions, with threatened decompensation of spinal stability. This technique should be used only on an adult.

Aspergillus spondylodiscitis: successful conservative treatment in 9 cases.

OBJECTIVE: To assess the effectiveness of medical treatment by clinical, radiological, and biological analysis of outcome in 9 patients with aspergillus spondylodiscitis. METHODS: Retrospective study including 9 patients with aspergillus discitis, in which 7 were immunosuppressed; 3 were heart transplant patients, 2 had acute lymphoblastic leukemia, 1 hairy cell leukemia and one was receiving prednisone for bronchial asthma. Four patients had isolated spinal aspergillosis infection. In 4 cases, disc space infection occurred after pulmonary aspergillosis. In the last case the spondylodiscitis occurred after aspergillus endocarditis and mycotic limb embolism. In all cases a percutaneous needle biopsy of the intervertebral disc was performed; the subsequent culture produced Aspergillus fumigatus in 8 cases and Aspergillus flavus in 1. Itraconazole was given to all patients (mean dose: 350 mg/day); it was given alone in 2 cases, in addition to 5 flucytosine and amphotericin B in 6 cases, and in addition to amphotericin B in the last case. RESULTS: Improvement was obtained in the 9 cases, with full recovery in the absence of any surgical debridement after a mean treatment duration of 5.5 months and a mean followup delay of 16 months. CONCLUSION: Early recognition of aspergillus spondylodiscitis in immunocompromised hosts is important. Itraconazole alone or in combination is an effective therapy. There may be an increased incidence of aspergillus discitis due to the increasing frequency of immunosuppression associated conditions including organ transplantation, chemotherapy, or acquired immune deficiency syndrome.

[Value of vertebroplasty combined with surgical decompression in the treatment of aggressive spinal angioma. Apropos of 3 cases]. / Intérêt de la vertébroplastie couplée à une décompression chirurgicale dans le traitement des angiomes vertébraux agressifs. A propos de trois cas.

Vertebral hemangiomas can cause difficult-to-treat neurological complications. We report our experience with three such cases. Patients no. 1 and 2 were females aged 64 and 71 years, respectively; patient no. 1 had a two-year history of weakness in the lower limbs and patient no. 2 had a five-month history of back pain. Both these patients had a pyramidal syndrome in the lower limbs. Patient no. 3 was a 61 year old male with a one-year history of left sciatica. Roentgenograms were suggestive of a hemangioma occupying the entire T8 (cases 1 and 2) or L5 (case 3) vertebra. Computed tomography and magnetic resonance imaging confirmed this diagnosis and showed that patients 1 and 2 had an anterior epidural hemangioma opposite T8 impinging on the spinal cord. In patients 1 and 2, treatment consisted in embolization of T8 followed by transpedicular injection of 6 cc of methylmethacrylate into the body of T8. One cubic centimeter of histoacryl was also injected in each lamina. The third patient had a similar vertebroplasty procedure without prior embolization since he had no epidural hemangioma. One patient (no. 1) developed intercostal neuralgia of several hours duration after the procedure. All three patients subsequently underwent laminectomy (T7-T8 with removal of the epidural hemangioma in cases 1 and 2, L5 in case 3). The pyramidal syndrome resolved within 15 days in patients 1 and 2; the nerve root pain resolved within 48 hours in patient 3.(ABSTRACT TRUNCATED AT 250 WORDS)

[Rheumatoid arthritis and multiple myeloma. Apropos of 22 cases. Results of a multicenter national survey]. / Polyarthrite rhumatoïde et myélome multiple. A propos de vingt-deux observations. Résultats d'une enquête nationale multicentrique.

