[Chlorpromazine-induced agranulocytosis: a case report]. / Toxicité médullaire des phénothiazines : à propos d'un cas d'agranulocytose sous chlorpromazine.

CASE REPORT: We report the case of a 50-year-old man, treated with chlorpromazine for schizophrenia, who developed an agranulocytosis. Three mechanisms of drugs-induced agranulocytosis have been reported: toxic, genetic and immune. Phenothiazines are responsible for drug-induced agranulocytosis. This patient had been treated with first and second generation antipsychotic drugs during his life and had already been exposed to chlorpromazine or other phenotiazines without any signs of toxicity. However, two months after the introduction of chlorpromazine he presented an agranulocytosis (leukocytes 1.4G/L and neutrophils 0.2G/L). After discontinuation of chlorpromazine, blood count returned to normal. The role of chlorpromazine in inducing toxic agranulocytosis was based on: (i) normal blood count before the introduction of chlorpromazine; (ii) occurrence of agranulocytosis within the first weeks of chlorpromazine treatment; (iii) normal bone marrow and blood count after discontinuation of chlorpromazine; (iv) chlorpromazine was the only new drug prescribed to this patient at the time the agranulocytosis occurred. Risk factors for toxic agranulocytosis in this patient were: old age, association of phenothiazine with other drugs known to be able to induce agranulocytosis, and past history of use of high doses of chlorpromazine. DISCUSSION: This case report highlights the risk of chlorpromazine in inducing agranulocytosis, a risk underestimated in regard of the clozapine risk to induce agranulocytosis or neutropenia. For this reason, it seems reasonable to recommend performing a blood count before introduction of phenothiazine in patients with risk factors for toxic drug-induced agranulocytosis (old age, female, receiving other drugs with a high potential to induce agranulocytosis and having received high doses of phenothiazine for a long time).

[Typhlitis: report of a case and review of the literature]. / Typhlite: à propos d'une observation et revue de la littérature.

INTRODUCTION: Typhlitis is a rare condition, characterized by necrotizing inflammation of the colon. It occurs mainly in neutropenic patients receiving chemotherapy for leukemia. EXEGESIS: We report the case of a 64-year-old woman with T-cell lymphocytic leukaemia, who exhibited asymptomatic reactivation of cytomegalovirus infection and developed subsequently typhlitis. CONCLUSION: The pathological mechanisms of typhlitis remain unclear in neutropenic patients. The role of cytotoxic drugs as well as both bacterial overgrowth and translocation has been postulated. In our patient, asymptomatic reactivation of cytomegalovirus infection may have increased chemotherapeutic-agents-digestive toxicity.

Typhlitis as a complication of alemtuzumab therapy.

Alemtuzumab is a humanized monoclonal antibody directed against lymphocytes through the CD-52 receptor, an antigen being found on > 95% of peripheral blood lymphocytes and monocytes, and to a smaller extent on granulocytes. It is an effective immunotherapeutic agent in patients with malignancies such as non-Hodgkin lymphoma, B cell chronic lymphocytic leukemia and T cell pro- lymphocytic leukemia. Adverse side effects are increasingly recognized in patients receiving alemtuzumab, mainly including fever, rigors, nausea/vomiting, skin rash; other severe alemtuzumab-related reactions have also been described, such as lymphopenia and neutropenia leading to both opportunistic (e.g. cytomegalovirus) and non-opportunistic infections. Digestive complications have more rarely been described, i.e.: gastroenteritis and peritonitis. We recently observed a case of particular interest as the patient with T cell prolymphocytic leukaemia treated with alemtuzumab, exhibited symptomatic reactivation of CMV infection and developed subsequently typhlitis.

[Pneumonia with bacteremia due to Yersinia enterocolitica in a diabetic patient carrying HLA-B27]. / Pneumopathie avec bactériémie à Yersinia enterocolitica chez un patient diabétique porteur de l'antigène HLA-B27.

INTRODUCTION: We report a new case of pneumonia and bacteremia due to Yersinia enterocolitica (YE) in a diabetic patient with HLA-B27 positive spondylarthritis. OBSERVATION: A 75-year-old man was admitted for a pneumonia. He was suffering from HLA-B27 positive spondylarthritis and stable diabetes mellitus. Amoxicillin with clavulanic acid was ineffective. Two blood and stool cultures were positive for YE. There was no evidence of septic metastases, immunodepression and iron overload. Outcome was uneventful after 21 days of ofloxacin. CONCLUSION: YE pneumonia is rare. In this patient, diabetes mellitus and spondylarthritis with HLA-B27 may have played a role in the infection but their imputability remain questionable.

[Tuberculosis peritonitis: an always present disease. About 4 new cases]. / La tuberculose péritonéale: une entité toujours présente. A propos de quatre observations.

