Successful rituximab therapy in a lupus patient with diffuse alveolar haemorrhage

Diffuse alveolar haemorrhage (DAH) is a rare but life-threatening complication of systemic lupus erythematosus (SLE). Specific therapy is based on a heavy immunosuppressive treatment that usually associates corticosteroid and cyclophosphamide boluses and plasma exchange. Despite this treatment, an early mortality rate of 20-50% is reported in the literature. Immunosuppression-related complications are responsible for further mortality and morbidity. Rituximab, a specific anti-CD20 antigen B-cell antibody, has been used with success for the treatment of several refractory autoimmune disorders, but rarely for SLE-induced DAH. We report here the first case of SLE-induced DAH treated successfully with rituximab without cyclophosphamide administration in a patient intolerant to cyclophosphamide. We review the two other cases of SLE-induced DAH managed with rituximab as a part of the immunosuppressive regimen.

Aspergillose pulmonaire invasive compliquant un choc septique

INTRODUCTION

Invasive pulmonary aspergillosis (IPA) is an opportunistic infection with a poor prognosis, occurring primarily in patients who are severely immunocompromised.

CASE REPORT

We report a case of IPA that occurred in a 37-year-old woman with no history of previous immunosuppression or significant co-morbidity. She was admitted to our intensive care unit (ICU) with septic shock and multi-organ failure complicating a bacterial pneumonia. After an initial improvement, her condition deteriorated on the 10th day after admission with fever and lesions consistent with IPA seen on high-resolution computed tomography (HRCT). IPA was confirmed by isolating Aspergillus fumigatus from bronchoalveolar lavage and by a positive circulating galactomannan test (sandwich ELISA). First line therapy with voriconazole had to be stopped after 12 days due to hepatic toxicity. The patient was successfully treated with caspofungine for 2 months then itraconazole for 4 months with progressive improvement of HRCT abnormalities. Her galactomannan test became negative at 6 months.

CONCLUSION

The diagnosis of IPA must be considered in critically ill patients even in the absence of underlying immunosupression where suggestive HRCT abnormalities occur in the context of septic shock and multiple organ failure.

[Complexation du 2-[(5-méthylpyrazolyl)méthyle]benzimidazole par les chlorures de cuivre et de cadmium]

The structures of dichloro[2-[(5-methyl-1H-pyrazol-3-yl-kappaN(2))methyl]-1H-1,3-benzimidazole-kappaN(3)]copper(II), [CuCl(2)(C(12)H(12)N(4))], and di-mu-chloro-bis(chloro[2-[(5-methyl-1H-pyrazol-3-yl-kappaN(2))methyl]-1H-1,3-benzimidazole-kappaN(3)]cadmium(II)), [Cd(2)Cl(4)(C(12)H(12)N(4))(2)], show that these compounds have the structural formula [ML(Cl)(2)](n), where L is 2-[(5-methylpyrazolyl)methyl]benzimidazole. When M is copper, the complex is a monomer (n = 1), with a tetrahedral coordination for the Cu atom. When M is cadmium (n = 2), the complex lies about an inversion centre giving rise to a centrosymmetric dimer in which the Cd atoms are bridged by two chloride ions and are pentacoordinated.

[The impact of a French guideline on the clinical management of severe head injury (SHI) published in 1999]

OBJECTIVE

To evaluate the impact of a French guideline on the clinical management of severe head injury (SHI) published in 1999.

STUDY DESIGN

Nationwide survey.

METHODS

182 medical centres answered the inquiry.

RESULTS

111 centres declared to manage such patients suffering from SHI. 68% of doctors from these clinical departments did report to have read these guidelines. Fifty percent of them found in these guidelines useful data for their clinical practice. Forty four percent of centres could not monitor ICP lacking neurosurgical facility in their hospital. Conversely, all hospitals with neurosurgery available did monitor ICP. Seventy six percent of centres reported difficulties to find a facility, which would take these patients in charge when discharged from ICU. We analysed the main items included in the guidelines and report their impact. Seventy four percent of responders found that clinical management of SHI patients had improved during the last years.

CONCLUSION

The French guidelines had a significant impact and seem to have provided a useful aid to clinical management of SHI patients. ICP monitoring and the shortage in post-ICU facilities are remaining issues.

Ethyl 5-[2-(2-aminophénylimino)-2-phényléthylidène]-4-(4-chlorophényl)-4,5-dihydro-1,3,4-thiadiazole-2-carboxylate et éthyl 5-[2-[2-(méthylamino)phénylimino]-2-phényléthylidène]-4-(4-nitrophényl)-4,5-dihydro-1,3,4-thiadiazole-2-carboxylate

Condensation of N-aryl-C-(ethoxycarbonyl)nitrilimines with 4-phenyl-1,2-dihydro-3H-1,5-benzodiazepine-2-thione lead to the title compounds, C(25)H(21)ClN(4)O(2)S, (IIIa), and C(26)H(23)N(5)O(4)S, (IIIb), respectively. Crystals of both compounds were obtained by evaporation of ethanol solutions at room temperature. In the structures of both compounds, a non-bonding interaction is observed between the S atom and the imino N atom. It is established that 1,3-dipolar cycloaddition occurs on the C=S double bond of the 1,5-benzodiazepine-2-thione.