Although studies of patients with rheumatoid arthritis have found no increases in overall cancer rates, significant elevations in rates of lymphoma and myeloma have been reported, suggesting a causal relationship between autoimmune disorders and lymphoid malignancies. Nevertheless, only 22 cases of concomitant rheumatoid arthritis and multiple myeloma were identified during a retrospective national multicenter study carried out in France. Neither disease exhibited unusual features. In every case, rheumatoid arthritis preceded multiple myeloma. Monoclonal gammopathy preceded multiple myeloma in two patients, by 3 and 7 years respectively. No patient had amyloid arthritis. Analysis of data from the cancer registry of the Somme district in northern France did not suggest a significantly increased risk of multiple myeloma in rheumatoid arthritis patients (relative risk 2.3). Use of interferon alpha to treat myeloma has been reported to exacerbate concomitant autoimmune disorders.

[Aspergillus spondylodiscitis. Apropos of 5 cases]. / Les spondylodiscites aspergillaires. A propos de cinq observations.

Five cases of Aspergillus discitis in male patients are reported. Three patients had impaired immune responses as a result of immunosuppressive therapy following a heart transplant (two cases) or hairy cell leukemia (one case). Two patients had a recent history of mycobacterial infection. All five patients were hospitalized for severe spinal pain suggestive of an inflammatory disease with no neurological abnormalities. Erythrocyte sedimentation rate was elevated in every case. The diagnosis of discitis was suspected on spinal roentgenograms and established by computed tomography and/or magnetic resonance imaging. In three patients the spine was the only site of Aspergillus infection (lumbar discitis in two cases and thoracic discitis in one case). One patient developed Aspergillus infection of several disks (L1-L2, L2-L3, and L4-L5) after Aspergillus endocarditis with embolization to the left lower limb. Another patient developed discitis after an Aspergillus lung infection. In every case, Aspergillus fumigatus was recovered in cultures of specimens harvested by a percutaneous needle biopsy of the intervertebral disk. All five patients were treated by itraconazole which was given as single drug therapy in one case and in combination with 5-flucytosine and amphotericin B in four cases. Recovery was achieved in every case after four to six months of this drug therapy. In contrast to most previously reported cases, none of the five patients reported herein required surgical treatment. Efficacy of conservative treatment in this study may be related to the use of itraconazole in every case.(ABSTRACT TRUNCATED AT 250 WORDS)

[Role of iatrogenic spondylodiscitis among pyogenic spondylodiscitis. 136 cases observed between 1980 and 1989]. / Place des spondylodiscites iatrogènes parmi les spondylodiscites à germes banals. 136 cas observés entre 1980 et 1989.

The authors report 136 cases of spondylodiscitis due to ordinary organisms seen between 1980 and 1989 and note the increasing incidence of iatrogenic forms which during the past three years accounted for 50 per cent of cases. 60 per cent of these cases of iatrogenic spondylodiscitis complicated a medical of surgical procedure involving the spine (form by direct inoculation). In 40 per cent of cases, the organism came from a site of infection located at a distance (from by blood-borne spread). The clinical picture in cases of primary spondylodiscitis and of iatrogenic disease by blood-borne spread is essentially similar. That of iatrogenic forms by direct inoculation is different: most often young subjects, virtually exclusive involvement of the lumbar spine, fever and inflammatory syndrome less common. Escherichia coli and Staphylococcus aureus were the organisms most often responsible for primary spondylodiscitis (23 and 21.7 per cent of case respectively). Streptococci were in third position only (15.6 per cent of cases). Staphylococcus aureus remained predominant in iatrogenic spondylodiscitis (34 per cent of cases), while Escherichia coli and streptococci were significantly rarer than in primary forms and there was the appearance of Pseudomonas aeruginosa and Staphylococcus albus. No organism was found in 23 per cent of cases of primary spondylodiscitis. This figure reached 44% of iatrogenic forms by direct inoculation. Because of their increasing incidence, these cases of apparently aseptic spondylodiscitis, frequently complicating a procedure involving the spine, are modifying the picture of infectious spondylodiscitis. No doubt worthy of separate identification, they raise the problem of the significance of the concept of aseptic spondylodiscitis.