INTRODUCTION: Tuberculous peritonitis, a major problem in developing country, occurs preferentially in immigrant population and in patients with acquired immune deficiency syndrome (AIDS). Although rare in France, it did not disappear and epidemiological, clinical and therapeutic approach deserve to be reminded. EXEGESIS: We reported 4 patients (immigrants in two cases), occurred in caucasian and African persons (one with AIDS). Disease was characterized by fever, abdominal pain, anorexia, weight loss and ascites. Biological and radiological were unconclusive. Cell count analysis from ascitic fluid show a lymphocytic predominance with negative direct smear for Ziehl-Neelsen strain. Tuberculous peritonitis was established with combined visual and histological diagnosic laparoscopic examination. CONCLUSION: These observations have the interest to underline that tuberculous peritonitis must be evoked in case of lymphocytic ascitis. We believe an aggressive diagnostic approach, particulary with peritoneal biopsy, is warranted for the diagnosis of tuberculous peritonitis. Validity of PCR amplification is ascitic fluid still needs to be established.

[Late manifestation of congenital intrahepatic portacaval shunt in a healthy liver]. / Révélation tardive d'une communication portocave intrahépatique congénitale sur foie sain.

We report the discovery of a congenital intrahepatic portocaval shunt during heart failure in a 68 year-old woman, without cirrhosis or portal hypertension. She had hepatic encephalopathy. Only 17 such cases have been reported. Their physiopathology remains unclear. Reasons for late revelation are debated. Color doppler imaging is very useful for diagnosis following and treatment of these shunts. Therapeutic options are presented.

[Isolated zinc deficiency and necrolytic migratory erythema. Apropos of a case]. / Déficit isolé en zinc et érythème nécrolytique migrateur. A propos d'une observation.

The case of 87-old year woman with necrolytic migratory erythematosus rash without elevated plasma enteroglucagon is discribed. Decreased serum zinc level, response to oral zinc substitution and follow up proved the zinc deficiency.

[Does hepatitis c virus-related autoimmune thyroiditis exist? Reflections on a controlled study of 58 consecutive subjects]. / Les dysthyroïdies auto-immunes liées au virus C existent-elles? Réflexions à propos d'une étude contrôlée de 58 sujets consécutifs.

PURPOSE: Interferon alpha treatment for virus C hepatitis may be responsible for autoimmune thyroiditis. Relationships between thyroiditis and virus C infection are still debated. The aim of this study was to evaluate the existence of this association. METHODS: The prevalence of autoimmune thyroiditis in 58 patients (35 male and 23 female patients, mean age 52.6) with untreated virus C hepatitis was compared to that of 56 alcoholic patients (41 male and 15 female patients, mean age 53.8). Autoimmune thyroiditis was defined as the association of abnormal TSH and an increase in antithyroid antibodies. RESULTS: We did not find any statistical difference in either autoimmune thyroiditis or antithyroid antibodies prevalences. CONCLUSION: Both our results and a literature review suggest that the few reported cases of related autoimmune thyroiditis and virus C infection are probably coincidental.

[Patients in a state of agitation at the admission service of a Rouen hospital emergency department]. / Les patients agités au service d'accueil et d'urgence du CHU de Rouen.

OBJECTIVE: To determine the incidence and causes of agitation states in patients presenting at the Rouen University Hospital emergency room and to analyze the management scheme. PATIENTS AND METHOD: A prospective study was conducted over a 9 month period in 100 consecutive patients presenting a state of agitation assessed using the Overt Aggression Scale. A pre-planned management protocol was applied. RESULTS: The incidence of states of agitation was 0.56%. There were 43 women and 57 men, mean age 33 years. Most of the agitated patients were admitted between 6 p.m. and 4 a.m. (69%). Over the 9 month period, 2 patients were admitted twice for agitation and 2 absconded. Low glucose level was the cause of agitation in 4 cases. Alcohol and/or drug use concerned 73% of the agitated patients and was the most frequently observed triggering factor (17%). Only 6% of the patients had a regular employment. Physical restraining measures and sedation were required in 86% and 84% of the cases respectively. Among 67 patients given loxapine for sedation, 2 developed acute dyskinesia and 9 low blood pressure. One out of 4 patients were referred to a psychiatric unit. CONCLUSION: Patients in a state of agitation are young, often female, and in a difficult socio-economic situation. Hypoglycemia is the main differential diagnosis. A triggering factor can often be identified. A state of agitation is not a repetitive condition but occurs as a short-lived episode in the patientís history. Such patients need rapid care to avoid further aggravation and disruption of the emergency room activity, and to prevent the patient from fleeing. Loxapine provides effective sedation but requires regular monitoring of blood pressure and can provoke acute dyskinesia in young subjects.