(1S,3R,8S,9S,10R)-2,2-Dichloro-9,10-epoxy-3,7,7,10-tetramethyltricyclo[6.4.0.0(1,3)]dodecane and (1S,3R,8S,10R)-2,2-dichloro-3,7,7,10-tetramethyltricyclo[6.4.0.0(1,3)]dodecan-9-one

The stereochemistries of the title compounds, both C(16)H(24)Cl(2)O, have been established by X-ray diffraction. In both structures, the seven-membered ring adopts the same conformation, whereas the six-membered ring shows an envelope conformation in the epoxydodecane structure and a boat conformation in the dodecan-9-one structure.

A stereospecific synthesis of oxazolinyloxiranes

Lithiooxiranes 3a and 3b, generated by deprotonation of oxiranes 2a and 2b with s-BuLi at -100 degrees C in Et(2)O, were found to be chemically very stable. trans-Lithiooxirane 3a was also configurationally stable and reacted stereospecifically with electrophiles to give 4a--k. In contrast, cis-lithiooxirane 3b was found to be configurationally much less stable and reacted with electrophiles affording mixtures of diastereomers 4, 7, and 8. After only a very short reaction time, 3b too reacted with electrophiles highly stereospecifically. Deprotonation--deuteration and deprotonation--alkylation of chiral oxazolinyloxiranes 12a and 12b to give oxiranes 12c and 12d were also examined. Semiempirical and ab initio calculations were carried out in an effort to explain the observed stereochemistry.

[Intoxications by hallucinogenic mushrooms]

In the context of excessive use of natural or synthetic psychoactive substances, with stimulating, psychedelic and hallucinogenic effects, an increase, if not a recurrence, in consumption of Psilocybe semilanceata has been observed in France over some fifteen years. Psilocybin and psilocin are the active compounds, responsible for the hallucinogenic effects and are a part of the substance group, derived from tryptamine and characterized by an indole nucleus. We report a clinical case observed in an emergency unit and review the historical, epidemiological and pharmacological data now available for these intoxications. Of particular interests in hallucinogenic mushroom abuse are: increased consumption in the context of youth cultural and entertainment movements; possible difficulties in the diagnosis in emergency conditions; possibility of severe and fatal complications.

2-Acetyl-4H-benzothiazin-3(2H)-one

The title compound, C(10)H(9)NO(2)S, has a boat-shaped heterocyclic six-membered ring such that the S and N atoms lie essentially in the plane of the benzene ring while the remaining two C atoms are above this plane.

Correlation between cerebral oxygen saturation measured by near-infrared spectroscopy and jugular oxygen saturation in patients with severe closed head injury

Near-infrared spectroscopy has been used to monitor cerebral oxygen saturation during cerebral circulatory arrest and carotid clamping. However, its utility has not been demonstrated in more complex situations, such as in patients with head injuries. The authors tested this method during conditions that may alter the arteriovenous partition of cerebral blood in different ways.

METHODS

The authors compared changes in measured cerebral oxygen saturation and other hemodynamic parameters, including jugular venous oxygen saturation, in nine patients with severe closed head injury during manipulation of arterial carbon dioxide partial pressure and after mean arterial pressure was altered by vasopressors.

RESULTS

The Bland and Altman representation of cerebral oxygen saturation versus jugular oxygen saturation showed a uniform scatter. Values for changing arterial carbon dioxide partial pressure were: bias = 1.1%, 2 SD = +/-21%, absolute value; and those for alterations in mean arterial pressure: bias = 3.7%, 2 SD = +/-24%, absolute value. However, a Bland and Altman plot of changes in cerebral oxygen saturation versus changes in jugular oxygen saturation had a negative slope (alteration in arterial carbon dioxide partial pressure: bias = 2.4%, 2 SD = +/-17%, absolute value; alteration in mean arterial pressure: bias = -4.9%, 2 SD = +/-31%, absolute value). Regression analysis showed that changes in cerebral oxygen saturation were positively correlated with changes in jugular venous oxygen saturation during the carbon dioxide challenge, whereas correlation was negative during the arterial pressure challenge.

CONCLUSIONS

Cerebral oxygen saturation assessed by near-infrared spectroscopy does not adequately reflect changes in jugular venous oxygen saturation in patients with severe head injury. Changes in arteriovenous partitioning, infrared-spectroscopy contamination by extracerebral signal, algorithm errors, and dissimilar tissue sampling may explain these findings.

[Interactions between naltrexone, an opioid antagonist, and opioids administered during general anesthesia]

We report a case of a probable interaction between sufentanil and naltrexone, an oral long acting opioid antagonist, prescribed for maintenance of abstinence in alcoholics and opioid addicts. The interaction resulted in an antagonisation of the effects of sufentanil and the necessity to increase the dosage. Anaesthetists should be aware of this potential drug interaction.